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Purpose: Intensive care unit (ICU)-acquired infections (IAI) result in increased hospital and ICU stay, costs and mortality. To date, no biomarker has shown sufficient evidence and ease of application in clinical routine for the identification of patients at risk of IAI. We evaluated the association of the systemic mRNA expression of two host response biomarkers, CD74 and IL10, with IAI occurrence in a large cohort of ICU patients., Methods: ICU patients were prospectively enrolled in a multicenter cohort study. Whole blood was collected on the day of admission (D1) and on day 3 (D3) and day 6 (D6) after admission. Patients were screened daily for IAI occurrence and data were censored after IAI diagnosis. mRNA expression levels of biomarkers were measured using RT-qPCR. Fine and Gray competing risk models were used to assess the association between gene expression and IAI occurrence., Results: A total of 725 patients were analyzed. At least one IAI episode occurred in 137 patients (19%). After adjustment for shock and sepsis status at admission, CD74 and IL10 levels were found to be significantly associated with IAI occurrence [subdistribution hazard ratio (95% confidence interval) 0.67 (0.46-0.97) for CD74 D3/D1 expression ratio and 2.21 (1.63-3.00) for IL10 at D3]. IAI cumulative incidence was significantly different between groups stratified according to CD74 or IL10 expression (Gray tests p < 0.001)., Conclusion: Our results suggest that two immune biomarkers, CD74 and IL10, could be relevant tools for the identification of IAI risk in ICU patients.

Background: In patients with severe sepsis, no randomized clinical trial has tested the concept of de-escalation of empirical antimicrobial therapy. This study aimed to compare the de-escalation strategy with the continuation of an appropriate empirical treatment in those patients., Methods: This was a multicenter non-blinded randomized noninferiority trial of patients with severe sepsis who were randomly assigned to de-escalation or continuation of empirical antimicrobial treatment. Recruitment began in February 2012 and ended in April 2013 in nine intensive care units (ICUs) in France. Patients with severe sepsis were assigned to de-escalation (n = 59) or continuation of empirical antimicrobial treatment (n = 57). The primary outcome was to measure the duration of ICU stay. We defined a noninferiority margin of 2 days. If the lower boundary of the 95 % confidence interval (CI) for the difference in patients assigned to the de-escalation group was less than 2 days, as compared with that of patients assigned to the continuation group, de-escalation was considered to be noninferior to the continuation strategy. Secondary outcomes included mortality at 90 days, occurrence of organ failure, number of superinfections, and number of days with antibiotics during the ICU stay., Results: The median duration of ICU stay was 9 [interquartile range (IQR) 5-22] days in the de-escalation group and 8 [IQR 4-15] days in the continuation group, respectively (P = 0.71). The mean difference was 3.4 (95 % CI -1.7 to 8.5). A superinfection occurred in 16 (27 %) patients in the de-escalation group and six (11 %) patients in the continuation group (P = 0.03). The numbers of antibiotic days were 9 [7-15] and 7.5 [6-13] in the de-escalation group and continuation group, respectively (P = 0.03). Mortality was similar in both groups., Conclusion: As compared to the continuation of the empirical antimicrobial treatment, a strategy based on de-escalation of antibiotics resulted in prolonged duration of ICU stay. However, it did not affect the mortality rate.

Purpose: Because severe preeclampsia (SP) may be associated with acute pulmonary oedema, fluid responsiveness needs to be accurately predicted. Passive leg raising (PLR) predicts fluid responsiveness. PLR has never been reported during pregnancy. Our first aim was to determine the percentage of SP patients with oliguria increasing their stroke volume after fluid challenge. Our second aim was to assess the accuracy of PLR to predict fluid responsiveness in those patients., Methods: Patients with SP were prospectively included in the study. In the subgroup developing oliguria, transthoracic echocardiography was performed at baseline, during PLR and after a 500 ml fluid infusion over 15 min. Fluid responders were defined by a 15 % increase of stroke volume index. Five consecutive measurements were averaged for all parameters., Results: Twenty-three (56 %) out of 41 patients with SP developed oliguria, 12 (52 %) out of these 23 responded to fluid challenge. During PLR, an increase of the velocity time integral of subaortic blood flow (ΔVTI) above 12 % predicted the response with a sensitivity and specificity of 75 [95 % confident interval (CI): 0.42-0.95] and 100 % (95 % CI: 0.72-1.00), respectively. An algorithm combining ΔVTI and the baseline value of VTI predicted fluid responsiveness with a sensitivity and specificity of 100 % (95 % CI: 0.74-1.00) and (95 % CI: 0.75-1.00). Urine output and respiratory variations of inferior vena cava diameter did not predict fluid responsiveness., Conclusions: Only 52 % of oliguric patients were responders. PLR accurately predicts fluid responsiveness in the specific setting of SP. This noninvasive test should be tested in future algorithms for the management of SP.