Colonization with methicillin-resistant Staphylococcus aureus in ICU patients: morbidity, mortality, and glycopeptide use.

peer reviewed[en] OBJECTIVE: To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization on the occurrence of S. aureus infections (methicillin-resistant and methicillin-susceptible), the use of glycopeptides, and outcome among intensive care unit (CU) patients. DESIGN: Prospective observational cohort survey. SETTING: A medical-surgical ICU with 10 single-bed rooms in a 460-bed, tertiary-care, university-affiliated hospital. PATIENTS: A total of 1,044 ICU patients were followed for the detection of MRSA colonization from July 1, 1995, to July, 1 1998. METHODS: MRSA colonization was detected using nasal samples in all patients plus wound samples in surgical patients within 48 hours of admission or within the first 48 hours of ICU stay and weekly thereafter. MRSA infections were defined using Centers for Disease Control and Prevention standard definitions, except for ventilator-associated pneumonia and catheter-related infections, which were defined by quantitative distal culture samples. RESULTS: One thousand forty-four patients (70% medical patients) were included in the analysis. Mean age was 61+/-18 years; mean Simplified Acute Physiologic Score (SAPS) II was 36.4+/-20; and median ICU stay was 4 (range, 1-193) days. Two hundred thirty-one patients (22%) died in the ICU. Fifty-four patients (5.1%) were colonized with MRSA on admission, and 52 (4.9%) of 1,044 acquired MRSA colonization in the ICU. Thirty-five patients developed a total of 42 S. aureus infections (32 MRSA, 10 methicillin-susceptible). After factors associated with the development of an S. aureus infection were adjusted for in a multivariate Cox model (SAPS II >36: hazard ratio [HR], 1.64; P=.09; male gender: HR, 2.2; P=.05), MRSA colonization increased the risk of S. aureus infection (HR, 3.84; P=.0003). MRSA colonization did not influence ICU mortality (HR, 1.01; P=.94). Glycopeptides were used in 11.4% of the patients (119/1,044) for a median duration of 5 days. For patients with no colonization, MRSA colonization on admission, and ICU-acquired MRSA colonization, respectively, glycopeptide use per 1,000 hospital days was 37.7, 235.2, and 118.3 days. MRSA colonization per se increased by 3.3-fold the use of glycopeptides in MRSA-colonized patients, even when an MRSA infection was not demonstrated, compared to non-colonized patients. CONCLUSIONS: In our unit, MRSA colonization greatly increased the risk of S. aureus infection and of glycopeptide use in colonized and non-colonized patients, without influencing ICU mortality. MRSA colonization influenced glycopeptide use even if an MRSA infection was not demonstrated; thus, an MRSA control program is warranted to decrease vancomycin use and to limit glycopeptide resistance in gram-positive cocci

Variability of Intensive Care Admission Decisions for the Very Elderly

Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear

Designing and conducting a cluster-randomized trial of ICU admission for the elderly patients: the ICE-CUB 2 study

International audienceBackgroundThe benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a cluster-randomized trial of intensive care unit (ICU) admission for critically ill elderly patients.MethodsWe designed an interventional open-label cluster-randomized controlled trial in 24 centres in France. Clusters were healthcare centres with at least one emergency department (ED) and one ICU. Healthcare centres were randomly assigned either to recommend a systematic ICU admission (intervention group) or to follow standard practices regarding ICU admission (control group). Clusters were stratified by the number of ED annual visits (44,616 visits), the presence or absence of a geriatric ward and the geographical area (Paris area vs other regions in France). All elderly patients (≥75 years of age) who got to the ED were assessed for eligibility. Patients were included if they had one of the pre-established critical conditions, a preserved functional status as assessed by an ADL scale ≥4 (0 = very dependent, 6 = independent), a preserved nutritional status (subjectively assessed by physicians) and without active cancer. Exclusion criteria were an ED stay >24 h, a secondary referral to the ED and refusal to participate. The primary outcome was the mortality at 6 months calculated at the individual patient level. Secondary outcomes were ICU and hospital mortality, as well as ADL scale and quality of life (as assessed by the SF-12 Health Survey) at 6 months.ResultsBetween January 2012 and April 2015, 3036 patients were included in the trial, 1518 patients in 11 clusters allocated to intervention group and 1518 patients in 13 clusters allocated to standard care. There were 51 protocol violations.ConclusionsThe ICE-CUB 2 trial was deemed feasible and ethically acceptable. The ICE-CUB 2 trial will be the first cluster-randomized trial to assess the benefits of ICU admission for selected elderly patients on long-term mortality

Reappraisal of visiting policies and procedures of patient’s family information in 188 French ICUs: a report of the Outcomerea Research Group

