Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial

BACKGROUND

Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation.

METHODS

PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406.

FINDINGS

From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone.

INTERPRETATION

In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation.

FUNDING

French Ministry of Social Affairs and Health.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Impact of Radial Arterial Location on Catheter Lifetime in ICU Surgical Intensive Care

The use of arterial catheters is frequent in intensive care for hemodynamic monitoring of patients and for blood sampling, but they are often removed because of dysfunction. The primary objective is to compare the prevalence of radial arterial catheter dysfunction according to location in relation to the radiocarpal joint in intensive care patients.

DESIGN

Prospective randomized, controlled, single-center study.

SETTING

The surgical ICU of the university hospital of Poitiers in France.

PATIENTS

From January 2016 to April 2017, all patients over 18 years old admitted to the surgical ICU and requiring an arterial catheter were included.

INTERVENTIONS

Randomization into two groups: catheter placed near the wrist (within 4 cm of the radiocarpal joint) and catheter placed away the wrist. The primary endpoint was the prevalence of dysfunction. We also compared the prevalence of infection and colonization.

MEASUREMENTS AND MAIN RESULTS

One hundred seven catheters were analyzed (14 failed placements with no difference between the two groups, and 16 catheters excluded for missing data), with 58 catheters in near the wrist group and 49 in away the wrist group. We did not find any significant difference in the number of catheter dysfunctions between the two groups (p = 0.56). The prevalence density of catheter dysfunction was 30.5 of 1,000 catheter days for near the wrist group versus 26.7 of 1,000 catheter days for away the wrist group. However, we observed a significant difference in terms of catheter-related infection in favor of away the wrist group (p = 0.04). In addition, distal positioning of the catheter was judged easier by the physicians.

CONCLUSIONS

The distal or proximal position of the arterial catheter in the radial position has no influence on the occurrence of dysfunction. However, there may be an association with the prevalence of infections.

Population pharmacokinetic/pharmacodynamic study suggests continuous infusion of ceftaroline daily dose in ventilated critical care patients with early-onset pneumonia and augmented renal clearance

OBJECTIVES

Ceftaroline could be suitable to treat early-onset ventilator-associated pneumonia (VAP) because of its antibacterial spectrum. However, augmented renal clearance (ARC) is frequent in ICU patients and may affect ceftaroline pharmacokinetics and efficacy. The objective of the study was to explore the impact of ARC on ceftaroline pharmacokinetics and evaluate whether the currently recommended dosing regimen (600 mg every 12 h) is appropriate to treat VAP in ICU patients.

METHODS

A population pharmacokinetic model was developed using pharmacokinetic data from 18 patients with measured creatinine clearance (CLCR) ranging between 83 and 309 mL/min. Monte Carlo simulations were conducted to determine the PTA and the cumulative fraction of response (CFR) against Streptococcus pneumoniae and MRSA for five dosing regimens. Study registered at ClinicalTrials.gov (NCT03025841).

RESULTS

Ceftaroline clearance increased non-linearly with CLCR, with lower concentrations and lower probability of reaching pharmacokinetic/pharmacodynamic targets when CLCR increases. For the currently recommended dosing regimen, the probability of having unbound ceftaroline concentrations above the MIC over the entire dose range is greater than 90% for MICs below 0.125 mg/L. Considering the distribution of MICs, this regimen would not be effective against MRSA infections (CFR between 21% and 67% depending on CLCR), but would be effective against S. pneumoniae infections (CFR >86%).

CONCLUSIONS

The recommended dosing regimen of ceftaroline seems sufficient for covering S. pneumoniae in ICU patients with ARC, but not for MRSA. Among the dosing regimens tested it appears that a constant infusion (50 mg/h) after a loading dose of 600 mg could be more appropriate for MRSA infections.

Cost-effectiveness analysis of bundled innovative devices versus standard approach in the prevention of unscheduled peripheral venous catheters removal due to complications in France

