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A returned traveler to Uganda presented with a Plasmodium falciparum kelch13 A675V mutant infection that exhibited delayed clearance under artesunate therapy. Parasites were genetically related to recently reported Ugandan artemisinin-resistant A675V parasites. Adequate malaria prevention measures and clinical and genotypic surveillance are important tools to avoid and track artemisinin resistance.

International audience; Rationale: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown.Objectives: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2

Initiation of antimicrobial therapy (IAT) with broad-spectrum antibiotics is usual in Intensive Care Unit (ICU) patients with secondary peritonitis. Carbapenems are widely proposed by recent guidelines contrasting with current antibiotic stewardship policies of carbapenem-sparing. However, prognosis of inappropriate IAT remains unclear in these patients and broad-spectrum antibiotics are probably overused. We aimed to assess the role of inappropriate IAT in ICU patients with secondary peritonitis and the use of carbapenems in our IAT regimens.We performed a retrospective analysis during a six-year period including 131 ICU patients with secondary peritonitis. We collected data concerning comorbidities, source and severity of peritonitis, management of IAT, peritoneal samples and outcome.Forty-one patients presented with community acquired peritonitis (CAP) and 90 with postoperative peritonitis (POP). Thirty-seven (28.2%) patients died during ICU stay. IAT was inappropriate in 35 (26.7%) patients. Inappropriate IAT was not associated with reduced survival with respectively 26 (27%) deaths when IAT was adequate and 11 (31.4%) deaths when IAT was inadequate (P=0.87). Inappropriate IAT was not associated with the need of re-operation and duration of ICU stay. Carbapenems were delivered in 29 patients but were only necessary for eight patients without alternative treatment.In our study, inappropriate IAT was not associated with a worse prognosis and carbapenems were overused. Extensive delivery of carbapenems proposed by recent guidelines could be reconsidered in the management of these patients.

IntroductionPrognosis of patients with COVID-19 depends on the severity of the pulmonary affection. The most severe cases may progress to acute respiratory distress syndrome (ARDS), which is associated with a risk of long-term repercussions on respiratory function and neuromuscular outcomes. The functional repercussions of severe forms of COVID-19 may have a major impact on quality of life, and impair the ability to return to work or exercise. Social inequalities in healthcare may influence prognosis, with socially vulnerable individuals more likely to develop severe forms of disease. We describe here the protocol for a prospective, multicentre study that aims to investigate the influence of social vulnerability on functional recovery in patients who were hospitalised in intensive care for ARDS caused by COVID-19. This study will also include an embedded qualitative study that aims to describe facilitators and barriers to compliance with rehabilitation, describe patients’ health practices and identify social representations of health, disease and care.Methods and analysisThe "Functional Recovery From Acute Respiratory Distress Syndrome (ARDS) Due to COVID-19: Influence of Socio-Economic Status" (RECOVIDS) study is a mixed-methods, observational, multicentre cohort study performed during the routine follow-up of post-intensive care unit (ICU) functional recovery after ARDS. All patients admitted to a participating ICU for PCR-proven SARS-CoV-2 infection and who underwent chest CT scan at the initial phase AND who received respiratory support (mechanical or not) or high-flow nasal oxygen, AND had ARDS diagnosed by the Berlin criteria will be eligible. The primary outcome is the presence of lung sequelae at 6 months after ICU discharge, defined either by alterations on pulmonary function tests, oxygen desaturation during a standardised 6 min walk test or fibrosis-like pulmonary findings on chest CT. Patients will be considered to be socially disadvantaged if they have an "Evaluation de la Précarité et des Inégalités de santé dans les Centres d’Examen de Santé" (EPICES) score ≥30.17 at inclusion.Ethics and disseminationThe study protocol and the informed consent form were approved by an independent ethics committee (Comité de Protection des Personnes Sud Méditerranée II) on 10 July 2020 (2020-A02014-35). All patients will provide informed consent before participation. Findings will be published in peer-reviewed journals and presented at national and international congresses.Trial registration numberNCT04556513

Background As an increasing number of deaths occur in the intensive care unit (ICU), studies have sought to describe, understand, and improve end-of-life care in this setting. Most of these studies are centered on the patient’s and/or the relatives’ experience. Our study aimed to develop an instrument designed to assess the experience of physicians and nurses of patients who died in the ICU, using a mixed methodology and validated in a prospective multicenter study. Methods Physicians and nurses of patients who died in 41 ICUs completed the job strain and the CAESAR questionnaire within 24 h after the death. The psychometric validation was conducted using two datasets: a learning and a reliability cohort. Results Among the 475 patients included in the main cohort, 398 nurse and 417 physician scores were analyzed. The global score was high for both nurses [62/75 (59; 66)] and physicians [64/75 (61; 68)]. Factors associated with higher CAESAR-Nurse scores were absence of conflict with physicians, pain control handled with physicians, death disclosed to the family at the bedside, and invasive care not performed. As assessed by the job strain instrument, low decision control was associated with lower CAESAR score (61 (58; 65) versus 63 (60; 67), p = 0.002). Factors associated with higher CAESAR-Physician scores were room dedicated to family information, information delivered together by nurse and physician, families systematically informed of the EOL decision, involvement of the nurse during implementation of the EOL decision, and open visitation. They were also higher when a decision to withdraw or withhold treatment was made, no cardiopulmonary resuscitation was performed, and the death was disclosed to the family at the bedside. Conclusion We described and validated a new instrument for assessing the experience of physicians and nurses involved in EOL in the ICU. This study shows important areas for improving practices.

