Denis Garot

Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy ☆

PURPOSE Data regarding outcome of patients with chronic liver disease with severe hepatic encephalopathy in intensive care unit are currently scarce. METHODS This study is a retrospective observational case series in a medical intensive care unit (ICU) in a university hospital from 1995 to 2005. Patients with hepatic encephalopathy (HE) (admitted with or developing) were identified. Clinical and laboratory parameters were analyzed to determinate predictors of ICU and 1-year mortality. RESULTS Seventy-one patients were included (53 male). Median Simplified Acute Physiology Score was 56 with Child-Pugh score 11 +/- 2. Seventy-six percent of patients were admitted with coma (Glasgow Coma Scale, 7.7 +/- 4). Eighty-two percent of patients required intubation, and 28% vasopressors. Thirty-five percent died during ICU stay. At 1 year, mortality was 54%. Univariate analysis identified arterial hypotension, mechanical ventilation, vasopressors at any time, acute renal failure, Simplified Acute Physiology Score, and sepsis associated with ICU mortality. In multivariate analysis, vasopressor use or acute renal failure was the main independent predictor of ICU death and 1-year mortality. Patients free of these risk factors, even requiring intubation, were identified as isolated HE, with lower mortality rates. CONCLUSION Predictors of outcome were similar to other groups of patients with liver disease admitted for other reasons. Intensive care unit mortality was lower than reported for other groups of patients with similar illness. Patients with severe HE admitted to ICU with no organ dysfunction other than mechanical ventilation had a better outcome and may require ICU admission.

Acute Kidney Injury in the Critically Ill: Is Iodinated Contrast Medium Really Harmful?*

Objectives:To assess whether the use of iodinated contrast medium increases the incidence of acute kidney injury in ICU patients, compared with patients not receiving iodinated contrast medium. Design:Prospective observational matched cohort study. Setting:Two ICUs in two tertiary teaching hospitals. Patients:A total of 380 adults were included (20% more than once), before an iodinated contrast medium infusion (contrast inclusions, n = 307) or before an intrahospital transfer without iodinated contrast medium infusion (control inclusions, n = 170). Interventions:None. Measurements and Main Results:Among contrast inclusions, iodinated contrast medium–associated acute kidney injury occurred after 23 administrations (7.5%) according to the Acute Kidney Injury Network definition (stage ≥ 1, over 48 hr). As expected, a broader definition (≥ 25% increase in serum creatinine over 72 hr) yielded a greater incidence (16%). In 146 pairs of contrast and control inclusions, matched on propensity for iodinated contrast medium infusion, the incidence of acute kidney injury was similar (absolute difference in incidence, 0%; 95% confidence interval, –5.2; 5.2%), Acute Kidney Injury Network definition). Hospital mortality was also similar in 71 contrast and 71 control patients included only once and matched the same way. Contrary to iodinated contrast medium infusion (odds ratio, 1.57; 95% confidence interval, 0.69–3.53), the Sequential Organ Failure Assessment score at inclusion (odds ratio, 1.18; 95% confidence interval, 1.07–1.31) and the number of other nephrotoxic agents (odds ratio, 1.38; 95% confidence interval, 1.03–1.85) were independent risk factors for acute kidney injury. Conclusions:The specific toxic effect of monomeric nonionic low-osmolar iodinated contrast medium in ICU patients with multiple renal aggressions seemed minimal. Severity of disease and the global nephrotoxic burden were risk factors for acute kidney injury, regardless of iodinated contrast medium infusion.