The objective of the study was to perform a cost-effectiveness analysis of bundled devices (BDs) versus standard devices (SDs) for the prevention of unscheduled peripheral venous catheter (PVC) removal due to complication from a French investigator-initiated, open-label, single center, randomized-controlled, two-by-two factorial trial (CLEAN-3 study). A 14-day time non homogeneous semi-markovian model was performed to be fitted to longitudinal individual patient data from CLEAN-3 database. This model includes five health states and eight transitional events; a base case scenario, two scenario analyses and bootstrap sensitivity analyses were performed. The cost-effectiveness criterion was the cost per patient with unscheduled PVC removal avoided. 989 adult (age≥18 years) patients were analyzed to compare the BDs group (494 patients), and the SDs group (495 patients). The assessed intervention was a combination of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes compared with the use of open catheters and three-way stopcocks for treatment administration. For the base case scenario, an unscheduled 1st PVC removal before discharge was significantly more frequent in the SDs group (235 patients (47.5%) in the SDs group and 172 patients (34.8%) in the BDs group, p = 0.00006). After adjustment for 1st catheter time, the number of patients with unscheduled PVC removal per day was of 16 (95%CI: 15; 18) patients (out of 100) in the BDs group and of 26 (95%CI: 24; 28) patients (out of 100) in the SDs group. The mean cost per patient (adjusted on catheter-time) was of €144 (95%CI: €135-€154) for patients in the SDs group versus €102 (95%CI: €95-€109) for patients in the BDs group; the mean saving per patient was of €42 (95%CI: €32-€54). As a consequence, the assessed BDs strategy was less costly and more effective than the SDs strategy. Trail registration: CLEAN-3 study is registered with ClinicalTrials.gov, NCT03757143.

Lower risk of peripheral venous catheter-related bloodstream infection by hand insertion

INTRODUCTION

Little is known about the bloodstream infection (BSI) risk associated with short-term peripheral venous catheters (PVCs) and no large study investigated the insertion site-related risk for PVC-BSI.

METHODS

We performed a cohort study at the University of Geneva Hospitals using the prospective hospital-wide BSI surveillance database. We analyzed the association between insertion site and risk of PVC-BSI on the upper extremity using univariable and multivariable marginal Cox models.

RESULTS

Between 2016 and 2020, utilization of 403'206 peripheral venous catheters were prospectively recorded in a 2000-bed hospital consortium with ten sites. Twenty-seven percent of PVC (n = 109'686) were inserted in the hand. After adjustment for confounding factors, hand insertion was associated with a decreased PVC-BSI risk (adjusted hazard ratio [HR] 0.42, 95% CI 0.18-0.98, p = 0.046) compared to more proximal insertion sites. In a sensitivity analysis for PVCs with ≥ 3 days of dwell time, we confirmed a decreased PVC-BSI risk after hand insertion (HR 0.37, 95% CI 0.15-0.93, p = 0.035).

CONCLUSION

Hand insertion should be considered for reducing PVC infections, especially for catheters with an expected dwell time of more than 2 days.

POS0538 PREDICTING VALUE OF CIRCULATING SEMAPHORIN 4A FOR RHEUMATOID ARTHRITIS PROGRESSION

Background

The lack of validated tools to predict rheumatoid arthritis (RA) disease course warrants the development of new reliable biomarkers. We have previously detected increased SEMA4A expression in endothelial cells, synovial tissue, and serum of patients with RA. In addition, SEMA4A serum levels correlated with multiple clinical, biological, and power doppler ultrasound markers of disease activity and angiogenesis (1).

Objectives

To evaluate the merit of circulating semaphorin 4A (SEMA4A) for the prediction of disease progression in RA patients.

Methods

Prospective monocentric observational study including consecutive RA patients between May 2016 and February 2018 with available SEMA4A concentrations, measured by quantitative ELISAs (Coud-Clone Corp, Katy, TX). Increased SEMA4A concentrations were defined as values >94 ng/mL, as previously reported (1). Patients were followed up on an annual basis until August 2021. Primary endpoints were the occurrence of patient-reported flares with swollen joints and the necessity to initiate or change a targeted biologic or synthetic disease-modifying anti-rheumatic drugs.

Results

A total of 101 patients (85 females, 84%) were included, with a mean age of 58±13 years and a mean disease duration of 14±11 years. During a follow-up period of 41±15 months, disease flares occurred in 38 patients and targeted therapy was added or modified in 26 patients because of insufficient disease control. Increased baseline SEMA4A levels were predictive of flares and treatment escalation (hazard ratio, HR: 2.43, 95% confidence interval, CI 1.27-4.68 and 2.73, 95%CI 1.24-5.96, respectively) (Figure 1A-B). Multivariate Cox analyses confirmed that SEMA4A was an independent predictors of flares and treatment escalation (HR: 2.12, 95%CI 1.04-4.32 and 2.71, 95%CI1.14-6.43, respectively), and revealed that DAS28-CRP and synovial hyperhemia were independent predictors of flares. Baseline age, disease duration, ACPA or RF positivity, smoking status, presence of erosions, line of targeted DMARDs, treatment with corticosteroids and CRP levels were not predictive of these outcomes. SEMA4A remained predictive of flares and treatment escalation in the 58 patients with a DAS28 <3.2 at baseline (HR: 3.68, 95%CI 1.33-10.17 and 3.50, 95%CI 1.02-12.01, respectively). Baseline SEMA4A levels also identified more active and difficult to treat patients who maintained higher mean DAS28-CRP values during the follow-up period (Figure 1C). The highest predictive value of flares and treatment escalation was obtained with the combination of increased circulating SEMA4A and/or DAS28-CRP>3.2 and/or the presence of synovial hyperemia on power-doppler ultrasound (HR:4.88, 95%CI 1.50-15.89 and 10.42, 95%CI 1.41-76.94, respectively).

