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Summary Colonization resistance by gut microbiota is a fundamental phenomenon in infection prevention and control. Hospitalized patients may be exposed to multi-drug-resistant bacteria when hand hygiene compliance among healthcare workers is not adequate. An additional layer of defence is provided by the healthy gut microbiota, which helps clear the exogenous bacteria and acts as a safety net when hand hygiene procedures are not followed. This narrative review focuses on the role of the gut microbiota in colonization resistance against multi-drug-resistant bacteria, and its implications for infection control. The review discusses the underlying mechanisms of colonization resistance (direct or indirect), the concept of resilience of the gut microbiota, the link between the antimicrobial spectrum and gut dysbiosis, and possible therapeutic strategies. Antimicrobial stewardship is crucial to maximize the effects of colonization resistance. Avoiding unnecessary antimicrobial therapy, shortening the antimicrobial duration as much as possible, and favouring antibiotics with low anti-anaerobe activity may decrease the acquisition and expansion of multi-drug-resistant bacteria. Even after antimicrobial therapy, the resilience of the gut microbiota often occurs spontaneously. Spontaneous resilience explains the existence of a window of opportunity for colonization of multi-drug-resistant bacteria during or just after antimicrobial therapy. Strategies favouring resilience of the gut microbiota, such as high-fibre diets or precision probiotics, should be evaluated.

International audience; Background: Bacterial resistance to antibiotics is a daily concern in intensive care units. However, few data are available concerning the clinical consequences of in-vitro-defined resistance. Aim: To compare the mortality of patients with nosocomial infections according to bacterial resistance profiles. Methods: The prospective surveillance registry in 29 French intensive care units (ICUs) participating during the years 2000-2013 was retrospectively analysed. All patients presenting with a nosocomial infection in ICU were included. Findings: The registry contained 88,000 eligible patients, including 10,001 patients with a nosocomial infection. Among them, 3092 (36.7%) were related to resistant microorganisms. Gram-negative bacilli exhibited the highest rate of resistance compared to Gram-positive cocci (52.8% vs 48.1%; P < 0.001). In-hospital mortality was higher in cases of patients with antibiotic-resistant infectious agents (51.9% vs 45.5%; P < 0.001), and critical care length of stay was longer (33 +/- 26 vs 29 +/- 22 days; P < 0.001). These results remained significant after SAPS II matching (P < 0.001) and in the Gram-negative bacilli and Gram-positive cocci subgroups. No difference in mortality was found with respect to origin prior to admission. Conclusion: Patients with bacterial resistance had higher ICU mortality and increased length of stay, regardless of the bacterial species or origin of the patient. (C) 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Background In 2007, the multidisciplinary European Task Force for Advanced Bleeding Care in Trauma published guidelines for the management of the bleeding trauma patient. The present study aimed to assess compliance with the European guidelines during the first 24 h in a level I trauma centre and to determine whether compliance impacts mortality. Methods This was a retrospective study of consecutive bleeding trauma patients referred to a university hospital in France between 2010 and 2014. A reference document was developed on the basis of the European guidelines to transform the guidelines pragmatically into 22 objectively measurable criteria. We measured per-patient and per-criterion compliance rates and assessed the impact of guideline compliance on mortality. Results A total of 121 bleeding trauma patients were included. The median (interquartile range) per-patient compliance rate was 75 (65–82)% and the per-criterion compliance rate 64 (57–81)%. Mortality rates were 18 and 32% at 24 h and 30 days, respectively. After adjusting for injury severity, per-patient compliance rates were associated with decreased mortality at 24 h (odds ratio per 10% increase in patient compliance score, 0.43; 95% confidence interval 0.26–0.71; P = 0.0001) and at 30 days (odds ratio per 10% increase in patient compliance score, 0.47; 95% confidence interval 0.31–0.72; P = 0.0004). Conclusions We found that compliance with protocols based on European guidelines impacts trauma outcome, because patient compliance was associated with survival. Further work is needed to improve adherence to these guidelines, with ongoing monitoring to ensure best practice and optimal patient outcome.

