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Martin M, Forveille S, Lascarrou JB, Seguin A, Canet E, Lemarié J, Agbakou M, Desmedt L, Blonz G, Zambon O, Corvec S, Le Thuaut A, Reignier J. Immediate vs. culture-initiated antibiotic therapy in suspected non-severe ventilator-associated pneumonia: a before-after study (DELAVAP). Ann Intensive Care 2024; 14:33. [PMID: 38411756 PMCID: PMC10897643 DOI: 10.1186/s13613-024-01243-z] [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: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the leading nosocomial infection in critical care and is associated with adverse outcomes. When VAP is suspected, starting antibiotic therapy (AT) immediately after pulmonary sampling may expose uninfected patients to unnecessary treatment, whereas waiting for bacteriological confirmation may delay AT in infected patients. As no robust data exist to choose between these strategies, the decision must balance the pre-test diagnostic probability, clinical severity, and risk of antimicrobial resistance. The objective of this study in patients with suspected non-severe VAP was to compare immediate AT started after sampling to conservative AT upon receipt of positive microbiological results. The outcomes were antibiotic sparing, AT suitability, and patient outcomes. METHODS This single-center, before-after study included consecutive patients who underwent distal respiratory sampling for a first suspected non-severe VAP episode (no shock requiring vasopressor therapy or severe acute respiratory distress syndrome). AT was started immediately after sampling in 2019 and upon culture positivity in 2022 (conservative strategy). The primary outcome was the number of days alive without AT by day 28. The secondary outcomes were mechanical ventilation duration, day-28 mortality, and AT suitability (active necessary AT or spared AT). RESULTS The immediate and conservative strategies were applied in 44 and 43 patients, respectively. Conservative and immediate AT were associated with similar days alive without AT (median [interquartile range], 18.0 [0-21.0] vs. 16.0 [0-20.0], p = 0.50) and without broad-spectrum AT (p = 0.53) by day 28. AT was more often suitable in the conservative group (88.4% vs. 63.6%, p = 0.01), in which 27.9% of patients received no AT at all. No significant differences were found for mechanical ventilation duration (median [95%CI], 9.0 [6-19] vs. 9.0 [6-24] days, p = 0.65) or day-28 mortality (hazard ratio [95%CI], 0.85 [0.4-2.0], p = 0.71). CONCLUSION In patients with suspected non-severe VAP, waiting for microbiological confirmation was not associated with antibiotic sparing, compared to immediate AT. This result may be ascribable to low statistical power. AT suitability was better with the conservative strategy. None of the safety outcomes differed between groups. These findings would seem to allow a large, randomized trial comparing immediate and conservative AT strategies.
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Affiliation(s)
- Maëlle Martin
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France.
| | - Solène Forveille
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | | | - Amélie Seguin
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Emmanuel Canet
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Jérémie Lemarié
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Maïté Agbakou
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Luc Desmedt
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Gauthier Blonz
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Olivier Zambon
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Stéphane Corvec
- Nantes Université, CHU Nantes, Institut de Biologie des Hôpitaux de Nantes, Service de Bactériologie Et Des Contrôles Microbiologiques, Nantes, France
| | - Aurélie Le Thuaut
- Nantes Université, CHU Nantes, Plateforme de méthodologie et biostatistique, Direction de la recherche et de l'innovation, Nantes, France
| | - Jean Reignier
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Movement - Interactions - Performance, MIP, UR 4334, Nantes, France
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2
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Martin-Loeches I, Povoa P, Nseir S. Ventilator associated tracheobronchitis and pneumonia: one infection with two faces. Intensive Care Med 2023; 49:996-999. [PMID: 37160828 PMCID: PMC10425498 DOI: 10.1007/s00134-023-07086-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/21/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), Leinster, D08 NHY1, Dublin, Ireland.
- University of Barcelona, Hospital Clinic of Barcelona, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), CIBERes, Barcelona, Spain.
