Comparison of suspected and confirmed internal EVD-related infections: a prospective multi-centre U.K. observational study

Background

Diagnosis of internal external ventricular drain (EVD)-related infections (iERI) is an area of diagnostic difficulty. Empiric treatment is often initiated on clinical suspicion. There is limited guidance around antimicrobial management of confirmed versus suspected iERI.

Methods

Data on patients requiring EVD insertion were collected from 21 neurosurgical units in the United Kingdom from 2014 to 2015. Confirmed iERI was defined as clinical suspicion of infection with positive cerebrospinal fluid (CSF) culture and/or Gram stain. Cerebrospinal fluid, blood, and clinical parameters and antimicrobial management were compared between the 2 groups. Mortality and Modified Rankin Scores were compared at 30 days post-EVD insertion.

Results

Internal EVD-related infection was suspected after 46 of 495 EVD insertions (9.3%), more common after an emergency insertion. Twenty-six of 46 were confirmed iERIs, mostly due to Staphylococci (16 of 26). When confirmed and suspected infections were compared, there were no differences in CSF white cell counts or glucose concentrations, nor peripheral blood white cell counts or C-reactive protein concentrations. The incidence of fever, meningism, and seizures was also similar, although altered consciousness was more common in people with confirmed iERI. Broad-spectrum antimicrobial usage was prevalent in both groups with no difference in median duration of therapy (10 days [interquartile range {IQR}, 7–24.5] for confirmed cases and 9.5 days [IQR, 5.75–14] for suspected, P = 0.3). Despite comparable baseline characteristics, suspected iERI was associated with lower mortality and better neurological outcomes.

Conclusions

Suspected iERI could represent sterile inflammation or lower bacterial load leading to false-negative cultures. There is a need for improved microbiology diagnostics and biomarkers of bacterial infection to permit accurate discrimination and improve antimicrobial stewardship.

102 A delay in maternal zygotic transition may lead to early embryonic loss in poor-quality bovine blastocysts

Increased genetic potential and performance of dairy cows has coincided with a decline in fertility. Early embryonic mortality accounts for 75-80% of this decline in fertility, costing the industry over $1.28 trillion worldwide. Despite advancements in assisted reproductive technologies and embryo transfer, many transferred embryos do not survive past Day 24 of gestation, suggesting flaws in embryo selection for transfer. It was hypothesised that visually lower-quality IVF Day 7 blastocysts were developmentally delayed as a result of altered mitotic signalling and were at higher risk of embryo mortality. To identify potential causes for early embryo mortality in IVF embryos, RNA-Seq was performed on 6 categories of Day 7 blastocysts: stages (S) 5 (early), 6 (full), and 7 (expanded), with quality scores (Q) of 1 or 2. Oocytes were matured, fertilized by routine procedure, and cultured for 7 days. Blastocysts were classified and graded, separated into the six categories, and subjected to Pronase digestion of the zona pellucida. From three biological replicates of each blastocyst group, RNA was extracted and submitted for RNA-sequencing. Secondary bioinformatics and analyses were performed using R to determine differentially expressed genes. When S7.Q1 blastocysts were compared to other categories, 55 genes were consistently differentially expressed (P<0.05) in S5.Q1 or 2 and S6.Q2. Of these 55 genes, 15 were significantly upregulated (>1.5 fold change), and 40 were downregulated (<−1.5 fold change). The nine most common upregulated genes in S5.Q1 or 2 and S6.Q2, compared with S7.Q1, were BTG4, ARGFX, GPC4, BOC, CNTNAP2, NR3C2, CCDC7, and PHYHIPL. The five most common downregulated genes included MUC1, HSD3B1, ADAM19, EVPL, and TGM1. The EVPL and TGM1 proteins are associated with cell barrier permeability, and a lack of TGM1 has been shown to cause neonatal death in mice. Therefore, early embryo mortality may begin with decreased EVPL and TGM1, limiting cell permeability and communication between blastomeres. This limited communication might delay gene expression in the embryo at the 4- to 8-cell stage, delaying the maternal zygotic transition (MZT), in spite of continued cell division. This explanation is supported by the observed increase in ARGFX and BTG4 mRNA. Normally, stored maternal BTG4 mRNA becomes translated during the MZT and degrades maternal mRNA. The increase of BTG4 mRNA in poor-quality embryos may reflect delayed translation of BTG4 and delayed MZT. The mRNA transcripts increased in poor-quality blastocysts may be excess maternal mRNA not yet degraded, like BTG4. The decreased mRNA transcripts observed may be indicative of zygotic genes which have not yet been transcribed. For instance, MUC1 is necessary for proper embryo implantation, and HSD3B1 converts placental pregnenolone to progesterone and produces a precursor to oestradiol. The delayed transcription of both MUC1 and HSD3B1 may impair maternal recognition of pregnancy, implantation, and communication to the maternal endometrium via oestradiol, thereby causing embryo mortality. This research was supported by USDA NNF 2016-38420-25289 and Zoetis Inc.

Management and control of a carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit

OBJECTIVE

We had for aim to describe the identification and management of a 14-clonal carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak, following admission of a known CRAB-infected patient in an ICU.

METHODS

We reviewed the carriers' files and outbreak management procedures.

RESULTS

The index patient was admitted with strict isolation precautions. The outbreak started 2 months after his discharge. It persisted despite reinforcement of strict isolation precautions, staff and patient cohorting, and extensive environmental decontamination including 2 rounds of routine terminal cleaning and disinfection or 1 round of cleaning and disinfection followed by hydrogen peroxide treatment. A second epidemic peak, after 4 weeks without any case, led to another wide environmental sampling and decontamination rounds. The source of the CRAB outbreak was suspected to be the blood pressure cuffs Velcro. Switching to cuffs submersible in a disinfectant stopped the outbreak.

