Incidence of Pneumocystis jiroveci Pneumonia among Groups at Risk in HIV-negative Patients

International audienceBackground - Pneumocystis jiroveci pneumonia in human immunodeficiency virus (HIV)-negative immunocompromised patients is associated with high mortality rates. Although trimethoprim-sulfamethoxazole provides a very effective prophylaxis, pneumocystosis still occurs and may even be emerging due to suboptimal characterization of patients most at risk, hence precluding targeted prophylaxis. Methods - We retrospectively analyzed all cases of documented pneumocystosis in HIV-negative patients admitted in our institution, a referral center in the area, from January 1990 to June 2010, and extracted data on their underlying condition(s). To estimate incidence rates within each condition, we estimated the number of patients followed-up in our area for each condition by measuring the number of patients admitted with the corresponding international classification diagnostic code, through the national hospital discharge database (Program of Medicalization of the Information System [PMSI]). Results - From 1990 to 2010, 293 cases of pneumocystosis were documented, of which 154 (52.6%) tested negative for HIV. The main underlying conditions were hematological malignancies (32.5%), solid tumors (18.2%), inflammatory diseases (14.9%), solid organ transplant (12.3%), and vasculitis (9.7%). Estimated incidence rates could be ranked in 3 categories: 1) high risk (incidence rates >45 cases per 100,000 patient-year): polyarteritis nodosa, granulomatosis with polyangiitis, polymyositis/dermatopolymyositis, acute leukemia, chronic lymphocytic leukemia, and non-Hodgkin lymphoma; 2) intermediate risk (25-45 cases per 100,000 patient-year): Waldenström macroglobulinemia, multiple myeloma, and central nervous system cancer; and 3) low risk (<25 cases per 100,000 patient-year): other solid tumors, inflammatory diseases, and Hodgkin lymphoma. Conclusions - These estimates may be used as a guide to better target pneumocystosis prophylaxis in the groups most at risk

Letter: liver disease and COVID-19 - not the perfect storm

This article is linked to Garrido et al papers. To view these articles, visit https://doi.org/10.1111/apt.15813 and https://doi.org/10.1111/apt.15886

Constipation is independently associated with delirium in critically ill ventilated patients

International audienceDelirium is a central nervous system (CNS) dysfunction reported in up to 80 % of intensive care unit (ICU) patients associated with negative short- and long-term outcomes [1, 2]. Gastrointestinal motility disorders are frequent in ICU patients leading to frequent delayed passage of stools [3]. Because there is a bi-directional communication between the CNS and the digestive tract [4], we believed it relevant to test the hypothesis that constipation and delirium are related in ICU patients

Neutrophil-to-Lymphocyte Ratio Predicts Death in Acute-on-Chronic Liver Failure Patients Admitted to the Intensive Care Unit : A Retrospective Cohort Study

Peer reviewedPublisher PD

Clinical features and predictors of mortality in admitted patients with community- and hospital-acquired legionellosis: A Danish historical cohort study

<p>Abstract</p> <p>Background</p> <p>Legionella is a common cause of bacterial pneumonia. Community-acquired [CAL] and hospital-acquired legionellosis [HAL] may have different presentations and outcome. We aimed to compare clinical characteristics and examine predictors of mortality for CAL and HAL.</p> <p>Methods</p> <p>We identified hospitalized cases of legionellosis in 4 Danish counties from January 1995 to December 2005 using the Danish national surveillance system and databases at departments of clinical microbiology. Clinical and laboratory data were retrieved from medical records; vital status was obtained from the Danish Civil Registration System. We calculated 30- and 90-day case fatality rates and identified independent predictors of mortality using logistic regression analyses.</p> <p>Results</p> <p>We included 272 cases of CAL and 60 cases of HAL. Signs and symptoms of HAL were less pronounced than for CAL and time from in-hospital symptoms to legionellosis diagnosis was shorter for CAL than for HAL (5.5 days vs. 12 days p < 0.001). Thirty-day case fatality was 12.9% for CAL and 33.3% for HAL; similarly 90-day case fatalities in the two groups were 15.8% and 55.0%, respectively. In a logistic regression analysis (excluding symptoms and laboratory tests) age >65 years (OR = 2.6, 95% CI: 1.1-5.9) and Charlson comorbidty index ≥2 (OR = 2.7, 95% CI: 1.1-6.5) were associated with an increased risk of death in CAL. We identified no statistically significant predictors of 30-day mortality in HAL.</p> <p>Conclusions</p> <p>Signs and symptoms were less pronounced in HAL compared to CAL. Conversely, 30-day case fatality was almost 3 times higher. Clinical awareness is important for the timely diagnosis and treatment especially of HAL. There is a need for further studies of prognostic factors in order to improve the therapeutic approach to legionellosis and potentially reduce mortality.</p

The GRADE System for Rating Clinical Guidelines

Brian Kavanagh critiques the GRADE system of grading guidelines, arguing that even though it has evolved through the Evidence-Based Medicine movement, there is no evidence that GRADE itself is reliable

High-flow nasal cannula oxygen therapy alone or with non-invasive ventilation during the weaning period after extubation in ICU: the prospective randomised controlled HIGH-WEAN protocol