Figure 1.

A-C: Predictive value of SEMA4A for the progression of rheumatoid arthritis. A, Disease flare-free survival according to circulating SEMA4A concentrations (≤ or > 94 ng/mL). B, Time to treatment escalation according to circulating SEMA4A concentrations (≤ or > 94 ng/mL). C, Course of the DAS28-CRP during the follow-up period according to baseline SEMA4A concentrations (≤ or > 94 ng/mL). All data are shown as the mean ± SEM. * p<0.05, ** p<0.01 and *** p<0.001, determined by Student’s t test.

Conclusion

Circulating SEMA4A was a robust biomarker of disease progression in this cohort, complementary of the DAS28 and synovial hyperemia on power-doppler ultrasound. These results need to be confirmed in replication cohorts.

References

[1]Avouac et al, Arthritis Rheumatol 2021

Disclosure of Interests

None declared.

Nebulized Antibiotics for Healthcare- and Ventilator-Associated Pneumonia

Global emergence of multidrug-resistant and extensive drug-resistant gram-negative bacteria has increased the risk of treatment failure, especially for healthcare- or ventilator-associated pneumonia (HAP/VAP). Nebulization of antibiotics, by providing high intrapulmonary antibiotic concentrations, represents a promising approach to optimize the treatment of HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria, while limiting systemic antibiotic exposure. Aminoglycosides and colistin methanesulfonate are the most common nebulized antibiotics. Although optimal nebulized drug dosing regimen is not clearly established, high antibiotic doses should be administered using vibrating-mesh nebulizer with optimized ventilator settings to ensure safe and effective intrapulmonary concentrations. When used preventively, nebulized antibiotics reduced the incidence of VAP without any effect on mortality. This approach is not yet recommended and large randomized controlled trials should be conducted to confirm its benefit and explore the impact on antibiotic selection pressure. Compared with high-dose intravenous administration, high-dose nebulized colistin methanesulfonate seems to be more effective and safer in the treatment of ventilator-associated tracheobronchitis and VAP caused by multidrug resistant and extensive-drug resistant gram-negative bacteria. Adjunctive nebulized aminoglycosides could increase the clinical cure rate and bacteriological eradication in patients suffering from HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria. As nebulized aminoglycosides broadly diffuse in the systemic circulation of patients with extensive bronchopneumonia, monitoring of plasma trough concentrations is recommended during the period of nebulization. Large randomized controlled trials comparing high dose of nebulized colistin methanesulfonate to high dose of intravenous colistin methanesulfonate or to intravenous new β-lactams in HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria are urgently needed.

Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial

OBJECTIVE

To assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery.

DESIGN

Phase III, randomised, double blind, placebo controlled trial.

SETTING

34 centres in France, December 2017 to March 2019.

PARTICIPANTS

1222 adults (>50 years) requiring major non-cardiac surgery with an expected duration of more than 90 minutes. The anticipated time frame for recruitment was 24 months.

INTERVENTIONS

Participants were randomised to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Randomisation was stratified on the two prespecified criteria of cancer and thoracic procedure.

MAIN OUTCOMES MEASURES

The primary outcome was a composite of postoperative complications or all cause mortality within 14 days after surgery, assessed in the modified intention-to-treat population (at least one treatment administered).

RESULTS

Of the 1222 participants who underwent randomisation, 1184 (96.9%) were included in the modified intention-to-treat population. 14 days after surgery, 101 of 595 participants (17.0%) in the dexamethasone group and 117 of 589 (19.9%) in the placebo group had complications or died (adjusted odds ratio 0.81, 95% confidence interval 0.60 to 1.08; P=0.15). In the stratum of participants who underwent non-thoracic surgery (n=1038), the primary outcome occurred in 69 of 520 participants (13.3%) in the dexamethasone group and 93 of 518 (18%) in the placebo group (adjusted odds ratio 0.70, 0.50 to 0.99). Adverse events were reported in 288 of 613 participants (47.0%) in the dexamethasone group and 296 of 609 (48.6%) in the placebo group (P=0.46).

CONCLUSIONS

Dexamethasone was not found to significantly reduce the incidence of complications and death in patients 14 days after major non-cardiac surgery. The 95% confidence interval for the main result was, however, wide and suggests the possibility of important clinical effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03218553.

