[Severe Legionnaire's disease revealing an invasive aspergillosis in an apparently immunocompetent patient]

INTRODUCTION

Invasive aspergillosis, a sever disease, usually occurs in immuno-depressed patients. However, it may also develop in presumably immuno-competent patients.

OBSERVATION

A 54-year-old man, smoker, was hospitalised for hypoxemia of the right lung and septic shock, rapidly requiring mechanical ventilation combined with administration of vasopressors, and followed by dialysis because of the rapid worsening of an acute kidney failure. The diagnosis of pulmonary Legionnaire's disease was made on the second day in view of the positivity of the urinary legionella antigen. The progression of the disease was marked by the discovery of a histologically documented gastric aspergillosis and three abscessed intracerebral lesions within the context of a strongly positive aspergillus antigenemia. The disease worsened and the patient died on D 17, despite the antibiotic and anti-aspergillus treatments, haemodynamic support and dialysis.

DISCUSSION

To our knowledge, the association of invasive aspergillosis and severe Legionnaire's disease has never been described in an presumably immunocompetent patient. This clinical case suggests the existence, other than the usual risk factors of invasive aspergillosis that characterise profound states of immunodepression, of more subtle alterations in the immune system that may enhance this type of infection.

A monthly systematic bacteriological report improves accuracy of identification of hospital-acquired infections in an ICU

A prospective cohort study with retrospective validation was initiated in order to assess whether a monthly bacteriological report improves the accuracy in detecting hospital-acquired infections (HAI). The setting was a 14-bed medical intensive care unit (ICU) in a 821 bed French university affiliated hospital. One thousand, six hundred and two patients were admitted during the two-year study period, the mean age was 58+/-19 years, the mean Simplified Acute Physiology Score 2 (SAPS 2) was 34+/-21, and ICU mortality was 14%. The microbiology laboratory sent monthly bacteriological reports of urine samples and central venous catheter (CVC) tips back to the intensive-care unit physician in charge of the HAI surveillance programme. This enabled a comparison to be made between prospectively and retrospectively diagnosed hospital-acquired urinary tract infections (HAUTI) and CVC-related infections (HACVCI), HAUTI were prospectively identified in 51 cases (incidence density=10.03/1,000 days) and 23 more cases were found after receiving the monthly bacteriological report (final HAUTI incidence density=14.6/1,000 days, P<0.05). HACVCI were prospectively recognized in 13 cases (incidence density=4/1,000 days) and eight more cases were discovered (final HACVCI incidence density=6.52/1,000 days,P >0.1). All retrospectively diagnosed HAI occurred during the last 48 h of the patients' ICU stay. We conclude that the routine HAI surveillance programme is reliable, except for the last 48 h in the ICU. The monthly bacteriological report improved the accuracy of the HAI reporting rate.

Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion?

We evaluated ultrasonic examination as a diagnostic tool for catheter misplacement and pneumothorax after central venous catheter insertion. Physicians in the intensive care unit (ICU) performed the ultrasonic examinations, and the results were compared with those of chest radiography. Eighty-five central venous catheters (70 subclavian and 15 internal jugular) were inserted into 81 patients; 10 misplacements and one pneumothorax occurred. Ultrasonic examination feasibility was 99.6%. The only pneumothorax and all misplacements except one were diagnosed by ultrasound. Taking into consideration misplacements and pneumothorax research, ultrasonic examination did not give any false positive results. The mean time of the entire ultrasonic examination was 6.8 +/- 3.5 min, whereas 80.3 +/- 66.7 min were needed for the radiography (p < 0.0001). This study has suggested that ultrasonic diagnosis of catheter misplacement and pneumothorax related to central venous catheterization is a rapid and accurate method that can be easily performed by ICU physicians.

Bedside detection of retained tracheobronchial secretions in patients receiving mechanical ventilation: is it time for tracheal suctioning?

OBJECTIVE

To identify parameters that indicate retained secretions and the need for tracheal suctioning (TS) in patients receiving mechanical ventilation (MV).

DESIGN

Prospective observational study.

SETTING

A 14-bed medical ICU in a 946-bed university hospital.

PATIENTS

Sixty-six consecutive patients receiving MV.

INTERVENTIONS

Two successive tracheal suctions, TS1 and TS2, performed at a 2-h interval as usual patient care. Retained secretions were considered significant if the volume of secretions removed by TS2 was > 0.5 mL.

MEASUREMENTS AND RESULTS

Variations between TS1 and TS2 of pulse oximetric saturation (SpO(2)), peak inspiratory pressure (Ppeak), tidal volume (VT), and Ramsay score were compared between patients with TS2 < or = 0.5 mL (group 1; n = 27) and patients with TS2 > 0.5 mL (group 2; n = 39). The presence of a sawtooth pattern on flow-volume loop displayed on the monitor screen of the ventilator and of respiratory sounds heard over the trachea before TS2 were compared between the two groups. Variations of Ppeak, VT, SpO(2), and Ramsay score between TS1 and TS2 did not differ between the two groups. However, group 2 had a sawtooth pattern (82% vs 29.6%; p = 0.0001) and respiratory sounds (66.6% vs. 25.9%; p = 0. 001) more frequently than group 1 before TS2. For the sawtooth pattern, the likelihood ratio (LR) of a positive test was 2.70 and the LR of a negative test was 0.25, while for respiratory sounds it was 2.50 and 0.45, respectively. When the presence of a sawtooth pattern and of respiratory sounds was combined, the LR of a positive test rose to 14.7 and the LR of a negative test was 0.42.

CONCLUSIONS

A sawtooth pattern and/or respiratory sounds over the trachea are good indicators of retained secretions in patients receiving MV and may indicate the need for TS. Conversely, the absence of a sawtooth pattern may rule out retained secretions.

Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit

We investigated whether rubbing with an alcohol solution increases compliance with hand disinfection in a medical intensive care unit (MICU). During a first period (P1), hand disinfection was achieved only through conventional washing, whereas during a second period (P2), hand disinfection could be achieved either through conventional washing or rubbing with an alcohol solution. There were 621 opportunities for hand disinfection during P1 and 905 opportunities during P2. General compliance during P1 was 42.4%, and reached 60.9% during P2 (p < 0.001). This improvement was observed among nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37. 2% versus 55.5%, p < 0.001), and residents (46.9% versus 59.1%, p = 0.03). Acceptability and tolerance were evaluated through the answers to an anonymous questionnaire distributed to all 53 health care workers in the MICU. Rubbing with alcohol solution was an easy procedure (100% of responses) and induced mild side effects in less than 10% of respondents. In a complementary study conducted 3 mo after the first one, compliance remained better than during P1 (51. 3% versus 42.4%, p = 0.007). These findings suggest that rubbing with alcohol solution increases compliance with hand disinfection, and that it could be proposed as an alternative to conventional handwashing in the MICU.

Prolonged sedation requiring mechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome

We report the cases of two patients who developed prolonged sedation after routine doses of clorazepam for alcohol withdrawal syndrome. They required prolonged mechanical ventilation (10 days for both patients) followed by continuous flumazenil infusion (16 days for one patient and 3 days for the other) to avoid reintubation. In the two patients, nordazepam accumulation (main active metabolite of clorazepam) was demonstrated as the cause of the coma. This accumulation could be attributed, in one case, to impaired hepatic cytochrome P 450 3A4 activity. Caution is required when prescribing benzodiazepines to alcoholic patients and the use of benzodiazepine which do not undergo hepatic oxidation by cytochrome P 450 such as oxazepam or lorazepam is suggested.