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Ewig S, Yagmur S, Sabelhaus T, Ostendorf U, Scherff A. [Chest ultrasound for imaging of pneumonia]. Pneumologie 2024. [PMID: 39321959 DOI: 10.1055/a-2405-2750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
Diagnosis of pneumonia can be challenging, particularly the differential diagnosis of lower respiratory tract infection and pneumonia, acute respiratory failure, the diagnosis of nosocomial pneumonia and in case of treatment failure. As compared to conventional chest radiography and CT of the scan, sonography of the chest offers advantages. It could be demonstrated that it was even superior to chest radiography in the identification of pneumonic consolidations. Since most pneumonias affect the lower lobes and include the pleura, pneumonic substrates could be identified in up to 90% of cases despite the limited penetration depth of lung ultrasound. Sonography of the chest has become an established method in the diagnosis of both adult as well as in pediatric community-acquired pneumonia. In addition, it is particularly powerful when used within a point of care (POCUS) approach which also includes the evaluation of the heart. Finally, it appears to have significant potential also in the diagnosis of nosomomial pneumonia and in the evaluation of treatment response, both in the ward as in the ICU.
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Affiliation(s)
- Santiago Ewig
- Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta Krankenhaus Bochum, Thoraxzentrum Ruhrgebiet, Bochum, Deutschland
| | - Saliha Yagmur
- Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta Krankenhaus Bochum, Thoraxzentrum Ruhrgebiet, Bochum, Deutschland
| | - Timo Sabelhaus
- Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta Krankenhaus Bochum, Thoraxzentrum Ruhrgebiet, Bochum, Deutschland
| | - Uwe Ostendorf
- Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta Krankenhaus Bochum, Thoraxzentrum Ruhrgebiet, Bochum, Deutschland
| | - Andreas Scherff
- Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta Krankenhaus Bochum, Thoraxzentrum Ruhrgebiet, Bochum, Deutschland
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2
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Elsheikh M, Kuriyama A, Goto Y, Takahashi Y, Toyama M, Nishikawa Y, El Heniedy MA, Abdelraouf YM, Okada H, Nakayama T. Incidence and predictors of ventilator-associated pneumonia using a competing risk analysis: a single-center prospective cohort study in Egypt. BMC Infect Dis 2024; 24:1007. [PMID: 39300386 PMCID: PMC11414232 DOI: 10.1186/s12879-024-09909-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 09/09/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a challenging nosocomial problem in low- and middle-income countries (LMICs) that face barriers to healthcare delivery and resource availability. This study aimed to examine the incidence and predictors of VAP in Egypt as an example of an LMIC while considering death as a competing event. METHODS The study included patients aged ≥ 18 years who underwent mechanical ventilation (MV) in an intensive care unit (ICU) at a tertiary care, university hospital in Egypt between May 2020 and January 2023. We excluded patients who died or were transferred from the ICU within 48 h of admission. We determined the VAP incidence based on clinical suspicion, radiological findings, and positive lower respiratory tract microbiological cultures. The multivariate Fine-Gray subdistribution hazard model was used to examine the predictors of VAP while considering death as a competing event. RESULTS Overall, 315 patients were included in this analysis. Sixty-two patients (19.7%) developed VAP (17.1 per 1000 ventilator days). The Fine-Gray subdistribution hazard model, after adjustment for potential confounders, revealed that emergency surgery (subdistribution hazard ratio [SHR]: 2.11, 95% confidence interval [CI]: 1.25-3.56), reintubation (SHR: 3.74, 95% CI: 2.23-6.28), blood transfusion (SHR: 2.23, 95% CI: 1.32-3.75), and increased duration of MV (SHR: 1.04, 95% CI: 1.03-1.06) were independent risk factors for VAP development. However, the new use of corticosteroids was not associated with VAP development (SHR: 0.94, 95% CI: 0.56-1.57). Klebsiella pneumoniae was the most common causative microorganism, followed by Pseudomonas aeruginosa. CONCLUSION The incidence of VAP in Egypt was high, even in the ICU at a university hospital. Emergency surgery, reintubation, blood transfusion, and increased duration of MV were independently associated with VAP. Robust antimicrobial stewardship and infection control strategies are urgently needed in Egypt.
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Affiliation(s)
- Mohamed Elsheikh
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Department of Emergency Medicine and Traumatology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Akira Kuriyama
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.
| | - Yoshihito Goto
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Clinical Research Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshimitsu Takahashi
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Mayumi Toyama
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | | | | | - Hiroshi Okada
- Department of Pharmaceutical Sciences, Wakayama Medical University, Wakayama, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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3
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Passarelli MT, Petit M, Garberi R, Lebreton G, Luyt CE, Pineton De Chambrun M, Chommeloux J, Hékimian G, Rezoagli E, Foti G, Combes A, Giani M, Schmidt M. Mechanical ventilation settings during weaning from venovenous extracorporeal membrane oxygenation. Ann Intensive Care 2024; 14:138. [PMID: 39230734 PMCID: PMC11374948 DOI: 10.1186/s13613-024-01359-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/02/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND The optimal timing of weaning from venovenous extracorporeal membrane oxygenation (VV ECMO) and its modalities have been rarely studied. METHODS Retrospective, multicenter cohort study over 7 years in two tertiary ICUs, high-volume ECMO centers in France and Italy. Patients with ARDS on ECMO and successfully weaned from VV ECMO were classified based on their mechanical ventilation modality during the sweep gas-off trial (SGOT) with either controlled mechanical ventilation or spontaneous breathing (i.e. pressure support ventilation). The primary endpoint was the time to successful weaning from mechanical ventilation within 90 days post-ECMO weaning. RESULTS 292 adult patients with severe ARDS were weaned from controlled ventilation, and 101 were on spontaneous breathing during SGOT. The 90-day probability of successful weaning from mechanical ventilation was not significantly different between the two groups (sHR [95% CI], 1.23 [0.84-1.82]). ECMO-related complications were not statistically different between patients receiving these two mechanical ventilation strategies. After adjusting for covariates, older age, higher pre-ECMO sequential organ failure assessment score, pneumothorax, ventilator-associated pneumonia, and renal replacement therapy, but not mechanical ventilation modalities during SGOT, were independently associated with a lower probability of successful weaning from mechanical ventilation after ECMO weaning. CONCLUSIONS Time to successful weaning from mechanical ventilation within 90 days post-ECMO was not associated with the mechanical ventilation strategy used during SGOT. Further research is needed to assess the optimal ventilation strategy during weaning off VV ECMO and its impact on short- and long-term outcomes.