AB0665 SWITCHING INTRAVENOUS ABATACEPT AND TOCILIZUMAB TO SUBCUTANEOUS INJECTIONS DURING THE COVID-19 PANDEMIC: A FRENCH EXPERIENCE

Background:

The COVID-19 pandemic requires measures to reduce patient exposure to the risk of contamination, in particular by limiting hospital admissions and promoting lockdown. In order to respond to these healthcare measures, patients were offered to replace intravenous infusions (IV) of abatacept (ABT) and tocilizumab (TCZ) to subcutaneous injections (SC).

Objectives:

To assess the outcome of patients who switched from IV ABT or TCZ to SC during the COVID-19 pandemic.

Methods:

A survey was conducted in December 2020 in partnership with the national AFP-RIC patient association to assess the outcome and satisfaction of patients who switched from ABT or TCZ IV to SC during the first wave of COVID-19 pandemic.

We also analysed the outcome of patients who switched from IV ABT or TCZ to SC in the rheumatology department of Cochin Hospital during the lockdown in April/may 2020. Articular activity parameters (swollen joint count, pain joint count, visual analogic pain scale, CRP, DAS-28 activity score) were assessed at medical visits before and 6 months after switching from IV to SC.

The data collected from the AFP-RIC patient association and the rheumatology department of Cochin Hospital were then aggregated and analyzed by Chi-square and Wilcoxon tests.

Results:

81 patients responded to the survey carried out by AFP-RIC patient association, including 29 treated with IV ABT (n=15, 52%) or TCZ (n=14, 48%). 17/29 (59%) were offered to switch from IV to SC, 14/17 patients (82%) accepted and 7 patients were still receiving ABT or TCZ SC injections in December 2020. In the rheumatology department of Cochin hospital, 71 patients were scheduled in April/May 2020 to receive IV ABT or TCZ, and 27 (38%) switched to SC. After 6 months, 19 patients (70%) had maintained SC injections, were satisfied with this injection route of administration and their articular activity parameters were unchanged (Table 1).

Table 1.

Course of Disease parameters evaluated in the 19 patients who maintained abatacept or tocilizumab SC injections in the Rheumatology department of Cochin Hospital

Parameter, mean(SD)Inclusion visitSwitch to SC(n=19)6 month visit (n=19)P-valueDAS282.3 (1.2)2.3 (0.7)0.62Tender joint count2.5 (3.5)1.3 (1.7)0.49Swollen joint count1.3 (2.5)0.9 (0.6)0.35Patient Global Health (cm)3.2 (1.9)2.6 (1.8)0.60CRP (mg/L)3.2 (4.1)5.2 (4.9)0.56

CRP: C-Reactive Protein, SD: Standard Deviation

The combined analysis of these two populations included 41 patients (33 rheumatoid arthritis, RA, 7 juvenile idiopathic arthritis, JIA and 1 polymyalgia rheumatica) who switched to SC ABT or TCZ. 26/41 (63.5%) patients maintained SC injections and IV was re-established in 15/41 (36.5%). Reasons for returning to IV were poor tolerance of SC injections (n=6, 40%), worsening symptoms (n=11, 73%), patient preference to see a rheumatologist in hospital (n=10, 67%) and the high number of SC injections (n=2, 13%). The proportion of patients returning to IV was higher in RA patients compared to patients with JIA (42% vs. 14%, p = 0.08). Age and disease duration were not significantly different between patients who maintained SC injections and those who returned to IV (respectively p=0.97 and p=0.63).

Conclusion:

Our study suggests that switching from IV ABT or TCZ to SC is an acceptable procedure during the COVID-19 pandemic, especially for patients with JIA.

Acknowledgements:

Association AFP-RIC (Angélique Hochedé, Cyrielle Beller, Sandrine Rollot) and the members of the association for their help in the conduction of the survey

Disclosure of Interests:

None declared.

Observance of preoperative clear fluid fasting in pediatric anesthesia: oral and written information versus text message information. A before-and-after study

INTRODUCTION

Prolonged fasting before surgery is common in pediatrics. In the literature, it is responsible for hypotension, irritability and postoperative nausea and vomiting. Despite clear instructions given during the preanesthetic consultation, fasting rules are respected in only 30%-40% of cases. We aimed to evaluate the benefit of sending a text message the day before surgery to improve the parents' observance of fasting rules.

METHODS

We conducted a before-and-after study at the University Hospital of Poitiers. From August to October 2018, 172 parents of children under 15 years of age scheduled for all types of surgery were enrolled into two groups according to the period: the control group with parents receiving information on preoperative fasting rules during the preanesthetic consultation several days before surgery, and the text message group, receiving the same information during consultation plus a text message the day before the surgery.

