Adaptive resistance to cefiderocol in carbapenem-resistant Acinetobacter baumannii (CRAB): Microbiological and clinical issues

Objectives

Determining the best available therapy for carbapenem-resistant Acinetobacter baumannii (CRAB) infections is a challenge. Cefiderocol is an attractive alternative drug effective against many resistance mechanisms in Gram-negative bacteria. However, its place in the treatment of Acinetobacter baumannii infections remains unclear and much debated, with contradictory results.

Methods

We describe here the case of a 37-year-old man with ventilator-associated bacteraemic CRAB pneumonia in an intensive care unit. He was initially treated with a combination of colistin and tigecycline, and was then switched onto colistin and cefiderocol. We then used a new accessible protocol to test 30 CRAB isolates (OXA-23/OXA-24/OXA-58/NDM-1) for adaptive resistance to cefiderocol (ARC) after exposure to this drug.

Results

After clinical failure with the initial combination, we noted a significant clinical improvement in the patient on the second combination, leading to clinical cure. No ARC was detected in the two OXA-23 case-CRAB isolates. All NDM-1 CRAB isolates were resistant to cefiderocol in standard tests; the OXA-23, OXA-24 and OXA-58 CRAB isolates presented 84.2 %, 50 % and 0 % ARC, respectively.

Conclusions

ARC is not routinely assessed for CRAB isolates despite frequently being reported in susceptible isolates (69.2 %). Subpopulations displaying ARC may account for treatment failure, but this hypothesis should be treated with caution in the absence of robust clinical data. The two main findings of this work are that (i) cefiderocol monotherapy should probably not be recommended for OXA-23/24 CRAB infections and (ii) the characterisation of carbapenemases in CRAB strains may be informative for clinical decision-making.

A transformer model for cause-specific hazard prediction

BACKGROUD

Modelling discrete-time cause-specific hazards in the presence of competing events and non-proportional hazards is a challenging task in many domains. Survival analysis in longitudinal cohorts often requires such models; notably when the data is gathered at discrete points in time and the predicted events display complex dynamics. Current models often rely on strong assumptions of proportional hazards, that is rarely verified in practice; or do not handle sequential data in a meaningful way. This study proposes a Transformer architecture for the prediction of cause-specific hazards in discrete-time competing risks. Contrary to Multilayer perceptrons that were already used for this task (DeepHit), the Transformer architecture is especially suited for handling complex relationships in sequential data, having displayed state-of-the-art performance in numerous tasks with few underlying assumptions on the task at hand.

RESULTS

Using synthetic datasets of 2000-50,000 patients, we showed that our Transformer model surpassed the CoxPH, PyDTS, and DeepHit models for the prediction of cause-specific hazard, especially when the proportional assumption did not hold. The error along simulated time outlined the ability of our model to anticipate the evolution of cause-specific hazards at later time steps where few events are observed. It was also superior to current models for prediction of dementia and other psychiatric conditions in the English longitudinal study of ageing cohort using the integrated brier score and the time-dependent concordance index. We also displayed the explainability of our model's prediction using the integrated gradients method.

CONCLUSIONS

Our model provided state-of-the-art prediction of cause-specific hazards, without adopting prior parametric assumptions on the hazard rates. It outperformed other models in non-proportional hazards settings for both the synthetic dataset and the longitudinal cohort study. We also observed that basic models such as CoxPH were more suited to extremely simple settings than deep learning models. Our model is therefore especially suited for survival analysis on longitudinal cohorts with complex dynamics of the covariate-to-outcome relationship, which are common in clinical practice. The integrated gradients provided the importance scores of input variables, which indicated variables guiding the model in its prediction. This model is ready to be utilized for time-to-event prediction in longitudinal cohorts.

Severe leptospirosis in tropical and non-tropical areas: A comparison of two french, multicentre, retrospective cohorts

BACKGROUND

Leptospirosis is an anthropozoonosis that occurs worldwide but is more common in tropical regions. Severe forms may require intensive care unit (ICU) admission. Whether the clinical patterns and outcomes differ between tropical and non-tropical regions with similar healthcare systems is unclear. Our objective here was to address this issue by comparing two cohorts of ICU patients with leptospirosis managed in mainland France and in the overseas French department of Réunion, respectively.

METHODOLOGY/PRINCIPAL FINDINGS

We compared two retrospective cohorts of patients admitted to intensive care for severe leptospirosis, one from Reunion Island in the Indian Ocean (tropical climate) and the other from metropolitan France (temperate climate). Chi-square and Student's t tests were used for comparisons. After grouping the two cohorts, we also performed multiple correspondence analysis and hierarchical clustering to search for distinct clinical phenotypes. The Réunion and Metropolitan France cohorts comprised 128 and 160 patients respectively. Compared with the Réunion cohort, the metropolitan cohort had a higher mean age (42.5±14.1 vs. 51.4±16.5 years, p<0.001). Severity scores, length of stay and mortality did not differ between the two cohorts. Three phenotypes were identified: hepato-renal leptospirosis (54.5%) characterized by significant hepatic, renal and coagulation failure, with a mortality of 8.3%; moderately severe leptospirosis (38.5%) with less severe organ failure and the lowest mortality rate (1.8%); and very severe leptospirosis (7%) manifested by neurological, respiratory and cardiovascular failure, with a mortality of 30%.

CONCLUSIONS/SIGNIFICANCE

The outcomes of severe leptospirosis requiring ICU admission did not differ between tropical and temperate regions with similar healthcare access, practices, and resources, despite some differences in patient characteristics. The identification of three different clinical phenotypes may assist in the early diagnosis and management of severe leptospirosis.

The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality.

DESIGN

This was a retrospective and observational study.

SETTING

The study was conducted at a University hospital.

PARTICIPANTS

This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021.

METHODS

The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio.

RESULTS

A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality.

CONCLUSIONS

In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.

Clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making

OBJECTIVES

The aim of this study using decision curve analysis (DCA) was to evaluate the clinical utility of a deep-learning mortality prediction model for cardiac surgery decision making compared with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II and to 2 machine-learning models.

METHODS

Using data from a French prospective database, this retrospective study evaluated all patients who underwent cardiac surgery in 43 hospital centers between January 2012 and December 2020. A receiver operating characteristic analysis was performed to compare the accuracy of the EuroSCORE II, machine-learning models, and an adapted Tabular Bidirectional Encoder Representations from Transformers deep-learning model in predicting postoperative in-hospital mortality. The clinical utility of these models for cardiac surgery decision making was compared using DCA.

RESULTS

Over the study period, 165,640 patients underwent cardiac surgery, with a mean EuroSCORE II of 3.99 ± 6.67%. In the receiver operating characteristic analysis, the area under the curve was significantly greater for the deep-learning model (0.834; 95% confidence interval, 0.831-0.838) than the EuroSCORE II (P < .001), the random forest model (P = .03), and the Extreme Gradient Boosting model (P = .03). In the DCA, the clinical utility of the 3 artificial intelligence models was superior to that of the EuroSCORE II, especially when the threshold probability of death was high (>45%). The deep-learning model showed the greatest advantage over the EuroSCORE II.

CONCLUSIONS

The deep-learning model had better predictive accuracy and greater clinical utility than the EuroSCORE II and the 2 machine-learning models. These findings suggest that deep learning with Tabular Bidirectional Encoder Representations from Transformers prediction model could be used in the future as the gold standard for cardiac surgery decision making.