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Affiliation(s)
- Maria Teresa Passarelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Matthieu Petit
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Roberta Garberi
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Assistance Publique-Hôpitaux de Paris, Thoracic and Cardiovascular Department, Pitié-Salpêtrière Hospital, 75651, Paris Cedex 13, France
| | - Charles Edouard Luyt
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Marc Pineton De Chambrun
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Alain Combes
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Marco Giani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Matthieu Schmidt
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, 47 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France.
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4
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Ewig S. [Nosocomial pneumonia]. DIE ANAESTHESIOLOGIE 2024; 73:630-644. [PMID: 39136734 DOI: 10.1007/s00101-024-01451-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
Nosocomial pneumonia is defined as pneumonia occurring ≥ 48 h after hospital admission in a patient without severe immunosuppression. It can occur in spontaneously breathing patients or with noninvasive ventilation (NIV) and mechanically ventilated patients. In patients with suspected ventilator-associated pneumonia (VAP) (semi)quantitative cultures of tracheobronchial aspirates or bronchoalveolar lavage fluid should be perfomed. The initial empirical antimicrobial treatment is determined by the risk for multidrug-resistant pathogens (MDRP). The advantage of combination treatment increases with the prevalence of MDRPs. The antibiotic treatment should be adapted when the microbiological results are available. After 72 h a standardized re-evaluation including the response to treatment and also checking of the suspected diagnosis of pneumonia in a structured form is mandatory. Treatment failure can occur as a primary or secondary failure and in the case of primary progression necessitates another comprehensive diagnostic work-up before any further antibiotic treatment.
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Affiliation(s)
- Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Kliniken für Pneumologie und Infektiologie, EVK Herne und Augusta-Krankenhaus Bochum, Hordeler Straße 7-9, 44651, Herne, Deutschland.
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5
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Collado-Lledó E, Moyon Q, Chommeloux J, Pineton de Chambrun M, Hékimian G, Saura O, Lévy D, Schmidt M, Combes A, Luyt CE, Le Fevre L. Recurrent ventilator-associated pneumonia in severe Covid-19 ARDS patients requiring ECMO support. Ann Intensive Care 2024; 14:67. [PMID: 38662274 PMCID: PMC11045714 DOI: 10.1186/s13613-024-01295-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE To describe ventilator-associated pneumonia (VAP) recurrence in COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support, and to evaluate the impact of antimicrobial treatment duration of the first VAP episode on VAP recurrence. METHODS Adult patients with COVID-19 severe pneumonia on ECMO admitted between March 2020 and January 2022 were retrospectively included. Primary outcome was incidence of VAP recurrence, and secondary outcome was the impact of duration of antimicrobial treatment on VAP recurrence. RESULTS Among the 252 included patients, 226 (90%) developed a first VAP. Sixteen had lung abscess and were excluded, leaving 210 patients. VAP recurrence occurred in 172 patients (82%), with a median (IQR) time from first VAP to recurrence of 10 (7-13) days. Pseudomonas aeruginosa and Enterobacteriaceae were respectively responsible for 28% and 52% of first VAP, and 51% and 62% of first recurrence episodes. Among the 210 patients with a first VAP, 158 (75%) received a short course of antibiotics [< 8 days, median (IQR) duration 6 (5-7) days] and 52 (25%) received a prolonged course of antibiotics [≥ 8 days, median (IQR) duration 9 (8-10) days]. Estimated cumulative incidence of VAP recurrence, taking into account death and extubation as competing risks, was not different in patients with short- and prolonged-antimicrobial treatment. CONCLUSIONS In patients with severe Covid-19-ARDS requiring ECMO support, VAP recurrence occurs frequently, with Enterobacteriaceae and Pseudomonas aeruginosa as predominant causative microorganisms. An antimicrobial treatment of ≥ 8 days for the treatment of first VAP episode did not reduce the risk of VAP recurrence, as compared to shorter duration.
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Affiliation(s)
- Elena Collado-Lledó
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Quentin Moyon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Ouriel Saura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - David Lévy
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
- INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France.
- INSERM, UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Lucie Le Fevre
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Médecine Intensive Réanimation, Assistance Publique, Hôpitaux de Paris (AP-HP), Paris, France
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6
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Wałaszek M, Serwacki P, Cholewa Z, Kosiarska A, Świątek-Kwapniewska W, Kołpa M, Rafa E, Słowik R, Nowak K, Różańska A, Wójkowska-Mach J. Ventilator-associated pneumonia in Polish intensive care unit dedicated to COVID-19 patients. BMC Pulm Med 2023; 23:443. [PMID: 37974141 PMCID: PMC10652561 DOI: 10.1186/s12890-023-02743-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Healthcare-Associated Infections (HAI) are most frequently associated with patients in the Intensive Care Unit (ICU). Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), led to ICU hospitalization for some patients. METHODS The study was conducted in 2020 and 2021 at a hospital in southern Poland. The Healthcare-Associated Infections Surveillance Network (HAI-Net) of the European Centre for Disease Prevention and Control (ECDC) was used for HAI diagnosis. The aim of this case-control study was to retrospectively assess the epidemiology of HAIs in ICU patients, distinguishing between COVID-19 and non-COVID-19 cases. RESULTS The study included 416 ICU patients: 125 (30%) with COVID-19 and 291 (70%) without COVID-19, p < 0.05. The mortality rate was 80 (64%) for COVID-19 patients and 45 (16%) for non-COVID-19 patients, p < 0.001. Ventilator-Associated Pneumonia (VAP) occurred in 40 cases, with an incidence rate density of 6.3/1000 patient-days (pds): 14.1/1000 pds for COVID-19 patients vs. 3.6/1000 pds for non-COVID-19 patients. Odds Ratio (OR) was 2.297, p < 0.01. Acinetobacter baumannii was the most often isolated microorganism in VAP, with 25 cases (incidence rate 8.5%): 16 (18.2%) in COVID-19 patients vs. 9 (4.4%) in non-COVID-19 patients. OR was 4.814 (1.084-4.806), p < 0.001. CONCLUSIONS Patients treated in the ICU for COVID-19 faced twice the risk of VAP compared to non-COVID-19 patients. The predominant microorganism in VAP cases was Acinetobacter baumannii.
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Affiliation(s)
- Marta Wałaszek
- University of Applied Sciences in Tarnów, ul. Mickiewicza 8, Tarnów, 33-100, Poland
| | - Piotr Serwacki
- St Luke Regional Hospital in Tarnów, ul. Lwowska 178A, Tarnów, 33-100, Poland
| | - Zbigniew Cholewa
- St Luke Regional Hospital in Tarnów, ul. Lwowska 178A, Tarnów, 33-100, Poland
| | - Alicja Kosiarska
- University of Applied Sciences in Tarnów, ul. Mickiewicza 8, Tarnów, 33-100, Poland
| | | | - Małgorza Kołpa
- University of Applied Sciences in Tarnów, ul. Mickiewicza 8, Tarnów, 33-100, Poland
| | - Elżbieta Rafa
- University of Applied Sciences in Nowy Sącz, ul. Staszica 1, Nowy Sącz, 33-300, Poland
| | - Róża Słowik
- University of Applied Sciences in Tarnów, ul. Mickiewicza 8, Tarnów, 33-100, Poland
| | - Karolina Nowak
- Department of Microbiology, Jagiellonian University Medical College, Czysta str. 18, Krakow, 31-121, Poland
| | - Anna Różańska
- Department of Microbiology, Jagiellonian University Medical College, Czysta str. 18, Krakow, 31-121, Poland.
| | - Jadwiga Wójkowska-Mach
- Department of Microbiology, Jagiellonian University Medical College, Czysta str. 18, Krakow, 31-121, Poland
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Massart N, Plainfosse E, Benameur Y, Dupin C, Legall F, Cady A, Gourmelin F, Legay F, Barbarot N, Magalhaes E, Fillatre P, Frerou A, Reizine F. Prediction of pulmonary aspergillosis in patients with ventilator-associated pneumonia. Ann Intensive Care 2023; 13:109. [PMID: 37935890 PMCID: PMC10630265 DOI: 10.1186/s13613-023-01199-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/30/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Predictors of ICU-acquired pulmonary aspergillosis (IPA) are not well-established in critically ill patients with ventilator-associated pneumonia (VAP), making IPA commonly misdiagnosed and anti-fungal therapy delayed. We aimed to develop a clinical score for prediction of IPA among patients with VAP. METHODS Mechanically ventilated patients who developed VAP in 4 ICUs in Bretagne, Western France, were included. The score was constructed in a learning cohort, based on predictors of IPA in logistic regression model, and validated in a validation cohort. RESULTS Among 1636 mechanically ventilated patients, 215 developed VAP but only 39 developed IPA (4 possible and 35 probable/putative) (18%). Most cases (31/39) were documented through a positive broncho-alveolar sample culture. Independent predictors of IPA were immunodepression (including onco-hematological disorder, immunomodulatory treatment, solid organ transplant, neutropenia < 0.5G/L and high-dose steroids ≥ 1 mg/kg/day of prednisolone equivalent) (p = 0.001; score = 1 point) and lymphocyte count at admission < 0.8 G/L (p = 0.019; score = 1 point). Operational values of the predictive score in the learning/validation cohort were 50%/52% sensitivity and 90%/87% specificity, respectively, for high PiPa score (score = 2) and 94%/91% sensitivity and 44%/46% specificity, respectively, for moderate PiPa score (score = 1). Finally, the AUC for the prediction of IPA was 0.783 in the learning cohort and 0.770 in the validation cohort. CONCLUSIONS We evaluated a clinical score with good predictive value which may help to predict IPA in patient with VAP. External validation will be needed to confirm our preliminary findings.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France.
| | - Emma Plainfosse
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
- Service d'Anesthésie et de Réanimation Chirurgicale, CHU de Rennes, 2, rue Henry le Guilloux, 35000, Rennes, France
| | - Yanis Benameur
- Service de Réanimation, CH de QUIMPER, 14Bis Avenue Yves Thépot, 29107, Quimper, France
| | - Clarisse Dupin
- Service de Microbiologie, CH de St BRIEUC, 10, rue marcel Proust, 22000, Saint-Brieuc, France
| | - Florence Legall
- Service de Microbiologie, CH de QUIMPER, 14bis Avenue Yves Thépot, 29107, Quimper, France
| | - Anne Cady
- Laboratoire de Biologie Médicale, CH de Vannes, 20, bd Maurice Guillaudot, 56000, Vannes, France
| | - Frederic Gourmelin
- Service de Réanimation, CH de Saint-Malo, 1 rue de la marne, 35400, Saint-Malo, France
| | - François Legay
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Nicolas Barbarot
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Eric Magalhaes
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St BRIEUC, 10, Rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Aurélien Frerou
- Service de Réanimation, CH de Saint-Malo, 1 rue de la marne, 35400, Saint-Malo, France
| | - Florian Reizine
- Service de Réanimation, CH de Vannes, 20, bd Maurice Guillaudot, 56000, Vannes, France
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8
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Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
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Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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9
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Luyt CE, Burrel S, Mokrani D, Pineton de Chambrun M, Luyt D, Chommeloux J, Guiraud V, Bréchot N, Schmidt M, Hekimian G, Combes A, Boutolleau D. Herpesviridae lung reactivation and infection in patients with severe COVID-19 or influenza virus pneumonia: a comparative study. Ann Intensive Care 2022; 12:87. [PMID: 36153427 PMCID: PMC9509504 DOI: 10.1186/s13613-022-01062-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/12/2022] [Indexed: 11/12/2022] Open
Abstract
Background Lung reactivations of Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) have been reported in COVID-19 patients. Whether or not those viral reactivations are more frequent than in other patients is not known. Methods Retrospective monocentric cohort study of 145 patients with severe COVID-19 pneumonia requiring invasive mechanical ventilation and who were tested for HSV and CMV in bronchoalveolar lavage performed during fiberoptic bronchoscopy for ventilator-associated pneumonia suspicion. Rates of HSV and CMV lung reactivations, and HSV bronchopneumonitis were assessed and compared with an historical cohort of 89 patients with severe influenza pneumonia requiring invasive mechanical ventilation. Results Among the 145 COVID-19 patients included, 50% and 42% had HSV and CMV lung reactivations, respectively, whereas among the 89 influenza patients, 63% and 28% had HSV and CMV lung reactivations, respectively. Cumulative incidence of HSV lung reactivation (taking into account extubation and death as competing events) was higher in influenza than in COVID-19 patients (p = 0.03), whereas the rate of HSV bronchopneumonitis was similar in both groups (31% and 25%, respectively). Cumulative incidence of CMV lung reactivation (taking into account extubation and death as competing events) was similar in COVID-19 and influenza patients (p = 0.07). Outcomes of patients with HSV or CMV lung reactivations were similar to that of patients without, whatever the underlying conditions, i.e., in COVID-19 patients, in influenza patients, or when all patients were grouped. Conclusions HSV and CMV lung reactivations are frequent in COVID-19 patients, but not more frequent than in patients with influenza-associated severe pneumonia, despite a higher severity of illness at intensive care unit admission of the latter and a longer duration of mechanical ventilation of the former. Although no impact on outcome of HSV and CMV lung reactivations was detected, the effect of antiviral treatment against these Herpesviridae remains to be determined in these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01062-0.
