Attributable cost of methicillin resistance: an issue that is difficult to evaluate

Estimating the consequences and the cost of methicillin resistance is a difficult challenge. Patients who develop methicillin-resistant ventilator-associated pneumonia (VAP) are very different from those who develop methicillin-sensitive VAP, and biased estimates are frequent. We reviewed some important confounding factors of which the reader should be aware

Pronostic vital et rénal à un an des patients encore dialysés en sortie de réanimation

L insuffisance rénale aiguë en réanimation est fréquente, de l ordre de 35 à 65%, et associée à une surmortalité propre. En cas de défaillance rénale persistante à l issue du séjour, aucune donnée n est disponible. Cette étude propose une description de cette population particulière et en évalue le pronostic vital et rénal à 1 an avec l étude des facteurs de risque associés. Les patients ayant présenté une IRA avec EER non sevrée avant la sortie de réanimation ont été inclus dans cette étude rétrospective du service de Réanimation médicale du CHU de Grenoble entre le 01/12/2005 et le 31/03/2011. Les modèles de Cox et de Fine & Gray ont été utilisés. Cent quinze patients ont été inclus. Pendant le séjour en réanimation, ils ont reçu une injection d iode, d aminoside ou de vancomycine dans respectivement 45,7%, 31% et 12,9% des cas. Le risque cumulé de décès et la survie sans dialyse sont respectivement de 23.5% (IC95% : 17- 32%) et 64,3% (IC95%=54,9-72,3%) à 1 an. Les facteurs indépendants associés à une moindre survie sans dialyse sont un âge élevé, un autre mécanisme que la nécrose tubulaire aiguë à l IRA, l administration de vancomycine et une fonction rénale antérieure inférieure à 60ml/min/1,73m2. De plus, la présence de statines dans le traitement de fond est un facteur protecteur avec un HR=0,35 (IC95%=0,17-0,71). L effet bénéfique des statines est aussi retrouvé dans le modèle à risque compétitif, avec un HR égal à O,06 (IC95%=0,01-0,49) de risque de dialyse chronique. Les aminosides apparaissent comme un facteur de mauvais pronostic rénal avec un risque de dialyse chronique à 1 an significatif (HR=4,25 ; IC95%=1,36-13,33).GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Caractéristiques et impact pronostique des différents types d immunodépression chez les patients admis en réanimation pour sepsis sévère ou choc septique

Introduction : les données actuelles sur les patients avec une immunodépression préalable et une infection grave sont limitées. Cette étude a pour objectifs de décrire ces patients lorsqu ils sont admis en réanimation pour sepsis sévère ou choc septique, les comparer aux immunocompétents et évaluer l impact pronostique du type d immunodépression. Matériel et Méthodes : étude observationnelle à partir d une base de données prospective en incluant tous les patients admis pour sepsis sévère ou choc septique de Janvier 1997 à Août 2011 dans 11 services de réanimation. Les patients immunodéprimés ont été classés en 6 profils d immunodépression. L analyse pronostique a utilisé un modèle à risque compétitifs (Fine et Gray), la sortie vivant avant J28 étant en compétition avec le décès. Résultats : 1981 patients ont été inclus parmi lesquels 607 (31%) sont immunodéprimés (cancer solide 27%, hémopathie maligne 46%, SIDA 11%, greffe d organes 9%, pathologie inflammatoire 13%, déficit primitif ou congénital 1%). Le taux de décès à J28 est de 31.3% chez l immunodéprimé (vs 28.8%). Après ajustement sur les autres facteurs pronostiques, l immunodépression est un facteur de risque indépendant de décès à J28 (sHR à 1.37 [1.12-1.67]). Analysée en classes, seuls le SIDA (sHR=1.9), l oncologie solide (sHR=1.8) ou en hématologie (sHR=1.4) non agranulocytaire et l agranulocytose (sHR=1.7) sont indépendamment associés au pronostic. Conclusion : l immunodépression est fréquente chez les patients présentant un sepsis sévère ou choc septique. L analyse de survie montre que certains profils d immunodépression, outre l agranulocytose déjà décrite, sont associés à une augmentation du risque de décès.Introduction: current data on patients with pre-existing immunosuppression and severe infection are limited. This study aims to describe these patients when admitted to ICU for severe sepsis or septic shock, to compare them with immunocompetent and to evaluate the prognostic impact of the type of immunosuppression. Materials and Methods: we conducted an observational study using a prospective multicenter database. All patients admitted for severe sepsis or septic shock from January 1997 to August 2011 in 11 French ICUs were included. Immunocompromised patients were classified into six profiles of immunosuppression. Prognostic analysis used a competitive risk model (Fine and Gray), in which ICU or hospital discharge being alive before D28 competed with death. Results: 1981 patients were included among whom 607 (31%) were immunocompromised (27% solid cancer, 46% hematological malignancy, 11% AIDS, 9% solid organ transplantation, 13% inflammatory disease, 1% primary or congenital deficiency). The death rate at D28 is 31.3% in immunocompromised (vs. 28.8%). After adjustment on other prognostic factors, immunosuppression (all causes) is an independent risk factor for death at D28 (sHR 1.37 [1.12-1.67]). When we analyzed immunosuppression in classes, only AIDS (sHR = 1.9), solid cancer (sHR = 1.8) or hematology (sHR = 1.4) without agranulocytosis and agranulocytosis (sHR = 1.7) are independently associated with prognosis. Conclusion: immunosuppression is common in patients with severe sepsis or septic shock. Survival analysis shows that some profiles of immunosuppression, in addition to agranulocytosis already described, are associated with an increased risk of death.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Comparison of four skin preparation strategies to prevent catheter-related infection in intensive care unit (CLEAN trial): a study protocol for a randomized controlled trial