PURPOSE: Over the last two decades, noninvasive ventilation (NIV) has been proposed in various causes of acute respiratory failure (ARF) but some indications are debated. Current trends in NIV use are unknown. METHODS: Comparison of three multicenter prospective audits including all patients receiving mechanical ventilation and conducted in 1997, 2002, and 2011 in francophone countries. RESULTS: Among the 4132 patients enrolled, 2094 (51%) required ventilatory support for ARF and 2038 (49 %) for non-respiratory conditions. Overall NIV use was markedly increased in 2010/11 compared to 1997 and 2002 (37% of mechanically ventilated patients vs. 16% and 28%, P < 0.05). In 2010/11, the use of first-line NIV for ARF had reached a plateau (24% vs. 16% and 23%, P < 0.05) whereas pre-ICU and post-extubation NIV had substantially increased (11% vs. 4% and 11% vs. 7%, respectively, P < 0.05). First-line NIV remained stable in acute-on-chronic RF, continued to increase in cardiogenic pulmonary edema, but decreased in de novo ARF (16% in 2010/11 vs. 23% in 2002, P < 0.05). The NIV success rate increased from 56% in 2002 to 70% in 2010/11 and remained the lowest in de novo ARF. NIV failure in de novo ARF was associated with increased mortality in 2002 but not in 2010/11. Mortality decreased over time, and overall, NIV use was associated with a lower mortality. CONCLUSION: Increases in NIV use and success rate, an overall decrease in mortality, and a decrease of the adverse impact NIV failure has in de novo ARF suggest better patient selection and greater proficiency of staff in administering NIV. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT01449331.

Pseudomonas aeruginosa is a common cause of ventilator-associated pneumonia (VAP). Guidelines recommend dual coverage of P. aeruginosa, but the beneficial effect of combination therapy is controversial. We described antibiotic prescriptions and evaluated the clinical impact of initial combination antibiotic therapy and de-escalation strategy in patients with VAP caused by P. aeruginosa.Between 1994 and 2014, all 100 patients with VAP caused by P. aeruginosa in our intensive care unit (ICU) were included in a retrospective cohort study to evaluate the prognostic impact of initial combination antibiotic therapy.Eighty-five patients received initial combination antibiotic therapy and 15 monotherapy. Nine patients received inadequate initial antibiotic therapy. De-escalation was performed in 42 patients. Thirty-nine patients died in the ICU. Factors independently associated with death were SAPS II score [SAPS II ≥40 versus 40: hazard ratio (HR) 2.49, 95% confidence interval (CI) 1.08-5.70, p = 0.03] and septic shock (HR = 4.80, 95% CI = 1.90-12.16, p 0.01) at onset of VAP. Initial combination antibiotic therapy (HR = 1.97, 95% CI = 0.56-6.93, p = 0.29) and early de-escalation (HR = 0.59, 95% CI = 0.27-1.31, p = 0.19) had no impact on mortality. In multivariate analysis, the risk for inappropriate initial antibiotic therapy was higher in cases with multi-drug resistant P. aeruginosa [odd ratio (OR) = 7.11, 95% CI = 1.42-35.51, p = 0.02], but lower in cases with initial combination antibiotic therapy (OR = 0.12, 95% CI = 0.02-0.63, p = 0.01).In our cohort, combination therapy increased the likelihood of appropriate therapy but did not seem to impact on mortality.

Résumé Grâce aux méthodes de diagnostic actuelles, l’identification microbiologique des pneumonies communautaires graves (PCG) peut être établie dans la moitié des cas. Si les études épidémiologiques ont permis d’établir des recommandations préconisant l’antibiothérapie empirique à débuter, l’identification microbiologique du ou des pathogène(s) responsable(s) est nécessaire pour la conduite ultérieure du traitement. Les principaux examens à effectuer pour l’identification bactérienne sont la réalisation d’hémocultures, d’un examen cytobactériologique des sécrétions respiratoires et la recherche d’une antigénurie pneumococcique ou légionnelle. Les hémocultures sont positives dans 15 à 25 % des cas de PCG. L’examen cytobactériologique des crachats ou l’aspiration endotrachéale, chez le patient intubé, aide au diagnostic sous réserve que le prélèvement ne soit pas contaminé par la flore oropharyngée. La positivité d’une antigénurie est également fonction de la sévérité de la pneumonie. Cet examen permet un diagnostic rapide et n’est pas influencé par une antibiothérapie préalable. Les virus à tropisme respiratoire seraient responsables de 10 à 40 % des PCG. En période épidémique, des prélèvements par écouvillonnage nasal à la recherche du virus influenza sont recommandés, en raison du bénéfice attendu avec l’instauration d’un traitement par oseltamivir. Les sérologies permettant de faire le diagnostic de pneumonie à germes intracellulaires ont peu d’intérêt aux urgences de même que la réalisation de prélèvements sous fibroscopie bronchique. Enfin, la recherche qualitative par reverse transcriptase (PCR) sérique présente peu d’intérêt pour le diagnostic de pneumonie bactérienne par rapport aux méthodes usuelles.