Population pharmacokinetics of ceftriaxone in critically ill septic patients: a reappraisal

AIMS To investigate the population pharmacokinetics of ceftriaxone in critically ill patients suffering from sepsis, severe sepsis or septic shock. METHODS Blood samples were collected at preselected times in 54 adult patients suffering from sepsis, severe sepsis or septic shock in order to determine ceftriaxone concentrations using high-performance liquid chromatography-ultraviolet detection. The pharmacokinetics of ceftriaxone were assessed on two separate occasions for each patient: on the second day of ceftriaxone therapy and 48 h after catecholamine withdrawal in patients with septic shock, or on the fifth day in patients with sepsis. The population pharmacokinetics of ceftriaxone were studied using nonlinear mixed effects modelling. RESULTS The population estimates (interindividual variability; coefficient of variation) for ceftriaxone pharmacokinetics were: a clearance of 0.88 l h(-1) (49%), a mean half-life of 9.6 h (range 0.83-28.6 h) and a total volume of distribution of 19.5 l (range 6.48-35.2 l). The total volume of distribution was higher than that generally found in healthy individuals and increased with the severity of sepsis. However, the only covariate influencing the ceftriaxone pharmacokinetics was creatinine clearance. Dosage simulations showed that the risk of ceftriaxone concentrations dropping below the minimum inhibitory concentration threshold was low. CONCLUSIONS Despite the wide interpatient variability of ceftriaxone pharmacokinetic parameters, our results revealed that increasing the ceftriaxone dosage when treating critically ill patients is unnecessary. The risk of ceftriaxone concentrations dropping below the minimum inhibitory concentration threshold is limited to patients with high glomerular filtration rates or infections with high minimum inhibitory concentration pathogens (>1 mg l(-1)).

Emergence of community-acquired Clostridium difficile infection: the experience of a French hospital and review of the literature

BACKGROUND Clostridium difficile infection (CDI) is a common cause of nosocomial diarrhoea. People in the general community are not usually considered to be at risk of CDI. CDI is associated with a high risk of morbidity and mortality. The risk of severity is defined by the Clostridium Severity Index (CSI). METHODS The cases of 136 adult patients with CDI treated at the University Hospital of Tours, France between 2008 and 2012 are described. This was a retrospective study. RESULTS Among the 136 patients included, 62 were men and 74 were women. Their median age was 64.4 years (range 18-97 years). Twenty-six of the 136 (19%) cases were community-acquired (CA) and 110 (81%) were healthcare-acquired (HCA). The major risk factors for both groups were long-term treatment with proton pump inhibitors (54% of CA, 53% of HCA patients) and antibiotic treatment within the 2.5 months preceding the CDI (50% of CA, 91% of HCA). The CSI was higher in the CA-CDI group (1.56) than in the HCA-CDI group (1.39). Intensive care was required for 8% of CA-CDI and 16.5% of HCA-CDI patients. CONCLUSIONS CDI can cause community-acquired diarrhoea, and CA-CDI may be more severe than HCA-CDI. Prospective studies of CDI involving people from the general community without risk factors are required to confirm this observation.

Clinical and economic outcomes of infective endocarditis

Abstract Background: In France, the estimated annual incidence of infective endocarditis (IE) is 33.8 cases per million residents. Valvular surgery is frequently undergone. We report an epidemiological and economic study of IE for 2007–2009 in a French region, using the hospital discharge database (HDD). Methods: The population studied concerned all the patients living in Centre region, France, hospitalized for IE. We extracted hospital stay data for IE from the regional HDD, with a definition based on IE-related diagnosis codes. The predictive positive value (PPV) and sensitivity (Se) of the definition were 87.4% and 90%, respectively, according to the Duke criteria (definite IE frequency 74.4%). Hospitalization costs were estimated, taking into account the fixed hospital charges of the diagnosis-related group (DRG) and supplementary charges due to intensive care unit (ICU) stay. Results: The analysis included 578 patients. The annual average incidence was 45.4 cases per million residents. Valvular surgery was performed in 19.4% of cases. The hospital mortality was 17.6%. Multivariate analysis identified as risk factors for mortality an age ≥ 70 years (odds ratio (OR) = 3.03, 95% confidence interval (CI) = 1.78–5.18), staphylococcal IE (OR = 3.3, 95% CI = 1.9–5.7), chronic renal insufficiency (OR = 2.04, 95% CI = 1.00–4.15), ischemic stroke (OR = 2.55, 95% CI = 1.19–5.47), and hemorrhagic stroke (OR = 5.7, 95% CI = 1.9–17.3). The average cost per episode was

Atteinte respiratoire sévère et choc septique à Mycobacterium bovis: Une complication rare de la BCG thérapie intravésicale

20 103 (€15 281). Conclusions: We report a higher incidence of IE than described by the French national study of 2008. Valvular surgery was considerably less frequent than in the published data, whereas mortality was similar. IE generates substantial costs.