International audienceBackgroundCatheter-related infection is the third cause of infections in intensive care units (ICU), increasing the length of stay in ICU and hospital, mortality, and costs. Skin antisepsis is one of the most prevalent preventive measures. In this respect, it would appear preferable to recommend the use of alcoholic povidone iodine or chlorhexidine rather than aqueous povidone iodine. However, the data comparing chlorhexidine to povidone-iodine, both of them in alcoholic solutions, remain limited. Moreover, the benefits of enhanced cleaning prior to disinfection of skin that is not visibly soiled have yet to be confirmed in a randomized study.MethodsA prospective multicenter, 2×2 factorial, randomized-controlled, assessor-blind trial will be conducted in 11 intensive care units in six French hospitals. All adult patients aged over 18 years requiring the insertion of at least one peripheral arterial catheter and/or a non-tunneled central venous catheter and/or a hemodialysis catheter and/or an arterial pulmonary catheter will be randomly assigned to have all their catheters cared with one of four skin preparation strategies (2% chlorhexidine/70% isopropyl alcohol or 5% povidone iodine/69% ethanol with or without prior skin scrubbing). At catheter removal, catheter tips will be quantitatively cultured. Sets of aerobic and anaerobic blood cultures will be routinely obtained when a patient has fever, hypothermia, or other indications. In case of suspected catheter-related infection the patient's form will be reviewed by an independent adjudication committee. We plan to enroll 2,400 patients (4,800 catheters). The main objective is to demonstrate that use of 2% alcoholic chlorhexidine compared to 5% alcoholic povidone iodine in skin preparation lowers the rate of catheter-related infection. The second endpoint is to demonstrate that enhanced skin cleaning prior to disinfection of skin that is not visibly soiled does not reduce catheter colonization. Other outcomes include comparison of skin colonization at catheter insertion site, comparison of catheter colonization and catheter-related bacteremia taking place during implementation of the four strategies of skin preparation, and cutaneous tolerance, length of hospitalization, mortality, and costs.DiscussionThis study will help to update recommendations on the choice of an antiseptic agent to use in skin preparation prior to insertion of a vascular catheter and, by extension, of an epidural catheter and it will likewise help to update recommendations on the usefulness of skin scrubbing prior to disinfection when the skin is not visibly soiled.Trial registrationClinicaltrials.gov number NCT0162955

Effect of previous antimicrobial therapy on the accuracy of the main procedures used to diagnose nosocomial pneumonia in patients who are using ventilation.

peer reviewedWe evaluated the effect of antibiotic treatment received before the suspicion of pneumonia on the diagnostic yield of protected specimen brush (PSB), direct examination (BAL D) and culture (BAL C) of lavage fluid on consecutive mechanically ventilated patients with suspected nosocomial pneumonia. Bronchoscopy was always performed before any treatment for suspected pneumonia. One hundred and sixty-one patients with suspected pneumonia underwent PSB and BAL before any institution or change in antibiotic therapy (AB). Sixty-five patients received AB for an earlier septic episode (ON AB group) and 96 patients did not (OFF AB group). All but two strains recovered were highly resistant to previous AB. Sensitivity and specificity of each test were not different between the ON AB and OFF AB groups as well as the percentage of complete agreement between the 3 procedures, 74 and 67% respectively. We conclude that previous AB received to treat an earlier septic episode unrelated to suspected pneumonia do not affect the diagnostic yield of PSB and BAL

Reappraisal of distal diagnostic testing in the diagnosis of ICU-acquired pneumonia.

