Multiple arterial thromboses in a patient with primary antiphospholipid syndrome receiving a bromocriptine therapy

We report a patient with a previously known primary antiphospholipid syndrome who had life threatening multiple arterial thromboses. The patient experienced a myocardial infarction with intraventricular thrombi under bromocriptine therapy in the puerperium, despite prophylactic low molecular weight heparin therapy. In this patient, no microvascular involvement was identified, thus eliminating the diagnosis of catastrophic antiphospholipid syndrome. Arterial thromboses may be explained by peripheral emboli originating from the intraventricular thrombi. This case emphasizes the necessity of a careful evaluation of the risk-benefit balance of bromocriptine therapy in patients with arterial risk factors. It also emphasizes the need for a correct diagnosis of catastrophic antiphospholipid syndrome allowing to limit the prescription of aggressive therapies.

Estimating attributable mortality due to nosocomial infections acquired in intensive care units

BACKGROUND

The strength of the association between intensive care unit (ICU)-acquired nosocomial infections (NIs) and mortality might differ according to the methodological approach taken.

OBJECTIVE

To assess the association between ICU-acquired NIs and mortality using the concept of population-attributable fraction (PAF) for patient deaths caused by ICU-acquired NIs in a large cohort of critically ill patients.

SETTING

Eleven ICUs of a French university hospital.

DESIGN

We analyzed surveillance data on ICU-acquired NIs collected prospectively during the period from 1995 through 2003. The primary outcome was mortality from ICU-acquired NI stratified by site of infection. A matched-pair, case-control study was performed. Each patient who died before ICU discharge was defined as a case patient, and each patient who survived to ICU discharge was defined as a control patient. The PAF was calculated after adjustment for confounders by use of conditional logistic regression analysis.

RESULTS

Among 8,068 ICU patients, a total of 1,725 deceased patients were successfully matched with 1,725 control patients. The adjusted PAF due to ICU-acquired NI for patients who died before ICU discharge was 14.6% (95% confidence interval [CI], 14.4%-14.8%). Stratified by the type of infection, the PAF was 6.1% (95% CI, 5.7%-6.5%) for pulmonary infection, 3.2% (95% CI, 2.8%-3.5%) for central venous catheter infection, 1.7% (95% CI, 0.9%-2.5%) for bloodstream infection, and 0.0% (95% CI, -0.4% to 0.4%) for urinary tract infection.

CONCLUSIONS

ICU-acquired NI had an important effect on mortality. However, the statistical association between ICU-acquired NI and mortality tended to be less pronounced in findings based on the PAF than in study findings based on estimates of relative risk. Therefore, the choice of methods does matter when the burden of NI needs to be assessed.

Necrotizing gastritis due to Bacillus cereus in an immunocompromised patient

Bacillus cereus is increasingly being acknowledged as a serious bacterial pathogen in immunocompromised patients. We present a case of acute necrotizing gastritis caused by B. cereus in a 37-year-old woman with acute myeloblastic leukemia, who recovered following total parenteral nutrition and treatment with imipenem and vancomycin. B. cereus was isolated from gastric mucosa and blood cultures. Up to now, no case of acute necrotizing gastritis due to this organism has been reported.

Detrimental role of delayed antibiotic administration and penicillin-nonsusceptible strains in adult intensive care unit patients with pneumococcal meningitis: the PNEUMOREA prospective multicenter study

OBJECTIVE

To identify factors associated with mortality and morbidity among adults admitted to intensive care units (ICUs) for pneumococcal meningitis, particularly the impact of delayed antibiotic administration.

DESIGN

We conducted a prospective, multicenter, observational study of 156 consecutive adults hospitalized for pneumococcal meningitis. We analyzed parameters associated with 3-month survival.

SETTING

Fifty-six medical and medical-surgical ICUs in France.

INTERVENTION

None.

RESULTS

Of the 148 strains isolated, 56 (38%) were nonsusceptible to penicillin G. At 3 months after ICU admission, the mortality rate was 33% (51/156), and 34% of survivors (36/105) had neurologic sequelae. Multivariate analysis identified three variables as independently associated with 3-month mortality: Simplified Acute Physiology Score II (odds ration [OR], 1.12; 95% confidence interval [CI], 1.072-1.153; p = .002); isolation of a nonsusceptible strain (OR, 6.83; 95% CI, 2.94-20.8; p < 10(-4)), and an interval of >3 hrs between hospital admission and administration of antibiotics (OR, 14.12; 95% CI, 3.93-50.9; p < 10(-4)). In contrast, a cerebrospinal fluid leukocyte count >10(3) cells/microL had a protective effect (OR, 0.30; 95% CI, 0.10-0.944; p = 0.04).

CONCLUSIONS

Independent of severity at the time of ICU admission, isolation of penicillin-nonsusceptible strains and a delay in antibiotic treatment following admission were predictors of mortality among patients with pneumococcal meningitis.

Association d'une encéphalite à herpès virus 6 et d'un syndrome d'hypersensibilité médicamenteuse au triméthoprime-sulfaméthoxazole

INTRODUCTION

Human herpesvirus 6 (HHV-6), the causative agent of the common exanthem subitum, is a known cause of central nervous system infection in immunocompromised patients. It has been suggested that HHV-6 participate in the development of drug-induced hypersensitivity syndrome.

