Admission criteria and management of critical care patients in a pandemic context: position of the Ethics Commission of the French Intensive Care Society, update of April 2021.

Intensive care unit professionals have experience in critical care and its proportionality, collegial decision-making, withholding or withdrawal of treatment deemed futile, and communication with patients' relatives. These elements rely on ethical values from which we must not deviate in a pandemic situation. The recommendations made by the Ethics Commission of the French Intensive Care Society reflect an approach of responsibility and solidarity towards our citizens regarding the potential impact of a pandemic on critical care resources in France, with the fundamental requirement of respect for human dignity and equal access to health care for all

Long-term outcome of patients hospitalized in intensive care units with central or extrapontine myelinolysis*

International audienc

Correlation of Parasite Load Determined by Quantitative PCR to Clinical Outcome in a Heart Transplant Patient with Disseminated Toxoplasmosis▿

Disseminated toxoplasmosis is a life-threatening infection in transplant recipients, which results either from reactivation of latent infection or from organ-transmitted primary infection. Preventive measures and diagnostic screening methods differ between countries and are related to the seroprevalence of Toxoplasma spp. in the general population. Here we report a case of disseminated toxoplasmosis in a heart transplant recipient with previous immunity that occurred after cotrimoxazole prophylaxis for the prevention of Pneumocystis jirovecii pneumonia was stopped. Quantitative PCR proved useful for the diagnosis and monitoring of Toxoplasma infection. Decreasing parasitic burdens in sequential samples of cerebrospinal fluid, blood, and bronchoalveolar lavage fluid correlated with a favorable outcome and allowed modulation of the immunosuppressive drug regimen. The duration of anti-Toxoplasma treatment and the need for maintenance prophylaxis are discussed, as well as prophylaxis for solid-organ transplant recipients. Although a rare event in heart transplant recipients, Toxoplasma reactivation must be investigated promptly, since early treatment improves the prognosis

Short-term decline in all-cause acquired infections with the routine use of a decontamination regimen combining topical polymyxin, tobramycin, and amphotericin B with mupirocin and chlorhexidine in the ICU: a single-center experience.

International audienceIn a multicenter, placebo-controlled, randomized, double-blind trial, we showed that acquired infections in intubated patients were reduced by the combination of topical polymyxin plus tobramycin and nasal mupirocin plus chlorhexidine body wash. Because intubated patients are particularly at risk for acquired infections, we reassessed the impact of this protocol as a routine procedure to control acquired infections in the ICU. Nonrandomized study comparing acquired infections in ICU patients during two 1-year periods: the last year before (group A, n = 925) and the first year after the implementation of the protocol (group B, n = 1,022). Acquired infections were prospectively recorded. Polyvalent medical ICU at a university-affiliated hospital. All patients admitted to the ICU. Administration of polymyxin/tobramycin/amphotericin B in the oropharynx and the gastric tube plus a mupirocin/chlorhexidine regimen in intubated patients and standard care in the other patients. The comparison of acquired infection rates between groups was adjusted for differences at baseline. Infection rates were lower in group B compared with group A (5.3% vs 11.0%; p < 0.001), as were the incidence rates of total acquired infections (9.4 vs 23.6 per 1,000 patient-days; p < 0.001), intubation-related pneumonia (5.1 vs 17.1 per 1,000 ventilator-days; p < 0.001), and catheter-related bloodstream infections (1.0 vs 3.5 per 1,000 catheter-days; p = 0.03). There were fewer acquired infections caused by ceftazidime-resistant Enterobacteriaceae (0.8‰ vs 3.6‰; p < 0.001), ciprofloxacin-resistant Enterobacteriaceae (0.8‰ vs 2.5‰; p = 0.02), ciprofloxacin-resistant Pseudomonas aeruginosa (0.5‰ vs 1.6‰; p = 0.05), and colistin-resistant Gram-negative bacilli (0.7‰ vs 1.9‰; p = 0.04). Fewer patients got acquired infections due to multidrug-resistant aerobic Gram-negative bacilli (p = 0.008). In intubated patients, the use of topical polymyxin/tobramycin/amphotericin B plus mupirocin/chlorhexidine was associated with the reduction of all-cause ICU-acquired infections. Long-term emergence of multidrug-resistant organisms deserves further investigation

Constipation in long-term ventilated patients: associated factors and impact on intensive care unit outcomes.

