Lung abscess following ventilator-associated pneumonia during COVID-19: a retrospective multicenter cohort study

BACKGROUND

Patients undergoing mechanical ventilation (MV) for COVID-19 exhibit an increased risk of ventilator-associated pneumonia (VAP). The occurrence of lung abscesses following VAP in these patients has been poorly studied. We aimed to describe the incidence, characteristics, risk factors and prognosis of lung abscesses complicating VAP after COVID-19.

METHODS

We conducted an observational, retrospective study in three French intensive care units. Patients admitted for acute respiratory failure with a confirmed SARS-CoV-2 PCR and requiring MV for more than 48 h were included.

RESULTS

Among the 507 patients included, 326 (64%) had a documented VAP. Of these, 23 (7%) developed a lung abscess. Enterobacterales (15/23, 65%) were the main documentation, followed by non-fermenting Gram-negative bacilli (10/23, 43%) and Gram-positive cocci (8/23, 35%). Lung abscesses were mainly plurimicrobial (15/23, 65%). In multivariate analysis, a plurimicrobial 1st VAP episode (OR (95% CI) 2.93 (1.16-7.51); p = 0.02) and the use of hydrocortisone (OR (95% CI) 4.86 (1.95-12.1); p = 0.001) were associated with lung abscess development. Intensive care unit (ICU) mortality of patients with lung abscesses reached 52%, but was not significantly higher than for patients with VAP but no lung abscess. Patients with lung abscesses had reduced ventilator-free days at day 60, a longer duration of MV and ICU stay than patients with VAP but no lung abscess (respectively, 0 (0-3) vs. 16 (0-42) days; p < 0.001, 49 (32-73) vs. 25 (11-41) days; p < 0.001, 52 (36-77) vs. 28 (16-47) days; p < 0.001).

CONCLUSIONS

Lung abscessing pneumonia is not uncommon among COVID-19 patients developing VAP. A plurimicrobial first VAP episode and the use of hydrocortisone are independently associated with this complication. In COVID-19 patients with persistent VAP, a chest CT scan investigating the evolution toward lung abscess should be considered.

Prévalence importante et mauvais pronostic de la dysfonction tubulaire proximale au cours du SDRA COVID en réanimation : l’étude URICOV

Introduction

La protéinurie et l’insuffisance rénale aiguë sont fréquentes au cours du COVID-19, et associées à la morbi-mortalité, mais la pathogénicité directe du SARS-CoV-2 sur le rein reste débattue. Notre objectif était d’évaluer la prévalence et la valeur pronostique de la tubulopathie proximale chez les patients en SDRA COVID en réanimation.

Description

Dans cette étude de cohorte prospective multicentrique, étaient inclus les patients majeurs présentant une détresse respiratoire nécessitant la ventilation mécanique avec rapport PaO2/FiO2 < 300 dans les 24 h de l’intubation.

Méthodes

Nous réalisions une analyse détaillée des marqueurs de dysfonction rénale avec électrophorèse des protéines urinaires (EPU) dans les 24 h de l’intubation chez 85 patients en réanimation pour un SDRA COVID.

Résultats

Seulement 16 (18,8 %) des patients présentaient une IRA initiale. L’uricémie était abaissée (moyenne 212 μmol/L), 87,1 % des patients présentaient une glycosurie. Une hématurie microscopique était retrouvée chez 74 (87,1 %) patients. Les rapports protéinurie/créatinine et albuminurie/créatinine étaient de 785 et 142 mg/g. L’EPU retrouvant un profil tubulaire chez 91 % des patients, avec une atteinte glomérulaire surajoutée dans chez 17 %. Il existait une fuite urinaire massive d’alpha-1-microglobuline (a1 m, 96,1 % des patients), beta-2-microglobuline (b2 m, 95,8 %), chaînes légères kappa et lambda (CLL) (100 % et 93,5 %) et Vitamine-D-Binding-Protein (87,5 %). Après un suivi moyen de 28 jours, 37 patients (43,5 %) ont développé une insuffisance rénale aiguë (13 KDIGO3, 3 nécessitant la dialyse). Les patients ayant développé une IRA KDIGO3 avaient une urémie, une créatininémie, des rapports protéinurie/créatininurie, albuminurie/créatininurie et a1 m/créatininurie significativement plus élevés et une bicarbonatémie plus basse. La dexamethasone semblait protéger de l’IRA. La survenue d’une IRA et des rapports b2 m/créatininurie et CLLl/créatininurie plus élevés était associés à la mortalité (p = 0,027, p = 0,04, p = 0,005, respectivement) (Fig. 1).

Conclusion

Les patients développant un SDRA au cours du COVID-19 présentent une dysfonction tubulaire proximale, précédant l’IRA, qui semble être un mécanisme important de la néphropathie COVID et pourrait être un marqueur de sévérité.

[Ventilator-associated viral pneumonia]

Viral infections (especially respiratory infections) are not rare in critically ill non-immunocompromised patients. Efficient and rapid virologic diagnosis tests such as polymerase chain reaction (PCR) are now widely available. Herpesviridae (herpes simplex virus and cytomegalovirus) are the most frequent viruses detected among non-immunocompromised patients admitted to the intensive care unit (ICU). However, causal relationships between detected viruses and outcomes are still debated, with a variable level of demonstration among the different viruses. The aim of this review was to assess the role of viruses in causing mechanical ventilation-acquired pneumonias in non-immunocompromised ICU adult patients. We also discuss the possible physiopathology of these viral infections, as well as the opportunity for therapeutic interventions.

Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy

Background

The aim of this case–control study was to compare the efficacy of non-invasive positive pressure ventilation (NPPV) with that of conventional treatment in patients who develop postoperative acute respiratory failure (ARF) after oesophagectomy.

Methods

Thirty-six consecutive patients with ARF treated by NPPV were matched for diagnosis, age within 5 years, sex, preoperative radiochemotherapy and Charlson co-morbidity index with 36 patients who received conventional treatment (control group).

Results

NPPV was associated with a lower reintubation rate (nine versus 23 patients; P = 0·008), lower frequency of acute respiratory distress syndrome (eight versus 19 patients; P = 0·015), and a reduction in intensive care stay (mean(s.d.) 14(13) versus 22(18) days; P = 0·034). Anastomotic leakage was less common in patients receiving NPPV (two versus ten; P = 0·027). These patients also showed a greater improvement in gas exchange in the first 3 days after onset of ARF (P = 0·013).

Conclusion

The use of NPPV for the treatment of postoperative ARF may decrease the incidence of endotracheal intubation and related complications, without increasing the risk of anastomotic leakage after oesophagectomy.

[Acute respiratory distress syndrome following inhalation of barium sulfate]

INTRODUCTION

Barium sulfate (BS) is chosen to explore swallowing disorders because of its reduced osmolality allowing no adverse reaction if aspirated in the bronchial tree.

CASE REPORT

A 66-years old man treated for an advanced stage mesothelioma experienced a BS aspiration during an esophagography. He developed 3 days after an acute respiratory distress syndrome (ARDS) and deceased. The post-mortem examination revealed a diffuse alveolar damage (DAD).

CONCLUSION

Whereas BS aspiration is generally well tolerated, serious adverse event as a DAD would exceptionally occurs. Thus, a close watch over respiratory symptoms has to be kept after BS administration, especially in debilitated and elderly patients.