International audience; Chronic postoperative pain exists in varying degrees for every type of surgery. An evaluation of the incidence, the typology and predictive factors of chronic pain was carried out at 3 and 6months after thyroidectomy. A prospective observational study, having included each of the patients prior to their thyroidectomy, was carried out over 12months. The patients used an 11-point numerical rating scale (NRS), a neuropathic pain screening questionnaire (DN4), an evaluation scale for anxiety and for the need for information related to anaesthesia and surgery (APAIS), a questionnaire describing pain (QDSA) and a questionnaire evaluating neuropathic pain (NPSI) before surgery and at three and six months later. Three hundred and four patients were included. The questionnaires were completed by 251 patients (57 males and 194 females) at 3 and 6months (82%). At 3months, 31 out of 251 (12%) patients mentioned a DN4≥3; at 6months, this rate dropped to 23 out of 251 (9%). The average intensity of chronic postoperative pain remained low to moderate. Levels of anxiety and the need for information were higher in patients with postoperative pain at 3 and 6months. In contrast, the number of intraoperative procedures using a bilateral superficial cervical plexus block (BSCPB) was lower in patients with DN4≥3. Multivariate analysis demonstrated that the type of anaesthesia procedure interfered with the risk of delayed pain after thyroidectomy. The presence of a DN4≥3 was nearly three-fold greater in patients without BSCPB (OR 2.647, CI=1.198-5.848).

Pseudomonas aeruginosa and Candida albicans are frequently coexisting opportunistic pathogens, responsible for colonization and infection in predisposed patients. They share a virulence specificity relying on auto-inducing, cell density-dependent molecules named quorum-sensing (QS). C. albicans virulence depends on its QS that influences morphological switch from yeast to filamentous form. Similarly, the production of P. aeruginosa virulence factors depends partly on QS molecules. Interactions have been investigated and demonstrated in vitro. P. aeruginosa may kill C. albicans either by producing toxins, such as pyocyanin, or by direct contact on its biofilm-dependent filamentous form. Cross-kingdom communication is a more subtle interaction: C. albicans can adapt its morphology in the presence of P. aeruginosa QS molecules, and inhibit P. aeruginosa QS-dependent virulence factor secretion, through farnesol, one of its QS molecule. But the in vivo relevance of these interactions is still controversial, as models of airway colonization/infection by C. albicans followed by subsequent P. aeruginosa pneumonia give contradictory results, suggesting the probable involvement of the immune system as a third party player. Finally, the authors of clinical studies performed in ventilated patients, indicate that C. albicans colonization could be a risk factor for P. aeruginosa pneumonia. The clinical outcome of C. albicans and P. aeruginosa interaction is uncertain, the virulence modulation demonstrated in these interactions opens new possibilities for future anti-infectious therapeutics.

This study aimed to evaluate the implementation of a strategy to prevent postoperative nausea and vomiting (PONV) in patients undergoing general surgery.Prospective observational study.A first period was observational. During a second period, a strategy to prevent PONV was based on five risk factors (RF) identified after the first phase. From two RF, antiemetic treatment was given according to the number of RF. The incidence of PONV was recorded in postoperative anaesthesic care unit (PACU) and at the 24th postoperative hour (24h).We prospectively enrolled 823 patients. Implementation of a prophylactic PONV strategy was associated with a decrease of nausea in PACU from 29.9 to 9.8% (P0.001) and at 24h from 19 to 10.3% (P0.001). Vomiting decreased from 12.4 to 2.3% (P0.001) in PACU and from 5.6 to 3.7% at 24h (non-significant).Prophylaxis of PONV by the administration of antiemetic treatment according to a strategy based on a local risk score was efficient and associated with a significant decrease of PONV.