CONCLUSIONS

CRAB outbreaks are difficult to manage and sources of persistent colonization can be unexpected.

Clostridium difficile colitis acquired in the intensive care unit: outcome and prognostic factors

PURPOSE

We assessed factors associated with mortality and complicated course in the case of Clostridium difficile infection (CDI) acquired in the intensive care unit (ICU).

METHOD

Retrospective cohort study conducted from 1 January 2002 through 1 January 2012. All patients who acquired CDI in our ICU were included.

RESULTS

Thirty-one patients were included. Twenty patients (65 %) had mild colitis, 8 (25 %) moderate colitis, and 3 (10 %) severe colitis. Initial antibiotherapy was metronidazole (n = 30, 97 %) and vancomycin (n = 1, 3 %). Seventeen patients (55 %) experienced at least one complication: failure of initial treatment (n = 16, 52 %), shock (n = 11, 34 %), need for surgery (n = 1, 3 %) or renal replacement (n = 4, 13 %), or death (n = 8, 26 %). Risk factors of ICU mortality were history of corticosteroids prescription, prolonged ICU stay, low serum albumin level, and high Sequential Organ Failure Assessment (SOFA) score at the time of CDI diagnosis. Factors associated with a complicated course were high Simplified Acute Physiology Score (SAPS II), high SOFA score, and low serum albumin level at the time of CDI onset.

CONCLUSION

Risk factors of poor outcome in patients with CDI acquired in the ICU are different from those in the general population suffering from CDI. The implementation of treatment algorithms taking into account these factors may reduce complication rates in this specific population.

Clinical spectrum and outcome of critically ill patients suffering from prosthetic joint infections

PURPOSE

To report the clinical characteristics and prognosis of prosthetic joint infections (PJIs) in Intensive care units (ICUs).

METHODS

Forty-one patients consecutively admitted to ICUs for PJIs between January 2004 and June 2011 were included in a retrospective case series.

RESULTS

A majority of patients (73 %) had severe underlying disease. Acute infection affected 26 patients (63 %). Blood cultures were positive in 16 patients (39 %). Staphylococcus species were the most commonly implicated causative organisms (n = 36, 88 %). The surgical strategy was two-stage replacement in 25 cases (61 %). The surgical procedure leading to ICU admission was mainly prosthesis removal with spacer implantation (n = 13, 32 %). Initial antibiotherapy was a broad-spectrum beta-lactam antibiotic combined with a glycopeptide, linezolid, or daptomycin in 26 cases (63 %). Mortality in the ICU was 20 %. In nonsurvivors, diabetes, acute infection, and American Society of Anesthesiologists (ASA) score >3 were more frequent. The distribution of surgical strategies and procedures was not statistically different in survivors and nonsurvivors. The proportion of patients treated with antibiotherapy adjusted according to previous microbiological findings was higher in nonsurvivors (50 vs. 12 %, p = 0.02).

CONCLUSIONS

In our case series of critically ill patients suffering from PJI, factors associated with a poor outcome were diabetes mellitus, ASA score >3, and acute infection. Surgical strategies and surgical procedures had no significant impact on the ICU mortality. Adjustment of initial antibiotherapy according to previous microbiological findings should be made with caution.

Impact of combination therapy with aminoglycosides on the outcome of ICU-acquired bacteraemias

Pharmacodynamic studies report on the rapid bactericidal activity of aminoglycosides, conferring them as being of theoretical interest for bacteraemia treatment. We assessed this issue in a retrospective study of patients with intensive care unit (ICU)-acquired bacteraemias. To determine the impact of aminoglycosides in antimicrobial combination on the outcome of patients with bacteraemia, we performed a monovariate analysis and a logistic regression analysis comparing patients treated with or without aminoglycosides. Forty-eight bacteraemias in 48 patients were included. Eighteen patients received aminoglycosides. Baseline characteristics as well as adaptation and adequation of antibiotherapy did not differ in patients who did or did not receive aminoglycosides. Patients who received aminoglycosides had longer time alive away from the ICU (11.3 ± 8.9 (10 [0–20]) vs. 3.2 ± 6.6 (0 [0–2] days; p = 0.002) and free from mechanical ventilation (12.5 ± 9.3 (14 [0–21] vs. 5.5 ± 9.2 (0 [0–10] days; p = 0.02) on day 28. The ICU mortality was 16% in the aminoglycoside group versus 46% (p = 0.03). In the multivariate analysis, patients treated with aminoglycosides were 6 times less likely to die than those treated without aminoglycosides (confidence interval [CI] = [1.3–28.9]; p = 0.02). Our study supports the hypothesis that combination short-term antibiotherapy with an aminoglycoside for ICU-acquired bacteraemias could increase survival.

Does posterior fossa decompression improve oculomotor and vestibulo-ocular manifestations in Chiari 1 malformation?

BACKGROUND

Oculomotor and vestibulo-ocular manifestations are associated with Chiari 1 malformation. Reports of the results of decompression of CM1 in resolution of these manifestations are limited.

METHODS

A retrospective review of case notes were undertaken from Jan 1998 to March 2003 of all the cases undergoing posterior fossa decompressions by the senior author. Forty patients were identified of which 12 had oculomotor and vestibulo-ocular manifestations.

RESULTS

Oculomotor and vestibulo-ocular symptoms were present in seven patients and eleven patients had clinical signs. There were only 2 patients who had symptoms and no objective findings. There was complete resolution of oculomotor and vestibulo-ocular manifestations in 8/12 patients and partial improvement in another one, leading to improvement in 9/12 patients. The mean time span to complete resolution was 15.5 months (range 3-71 months).

CONCLUSION

Posterior fossa decompression appears to be highly effective in causing complete resolution of disabling oculomotor and vestibule-ocular manifestations in most cases of CM1.

Diagnostic and prognostic values of admission procalcitonin levels in community-acquired pneumonia in an intensive care unit

Background:

Measurement of procalcitonin (PCT) has been studied for several years in infectious diseases. Some studies have focused on community–acquired pneumonia (CAP) but only one was conducted in critically ill patients hospitalized in an intensive care unit (ICU).

Patients and Methods:

To determine the diagnostic and prognostic role of PCT in patients admitted in an intensive care unit for severe CAP, 110 patients hospitalized in our unit were prospectively studied. Within 48 hours following ICU admission, PCT serum level was measured with a quantitative method above a threshold value of 0.5 ng/ml.

Results:

Initially focusing on the diagnostic value of PCT, 20% of the patients had a serum PCT level < 0.5 ng/ml, 30% between 0.5 ng/ml and 2 ng/ml, and 50% ≥ 2 ng/ml. Serum PCT level was higher in microbiologically documented CAP (median = 4.9 ng/ml vs 1.5 ng/ml if no bacteria were found; p = 0.001), but was not predictive of any specific bacterial agent. Concerning the prognostic value, the serum PCT level was higher for bacteremic patients and/or septic shock patients (4.9 ng/ml vs 1.5 ng/ml; p = 0.0003). Moreover, PCT levels were increased in patients who developed, during their ICU stay, infection–related complications (septic shock, multiorgan dysfunction, acute respiratory distress syndrome and disseminated intravascular coagulation). Finally, the initial PCT level was significantly higher in patients who died during the ICU stay (5.6 ng/ml vs 1.5 ng/ml; p < 0.0001). Such a relationship was not found with C–reactive protein (CRP).

Conclusion:

In ICU patients admitted for severe CAP, initial PCT values could be an interesting predictor for complications and mortality.

Hospital-Acquired Pneumonia in Critically Ill Patients: Factors Associated with Episodes Due to Imipenem-Resistant Organisms

BACKGROUND

Inadequate initial antimicrobial therapy represents one of the factors associated with mortality of patients suffering from hospital-acquired pneumonia. According to its wide antimicrobial spectrum, imipenem belongs to the usual antibiotics proposed by current guidelines for such a therapy. However, major changes in the antibiotic susceptibility patterns of bacteria in the intensive care unit (ICU) have occurred. Our goal was to determine the incidence of hospital-acquired pneumonia (HAP) due to imipenem-resistant organism(s) in our ICU and to identify factors associated with such a resistance.

PATIENTS AND METHODS

From January 1994 to December 2001, all consecutive patients admitted to our ICU for HAP or exhibiting HAP during their ICU stay were included in an observational cohort. Patients with a bacteriologically documented HAP were studied. For each causative pathogen, imipenem susceptibility was routinely determined. Patients with an HAP episode due to at least one imipenem-resistant causative organism were compared with patients who developed HAP in which all incriminated pathogens were imipenem susceptible.

RESULTS

235 patients were included in our observational cohort. Among them, 168 had an HAP episode with a bacteriologically proven infection. In 42 patients (25%), at least one causative organism was resistant to imipenem. The 44 imipenem-resistant organisms were Staphylococcus aureus (n = 15), Pseudomonas aeruginosa (n = 14), Stenotrophomonas maltophilia (n = 13), and Acinetobacter baumannii (n = 2). Multivariate analysis identified four significant independent factors associated with resistance of causative organism(s) to imipenem: prior use of a fluoroquinolone (AOR = 3.9; 95% CI: 1.8 to 8.8; p < 0.0001), prior use of an aminoglycoside (AOR = 2.6; CI: 1.2 to 5.9; p = 0.02), use of invasive blood pressure monitoring (AOR = 2.7; CI: 1.0 to 7.0; p = 0.04) and bilateral chest X-ray involvement (AOR = 2.6; CI: 1.1 to 5.8; p = 0.02).

CONCLUSION

Factors associated with potential inadequacy of imipenem used as the single antibiotic for initial empiric treatment for HAP were identified. When they are present, imipenem should be either combined with antibiotics such as vancomycin and ciprofloxacin or replaced with another broad-spectrum antimicrobial regimen.

Patient perceptions of "awake" brain tumour surgery

BACKGROUND

Awake brain tumour surgery allows intraoperative patient assessment and is done to optimise safe tumour removal. It is an established technique but little is known about patient perceptions of the procedure.

METHOD

Fifteen adult patients filled out a dedicated questionnaire to assess 10 aspects of patient perceptions of the procedure.

FINDINGS

All patients, who were awake for a median of 45 minutes (range 10-105), stated they were adequately prepared for the operation. Most recollected various aspects of the procedure, although 3 patients (20%) had little memory of actually being awake during the surgery despite being cooperative. A minority reported more than minor discomfort (20%), fear (15%) or anxiety (29%), and most felt they coped with the cortical stimulations and functional testing well. Sources of discomfort and pain were the cranial pin holding device, operative position, inadequate infiltration of the cranial wound with local anesthetic, a full bladder causing a desire to micturate and a hard and uncomfortable operating table.

CONCLUSIONS

These results, are very similar to a previous American report using a different anesthetic technique, in that most patients tolerate awake craniotomy remarkably well if the procedure is explained to them and some simple precautions are taken. Additionally between 8%-37% of patients (95% Confidence Interval, summing data from the two studies, n = 35) will have no recollection of being awake. Ways of minimising discomfort and problems of anxiety in this patient cohort are discussed.

[Severe acute respiratory syndrome]

In the Fall of 2002 a report from Guangdong Province in China showed the occurrence of an outbreak of atypical pneumonia. This outbreak rapidly progressed from China to Hong Kong, Singapore, Toronto, and the USA, to more than 25 countries worldwide and almost 3500 cases to date in april 2003. The clinical features associate a fever with mild respiratory symptoms which can progress to a typical acute respiratory distress syndrome requiring intensive care unit admission. Enteric forms with diarrhea were recently described in Hong Kong. The medical community responded very rapidly and united in front of this major health crisis. In a couple weeks, the agent, a new Coronavirus was isolated, therapeutic guidelines were proposed and measures to limit the outbreak diffusion were started worldwide. We summarize here the history of the outbreak, the clinical, laboratory and radiological features of SARS. April 2003 therapeutic guidelines are also reported.

Hospital-acquired pneumonia: microbiological data and potential adequacy of antimicrobial regimens

Adequate antimicrobial therapy is a main approach employed to decrease the mortality associated with hospital-acquired pneumonia (HAP). All methods that optimise empirical treatment without increasing antibiotic selective pressure are relevant. Categorisation of patients according to HAP time of onset, severity and risk factors (American Thoracic Society (ATS) classification) or duration of mechanical ventilation and prior antibiotics (Trouillet's classification) are two such methods. The aim of this study was to catagorise patients with HAP according to these classifications and to determine the frequency of resistant pathogens and the most adequate antimicrobial regimens in each group. A total 124 patients with bacteriologically proven HAP were studied. The ATS classification categorised patients by increasing frequency of resistant pathogens from 0-30.3%. The ATS empirical antibiotic recommendations appeared valid but proposed combinations including vancomycin for 72.5% of patients. Trouillet's classification categorised patients into four groups with a frequency of resistant pathogens from 4.9-35.6%. Vancomycin was proposed for 48.5% of patients. The American Thoracic Society classification appears to be more specific than Trouillet's for predicting the absence of resistant causative pathogens in hospital-acquired pneumonia but could lead to a greater use of vancomycin. Stratification combining the two classifications is an interesting alternative.

Mortality due to ventilator-associated pneumonia: impact of medical versus surgical ICU admittance status

PURPOSE

The purpose of this study was to compare the prognosis of medical versus surgical patients developing ventilator-associated pneumonia (VAP).

MATERIALS AND METHODS

An observational cohort study included 125 consecutive patients exhibiting VAP. Incidence of death occurred at two different times: during intensive care unit (ICU) stay and during hospital stay.

RESULTS

Eighty-seven patients were included in the medical group and 38 in the surgical group. On ICU admission and at the time of VAP onset, most collected data, such as demographic parameters, severity of underlying diseases, and current illness, risk factors forVAP development andVAP characteristics were similar in the two groups. Mortality rates during ICU and hospital stays were not significantly different in medical (49%, 56%) and surgical (55%, 61%) groups. In multivariate logistic regression model adjusting for main factors of VAP mortality, surgical admittance status demonstrated no significant impact on mortality assessed during ICU stay (AOR = 1.6; 0.6 - 4.3 CI) and during hospital stay (AOR = 1.6; 0.6 - 4.2 CI).

CONCLUSIONS

In this series, after adjustment for mortality confounding factors, medical versus surgical admittance status was not a significant determinant of VAP mortality.

Exchange transfusion for severe malaria

BACKGROUND

Exchange transfusion (ET) is a controversial ancillary treatment of severe falciparum malaria.

PATIENTS AND METHODS

We conducted a retrospective analysis of severe malaria treated in our institution. Nine cases of ET were identified between 1991 and 1998 and compared to 12 controls with similar parasitemia.

RESULTS

Groups were similar at admission except for an increased age in the ET group (p < 0.02). All patients received iv quinine. Outcome was similar in both groups (two deaths in the ET group, three in the control group). However, in patients with parasitemia > 30%, the death rate was significantly lower in ET patients than in controls (0/4 vs 3/3, p < 0.029).

CONCLUSION

Despite definitive data from controlled trials, we suggest that ET should be considered in severe malaria cases with very high parasitemia and severity criteria or worsening clinical condition despite adequate chemotherapy.

Predisposing factors for nosocomial pneumonia in patients receiving mechanical ventilation and requiring tracheotomy

STUDY OBJECTIVES

To assess the incidence of nosocomial pneumonia (NP) after tracheotomy in an ICU population and to determine NP risk factors during the ICU stay, particularly on the day of tracheotomy.

DESIGN

A retrospective study using prospectively collected data.

SETTING

A 16-bed multidisciplinary ICU.

PATIENTS

One hundred thirty-five patients requiring tracheotomy for mechanical ventilation (MV) weaning.

RESULTS

The mean (+/- SD) duration of MV before tracheotomy was 17.8 +/-13.4 days. Thirty-seven cases of NP occurred in 35 patients (25.9%), 8.7+/-7.3 days after the tracheotomy procedure. NP cases were classified as early NP (n = 19) if they occurred within 5 days after the procedure (mean, 2.7+/-1.1 days), and as late NP (n = 18) if they occurred beyond the fifth day (mean, 14.4+/-6.1 days). Multivariate analysis identified the following three independent factors associated with early NP: the presence of positive endotracheal aspirates (EAs) with pathogen levels of > or =10(5) cfu/mL (p = 0.0001); hyperthermia (temperature, > or =38.3 degrees C; p = 0.002) on the day of tracheotomy; and the continuation of sedation beyond 24 h after the tracheotomy (p = 0. 0001). Accountable pathogens of early NP were present in EA on the day of tracheotomy (p = 0.001). Cases of late NP were significantly associated with the duration of sedation before the procedure (p = 0. 002) and with hyperthermia (temperature, > or =38.3 degrees C) on the day of tracheotomy (p = 0.0005). The ICU admitting diagnosis, previous NP, duration of administration of antimicrobial agents and MV before tracheotomy, indication for tracheotomy, PO(2)/fraction of inspired oxygen ratio, and use of steroids on the day of the procedure were not associated with the occurrence of NP. The mortality rate of our population was 33.3%, and NP increased this percentage to 54.3%.

