L'anticoagulation de l'hémofiltration continue: Citrate versus Héparine

peer reviewedL'insuffisance rénale aiguë aux Soins Intensifs affecte un patient sur cinq et souvent nécessite le recours à une épuration extra-rénale. L'hémofiltration continue est choisie pour certains patients (instabilité hémodynamique, neurologique, mais nécessite, comme d'ailleurs l'hémodialyse, une anticoagulation. Le citrate, utilisé dans le travail publié, est sorti vainqueur de sa comparaison avec l'héparine non fractionnée. Son utilisation nécessite cependant une surveillance attentive

Quality of documentation on antibiotic treatment in medical records: evaluation of the long-term impact of an antimicrobial stewardship intervention

Background: In 2016, the antimicrobial stewardship team (AST) of the University Hospital of Liège, Belgium published a prospective, uncontrolled, interrupted time series study demonstrating the successful implementation of a combined intervention strategy from the AST to improve the quality of documentation on antibiotic therapy in the computerized medical records between 2012 and 2014. Since 2016, the AST repeated a point prevalence surveys (PPS) twice a year about that topic. Materials/methods: We aimed to evaluate if the impact of the interventions remained stable over time on the documentation rate of 3 quality indicators: (1) the indication (2) the antibiotics prescribed and (3) the expected duration or review date, with a goal of achieving 90 % compliance on each indicator. Using the PPS approach, a clinical pharmacist and physician, both from the AST, identified patients receiving one or more antibacterial agents from the Medication Administration Record (MAR). Patients seen in the outpatients or dialysis department or the emergency room, and those who underwent a specific medical intervention or surgery the same day were excluded. Results: From 2016-2019, six PPS were performed. Overall 4691 patient MARs were reviewed from a total of 34 wards: 1118 (23.8 %) took one or more antibiotics, 84.9 % for the treatment of an infection, which was slightly lower than previous results (26-28 % and 82-83 %, respectively). The medical records of 949 patients receiving antibiotics for infection were carefully reviewed and analyzed. On average, 90.4 % (vs 90.3 % in comparison with our previous results) had an indication documented; 95.1 % (vs 95.6 %) had documentation of the antibiotics prescribed; and 65.2 % (vs 67.7 %) had a duration or review date documented. Conclusions: In our institution, the quality of documentation on antibiotic therapy remained stable over a 5 years period of time, with 90 % or more compliance on average for two quality indicators: the indication and the antibiotics prescribed, but less than 70 % for duration or review date. This last point should be analyzed and new interventions should be considered to reach 90 % compliance for this quality indicator

Combination therapy versus monotherapy: a randomised pilot study on the evolution of inflammatory parameters after ventilator associated pneumonia [ISRCTN31976779]

INTRODUCTION: Combination antibiotic therapy for ventilator associated pneumonia (VAP) is often used to broaden the spectrum of activity of empirical treatment. The relevance of such synergy is commonly supposed but poorly supported. The aim of the present study was to compare the clinical outcome and the course of biological variables in patients treated for a VAP, using a monotherapy with a beta-lactam versus a combination therapy. METHODS: Patients with VAP were prospectively randomised to receive either cefepime alone or cefepime in association with amikacin or levofloxacin. Clinical and inflammatory parameters were measured on the day of inclusion and thereafter. RESULTS: Seventy-four mechanically ventilated patients meeting clinical criteria for VAP were enrolled in the study. VAP was microbiologically confirmed in 59 patients (84%). Patients were randomised to receive cefepime (C group, 20 patients), cefepime with amikacin (C-A group, 19 patients) or cefepime with levofloxacin (C-L group, 20 patients). No significant difference was observed regarding the time course of temperature, leukocytosis or C-reactive protein level. There were no differences between length of stay in the intensive care unit after infection, nor in ventilator free days within 28 days after infection. No difference in mortality was observed. CONCLUSION: Antibiotic combination using a fourth generation cephalosporin with either an aminoside or a fluoroquinolone is not associated with a clinical or biological benefit when compared to cephalosporin monotherapy against common susceptible pathogens causing VAP

Detection of decreased glomerular filtration rate in intensive care units: serum cystatin C versus serum creatinine

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Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury

INTRODUCTION: Outcome studies in patients with acute kidney injury (AKI) have focused on differences between modalities of renal replacement therapy (RRT). The outcome of conservative treatment, however, has never been compared with RRT. METHODS: Nine Belgian intensive care units (ICUs) included all adult patients consecutively admitted with serum creatinine >2 mg/dl. Included treatment options were conservative treatment and intermittent or continuous RRT. Disease severity was determined using the Stuivenberg Hospital Acute Renal Failure (SHARF) score. Outcome parameters studied were mortality, hospital length of stay and renal recovery at hospital discharge. RESULTS: Out of 1,303 included patients, 650 required RRT (58% intermittent, 42% continuous RRT). Overall results showed a higher mortality (43% versus 58%) as well as a longer ICU and hospital stay in RRT patients compared to conservative treatment. Using the SHARF score for adjustment of disease severity, an increased risk of death for RRT compared to conservative treatment of RR = 1.75 (95% CI: 1.4 to 2.3) was found. Additional correction for other severity parameters (Acute Physiology And Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA)), age, type of AKI and clinical conditions confirmed the higher mortality in the RRT group. CONCLUSIONS: The SHARF study showed that the higher mortality expected in AKI patients receiving RRT versus conservative treatment can not only be explained by a higher disease severity in the RRT group, even after multiple corrections. A more critical approach to the need for RRT in AKI patients seems to be arrante

Prospective survey of digestive tract colonization with enterobacteriaceae that produce ESBLs in intensive care units

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Pharmacokinetics of Extended vs Intermittent Intravenous Infusion of Meropenem in Critically Ill Patients Receiving Continuous Veno-Venous Haemofiltration

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