Resume La noradrenaline est le medicament recommande en premiere intention dans les consensus nationaux et internationaux pour le traitement hemodynamique du choc septique, parallelement au remplissage vasculaire. Cependant, aucune recommandation n’encadre le sevrage en noradrenaline qui suit necessairement cette prise en charge hemodynamique. Or, les proprietes pharmacodynamiques justifiant l’utilisation de la noradrenaline au cours du choc septique, a savoir vasoconstriction veineuse et arterielle, permettent de « normaliser » rapidement l’hemodynamique macrocirculatoire au prix potentiel d’une malperfusion regionale et/ou microcirculatoire, d’autant plus que le remplissage n’aura pas ete optimise. Le sevrage en noradrenaline, qui « relâche » la contrainte exercee sur la circulation veineuse, constitue donc une etape pendant laquelle tout defaut de remplissage initial ou secondaire peut se reveler. Les rares etudes disponibles sur le sujet montrent que le mode de sevrage habituel en noradrenaline est arbitraire et prolonge inutilement son utilisation potentiellement deletere. Le sevrage en noradrenaline pourrait se concevoir comme une epreuve fonctionnelle hemodynamique au cours de laquelle serait evaluee la precharge-dependance, demasquant un eventuel besoin en remplissage permettant de poursuivre et accelerer le sevrage ou, au contraire, un etat de « noradrenaline dependance » a respecter mais a reevaluer regulierement. De telles epreuves de sevrage pourraient etre envisagees precocement dans la prise en charge hemodynamique du choc septique, lors de toute stabilisation hemodynamique apparente, afin de prevenir ou eviter d’aggraver des troubles de perfusion regionales et microcirculatoires. Ainsi, l’enjeu du sevrage de la noradrenaline pourrait prendre une nouvelle dimension et meriter plus d’attention.

Background Proteomics is increasingly leading to biomarker discovery in human disease. Epithelial lining fluid (ELF), until now only recovered indirectly, diluted in BAL fluid, is an attractive sample for lung disease proteomics. The direct recovery of undiluted ELF is now possible using a bronchoscopic microsampling (BMS) probe. In this preliminary study of anesthetized ventilated rabbits, we applied this probe to recover ELF and to analyze the resulting samples with the aim of determining their potential in lung disease biomarker discovery. Methods In order to do so, a method was devised and evaluated in preliminary experiments both for nonbronchoscopic use of the probe and for recovering undiluted ELF from probe tips. To verify the proteomic potential of the sample, the recovered ELF was separated by one-dimensional polyacrylamide gel electrophoresis, and the resulting lane was cut into multiple fractions, each of which was digested and analyzed by liquid chromatography tandem mass spectrometry. The identified proteins were then searched against Medline for association with broad categories of lung disease. Results Nonbronchoscopic use of the probe allowed successful ELF sampling and the recovery of undiluted ELF from probe tips. Proteomic analysis showed that ELF contains many proteins that have already been reported as being associated with lung disease as well as proteins potentially correlated with lung disease. Conclusions This preliminary study of undiluted ELF, as recovered by the BMS probe, shows that it may be an ideal sample for lung proteomics. The potential application of this sampling technique in various lung diseases will need to be confirmed by future studies.

Background The aim of this study was to evaluate potential predictors of fluid responsiveness obtained during major hepatic surgery. The predictors studied were invasive monitoring of intravascular pressures (radial and pulmonary artery catheter), including direct measurement of respiratory variation in arterial pulse pressure (PPVart), transoesophageal echocardiography (TOE), and non-invasive estimates of PPVart from the infrared photoplethysmography waveform from the Finapres ® (PPVfina) and the pulse oximetry waveform (PPVsat). Methods We conducted a prospective study of 54 fluid challenges (250 ml colloid) given for haemodynamic instability in eight patients undergoing hepatic resection. Fluid responsiveness was defined as an increase in stroke volume index (SVI) ≥10%. The following variables were recorded before each fluid challenge: right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), PPVart, PPVfina, PPVsat, and the TOE-derived variables left ventricular end-diastolic area index (LVEDAI), early/late (E/A) diastolic filling wave ratio, deceleration time of the E wave (MDT) of mitral flow and the systolic fraction of the pulmonary venous flow (SF). Results Only PPVfina, PPVart (both P P =0.02), LVEDAI and MDT (both P =0.04) were different in responder vs non-responder fluid challenges. The areas under the receiver operating characteristic (ROC) curves were 0.81 (PPVfina), 0.79 (PPVart), 0.70 (LVEDAI), 0.68 (PPVsat and MDT), 0.63 (RAP), 0.62 (E/A), 0.55 (PAOP) and 0.42 (SF). The areas under the ROC curves for RAP, E/A, PAOP and SF were significantly less than that for PPVfina ( P r =0.59, P =0.0001) and PPVfina ( r =0.56, P =0.0001) correlated with the fluid challenge-induced changes in SVI. Conclusions PPVart and PPVfina predict fluid responsiveness during major hepatic surgery. This suggests that intraoperative monitoring of fluid responsiveness may be implemented simply and non-invasively.