INTRODUCTION: Recent practice guidelines suggest applying non-invasive ventilation (NIV) to prevent postextubation respiratory failure in patients at high risk of extubation failure in intensive care unit (ICU). However, such prophylactic NIV has been only a conditional recommendation given the low certainty of evidence. Likewise, high-flow nasal cannula (HFNC) oxygen therapy has been shown to reduce reintubation rates as compared with standard oxygen and to be as efficient as NIV in patients at high risk. Whereas HFNC may be considered as an optimal therapy during the postextubation period, HFNC associated with NIV could be an additional means of preventing postextubation respiratory failure. We are hypothesising that treatment associating NIV with HFNC between NIV sessions may be more effective than HFNC alone and may reduce the reintubation rate in patients at high risk. METHODS AND ANALYSIS: This study is an investigator-initiated, multicentre randomised controlled trial comparing HFNC alone or with NIV sessions during the postextubation period in patients at high risk of extubation failure in the ICU. Six hundred patients will be randomised with a 1:1 ratio in two groups according to the strategy of oxygenation after extubation. The primary outcome is the reintubation rate within the 7 days following planned extubation. Secondary outcomes include the number of patients who meet the criteria for moderate/severe respiratory failure, ICU length of stay and mortality up to day 90. ETHICS AND DISSEMINATION: The study has been approved by the ethics committee and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03121482

Community-acquired pneumonia related to intracellular pathogens

Community-acquired pneumonia (CAP) is associated with high rates of morbidity and mortality worldwide; the annual incidence of CAP among adults in Europe has ranged from 1.5 to 1.7 per 1000 population. Intracellular bacteria are common causes of CAP. However, there is considerable variation in the reported incidence between countries and change over time. The intracellular pathogens that are well established as causes of pneumonia are Legionella pneumophila, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Chlamydophila psittaci, and Coxiella burnetii. Since it is known that antibiotic treatment for severe CAP is empiric and includes coverage of typical and atypical pathogens, microbiological diagnosis bears an important relationship to prognosis of pneumonia. Factors such as adequacy of initial antibiotic or early de-escalation of therapy are important variables associated with outcomes, especially in severe cases. Intracellular pathogens sometimes appear to cause more severe disease with respiratory failure and multisystem dysfunction associated with fatal outcomes. The clinical relevance of intracellular pathogens in severe CAP has not been specifically investigated. We review the prevalence, general characteristics, and outcomes of severe CAP cases caused by intracellular pathogens

Etat des lieux de la recherche d'informations médicales sur Internet par les familles de patients hospitalisés en réanimation et impact sur la relation médecin-famille (une étude prospective multicentrique)

Introduction: Internet procure aux familles un accès aux informations médicales. Les caractéristiques de ce recours et son impact sur la relation médecin-famille n'ont jamais été évalué en réanimation. Méthodes: Etude prospective réalisée pendant un an dans 3 services de réanimation. Un questionnaire était remis après un entretien médical aux familles de patients hospitalisés plus de 48 heures. Un autre questionnaire était donné au médecin ayant conduit l'entretien. Résultats: Il y a eu 243 questionnaires récupérés, parmi lesquels le recours à Internet était de 44%. Il était plus fréquent si les patients ou leurs familles étaient plus jeunes, avec un niveau d'études plus élevé, si les patients étaient hospitalisés avant la réanimation et si l'entretien médical était plus long. Les principaux motifs de consultation d'Internet étaient la vérification des informations données par le médecin et la survenue de questions après l'entretien, et concernaient surtout le diagnostic et le pronostic de la pathologie. Les informations retrouvées étaient concordantes avec celles reçues en réanimation. Dans le cas contraire 99% des familles faisaient davantage confiance aux médecins. La moitié d'entre elles estimait que les informations étaient de bonne qualité et la majorité rapportait qu'Internet avait un bénéfice sur leur compréhension et leur relation avec l'équipe médicale. Conclusion: Seule la moitié des familles a consulté Internet mais son impact leur semble plutôt bénéfique. Nos résultats suggèrent que les médecins devraient jouer un rôle de guide sur Internet auprès des patients.Purpose: The Internet provides to families an access to the medical information. The characteristics of this practice and its impact on the family-clinician relationship in intensive care units (ICU) has never been evaluated. Methods: This prospective study has been realized during one year in three french ICU. A questionnaire has been given to th patients' families hospitalized more than 48 hours. Another questionnaire was given to the doctor who conducted the meeting. Results: A total of 243 questionnaires were returned. Among them, 44% of families searched for health information on the Internet. It was more frequent if the patient or his family were younger, with a higher level of education, if the patient was hospitalized before ICU admission and if meetings with families were longer. The main reasons for having visited internet websites were the control of the information received in ICU but also the occurrence of questions after the meeting. Researches done by families concerned mainly the diagnosis and the prognosis of the patient's disease. Most informations found on the Internet were in agreement with those received in ICU. Otherwise, 99% of families were more confident in doctors. Barely half families appraised the information found on the Internet to be of good quality. However, the majority thought that using the Internet was beneficial for their understanding and for their relation with the medical team. Conclusion: Barely half families used the Internet in this study, but for them, Internet seemed to have a good impact on the family-clinician relationship. Doctors should probably accept the patient's investment and provide advices to help them in their research.RENNES1-BU Santé (352382103) / SudocSudocFranceF