The strategy of antibiotic use in critically ill neutropenic patients

Suspicion of sepsis in neutropenic patients requires immediate antimicrobial treatment. The initial regimen in critically ill patients should cover both Gram-positive and Gram-negative pathogens, including Pseudomonas aeruginosa. However, the risk of selecting multidrug-resistant pathogens should be considered when using broad-spectrum antibiotics for a prolonged period of time. The choice of the first-line empirical drugs should take into account the underlying malignancy, local bacterial ecology, clinical presentation and severity of acute illness. This review provides an up-to-date guide that will assist physicians in choosing the best strategy regarding the use of antibiotics in neutropenic patients, with a special focus on critically ill patients, based on the above-mentioned considerations and on the most recent international guidelines and literature

Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology : a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study

Background: Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology. Methods: This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders. Results: This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p 7 (OR 3.32 (95% CI 2.15-5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p < 0.005). Conclusions: In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted

Acute respiratory failure in kidney transplant recipients: a multicenter study

International audienceINTRODUCTION: Data on pulmonary complications in renal transplant recipients are scarce. The aim of this study was to evaluate acute respiratory failure (ARF) in renal transplant recipients. METHODS: We conducted a retrospective observational study in nine transplant centers of consecutive kidney transplant recipients admitted to the intensive care unit (ICU) for ARF from 2000 to 2008. RESULTS: Of 6,819 kidney transplant recipients, 452 (6.6%) required ICU admission, including 200 admitted for ARF. Fifteen (7.5%) of these patients had combined kidney-pancreas transplantations. The most common causes of ARF were bacterial pneumonia (35.5%), cardiogenic pulmonary edema (24.5%) and extrapulmonary acute respiratory distress syndrome (ARDS) (15.5%). Pneumocystis pneumonia occurred in 11.5% of patients. Mechanical ventilation was used in 93 patients (46.5%), vasopressors were used in 82 patients (41%) and dialysis was administered in 104 patients (52%). Both the in-hospital and 90-day mortality rates were 22.5%. Among the 155 day 90 survivors, 115 patients (74.2%) were dialysis-free, including 75 patients (65.2%) who recovered prior renal function. Factors independently associated with in-hospital mortality were shock at admission (odds ratio (OR) 8.70, 95% confidence interval (95% CI) 3.25 to 23.29), opportunistic fungal infection (OR 7.08, 95% CI 2.32 to 21.60) and bacterial infection (OR 2.53, 95% CI 1.07 to 5.96). Five factors were independently associated with day 90 dialysis-free survival: renal Sequential Organ Failure Assessment (SOFA) score on day 1 (OR 0.68/SOFA point, 95% CI 0.52 to 0.88), bacterial infection (OR 0.43, 95% CI 0.21 to 0.90), three or four quadrants involved on chest X-ray (OR 0.44, 95% CI 0.21 to 0.91), time from hospital to ICU admission (OR 0.98/day, 95% CI 0.95 to 0.99) and oxygen flow at admission (OR 0.93/liter, 95% CI 0.86 to 0.99). CONCLUSIONS: In kidney transplant recipients, ARF is associated with high mortality and graft loss rates. Increased Pneumocystis and bacterial prophylaxis might improve these outcomes. Early ICU admission might prevent graft loss

Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients

<p>Abstract</p> <p>Background</p> <p>Recognizing infection is crucial in immunocompromised patients with organ dysfunction. Our objective was to assess the diagnostic accuracy of procalcitonin (PCT) in critically ill immunocompromised patients.</p> <p>Methods</p> <p>This prospective, observational study included patients with suspected sepsis. Patients were classified into one of three diagnostic groups: no infection, bacterial sepsis, and nonbacterial sepsis.</p> <p>Results</p> <p>We included 119 patients with a median age of 54 years (interquartile range [IQR], 42-68 years). The general severity (SAPSII) and organ dysfunction (LOD) scores on day 1 were 45 (35-62.7) and 4 (2-6), respectively, and overall hospital mortality was 32.8%. Causes of immunodepression were hematological disorders (64 patients, 53.8%), HIV infection (31 patients, 26%), and solid cancers (26 patients, 21.8%). Bacterial sepsis was diagnosed in 58 patients and nonbacterial infections in nine patients (7.6%); 52 patients (43.7%) had no infection. PCT concentrations on the first ICU day were higher in the group with bacterial sepsis (4.42 [1.60-22.14] vs. 0.26 [0.09-1.26] ng/ml in patients without bacterial infection, <it>P </it>< 0.0001). PCT concentrations on day 1 that were > 0.5 ng/ml had 100% sensitivity but only 63% specificity for diagnosing bacterial sepsis. The area under the receiver operating characteristic (ROC) curve was 0.851 (0.78-0.92). In multivariate analyses, PCT concentrations > 0.5 ng/ml on day 1 independently predicted bacterial sepsis (odds ratio, 8.6; 95% confidence interval, 2.53-29.3; <it>P </it>= 0.0006). PCT concentrations were not significantly correlated with hospital mortality.</p> <p>Conclusion</p> <p>Despite limited specificity in critically ill immunocompromised patients, PCT concentrations may help to rule out bacterial infection.</p

Control of bacterial resistance and proper use of antibiotics in human health: have we done enough? : proper use of antibiotics

In France, antibiotic overuse and increasing bacterial resistance led the health authorities to launch concerted actions in 2001, to promote the surveillance of bacterial resistance, provide detailed information to health professionals and the general public, and promote the proper use of antibiotics in human medicine, both in community practices and in healthcare facilities. However, even though this policy has borne fruit, results are still insufficient given the burden of bacterial resistance on public health and on medical advances. The policy must therefore be vigorously reinforced, both in human and in animal health.En France, un usage immodéré des antibiotiques et l'essor des résistances bactériennes ont conduit les autorités de santé à mettre en place, en 2001, des actions concertées visant à promouvoir la surveillance des résistances et des consommations, à mieux informer les professionnels de la santé et le grand public, et à promouvoir un bon usage des antibiotiques en santé humaine, tant en ville que dans les établissements de soins. Néanmoins, même si cette politique a porté ses fruits, les résultats sont encore insuffisants au regard des risques que fait peser la résistance bactérienne sur la santé publique et sur les progrès de la médecine. Elle doit donc être vigoureusement renforcée, tant en santé humaine qu'animale

Diminution de la résistance des bactéries nosocomiales dans une structure hospitalière (Résultats de 5 années d'un contrôle du bon usage des antibiotiques par une unité mobile d'infectiologie)

Le développement de la résistance bactérienne aux antibiotiques est une préoccupation mondiale. L'environnement hospitalier est propice à l'émergence de cette résistance. Le rôle de la surconsommation et de l'utilisation inappropriée des antibiotiques dans l'émergence et le développement de cette résistance a été décrit dans de nombreuses études. Nous avons évalué l'impact d'une consultation systématique d'infectiologues pour la prescription des antibiotiques des bactéries repsonsables de plusieurs infections nosocomiales dans notre hôpital...Résultats : Alors que le nombre de patients hospitalisés pour infection et le nombre de patients ayant acquis une infection nosocomiale sont restés relativement stables, un meilleur contrôle de la prescription des antibiotiques (choix, doses, début et durée du traitement) a entraîné une baisse spéctaculaire de la consommation d'antibiotiques. Ceci a été particulièrement net pour l'amikacine, les fluoroquinolones intraveineuses, et les teicoplanine. Cette diminution de la consommation d'antibiotiques a été associée à une diminution du coût total, et particulièrement dans le groupe des antibiotiques contrôlés. De plus une diminution des bactéries multirésistantes a été observée durant la même période quand ce contrôle a été associé aux guidelines et aux recommandations pour prévenir la transmission des microorganismes résistants.conclusion: Cette étude attire l'attention sur le rôle d'une surveillance quotidienne par une équipe d'infectiologie de la prescription et la consommation d'antibiotiques.PARIS7-Villemin (751102101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF