Antibiothérapie initiale des péritonites graves en réanimation chirurgicale (évaluation des pratiques et intérêt de l'antibiogramme chromogène)

Une antibiothérapie rapide et couvrant tous les germes en cause est un facteur de survie dans les infections abdominales graves. La pression de sélection exercée par ce traitement doit être réduite au strict nécessaire. Objectif : évaluer les pratiques de prescription et d'adaptation des antibiothérapies aux résultats bactériologiques dans les péritonites graves dans un service de Réanimation Chirurgicale d'un Centre Hospitalier Universitaire. Déterminer l'intérêt potentiel d'un antibiogramme chromogène systématique et son apport pour les prescriptions quotidiennes. Matériel et méthodes : Tous les patients hospitalisés en Réanimation chirurgicale en 2005 au CHU de Rouen, ayant présenté une infection intra abdominale grave et chez qui a été réalisé au moins un prélèvement intra péritonéal ont été inclus de façon rétrospective. Les données épidémiologiques, cliniques et les résultats bactériologiques ont été recueillis rétrospectivement. Les résultats bactériologiques disponibles chaque jour ont été confrontés aux prescriptions d'antibiotiques afin de déterminer : - si l'antibiothérapie initiale couvrait tous les germes pathogènes identifiés - si toutes les rétrocessions souhaitables ont été réalisées et dans quel délai - si l'utilisation du métronidazole aurait pu réduire encore la pression de sélection. - s'il y a eu des journées supplémentaires indues de couverture des germes anaérobies. - l'apport potentiel d'un antibiogramme chromogène direct.Résultats : Quarante-quatre patients ayant présenté 68 épisodes infectieux intra-abdominaux ont été inclus. La mortalité, l'étiologie des épisodes infectieux et les données microbiologiques sont concordantes avec les données de la littérature. L'examen direct n'apporte jamais d'information faisant modifier l'antibiothérapie initiale. Dans 29,4% des cas l'antibiothérapie initiale était insuffisante (pendant 3,2+-1,5 jours). 61% des rétrocessions souhaitables ont été faites (41% le jour même, 27% à 24h, 13,5% à 48h, 13,5% à 72h, 5% au-delà). Une antibiothérapie à spectre trop large a été maintenue pendant 6,6+-5 jours. Seules 10% des possibilités de réduction du spectre en utilisant le métronidazole ont été saisies. Le traitement anti-anaérobies a été poursuivi indûment dans 13,2% des cas pendant 3,4+-1,2 jours. L'antibiogramme chromogène aurait permis de modifier l'antibiothérapie dans 50% des cas, 2,4 jours plus tôt en moyenne. Conclusion : cet audit montre la nécessité d'amélioration de nos antibiothérapies dans les infections abdominales graves, en particulier par une plus grande réactivité aux résultats bactériologiques disponibles. Le potentiel de réductionde la pression de sélection par l'utilisation du métronidazole est sous-exploité. L'antibiogramme chromogène semble avoir un potentiel important pour améliorer nos prescriptions, qui devrait être évalué par les études prospectives.ROUEN-BU Médecine-Pharmacie (765402102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Constipation in critical care patients: both timing and duration matter

International audienceObjective Most of the studies have defined constipation as a period without stool after ICU admission. We aimed to test the impact of both duration and timing of infrequent defecation in critical care patients. Patients and methods We performed a prospective, bi-center, observational study. Patients were divided into three subgroups: ‘not constipated’, ‘3–5 days’, and ‘at least 6 days’ (longest period without stool passage, respectively, shorter than 3 days, 3–5 days, and ≥6 days). Furthermore, ‘early’ constipated patients were defined as those for whom the longest time to stool passage occurred just after ICU admission, whereas for ‘late’ constipated patients the longest period without stool occurred later during ICU stay. Results A total of 182 patients were included: the mean age was 67.2 years (54.4–78.9 years), 80 were women, and simplified acute physiology score II was 42 (34–52). In all, 42 (23.1%), 82 (45.1%), and 58 (31.8%) belonged to the nonconstipated, 3–5 days, or greater than or equal to 6 days subgroup of patients, respectively. Time spent under mechanical ventilation and ICU length of stay was longer in the greater than or equal to 6 days subgroups as compared with both other subgroups. ICU stay was longer in the 3–5 days subgroup as compared with the not constipated patients. Furthermore, the late patients of the greater than or equal to 6 days subgroups exhibited worse survival as compared with all other patients. Conclusion Both timing and duration of infrequent defecation seem to have an impact on critical care patient’s outcome, and should therefore be included in the diagnostic criteria