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10
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Guihot A, Plu I, Soulié C, Rousseau A, Nakid-Cordero C, Dorgham K, Parizot C, Litvinova E, Mayaux J, Malet I, Quentric P, Combadière B, Combadière C, Bonduelle O, Adam L, Rosenbaum P, Beurton A, Hémon P, Debré P, Vieillard V, Autran B, Seilhean D, Charlotte F, Marcelin AG, Gorochov G, Luyt CE. Memory CD4+ T-Cell Lymphocytic Angiopathy in Fatal Forms of COVID-19 Pulmonary Infection. Front Immunol 2022; 13:844727. [PMID: 35529881 PMCID: PMC9074842 DOI: 10.3389/fimmu.2022.844727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/11/2022] [Indexed: 01/08/2023] Open
Abstract
The immunopathological pulmonary mechanisms leading to Coronavirus Disease (COVID-19)-related death in adults remain poorly understood. Bronchoalveolar lavage (BAL) and peripheral blood sampling were performed in 74 steroid and non-steroid-treated intensive care unit (ICU) patients (23-75 years; 44 survivors). Peripheral effector SARS-CoV-2-specific T cells were detected in 34/58 cases, mainly directed against the S1 portion of the spike protein. The BAL lymphocytosis consisted of T cells, while the mean CD4/CD8 ratio was 1.80 in non-steroid- treated patients and 1.14 in steroid-treated patients. Moreover, strong BAL SARS-CoV-2 specific T-cell responses were detected in 4/4 surviving and 3/3 non-surviving patients. Serum IFN-γ and IL-6 levels were decreased in steroid-treated patients when compared to non-steroid treated patients. In the lung samples from 3 (1 non-ICU and 2 ICU) additional deceased cases, a lymphocytic memory CD4 T-cell angiopathy colocalizing with SARS-CoV-2 was also observed. Taken together, these data show that disease severity occurs despite strong antiviral CD4 T cell-specific responses migrating to the lung, which could suggest a pathogenic role for perivascular memory CD4 T cells upon fatal COVID-19 pneumonia.
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Affiliation(s)
- Amélie Guihot
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Département d’Immunologie, Paris, France
| | - Isabelle Plu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Département de Neuropathologie, Paris, France
| | - Cathia Soulié
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de Virologie, Paris, France
| | - Alice Rousseau
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Cecilia Nakid-Cordero
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Karim Dorgham
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Christophe Parizot
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Département d’Immunologie, Paris, France
| | - Elena Litvinova
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Département d’Immunologie, Paris, France
| | - Julien Mayaux
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Service de Médecine Intensive–Réanimation et Pneumologie, Paris, France
| | - Isabelle Malet
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de Virologie, Paris, France
| | - Paul Quentric
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Béhazine Combadière
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Christophe Combadière
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Olivia Bonduelle
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Lucille Adam
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Pierre Rosenbaum
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandra Beurton
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Service de Médecine Intensive–Réanimation et Pneumologie, Paris, France
| | - Patrice Hémon
- LBAI, Hyperion platform, University of Brest, INSERM, CHU de Brest, Brest, France
| | - Patrice Debré
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Vincent Vieillard
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Brigitte Autran
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
| | - Danielle Seilhean
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Département de Neuropathologie, Paris, France
| | - Frédéric Charlotte
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service d’Anatomopathologie, Hôpital Pitié-Salpêtrière, Paris, France; Sorbonne Université, Paris, France
| | - Anne-Geneviève Marcelin
- Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique (iPLESP), AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de Virologie, Paris, France
| | - Guy Gorochov
- Sorbonne Université INSERM, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Pitié-Salpêtrière, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Département d’Immunologie, Paris, France
| | - Charles-Edouard Luyt
- Assistance Publique–Hôpitaux de Paris (AP-HP), Hôpital Pitié–Salpêtrière, Service de Médecine Intensive Réanimation, Institut de Cardiologie, Paris, France
- Sorbonne Université, Inserm, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
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11
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Ventilator-Associated Lower Respiratory Tract Bacterial Infections in COVID-19 Compared With Non-COVID-19 Patients. Crit Care Med 2022; 50:825-836. [PMID: 35148524 PMCID: PMC9005099 DOI: 10.1097/ccm.0000000000005462] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventilator-associated lower respiratory tract infections (VA-LRTIs) are associated with prolonged length of stay and increased mortality. We aimed to investigate the occurrence of bacterial VA-LRTI among mechanically ventilated COVID-19 patients and compare these findings to non-COVID-19 cohorts throughout the first and second wave of the pandemic.
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12
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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13
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Jain S, Khanna P, Sarkar S. Comparative evaluation of ventilator-associated pneumonia in critically ill COVID- 19 and patients infected with other corona viruses: a systematic review and meta-analysis. Monaldi Arch Chest Dis 2021; 92. [PMID: 34585556 DOI: 10.4081/monaldi.2021.1610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 08/12/2021] [Indexed: 01/08/2023] Open
Abstract
The Coronavirus disease 19 (COVID-19) pandemic is associated with an unprecedented requirement for intensive care unit (ICU) admission, invasive mechanical ventilation, and thereby significantly increasing the risk of secondary nosocomial pneumonia, Ventilator-Associated Pneumonia (VAP). Our study aims to identify the overall incidence of VAP, common organisms associated with it, and outcome in COVID-19 patients in comparison to the non-SARS-CoV-2 infected critically ill ventilated COVID-19 patients. A comprehensive screening was conducted using major electronic databases), from January 1st 2020 to May 31st 2021, as per the PRISMA statement. In our rapid review, we included a total of 34 studies (involving 8901 cases. Overall VAP was reported in 48.15 % (95% CI 42.3%-54%) mechanically ventilated COVID-19 patients and the mortality rate was 51.4% (95% CI 42.5%-60%). COVID-19 patients had increased risk of VAP and mortality in comparison to other non-SARS-CoV-2 viral pneumonia (OR=2.33; 95%CI 1.75-3.11; I2=15%, and OR=1.46; 95%CI 1.15-1.86; I2=0% respectively). Critically ill COVID-19 patients are prone to develop VAP, which worsens the outcome.
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Affiliation(s)
- Shikha Jain
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh.
| | - Puneet Khanna
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences (AIIMS), New Delhi.
| | - Soumya Sarkar
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences (AIIMS), New Delhi.