RESULTS

There was a difference in observance of clear fluid fasting instructions (between 2 and 3 h before the admission at hospital) in favor of the text message group 33% versus 92% OR 29.2 (10.9-95.2) p < 0.001, and in average fasting time for clear fluids 8.7 h ± 4.8 h vs. 4.3 h ± 2.4 h (p < 0.001).

CONCLUSION

Sending of a reminder text message to the parents the day before the surgery resulted in a significant increase in observance of fasting rules in children undergoing scheduled surgery.

Continuous Pneumatic Regulation of Tracheal Cuff Pressure to Decrease Ventilator-associated Pneumonia in Trauma Patients Who Were Mechanically Ventilated: The AGATE Multicenter Randomized Controlled Study

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most frequent health care-associated infection in severely ill patients, and aspiration of contaminated oropharyngeal content around the cuff of the tracheal tube is the main route of contamination.

RESEARCH QUESTION

Is continuous regulation of tracheal cuff pressure using a pneumatic device superior to manual assessment three times daily using a portable manometer (routine care) in preventing VAP in patients with severe trauma?

STUDY DESIGN AND METHODS

In this open-label, randomized controlled superiority trial conducted in 13 French ICUs, adults (age ≥ 18 years) with severe trauma (Injury Severity Score > 15) and requiring invasive mechanical ventilation for ≥ 48 h were enrolled. Patients were randomly assigned (1:1) via a secure Web-based random number generator in permuted blocks of variable sizes to one of two groups according to the method of tracheal cuff pressure control. The primary outcome was the proportion of patients developing VAP within 28 days following the tracheal intubation, as determined by two assessors masked to group assignment, in the modified intention-to-treat population. This study is closed to new participants.

RESULTS

A total of 434 patients were recruited between July 31, 2015, and February 15, 2018, of whom 216 were assigned to the intervention group and 218 to the control group. Seventy-three patients (33.8%) developed at least one episode of VAP within 28 days following the tracheal intubation in the intervention group compared with 64 patients (29.4%) in the control group (adjusted subdistribution hazard ratio, 0.96; 95% CI, 0.76-1.20; P = .71). No serious adverse events related to the use of the pneumatic device were noted.

INTERPRETATION

Continuous regulation of cuff pressure of the tracheal tube using a pneumatic device was not superior to routine care in preventing VAP in patients with severe trauma.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02534974; URL: www.clinicaltrials.gov.

Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial

BACKGROUND

Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure.

METHODS

We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov, NCT03757143.

FINDINGS

1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02-0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6-69·4] h vs 30·0 [16·6-52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group.

INTERPRETATION

For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time.

FUNDING

Becton Dickinson.

Multicentre, open-label, randomised, controlled clinical trial comparing 2% chlorhexidine-70% isopropanol and 5% povidone iodine-69% ethanol for skin antisepsis in reducing surgical-site infection after cardiac surgery: the CLEAN 2 study protocol

INTRODUCTION

Surgical-site infection (SSI) is the second most frequent cause of healthcare-associated infection worldwide and is associated with increased morbidity, mortality and healthcare costs. Cardiac surgery is clean surgery with low incidence of SSI, ranging from 2% to 5%, but with potentially severe consequences.Perioperative skin antisepsis with an alcohol-based antiseptic solution is recommended to prevent SSI, but the superiority of chlorhexidine (CHG)-alcohol over povidone iodine (PVI)-alcohol, the two most common alcohol-based antiseptic solutions used worldwide, is controversial. We aim to evaluate whether 2% CHG-70% isopropanol is more effective than 5% PVI-69% ethanol in reducing the incidence of reoperation after cardiac surgery.

METHODS AND ANALYSIS

The CLEAN 2 study is a multicentre, open-label, randomised, controlled clinical trial of 4100 patients undergoing cardiac surgery. Patients will be randomised in 1:1 ratio to receive either 2% CHG-70% isopropanol or 5% PVI-69% ethanol for perioperative skin preparation. The primary endpoint is the proportion of patients undergoing any re-sternotomy between day 0 and day 90 after initial surgery and/or any reoperation on saphenous vein/radial artery surgical site between day 0 and day 30 after initial surgery. Data will be analysed on the intention-to-treat principle.

ETHICS AND DISSEMINATION

This protocol has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

EudraCT 2017-005169-33 and NCT03560193.

Reassessing the dosing of cefoxitin prophylaxis during major abdominal surgery: insights from microdialysis and population pharmacokinetic modelling

Objectives

Cefoxitin is frequently used for surgical antibiotic prophylaxis (SAP). Using microdialysis, we evaluated whether the currently recommended dosing regimen is appropriate to maintain cefoxitin subcutaneous tissue concentrations above the MIC for pathogens involved in abdominal surgical site infection.