Introducing the BlendedICU dataset, the first harmonized, international intensive care dataset

OBJECTIVE

This study introduces the BlendedICU dataset, a massive dataset of international intensive care data. This dataset aims to facilitate generalizability studies of machine learning models, as well as statistical studies of clinical practices in the intensive care units.

METHODS

Four publicly available and patient-level intensive care databases were used as source databases. A unique and customizable preprocessing pipeline extracted clinically relevant patient-related variables from each source database. The variables were then harmonized and standardized to the Observational Medical Outcomes Partnership (OMOP) Common Data Format. Finally, a brief comparison was carried out to explore differences in the source databases.

RESULTS

The BlendedICU dataset features 41 timeseries variables as well as the exposure times to 113 active ingredients extracted from the AmsterdamUMCdb, eICU, HiRID, and MIMIC-IV databases. This resulted in a database of more than 309000 intensive care admissions, spanning over 13 years and three countries. We found that data collection, drug exposure, and patient outcomes varied strongly between source databases.

CONCLUSION

The variability in data collection, drug exposure, and patient outcomes between the source databases indicated some dissimilarity in patient phenotypes and clinical practices between different intensive care units. This demonstrated the need for generalizability studies of machine learning models. This study provides the clinical data research community with essential data to build efficient and generalizable machine learning models, as well as to explore clinical practices in intensive care units around the world.

Impact of the COVID-19 pandemic on severe non-SARS-CoV-2 community-acquired pneumonia in Reunion Island: a multicenter retrospective observational study, 2016-2021

The Coronavirus 2019 (COVID-19) pandemic has had a considerable impact on the incidence of severe community-acquired pneumonia (CAP) worldwide. The aim of this study was to assess the early impact of the COVID-19 pandemic in the Reunion Island. This multicenter retrospective observational study was conducted from 2016 to 2021 in the hospitals of Reunion Island. The incidence of severe non-SARS-CoV-2 CAP, microorganisms, characteristics and outcomes of patients hospitalized in intensive care unit were compared between the pre-COVID-19 period (January 1, 2016 to February 29, 2020) and the early COVID-19 period (March 1, 2020 to October 31, 2021). Over the study period, 389 patients developed severe non-SARS-CoV-2 CAP. The incidence of severe non-SARS-CoV-2 CAP significantly decreased between the two periods (9.16 vs. 4.13 cases per 100,000 person-years). The influenza virus was isolated in 43.5% patients with severe non-SARS-CoV-2 CAP in the pre-COVID-19 period and in none of the 60 patients in the early COVID-19 period (P < 0.0001). The only virus that did not decrease was rhinovirus. Streptococcus pneumoniae was the most frequently isolated bacterial microorganism, with no significant difference between the two periods. In Reunion Island, the COVID-19 pandemic led to a significant decrease in the incidence of influenza, which likely explains the observed decrease in the incidence of severe non-SARS-CoV-2 CAP. The pandemic had no impact on the incidence of other viral and bacterial severe non-SARS-CoV-2 CAP. Monitoring influenza incidence is crucial now that COVID-19 control measures have been removed.

Image augmentation and automated measurement of endotracheal-tube-to-carina distance on chest radiographs in intensive care unit using a deep learning model with external validation

BACKGROUND

Chest radiographs are routinely performed in intensive care unit (ICU) to confirm the correct position of an endotracheal tube (ETT) relative to the carina. However, their interpretation is often challenging and requires substantial time and expertise. The aim of this study was to propose an externally validated deep learning model with uncertainty quantification and image segmentation for the automated assessment of ETT placement on ICU chest radiographs.

METHODS

The CarinaNet model was constructed by applying transfer learning to the RetinaNet model using an internal dataset of ICU chest radiographs. The accuracy of the model in predicting the position of the ETT tip and carina was externally validated using a dataset of 200 images extracted from the MIMIC-CXR database. Uncertainty quantification was performed using the level of confidence in the ETT-carina distance prediction. Segmentation of the ETT was carried out using edge detection and pixel clustering.

RESULTS

The interrater agreement was 0.18 cm for the ETT tip position, 0.58 cm for the carina position, and 0.60 cm for the ETT-carina distance. The mean absolute error of the model on the external test set was 0.51 cm for the ETT tip position prediction, 0.61 cm for the carina position prediction, and 0.89 cm for the ETT-carina distance prediction. The assessment of ETT placement was improved by complementing the human interpretation of chest radiographs with the CarinaNet model.

CONCLUSIONS

The CarinaNet model is an efficient and generalizable deep learning algorithm for the automated assessment of ETT placement on ICU chest radiographs. Uncertainty quantification can bring the attention of intensivists to chest radiographs that require an experienced human interpretation. Image segmentation provides intensivists with chest radiographs that are quickly interpretable and allows them to immediately assess the validity of model predictions. The CarinaNet model is ready to be evaluated in clinical studies.

A descriptive study of routine laboratory testing in intensive care unit in nearly 140,000 patient stays

To describe the relationship between the use of laboratory tests and changes in laboratory parameters in ICU patients is necessary to help optimize routine laboratory testing. A retrospective, descriptive study was conducted on the large eICU-Collaborative Research Database. The relationship between the use of routine laboratory tests (chemistry and blood counts) and changes in ten common laboratory parameters was studied. Factors associated with laboratory tests were identified in a multivariate regression analysis using generalized estimating equation Poisson models. The study included 138,734 patient stays, with an ICU mortality of 8.97%. For all parameters, the proportion of patients with at least one test decreased from day 0 to day 1 and then gradually increased until the end of the ICU stay. Paradoxically, the results of almost all tests moved toward normal values, and the daily variation in the results of almost all tests decreased over time. The presence of an arterial catheter or teaching hospitals were independently associated with an increase in the number of laboratory tests performed. The paradox of routine laboratory testing should be further explored by assessing the factors that drive the decision to perform routine laboratory testing in ICU and the impact of such testing on patient.

Prognosis of patients with acute respiratory failure due to the SARS-CoV-2 501Y.V2 variant: a multicenter retrospective matched cohort study

The aim of this study was to compare the prognosis of patients with acute respiratory failure (ARF) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant 501Y.V2 to that of patients with ARF due to the original strain. This retrospective matched cohort study included all consecutive patients who were hospitalized for ARF due to SARS-CoV-2 in Reunion Island University Hospital between March 2020 and March 2021. Twenty-eight in hospital mortality was evaluated before and after matching. A total of 218 patients with ARF due to SARS-CoV-2 were enrolled in the study. Of these, 83 (38.1%) were infected with the 501Y.V2 variant. During intensive care unit stay, 104 (47.7%) patients received invasive mechanical ventilation and 20 (9.2%) patients were supported by venovenous extracorporeal membrane oxygenation. Patients infected with the 501Y.V2 variant were younger (58 [51–68] vs. 67 [56–74] years old, P = 0.003), had less hypertension (54.2% vs 68.1%, P = 0.04), and had less chronic kidney disease (13.3% vs. 31.9%, P = 0.002) than patients infected with the original strain. After controlling for confounding variables (62 matched patients in each group), 28-day mortality was higher in the group of patients infected with the 501Y.V2 variant (30.6%) than in the group of patients infected with the original strain (19.4%, P = 0.04). In Reunion Island, where SARS-CoV-2 incidence remained low until February 2021 and the health care system was never saturated, mortality was higher in patients with ARF infected with the 501Y.V2 variant than in patients infected with the original strain.

Severe community-acquired pneumonia in Reunion Island: Epidemiological, clinical, and microbiological characteristics, 2016–2018

Purpose

No data are available on severe community-acquired pneumonia (CAP) in the French overseas department of Reunion Island. This is unfortunate as the microorganisms responsible for the disease are likely to differ from those in temperate regions due to a tropical climate and proximity to other islands of the Indian Ocean region. The aim of this study was to assess the epidemiological, clinical, prognosis, and microbiological characteristics of patients with severe CAP in Reunion Island.

Materials and methods

This retrospective study evaluated all patients with CAP aged >18 years and hospitalized in one of the two intensive care units of Reunion Island between 2016 and 2018. Microorganisms were identified by culture from blood and respiratory samples, multiplex polymerase chain reaction from respiratory samples, urinary antigen tests, and serology.

Results

Over the study period, 573 cases of severe CAP were recorded, with a mean incidence of 22 per 100,000 person-years. The most frequently isolated microorganism was influenza (21.9%) followed by Streptococcus pneumoniae (12%). The influenza virus was detected in affected patients all year round. Twenty-four patients with severe CAP came from another island of the Indian Ocean region (4.2%), mainly Madagascar (>50%). Two of these patients presented with melioidosis and 4 were infected with Acinetobacter spp.

Conclusions

Our findings have major implications for the management of severe CAP in tropical regions. The most frequently isolated microorganism in patients with severe CAP in Reunion Island is influenza followed by S. pneumoniae. Physicians should be aware that influenza is the main cause of severe CAP in patients living in or returning from Reunion Island, where this virus circulates all year round.

Emergency air evacuation of patients with acute respiratory failure due to SARS-CoV-2 from Mayotte to Reunion Island

In February 2021, an explosion of cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia overwhelmed the only hospital in Mayotte. To report a case series of patients with acute respiratory failure (ARF) due to SARS-CoV-2 who were evacuated by air from Mayotte to Reunion Island.This retrospective observational study evaluated all consecutive patients with ARF due to SARS-CoV-2 who were evacuated by air from Mayotte Hospital to the intensive care unit (ICU) of Félix Guyon University Hospital in Reunion Island between February 2, and March 5, 2021.A total of 43 patients with SARS-CoV-2 pneumonia were evacuated by air, for a total flight time of 2 hours and a total travel time of 6 hours. Of these, 38 patients (88.4%) with a median age of 55 (46-65) years presented with ARF and were hospitalized in our ICU. Fifteen patients were screened for the SARS-CoV-2 501Y.V2 variant, all of whom tested positive. Thirteen patients (34.2%) developed an episode of severe hypoxemia during air transport, and the median paO2/FiO2 ratio was lower on ICU admission (140 [102-192] mmHg) than on departure (165 [150-200], P = .022). Factors associated with severe hypoxemia during air transport was lack of treatment with curare (P = .012) and lack of invasive mechanical ventilation (P = .003). Nine patients (23.7%) received veno-venous extracorporeal membrane oxygenation support in our ICU. Seven deaths (18.4%) occurred in hospital.Emergency air evacuation of patients with ARF due to SARS-CoV-2 was associated with severe hypoxemia but remained feasible. In cases of ARF due to SARS-CoV-2 requiring emergency air evacuation, sedated patients receiving invasive mechanical ventilation and curare should be prioritized over nonintubated patients. It is noteworthy that patients with SARS-CoV-2 pneumonia related to the 501Y.V2 variant were very severe despite their young age.

Effect of antibiotic therapy on the prognosis of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia

BACKGROUND

Ventilator-associated pneumonia (VAP) caused by Stenotrophomonas maltophilia is poorly described in the literature. However, it has been shown to be associated with increased morbidity and mortality. Probabilistic antibiotic therapy against S. maltophilia is often ineffective as this pathogen is resistant to many antibiotics. There is no consensus at present on the best therapeutic strategy to adopt (class of antibiotics, antibiotic combination, dosage, treatment duration). The aim of this study was to evaluate the effect of antibiotic therapy strategy on the prognosis of patients with VAP caused by S. maltophilia.

RESULTS

This retrospective study evaluated all consecutive patients who developed VAP caused by S. maltophilia between 2010 and 2018 while hospitalized in the intensive care unit (ICU) of a French university hospital in Reunion Island, in the Indian Ocean region. A total of 130 patients with a median Simplified Acute Physiology Score II of 58 [43-73] had VAP caused by S. maltophilia after a median duration of mechanical ventilation of 12 [5-18] days. Ventilator-associated pneumonia was polymicrobial in 44.6% of cases, and ICU mortality was 50.0%. After multivariate Cox regression analysis, the factors associated with increased ICU mortality were older age (hazard ratio (HR): 1.03; 95% CI 1.01-1.04, p = 0.001) and high Sequential Organ Failure Assessment score on the day of VAP onset (HR: 1.08; 95% CI 1.03-1.14, p = 0.002). Appropriate antibiotic therapy, and in particular trimethoprim-sulfamethoxazole, was associated with decreased ICU mortality (HR: 0.42; 95% CI 0.24-0.74, p = 0.003) and decreased hospital mortality (HR: 0.47; 95% CI 0.28-0.79, p = 0.04). Time to start of appropriate antibiotic therapy, combination therapy, and duration of appropriate antibiotic therapy had no effect on ICU mortality (p > 0.5).

CONCLUSION

In our study, appropriate antibiotic therapy, and in particular trimethoprim-sulfamethoxazole, was associated with decreased ICU and hospital mortality in patients with VAP caused by S. maltophilia.

Effect of Body Mass Index on the Clinical Outcomes of Adult Patients Treated With Venoarterial ECMO for Cardiogenic Shock

OBJECTIVE

Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock.

DESIGN

This was a retrospective and observational study.

SETTING

University hospital.

PARTICIPANTS

The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications.

CONCLUSION

The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.

Nosocomial cluster of carbapenemase-producing Enterobacter cloacae in an intensive care unit dedicated COVID-19

Concomitant prevention of SARS-CoV-2 and extensively drug-resistant bacteria transmission is a difficult challenge in intensive care units dedicated to COVID-19 patients. We report a nosocomial cluster of four patients carrying NDM-1 plasmid-encoded carbapenemase-producing Enterobacter cloacae. Two main factors may have contributed to cross-transmission: misuse of gloves and absence of change of personal protective equipment, in the context of COVID-19-associated shortage. This work highlights the importance of maintaining infection control measures to prevent CPE cross-transmission despite the difficult context and that this type of outbreak can potentially involve several species of Enterobacterales.

Profil épidémiologique des décès en réanimation à La Réunion

Introduction

En mars 2020, l’Organisation Mondiale de la Santé déclare comme une pandémie le SARS-CoV-2. Avec une circulation active de ce virus respiratoire, les services de réanimation de La Réunion ont fait face à une augmentation de cas graves Covid-19. L’objectif de notre présentation est de dresser le « portrait-robot » des cas graves décédés admis dans un service de réanimation à partir d’indicateurs temporels, démographiques et cliniques et constater si ce profil a évolué.

Matériels et méthodes

La période retenue dans notre étude est de mars 2020 à mars 2021. Un cas grave est défini par: un patient présentant une confirmation biologique d’infection au SARS-CoV2 et nécessitant une prise en charge en réanimation. Les données analysées sont issues de la surveillance active des cas graves développée et animée par Santé publique France. Les cas graves hors résidence à la Réunion ont été exclus.

Résultats

Au 31 mars 2021, 38 cas graves sont décédés soit un taux de létalité de 19% (n = 38/197). Entre 2020 et 2021, on ne constate pas de différence du taux de létalité avec respectivement 20 % et 18 %. Le sex-ratio (H/F) est de 0,9. L’âge médian est de 68 ans. La durée médiane de séjour en réanimation est de 9,5 jours avec un minimum de 0 et un maximum de 38 jours. La répartition par classe d’âge révèle que les 65-74 ont le taux de létalité le plus élevé avec 30,6 %. À l’opposé, les 15-44 ans et les 45-64 ans enregistrent une létalité plus faible avec respectivement 7,7% e 16,6 %. Il faut souligner, que la classe d’âge 75 ans et plus considérée comme une population vulnérable à un taux de létalité de 19% équivalent au taux de létalité général. D’un point de vue des indicateurs cliniques, plus de 9 décès sur 10 présentent au moins un facteur de risque (p < 0,001). Les comorbidités les plus fréquemment rapportées sont l’hypertension artérielle (63 %), le diabète (55 %) et l’obésité (39%). Les cas graves décédés ont en moyenne au moins deux comorbidités. À propos de la gravité, 81% des décès ont développés un SDRA dont 63% un SDRA sévère (p < 0,001). Pour la prise en charge thérapeutique, l’oxygénothérapie haute débit (58 %), la ventilation invasive (47 %) et l’ECMO (24 %) ont été les pratiques d’assistance respiratoires privilégiées. Entre 2020 et 2021, nous constatons une modification du profil démographique des décès en réanimation. En 2020, l’âge médian est de 70 ans. Pour 2021, il baisse à 62 ans. En outre, alors qu’en 2020 la majorité des décès est attribuable aux femmes (61 %) pour 2021, 60 % des décès sont des hommes. À l’heure actuelle, on ne constate pas de changement dans la durée de séjour, la gravité, et les comorbidités entre les patients décédés en 2020 et ceux de 2021.

Conclusion

Le profil type d’une personne décédée en réanimation est: une personne de 65-74 ans, présentant au moins deux facteurs de comorbidités comme l’hypertension artérielle, un diabète ou une obésité avec un SDRA sévère. La circulation du variant sud-africain à partir de janvier 2021 a probablement modifié la démographie du profil. Pour confirmer cette hypothèse, les résultats de séquençage des cas graves permettraient de le confirmer. Une seconde hypothèse du rajeunissement des cas graves décédés est la vaccination en janvier 2021 des personnes de 75 ans plus.

Molecular and epidemiological investigation of a colistin-resistant OXA-23-/NDM-1-producing Acinetobacter baumannii outbreak in the Southwest Indian Ocean Area

Dual resistance to colistin and carbapenems is a milestone reached by certain extensively-drug resistant (XDR) Gram-negative bacteria. This study describes the first outbreak of XDR colistin- and carbapenem-resistant OXA-23-/NDM-1-producing Acinetobacter baumannii (CCRAB) in the European overseas territory of Reunion Island (France, Indian Ocean). Between April 2019 and June 2020, 13 patients admitted to the University Hospital of Reunion Island were involved in the outbreak, of whom eight were infected and six died. The first case was traced to a medical evacuation from Mayotte Island (Comoros archipelago). An epidemiological link could be established for 11 patients. All of the collected CCRAB isolates showed the same resistance profile and co-produced intrinsic β-lactamases OXA-69 and ADC-191, together with acquired carbapenem-hydrolysing β-lactamases OXA-23 and NDM-1. A mutation likely involved in colistin resistance was detected in the two-component system PmrAB (D82N in PmrA). All of the isolates were found to belong to ST^Pas1/ST^Ox231 clonal complex and were phylogenetically indistinguishable. Their further characterization by whole-genome sequence analyses (whole-genome multi-locus sequence typing, single nucleotide polymorphisms) provided hints about the transmission pathways. This study pleads for strict application of control and prevention measures in institutions where the risk of imported XDR bacteria is high.

Case Report: Transmission of Dengue Virus from a Deceased Donor to a Kidney Transplant Recipient Previously Infected by Dengue Virus

Since 2018, a dengue epidemic has been ongoing in the French overseas department of Reunion Island, in the Indian Ocean, with more than 25,000 serologically confirmed cases. Currently, three dengue serotypes have been identified in Réunion Island (DENV-1, DENV-2, and DENV-3) progressing in the form of epidemic outbreaks. This arbovirus is mainly transmitted by mosquitoes of the genus Aedes and may be responsible for serious clinical forms. To date, very few cases of kidney transplant-related dengue virus infection have been described. Here we report the first case of severe dengue virus infection related to kidney transplantation from a patient previously infected with dengue. Testing for dengue fever with PCR search in donor's urine may help complete the pretransplant assessment in areas where this disease occurs.

Co-infection in patients with hypoxemic pneumonia due to COVID-19 in Reunion Island

This study aimed to evaluate the incidence of co-infection with different types of pathogens in patients with hypoxemic pneumonia due to coronavirus disease 2019 (COVID-19) in Reunion Island.This observational study using a prospectively collected database of hypoxemic pneumonia due to COVID-19 cases was conducted at Félix Guyon University Hospital in Reunion Island, France.Between 18 March 2020 and 15 April 2020, 156 patients were admitted to our hospital for COVID-19. A total of 36 patients had hypoxemic pneumonia (23.1%) due to COVID-19. Thirty of these cases (83.3%) were imported by travelers returning mainly from metropolitan France and Spain. Patients were screened for co-infection with other pathogens at admission: 31 (86.1%) by multiplex polymerase chain reaction (PCR) and 16 (44.4%) by cytobacteriological examination of sputum culture. Five patients (13.9%) were found to have co-infection: 1 with influenza virus A H1N1 (pdm09) associated with Branhamella catarrhalis, 1 with Streptococcus pneumoniae associated with Haemophilus influenzae, 1 with Human Coronavirus 229E, 1 with Rhinovirus, and 1 with methicillin-susceptible Staphylococcus aureus. Patients with co-infection had higher D-dimer levels than those without co-infection (1.36 [1.34-2.36] μg/mL vs 0.63 [0.51-1.12] μg/mL, P = .05).The incidence of co-infection in our cohort was higher than expected (13.9%). Three co-infections (with influenza virus A(H1N1) pdm09, Streptococcus pneumoniae, and Staphylococcus aureus) required specific treatment. Patients with hypoxemic pneumonia due to COVID-19 should be screened for co-infection using respiratory cultures or multiplex PCR. Whilst our study has a number of limitations, the results from our study suggest that in the absence of screening, patients should be commenced on treatment for co-infection in the presence of an elevated D-dimer.

Differential diagnoses of severe COVID-19 in tropical areas: the experience of Reunion Island

OBJECTIVE

To identify the differential diagnoses of severe COVID-19 and the distinguishing characteristics of critically ill COVID-19 patients in Reunion Island to help improve the triage and management of patients in this tropical setting.

METHODS

This retrospective observational study was conducted from 11 March to 4 May 2020 in the only intensive care unit (ICU) authorised to manage COVID-19 patients in Reunion Island, a French overseas department located in the Indian Ocean region. All patients with unknown COVID-19 status were tested by polymerase chain reaction (PCR) on ICU admission; those who tested negative were transferred to the COVID-19-free area of the ICU.

