Biological markers and diagnosis of ventilator-associated pneumonia

Evaluation of a new biomarker from bronchoalveolar fluid, the Clara cell protein 10, adds data to the search for a diagnostic marker for ventilator-associated pneumonia (VAP). For more than 15 years, investigators tried to identify such a marker for predicting or diagnosing VAP. Unfortunately, the results of a number of these studies are disappointing. For optimal management of critically ill, ventilated patients with clinical suspicion of VAP, clinicians need accurate microbiological information to decide to treat in case of confirmed infection and to guide the initial choice of antibiotic therapy with identification of the responsible pathogen(s). Thus, today, the potential advantages of biomarkers are to improve the rapidity and performance of current diagnostic procedures and to reduce antibiotic exposure and selective pressure

Is bronchoalveolar lavage with quantitative cultures a useful tool for diagnosing ventilator-associated pneumonia?

The results of a recently published Canadian study suggest that bronchoalveolar lavage and endotracheal aspiration are associated with similar clinical outcomes and similar overall use of antibiotics in critically ill patients with suspected ventilator-associated pneumonia (VAP). The study, however, does not provide convincing information on the best strategy to diagnose VAP, to accurately choose initial treatment and to exclude VAP in order to avoid administering antibiotics to patients without bacterial infection. In fact, this trial has several limitations or drawbacks: patients at risk for developing VAP due to Pseudomonas aeruginosa or methicillin-resistant Staphylococcus aureus were excluded, far from the real-life scenario; a significant number of patients were receiving recent antimicrobial therapy at the time of sampling, with, consequently, difficult-to-interpret culture results; randomization of included patients for initial treatment – meropenem plus ciprofloxacin or meropenem alone – resulted in a high rate of inappropriate initial empirical therapy due to the absence of customization to local epidemiology; and the initial decision to treat and the re-evaluation at day 3 were, in fact, based on clinical judgment and not on direct examination and quantitative culture results. In summary, because antimicrobial treatment was initiated in all suspected patients and was rarely withheld in patients with negative cultures, the study does not suggest an appropriate strategy for improving the use of antibiotics in intensive care unit patients. Such a strategy has two requirements: immediate administration of adequate therapy in patients with true VAP, and avoidance of administering antibiotics in patients without bacterial infection

0130: Mortality related to cardiogenic shock in critically ill patients in France, 1997-2012

IntroductionMost of data reporting epidemiology of cardiogenic shock (CS) concern patients with acute myocardial infarction admitted in intensive care unit of cardiology. However, CS patients managed in critical care unit (CCU) have often multiorgan failure and seem to have different characteristics and outcome. To our best knowledge no study reported characteristics and clinical outcomes of CS patients admitted in CCU.AimTo report key features, Mortality and Trends in mortality in a large cohort of patients with CS admitting in 33 French CCUs from 1997 to 2012.Methods and resultsWe queried the 1997–2012 database of Parisian area ICUs-the CubRea (Intensive Care Database User Group) database to identify all hospital stays with a principal or an associated diagnosis of CS (National classification of disease R 570). Among 303 314 hospital stays, 17 494 (5.8%) were CS. The patients were managed in 60% of cases in universitary centers. Mean age was 64.3±17.0. Men accounted for 11047 (63.1%). Mean SAPS II was 62.0±24.3. Among CS, only 535 (3.06%) were AMI whereas 2685 (15.3%) were cardiac arrest and 858 (4.9%) were drug intoxications. Mechanical ventilation was required in 12967 (74.1%) of cases, inotropes in 14640 (83.7%) of cases and renal support in 3886 (22.2%) of cases. Mean duration of hospital was 19.1 days±24.7. Intrahospital Mortality was high (46.2%). Predictors of intrahospital death are reported in Table. Over the 15-year period, mortality decreased (49.8% in 1997-2000 and 42.7% in 2009-2012, p<0.001) whereas the patients were more critically ill (SAPS II 58.8±25.4 in 1997-2000 vs 64.2 8±23.6 in 2009-2012, p<0.001).Conclusionit is the first study reporting the prevalence, determinants and prognostic factors of CS patients managed in reanimation. The mortality of these very critically ill patients remains high. However over the 15-year period, even if these patients are more and more critically ill, early mortality decreased.Abstratct 0130 – TableVariablesOR95% CIDrug intoxication.307.236.401Age (<60 yo).436.383.496Mechanical circulatory support.681.3781.228Sepsis.715.637.8022009-2012.998.8851.125SAPS II1.0361.0331.038Acidosis1.4531.2641.670Mechanical ventilation1.7181.4831.990Acute respiratory distress syndrome1.7941.5582.0661997-20001.8141.4522.267Hemodialysis1.8201.6092.060Inotropic use1.9821.1133.530Disseminated intravascular coagulation2.1191.5912.822Cardiac arrest4.3333.8404.88

LES PATIENTS AGES ADMIS EN REANIMATION MEDICALE (PRONOSTIC IMMEDIAT ET A LONG TERME ; ETUDE D'UNE COHORTE DE 410 PATIENTS AGES DE 75 ANS ET PLUS)

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Évaluation médico-économique des produits de santé. Méthodologie pour la définition d’un impact significatif sur les dépenses de l’Assurance maladie et choix des référentiels pour l’interprétation des résultats

Le décret n° 2012-1116 du 2 octobre 2012 relatif aux missions médico-économiques de la Haute autorité de santé modifie significativement les conditions d’accès au marché des biens de santé en France. Cet article présente le cadre théorique d’interprétation des résultats de l’évaluation économique des technologies de santé et synthétise les éléments factuels disponibles en France pour l’élaboration de référentiels pour l’interprétation des ratios différentiels coût/résultats. Cette revue de littérature montre qu’il est difficile de déterminer une valeur-seuil mais qu’il est également difficile d’interpréter des résultats de ratio différentiel coût/résultats (RDCR) sans valeur-seuil. Dans ce contexte, les participants à la table ronde privilégient une approche pragmatique reposant sur « des référentiels » et non une valeur-seuil, dans une perspective interprétative et non normative, référentiels qui pourront évoluer dans le temps au regard des retours d’expérience