- St. James's Hospital, St. James Street, Dublin 8, Dublin, Ireland.
| | - Pedro Povoa
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
- Department of Critical Care Medicine, Hospital de São Francisco Xavier, CHLO, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal
| | - Saad Nseir
- Médecine Intensive Réanimation, CHU de Lille, 59000, Lille, France
- Inserm U1285, Université de Lille, CNRS, UMR 8576-UGSF, 59000, Lille, France
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3
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Le Pape M, Besnard C, Acatrinei C, Guinard J, Boutrot M, Genève C, Boulain T, Barbier F. Clinical impact of ventilator-associated pneumonia in patients with the acute respiratory distress syndrome: a retrospective cohort study. Ann Intensive Care 2022; 12:24. [PMID: 35290537 PMCID: PMC8922395 DOI: 10.1186/s13613-022-00998-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/27/2022] [Indexed: 12/15/2022] Open
Abstract
Background The clinical impact and outcomes of ventilator-associated pneumonia (VAP) have been scarcely investigated in patients with the acute respiratory distress syndrome (ARDS). Methods Patients admitted over an 18-month period in two intensive care units (ICU) of a university-affiliated hospital and meeting the Berlin criteria for ARDS were retrospectively included. The association between VAP and the probability of death at day 90 (primary endpoint) was appraised through a Cox proportional hazards model handling VAP as a delay entry variable. Secondary endpoints included (i) potential changes in the PaO2/FiO2 ratio and SOFA score values around VAP (linear mixed modelling), and (ii) mechanical ventilation (MV) duration, numbers of ventilator- and vasopressor-free days at day 28, and length of stay (LOS) in patients with and without VAP (median or absolute risk difference calculation). Subgroup analyses were performed in patients with COVID-19-related ARDS and those with ARDS from other causes. Results Among the 336 included patients (101 with COVID-19 and 235 with other ARDS), 176 (52.4%) experienced a first VAP. VAP induced a transient and moderate decline in the PaO2/FiO2 ratio without increase in SOFA score values. VAP was associated with less ventilator-free days (median difference and 95% CI, − 19 [− 20; − 13.5] days) and vasopressor-free days (− 5 [− 9; − 2] days) at day 28, and longer ICU (+ 13 [+ 9; + 15] days) and hospital (+ 11.5 [+ 7.5; + 17.5] days) LOS. These effects were observed in both subgroups. Overall day-90 mortality rates were 35.8% and 30.0% in patients with and without VAP, respectively (P = 0.30). In the whole cohort, VAP (adjusted HR 3.16, 95% CI 2.04–4.89, P < 0.0001), the SAPS-2 value at admission, chronic renal disease and an admission for cardiac arrest predicted death at day 90, while the COVID-19 status had no independent impact. When analysed separately, VAP predicted death in non-COVID-19 patients (aHR 3.43, 95% CI 2.11–5.58, P < 0.0001) but not in those with COVID-19 (aHR 1.19, 95% CI 0.32–4.49, P = 0.80). Conclusions VAP is an independent predictor of 90-day mortality in ARDS patients. This condition exerts a limited impact on oxygenation but correlates with extended MV duration, vasoactive support, and LOS. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00998-7.
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Affiliation(s)
- Marc Le Pape
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France.,Réanimation Chirurgicale, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Céline Besnard
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - Camelia Acatrinei
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - Jérôme Guinard
- Laboratoire de Bactériologie, Pôle de Biopathologies, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Maxime Boutrot
- Réanimation Chirurgicale, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Claire Genève
- Réanimation Chirurgicale, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Thierry Boulain
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France
| | - François Barbier
- Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de l'Hôpital, 45100, Orléans, France. .,Centre d'Étude des Pathologies Respiratoires (CEPR), INSERM U1100, Université de Tours, Tours, France.
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Wicky PH, Martin-Loeches I, Timsit JF. "HAP and VAP after Guidelines". Semin Respir Crit Care Med 2022; 43:248-254. [PMID: 35042265 DOI: 10.1055/s-0041-1740246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.
