Successfully treated necrotizing fasciitis using extracorporeal life support combined with hemoadsorption device and continuous renal replacement therapy

INTRODUCTION: Necrotizing fasciitis represents a life-threatening infectious condition that causes spreading necrotisis of superficial fascia and subcutaneous cellular tissues. We describe the case of a patient diagnosed with septic and toxic shocks leading to multiple organ failure successfully treated with a combination of extracorporeal life support, continuous renal replacement therapy, and a hemoadsorption device. METHODS: A 41-year-old patient presented with necrotizing fasciitis and multi-organ failure. Initial extracorporeal life support therapy was implanted, compensating for systolic failure. Due to acute renal failure that persisted in time, continuous renal replacement therapy was added. Despite these treatments and as a last attempt to control the septic condition, a CytoSorb hemoadsorption device was installed in parallel to the extracorporeal life support circuit and two sessions were run. RESULTS: During the days following CytoSorb treatment, hemodynamic stabilization was observed, as well as normalization of lactic acidosis and blood parameters. CONCLUSION: This case describes the successful use of CytoSorb with continuous renal replacement therapy and extracorporeal life support in a combined way to overcome a critical phase of septic shock in a young adult patient. This combination of treatments turned out to be efficient for this patient in the context of necrotizing fasciitis

Factors affecting compliance with glove removal after contact with a patient or environment in four intensive care units

International audienc

Impact of screening and identifying methicillin-resistant Staphylococcus aureus carriers on hand hygiene compliance in 4 intensive care units

BackgroundOur objective was to assess the impact of screening and identifying methicillin-resistant Staphylococcus aureus (MRSA) carriers as a single measure in 4 intensive care units (ICUs). Methods An evaluative study including two 6-month periods was conducted prospectively. The evaluation concerned the hand hygiene compliance (HHC) for contacts with MRSA carriers versus contacts with noncarriers (comparison C1, main objective) and for a period of absence of identification (P1) versus a period of identification (P2) (comparison C2) and MRSA cross transmission (P1 vs P2) (comparison C3) measured with 2 indicators. Results Overall, 1326 opportunities of hand hygiene were observed. Concerning C1, the HHC for contacts with MRSA carriers was 42.5% versus 43.1% for contacts with noncarriers (not significant). This absence of difference was recorded whatever the ICU specialty, the category of personnel, and the nature of contacts. Concerning C2, the HHC in P1 was 44.8% versus 48.5% in P2 (not significant). Concerning C3, no significant difference was identified between the 2 periods. Conclusion We did not identify any advantage by using screening and identifying MRSA carriers in those 4 ICUs in which no specific strategy of additional contact measures was implemented for MRSA carriers

Measurement and interpretation of hand hygiene compliance rates: importance of monitoring entire care episodes

SummaryOur objective was to assess the importance of monitoring hand hygiene compliance (HHC) during series of successive contacts with patients or surroundings for measurement and interpretation of the compliance rates. A direct observational study of HHC was performed in four intensive care units (ICUs) and four healthcare settings with non-intensive care wards (NICWs). Hand hygiene (HH) opportunities were differentiated into two categories: extra-series opportunities (ESOs) (before or after a single contact, and before the first contact or after the last contact of a series of successive contacts) or as intra-series opportunities (ISOs) (from the opportunity following the first contact to the opportunity preceding the last in the same series). In all, 903 opportunities of HH were performed in ICUs and 760 in NICWs. The proportion of ISOs was 46.0% in ICUs and 22.9% in NICWs. The overall HHC was significantly higher in NICWs than in ICUs (61.2% vs 47.5%, P < 0.00001). The HHC was significantly higher for ESOs than for ISOs (67.7% vs 28.5%, P < 0.00001). The HHC for ISOs was significantly higher in ICUs (32.2% vs 19.0%, P < 0.005). If the distribution of categories of HH opportunities observed in NICWs had been the same as in ICUs, the overall HHC would have been similar in NICWs (46.4%) and in ICUs (47.5%). Monitoring HHC during entire care episodes in series of successive contacts is necessary to avoid a strong overestimation of the overall compliance rates. Concurrently, comparison of compliance data should take into account the proportion of ISOs included in the evaluation study

The impact of performing bacterial identification (BI) and antimicrobial susceptibility testing (AST) for bronchoalveolar fluid (BAL) cultures 24h a day in a clinical microbiology laboratory

We previously demonstrated the positive impact of performing bacterial identification and antimicrobial susceptibility testing (AST) after day hours (night service [NS]) for certain clinical samples on the treatment of infected patients. Our objective was to evaluate the impact of including positive bronchoalveolar lavage (BAL) cultures in our NS. Two major positive consequences were recorded: initiation of earlier appropriate treatment and earlier change to a reduced-spectrum but still effective regimen. Reductions in delay were defined as the differences between the hours actually spent and hours estimated as though laboratory tests had been performed in the absence of NS. Fifty BALs were included. The NS led to the implementation of earlier appropriate therapy in 10 cases (20%), to earlier de-escalation in 15 cases (30%), and to earlier appropriate therapy and de-escalation in 4 cases (8%). In conclusion, performing bacterial identification and AST for positive BAL after laboratory opening hours could be relevant