peer reviewed[en] BACKGROUND: The thresholds of the diagnostic procedures performed to diagnose ICU-acquired pneumonia (IAP) are either speculated or incompletely tested. PURPOSE: To evaluate the best threshold of protected specimen brush (PSB), plugged telescoping catheter (PTC), BAL culture (BAL C), and direct examination of cytocentrifugated lavage fluid (BAL D) to diagnose IAP. Each mechanically ventilated patient with suspected IAP underwent bronchoscopy successively with PSB, PTC, and BAL in the lung segment identified radiographically. POPULATION: One hundred twenty-two episodes of suspected IAP (occurring in 26% of all mechanically ventilated patients) were studied. Forty-five patients had definite IAP, and 58 had no IAP. Diagnosis was uncertain in 19 cases. RESULTS: Using the classic thresholds, sensitivity was 67% for PSB, 54% for PTC, 59% for BAL D, and 77% for BAL C. Specificity was 88% for PSB, 77% for PTC, 98% for BAL D, and 77% for BAL C. We used receiver operating characteristics methods to reappraise thresholds. Decreasing the thresholds to 500 cfu/mL for PSB, 10(2) cfu/mL for PTC, 2% cells containing bacteria for BAL D, 4 x 10(3) cfu/mL for BAL C increased the sensitivities (plus 14%, 23%, 25%, 10%, respectively) and moderately decreased the specificities (minus 4%, 9%, 2%, 4%, respectively) of the four examinations. The association of PSB with a 500 cfu/mL threshold and BAL D with a 2% threshold recovered all but one episode of pneumonia (SE 96 +/- 4%) with a 84 +/- 10% specificity. For a similar ICU population, these "best" thresholds increased negative predictive value with a minimal decrease of positive predictive value. They need to be confirmed in multiple ICU settings in prospective fashion

Clinical Impact of Antifungal Susceptibility, Biofilm Formation and Mannoside Expression of Candida Yeasts on the Outcome of Invasive Candidiasis in ICU: An Ancillary Study on the Prospective AmarCAND2 Cohort

Background: The link between Candida phenotypical characteristics and invasive candidiasis (IC) prognosis is still partially unknown.Methods:Candida strains isolated during the AmarCAND2 study were centrally analyzed for species identification, antifungal susceptibility, biofilm formation, and expression of surface and glycoconjugate mannosides. Correlation between these phenotypical features and patient outcome was sought using a multivariable Cox survival model.Results:Candida albicans was predominant (65.4%, n = 285), with a mortality rate significantly lower than that in patients with non-albicans strains [HR 0.67 (0.46–1.00), p = 0.048]. The rate of fluconazole-resistant strains was low (C. albicans and Candida glabrata: 3.5 and 6.2%, respectively) as well as caspofungin-resistant ones (1 and 3.1%, respectively). Early biofilm formation was less frequent among C. albicans (45.4%) than among non-albicans (81.2%). While the strains of C. albicans showed variable levels of surface mannosides expression, strains isolated from candidemia exhibited a high expression of β-man, which was correlated with an increased mortality (p = 0.02).Conclusion:Candida albicans IC were associated with lower mortality, and with strains that exhibited less frequently early biofilm formation than non-albicans strains. A high expression of β-man was associated with increased IC mortality. Further studies are warranted to confirm this data and to evaluate other virulence factors in yeasts

Is protected specimen brush a reproducible method to diagnose ICU-acquired pneumonia?

peer reviewed[en] UNLABELLED: Protected specimen brush (PSB) is considered to be one of the standard methods for the diagnosis of ventilator-associated pneumonia, but to our knowledge, intraindividual variability in results has not been reported previously. PURPOSE: To compare the results of two PSB performed in the same subsegment on patients with suspected ICU-acquired pneumonia (IAP). STUDY DESIGN: Between October 1991 and April 1992, each mechanically ventilated patient with suspected IAP underwent bronchoscopy with two successive PSB in the lung segment identified as abnormal on radiographs. Results of the two PSB cultures were compared using 10(3) cfu/ml cutoff for a positive result. Four definite diagnoses were established during the follow up: definite pneumonia, probable pneumonia, excluded pneumonia, and uncertain pneumonia. POPULATION: Forty-two episodes in 26 patients were studied; 60 percent of patients received prior antibiotic therapy. Thirty-two microorganisms were isolated from 24 pairs of PSB. Definite diagnosis was definite pneumonia in 7, probable pneumonia in 8, excluded pneumonia in 17, and uncertain pneumonia in 10 cases. RESULTS: The PSB recovered the same microorganisms and argued for a good qualitative reproducibility. The distinction of positive and negative results on the basis of the 10(3) cfu/ml classic threshold was less reproducible. For 24 percent of the microorganisms recovered and in 16.7 percent of episodes of suspected IAP, the two consecutive samples gave results spread out on each side of the 10(3) cfu/ml cutoff. Discordance was higher when definite diagnosis was certain or probable than when diagnosis was excluded (p = 0.015). There was no statistical effect of the order of samples between the two specimens for bacterial index and microorganism concentrations. CONCLUSION: These findings argue for the poor repeatability of PSB in suspected IAP and question the yield of the 10(3) cfu/ml threshold. In attempting to diagnose IAP, the results of PSB must be interpreted with caution considering the intraindividual variability