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Affiliation(s)
- Paul-Henri Wicky
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
| | - Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland.,Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France.,UMR 1137, IAME, Université Paris Diderot, Paris, France
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ICU-Acquired Pneumonia Is Associated with Poor Health Post-COVID-19 Syndrome. J Clin Med 2021; 11:jcm11010224. [PMID: 35011967 PMCID: PMC8746263 DOI: 10.3390/jcm11010224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 01/08/2023] Open
Abstract
Background. Some patients previously presenting with COVID-19 have been reported to develop persistent COVID-19 symptoms. While this information has been adequately recognised and extensively published with respect to non-critically ill patients, less is known about the incidence and factors associated with the characteristics of persistent COVID-19. On the other hand, these patients very often have intensive care unit-acquired pneumonia (ICUAP). A second infectious hit after COVID increases the length of ICU stay and mechanical ventilation and could have an influence on poor health post-COVID 19 syndrome in ICU-discharged patients. Methods: This prospective, multicentre, and observational study was carrid out across 40 selected ICUs in Spain. Consecutive patients with COVID-19 requiring ICU admission were recruited and evaluated three months after hospital discharge. Results: A total of 1255 ICU patients were scheduled to be followed up at 3 months; however, the final cohort comprised 991 (78.9%) patients. A total of 315 patients developed ICUAP (97% of them had ventilated ICUAP). Patients requiring invasive mechanical ventilation had more persistent post-COVID-19 symptoms than those who did not require mechanical ventilation. Female sex, duration of ICU stay, development of ICUAP, and ARDS were independent factors for persistent poor health post-COVID-19. Conclusions: Persistent post-COVID-19 symptoms occurred in more than two-thirds of patients. Female sex, duration of ICU stay, development of ICUAP, and ARDS all comprised independent factors for persistent poor health post-COVID-19. Prevention of ICUAP could have beneficial effects in poor health post-COVID-19.
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Garduno A, Martín-Loeches I. Efficacy and appropriateness of novel antibiotics in response to antimicrobial-resistant Gram-negative bacteria in patients with sepsis in the ICU. Expert Rev Anti Infect Ther 2021; 20:513-531. [PMID: 34727820 DOI: 10.1080/14787210.2022.1999804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There is an ever-increasing range of antibiotic-resistant pathogens that have led to higher community-acquired infections, and substantial mortality rates in critically ill patients. AREAS COVERED We have critically appraised available evidence through a structured literature review, investigating effective empiric antibiotic administration and appropriateness on outcomes of critically ill patients with an increased risk of developing resistant pathogens. The use of new antibiotics should be determined based on relevant knowledge of their spectrum and properties to provide effective mode of action for critically ill patients. EXPERT OPINION Restricting severely ill patients access to new broad-spectrum empirical drugs is not the answer. Rather there should be a focus on identifying host response to infection to differentiate between colonization or contamination and true infection, and the sensitivity to antibiotics used in the intensive care unit (ICU). Management relies on adequate antibiotic administration, the ability to monitor response, and facilitate the cessation of antibiotic treatment. The major determinant of patient success in a patient with a severe infection is the 'right' antibiotic or complementary course of treatment. As an overarching criterion, the following 3 appropriate "Ds" should be considered: Dosing, Duration and De-escalation to empirically assess the right antibiotic optimal antimicrobial selection.