RESULTS

Over the study period, 99 patients were admitted to our ICU. A total of 33 patients were hospitalised in the COVID-19 isolation ward, of whom 11 were positive for COVID-19. The main differential diagnoses of severe COVID-19 were as follows: community-acquired pneumonia, dengue, leptospirosis causing intra-alveolar haemorrhage and cardiogenic pulmonary oedema. The median age of COVID-19-positive patients was higher than that of COVID-19-negative patients (71 [58-74] vs. 54 [46-63.5] years, P = 0.045). No distinguishing clinical, biological or radiological characteristics were found between the two groups of patients. All COVID-19-positive patients had recently travelled or been in contact with a recent traveller.

CONCLUSIONS

In Reunion Island, dengue and leptospirosis are key differential diagnoses of severe COVID-19, and travel is the only distinguishing characteristic of COVID-19-positive patients. Our findings apply only to the particular context of Reunion Island at this time of the epidemic.

Case Report: Refractory Acute Respiratory Distress Syndrome Supported by Extracorporeal Membrane Oxygenation due to Coinfection with Chlamydia pneumoniae and Leptospirosis in Reunion Island

Infection with Leptospira spp. is common in Réunion, a tropical island in the Indian Ocean. However, respiratory coinfections between strains of Leptospira spp. and other microorganisms are rarely described. Here, we describe the first reported case of coinfection between Leptospira spp. and Chlamydia pneumoniae, responsible for refractory acute respiratory distress syndrome requiring extracorporeal membrane oxygenation with a favorable outcome. In a case of leptospirosis with severe respiratory illness, testing for respiratory coinfection, especially with atypical pathogens, could explain the seriousness of the clinical condition and lead to specific treatment.

Case Report: Emergence of Candida auris in the Indian Ocean Region

Candida auris is an emerging multidrug-resistant yeast that can cause severe infections and spread easily between hospitalized patients, leading to outbreaks in hospital. Here, we report the first four cases of colonization and invasive infection with C. auris reported in the Indian Ocean region. All cases were observed in the French overseas Reunion Island, a very popular destination for European travelers. Three patients had urinary tract or skin colonization, and one had a fatal invasive infection. In three cases, including that of the infected patient, the yeast was not initially identified as C. auris, preventing specific hygiene measures to be implemented as suggested in the December 2016 clinical alert to European healthcare facilities. The infected patient likely acquired C. auris in the intensive care unit from the first colonized patient. This is the first case of C. auris infection and the first potential case of nosocomial transmission of the pathogen to be reported in the French overseas Reunion Island.

Adversarial attack on deep learning-based dermatoscopic image recognition systems: Risk of misdiagnosis due to undetectable image perturbations

Deep learning algorithms have shown excellent performances in the field of medical image recognition, and practical applications have been made in several medical domains. Little is known about the feasibility and impact of an undetectable adversarial attacks, which can disrupt an algorithm by modifying a single pixel of the image to be interpreted. The aim of the study was to test the feasibility and impact of an adversarial attack on the accuracy of a deep learning-based dermatoscopic image recognition system.First, the pre-trained convolutional neural network DenseNet-201 was trained to classify images from the training set into 7 categories. Second, an adversarial neural network was trained to generate undetectable perturbations on images from the test set, to classifying all perturbed images as melanocytic nevi. The perturbed images were classified using the model generated in the first step. This study used the HAM-10000 dataset, an open source image database containing 10,015 dermatoscopic images, which was split into a training set and a test set. The accuracy of the generated classification model was evaluated using images from the test set. The accuracy of the model with and without perturbed images was compared. The ability of 2 observers to detect image perturbations was evaluated, and the inter observer agreement was calculated.The overall accuracy of the classification model dropped from 84% (confidence interval (CI) 95%: 82-86) for unperturbed images to 67% (CI 95%: 65-69) for perturbed images (Mc Nemar test, P < .0001). The fooling ratio reached 100% for all categories of skin lesions. Sensitivity and specificity of the combined observers calculated on a random sample of 50 images were 58.3% (CI 95%: 45.9-70.8) and 42.5% (CI 95%: 27.2-57.8), respectively. The kappa agreement coefficient between the 2 observers was negative at -0.22 (CI 95%: -0.49--0.04).Adversarial attacks on medical image databases can distort interpretation by image recognition algorithms, are easy to make and undetectable by humans. It seems essential to improve our understanding of deep learning-based image recognition systems and to upgrade their security before putting them to practical and daily use.

Case Report: Refractory Shock due to Fulminant Dengue Myocarditis Treated with Venoarterial Extracorporeal Membrane Oxygenation: A Report of Four Cases

Dengue disease is found worldwide and has been spreading exponentially in the past decades. Severe forms affect about 2% of patients, sometimes leading to organ failure. Recent studies have shown that fulminant dengue myocarditis is more common than previously thought, and fatal cases have been reported. The treatment of fulminant dengue myocarditis remains supportive and is very challenging in cases of cardiogenic shock. Here, we describe four cases presenting with fulminant dengue myocarditis treated with extracorporeal membrane oxygenation, among two survived.

Case Report: Six New Cases of Melioidosis in the Indian Ocean Region: Comoros, Madagascar, Reunion Island

Melioidosis is an emerging disease caused by the environmental Gram-negative bacillus Burkholderia pseudomallei. Melioidosis has been reported to be endemic mainly in northern Australia and Southeast Asia. Here, we report the first two cases of melioidosis on the Comorian island of Mayotte. We also describe four cases that occurred over a short period of time in patients who had traveled between Mayotte, Madagascar, and Reunion Island.

Pulmonary embolism in a returning traveller with COVID-19 pneumonia

Pulmonary embolism and COVID-19 pneumonia

A comprehensive strategy for the early treatment of COVID-19 with azithromycin/hydroxychloroquine and/or corticosteroids: Results of a retrospective observational study in the French overseas department of Réunion Island

Background

This study aimed to evaluate the prognosis of COVID-19 patients in Reunion Island, with a particular focus on the management of patients with hypoxemic pneumonia.

Methods

This retrospective observational study was conducted from 11 March to 17 April 2020 at the only hospital authorized to manage patients with COVID-19 in Reunion Island.

Results

Over the study period, 164 out of 398 patients (41.2%) infected with COVID-19 were admitted to Félix Guyon University Hospital. Of these, 36 (22%) developed hypoxemic pneumonia. Patients with hypoxemic pneumonia were aged 66 [56–77] years, 69% were male and 33% had hypertension. Ten patients (27.8%) were hospitalized in intensive care unit (ICU). Hydroxychloroquine/azithromycin treatment was associated with a lower ICU admission rate (P = 0.008). None of the 6 patients treated with corticosteroids were hospitalized in ICU (P = 0.16). There were no deaths at follow up (minimum 80 days).

Conclusions

Despite the risk profile of COVID-19 patients with severe hypoxemic pneumonia, the mortality rate of the disease in Reunion Island was 0%. This may be due to the care bundle used in our hospital (early hospitalisation, treatment with hydroxychloroquine/azithromycin and/or corticosteroids, non-invasive respiratory support, etc).

Detection of Pulmonary Embolism in Returning Travelers with Hypoxemic Pneumonia due to COVID-19 in Reunion Island

The aim of this study was to evaluate the occurrence of pulmonary embolism in returning travelers with hypoxemic pneumonia due to COVID-19. All returning travelers to Reunion Island with hypoxemic pneumonia due to COVID-19 underwent computed tomography pulmonary angiography (CTPA) and were included in the cohort. Thirty-five patients were returning travelers with hypoxemic pneumonia due to COVID-19 and had recently returned from one of the countries most affected by the COVID-19 outbreak (mainly from France and Comoros archipelago). Five patients (14.3%) were found to have pulmonary embolism and two (5.9%) were incidentally found to have deep vein thrombosis on CTPA. Patients with pulmonary embolism or deep vein thrombosis had higher D-dimer levels than those without pulmonary embolism or deep vein thrombosis (P = 0.04). Returning travelers with hypoxemic pneumonia due to COVID-19 should be systematically screened for pulmonary embolism.