International audienceOBJECTIVES: To characterize the factors associated with delayed defecation in long-term ventilated patients and to examine the relationship between delayed defecation and logistic organ dysfunction scores, acquired bacterial infections, and mortality in the intensive care unit. DESIGN: Prospective observational cohort study. SETTING: A 21-bed polyvalent intensive care unit in a university hospital. PATIENTS: A total of 609 adult patients admitted over a 41-month period who underwent mechanical ventilation for ≥ 6 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three hundred fifty-three patients (58%) passed stools ≥ 6 days after they were admitted to the intensive care unit ("late" defecation). Patients with early and late defecation had similar general characteristics when admitted to the intensive care unit and had similar logistic organ dysfunction scores on the first day of mechanical ventilation. Several variables were independently associated with a delay in defecation: a Pao2/Fio2 ratio of less than 150 mm Hg (adjusted hazard ratio 1.40; 95% confidence interval: 1.06-1.60; p = .0073), a systolic blood pressure between 70 and 89 mm Hg (adjusted hazard ratio 1.48; 95% confidence interval: 1.17-1.79; p = .002), and systolic blood pressure < 68 mm Hg (adjusted hazard ratio 1.29; 95% confidence interval: 1.01-1.60; p = .03). Logistic organ dysfunction scores were significantly higher on the fourth and ninth days of mechanical ventilation in patients with late defecation than in those with early defecation. The crude intensive care unit mortality rate was 18% in patients with early defecation and 30% in patients with late defecation (p < .001). Acquired bacterial infections at any site occurred in 34% of patients with early defecation and 66% of patients with late defecation (p < .001). CONCLUSION: A Pao2/Fio2 ratio of < 150 mm Hg and systolic blood pressure of < 90 mm Hg during the first 5 days of mechanical ventilation were independently associated with a delay in defecation. Our results suggest that constipation is associated with adverse outcomes in long-term ventilated patients

Severe left-sided heart failure early after liver transplantation.

International audienceLeft-sided heart failure (LHF) after liver transplantation (LT) is rare and poorly understood. We performed a case-control study. We reviewed the data of all patients with LHF after LT at our center from November 2000 to July 2007. Each case was matched to 1 LT control without LHF for age, sex, date of transplantation, and liver disease. Twenty of 599 patients developed LHF (3.3%). Pretransplant cardiovascular characteristics and risk factors were similar in cases and controls, except for the prevalence of left ventricular enlargement, which was greater in controls. At the time of diagnosis, the median left ventricular ejection fraction was 25% in cases, and increased afterload was documented by markedly elevated vascular resistances. The prevalence of infection at the time of LHF in cases was higher (55%) than in controls (10%, P = 0.02). The reported causes of LHF were infection [bacterial (n = 1) or viral (n = 7)], intraoperative cardiac arrest (n = 2), and unknown (n = 10). In comparison with their controls, cases with immediate postoperative LHF (day 0) did not have a higher Model for End-Stage Liver Disease (MELD) score (15 versus 21.5) or infection prevalence rate (17% versus 34%), whereas those with later onset LHF had a significantly higher MELD score (25.5 versus 17, P = 0.01) and infection prevalence rate (71% versus 0%, P = 0.002). Mortality was 45% in cases versus 0% in controls (P = 0.004), and the 11 cases who survived recovered from LHF. In conclusion, LHF after LT carries a high mortality risk and may have different causes. Except for immediate postoperative cases, an infection and an elevated MELD score appear to be determinant

Characteristics and prognosis of pneumococcal endocarditis: a case-control study

International audienceCase series have suggested that pneumococcal endocarditis is a rare disease, mostly reported in patients with comorbidities but no underlying valve disease, with a rapid progression to heart failure, and high mortality. We performed a case-control study of 28 patients with pneumococal endocarditis (cases), and 56 patients with non-pneumococcal endocarditis (controls), not matched on sex and age, during years 1991-2013, in one referral center. Alcoholism (39.3% vs. 10.7%; P&lt;.01), smoking (60.7% vs. 21.4%%; P&lt;.01), the absence of previously known valve disease (82.1% vs. 60.7%; P=0.047), heart failure (64.3% vs. 23.2%; P&lt;.01), and shock (53.6% vs. 23.2%; P&lt;.01) were more common in pneumococcal than in non-pneumococcal endocarditis. Cardiac surgery was required in 64.3% of patients with pneumococcal endocarditis, much earlier than in patients with non-pneumococcal endocarditis (mean time from symptoms onset, 14.1 ± 18.2 vs. 69.0 ± 61.1 days). In-hospital mortality rates were similar (7.1% vs. 12.5%). Streptococcus pneumoniae causes rapidly progressive endocarditis requiring life-saving early cardiac surgery in most case

Decline of multidrug-resistant Gram negative infections with the routine use of a multiple decontamination regimen in ICU