Extended-spectrum β-lactamase Enterobacteriaceae (ESBLE) in intensive care units: strong correlation with the ESBLE colonization pressure in patients but not same species

Sink drains of six intensive care units (ICUs) were sampled for screening contamination with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE). A high prevalence (59.4%) of sink drain contamination was observed. Analysing the data by ICU, the ratio \u27number of ESBLE species isolated in sink drains/total number of sink drains sampled\u27 was highly correlated (Spearman coefficient: 0.87; P = 0.02) with the ratio \u27number of hospitalization days for patients with ESBLE carriage identified within the preceding year/total number of hospitalization days within the preceding year\u27. Concurrently, the distribution of ESBLE species differed significantly between patients and sink drains

Le personnel soignant et l'hygiène des mains en réanimation : une analyse sociologique

Introduction/objectif du travail : Depuis quelques années, l’intérêt de l’analyse du comportement du personnel hospitalier vis-à-vis de règles d’hygiène des mains (HM) a été beaucoup étudié, ce qui a permis de mieux comprendre l’échec ou le caractère transitoire du succès de nombreux programmes d’amélioration de son observance. Cependant, peu d’études de ce type ont été réalisées en France. Notre objectif était d’étudier les aspects sociologiques des pratiques d’HM en réanimation. Matériel et Méthodes : L’étude a été réalisée par l\u27Institut de Psychologie et de Sociologie Appliquées de l\u27Université Catholique de l\u27Ouest (UCO, Angers), en collaboration avec l\u27équipe opérationnelle d\u27hygiène et deux services de réanimation du CHU d\u27Angers. Elle a comporté une phase d\u27observation participante menée par une étudiante en sociologie (Master-1), infirmière (IDE) de formation initiale, et une phase d\u27entretiens semi directifs réalisés par deux enseignants chercheurs de l\u27UCO. Résultats : Une constatation importante a été l\u27existence d\u27un conflit pour les soignants entre la règle ontextualisée telle qu\u27elle est pratiquée avec l\u27influence des antériorités du service, de la socialisation par les pairs (périodes de doublage) ou des situations d\u27urgence d\u27une part, et la règle institutionnalisée (recommandations) telle qu\u27elle est définie par les experts et transmise par les IDE hygiénistes. Les professionnels de l\u27hygiène et les soignants ont souvent une conception différente des soins : les premiers les décomposent en séquences de plusieurs tâches avec un acte d\u27HM à pratiquer entre chacune d\u27elles, alors que les seconds perçoivent un soin comme un tout, et effacent mentalement certaines interruptions pour assurer l\u27enchaînement des tâches. Il est apparu que d\u27après les entretiens, l\u27"asepsie" était la règle absolue pour les IDE, constituant un "plus" par rapport à l\u27"hygiène". Ainsi, une pratique comme l\u27HM ne serait "que" de l\u27hygiène par rapport à d\u27autres pratiques considérées comme garantes de l\u27"asepsie", ce qui pourrait constituer un facteur de mauvaise observance de l\u27HM. Enfin, il a été observé le fréquent ressenti d\u27un risque plus important de contamination du patient vers le soignant que du soignant vers un autre patient, ce qui génère des comportements auto protecteurs. Conclusion : Il paraît important que dans leurs relations avec les soignants, les professionnels de l\u27hygiène hospitalière aient conscience que le non suivi des règles d\u27hygiène ne doit pas être interprété comme un dysfonctionnement ou un acte non rationnel, mais qu\u27il correspond à l\u27application d\u27autres logiques d\u27action à caractère prioritaire pour les soignants

The impact of performing bacterial identification and antimicrobial susceptibility testing on bronchoalveolar fluid cultures 24 h a day in a microbiology laboratory

We previously demonstrated the positive impact of performing bacterial identification and antimicrobial susceptibility testing (AST) after day hours (night service [NS]) for certain clinical samples on the treatment of infected patients. Our objective was to evaluate the impact of including positive bronchoalveolar lavage (BAL) cultures in our NS. Two major positive consequences were recorded: initiation of earlier appropriate treatment and earlier change to a reduced-spectrum but still effective regimen. Reductions in delay were defined as the differences between the hours actually spent and hours estimated as though laboratory tests had been performed in the absence of NS. Fifty BALs were included. The NS led to the implementation of earlier appropriate therapy in 10 cases (20%), to earlier de-escalation in 15 cases (30%), and to earlier appropriate therapy and de-escalation in 4 cases (8%). In conclusion, performing bacterial identification and AST for positive BAL after laboratory opening hours could be relevant