Bleeding risk of ticagrelor compared to clopidogrel in intensive care unit patients with acute coronary syndrome: A propensity-score matching analysis

BACKGROUND

Intensive care unit (ICU) patients with the most severe forms of acute coronary syndrome (ACS) require invasive therapies such as extracorporeal life support. The risk of bleeding in ICU patients with ACS treated with a dual antiplatelet therapy of aspirin and ticagrelor is unknown. The primary objective of this study was to compare the bleeding risk of ticagrelor and clopidogrel in ICU patients with ACS.

METHODS AND FINDINGS

We conducted a retrospective study based on a propensity score and a proportional hazards model. All patients with ACS hospitalized in the ICU of a French university hospital between January 2013 and January 2017 were included in the study. Bleeding during ICU stay was defined as all Thrombolysis in myocardial infarction (TIMI) major or minor events. A total of 155 patients were included in the study. According to propensity score matching, 57 patients treated with aspirin and ticagrelor were matched with 57 patients treated with aspirin and clopidogrel. Median (first-third quartile) Simplified Acute Physiology Score II was 61.5 (41.0-85.0). Bleeding during ICU stay occurred in 12 patients (21.1%) treated with clopidogrel and in 35 patients (61.4%) treated with ticagrelor (p<0.0001). This significant association was found for both TIMI major bleeding (12.3% vs. 35.1%, p = 0.004) and TIMI minor bleeding (8.8% vs. 26.3%, p = 0.01). The relative risk of bleeding occurrence during ICU stay was 2.60 (confidence interval 95%: 1.55-4.35) for ticagrelor compared to clopidogrel. No significant difference in ICU mortality was found between the two groups (45.6% in the clopidogrel group vs. 29.8% in the ticagrelor group, p = 0.08).

CONCLUSIONS

Bleeding complications are frequent and serious in ICU patients with ACS. A dual antiplatelet therapy of aspirin and ticagrelor is associated with a higher risk of bleeding compared to a dual antiplatelet therapy of aspirin and clopidogrel.

Carbapenemase-producing Enterobacteriaceae circulating in the Reunion Island, a French territory in the Southwest Indian Ocean

BACKGROUND

The spread of carbapenemase-producing Enterobacteriaceae (CPE) in the Southwest Indian Ocean area (SIOA) is poorly documented. Reunion Island is a French overseas territory located close to Madagascar and connected with Southern Africa, Indian sub-continent and Europe, with several weekly flights. Here we report the results of the CPE surveillance program in Reunion Island over a six-year period.

METHODS

All CPE were collected between January 2011 and December 2016. Demographics and clinical data of the carrier patients were collected. We determined their susceptibility to antimicrobials, identified the carbapenemases and ESBL by PCR and sequencing, and explored their genetic relationship using pulsed-field gel electrophoresis and multi-locus sequence typing.

RESULTS

A total of 61 CPEs isolated from 53 patients were retrieved in 6 public or private laboratories of the island. We found that 69.8% of CPE patients were linked to a foreign country of SIOA and that almost half of CPE cases (47.2%) reached the island through a medical evacuation. The annual number of CPE cases strongly increased over the studied period (one case in 2011 vs. 21 cases in 2016). A proportion of 17.5% of CPE isolates were non-susceptible to colistin. bla_NDM was the most frequent carbapenemase (79.4%), followed by bla_IMI (11.1%), and bla_IMP-10 (4.8%). Autochtonous CPE cases (30.2%) harboured CPE isolates belonging to a polyclonal population.

CONCLUSIONS

Because the hospital of Reunion Island is the only reference healthcare setting of the SIOA, we can reasonably estimate that its CPE epidemiology reflects that of this area. Mauritius was the main provider of foreign CPE cases (35.5%). We also showed that autochthonous isolates of CPEs are mostly polyclonal, thus unrelated to cross-transmission. This demonstrates the local spread of carbapenemase-encoding genes (i.e. bla_NDM) in a polyclonal bacterial population and raises fears that Reunion Island could contribute to the influx of NDM-carbapenemase producers into the French mainland territory.

Derivation and validation of a simple score to predict the presence of bacteria requiring carbapenem treatment in ICU-acquired bloodstream infection and pneumonia: CarbaSCORE

Background

The recommendations of learned societies mention risk factors for the presence of multidrug resistant bacteria in hospital-acquired infections, but they do not propose a scoring system to guide empiric antibiotic therapy. Our study was aimed at developing a simple score for predicting "the presence of bacteria requiring carbapenem treatment" in ICU-acquired bloodstream infection and pneumonia.

Methods

Between December 2011 and January 2015, we conducted a retrospective study using a prospectively collected French database of nosocomial infections in the polyvalent intensive care unit of a French university hospital. All patients with ICU-acquired bloodstream infection or pneumonia were included in the study. Bivariate and multivariate analyses were performed to develop the CarbaSCORE, and this score was internally validated.

Results

In total, 338 patients were analyzed, including 27 patients requiring carbapenem treatment. The CarbaSCORE was composed of four criteria: "presence of bloodstream infection" (as opposed to pneumonia) scored 2 points, "chronic hemodialysis" scored 4 points, "travel abroad in the last 6 months" scored 5 points, and "MDR-colonization or prior use of a β-lactam of class ≥ 3" scored 6 points. Internal validation by bootstrapping showed an area under the receiver operating characteristic curve of 0.81 [0.73-0.89]. Sensitivity was 96% at the 6-point threshold and specificity was 91% at the 9-point threshold.

Conclusions

The CarbaSCORE is a simple and efficient score for predicting the presence of bacteria requiring carbapenem treatment. Further studies are needed to test this score before it can be used in practice.

Impact of levosimendan on weaning from peripheral venoarterial extracorporeal membrane oxygenation in intensive care unit

BACKGROUND

Few data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU).

METHODS

This retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated.

RESULTS

A total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity-time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04-0.7; P = 0.01). Kaplan-Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27-1.10; P = 0.09).

CONCLUSIONS

Our results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients.

Intensive care admission for Coronavirus OC43 respiratory tract infections

Background

Coronavirus OC43 infection causes severe pneumonia in patients presenting with comorbidities, but clinical signs alone do not allow for viral identification.

Objectives

To analyze acute manifestations of Coronavirus OC43 infections and outcomes of patients admitted to an intensive care unit (ICU).

Patients and methods

Retrospective and monocentric study performed during a Coronavirus OC43 outbreak. We used multiplex PCR to detect an OC43 outbreak in Reunion Island during the 2016 Southern Hemisphere's winter: seven admissions to the ICU.

Results

Mean age of patients was 71 [67;76] years, SAPS II was 42 [28;53], pneumonia severity index 159 [139;182] vs 73 [40.5;107] for patients in medical wards, and 43% required mechanical ventilation. Comorbidities were diabetes mellitus (87%), chronic respiratory failure (57%), and chronic renal failure (29%). One patient died from Haemophilus influenzae co-infection.

Conclusion

As for MERS Co-V infections, underlying comorbidities impacted the clinical outcomes of OC43 infections.