International audienceObjectives: We have shown that the routine use of a multiple decontamination regimen with oropharyngeal and digestive polymyxin/tobramycin/amphotericin B plus mupirocin/chlorhexidine in intubated patients reduced all-cause acquired infections (AIs) in the intensive care unit (ICU). We now assessed the long-term impact of this strategy on AIs involving multidrug-resistant aerobic Gram negative bacilli (AGNB) and acquired episodes of extended-spectrum betalactamase (ESBL)-producing Enterobacteriaceae rectal carriage. Methods: This was an observational single center study of all patients admitted to an ICU over 5 years (study population). Decontamination was given for the period of intubation and standard care otherwise. AIs and colonization rates were prospectively recorded. AIs rates were compared between the study period and a 1-year pre-intervention period. During study, trends were analyzed by semester using a Poisson regression model. Results: The incidence rate of multidrug-resistant AGNB AIs was lower during the study (1.59 per 1000 patient-days, versus pre-intervention: 5.43 parts per thousand, p < 0.001) and declined with time (adjusted OR = 0.85, 95 percent confidence interval 0.77-0.93, p < 0.001). ESBL-producing Enterobacteriaceae acquired colonization episodes (OR = 0.94 [0.88-1.00] P = 0.04) and the use of five major antibiotics (p < 0.001) also declined. Conclusion: A multiple decontamination regimen did not favor the emergence of multidrug-resistant AGNB. In contrast, infection and colonization rates declined with time. (C) 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved

Acute Neurologic Disorder from an Inhibitor of Fatty Acid Amide Hydrolase

International audienceBACKGROUND A decrease in fatty acid amide hydrolase (FAAH) activity increases the levels of endogenous analogues of cannabinoids, or endocannabinoids. FAAH inhibitors have shown analgesic and antiinflammatory activity in animal models, and some have been tested in phase 1 and 2 studies. In a phase 1 study, BIA 10-2474, an orally administered reversible FAAH inhibitor, was given to healthy volunteers to assess safety. METHODS Single doses (0.25 to 100 mg) and repeated oral doses (2.5 to 20 mg for 10 days) of BIA 10-2474 had been administered to 84 healthy volunteers in sequential cohorts; no severe adverse events had been reported. Another cohort of participants was then assigned to placebo (2 participants) or 50 mg of BIA 10-2474 per day (6 participants). This report focuses on neurologic adverse events in participants in this final cohort. A total of 4 of the 6 participants who received active treatment consented to have their clinical and radiologic data included in this report. RESULTS An acute and rapidly progressive neurologic syndrome developed in three of the four participants starting on the fifth day of drug administration. The main clinical features were headache, a cerebellar syndrome, memory impairment, and altered consciousness. Magnetic resonance imaging showed bilateral and symmetric cerebral lesions, including microhemorrhages and hyperintensities on fluid-attenuated inversion recovery and diffusion-weighted imaging sequences predominantly involving the pons and hippocampi. One patient became brain dead; the condition of two patients subsequently improved, but one patient had residual memory impairment, and the other patient had a residual cerebellar syndrome. One patient remained asymptomatic. CONCLUSIONS An unanticipated severe neurologic disorder occurred after ingestion of BIA 10-2474 at the highest dose level used in a phase 1 trial. The underlying mechanism of this toxic cerebral syndrome remains unknown

Randomized comparison of 2 protocols to prevent acquisition of methicillin-resistant Staphylococcus aureus: results of a 2-center study involving 500 patients.

International audienceObjective - To compare an interventional protocol with a standard protocol for preventing the acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in the intensive care unit (ICU).Design - Prospective, randomized, controlled, parallel-group, nonblinded clinical trial.Setting - Medical ICUs of 2 French university hospitals.Participants - Five hundred adults with an expected length of stay in the ICU greater than 48 hours.Interventions - For the intervention group, the protocol required repeated MRSA screening, contact and droplet isolation precautions for patients at risk for MRSA at ICU admission and for MRSA-positive patients, and decontamination with nasal mupirocin and chlorhexidine body wash for MRSA-positive patients. For the standard group, the standard precautions protocol was used, and the results of repeated MRSA screening in the standard group were not communicated to investigators.Main outcome measure - MRSA acquisition rate in the ICU. An audit was conducted to assess compliance with hygiene and isolation precautions.Results - In the intent-to-treat analysis ([Formula: see text]), the MRSA acquisition rate in the ICU was similar in the standard (13 [5.3%] of 243) and intervention (16 [6.5%] of 245) groups ([Formula: see text]). The audit showed that the overall compliance rate was 85.5% in the standard group and 84.1% in the intervention group ([Formula: see text]), although compliance was higher when isolation precautions were absent than when they were in place (88.2% vs 79.1%; [Formula: see text]). MRSA incidence rates were higher without isolation precautions (7.57‰) than with isolation precautions (2.36‰; [Formula: see text]).Conclusions - Individual allocation to MRSA screening, isolation precautions, and decontamination do not provide individual benefit in reducing MRSA acquisition, compared with standard precautions, although the collective risk was lower during the periods of isolation.Trial registration - Clinicaltrials.gov identifier: NCT00151606.<br