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14
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Emanuele Cattaneo
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gaetano Florio
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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15
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Rouyer M, Strazzulla A, Youbong T, Tarteret P, Pitsch A, de Pontfarcy A, Cassard B, Vignier N, Pourcine F, Jochmans S, Monchi M, Diamantis S. Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Cohort Study. Antibiotics (Basel) 2021; 10:antibiotics10080988. [PMID: 34439038 PMCID: PMC8388913 DOI: 10.3390/antibiotics10080988] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Aim of this study is to analyse the characteristics of ventilator-associated pneumonia (VAP) inpatients infected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). MATERIALS AND METHODS A retrospective study was conducted, including coronavirus infectious disease 2019 (COVID-19) patients who developed VAP from March to May 2020 (VAP COVID-19). They were compared to non-COVID-19 patients who developed VAP from January 2011 to December 2019 (VAP NO COVID-19) and COVID-19 patients who did not develop VAP (NO VAP COVID-19). RESULTS Overall, 42 patients were included in the VAP COVID-19group, 37 in the NO VAP COVID-19 group, and 188 in the VAP NO COVID-19 group. VAP COVID-19 had significantly higher rates of shock (71% vs. 48%, p = 0.009), death in ICU (52% vs. 30%, p = 0.011), VAP recurrence (28% vs. 4%, p < 0.0001), positive blood culture (26% vs. 13%, p = 0.038), and polymicrobial culture (28% vs. 13%, p = 0.011) than VAP NO COVID-19. At the multivariate analysis, death in patients with VAP was associated with shock (p = 0.032) and SARS-CoV-2 (p = 0.008) infection. CONCLUSIONS VAP in COVID-19 patients is associated with shock, bloodstream, and polymicrobial infections.
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Affiliation(s)
- Maxence Rouyer
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Alessio Strazzulla
- Internal Medicine Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France
- Correspondence: ; Tel.: +33-181742070
| | - Tracie Youbong
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Paul Tarteret
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Aurélia Pitsch
- Medical Biology Laboratory, Groupe Hospitalier Sud Ile de France, 77000 Melun, France;
| | - Astrid de Pontfarcy
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Bruno Cassard
- Pharmacy Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France;
| | - Nicolas Vignier
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
| | - Franck Pourcine
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (F.P.); (S.J.); (M.M.)
| | - Sébastien Jochmans
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (F.P.); (S.J.); (M.M.)
| | - Mehran Monchi
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (F.P.); (S.J.); (M.M.)
| | - Sylvain Diamantis
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France; (M.R.); (T.Y.); (P.T.); (A.d.P.); (N.V.); (S.D.)
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16
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Le Terrier C, Vinetti M, Bonjean P, Richard R, Jarrige B, Pons B, Madeux B, Piednoir P, Ardisson F, Elie E, Martino F, Valette M, Ollier E, Breurec S, Carles M, Thiéry G. Impact of a restrictive antibiotic policy on the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in an endemic region: a before-and-after, propensity-matched cohort study in a Caribbean intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:261. [PMID: 34311760 PMCID: PMC8311634 DOI: 10.1186/s13054-021-03660-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/27/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND High-level antibiotic consumption plays a critical role in the selection and spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) in the ICU. Implementation of a stewardship program including a restrictive antibiotic policy was evaluated with respect to ESBL-E acquisition (carriage and infection). METHODS We implemented a 2-year, before-and-after intervention study including all consecutive adult patients admitted for > 48 h in the medical-surgical 26-bed ICU of Guadeloupe University Hospital (French West Indies). A conventional strategy period (CSP) including a broad-spectrum antibiotic as initial empirical treatment, followed by de-escalation (period before), was compared to a restrictive strategy period (RSP) limiting broad-spectrum antibiotics and shortening their duration. Antibiotic therapy was delayed and initiated only after microbiological identification, except for septic shock, severe acute respiratory distress syndrome and meningitis (period after). A multivariate Cox proportional hazard regression model adjusted on propensity score values was performed. The main outcome was the median time of being ESBL-E-free in the ICU. Secondary outcome included all-cause ICU mortality. RESULTS The study included 1541 patients: 738 in the CSP and 803 in the RSP. During the RSP, less patients were treated with antibiotics (46.8% vs. 57.9%; p < 0.01), treatment duration was shorter (5 vs. 6 days; p < 0.01), and administration of antibiotics targeting anaerobic pathogens significantly decreased (65.3% vs. 33.5%; p < 0.01) compared to the CSP. The incidence of ICU-acquired ESBL-E was lower (12.1% vs. 19%; p < 0.01) during the RSP. The median time of being ESBL-E-free was 22 days (95% CI 16-NA) in the RSP and 18 days (95% CI 16-21) in the CSP. After propensity score weighting and adjusted analysis, the median time of being ESBL-E-free was independently associated with the RSP (hazard ratio, 0.746 [95% CI 0.575-0.968]; p = 0.02, and hazard ratio 0.751 [95% CI 0.578-0.977]; p = 0.03, respectively). All-cause ICU mortality was lower in the RSP than in the CSP (22.5% vs. 28.6%; p < 0.01). CONCLUSIONS Implementation of a program including a restrictive antibiotic strategy is feasible and is associated with less ESBL-E acquisition in the ICU without any worsening of patient outcome.
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Affiliation(s)
- Christophe Le Terrier
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France. .,Division of Intensive Care, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland.
| | - Marco Vinetti
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France.,Division of Intensive Care, Saint-Pierre Clinic, Ottignies, Belgium
| | - Paul Bonjean
- Division of Clinical Epidemiology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Régine Richard
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Bruno Jarrige
- Division of Hospital Infection Control, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Bertrand Pons
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Benjamin Madeux
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Pascale Piednoir
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Fanny Ardisson
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Elain Elie
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Frédéric Martino
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Marc Valette
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France
| | - Edouard Ollier
- Division of Clinical Epidemiology, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Sébastien Breurec
- Laboratory of Clinical Microbiology, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France.,Faculty of Medecine Hyacinthe Bastaraud, University of Antilles, Pointe-à-Pitre, French West Indies, France.,INSERM Center for Clinical Investigation 1424, Pointe-à-Pitre, Les Abymes, French West Indies, France.,Transmission, Reservoir and Diversity of Pathogens Unit, Institut Pasteur de Guadeloupe, Pointe-à-Pitre, French West Indies, France
| | - Michel Carles
- Division of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, Les Abymes, French West Indies, France.,Faculty of Medecine Hyacinthe Bastaraud, University of Antilles, Pointe-à-Pitre, French West Indies, France
| | - Guillaume Thiéry
- Division of Intensive Care, University Hospital of Saint-Etienne, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France. .,University Jean Monnet, Saint-Etienne, France.