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Affiliation(s)
- Alexis Garduno
- Department of Clinical Medicine, Intensive Care Translational Research, Trinity College Dublin
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, (Ireland)
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7
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Du H, Wei L, Li W, Huang B, Liu Y, Ye X, Zhang S, Wang T, Chen Y, Chen D, Liu J. Effect of Nebulized Amphotericin B in Critically ill Patients With Respiratory Candida spp. De-colonization: A Retrospective Analysis. Front Med (Lausanne) 2021; 8:723904. [PMID: 34540870 PMCID: PMC8446355 DOI: 10.3389/fmed.2021.723904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
The potential relationship among airway Candida spp. de-colonization, nebulized amphotericin B (NAB), and occurrence of ventilator-associated pneumonia (VAP) in patients who are critically ill has not been fully investigated, especially concerning effects on survival. In this observational, retrospective, cohort study in a 22-bed central intensive care unit, we included patients aged >18 years who required mechanical ventilation (MV) for >48 h, with at least two consecutive positive Candida spp. test results. Patients were categorized into NAB and no NAB (control) groups. Propensity matching at 1:1 was performed according to strict standards, and multiple Cox proportional hazard model and multivariate analyses were performed to evaluate the effects of NAB treatment. Throughout an 8-year study period, 526 patients had received MV and had positive respiratory tract Candida spp. cultures. Of these, we included 275 patients and excluded 251 patients. In total, we successfully matched 110 patients from the two groups (each group, n = 55; total population median age, 64 years; Acute Physiology and Chronic Health Evaluation II [APACHE II] score, 25.5; sequential organ failure assessment score, 9). The Candida spp. de-colonization rate was 69.1% in patients treated with NAB. VAP incidence did not differ significantly between the NAB (10.91%) and control (16.36%) groups (P = 0.405). Pseudomonas aeruginosa-related VAP rates differed significantly between the NAB (10.91%) and control (25.45%) groups (P = 0.048). Five (9.1%) patients in the NAB group died during hospitalization compared with 17 (30.9%) controls (P = 0.014). At 28 days, 9 (16.4%) and 16 (29.1%) deaths occurred in the NAB and control groups, respectively, (P = 0.088). The cumulative 90-day mortality rate differed significantly between the two groups (23.6 vs. 43.6%, P = 0.015). Multivariate logistic regression analyses indicated a decreased 90-day mortality in the NAB group (adjusted odds ratio 0.413; 95% confidence interval 0.210–0.812; P = 0.01). In subgroup analyses, the NAB-associated decreased risk of death at 90 days was consistent across subgroups of patients with a Candida score of 2, younger age (<64 years), a higher APACHE II score (≥25), fewer Candida sites (<2), or MV at admission. NAB treatment contributed to Candida spp. airway de-colonization, was associated with a reduced risk of P. aeruginosa-related VAP, and improved 90-day mortality in patients critically ill with Candida spp. tracheobronchial colonization who had received MV for >2 days. NAB may be an alternative treatment option for critically ill patients with VAP.
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Affiliation(s)
- Hangxiang Du
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Limin Wei
- Department of Women Health Care, Maternal and Children Healthcare Hospital of Jiading District, Shanghai, China
| | - Wenzhe Li
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bixia Huang
- Department of Intensive Care Medicine, Xinchang Hospital of Traditional Chinese Medicine, Shaoxing, China
| | - Yongan Liu
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Sheng Zhang
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yizhu Chen
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dechang Chen
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiao Liu
- Department of Intensive Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Nseir S, Martin-Loeches I, Povoa P, Metzelard M, Du Cheyron D, Lambiotte F, Tamion F, Labruyere M, Makris D, Boulle Geronimi C, Pinetonde Chambrun M, Nyunga M, Pouly O, Mégarbane B, Saade A, Gomà G, Magira E, Llitjos JF, Torres A, Ioannidou I, Pierre A, Coelho L, Reignier J, Garot D, Kreitmann L, Baudel JL, Voiriot G, Contou D, Beurton A, Asfar P, Boyer A, Thille AW, Mekontso-Dessap A, Tsolaki V, Vinsonneau C, Floch PE, Le Guennec L, Ceccato A, Artigas A, Bouchereau M, Labreuche J, Duhamel A, Rouzé A. Relationship between ventilator-associated pneumonia and mortality in COVID-19 patients: a planned ancillary analysis of the coVAPid cohort. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:177. [PMID: 34034777 PMCID: PMC8146175 DOI: 10.1186/s13054-021-03588-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022]
Abstract
Background Patients with SARS-CoV-2 infection are at higher risk for ventilator-associated pneumonia (VAP). No study has evaluated the relationship between VAP and mortality in this population, or compared this relationship between SARS-CoV-2 patients and other populations. The main objective of our study was to determine the relationship between VAP and mortality in SARS-CoV-2 patients. Methods Planned ancillary analysis of a multicenter retrospective European cohort. VAP was diagnosed using clinical, radiological and quantitative microbiological criteria. Univariable and multivariable marginal Cox’s regression models, with cause-specific hazard for duration of mechanical ventilation and ICU stay, were used to compare outcomes between study groups. Extubation, and ICU discharge alive were considered as events of interest, and mortality as competing event.
Findings Of 1576 included patients, 568 were SARS-CoV-2 pneumonia, 482 influenza pneumonia, and 526 no evidence of viral infection at ICU admission. VAP was associated with significantly higher risk for 28-day mortality in SARS-CoV-2 group (adjusted HR 1.65 (95% CI 1.11–2.46), p = 0.013), but not in influenza (1.74 (0.99–3.06), p = 0.052), or no viral infection groups (1.13 (0.68–1.86), p = 0.63). VAP was associated with significantly longer duration of mechanical ventilation in the SARS-CoV-2 group, but not in the influenza or no viral infection groups. VAP was associated with significantly longer duration of ICU stay in the 3 study groups. No significant difference was found in heterogeneity of outcomes related to VAP between the 3 groups, suggesting that the impact of VAP on mortality was not different between study groups. Interpretation VAP was associated with significantly increased 28-day mortality rate in SARS-CoV-2 patients. However, SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, did not significantly modify the relationship between VAP and 28-day mortality.
Clinical trial registration The study was registered at ClinicalTrials.gov, number NCT04359693. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03588-4.
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Affiliation(s)
- Saad Nseir
- Médecine Intensive-Réanimation, CHU de Lille, F-59000, Lille, France. .,Inserm U1285, CNRS, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, Univ. Lille, Lille, France.
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St. James Street, Dublin 8, Dublin, Eire, Ireland.,Hospital Clinic, IDIBAPS, Universided de Barcelona, CIBERes, Barcelona, Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, and NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | | | - Damien Du Cheyron
- Department of Medical Intensive Care, Caen University Hospital, 14000, Caen, France
| | - Fabien Lambiotte
- Service de Réanimation Polyvalente, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, Rouen University Hospital, Normandie Université, UNIROUEN, Inserm U1096, FHU-REMOD-VHF, 76000, Rouen, France
| | - Marie Labruyere
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Demosthenes Makris
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly, 41110, Biopolis Larissa, Greece
| | - Claire Boulle Geronimi
- Service de Réanimation Et de Soins Intensifs, Centre Hospitalier de Douai, Route de Cambrai, Douai, France
| | - Marc Pinetonde Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | | | - Olivier Pouly
- Médecine Intensive Réanimation, Hôpital Saint Philibert GHICL, Université Catholique, Lille, France
| | - Bruno Mégarbane
- Réanimation Médicale Et Toxicologique, Hôpital Lariboisière, Université de Paris, INSERM UMRS-1144, Paris, France
| | - Anastasia Saade
- Service de Médecine Intensive Et Réanimation, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Gemma Gomà
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - Eleni Magira
- 1St Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos Hospital, Athens, Greece
| | - Jean-François Llitjos
- Medical Intensive Care Unit, Cochin Hospital, AP-HP. Centre, Université de Paris, Paris, France
| | - Antoni Torres
- Department of Pulmonology, Hospital Clinic Barcelona, University of Barcelona, IDIBAPS, CIBERES, ICREA, Barcelona, Spain
| | - Iliana Ioannidou
- 1St Department of Pulmonary Medicine and Intensive Care Unit, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Athens, Greece
| | | | - Luis Coelho
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, and NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
| | - Denis Garot
- Service de Médecine Intensive Réanimation, CHU de Tours, Hôpital Bretonneau, 2 Bd Tonnellé, 37000, Tours, France
| | - Louis Kreitmann
- Service de Médecine Intensive - Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 5, place d'Arsonval, 69437, Lyon Cedex 03, France
| | - Jean-Luc Baudel
- Service de Médecine Intensive Réanimation, AP-HP, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France
| | - Guillaume Voiriot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, Paris, France
| | - Damien Contou
- Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France
| | - Alexandra Beurton
- Service de Pneumologie, Médecine Intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation, CHU D'Angers, Université D'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Alexandre Boyer
- Intensive Care Unit, Pellegrin-Tripode Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, CIC 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Armand Mekontso-Dessap
- APHP, CHU Henri Mondor, Service de Médecine Intensive RéanimationUniversité Paris Est-Créteil, Faculté de Santé, Groupe de Recherche Clinique CARMASINSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Vassiliki Tsolaki
- Intensive Care Unit, University Hospital of Larissa, University of Thessaly, 41110, Biopolis Larissa, Greece
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Réseau de Recherche Boréal, 62408, Béthune, France
| | - Pierre-Edouard Floch
- Service de Réanimation, Hôpital Duchenne, Rue Monod, 62200, Boulogne-sur-Mer, France
| | - Loïc Le Guennec
- Sorbonne Université, AP-HP, Hôpital de La Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive Réanimation Neurologique, Paris, France
| | - Adrian Ceccato
- Intensive Care Unit, Hospital Universitari Sagrat Cor, and Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028)-Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Antonio Artigas
- Critical Care Center, Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Parc Tauli 1, 08028, Sabadell, Spain
| | | | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation Des Technologies de Santé Et Des Pratiques Médicales, 59000, Lille, France
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation Des Technologies de Santé Et Des Pratiques Médicales, 59000, Lille, France
| | - Anahita Rouzé
- Médecine Intensive-Réanimation, CHU de Lille, F-59000, Lille, France.,Inserm U1285, CNRS, UMR 8576-UGSF-Unité de Glycobiologie Structurale et Fonctionnelle, Univ. Lille, Lille, France
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9
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Abstract
PURPOSE OF REVIEW We have highlighted the recent advances in infection in neurocritical care. RECENT FINDINGS Central nervous system (CNS) infections, including meningitis, encephalitis and pyogenic brain infections represent a significant cause of ICU admissions. We underwent an extensive review of the literature over the last several years in order to summarize the most important points in the diagnosis and treatment of severe infections in neurocritical care. SUMMARY Acute brain injury triggers an inflammatory response that involves a complex interaction between innate and adaptive immunity, and there are several factors that can be implicated, such as age, genetic predisposition, the degree and mechanism of the injury, systemic and secondary injury and therapeutic interventions. Neuroinflammation is a major contributor to secondary injury. The frequent and challenging presence of fever is a common denominator amongst all neurocritical care patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Alan Blake
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
| | - Daniel Collins
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
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10
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Martin-Loeches I, Metersky M, Kalil A, Pezzani MD, Torres A. Strategies for implementation of a multidisciplinary approach to the treatment of nosocomial infections in critically ill patients. Expert Rev Anti Infect Ther 2020; 19:759-767. [PMID: 33249874 DOI: 10.1080/14787210.2021.1857730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Intensive Care Units (ICU) are among the hospital wards exhibiting the highest prevalence of antimicrobial resistance (AMR), and resulting impact on patient outcomes. Antimicrobial resistance surveillance and antimicrobial stewardship (AMS) programs play a pivotal role in promoting interventions tailored to optimize infection diagnosis and treatment in the final attempt to limit unnecessary antimicrobial use and development of resistance. AREAS COVERED A narrative review of the literature was carried out to summarize the available evidence and develop a set of actions that should be considered for integration into the ICU stewardship framework. Four questions were addressed: how AMR surveillance can inform antibiotic policy in ICU; whether pharmacokinetic and pharmacodynamic (PK/PD) principles and the use of procalcitonin should be incorporated as a standard practice in ICU AMS programs to optimize antibiotic treatment and to drive antibiotic discontinuation; which criteria should drive treatment duration of ICU-associated infections. EXPERT OPINION In this review we aim to highlight that the ICU must be considered in its own right. Each ICU has its own characteristics depending on the country, on the local antibiotic resistance profile, on the patients feature and the severity of infection.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization, St James's Hospital, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad De Barcelona, CIBERES, Barcelona, Spain
| | - Mark Metersky
- Dept of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Andre Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Maria Diletta Pezzani
- Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona Italy
| | - Antoni Torres
- Hospital Clinic, IDIBAPS, Universidad De Barcelona, CIBERES, Barcelona, Spain