La prevention des infections nosocomiales est un enjeu majeur dans les services de reanimation. La colonisation cutanee bacterienne precede frequemment la survenue de ces infections, notamment les infections a staphylocoques. La chlorhexidine est un antiseptique topique bactericide ayant une excellente activite vis-a-vis des cocci a Gram positif, des levures et une efficacite moindre vis-a-vis des bacilles a Gram negatif. La toilette quotidienne des patients a la chlorhexidine pourrait ainsi diminuer l’incidence des infections nosocomiales en diminuant la colonisation cutanee. Les premieres etudes observationnelles ont mis en evidence une diminution du portage cutane a staphylocoque et a enterocoque. Une diminution du taux des bacteriemies sur catheter et des bacteriemies primitives a egalement ete reportee. Les etudes multicentriques randomisees, plus recentes, retrouvent une diminution des bacteriemies a staphylocoques a coagulase negative. La toilette a la chlorhexidine n’est pas associee a une diminution de l’incidence des pneumonies acquises sous ventilation mecanique et des infections urinaires. Cette procedure n’entraine pas de diminution des infections acquises a bacille Gram negatif. S’il ne semble pas exister de resistance a la chlorhexidine apres une periode d’application de quelques mois, une utilisation plus prolongee serait associee a des augmentations des concentrations minimales inhibitrices des souches de staphylocoques vis-a-vis de cet antiseptique. La toilette a la chlorhexidine pourrait etre proposee dans les services de reanimation ou l’incidence des bacteriemies a Staphylocoques demeure importante.

BACKGROUND Terminal extubation (TE) is applied in some Intensive Care Units (ICU) patients when a decision of withdrawal of mechanical ventilation is decided. Other units prefer terminal weaning (TW) with no removal of the endotracheal tube. We report our experience with these two procedures. METHODS We conducted a retrospective study analyzing patients deceased in our ICU after a decision of life sustained therapy (LST) during the year 2013. TE was proposed to family members for patients presenting with two medical conditions: lack of vasoactive drugs (VAD) and SaO2>95% with a FIO2

Water precipitation in road slopes, pavements, and shoulders may cause disturbances such as erosion, increase of the water table level, decrease of the carriageway bearing capacity, and so on. Roads are normally equiped with drainage systems that are sized and implemented in accordance with the rules of art. These equipments are used for the collection and quick evacuation of water precipitation estimated on the basis of the return period that is taken into account. Despite that, rainwater can still infiltrate unprotected cut or fill slopes, and pavements for repeated and intense rainfalls, which may cause a raise in pore-water pressure and a decrease of the factor of safety of road slopes. Using laboratory rainfall simulation techniques, infiltration measurements were made on intact samples to determine with respect to soil properties, how cumulative rainfalls cause decrease in apparent cohesion and lead to slope failure. This paper focuses on describing the relationship between the rainfall characteristics, the changes in soil water profile, and the changes in apparent cohesion for sandy clay samples collected on the national road RN3 located in Haiti. For a set of consecutive rainfall events at around an interval of 24 hours, the results prove that when wetting front depth approaches 2 meters or more, the risk of landslide is proportionally high in a soil with apparent cohesion (Ca) initially high and an effective cohesion (c′) relatively low.

PurposeEarly renal replacement therapy (RRT) initiation should theoretically influence many physiological disorders related to acute kidney injury (AKI). Currently, there is no consensus about RRT timing in intensive care unit (ICU) patients.MethodsWe performed a retrospective analysis of all critically ill patients who received RRT in our ICU during a 3 year-period. Our goal was to identify mortality risk factors and if RRT initiation timing had an impact on survival. RRT timing was calculated from the moment the patient was classified as having acute kidney injury in the RIFLE classification.ResultsA hundred and ten patients received RRT. We identified four independent mortality risk factors: need for mechanical ventilation (OR = 12.82 (1.305 - 125.868, p = 0.0286); RRT initiation timing >16 h (OR = 5.66 (1.954 - 16.351), p = 0.0014); urine output on admission 70 (OR = 3.45 (1.216 - 9.815), p = 0.02). The RRT initiation 16 h groups presented the same baseline characteristics, except for more severe gravity scores and kidney failure in the early RRT group.ConclusionsEarly RRT in ICU patients with acute kidney injury or failure was associated with increased survival.

