Jl Vincent

Rapid Diagnosis of Infection in the Critically Ill, a Multicenter Study of Molecular Detection in Bloodstream Infections, Pneumonia, and Sterile Site Infections*

Objective: Early identification of causative microorganism(s) in patients with severe infection is crucial to optimize antimicrobial use and patient survival. However, current culture-based pathogen identification is slow and unreliable such that broad-spectrum antibiotics are often used to insure coverage of all potential organisms, carrying risks of overtreatment, toxicity, and selection of multidrug-resistant bacteria. We compared the results obtained using a novel, culture-independent polymerase chain reaction/electrospray ionization-mass spectrometry technology with those obtained by standard microbiological testing and evaluated the potential clinical implications of this technique. Design: Observational study. Setting: Nine ICUs in six European countries. Patients: Patients admitted between October 2013 and June 2014 with suspected or proven bloodstream infection, pneumonia, or sterile fluid and tissue infection were considered for inclusion. Interventions: None. Measurements and Main Results: We tested 616 bloodstream infection, 185 pneumonia, and 110 sterile fluid and tissue specimens from 529 patients. From the 616 bloodstream infection samples, polymerase chain reaction/electrospray ionization-mass spectrometry identified a pathogen in 228 cases (37%) and culture in just 68 (11%). Culture was positive and polymerase chain reaction/electrospray ionization-mass spectrometry negative in 13 cases, and both were negative in 384 cases, giving polymerase chain reaction/electrospray ionization-mass spectrometry a sensitivity of 81%, specificity of 69%, and negative predictive value of 97% at 6 hours from sample acquisition. The distribution of organisms was similar with both techniques. Similar observations were made for pneumonia and sterile fluid and tissue specimens. Independent clinical analysis of results suggested that polymerase chain reaction/electrospray ionization-mass spectrometry technology could potentially have resulted in altered treatment in up to 57% of patients. Conclusions: Polymerase chain reaction/electrospray ionization-mass spectrometry provides rapid pathogen identification in critically ill patients. The ability to rule out infection within 6 hours has potential clinical and economic benefits.

The detection of microbial DNA but not cultured bacteria is associated with increased mortality in patients with suspected sepsis—a prospective multi-centre European observational study

OBJECTIVES Blood culture results inadequately stratify the mortality risk in critically ill patients with sepsis. We sought to establish the prognostic significance of the presence of microbial DNA in the bloodstream of patients hospitalized with suspected sepsis. METHODS We analysed the data collected during the Rapid Diagnosis of Infections in the Critically Ill (RADICAL) study, which compared a novel culture-independent PCR/electrospray ionization-mass spectrometry (ESI-MS) assay with standard microbiological testing. Patients were eligible for the study if they had suspected sepsis and were either hospitalized or were referred to one of nine intensive care units from six European countries. The blood specimen for PCR/ESI-MS assay was taken along with initial blood culture taken for clinical indications. RESULTS Of the 616 patients recruited to the RADICAL study, 439 patients had data on outcome, results of the blood culture and PCR/ESI-MS assay available for analysis. Positive blood culture and PCR/ESI-MSI result was found in 13% (56/439) and 40% (177/439) of patients, respectively. Either a positive blood culture (p 0.01) or a positive PCR/ESI-MS (p 0.005) was associated with higher SOFA scores on enrolment to the study. There was no difference in 28-day mortality observed in patients who had either positive or negative blood cultures (35% versus 32%, p 0.74). However, in patients with a positive PCR/ESI-MS assay, mortality was significantly higher in comparison to those with a negative result (42% versus 26%, p 0.001). CONCLUSIONS Presence of microbial DNA in patients with suspected sepsis might define a patient group at higher risk of death.