Complication patterns in patients undergoing venoarterial extracorporeal membrane oxygenation in intensive care unit: Multiple correspondence analysis and hierarchical ascendant classification

Background

Treatment by venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used today, even though it is associated with high risks of complications and death. While studies have focused on the relationship between some of these complications and the risk of death, the relationship between different complications has never been specifically examined, despite the fact that the occurrence of one complication is known to favor the occurrence of others. Our objective was to describe the relationship between complications in patients undergoing VA-ECMO in intensive care unit (ICU) and to identify, if possible, patterns of patients according to complications.

Methods and findings

As part of a retrospective cohort study, we conducted a multiple correspondence analysis followed by a hierarchical ascendant classification in order to identify patterns of patients according to main complications (sepsis, thromboembolic event, major transfusion, major bleeding, renal replacement therapy) and in-ICU death. Our cohort of 145 patients presented an in-ICU mortality rate of 50.3%. Morbidity was high, with 36.5% of patients presenting three or more of the five complications studied. Multiple correspondence analysis revealed a cumulative inertia of 76.9% for the first three dimensions. Complications were clustered together and clustered close to death, prompting the identification of four patterns of patients according to complications, including one with no complications.

Conclusions

Our study, based on a large cohort of patients undergoing VA-ECMO in ICU and presenting a mortality rate comparable to that reported in the literature, identified numerous and often interrelated complications. Multiple correspondence analysis and hierarchical ascendant classification yielded clusters of patients and highlighted specific links between some of the complications studied. Further research should be conducted in this area.

Waterborne Infections in Reunion Island, 2010-2017

Gram-negative bacilli Vibrio spp., Aeromonas spp., and Shewanella spp. are a major cause of severe waterborne infection. The aim of this study was to assess the clinical and microbiological characteristics and prognosis of patients hospitalized in Reunion Island for a waterborne infection. This retrospective study was conducted in the two university hospitals of Reunion Island between January 2010 and March 2017. Patients diagnosed with a Vibrio, Aeromonas, or Shewanella infection were evaluated. Over the study period, 112 aquatic strains were isolated at Reunion Island: Aeromonas spp. were found in 91 patients (81.3%), Shewanella spp. in 13 patients (11.6%), and Vibrio spp. in eight patients (7.2%). The in-hospital mortality rate was 11.6%. The main sites of infection were skin and soft tissue (44.6%) and the abdomen (19.6%). Infections were polymicrobial in 70 cases (62.5%). The most commonly prescribed empiric antibiotic regimen was amoxicillin-clavulanate (34.8%). Eighty-four percent of the aquatic strains were resistant to amoxicillin-clavulanate and more than > 95% were susceptible to third or fourth generation cephalosporins and fluoroquinolones. After multivariate analysis, the only independent risk factor of in-hospital mortality was the presence of sepsis (P < 0.0001). In Reunion Island, the most commonly isolated aquatic microorganisms were Aeromonas spp. Sepsis caused by aquatic microorganisms was frequent (> 50%) and associated with higher in-hospital mortality. This study suggests that empiric antibiotic regimens in patients with sepsis or septic shock caused by suspected aquatic microorganisms (tropical climate, skin lesion exposed to seawater…) should include broad-spectrum antibiotics (third or fourth generation cephalosporins).

Medical evacuation from abroad of critically ill patients: A case report and ethical issues

RATIONALE

Patients repatriated from foreign hospitals are sources of extensively drug-resistant (XDR) bacteria outbreaks. Thus, an individual benefit potential for the patient opposes a collective ecological risk potential. These ethical issues have not been well studied.

PATIENT CONCERNS

We report the case of a 74-year-old patient repatriated from Mauritius to the French island of Reunion who presented mesenteric infarction evolving over several days, and who suffered a cardiac arrest before transfer.

DIAGNOSES

In Reunion Island, a CT-scan revealed a multisegmental enlarged parietal enlargement associated with free peritoneal effusion and a suboccluded aspect of the superior mesenteric artery.

INTERVENTIONS

Surgical exploration showed a severe mesenteric infarction with peritonitis, and a resection of 120cm of the small intestine was conducted. This patient was infected with a vanA glycopeptide-resistant Enterococcus faecium and a carbapenem-resistant Klebsiella pneumoniae which produced carbapenemases NDM-1 and OXA-181, which required specific care and could have led to a local epidemic.

OUTCOMES

The patient died after 9 days after being admitted to the ICU.

LESSONS

Repatriation of critically ill patients from abroad should be considered according to ethical criteria, evaluating, if possible, the expected benefits, and ecological risks incurred. Limiting unnecessary transfers could be an effective measure to limit the spread of XDR bacteria.

Predictors of red blood cell transfusion and its association with prognosis in patients undergoing extracorporeal membrane oxygenation

PURPOSE

Few data are available on the potential benefits and risks of red blood cell transfusion in patients undergoing extracorporeal membrane oxygenation. The aim of this study was to identify the determinants and prognosis of red blood cell transfusion in patients undergoing extracorporeal membrane oxygenation, with a special focus on biological parameters during extracorporeal membrane oxygenation treatment.

METHODS

We conducted a single-center retrospective cohort study including all consecutive patients who underwent extracorporeal membrane oxygenation between January 2010 and December 2015.

RESULTS

The 201 evaluated patients received a median of 0.9 [0.5-1.7] units of red blood cell per day. Significant and clinically relevant variables that best correlated with units of red blood cell transfused per day of extracorporeal membrane oxygenation were lower median daily prothrombin time in percentage (Quick) ( t = -0.016, p < 0.0001), higher median daily free bilirubin level ( t = 0.016, p < 0.0001), and lower pH ( t = -2.434, p < 0.0001). In multivariate analysis, red blood cell transfusion was associated with a significantly higher rate of in-intensive care unit mortality (per red blood cell unit increment; adjusted odds ratio: 1.07, 95% confidence interval: 1.02-1.12, p = 0.005). It was also associated with higher rates of acute renal failure ( p = 0.025), thromboembolic complications ( p = 0.0045), and sepsis ( p = 0.015).

CONCLUSION

This study suggests that red blood cell transfusion may be associated with a higher mortality rate and with severe complications. However, we cannot conclude a direct causal relationship, as red blood cell transfusion may be only a marker of poor outcome. We recommend that physicians correct acidosis and hemolysis in patients undergoing extracorporeal membrane oxygenation whenever possible.

Delayed surgery in a patient with pneumococcal peritonitis and bacteremia secondary to perforation of gastroduodenal ulcer: A case report

RATIONALE

Very few cases of secondary peritonitis caused by Streptococcus pneumoniae have been described in the literature, and they have been found to occur mostly in patients with predisposing factors. Here, we report the case of an elderly patient who developed pneumococcal peritonitis secondary to perforation of gastroduodenal ulcer.

PATIENT CONCERNS

An 82-year-old man was admitted to intensive care unit (ICU) for septic shock with cardiac impairment 1 day after arriving in the Emergency Department.

DIAGNOSES

The patient presented with pneumococcal bacteremia and pneumococcal antigenuria. No abdominal defense was found on examination. A computed tomography scan revealed pneumoperitoneum and peritoneal effusions.

INTERVENTIONS

The patient was treated with effective empiric antibiotic therapy, and delayed surgery.

OUTCOMES

The patient gradually improved and was discharged from ICU on day 14. The ultimate outcome was unfavorable, with death occurring on day 28.

LESSONS

This rare infection can occur in elderly patients even in the absence of other predisposing factors. Secondary peritonitis may be suspected in patients with positive pneumococcal antigenuria or unexplained pneumococcal bacteremia, especially if an asthenic form is possible.