International audience; Purpose: To develop an instrument designed specifically to assess the experience of relatives of patients who die in the intensive care unit (ICU). Methods: The instrument was developed using a mixed methodology and validated in a prospective multicentre study. Relatives of patients who died in 41 ICUs completed the questionnaire by telephone 21 days after the death, then completed the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief after 3, 6, and 12 months. Results: A total of 600 relatives were included, 475 in the main cohort and 125 in the reliability cohort. The 15-item questionnaire, named CAESAR, covered the patient's preferences and values, interactions with/around the patient and family satisfaction. We defined three groups based on CAESAR score tertiles: lowest (= 69, n = 121, 29.3 %). Factorial analysis showed a single dimension. Cronbach's alpha in the main and reliability cohorts was 0.88 (0.85-0.90) and 0.85 (0.79-0.89), respectively. Compared to a high CAESAR score, a low CAESAR score was associated with greater risks of anxiety and depression at 3 months [1.29 (1.13-1.46), p = 0.001], post-traumatic stress-related symptoms at 3 [1.34 (1.17-1.53), p < 0.001], 6 [OR = 1.24 (1.06-1.44), p = 0.008] and 12 [OR = 1.26 (1.06-1.50), p = 0.01] months and complicated grief at 6 [OR = 1.40 (1.20-1.63), p < 0.001] and 12 months [OR = 1.27 (1.06-1.52), p = 0.01]. Conclusions: The CAESAR score 21 days after death in the ICU is strongly associated with post-ICU burden in the bereaved relatives. The CAESAR score should prove a useful primary endpoint in trials of interventions to improve relatives' well-being.

To report the clinical characteristics and prognosis of prosthetic joint infections (PJIs) in Intensive care units (ICUs). Forty-one patients consecutively admitted to ICUs for PJIs between January 2004 and June 2011 were included in a retrospective case series. A majority of patients (73 %) had severe underlying disease. Acute infection affected 26 patients (63 %). Blood cultures were positive in 16 patients (39 %). Staphylococcus species were the most commonly implicated causative organisms (n = 36, 88 %). The surgical strategy was two-stage replacement in 25 cases (61 %). The surgical procedure leading to ICU admission was mainly prosthesis removal with spacer implantation (n = 13, 32 %). Initial antibiotherapy was a broad-spectrum beta-lactam antibiotic combined with a glycopeptide, linezolid, or daptomycin in 26 cases (63 %). Mortality in the ICU was 20 %. In nonsurvivors, diabetes, acute infection, and American Society of Anesthesiologists (ASA) score >3 were more frequent. The distribution of surgical strategies and procedures was not statistically different in survivors and nonsurvivors. The proportion of patients treated with antibiotherapy adjusted according to previous microbiological findings was higher in nonsurvivors (50 vs. 12 %, p = 0.02). In our case series of critically ill patients suffering from PJI, factors associated with a poor outcome were diabetes mellitus, ASA score >3, and acute infection. Surgical strategies and surgical procedures had no significant impact on the ICU mortality. Adjustment of initial antibiotherapy according to previous microbiological findings should be made with caution.

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

Numerous guidelines are available to guide empirical antimicrobial therapy (EAT) in acute bacterial meningitis (ABM) patients. We analysed prognosis factors and compliance to the Infectious Diseases Society of America (IDSA) guidelines in ABM patients requiring stay in an intensive care unit (ICU). A 10-year retrospective study, using prospectively collected data, in 82 ABM patients admitted to a 16-bed university-affiliated French ICU was undertaken. Seventeen patients (20.7%) died during ICU stay. Multivariate analysis isolated four factors associated with in-ICU death: alcoholism (P = 0.007), acute kidney injury (P = 0.006), age >60 years (P = 0.006) and ICU admission for neurological failure (P = 0.01). Causative pathogens were isolated for 62 (75.6%) patients, including 29 pneumococci, 14/28 of which were non-susceptible to penicillin. No characteristics, particularly recent hospitalisation and/or antibiotic delivery, was associated with penicillin susceptibility. Compliance to IDSA guidelines was 65%. Non-compliance concerned to be essentially the non-delivery or low dosage of vancomycin. Treatment compatible with IDSA guidelines was associated with a decreased ICU mortality in univariate (61.5% survival vs. 35.3%, P = 0.05) but not in multivariate analysis. In-ICU mortality associated with ABM remains high. Prognosis factors are related to the severity of disease or underlying conditions. Penicillin non-susceptible Streptococcus pneumoniae can occur without any of the usual predisposing factors.