Methods

Data from eight patients undergoing major abdominal surgery were analysed using population pharmacokinetic modelling, and Monte Carlo simulations were conducted to determine the PTA for aerobic and anaerobic pathogens. ClinicalTrials.gov: NCT02703857.

Results

Only 2.3% and 47.4% of the simulated patients maintained cefoxitin subcutaneous concentrations above the MIC breakpoint for anaerobic (MIC = 16 mg/L) and aerobic (MIC = 8 mg/L) pathogens, respectively. New simulations with administration of a loading dose followed by a constant infusion of cefoxitin were conducted and demonstrate that, notwithstanding using the same total dose per unit of time, continuous infusion of cefoxitin can cover aerobes in 96.6% of the simulated patients, but remains insufficient for anaerobic bacteria.

Conclusions

The recommended dosing regimen of cefoxitin is insufficient for covering the usual bacteria during abdominal surgery. Administration of a loading dose followed by a constant infusion should be considered for aerobic bacteria and cefoxitin should be avoided as SAP for anaerobic bacteria.

Pharmacokinetics of nebulized colistin methanesulfonate in critically ill patients

Objectives

Optimal dosing for nebulized colistin methanesulfonate (CMS), the prodrug of colistin, is unknown. We describe the pulmonary and systemic pharmacokinetics of CMS and colistin following nebulization of 0.5 million IU (MIU) of CMS in ventilated patients.

Methods

Twelve critically ill patients received 0.5 MIU of CMS administered every 8 h as 30 min nebulizations. Blood samples were collected immediately before and until 8 h after first nebulization; mini-bronchoalveolar lavage (mini-BAL) was performed at 1 and 5 h or 3 and 8 h (six patients each) post-dose. Pharmacokinetic analysis was performed for CMS and colistin plasma concentrations using a non-compartmental method. ClinicalTrials.gov: NCT01060891.

Results

After nebulization, CMS concentrations in epithelial lining fluid (ELF) were much higher (100- to 1000-fold) than those in plasma. Concentrations of colistin in ELF should be considered with caution because when <6 mg/L in BAL, colistin bound to mini-BAL devices. Nevertheless, CMS and colistin concentrations in ELF were much lower than expected from previous results with a 2 MIU dose. From CMS plasma pharmacokinetics it was shown that CMS systemic bioavailability was only slightly decreased for the 0.5 MIU dose compared with 2 MIU.

Conclusions

This study shows that CMS concentrations were much higher (100- to 1000-fold) in ELF than in plasma after a 0.5 MIU aerosol of CMS, but much lower (10-fold) than expected from previous results with a 2 MIU dose. Therefore, until new pharmacokinetic and pharmacodynamic assessments of the treatment of ventilator-associated pneumonia with nebulized CMS are performed, the 2 MIU dose should be preferred to the 0.5 MIU dose.

Postoperative fasting after general anaesthesia: A survey of French anaesthesiology practices

BACKGROUND

Preoperative fasting is well codified worldwide. In contrast, the literature on the postoperative fasting (POF) is scarce, leading to potentially wide discrepancies among anaesthesiology practices. This survey assessed French POF practices.

METHODS

From March 2013 to January 2014, a survey was conducted among anaesthesiologists, members of the French Society of Anaesthesiology and Intensive Care Medicine (SFAR). The POF durations of either fluid or solid food intake was assessed according to airway management procedures (endotracheal intubation [EI] or laryngeal mask [LMA]) and age of the patients (adult or paediatric).

RESULTS

Seven hundred and fifty-four surveys were returned (67% from public hospital practitioners and 33% from private hospital and clinic practitioners). The majority of anaesthesiologists allowed fluid intake 2h after EI and immediately after discharge from PACU following LMA. For solid food resumption, it was 2h for children and 4h for adults after EI and 2h for both children and adults after LMA. Regardless of the airway management procedures, fasting was permitted immediately after PACU discharge more frequently in public than in private hospitals (36% vs. 33%, P<0.05). Four hours after the end of surgery, the rate was significantly higher in private than in public hospitals (93% vs. 89 %, P<0.001).

CONCLUSIONS

All in all, POF lasted less than 4hours after surgery regardless of airway management. They were shorter with regard to fluid intake, paediatric patients and LMA in comparison with solid food, adult patients and EI respectively.

Colistin in critically ill patients

Colistin is a re-emerging old antibiotic that is used as a salvage treatment against multidrug-resistant Gram-negative infections. Because it is administrated as an inactive prodrug, colistin methanesulfonate (CMS) that undergoes rapid hydrolyze to colistin, pharmacokinetic studies using biological assays are unreliable. With the recent development of new assays using high performance liquid chromatography (HPLC) accurate pharmacokinetic of CMS and formed colistin is now available in various populations. This article aims to update previous reports on pharmacodynamics, pharmacokinetics, safety and clinical use of colistin, with a special focus on data useful to treat critically ill patients.