CONCLUSIONS

Our results could suggest that tracheotomy should be delayed in mechanically ventilated patients with bronchial colonization and hyperthermia, when sedation cannot be discontinued after the procedure, to prevent occurrence of early NP.

In vitro stereoselective degradation of carprofen glucuronide by human serum albumin. Characterization of sites and reactive amino acids

Acyl glucuronides formed from carboxylic acids can undergo hydrolysis, acyl migration, and covalent binding to proteins. In buffers at physiological pH, the degradation of acylglucuronide of a chiral NSAID, carprofen, consisted mainly of acyl migration. Acidic pH reduced hydrolysis and acyl migration, thus stabilizing the carprofen acyl glucuronides. Addition of human serum albumin (HSA) led to an increased hydrolysis of the conjugates of both enantiomers. This protein protected R-carprofen glucuronide from migration and therefore improved its overall stability. Hydrolysis was stereoselective in favor of the S conjugate. The protein domains and the amino acid residues likely to be responsible for the hydrolytic activity of HSA were deduced from the results of various investigations: competition with probes specific of binding sites, effects of pH and of chemical modifications of albumin. Dansylsarcosine (DS), a specific ligand of site II of HSA, impaired the hydrolysis, whereas dansylamide (DNSA) and digoxin, which are specific ligands of sites I and III, respectively, had no effect. The extent of hydrolysis by HSA strongly increased with pH, indicating the participation of basic amino acids in this process. The results obtained with chemically modified HSA suggest the major involvement of Tyr and Lys residues in the hydrolysis of glucuronide of S-carprofen, and of other Lys residues for that of its diastereoisomer.

Glycation of human serum albumin by acylglucuronides of nonsteroidal anti-inflammatory drugs of the series of phenylpropionates

The covalent binding to human serum albumin (HSA), of acylglucuronides from carboxylic nonsteroidal anti-inflammatory drugs (NSAIDs) was investigated. The adduct formation was followed and quantitated by HPLC and by radiometric detection. Three types of albumin adducts were evidenced. The acylglucuronide or the drug itself was bound to 0.2 up to 9% of the albumin molecules, depending on the drug, whereas the majority of adducts (23-49% of albumin molecules) retained the glucuronic acid moiety. The possible involvement of specific Lys located in site I of albumin in the formation of these main adducts was demonstrated, using a series of HSA whose specific Lys residues have been modified chemically. This study shows that acylglucuronides from NSAIDs can significantly contribute to the glycation of proteins, such as albumin.

Simplified prediction rule for prognosis of patients with severe community-acquired pneumonia in ICUs

STUDY OBJECTIVES

To develop a simplified prognostic prediction rule for patients admitted to ICUs for severe community-acquired pneumonia (CAP).

SETTING

Six ICUs in the north of France.

PATIENTS

Five hundred five patients admitted to ICUs over a 9-year period (from 1987 to 1995) for severe CAP.

INTERVENTIONS

Retrospective prognosis analysis and multivariate analysis using a credit scoring technique.

MEASUREMENTS

The primary outcome measure was ICU mortality.

RESULTS

Among the 505 patients, 472 were eligible for the prognosis study. The ICU mortality rate was 22.9%. Multivariate analysis identified, on the basis of the patient's medical history and initial examination on ICU admission, six independent predictors of mortality: age > or = 40 years, anticipated death within 5 years, nonaspiration pneumonia, chest radiograph involvement > 1 lobe, acute respiratory failure requiring mechanical ventilation, and septic shock. An initial risk score based on these factors classified patients into three risk classes of increasing mortality: 4% in class I, 25% in class II, and 60% in class III. Multivariate analysis of events occurring during ICU stay identified three independent predictors of mortality: hospital-acquired lower respiratory tract superinfections, nonspecific CAP-related complications, and sepsis-related complications. An adjustment risk score based on these factors was essential to accurately predict the final outcome of patients in the initial risk class II.

CONCLUSIONS

As an aid to clinicians in stratifying the prognosis of patients with severe CAP, the simplified prediction rule used in this study could be useful for therapeutic decisions and appropriate care.

Community-acquired pneumonia in the intensive care unit: epidemiological and prognosis data in older people

OBJECTIVES

To compare epidemiological data, etiology, and prognosis of severe community-acquired pneumonia (CAP) in the intensive care unit (ICU) according to age (< or > or = 65 years) and to determine prognostic factors of CAP in older people.

DESIGN

A retrospective (1987-1992) and prospective (1993-95) multicenter study.

SETTING

Six ICUs in the north of France.

PATIENTS

Five hundred five patients admitted to an ICU for severe CAP.

MEASUREMENTS

Patient characteristics were compared with regard to age. Prognosis of CAP in older patients was studied by stepwise discriminant analysis.

RESULTS

Two hundred seventy-eight patients (55%) were aged 65 years or older. Comparison of epidemiological data between older and younger patients revealed a higher prevalence of women (38% vs 29%), more severe underlying comorbidities (anticipated death within 5 years: 59% vs 26%), and more frequent chronic respiratory insufficiency (48% vs 33%) in the older patients. In this study group, 224 organisms were isolated from 172 patients (62%); those identified most frequently were Gram-negative bacilli (34%), S. pneumoniae (32%), and Staphylococcus sp. (19%). Compared with younger patients, no significant differences in bacteriological data were observed. However, crude and attributable mortality rates were significantly higher in the older patients (33% vs 21% and 30% vs 19%, respectively). Prognosis analysis identified four independent predictors of mortality in the older patients: initial septic shock (relative risk (RR) = 3), sepsis-related complications (RR = 4.3), hospital-acquired lower respiratory tract superinfections (RR = 2), and nonspecific pneumonia-related complications (RR = 2.8).

CONCLUSION

The bacterial etiology provides some approaches to empirical therapy for older patients with severe community-acquired pneumonia. In addition, the inappropriateness of withholding intensive care for reasons of age alone is emphasized.

Effect of hospital-acquired ventilator-associated pneumonia on mortality of severe community-acquired pneumonia

PURPOSE

The purpose of this article is to evaluate, using two pairwise case-control studies, attributable mortality linked to hospital-acquired ventilator-associated pneumonia (HA-VAP) complicating the intensive care unit (ICU) stay of patients exhibiting severe community-acquired pneumonia (CAP).

MATERIALS AND METHODS

Over an 11-year period, 498 patients with severe CAP were collected. Among them, 43 exhibited HA-VAP. In a first case-control study, these patients were matched with control on the basis of six confounding variables known to be general ICU prognosis factors. In a second case-control study, six variables specifically linked to CAP prognosis were used for matching.

RESULTS

In the two case-control studies, each case patient was matched with one control patient. In the first analysis, success of matching was achieved in 198 of 258 (77%) variables used for matching. In the second analysis, matching was successful for 242 of 258 (94%) confounding variables used. Eighteen patients died, compared with, respectively, 6 (P = .003) and 7 (P = .01) controls. Attributable mortality of HA-VAP was similar in the two pairwise analyses, respectively, 28% (risk ratio = 3.0; 95% confidence interval, 1.32 to 6.82) and 26% (risk ratio = 2.57; 95% confidence interval, 1.2 to 5.52).

CONCLUSION

When confounding factors were controlled, HA-VAP appeared to increase mortality of severe CAP requiring ICU admission.

Epidemiological features and prognosis of severe community-acquired pneumococcal pneumonia

OBJECTIVE

To describe risk factors of severe pneumococcal community-acquired pneumonia and to study variables influencing outcome.

DESIGN

Retrospective (1987-1992) and prospective (1993-1995) study.

SETTING

Three participating ICUs from primary care hospitals.

PATIENTS

Five hundred and five patients (mean age: 63 +/- 17 years) with severe community-acquired pneumonia (CAP). Three groups of patients were defined: pneumococcal CAP (group 1), CAP with microbial diagnosis other than Streptococcus pneumoniae (group 2), CAP from group 2 and CAP without microbial diagnosis (group 3).

MEASUREMENTS AND RESULTS

Admission data and data on the disease's course were recorded. The mean Simplified Acute Physiologic Score (SAPS) was 12.5 +/- 5.4. On admission 288 (57 %) patients were mechanically ventilated (mv) and 82 (16.2 %) required inotropic support. A microbial diagnosis was established for 309 (61.2%) patients. S. pneumoniae was isolated in 137 (27.1%) patients. Severe pneumococcal CAP was independently associated with male sex (p = 0.01), lack of antibiotics use before admission (p = 0.0001), non-aspiration pneumonia (p = 0.01) and septic shock (p = 0.0001). The overall mortality rate was 27.5 % (29.2 % in group 1). In patients with severe pneumococcal CAP, multivariate analysis showed that leukopenia less than 3,500/mm3 (p = 0.0004), age over 65 years (p = 0.01), septic shock (p = 0.01), sepsis related complications (p = 0.0001), ICU complications (p = 0.001) and inadequacy of antimicrobial therapy (p = 0.002) worsened the prognosis.

CONCLUSIONS

Few features facilitate the identification of pneumococcal CAP on ICU admission. The prognosis is mostly related to severity of illness (leukopenia, septic shock) while comorbidities do not seem to influence outcome. Sepsis-related disorders, ICU complications and adequate antimicrobial chemotherapy are the major variables affecting the outcome during an ICU stay.

[Evaluation of prescription of antibiotics in an intensive care unit]

OBJECTIVES

In order to optimize prescriptions, we conducted a qualitative evaluation of antibiotic prescription in an intensive care unit.

METHODS

A prospective observational study was performed on 100 consecutive prescriptions from 11/95 to 4/96.

RESULTS

Among 14 documented cases, initial antibiotic therapy was in accordance with antimicrobial susceptibility patterns in all but one case. Among 86 empirical cases, 38 were secondarily documented, yielding 43 microorganisms. Of these 38, 27 were susceptible to 2 or more empirical antibiotics, 3 to only 1 and 8 to none. Antibiotics were modified in 23/38 (60%) cases, resulting in drug changes (n = 21) or drug addition (n = 2). In all cases, the new prescription was consistent with the antibiogram. In the 48 cases where no microorganism was isolated, antibiotic change was guided by clinical course and occurred in 6 (12.5%) cases. A switch to older, cheaper or more narrow spectrum antibiotics was possible in 18 cases, but was actually done in only 4 (22%). Dosage errors were observed in 5 cases of initial therapy. Second line therapy contained 8(21%) dosage errors. Most frequently, isolated organisms at admission were: Staphylococcus sp. (n = 15), P. aeruginosa (n = 11) and S. pneumoniae (n = 10). New pathogens emerged in 16 patients (16%) receiving antibiotics. The most frequent was P. aeruginosa in 4 patients receiving ofloxacin + amoxicillin +/- clavulanic acid.

CONCLUSION

These results are encouraging, however, the use of guidelines and periodic evaluation of antibiotic prescription practices might improve the efficiency of empirical antibiotic prescriptions and reduce overall antibiotic costs.

Community-acquired aspiration pneumonia in intensive care units. Epidemiological and prognosis data

Over a 9-yr period, among 505 patients exhibiting severe community-acquired pneumonia and admitted into a total of six medical ICUs in the north of France, we collected 116 patients (23%) meeting the usual criteria for aspiration pneumonia. Main medical grounds of ICU admission were respiratory distress in 54 patients and neurological disturbances in 62 patients. The main underlying risk factor for aspiration pneumonia was drug overdose (39%). Mechanical ventilation was required for 73 patients. Initial shock was present in 15 patients. Pulmonary involvement was bilateral in 27 patients. There were 94 aerobic organisms isolated from 70 patients (60%), the most frequent being gram-negative bacilli (n = 38), Staphyloccus spp. (n = 27) and Streptococcus pneumoniae (n = 22). Overall mortality was 22%, but only 11 (11%) deaths were directly or indirectly related to aspiration pneumonia. Stepwise multivariate analysis identified four independent predictors of mortality: ineffective initial antimicrobial therapy (p = 0.0001), positive initial blood culture (p = 0.0001), hospital-acquired lower respiratory tract superinfections (p = 0.0054), and use of inotropic support (p = 0.0078). The importance of prevention of hospital-acquired superinfections and permanent optimization of our antimicrobial strategies warranting efficacy of the initial antimicrobial therapy is underlined.

Pulmonary disposition of vancomycin in critically ill patients

Vancomycin penetration in epithelium lining fluid was studied in ten mechanically ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia 24 hours after the onset of treatment. Vancomycin was given intravenously at a daily dose of 30 mg/kg. Vancomycin levels were detectable in four patients (range, 1-2.77 micrograms/ml). Concordance between high plasma concentrations (> 20 micrograms/ml) and detectable vancomycin levels in epithelium lining fluid was noted. These results suggest that the pulmonary disposition of vancomycin remains low for most patients 24 h after the onset of treatment compared with the minimum inhibitory concentrations for most gram-positive organisms. One therapeutic goal of vancomycin treatment could be to obtain through plasma levels of 20 micrograms/ml. Further studies are required to determine the clinical relevance of these observations.

Severe community-acquired pneumonia in ICUs: prospective validation of a prognostic score

OBJECTIVE

To determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively.

DESIGN

Combined retrospective and prospective clinical study over two periods: January 1987-December 1992 and January 1993-December 1994.

SETTING

Four medical ICUs in the north of France.

PATIENTS

Derivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index.

RESULTS

In the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (-0.37), grading of sepsis > or = 11 (-0.2), antimicrobial combination (-0.01), Glasgow score > 12+mechanical ventilation (MV) (+0.09), serum creatinine > or = 15 mg/l (+0.22), chest involvement shown by X-ray > or = 3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score > or = 12 (+0.49), neutrophil count < or = 3500/ mm3 (+0.52), acute organ system failure score > or = 2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patient's points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of > or = 2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98.

CONCLUSION

This index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).

Fatal infection of coronary stent implantation

Among systemic infections occurring after percutaneous transluminal coronary angioplasty (PTCA) and coronary stent implantation, septic cardiac complications are rare. We report a new case of infective aneurysm of the left anterior descending coronary artery (LAD) following stent implantation. Infective mitral endocarditis due to Pseudomonas aeruginosa occurring a few weeks after stenting led to search for stent infection. Coronary angiography revealed a saccular aneurysm of the LAD. Despite surgical repair, a fatal outcome resulted.

Reliability of quantitative cultures of protected specimen brush after freezing

Protected specimen brush (PSB) is considered to be one of the standard methods for diagnosing mechanical ventilator-acquired pneumonia at a threshold value > or = 10(3) cfu/ml. Nevertheless, this procedure requires immediate cultures which are not always possible 24 h per day. We therefore wanted to appreciate the diagnostic value of delayed quantitative cultures after specimen freezing. PSB was performed by fiberoptic bronchoscopy on 43 mechanically ventilated patients with suspicion of nosocomial bronchopneumonia. After PSB procedure, two aliquots of 0.5 ml were prepared. One aliquot was plated immediately on different culture media (Group 1). A second aliquot was frozen at -80 degrees C for 24 h, then plated on the same culture media as Group 1 (Group 2). All samples were incubated for 48 h. The diagnostic value threshold of PSB was 10(3) cfu/ml. A total of 47 samples were performed on 43 patients. In Group 1, cultures from PSB were positive in 26 samples and revealed 41 species yielding > or = 10(3) cfu/ml. In Group 2, PSB cultures were positive in 24 samples and revealed 36 species yielding > or = 10(3) cfu/ml. Despite a mean decrease in bacterial count of 1.00 +/- 1.44 log 10 (p < 0.001), most important for Streptococcus pneumoniae and Escherichia coli (respectively 3.22 +/- 2.21 log10 and 2.41 +/- 0.52 log 10), sensitivity and specificity of quantitative cultures after specimen freezing, compared with immediate cultures, were 88% and 100% respectively. We concluded that specimens from PSB could be frozen at -80 degrees C with good reliability except for S. pneumoniae and E. coli, enabling PSB procedure to be performed around the clock.

[Acute necrotizing enterocolitis during a prolonged treatment with neuroleptics]

A 32-year old man treated for several years with phenothiazine for chronic psychosis developed acute necrotizing colitis. The causal relationship with neuroleptics was reinforced by the absence of any other treatment and by histological findings including extensive mucosal necrosis without stenotic lesion and without mesenteric vessels alteration. The patient required emergency total colectomy and was discharged after 7 weeks of hospitalisation in the intensive care unit.