In a previous study, we developed a prognostic prediction rule, based on nine prognostic variables, capable to estimate and to adjust the mortality rate of patients admitted in intensive care unit for severe community-acquired pneumonia. A prospective multicenter study was undertaken to evaluate the performance of this rule. Five hundred eleven patients, over a 7-year period, were studied. The ICU mortality rate was 29.0%. In the 3 initial risk classes, we observed significantly increasing mortality rates (8.2% in class I, 22.8% in class II and 65.0% in class III) (p

High volume hemofiltration (HVHF) has shown potential benefits in septic animals and a few reports suggested a hemodynamic improvement in humans. However, randomized studies are still lacking. Our goal was to evaluate the hemodynamic effects of HVHF in septic shock patients with acute renal failure (ARF).Prospective randomized study in an intensive care unit (ICU).Twenty patients with septic shock and ARF.Patients were randomized to either high volume hemofiltration [HVHF 65 ml/(kg h)] or low volume hemofiltration [LVHF 35 ml/(kg h). Vasopressor dose was adjusted to reach a mean arterial pressure (MAP)65 mmHg.We performed six hourly measurements of MAP, norepinephrine dose, PaO(2)/FiO(2) and lactate, and four daily urine output and logistic organ dysfunction (LOD) score. Baseline characteristics of the two groups were comparable on randomization. Mean norepinephrine dose decreased more rapidly after 24 h of HVHF treatment compared to LVHF treatment (P = 0.004) whereas lactate and PaO(2)/FiO(2) did not differ between the two treatment groups. During the 4-day follow-up, urine output was slightly increased in the HVHF group (P = 0.059) but the LOD score evolution was not different. Duration of mechanical ventilation, renal replacement therapy and ICU length of stay were also comparable. Survival on day 28 was not affected.HVHF decreased vasopressor requirement and tended to increase urine output in septic shock patients with renal failure. However, a larger trial is required to confirm our results and perhaps to show a benefit in survival.

To evaluate the prevalence and the prognostic value of thrombocytopenia in patients admitted to ICU for severe community-acquired pneumonia.Multicentre observational study was conducted in 7 ICUs in the north of France over a 19-year period (1987-2005). The primary outcome measure was the ICU mortality.Eight hundred and twenty-two patients were studied. A platelet count150x10(9)/L was observed at ICU admission in 202 (25%) patients. Admission platelet count was between 101 and 149x10(9)/L, 51 and 100x10(9)/L, 21 and 50x10(9)/L, andor = 20x10(9)/L in 100, 61, 32 and 9 patients, respectively. ICU mortality rate was 35.4%. Classifying patients into 3 categories with the following cut-offs of platelet count,or = 150x10(9)/L, 51-149x10(9)/L, andor = 50x10(9)/L, we observed a significant increase in ICU mortality rates which were 30.8% in the first group, 44.1% in the second group and 70.7% in the last one (p0.0001). In multivariate analysis, thrombocytopeniaor = 50x10(9)/L appeared as an independent predictor of mortality (AOR=4.386).In patients admitted to ICU for severe community-acquired pneumonia, thrombocytopenia has a high prevalence and influences the outcome.

An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements. End-of-life care and communication in the ICU are associated with the prevalence of complicated grief

Resume La desescalade antibiotique en reanimation est une strategie ayant un double but : assurer l'adequation de l'antibiotherapie initiale probabiliste et diminuer l'emergence des germes multiresistants. Stricto sensu, la desescalade ne peut s'appliquer que chez les patients presentant, apres 48 a 72 heures d'evolution, a la fois une amelioration de leur etat clinique et des prelevements bacteriologiques positifs. La desescalade consiste a adapter etroitement le spectre de l'antibiotherapie curative aux donnees de l'antibiogramme. Cette strategie est clairement proposee comme approche ideale du traitement des pneumonies nosocomiales. Elle peut egalement s'appliquer a l'ensemble des pathologies infectieuses de reanimation sous reserve de connaitre la fiabilite des explorations microbiologiques et de savoir evaluer l'evolution clinique.

Purpose The objective of this study is to study the epidemiology, outcome, and prognostic factors of critically ill patients treated with continuous venovenous hemodiafiltration (CVVHDF). Materials and Methods Observational cohort was done in a French 16-bed intensive care unit (ICU) from a university-affiliated urban hospital. All patients requiring, in the opinion of the treating physician, the initiation of CVVHDF were included in the study. Results One hundred ninety-seven patients with acute renal failure (ARF) treated with CVVHDF were studied. The incidence of ARF treated with CVVHDF was 5.9% in the ICU with a mortality rate of 71.6%. A multivariate analysis identified 3 independent factors associated with fatal outcome: mechanical ventilation, sepsis, and septic shock requiring vasoactive drug. In contrast, 2 independent factors predicted a favorable outcome: nonoliguric ARF and serum creatinine concentration higher than 34 mg/L at CVVHDF initiation. A flowchart determined by the χ 2 Automatic Interaction and Detection statistical method allowed for the identification of patients' subgroups with different mortality rates ranging from 25% to 100%. Conclusions In our series, ARF treated with CVVHDF was associated with a high overall ICU mortality rate (71.6%). However, our prognostic flowchart identified patients with low mortality rates for which renal replacement therapy must be initiated with no discussion as soon as required.