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17
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Gragueb-Chatti I, Lopez A, Hamidi D, Guervilly C, Loundou A, Daviet F, Cassir N, Papazian L, Forel JM, Leone M, Dellamonica J, Hraiech S. Impact of dexamethasone on the incidence of ventilator-associated pneumonia and blood stream infections in COVID-19 patients requiring invasive mechanical ventilation: a multicenter retrospective study. Ann Intensive Care 2021; 11:87. [PMID: 34057642 PMCID: PMC8165680 DOI: 10.1186/s13613-021-00876-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background Dexamethasone decreases mortality in patients with severe coronavirus disease 2019 (COVID-19) and has become the standard of care during the second wave of pandemic. Dexamethasone is an immunosuppressive treatment potentially increasing the risk of secondary hospital acquired infections in critically ill patients. We conducted an observational retrospective study in three French intensive care units (ICUs) comparing the first and second waves of pandemic to investigate the role of dexamethasone in the occurrence of ventilator-associated pneumonia (VAP) and blood stream infections (BSI). Patients admitted from March to November 2020 with a documented COVID-19 and requiring mechanical ventilation (MV) for ≥ 48 h were included. The main study outcomes were the incidence of VAP and BSI according to the use of dexamethasone. Secondary outcomes were the ventilator-free days (VFD) at day-28 and day-60, ICU and hospital length of stay and mortality. Results Among the 151 patients included, 84 received dexamethasone, all but one during the second wave. VAP occurred in 63% of patients treated with dexamethasone (DEXA+) and 57% in those not receiving dexamethasone (DEXA−) (p = 0.43). The cumulative incidence of VAP, considering death, duration of MV and late immunosuppression as competing factors was not different between groups (p = 0.59). A multivariate analysis did not identify dexamethasone as an independent risk factor for VAP occurrence. The occurrence of BSI was not different between groups (29 vs. 30%; p = 0.86). DEXA+ patients had more VFD at day-28 (9 (0–21) vs. 0 (0–11) days; p = 0.009) and a reduced ICU length of stay (20 (11–44) vs. 32 (17–46) days; p = 0.01). Mortality did not differ between groups. Conclusions In this cohort of COVID-19 patients requiring invasive MV, dexamethasone was not associated with an increased incidence of VAP or BSI. Dexamethasone might not explain the high rates of VAP and BSI observed in critically ill COVID-19 patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00876-8.
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Affiliation(s)
- Ines Gragueb-Chatti
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France.,Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France
| | - Alexandre Lopez
- Service d'Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Dany Hamidi
- Service de Médecine Intensive Réanimation CHU de Nice et UR2CA, Université Cote d'Azur, Nice, France
| | - Christophe Guervilly
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France.,Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France
| | - Anderson Loundou
- Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France
| | - Florence Daviet
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France.,Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France
| | - Nadim Cassir
- Institut Hospitalo-Universitaire Méditerranée Infection, Marseille, France
| | - Laurent Papazian
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France.,Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France
| | - Jean-Marie Forel
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France.,Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Jean Dellamonica
- Service de Médecine Intensive Réanimation CHU de Nice et UR2CA, Université Cote d'Azur, Nice, France
| | - Sami Hraiech
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015, Marseille, France. .,Centre d'Études et de Recherches sur les Services de Santé et qualite de vie EA 3279, 13005, Marseille, France. .,Service de Médecine Intensive Réanimation, APHM, CHU Nord, 13015, Marseille, France.
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18
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Luyt CE, Sahnoun T, Gautier M, Vidal P, Burrel S, Pineton de Chambrun M, Chommeloux J, Desnos C, Arzoine J, Nieszkowska A, Bréchot N, Schmidt M, Hekimian G, Boutolleau D, Robert J, Combes A, Chastre J. Ventilator-associated pneumonia in patients with SARS-CoV-2-associated acute respiratory distress syndrome requiring ECMO: a retrospective cohort study. Ann Intensive Care 2020; 10:158. [PMID: 33230710 PMCID: PMC7682692 DOI: 10.1186/s13613-020-00775-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/13/2020] [Indexed: 02/08/2023] Open
Abstract
Background The data on incidence, clinical presentation, and outcomes of ventilator-associated pneumonia (VAP) in patients with severe coronavirus disease 2019 (COVID-19) pneumonia requiring mechanical ventilation (MV) are limited. We performed this retrospective cohort study to assess frequency, clinical characteristics, responsible pathogens, and outcomes of VAP in patients COVID-19 pneumonia requiring MV between March 12th and April 24th, 2020 (all had RT-PCR-confirmed SARS-CoV-2 infection). Patients with COVID-19-associated acute respiratory distress syndrome (ARDS) requiring ECMO were compared with an historical cohort of 45 patients with severe influenza-associated ARDS requiring ECMO admitted to the same ICU during the preceding three winter seasons. Results Among 50 consecutive patients with Covid-19-associated ARDS requiring ECMO included [median (IQR) age 48 (42–56) years; 72% male], 43 (86%) developed VAP [median (IQR) MV duration before the first episode, 10 (8–16) days]. VAP-causative pathogens were predominantly Enterobacteriaceae (70%), particularly inducible AmpC-cephalosporinase producers (40%), followed by Pseudomonas aeruginosa (37%). VAP recurred in 34 (79%) patients and 17 (34%) died. Most recurrences were relapses (i.e., infection with the same pathogen), with a high percentage occurring on adequate antimicrobial treatment. Estimated cumulative incidence of VAP, taking into account death and extubation as competing events, was significantly higher in Covid-19 patients than in influenza patients (p = 0.002). Despite a high P. aeruginosa-VAP rate in patients with influenza-associated ARDS (54%), the pulmonary infection recurrence rate was significantly lower than in Covid-19 patients. Overall mortality was similar for the two groups. Conclusions Patients with severe Covid-19-associated ARDS requiring ECMO had a very high late-onset VAP rate. Inducible AmpC-cephalosporinase-producing Enterobacteriaceae and Pseudomonas aeruginosa frequently caused VAP, with multiple recurrences and difficulties eradicating the pathogen from the lung.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France. .,INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France.