Effects of low-dose dopamine on ventilation in patients with chronic obstructive pulmonary disease

Background  Dopamine plays an important role in the regulation of respiration and low‐dose dopamine infusion is associated with a decreased respiratory drive response to hypoxia in animals and humans. The effects of dopamine on ventilation in patients with chronic obstructive pulmonary disease (COPD) is unknown. We tested the hypothesis that dopamine inhibits ventilation in patients with COPD.

A RADICAL APPROACH TO DIAGNOSING INFECTION

The cornerstone of sepsis management requires identifying the causative pathogen and initiating appropriate antimicrobial therapy. Current pathogen detection relies on culture techniques, a technology that is over 100 years old, slow and unreliably. It is not unusual for only 10% of critical care blood cultures to be positive. Due to the low yield and time taken to obtain a result, they rarely alter patient management. a novel molecular pathogen detection system, known as IRIDICA, employs polymerase chain reaction and electro spray ionisation mass spectroscopy (PCR/ESI-MS) to identify over 1000 pathogens, direct from sample without culture and within 8 hours. The RADICAL study was created to assess this technology in a real world critical care environment.

Elevated endocan levels are associated with development of renal failure in ARDS patients.

Objectives The aim of the study was to determine whether plasma endocan levels were correlated with renal function in patients with acute respiratory distress syndrome (ARDS) and could predict the need for renal replacement therapy (RRT), as an indicator of acute renal dysfunction, during the ICU stay. Methods This was a post hoc analysis of prospectively collected data from 96 consecutive patients with ARDS (Berlin definition) who were not receiving RRT at diagnosis. Plasma endocan concentrations were measured using a quantitative ELISA method (Lunginov, France). We analyzed the predictive value of creatinine and endocan levels at diagnosis on the subsequent need for RRT using the area under the receiver operating characteristic curve (ROC AUC). We dichotomized values of creatinine (using a renal SOFA cut-off of 1.2 mg/dL) and endocan (best sensitivity and specificity based on the ROC curve) to predict need for RRT. All analyses were performed using SPSS 22.0 and a p value < 0.05 was considered as significant. Al values are presented as median with p25-75.

Thermal challenge of the microcirculation in patients after cardiac surgery

Microcirculatory alterations have been correlated with poorer outcomes in different populations of critically ill patients. A controlled increase in the local skin temperature (thermal challenge) induces vasodilation, which may represent a measure of microcirculation recruitability and can be easily evaluated non-invasively using skin laser Doppler (SLD) (1). We previously demonstrated lower SLD values during thermal challenge in patients with circulatory shock, particularly in non-survivors (2).

Red cells distribution width after cardiac arrest

Methods Retrospective analysis of an institutional database including all adult comatose patients admitted to the Intensive Care Unit (ICU) after CA from January 2007 to December 2014. Inclusion criteria were as follows: age ≥18, non-traumatic arrest and survival ≥ 24 hours after admission. We collected demographics and CA related data. We also collected daily routine blood analyses; RDW (normal values: 10.9-13.4%), was obtained from the day of admission to day 3. We recorded ICU mortality and long-term neurological outcome; a CPC score of 3-5 at 3-months was used to define poor neurological outcome (PNO).

Validation of mid-infrared spectroscopy for continuous glucose monitoring: the manage II study

Intravascular continuous glucose monitoring (CGM) in critically ill patients represents a major advance to improve the quality of care and to decrease the nursing workload dedicated to glycemic control. However, the presence of several physical or chemical interferences can limit the accuracy of the blood glucose readings (BG) measured by the CGM, implying the need for a thorough validation process for each technique or device used for CGM.

A high aminoglycoside regimen associated with renal replacement therapy for the treatment of multi-drug resistant pathogens

Infections caused by multi-drug resistant (MDR) Gram-negative (GN) organisms in critically ill patients are a therapeutic challenge. Few therapeutical options are available.

B-lactams serum concentrations in critically ill cirrhotic patients: a matched-control study

Few data are available on the pharmacokinetics (PKs) of b-lactams in critically ill cirrhotic patients.