Background: The relatives of intensive care unit (ICU) patients must cope with both the severity of illness of their loved one and the unfamiliar and stressful ICU environment. This hardship may lead to post-intensive care syndrome. French guidelines provide recommendations on welcoming and informing families of ICU patients. We questioned whether and how they are applied 5\ua0years after their publication. Methods: We conducted a large survey among French ICUs to evaluate their visiting policies and how information was provided to patient’s family. A questionnaire was built up by intensivists and nurses. French ICUs were solicited, and the questionnaire was sent to all participating ICUs, for being filled in by the unit medical and/or nursing head. Data regarding the hospital and ICU characteristics, the visiting policy and procedures, and the management of family information were collected. Results: Among the 289 French ICUs, 188 (65\ua0%) participated. Most ICUs have a waiting room 118/188 (62.8\ua0%) and a dedicated room for meeting the family 152/188 (80.8\ua0%). Of the 188 ICUs, 45 (23.9\ua0%) were opened on a 24-h-a-day basis. In the remaining ICUs, the time period allowed for visits was 4.75\ua0±\ua01.83\ua0h (median 5\ua0h). In ICUs where visiting restrictions were reported, open visiting was allowed for end-of-life situations in 107/143 (74.8\ua0%). Children are allowed to visit a patient\ua0in 164/188 (87.2\ua0%) regardless of their age in 97/164 (59.1\ua0%) of ICUs. Families received an information leaflet in 168/188 (89.3\ua0%). Information was provided to families through structured meetings in 149/188 (79.2\ua0%) of ICUs at patient admission with participation of nurses and nursing assistants in 133/188 (70.4\ua0%) and 55/188 (29.2\ua0%), respectively. Information delivered to the family was reported in the patient chart by only 111/188 ICUs (59\ua0%). Participation in care was infrequent. Conclusions: Although French ICUs do not follow the consensus recommendations, slow progress exists compared to previous reports. Implementation of these recommendations is largely needed to offer better welcome and information improvement. Further studies on that topic would enable evaluating remaining obstacles and increasing caregivers’ awareness, both critical for further progresses on that topic

The effect of ICU diaries on psychological outcomes and quality of life of survivors of critical illness and their relatives: a systematic review and meta-analysis

Objectives: To evaluate the effect of ICU diaries on posttraumatic stress disorder symptoms in ICU survivors and their relatives. Secondary objectives were to determine the effect on anxiety, depression, and health-related quality of life in patients and their relatives. Data Sources: We searched online databases, trial registries, and references of relevant articles. Study Selection: Studies were included if there was an ICU diary intervention group which was compared with a group without a diary. Data Extraction: Titles, abstracts, and full-text articles were reviewed independently by two authors. Data was abstracted using a structured template. Data Synthesis: Our search identified 1,790 articles and retained eight studies for inclusion in the analysis. Pooled results found no significant reduction in patients’ posttraumatic stress disorder symptoms with ICU diaries (risk ratio, 0.75 [0.3–1.73]; p = 0.5; n = 3 studies); however, there was a significant improvement in patients’ anxiety (risk ratio, 0.32 [0.12, 0.86]; p = 0.02; n = 2 studies) and depression (risk ratio, 0.39 [0.17–0.87]; p = 0.02; n = 2 studies) symptoms. Two studies reported significant improvement in posttraumatic stress disorder symptoms of relatives of ICU survivors; however, these results could not be pooled due to reporting differences. One study reported no significant improvement in either anxiety (risk ratio, 0.94; 95% [0.66–1.33]; p = 0.72) or depression (risk ratio, 0.98; 95% [0.5–1.9]; p = 0.95) in relatives. There was a significant improvement in health-related quality of life of patients with a mean increase in the Short Form-36 general health score by 11.46 (95% CI, 5.87–17.05; p ≤ 0.0001; n = 2 studies). No studies addressed health-related quality of life of relatives. Conclusions: ICU diaries decrease anxiety and depression and improve health-related quality of life, but not posttraumatic stress disorder among ICU survivors and may result in less posttraumatic stress disorder among relatives of ICU patients. Multicenter trials with larger sample sizes are necessary to confirm these findings

Local signs at insertion site and catheter-related bloodstream infections: an observational post hoc analysis using individual data of four RCTs

International audienceAbstract Background Little is known on the association between local signs and intravascular catheter infections. This study aimed to evaluate the association between local signs at removal and catheter-related bloodstream infections (CRBSI), and which clinical conditions may predict CRBSIs if inflammation at insertion site is present. Methods We used individual data from four multicenter randomized controlled trials in intensive care units (ICUs) that evaluated various prevention strategies for arterial and central venous catheters. We used multivariate logistic regressions in order to evaluate the association between ≥ 1 local sign, redness, pain, non-purulent discharge and purulent discharge, and CRBSI. Moreover, we assessed the probability for each local sign to observe CRBSI in subgroups of clinically relevant conditions. Results A total of 6976 patients and 14,590 catheters (101,182 catheter-days) and 114 CRBSI from 25 ICUs with described local signs were included. More than one local sign, redness, pain, non-purulent discharge, and purulent discharge at removal were observed in 1938 (13.3%), 1633 (11.2%), 59 (0.4%), 251 (1.7%), and 102 (0.7%) episodes, respectively. After adjusting on confounders, ≥ 1 local sign, redness, non-purulent discharge, and purulent discharge were associated with CRBSI. The presence of ≥ 1 local sign increased the probability to observe CRBSI in the first 7 days of catheter maintenance (OR 6.30 vs. 2.61 [> 7 catheter-days], p heterogeneity = 0.02). Conclusions Local signs were significantly associated with CRBSI in the ICU. In the first 7 days of catheter maintenance, local signs increased the probability to observe CRBSI