Clinical phenotype and outcomes of pneumococcal versus meningococcal purpura fulminans: a multicenter retrospective cohort study

International audienceNo abstract availabl

Long-term Quality of Life in Adult Patients Surviving Purpura Fulminans: An Exposed-Unexposed Multicenter Cohort Study

International audienceAbstract Background Long-term health-related quality of life (HR-QOL) of patients surviving the acute phase of purpura fulminans (PF) has not been evaluated. Methods This was a French multicenter exposed-unexposed cohort study enrolling patients admitted in 55 intensive care units (ICUs) for PF from 2010 to 2016. Adult patients surviving the acute phase of PF (exposed group) were matched 1:1 for age, sex, and Simplified Acute Physiology Score II with septic shock survivors (unexposed group). HR-QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36) questionnaire, the Hospital Anxiety and Depression (HAD) scale, the Impact of Event Scale–Revised (IES-R), and the activity of daily living (ADL) and instrumental ADL (IADL) scales. The primary outcome measure was the physical component summary (PCS) of the SF-36 questionnaire. Results Thirty-seven survivors of PF and 37 of septic shock were phone-interviewed at 55 (interquartile range [IQR], 35–83) months and 44 (IQR, 35–72) months, respectively, of ICU discharge (P = .23). The PCS of the SF-36 was not significantly different between exposed and unexposed patients (median, 47 [IQR, 36–53] vs 54 [IQR, 36–57]; P = .18). There was also no significant difference between groups regarding the mental component summary of the SF-36, and the HAD, IES-R, ADL and IADL scales. Among the 37 exposed patients, those who required limb amputation (n = 12/37 [32%]) exhibited lower PCS (34 [IQR, 24–38] vs 52 [IQR, 42–56]; P = .001) and IADL scores (7 [IQR, 4–8] vs 8 [IQR, 7–8]; P = .021) compared with nonamputated patients. Conclusions Long-term HR-QOL does not differ between patients surviving PF and those surviving septic shock unrelated to PF. Amputated patients have an impaired physical HR-QOL but a preserved mental health. Clinical Trials Registration NCT03216577

Long-term quality of life in adult patients surviving purpura fulminans: an exposed-unexposed multicenter cohort study

International audienceBACKGROUND : Long-term health-related quality of life (HR-QOL) of patients surviving the acute phase of purpura fulminans (PF) has not been evaluated.METHODS : This was a French multicenter exposed-unexposed cohort study enrolling patients admitted in 55 intensive care units (ICUs) for PF from 2010 to 2016. Adult patients surviving the acute phase of PF (exposed group) were matched 1:1 for age, sex, and Simplified Acute Physiology Score II with septic shock survivors (unexposed group). HR-QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36) questionnaire, the Hospital Anxiety and Depression (HAD) scale, the Impact of Event Scale-Revised (IES-R), and the activity of daily living (ADL) and instrumental ADL (IADL) scales. The primary outcome measure was the physical component summary (PCS) of the SF-36 questionnaire.RESULTS : Thirty-seven survivors of PF and 37 of septic shock were phone-interviewed at 55 (interquartile range [IQR], 35-83) months and 44 (IQR, 35-72) months, respectively, of ICU discharge (P = .23). The PCS of the SF-36 was not significantly different between exposed and unexposed patients (median, 47 [IQR, 36-53] vs 54 [IQR, 36-57]; P = .18). There was also no significant difference between groups regarding the mental component summary of the SF-36, and the HAD, IES-R, ADL and IADL scales. Among the 37 exposed patients, those who required limb amputation (n = 12/37 [32%]) exhibited lower PCS (34 [IQR, 24-38] vs 52 [IQR, 42-56]; P = .001) and IADL scores (7 [IQR, 4-8] vs 8 [IQR, 7-8]; P = .021) compared with nonamputated patients.CONCLUSIONS : Long-term HR-QOL does not differ between patients surviving PF and those surviving septic shock unrelated to PF. Amputated patients have an impaired physical HR-QOL but a preserved mental healt