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11
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Plata-Menchaca EP, Ferrer R, Ruiz Rodríguez JC, Morais R, Póvoa P. Antibiotic treatment in patients with sepsis: a narrative review. Hosp Pract (1995) 2020; 50:203-213. [PMID: 32627615 DOI: 10.1080/21548331.2020.1791541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Juan Carlos Ruiz Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal
| | - Pedro Póvoa
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
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12
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Martin-Loeches I. Current Concepts in Community and Ventilator Associated Lower Respiratory Tract Infections in ICU Patients. Antibiotics (Basel) 2020; 9:antibiotics9070380. [PMID: 32635601 PMCID: PMC7399936 DOI: 10.3390/antibiotics9070380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/27/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022] Open
Abstract
It is widely known that pneumonia (either community acquired or hospital acquired, as like ventilator associated pneumonia (VAP)), is the most frequent type of severe infection and continues to pose a significant burden on healthcare services worldwide. Despite new diagnostic developments, most pneumonia cases continue to be difficult to diagnose clinically, partly due to acquired antibiotic resistance and the lack of a ‘gold standard’ method of diagnosis. In other words, the lack of a rapid, accurate diagnostic test, as well as the uncertainty of the initial etiologic diagnosis and the risk stratification, results in empirical antibiotic treatments. There are significant changes in the aetiology of patients with ventilator associated lower respiratory tract infections (VA-LRTI), which are characterised by a higher incidence of multi drug resistant organisms. Evidence suggests that when patients with VA-LRTI develop organ failure, the associated mortality can be exceptionally high with frequent complications, including acute respiratory distress syndrome, acute kidney injury, and septic shock. Appropriate antibiotic treatments must consider that the present cardiovascular failure seen in patients has a different association with the patient’s mortality. Unlike patients with less severe clinical presentations, who have a higher chance of survival when the appropriate antibiotics are administered promptly, for patients with a severe subtype of the disease, the appropriateness of antibiotic treatment will impact the patient’s outcome to a lesser extent. The present review highlights certain factors detectable at the time of admission that could indicate patients who are at a high risk of bacteraemia and who, therefore, merit more intense therapy and stratified care.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St James’s Hospital, D08 X4RX Dublin, Ireland;
- Multidisciplinary Intensive Care Research Organization (MICRO), St James’s Hospital, D08 X4RX Dublin, Ireland
- Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, CIBERes, 08036 Barcelona, Spain
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13
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Martin-Loeches I, Povoa P, Nseir S. A way towards ventilator-associated lower respiratory tract infection research. Intensive Care Med 2020; 46:1504-1505. [PMID: 32451575 PMCID: PMC7246288 DOI: 10.1007/s00134-020-06101-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James’s Hospital, St. James Street, Dublin 8, Dublin, Eire Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
- NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Saad Nseir
- Critical Care Center, CHU Lille, 59000 Lille, France
- Medicine Faculty, Lille University, 59000 Lille, France
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14
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Martin-Loeches I, Povoa P, Poulakou G. Focus on infection. Intensive Care Med 2020; 46:787-789. [PMID: 32157355 PMCID: PMC7224144 DOI: 10.1007/s00134-020-05995-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/02/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St. James Street, Dublin 8, Dublin, Ireland. .,Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain.
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Garyphallia Poulakou
- 3rd Department of Internal Medicine, Sotiria General Hospital, Medical School, National and Kapodistrian University of Athens, 152 Mesogion St., 115 27, Athens, Greece
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15
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Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
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Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
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