An inventory of trace elements inputs to French agricultural soils

The inputs of ten trace elements (As, Cd, Cu, Cr, Hg, Mo, Ni, Pb, Se, Zn) to French agricultural soils have been assessed. The six main sources considered were: pesticides, mineral fertilizers, animal manure, liming materials, sludge and composts and atmospheric deposition. Data were collected to compute inputs at both national and regional (departmental) scales. The inventory methodology is based on two principles: data are traceable and easy to update. At a national scale, the inventory showed that trace elements inputs can be ranked: Zn≫Cu≫Cr>Pb>Ni>As=Mo>Se>Cd>Hg. Animal manure, mineral fertilizers and pesticides are the predominant sources of TEs. These results are globally in agreement with literature data though atmospheric deposition is shown to be lower than in more industrial countries such as China and United Kingdom where similar surveys were conducted. The inputs of trace elements vary strongly between regions in relation with agricultural activities. This inventory (and the related database) provides basis for developing and monitoring policies to control and reduce trace elements contamination of agricultural soils at both national and regional (departmental) scales.

[Practice assessment of central venous lines care in surgical ICU of French university hospitals]

INTRODUCTION

Recommendations on insertion and maintenance of central venous catheters (CVC) in intensive care unit (ICU) patients were updated in 2002. The aim of this study was to estimate their knowledge and/or application by physicians in French university hospital ICUs.

METHODS

Two forms were sent to 124 professors of anaesthesia and intensive care encouraging them to participate to the survey. The first one was completed by the physician in charge of each unit and concerned the structure and activity of the unit in 2006. The second one was filled by each junior or senior physician working in the units and asked for experience, CVC insertion modalities and knowledge of CVC care protocols.

RESULTS

Forty-one (75 %) university hospitals with at least one adult surgical ICU took part to the study. A questionnaire was filled by 124 senior (75 % of the staff) and 53 junior (43 % of the staff) physicians inserting an average of 10 CVC per month (range, 1-35). A written protocol for CVC insertion was known by 127 (72 %) of them. CVC insertion was done while wearing sterile gown (97 %), cap (100 %) and surgical mask (100 %) and using large sterile drapes (96 %). The antiseptic solution used for cutaneous antisepsis was povidone iodine in aqueous (36 %) or alcoholic solution (40 %), or an alcoholic solution of chlorhexidine (24 %) applied one (9 %), two (64 %) or three (27 %) times before insertion. A 4-times disinfection sequence (washing, rinsing, drying and disinfection) was performed by 161 (91 %) physicians. Ultrasound-guided insertion was realized by only eight (5 %) operators. CVCs were made of polyurethane (84 %), usually multi-lumens (>96 %) and rarely tunnelised (14 %). Only two physicians (1 %) sometimes use catheters coated with antibiotics or antiseptics. The site for catheter insertion was mostly the sub-clavian (47 %) or internal jugular vein (34 %), and rarely the femoral vein (20 %). CVCs were secured with a thread (99 %) and covered with a semi-permeable dressing (76 %). Concerning CVCs maintenance, 91 % of physicians acknowledged the existence of a written protocol in the unit. Dressings were changed every day (10 %), every two days (49 %), every three days (29 %) or every four days or more (12 %) by using the same antiseptic solution and semi-permeable transparent dressing in 78 % of cases. Venous lines changes were done during dressing maintenance (48 %), every day in case of administration of lipids (32 %) or just after administration of blood products via the catheter (32 %). Routine change of CVC was rarely recommended (11 %).

CONCLUSION

The high number of answers allows setting of a precise state of CVCs insertion practices in adult surgical ICUs. Recommendations for central venous catheter insertion and maintenance are not still known and\or applied.