Acute respiratory distress syndrome secondary to human metapneumovirus infection in a young healthy adult

INTRODUCTION Intravesical bacillus Calmette-Guerin (BCG) therapy, recommended for superficial bladder tumors, triggers side effects in fewer than 5% of patients. The most severe side effects, however, are septic shock and acute respiratory failure. CASE A 70-year-old man was hospitalized for septic shock with acute respiratory and renal failure after intravesical instillation of BCG, which was identified in the gastric aspiration sample. Treatment with rifampicin, ethambutol, isoniazid, and corticosteroid therapy, as well as standard reanimation measures, led to the patients recovery. DISCUSSION This case shows the potentially severe side effects of intravesical BCG instillation. Although this treatment is well tolerated in more than 95% of patients and its systemic complications can be effectively treated, these side effects can be life-threatening.

Diagnostic performance of multiplex PCR on pulmonary samples versus nasopharyngeal aspirates in community-acquired severe lower respiratory tract infections

Dear Editor, There is growing interest in human metapneumovirus (hMPV) lung infection in intensive care unit (ICU). hMPV is a respiratory pathogen first discovered 10 years ago [1], but despite increasing data, the complete epidemiological features of hMPV remain largely unknown. In your journal, Vanspauwen et al. [2] reported six cases of hMPV detection in critically ill patients suspected of having hospital-acquired pneumonia. Recently, a case of severe hMPV lung infection in a pregnant woman was reported [3], and hMPV was identified in 18 % of patients hospitalized for severe pneumonia in ICU [4]. It is generally known that adults with underlying cardiopulmonary disease or immunocompromised patients are susceptible to hMPV infection [5]. However, we report a case of acute respiratory distress syndrome (ARDS) secondary to hMPV in a healthy woman. A 59-year-old woman without relevant medical history was admitted to the ICU for acute dyspnea. Vital signs on admission were: heart rate 96/min, blood pressure 105/73 mmHg, Glasgow Coma Scale 15, tympanic temperature 40 C, respiratory rate 40/min, and oxygen saturation 83 % on room air. Physical examination revealed bilateral crackles and right bronchial breath sounds. Blood gases were pH 7.60, PaCO2 23 mmHg, PaO2 43 mmHg, and HCO3 -

Prevalence of low central venous oxygen saturation in the first hours of intensive care unit admission and associated mortality in septic shock patients: a prospective multicentre study

Abstract Background PCR-based techniques for the diagnosis of community- acquired severe lower respiratory tract infections are becoming the standard of care. However, their relative ability to identify either atypical bacteria or viruses that cause LRTI from clinical samples from various sources is yet to be determined. Objectives and study design The aim of our study was to compare the diagnostic yield of nasopharyngeal aspirates with that of pulmonary samples for the etiological diagnosis of severe acute lower respiratory tract infections by multiplex PCR. Patients were adults with community-acquired pneumonia or acute exacerbation of chronic obstructive pulmonary disease. Results We obtained concordant results for 81 (79%) of the 103 pairs of samples. In 14 of the 22 discordant results, more pathogens were evidenced in the lower respiratory tract samples. Conclusions Pulmonary samples had a similar diagnostic sensitivity for virus detection by multiplex PCR as nasopharyngeal aspirates. In contrast, in our study, the diagnostic efficacy of pulmonary samples for Legionella pneumophila over simple aspirates was clearly superior.