Pseudomonas aeruginosa is an opportunistic pathogen responsible for ventilator-acquired pneumonia, acute lower respiratory tract infections in immunocompromised patients and chronic respiratory infections in cystic fibrosis patients. High incidence, infection severity and increasing resistance characterize P. aeruginosa infections, highlighting the need for new therapeutic options. One such option is to target the many pathogenic mechanisms conferred to P. aeruginosa by its large genome encoding many different virulence factors. This article reviews the pathogenic mechanisms and potential therapies targeting these mechanisms in P. aeruginosa respiratory infections.

Resume Le syndrome respiratoire aigu severe (severe acute respiratory syndrome, SARS) est apparu a l’automne 2002 dans la province de Guangdong en Chine. L’epidemie s’est rapidement propagee a travers le monde pour toucher, courant avril, plus de 26 pays avec un total de cas a cette meme date proche de 3500 cas. La symptomatologie associe des formes moderees se manifestant par une fievre, une hypoxie, avec des formes de gravite majeure responsables de syndrome de detresse aigue necessitant l’hospitalisation en unite de reanimation. Des formes digestives ont aussi recemment ete decrites. Cette epidemie a suscite une reponse extremement rapide de la communaute internationale qui en quelques semaines a permis d’isoler l’agent responsable, un nouveau Coronavirus, de proposer une prise en charge therapeutique et des mesures specifiques pour limiter la diffusion de l’epidemie. Cette revue rassemble l’ensemble des donnees actuellement disponibles sur le SARS, de l’histoire de l’epidemie aux propositions therapeutiques disponibles en date d’avril 2003.

Introduction L’hemorragie par traumatisme est la premiere cause de deces evitable chez le jeune en France. Pour ameliorer la qualite et la securite des soins, un audit clinique cible, utilisant l’echelle de conformite de la Haute Autorite de sante et base sur les recommandations europeennes mises a jour en 2013 [1] a ete realise. Materiel et methodes Etude observationnelle, retrospective, non interventionnelle, realisee de mai 2010 a octobre 2014 (CNIL). Les dossiers audites etaient les patients victimes d’un traumatisme, ayant recu 6 culots de globules rouges ou plus au cours des 24 premieres heures de prise en charge. La pratique observee etait comparee a la pratique attendue, selon un referentiel cree a partir des 37 recommandations traduites puis regroupees en 20 criteres. Chacun des criteres etait classe dans 1 des 5 items qui correspondaient aux differents temps et objectifs de la prise en charge decrits dans les recommandations de 2013 : – reanimation initiale et prevention du saignement ; – diagnostic et monitorage ; – oxygenation, remplissage, lutte contre l’hypothermie ; – controle rapide du saignement ; – gestion du saignement et de la coagulopathie. Pour chaque critere des limites de conformite (conforme/non conforme/non applicable) ont ete discutees par des experts et validees par le medecin coordinateur a la gestion des risques associes aux soins. Ils etaient classes selon un niveau de maturite (1 a 4) decrit par l’HAS [2] . Les resultats sont exprimes en nombre ou %, en moyenne (ecart-type) ou mediane [1 er quartile;3 e quartile]. Test statistique de Kruskal–Wallis. p Resultats Ainsi, 121 dossiers ont ete audites. L’âge etait de 42 (± 16) ans, 66 % etaient des hommes. L’ISS etait de 34 [19;45], la mortalite a H24 etait de 18 % et a j30 de 32 %. Le delai entre l’arrivee et la realisation d’un body-scanner etait de 30 [21;47] min et de 168 [106;222] min entre l’arrivee et le geste d’hemostase. Sept criteres avaient un niveau de maturite maitrise et optimise (niveaux 3 et 4, conformes dans plus de 80 % des dossiers), 10 avaient un niveau de maturite defini (niveau 2, conformes dans 45 a 80 % des cas) et 2 avaient un niveau de base (niveau 1, conformes dans moins de 45 % des cas). Les patients vivants a H24 et j30 avaient un nombre de criteres conformes superieur aux patients decedes, respectivement : 11[10;13] vs 9,5[8;11]; p = 0,0005 a H24 et 11 [10;13] vs 10 [8;11], p Discussion La grille d’audit mise au point pour les besoins de ce travail a permis une evaluation objective et exhaustive des pratiques de prise en charge initiale du choc hemorragique traumatique dans notre hopital. Elle pourrait etre utilisee par toute structure souhaitant evaluer ses pratiques dans ce domaine. Des protocoles de prise en charge bases sur les recommandations francaises de 2014 seront proposes afin d’ameliorer nos pratiques [3] et un nouvel audit sera realise.