Amikacin levels in bronchial secretions of 10 pneumonia patients with respiratory support treated once daily versus twice daily

In this study, concentrations of amikacin in blood and bronchial secretions of 10 patients with mechanical ventilation for acute respiratory failure due to pneumonia were measured. One-half of the patients received amikacin twice daily, and the others received once-daily administration. Concentrations in bronchial secretions of the patients treated twice daily ranged from 3 to 4 mg/liter, i.e., they were similar to those in previously published reports. Peak concentrations in bronchial secretions occurred between 3 and 4 h after the onset of infusion, and they reached 4.8 +/- 2.6 mg/liter on day 1 and 4.0 +/- 2.7 mg/liter on day 3. For the patients treated with amikacin once daily, concentrations in bronchial secretions were more than twofold higher, above 8 mg/liter for 12 h. Peak concentrations in bronchial secretions occurred between 3 and 4 h after the onset of infusion and reached 13.6 +/- 9.3 mg/liter on day 1 and 10.4 +/- 3.5 mg/liter on day 3. These concentrations are higher than the MICs for less sensitive bacterial strains, such as Acinetobacter spp. and Pseudomonas aeruginosa.

A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit

OBJECTIVES

To characterize the epidemiology and to determine the prognosis factors in severe community-acquired pneumonia among patients admitted to an intensive care unit.

DESIGN

Retrospective clinical study.

SETTING

Intensive Care and Infectious Diseases Unit of a municipal general hospital of Lille University Medical School.

PATIENTS

299 consecutive patients exhibiting severe community-acquired pneumonia.

MEASUREMENTS AND RESULTS

On admission to ICU, 149 patients required mechanical ventilation for acute respiratory failure and 44 exhibited septic shock. Pulmonary involvement was bilateral in 71 patients. There were 260 organisms isolated from 197 patients (65.9%), the most frequent being Streptococcus pneumoniae (n = 80), Staphylococcus spp. (n = 57) and Gram-negative bacilli (n = 81). Overall mortality was 28.5% (85 patients). According to univariate analysis, mortality was associated with age over 60 years, anticipated death within 5 years, immunosuppression, shock, mechanical ventilation, bilateral pulmonary involvement, bacteremia, neutrophil count < 3500/mm3, total serum protein level < 45 g/l, serum creatinine > 15 mg/l, non-aspiration pneumonia, ineffective initial therapy and complications. Multivariate analysis selected only 5 factors significantly associated with prognosis: anticipated death within 5 years, shock, bacteremia, non-pneumonia-related complications and ineffective initial therapy.

CONCLUSION

The effectiveness of the initial therapy appears to be the most significant prognosis factor and, as the one and only related to the initial medical intervention, suggests a need for permanent optimization of our antimicrobial strategies.

Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush

The objectives of the study were to determine the agreement between the protected specimen brush technique (PSB) with quantitative cultures and endotracheal aspirates (EA) with quantitative cultures when using increasing interpretative cutoff points and to investigate the respective operating characteristics for the diagnosis of pneumonia of PSB and EA when using quantitative cultures. Consecutive sampling of respiratory secretions using these two techniques was conducted in the respiratory intensive care units in 52 mechanically ventilated patients with clinical and radiologic suspicion of pneumonia. Quantitative bacterial cultures of PSB and EA samples were obtained. The 10(6) cfu/ml cutoff point was the most accurate diagnostic threshold for the EA technique. When using this threshold, there was a high level of agreement (84.6%) between PSB and EA results. Among the few discrepancies, the EA result was always indicative of pneumonia, whereas the PSB result was nonindicative, thus permitting us to classify correctly five patients in whom pneumonia would have been erroneously excluded on the basis of the sole result of PSB. Conversely, there was no case where the PSB result was indicative of pneumonia when the EA result (at the 10(6) cfu/ml level) was not. The operating characteristics of the PSB technique for the diagnosis of pneumonia were in accordance with previously published studies. The operating characteristics of the EA technique (when taking the 10(6) cfu/ml of respiratory secretions as the interpretative cutoff point) compared favorably with those of the PSB technique. Diagnostic accuracy rates were similar. The specificity of EA was somewhat lower (83 versus 96%), but the sensitivity was higher (82 versus 64%).(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of vancomycin during continuous hemodiafiltration

OBJECTIVE

To study the pharmacokinetics of vancomycin in three patients with acute renal failure related to multi-organ failure during continuous venovenous hemodiafiltration (CVVHD).

DESIGN

Prospective exploratory, open-labelled study.

SETTING

Critical Care Unit in a University Medical Centre.

PATIENTS

3 patients exhibiting hemodynamic instability and oligo-anuric acute renal failure requiring extra-renal epuration were included in this study.

INTERVENTION

Every patient received 7.5 mg/kg IV vancomycin over 1 h for a documented or suspected nosocomial staphylococcal infection. Serum and dialysate outlets samples were collected before infusion and 1, 3, 6, 12, 18, 24 after the end of infusion.

MEASUREMENTS AND RESULTS

Mean age was 58.7 years (range 41-79) and mean SAPS 15.7 (9-23). The mean peak concentrations were 27.3 mg/l (range 15.6-45.6) one hour after the end of infusion. The average remaining vancomycin concentration 24 h after the onset of infusion was 3.6 mg/l (range 2.6-4.5). The mean terminal disposition rate constant and elimination half-life were 0.05 h-1 and 13.9 h respectively. Mean total body clearance was 38.9 +/- 4.3 ml/min and dialysate outlet (DO) clearance 4.2 +/- 1.3 ml/min. The mean volume of distribution was 47.4 +/- 6.4 l.

CONCLUSION

CVVHD is effective for vancomycin elimination. In these patients, the elimination half-life is almost constant, involving a following injection of vancomycin 12 h later to achieve effective concentrations.