Determinants and prognosis of high-sensitivity cardiac troponin T peak plasma concentration in patients hospitalized for non-cardiogenic shock

Purpose:

The aim of this study was to assess the determinants and prognostic value of high-sensitivity cardiac troponin T peak plasma concentration in intensive care unit patients with non-cardiogenic shock.

Material and methods:

A prospective observational cohort study was conducted in a single intensive care unit between November 2014 and December 2015.

Results:

During the study period, 206 patients were hospitalized in the intensive care unit for non-cardiogenic shock and the median peak high-sensitivity cardiac troponin T was 55.1 [24.5–136] pg/mL. A multivariate analysis combining all variables showed that higher body mass index (t = 2.52, P = 0.01), lower left ventricular systolic function (t = −2.73, P = 0.007), higher white blood cell count (t = 3.72, P = 0.0001), lower creatinine clearance (t = −2.84, P = 0.0005), higher lactate level (t = 2.62, P = 0.01) and ST-segment depression (t = 3.98, P = 0.0001) best correlated with log₁₀-transformed high-sensitivity cardiac troponin T peak plasma concentration. After multivariate analysis, the high-sensitivity cardiac troponin T peak was not associated with a significant reduction of in-hospital mortality (adjusted odds ratio = 0.99 (95% confidence interval: 0.93–1.02)).

Conclusion:

High-sensitivity cardiac troponin T elevation was very common in patients hospitalized for non-cardiogenic shock. The factors significantly associated with high-sensitivity cardiac troponin T peak plasma concentration were higher body mass index, decreased left ventricular systolic ejection fraction, higher leucocyte count, decreased renal function, increased lactate level, and ST-segment depression. The high-sensitivity cardiac troponin T peak was not significantly associated with in-hospital mortality in this setting.

Extracorporeal membrane oxygenation for cardiogenic shock due to alcoholic cardiomyopathy: a long-term follow-up of 4 cases

Even though alcoholism is a major health concern, alcoholic cardiomyopathy is a little-known pathology. The exact prevalence remains elusive (20-40% of dilated cardiomyopathy). However, it can lead to dilated cardiomyopathy, heart failure and refractory cardiogenic shock. The literature on cardiogenic shock in alcoholic cardiomyopathy is limited. We report 4 cases of patients with refractory cardiogenic shock due to heavy alcohol consumption, who were treated with venoarterial extracorporeal membrane oxygenation. The evolution was favourable with recovery in 3 patients and the need for heart transplantation in 1 patient. After 3-5 years, all patients are alive, 2 of 4 are sober, all of them are on cardiac follow-up and none of them have presented with a cardiac relapse.

Melioidosis in the Western Indian Ocean and the Importance of Improving Diagnosis, Surveillance, and Molecular Typing

Melioidosis, caused by the bacterium Burkholderia pseudomallei, is an infectious disease of humans or animals, and the specific environmental conditions that are present in western Indian Ocean islands are particularly suitable for the establishment/survival of B. pseudomallei. Indeed, an increasing number of new cases have been reported in this region (Madagascar, Mauritius, Réunion (France), and Seychelles, except Comoros and Mayotte (France)), and are described in this review. Our review clearly points out that further studies are needed in order to investigate the real incidence and burden of melioidosis in the western Indian Ocean and especially Madagascar, since it is likely to be higher than currently reported. Thus, research and surveillance priorities were recommended (i) to improve awareness of melioidosis in the population and among clinicians; (ii) to improve diagnostics, in order to provide rapid and effective treatment; (iii) to implement a surveillance and reporting system in the western Indian Ocean; and (iv) to investigate the presence of B. pseudomallei in environmental samples, since we have demonstrated its presence in soil samples originating from the yard of a Madagascan case.

Emergence of melioidosis in the Indian Ocean region: Two new cases and a literature review

Melioidosis is a disease caused by bacteria called B. pseudomallei. Infections can develop after contact with standing water. This disease can reach all the organs and especially the lungs. It is associated with a high mortality rate (up to 50%). Melioidosis is endemic in northern Australia and in Southeast Asia. Nevertheless, B. pseudomallei may be endemic in the Indian Ocean region and in Madagascar in particular, so clinicians and microbiologists should consider acute melioidosis as a differential diagnosis in the Indian Ocean region, in particular from Madagascar.

Evaluation of Cardiac Index and Extravascular Lung Water After Single-Lung Transplantation Using the Transpulmonary Thermodilution Technique by the PiCCO2 Device

OBJECTIVES

First evaluation of the transpulmonary thermodilution technique by the PiCCO2 device to assess cardiac index and pulmonary edema during the postoperative course after single-lung transplantation.

DESIGN

Prospective observational study.

SETTINGS

Intensive care unit, university hospital (single center).

PARTICIPANTS

Single-lung transplant patients.

INTERVENTIONS

The authors compared cardiac index measured by PiCCO2 and pulmonary artery catheter and assessed pulmonary edema using extravascular lung water index and pulmonary vascular permeability index measured by PiCCO2.

MEASUREMENTS AND MAIN RESULTS

A Bland-Altman method was used to compare cardiac index measured by PiCCO2 and pulmonary artery catheter. Extravascular lung water index and pulmonary vascular permeability index were compared according to the PaO₂/FiO₂ ratio with a threshold value of 150 mmHg. Ten single-lung transplant patients were included. Cardiac index measured by PiCCO2 and pulmonary artery catheter were 3.3 L/min/m² (2.9-3.6) and 2.5 L/min/m² (2.2-3.0). Bias for cardiac index was 0.71 L/min/m² (-0.03; 1.44) and limit of agreements were -0.03 and 1.44 L/min/m². Extravascular lung water index was 12 mL/kg (11-16) and pulmonary vascular permeability index was 2.3 (2.0-3.1), consistent with pulmonary edema. Extravascular lung water index was higher in the group of PaO₂/FiO₂ ratio ≤150 mmHg compared with the group of PaO₂/FiO₂ ratio >150 mmHg (17 v 12 mL/kg, p = 0.04), whereas pulmonary vascular permeability index only tended to be higher (3.1 v 2.1, p = 0.06).

CONCLUSION

PiCCO2 device systematically overestimated cardiac index compared with pulmonary artery catheter. However, it might be useful to assess pulmonary edema in acute respiratory failure after single-lung transplantation.

Case Report: Severe Imported Influenza Infections Developed during Travel in Reunion Island

We report two cases of severe influenza infection imported by tourist patients from their country of origin and developed during travel. While studies have reported cases of influenza infections acquired during travel, here we examine two cases of severe influenza infection contracted in the country of origin that led to diagnosis and therapeutic problems in the destination country. No international recommendation exists concerning influenza vaccination before travel, and few countries recommend it for all travelers. Our study suggests that travel should be canceled when infectious signs are observed before departure. Influenza is a very common infection that is often benign, but sometimes very severe. The most severe cases include shock, acute respiratory distress syndrome (ARDS), myocarditis, rhabdomyolysis, and multiple organ failure. Management can require exceptional therapies, such as extracorporeal membrane oxygenation. A number of studies have focused on influenza infection in travelers. Cases of influenza acquired during travel have been reported in this literature, but no study has examined cases of influenza imported from the country of origin and developed while abroad. The latter situation may lead to 1) diagnostic problems during the nonepidemic season or in places where diagnostic techniques are lacking and 2) therapeutic difficulties resulting from the unavailability of techniques for the management of severe influenza infection in tourist areas. Here, we report two cases of extremely severe influenza infection imported by tourists from their country of origin and developed during travel.