Inadequate initial antimicrobial therapy represents one of the factors associated with mortality of patients suffering from hospital-acquired pneumonia. According to its wide antimicrobial spectrum, imipenem belongs to the usual antibiotics proposed by current guidelines for such a therapy. However, major changes in the antibiotic susceptibility patterns of bacteria in the intensive care unit (ICU) have occurred. Our goal was to determine the incidence of hospital-acquired pneumonia (HAP) due to imipenem-resistant organism(s) in our ICU and to identify factors associated with such a resistance. From January 1994 to December 2001, all consecutive patients admitted to our ICU for HAP or exhibiting HAP during their ICU stay were included in an observational cohort. Patients with a bacteriologically documented HAP were studied. For each causative pathogen, imipenem susceptibility was routinely determined. Patients with an HAP episode due to at least one imipenem-resistant causative organism were compared with patients who developed HAP in which all incriminated pathogens were imipenem susceptible. 235 patients were included in our observational cohort. Among them, 168 had an HAP episode with a bacteriologically proven infection. In 42 patients (25%), at least one causative organism was resistant to imipenem. The 44 imipenem-resistant organisms were Staphylococcus aureus (n = 15), Pseudomonas aeruginosa (n = 14), Stenotrophomonas maltophilia (n = 13), and Acinetobacter baumannii (n = 2). Multivariate analysis identified four significant independent factors associated with resistance of causative organism(s) to imipenem: prior use of a fluoroquinolone (AOR = 3.9; 95% CI: 1.8 to 8.8; p < 0.0001), prior use of an aminoglycoside (AOR = 2.6; CI: 1.2 to 5.9; p = 0.02), use of invasive blood pressure monitoring (AOR = 2.7; CI: 1.0 to 7.0; p = 0.04) and bilateral chest X-ray involvement (AOR = 2.6; CI: 1.1 to 5.8; p = 0.02). Factors associated with potential inadequacy of imipenem used as the single antibiotic for initial empiric treatment for HAP were identified. When they are present, imipenem should be either combined with antibiotics such as vancomycin and ciprofloxacin or replaced with another broad-spectrum antimicrobial regimen.

Background: Measurement of procalcitonin (PCT) has been studied for several years in infectious diseases. Some studies have focused on community–acquired pneumonia (CAP) but only one was conducted in critically ill patients hospitalized in an intensive care unit (ICU). Patients and Methods: To determine the diagnostic and prognostic role of PCT in patients admitted in an intensive care unit for severe CAP, 110 patients hospitalized in our unit were prospectively studied. Within 48 hours following ICU admission, PCT serum level was measured with a quantitative method above a threshold value of 0.5 ng/ml. Results: Initially focusing on the diagnostic value of PCT, 20% of the patients had a serum PCT level < 0.5 ng/ml, 30% between 0.5 ng/ml and 2 ng/ml, and 50% ≥ 2 ng/ml. Serum PCT level was higher in microbiologically documented CAP (median = 4.9 ng/ml vs 1.5 ng/ml if no bacteria were found; p = 0.001), but was not predictive of any specific bacterial agent. Concerning the prognostic value, the serum PCT level was higher for bacteremic patients and/or septic shock patients (4.9 ng/ml vs 1.5 ng/ml; p = 0.0003). Moreover, PCT levels were increased in patients who developed, during their ICU stay, infection–related complications (septic shock, multiorgan dysfunction, acute respiratory distress syndrome and disseminated intravascular coagulation). Finally, the initial PCT level was significantly higher in patients who died during the ICU stay (5.6 ng/ml vs 1.5 ng/ml; p < 0.0001). Such a relationship was not found with C–reactive protein (CRP). Conclusion: In ICU patients admitted for severe CAP, initial PCT values could be an interesting predictor for complications and mortality.

To study the prognostic impact of the appropriateness of initial antimicrobial therapy in patients suffering from ventilator-associated pneumonia (VAP). Observational cohort from January 1994 to December 2001 in one intensive care unit (ICU) from an university-affiliated, urban teaching hospital. All 132 consecutive patients exhibiting bacteriologically documented VAP during ICU stay. Initial antimicrobial treatment was deemed appropriate when the period from initial VAP diagnosis and subsequent administration of antibiotics was within 24 h and all causative pathogens were in vitro susceptible to at least one of the antibiotics of the regimen. Such a treatment was present in 106 episodes. Fifty-eight patients died. In bivariate analysis an appropriate initial antimicrobial therapy was associated with a significantly lower mortality rate (40% vs. 62%). In multivariate analysis the three independent factors present upon VAP onset and associated with death were pulmonary involvement of more than a single lobe on chest radiograph, platelet count less than 150,000/mm3, and Simplified Acute Physiology Score II higher than 37. Appropriate antimicrobial therapy was associated with a nonsignificant trend toward a lower mortality. In our cohort the mortality rate was lower in patients suffering from VAP when the initial antimicrobial therapy was appropriate. However, such a factor did not appear as an independent prognostic factor.