| | - Tarek Sahnoun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Melchior Gautier
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Pauline Vidal
- Service de Bactériologie-Hygiène, APHP, Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sonia Burrel
- Centre National de Référence Herpesvirus (Laboratoire Associé), Service de Virologie, Groupe Hospitalo-Universitaire (GHU) AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM U1136, Institut Pierre Louis D'Epidémiologie Et de Santé Publique (iPLESP), Sorbonne Université, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Cyrielle Desnos
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Jeremy Arzoine
- Département D'Anesthésie-Réanimation, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Ania Nieszkowska
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Guillaume Hekimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - David Boutolleau
- Centre National de Référence Herpesvirus (Laboratoire Associé), Service de Virologie, Groupe Hospitalo-Universitaire (GHU) AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM U1136, Institut Pierre Louis D'Epidémiologie Et de Santé Publique (iPLESP), Sorbonne Université, Paris, France
| | - Jérôme Robert
- Service de Bactériologie-Hygiène, APHP, Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alain Combes
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Jean Chastre
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne-Université, Groupe Hospitalier Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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19
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Luyt CE, Hékimian G, Bonnet I, Bréchot N, Schmidt M, Robert J, Combes A, Aubry A. Usefulness of point-of-care multiplex PCR to rapidly identify pathogens responsible for ventilator-associated pneumonia and their resistance to antibiotics: an observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:378. [PMID: 32586347 PMCID: PMC7316635 DOI: 10.1186/s13054-020-03102-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/17/2020] [Indexed: 01/07/2023]
Abstract
Background The use of multiplex PCR to shorten time to identification of pathogens and their resistance mechanisms for patients with ventilator-associated pneumonia (VAP) is attractive, but poorly studied. The multiplex PCR–based Unyvero pneumonia cartridge assay can directly identify 20 bacteria and one fungus, amongst the most frequently causing VAP, and 19 of their resistance markers in clinical specimens (bronchoalveolar lavage or tracheal aspirate), with a turnaround time of 4–5 h. We performed this study to evaluate the concordance between the multiplex PCR–based Unyvero pneumonia cartridge assay and conventional microbiological techniques to identify pathogens and their resistance mechanisms in patients with VAP. Methods All patients suspected of having VAP (January 2016 to January 2019), who underwent fiberoptic bronchoscopy with bronchoalveolar lavage fluid (BALF) and whose BALF microscopy examination revealed intracellular bacteria, were included. BALF conventional cultures (gold standard), antimicrobial susceptibility testing and processing for the Unyvero pneumonia cartridge were done. Culture and Unyvero results were compared. Results Compared to cultures of the 93 samples processed for both techniques, Unyvero correctly identified pathogens in 68 (73%) proven VAP episodes, was discordant for 25 (27%), detected no pathogen in 11 and overdetected a not otherwise found pathogen in six. For the eight remaining discordant results, the pathogen responsible for VAP was not included in the Unyvero cartridge panel or it grew at a non-significant level in culture. Amongst the 31 (33%) resistance mechanism discordances observed, 22 were resistance detection failures and 24 concerned Pseudomonas aeruginosa. Conclusions Compared to conventional microbiological cultures, the Unyvero pneumonia cartridge had poor diagnostic performance: it correctly identified pathogens and their resistance mechanisms in 73% and 67% of VAP cases, respectively. The lack of performance on the resistance mechanism was more pronounced when the pathogen detected was a Pseudomonas aeruginosa.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France. .,Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Isabelle Bonnet
- Service de Bactériologie-Hygiène, Hospital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, équipe 2, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.,Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.,Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jérôme Robert
- Service de Bactériologie-Hygiène, Hospital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, équipe 2, Paris, France
| | - Alain Combes
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.,Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alexandra Aubry
- Service de Bactériologie-Hygiène, Hospital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France.,Sorbonne Université, INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses, CIMI-Paris, équipe 2, Paris, France
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20
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François B, Laterre PF, Luyt CE, Chastre J. The challenge of ventilator-associated pneumonia diagnosis in COVID-19 patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:289. [PMID: 32503590 PMCID: PMC7273812 DOI: 10.1186/s13054-020-03013-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/20/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Bruno François
- Intensive Care Unit and Inserm CIC1435 & UMR1092, CHU Dupuytren, Limoges, France.
| | - Pierre-François Laterre
- Intensive Care Unit, St Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Charles-Edouard Luyt
- Intensive Care Unit, Hôpital La Pitié-Salpétrière, APHP-Sorbonne Université, Paris, France
| | - Jean Chastre
- Intensive Care Unit, Hôpital La Pitié-Salpétrière, APHP-Sorbonne Université, Paris, France
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21
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Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med 2020; 46:888-906. [PMID: 32157357 PMCID: PMC7095206 DOI: 10.1007/s00134-020-05980-0] [Citation(s) in RCA: 337] [Impact Index Per Article: 84.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/19/2020] [Indexed: 12/15/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.
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Affiliation(s)
- Laurent Papazian
- Médecine Intensive Réanimation, Hôpital Nord, Hôpitaux de Marseille, Chemin des Bourrely, 13015, Marseille, France. .,Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Groupe de recherche en Réanimation et Anesthésie de Marseille pluridisciplinaire (GRAM +), Faculté de médecine, Aix-Marseille Université, 13005, Marseille, France.
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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22
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Abstract
Ventilator-associated tracheobronchitis (VAT) might represent an intermediate process between lower respiratory tract colonization and ventilator-associated pneumonia (VAP), or even a less severe spectrum of VAP. There is an urgent need for new concepts in the arena of ventilator-associated lower respiratory tract infections. Ideally, the gold standard of care is based on prevention rather than treatment of respiratory infection. However, despite numerous and sometimes imaginative efforts to validate the benefit of these measures, most clinicians now accept that currently available measures have failed to eradicate VAP. Stopping the progression from VAT to VAP could improve patient outcomes.
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23
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Bouhemad B, Dransart-Rayé O, Mojoli F, Mongodi S. Lung ultrasound for diagnosis and monitoring of ventilator-associated pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:418. [PMID: 30581826 DOI: 10.21037/atm.2018.10.46] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ventilator-associated pneumonia (VAP) is the most frequent nosocomial infection in intensive care units (ICU) and is associated with increased mortality, use of antimicrobials, longer mechanical ventilation, and higher healthcare costs. Lung ultrasonography (LUS) can be used at the bedside and gained widespread acceptance in ICU. Although the visualization of a single LUS sign cannot be considered specific for a diagnosis, clinically-driven LUS examination in particular setting and clinical conditions allow ruling in or out quickly and accurately several causes of acute respiratory failure. This article reviews LUS signs for VAP diagnosis and summarizes the studies testing LUS for VAP diagnosis and monitoring. Many VAP occurs in already injured regions, thus presence of lobar consolidation is not enough to affirm VAP. However, a linear/arborescent air-bronchogram confirms the diagnosis of VAP with a good specificity, a normal LUS rules out the diagnosis of VAP (in experimented hands). LUS, thanks to its bedside ready availability, has the potential to become a key tool in early VAP diagnosis. LUS could ideally represent the decision-making tool for antimicrobial therapy administration in the timeframe of the technical time required for bronchoalveolar lavage analysis. A systematic approach for diagnosis and monitoring of VAP with LUS is also proposed in this review. But specific data on LUS specificity and sensitivity for the diagnosis of VAP are still lacking and should be investigated.