Introduction La distension pulmonaire est un mecanisme majeur de lesions induites par la ventilation mecanique pouvant entrainer un syndrome de detresse respiratoire de l’adulte (SDRA). Or, il a ete demontre par tomodensitometrie, que meme lors d’une ventilation dite « protectrice », pouvaient persister des zones distendues [1] . La distension peut etre aussi etre mesuree sur le degre convexite ou de concavite de la courbe pression/temps lors de la phase a debit constant aussi appele le stress index (SI) [2] . L’objectif de notre etude est de depister la distension (SI > 1) et identifier les facteurs de risque associes. Materiel et methodes Etude observationnelle, retrospective, en reanimation chirurgicale du CHRU de Lille de mai 2013 a fevrier 2014. Recueil dans 30 dossiers, apres information et consentement des proches de patients consecutirifs ventiles en volume assiste controle avec un ventilateur comportant la mesure automatisee du SI (Servo i™, Maquet GmbH), sans efforts de respiration spontanee. Recueil de donnees anamnestiques, cliniques, d’imagerie, parametres de ventilation dont le SI, et gazometriques des 1eres 24 h. Comparaison des patients distendus (SI > 1) ou non (SI≤1) au sein de l’effectif global et de sous-groupes par analyse des donnees du dossier, notamment l’imagerie pulmonaire tomodensitometrique et/ou ultrasonographique (groupes SDRA ou non selon les definitions de l’American-European Consensus Conference ou de Berlin [3] , groupe epanchements et/ou atelectasies, et groupe de patients sans atteinte respiratoire aigue). Comparaisons effectuees avec les tests non-parametrique de Mann-Whitney, Chi 2 et Fisher exact lorsqu’approprie (logiciel SPSS v18, IBM Corp). Resultats Soixante-douze patients ont ete ventiles sur les 4 mois du recueil, dont 30 ventiles en VAC avec mesure automatisee du SI dans des conditions de validite. Le SI recueilli revele 30 % de distension (9/30) avec comme facteurs de risque : volume courant (Vt) bas ( p = 0,028), FiO2 elevee ( p = 0,040), et PEP elevee ( p = 0,040). Les patients en SDRA etaient distendus dans 64 % des cas (9/14) avec comme facteurs de risque : Vt bas ( p = 0,048) et pression de plateau (Pplat) plus elevee ( p = 0,036). Les patients atteints d’atelectasies et/ou d’epanchement etaient distendus dans 63 % des cas (5/8) avec comme facteurs de risque: Vt bas ( p = 0,043) et PEP plus elevee ( p = 0,018). Aucune distension n’etait relevee dans le groupe sans atteinte respiratoire Discussion Ce premier recueil du SI en routine clinique revele jusqu’a 64 % de distension chez des patients atteints de SDRA malgre ventilation protectrice et limites de Pplat respectees, confirmant l’impossibilite en routine d’avoir une certitude de ventilation « protectrice ». D’autre part, le groupe de patients ayant des epanchements et/ou atelectasies, individualises dans la definition de Berlin, sont a haut risque de distension par la PEP. Enfin, les patients n’ayant pas d’atteinte respiratoire n’ont pas de distension lorsque ventiles a faible volume courant. En conclusion, le SI pourrait etre un outil de titration et de surveillance de la PEP chez les patients a risque de distension.