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.

Study objectives To determine factors associated with antimicrobial-resistant hospital-acquired pneumonia (AR-HAP), to build an algorithm evaluating the risk for such a pneumonia, and to test this algorithm. Design Combined observational and validation cohorts over two periods: January 1994 to December 1999, and January 2000 to March 2001. Setting One ICU from a university-affiliated urban teaching hospital. Patients One hundred twenty-four patients in the observational cohort and 26 patients in the validation cohort exhibiting bacteriologically documented hospital-acquired pneumonia (HAP). Interventions Prospective data collection and multivariate analysis using the χ 2 automatic interaction and detection technique. Results In the observational cohort, 39 antimicrobial-resistant bacteria were incriminated in 37 patients (30%). Multivariate analysis identified four independent variables allowing a binary stratification of risk. According to the presence or absence of prior antimicrobial treatment, neurologic disturbances on ICU admission, aspiration on ICU admission, and time elapsed between ICU admission and the onset of pneumonia, we were able to identify and separate patients at high, low, or even no risk for acquiring AR-HAP. In the validation cohort, nine antimicrobial-resistant bacteria were incriminated in nine patients (34.6%). In this cohort, the algorithm performed well allowing the identification of null risk categories: the absence of prior antimicrobial treatment, the presence of prior antimicrobial treatment with neurologic disturbances on ICU admission and an early-onset pneumonia, and the presence of prior antimicrobial treatment without neurologic disturbances but with aspiration on ICU admission were always associated with antimicrobial-susceptible HAP. Conclusion We developed and tested a binary algorithm allowing the identification of patients at low risk for acquiring AR-HAP. An antibiotic strategy including an initial antimicrobial treatment guided by such an algorithm, followed, if possible, by a de-escalation when antimicrobial data are available, could increase the administration of adequate initial antimicrobial treatment and help prevent the emergence of antibiotic resistance in the ICU.

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

Objective We had for aim to describe the identification and management of a 14-clonal carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak, following admission of a known CRAB-infected patient in an ICU. Methods We reviewed the carriers’ files and outbreak management procedures. Results The index patient was admitted with strict isolation precautions. The outbreak started 2 months after his discharge. It persisted despite reinforcement of strict isolation precautions, staff and patient cohorting, and extensive environmental decontamination including 2 rounds of routine terminal cleaning and disinfection or 1 round of cleaning and disinfection followed by hydrogen peroxide treatment. A second epidemic peak, after 4 weeks without any case, led to another wide environmental sampling and decontamination rounds. The source of the CRAB outbreak was suspected to be the blood pressure cuffs Velcro. Switching to cuffs submersible in a disinfectant stopped the outbreak. Conclusions CRAB outbreaks are difficult to manage and sources of persistent colonization can be unexpected.

Resume Cas cliniques – Nous rapportons deux observations de bacteriemie a M. bovis , apres instillation endovesicale du BCG pour carcinome vesical. Un sondage traumatique a precede la BCG-therapie dans les deux cas. Cas n°1 : Un homme de 64 ans a ete hospitalise pour choc septique apres la deuxieme instillation endovesicale. Le traitement initial par ciprofloxacine a ete un echec. Le diagnostic de BCGite a ete affirme par la ponction biopsie hepatique. L'evolution a ete favorable sous traitement antituberculeux et corticoides. Cas n°2 : Un homme de 70 ans a ete hospitalise, dans les memes conditions, quelques heures apres la troisieme instillation endovesicale. Une hemoculture a ete positive a M. bovis variant BCG Connaught (souche vaccinale). Le traitement antituberculeux triple et corticoides a permis une amelioration franche. Commentaires – Les deux observations plaident pour l'utilisation systematique de corticosteroides dans les formes graves de BCGites en association avec une tri therapie antituberculeuse.

Resume Objectif Nous avons voulu apprecier l'influence des ordonnances nominatives a duree limitee sur la prescription des antibiotiques dans un CHU. Methodes Nous avons instaure, en janvier 1998, des ordonnances nominatives a duree limitee (quatre jours pour les traitements probabilistes et sept jours pour les traitements documentes). Les formes intraveineuses des molecules suivantes etaient concernees: amikacine, cefepime, sulbactam, ciprofloxacine, ceftazidime, fosfomycine, acide fusidique, ofloxacine, piperacilline, teicoplanine, tazocilline, imipeneme, fluconazole et vancomycine. Elles n'etaient delivrees que sur presentation d'une ordonnance specifique. Les quantites consommees ont ete suivies mensuellement depuis 1997 et exprimees en doses definies journalieres pour 100 jours d'hospitalisation. Les antibiotiques non restreints etaient evalues annuellement. Resultats L'activite de l'etablissement a legerement augmente (journees d'hospitalisation: + 1,9 %, admissions: + 5,1 %) de 1997 a 1998. Une diminution de 17,7 % de la consommation des antibiotiques restreints et une augmentation de 3 % des autres a ete observee. La baisse des molecules restreintes etait compensee par une hausse des molecules non restreintes de meme classe. Cependant, une diminution globale de 1,6 % des doses consommees a ete observee. Cela s'est traduit par une baisse de 7,4 % du budget antibiotique et de 11,7 % du ≪ cout antibiotique ≫ par patient. Commentaires La qualite des soins ne semble pas avoir ete modifiee (stabilite de la duree de sejour et du taux de mortalite). Le suivi est trop court pour voir un effet sur les isolements de bacteries multiresistantes. Cette etude suggere que des methodes faiblement coercitives peuvent reduire l'utilisation des antibiotiques a l'hopital.

Resume Un questionnaire a ete distribue aux participants a la reunion annuelle organisee le 26.5.97 parl'ARECLIN (association regionale des comites de lutte contre l'infection nosocomiale) consacree aux accidents d'exposition au sang. L'ARECLIN regroupe une trentaine d'hopitaux du Nord-Pas de Calais. Sur 529 questionnaires distribues, 446 ont ete recus dont 445 evaluables (84%). La plupart des repondants etaient infirmiers (63%), eleves infirmiers (10%), cadres infirmiers (6%) ou medecins (5%). 63% avaient termine leur formation initiale depuis plus de 10 ans, 60% exercaient en CHG, 22% en CHU et 8% en clinique privee. 47,2% (180/381) des repondants a une question specifique declaraient avoir eu au moins un accident d'exposition au sang. Le taux etait maximum chez les infirmieres (58%), mais present dans toutes les categories professionnelles: puericultrices et sages-femmes (55%), cadres infirmiers (35%), eleves infirmieres (32%), personnel de laboratoire (27%) medecins (25%), aides-soignantes (17%) et personnel medico-technique (12%). La declaration systematique de tout accident d'exposition au sang etait reconnue par 97% des repondants; cette declaration se faisant preferentiellement au medecin du travail (81%) ou a la surveillante du service (75%). Sur l'ensemble des repondants, 34% declaraient dans l'heure suivant l'accident d'exposition au sang, invoquant la prophylaxie anti-VIH et 41% declaraient dans les 24 h. La conduite pratique comportait nettoyage au savon pour 68% et desinfection par eau de Javel pour 83%. 71% connaissaient le concept de precautions universelles. Sur 10 mesures, seules 3 etaient connues par moins de 80% des personnes: non desadaptation des aiguilles a la main (73%), panser et couvrir les plaies des soignants (77%) et decontamination des surfaces souillees par eau de Javel (66%). La moyenne globale etant de 8,6 bonnes reponses sur 10. Bien que le theme de la reunion ait probablement selectionne des personnes motivees par le risque d'accident d'exposition au sang, les resultats sont encourageants et montrent une bonne connaissance des accidents d'exposition au sang et des precautions universelles dans le personnel soignant.

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

IMPORTANCE Despite advances in care, mortality and morbidity remain high in adults with acute bacterial meningitis, particularly when due to Streptococcus pneumoniae. Induced hypothermia is beneficial in other conditions with global cerebral hypoxia. OBJECTIVE To test the hypothesis that induced hypothermia improves outcome in patients with severe bacterial meningitis. DESIGN, SETTING, AND PATIENTS An open-label, multicenter, randomized clinical trial in 49 intensive care units in France, February 2009-November 2011. In total, 130 patients were assessed for eligibility and 98 comatose adults (Glasgow Coma Scale [GCS] score of

Jusqu’a ces dernieres annees, il etait traditionnel de considerer qu’il existait en milieu de reanimation deux types de pneumonies graves: les pneumonies communautaires acquises en ville et les pneumonies nosocomiales qui survenaient au-dela des 48 premieres heures d’hospitalisation. Actuellement, il est clair que cette classification dichotomique n’est pas suffisante pour caracteriser l’ensemble des pneumonies rencontrees en reanimation. d’une part, il convient de distinguer les pneumonies nosocomiales acquises sous ventilation des autres pneumonies nosocomiales; d’autre part, de nombreux patients beneficient en dehors d’une hospitalisation traditionnelle de soins ambulatoires tels que chirurgie, dialyse ou chimiotherapie. De meme, dans la plupart des structures d’hebergement ou de reeducation, les patients peuvent beneficier de soins medicaux intensifs ou invasifs. Les pneumonies survenant chez ces patients sont actuellement definies comme liees aux soins [1]. Il convient donc actuellement de considerer comme communautaires les seules pneumonies acquises en ville par des patients indemnes de tout soin ambulatoire recent ou de toute hospitalisation recente. Cette definition stricte etant recente, il est evident que bon nombre des etudes qui seront citees dans cette revue avaient inclus des patients souffrant de pneumonies liees aux soins.