CASE REPORT

We reported a case of HHV-6 encephalitis associated with hypersensitivity syndrome induced by trimethoprim-sulfamethoxazole in a 72-year-old HIV-negative woman.

DISCUSSION

Our case confirmed that reactivation of HHV-6 infection may contribute to the development of the hypersensitivity syndrome.

Loading dose of vancomycin in critically ill patients: 15mg/kg is a better choice than 500mg

Delays in antimicrobial therapy in high-risk patients with infection may have deleterious effects on clinical outcomes. Therefore, appropriate treatment must be initiated promptly. The objective of this prospective study was to determine the better loading dose of vancomycin in critically ill patients with suspected Gram-positive infections. Two groups of patients were studied successively: Group A, loading dose of 500 mg; and Group B, loading dose of 15 mg/kg. The mean post-loading dose serum vancomycin concentration was significantly higher in Group B than in Group A (19.1 +/- 7.4 mg/L versus 10.4 +/- 2.7 mg/L; P < 0.001), without producing toxic peak levels. Clinical cure rates were significantly different for infected patients in Group B compared with Group A: 93% (14 of 15 patients) versus 56% (10 of 18 patients), respectively. However, the proportion of patients surviving to Intensive Care Unit discharge was similar. Because vancomycin is believed to achieve maximum killing at concentrations in serum of four to five times the minimum inhibitory concentration for the infecting organism, our results suggest that the 15 mg/kg loading dose should be preferred.

The relation between preprocedural C-reactive protein levels and early and late complications in patients with acute myocardial infarction undergoing interventional coronary angioplasty

BACKGROUND

Inflammation is an important feature of arteriosclerotic disease, and the vulnerability of coronary plaques in acute myocardial infarction (AMI) may be related to the levels of serum C-reactive proteins (CRP). While some risk factors for early and late complications have been suggested, an accurate and definitive preprocedural risk stratification of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is still lacking.

HYPOTHESIS

The study was undertaken to investigate whether early and late complications after PTCA could be predicted by evaluation of baseline serum CRP levels in patients with AMI.

METHODS

Levels of serum CRP were measured in a total of 230 patients with AMI undergoing PTCA and provisional stent. They were divided into two groups: Group 1 (n = 48) with elevated CRP levels (> or = 5 mg/l) and Group 2 (n = 182) with normal CRP levels (< 5 mg/l).

RESULTS

There were no significant differences in baseline clinical, angiographic, and procedural characteristics between the two groups. However, the incidence of in-hospital adverse coronary events (reinfarction, coronary reocclusion, target vessel revascularization, and death) and severe left ventricular dysfunction was significantly higher in Group 1 (18.3 vs. 6.1%, p < 0.05 and 20.9 vs. 6.1%, p < 0.05, respectively). In addition, bailout stenting was performed more frequently in Group 1 than in Group 2 (60.4 vs. 36.3%, p < 0.005). No significant late complications were noted. The serum levels of CRP were the only independent predictors of early adverse events.

CONCLUSIONS

Preprocedural serum CRP level might be considered a powerful predictor of early but not late complications in patients undergoing PTCA/stent procedures.

Fatal Microascus trigonosporus (anamorph Scopulariopsis) pneumonia in a bone marrow transplant recipient

Over the past decade, an increasing number of opportunistic mycelial fungal infections have been reported in immunocompromised patients. Presented here is the first reported case of Microascus trigonosporus pneumonia, which occurred in a 24-year-old-man with a history of allogenic bone marrow transplantation with graft-versus-host disease. Despite the administration of effective antifungal treatment, the patient died after uncontrollable respiratory failure and multiorgan failure developed. This report confirms the results of previous studies that suggested a very poor outcome for bone marrow transplant recipients with non-Aspergillus mould infections.

C-reactive protein levels and arterial abnormalities in the offspring of patients with premature myocardial infarction

AIMS

To determine whether high C-reactive protein (CRP) levels and increased intima-media thickness of the common carotid arteries are coexistent in adolescents and young adults with a family history (FH) of premature myocardial infarction (MI).

METHODS

50 healthy young subjects whose parents had had premature MI and 50 control matched subjects were enrolled in the study. CRP levels and the intima-media thickness of the distal common carotid arteries were evaluated in all subjects.

RESULTS

As compared with the control subjects, the offspring of patients with premature MI had a higher CRP concentration (mean +/- SD 8.8 +/- 2.6 versus 3.9 +/- 0.6 mg/l, p < 0.02) and greater intima-media thickness of the common carotid arteries (values for combined sides, mean +/- SD 0.48 +/- 0.02 versus 0.43 +/- 0.02 mm, p < 0.03).

CONCLUSION

High serum levels of CRP and arterial structural changes are coexistent at an early age in subjects with an FH of premature MI.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

STUDY DESIGN

Prospective, consecutive sample survey study.

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

Prospective, consecutive sample survey study.

SETTING

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

PATIENTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

OBJECTIVE

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

DESIGN

Retrospective clinical investigation.

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

TYPE OF STUDY

Prospective comparative study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Major cellulitis following percutaneous tracheostomy

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

[Cervical necrotizing fasciitis disclosing HIV infection]

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

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

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