Partial sequences of nitrogen metabolism genes in hexaploid wheat

Our objective was to partially sequence genes controlling nitrogen metabolism in wheat species in order to find sequence polymorphism that would enable their mapping. Primers were designed for nitrate reductase, nitrite reductase, glutamate dehydrogenase and glutamate synthase (GOGAT), and gene fragments were amplified on Triticum aestivum, T. durum, T. monococcum, T. speltoides and T. tauschii. We obtained more than 8 kb of gene sequences, mainly as coding regions (60%). Polymorphism was quantified by comparing two-by-two the three genomes of the hexaploid cultivar Arche and genomes of diploid wheat species. On average, the polymorphism rate was higher for non-coding regions, where it ranged from 1/60 to 1/23, than for coding regions (range: 1/110-1/40) except when the hexaploid D genome was compared to that of T. tauschii (1/800 and 1/816, respectively). Genome-specific primers were devised for the ferredoxin-dependent (Fd)-GOGAT gene, and they enabled the mapping of this gene on homoeologous chromosomes of group 2 using Chinese Spring deletion lines. A single nucleotide polymorphism (SNP) detected between the two hexaploid wheat cultivars Arche and Recital was used to genetically map Fd-GOGAT on chromosome 2D using a population of dihaploid lines. Fd-GOGAT-specific primers were used to estimate the SNP rate on a set of 11 hexaploid and nine Durum wheat genotypes leading to the estimate of 1 SNP/515 bp. We demonstrate that polymorphism detection enables heterologous, homeologous and even paralogous copies to be assigned, even if the elaboration of specific primer pairs is time-consuming and expensive because of the sequencing.

Valeur de la cholestérolémie chez l’enfant

INTRODUCTION

There is a need to dispose of normal cholesterol levels in young children. In view of the paucity of such data in France, we analysed the results of screening conducted in children.

METHOD

We analysed the cholesterol levels of 4697 children, with a mean age of 4.3 years, attending a medical check-up in a Child Health Unit in a National Health Scheme centre in Paris. All the children were recruited consecutively during the year 2002.

RESULTS

The mean cholesterol level was of 4.4 mmol/L +/- 0.75. We detected a slight gender-related variation (the mean in girls and boys were of 4.5 +/- 0.76 and 4.4 +/- 0.74 respectively). The 95 percentile in girls and boys were 5.7 and 5.6 mmol/L, respectively.

DISCUSSION

For the first time in France, we now have access to data on normal cholesterol levels in a large cohort of 4 year-old children. Screening for hypercholesterolaemia in children provides the opportunity to discuss dietary counselling.

The Arabidopsis AtEPR1 extensin-like gene is specifically expressed in endosperm during seed germination

Screening of 10 000 Arabidopsis transgenic lines carrying a gene-trap (GUS) construct has been undertaken to identify markers of seed germination. One of these lines showed GUS activity restricted to the endosperm, at the micropylar end of the germinating seed. The genomic DNA flanking the T-DNA insert was cloned by walking PCR and the insertion was shown to be located 70 bp upstream of a 2285 bp open reading frame (AtEPR1) sharing strong similarities with extensins. The AtEPR1 open reading frame consists of 40 proline-rich repeats and is expressed in both wild-type and mutant lines. The expression of the AtEPR1 gene appears to be under positive control of gibberellic acid, but is not downregulated by abscisic acid during seed germination. No expression was detected in organs other than endosperm during seed germination. The putative role of AtEPR1 is discussed in the light of its specific expression in relation to seed germination.

Electroshock afterdischarges are related to neuronal oscillability: neuronal models of Aplysia

Identifiable giant neurons of Aplysia explored intracellularly behave differently at the offset of an intracellular electroshock (IES) or after a synaptic 'tetanization', according to their functional type: neurons of the stable type depolarize and fire at the offset of the IES, anodal or cathodal, thus eliciting an afterdischarge (AD). The threshold of this AD is lowered if the neuron is destabilized, i.e. converted from the stable to an oscillatory type (for instance by decalcification). Neurons normally of the tonic type are more sensitive to an IES, eliciting a longer afterdischarge than the stable neurons. Extracellular electroshock (EES) anodal or cathodal, applied directly on desheathed somata of Helix give long-lasting afterdischarges at the offset. In addition, EES stimulating presynaptic terminals or axons leads to a high frequency synaptic input on remote neurons. At the offset of this input either prolonged synaptic afterdischarges or postsynaptic rebounds of the membrane potential sustaining bursts of decreasing amplitude denote apparent oscillatory properties of the synaptically activated neuron. Finally, any conversion by convulsants of tonic neurons to oscillators highly facilitates the elicitation of afterdischarges of axons simultaneous to paroxysmal depolarization shifts of the homologous somata. These results indicate that afterdischarge elicitation is highly facilitated (low threshold) in normal oscillatory neurons and/or chemically destabilized neurons.

Collagen synthesis in rat gingiva during tooth movement

The response of the gingiva to an increased interdental space was studied by creating a diastema between the central incisors of rats and analyzing autoradiographically the incorporation of H3 proline in the gingiva to detect increased collagen production. In addition, conventional histologic methods were used to determine changes in the gingival architecture. The results indicate that the gingiva responds to an increased space in at least two ways. One is the production of more collagen fibers. The other involves the reorientation of the existing fibers in a horizontal plane as the gingival papilla becomes flattened.