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Affiliation(s)
- Bélaïd Bouhemad
- Department of Anesthesiology and Intensive Care, C.H.U. Dijon, France.,Dijon and Université Bourgogne Franche-Comté, LNC UMR866, Dijon, France
| | - Ophélie Dransart-Rayé
- Department of Anesthesiology and Intensive Care, C.H.U. Dijon, France.,Dijon and Université Bourgogne Franche-Comté, LNC UMR866, Dijon, France
| | - Francesco Mojoli
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy.,Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvia Mongodi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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24
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Hommelsheim C, Sichau M, Heipel R, Müller E, Gatermann S, Pfeifer M, Ewig S. Predictors of Outcomes in Patients with Prolonged Weaning with Focus on Respiratory Tract Pathogens and Infection. Respiration 2018; 97:135-144. [PMID: 30332675 DOI: 10.1159/000493430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/30/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The impact of respiratory tract pathogens and infection on outcomes in patients with prolonged weaning is largely unknown. OBJECTIVE We studied predictors of weaning outcomes (death and failure to achieve spontaneous ventilation) in a population treated during a 3.5-year period in a specialized and certified weaning centre. METHODS Patient data were retrieved retrospectively from the clinical charts. Complete datasets were available in 173 patients. The following parameters were investigated as potential predictors of both endpoints: age; comorbidities; tracheobronchial pathogens; bacteraemia, pneumonia and number of pneumonias; and number of inhouse treatment cycles (none vs. ≥1). RESULTS Tracheobronchial pathogens, pneumonia, bacteraemia and the number of antibiotic cycles all significantly increased weaning duration and hospitalisation times. Independent predictors of death were atrial fibrillation (OR 2.6, 95% CI 1.2-5.8, p = 0.02) and tracheobronchial multiresistant Pseudomonas aeruginosa (OR 3.9, 95% CI 1.4-11.0, p = 0.01). Independent predictors of failure to achieve spontaneous ventilation included chronic obstructive pulmonary disease (OR 2.8, 95% CI 1.0-7.8, p = 0.045); neuromuscular disease (OR 8.3, 95% CI 1.2-27.2, p = 0.02); tracheobronchial P. aeruginosa (OR 3.3, 95% CI 1.3-9.3, p = 0.01); Stenotrophomonas maltophilia (OR 7.9, 95% CI 1.4-51.6, p = 0.02); and pneumonia (OR 4.4, 95% CI 1.5-10.9, p = 0.003). CONCLUSIONS The impact of respiratory tract pathogens and infection on weaning outcomes was remarkable. Predictors of death and failure to achieve spontaneous ventilation differed considerably. A priority may be to investigate preventive strategies against colonisation and infection with respiratory pathogens, particularly P. aeruginosa.
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Affiliation(s)
- Catharina Hommelsheim
- Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Herne, Germany.,Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Bochum, Germany
| | - Mathias Sichau
- Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Herne, Germany.,Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Bochum, Germany
| | - Roland Heipel
- Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Herne, Germany.,Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Bochum, Germany
| | - Eckhard Müller
- Klinik für Anästhesiologie, Intensiv-, Notfall- und Schmerzmedizin, Thoraxzentrum Ruhrgebiet, Herne, Germany
| | | | - Michael Pfeifer
- Klinik für Pneumologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Santiago Ewig
- Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Herne, .,Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Bochum,
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25
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Barbier F, Bailly S, Schwebel C, Papazian L, Azoulay É, Kallel H, Siami S, Argaud L, Marcotte G, Misset B, Reignier J, Darmon M, Zahar JR, Goldgran-Toledano D, de Montmollin É, Souweine B, Mourvillier B, Timsit JF. Infection-related ventilator-associated complications in ICU patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae. Intensive Care Med 2018; 44:616-626. [PMID: 29663045 DOI: 10.1007/s00134-018-5154-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/27/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE To investigate the clinical significance of infection-related ventilator-associated complications (IVAC) and their impact on carbapenem consumption in mechanically ventilated (MV) patients colonised with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE). METHODS Inception cohort study from the French prospective multicenter OUTCOMEREA database (17 ICUs, 1997-2015) including all ESBLE carriers (systematic rectal swabbing at admission then weekly and/or urinary or superficial surgical site colonisation) with MV duration > 48 h and ≥ 1 episode of IVAC after carriage documentation. All ICU-acquired infections were microbiologically documented. RESULTS The 318 enrolled ESBLE carriers (median age 68 years; males 67%; medical admission 68%; imported carriage 53%) experienced a total of 576 IVAC comprising 361 episodes (63%) without documented infection, 124 (21%) related to infections other than ventilator-associated pneumonia (VAP), 73 (13%) related to non-ESBLE VAP and 18 (3%) related to ESBLE VAP. Overall, ESBLE infections accounted for only 43 episodes (7%). Carbapenem exposure within the preceding 3 days was the sole independent predictor of ESBLE infection as the causative event of IVAC, with a protective effect (adjusted odds ratio 0.2, 95% confidence interval 0.05-0.6; P < 0.01). Carbapenems were initiated in 9% of IVAC without infection, 15% of IVAC related to non-VAP infections, 42% of IVAC related to non-ESBLE VAP, and 56% of IVAC related to ESBLE VAP (ESBLE VAP versus non-ESBLE VAP: P = 0.43). CONCLUSIONS IVAC in ESBLE carriers mostly reflect noninfectious events but act as a strong driver of empirical carbapenem consumption. ESBLE infections are scarce yet hard to predict, strengthening the need for novel diagnostic approaches and carbapenem-sparing alternatives.
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Affiliation(s)
| | - Sébastien Bailly
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, Paris Diderot, Sorbonne Paris Cité University, Paris, France
| | - Carole Schwebel
- Medical ICU, Albert Michallon University Hospital, Grenoble, France
| | - Laurent Papazian
- Respiratory and Infectious Diseases ICU, North Hospital, Marseille, France
| | - Élie Azoulay
- Medical ICU, Saint-Louis Hospital, APHP, Paris, France
| | - Hatem Kallel
- Medical Surgical ICU, Andrée Rosemon Hospital, Cayenne, France
| | - Shidasp Siami
- Medical Surgical ICU, Corbeil-Essone Hospital, Corbeil-Essone, France
| | - Laurent Argaud
- Medical ICU, Edouard-Herriot University Hospital, Lyon, France
| | | | - Benoît Misset
- Medical ICU, Charles Nicolle University Hospital, Rouen, France
| | - Jean Reignier
- Medical ICU, Hôtel-Dieu University Hospital, Nantes, France
| | | | | | | | | | | | - Bruno Mourvillier
- Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France
| | - Jean-François Timsit
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, Paris Diderot, Sorbonne Paris Cité University, Paris, France. .,Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, APHP, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
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26
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Harward M, Smith A, Aitken LM. Inconsistent VAP definitions raise questions of usefulness. Aust Crit Care 2018; 31:54-55. [DOI: 10.1016/j.aucc.2017.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 11/25/2022] Open
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27
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Luyt CE, Rice TW. Co-infection in severe influenza: a new epidemiology? Intensive Care Med 2016; 43:107-109. [PMID: 27798740 PMCID: PMC7095403 DOI: 10.1007/s00134-016-4597-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Groupe Hospitalier La Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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28
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Is there a continuum between ventilator-associated tracheobronchitis and ventilator-associated pneumonia? Intensive Care Med 2016; 42:1190-2. [PMID: 27080532 DOI: 10.1007/s00134-016-4283-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2016] [Indexed: 10/22/2022]
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