Olivier Leroy

A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit

ObjectivesTo characterize the epidemiology and to determine the prognosis factors in severe community-acquired pneumonia among patients admitted to an intensive care unit.DesignRetrospective clinical study.SettingIntensive Care and Infectious Diseases Unit of a municipal general hospital of Lille University Medical School.Patients299 consecutive patients exhibiting severe community-acquired pneumonia.Measurements and resultsOn admission to ICU, 149 patients required mechanical ventilation for acute respiratory failure and 44 exhibited septic shock. Pulmonary involvement was bilateral in 71 patients. There were 260 organisms isolated from 197 patients (65.9%), the most frequent beingStreptococcus pneumoniae (n=80),Staphylococcus spp. (n=57) and Gram-negative bacilli (n=81). Overall mortality was 28.5% (85 patients). According to univariate analysis, mortality was associated with age over 60 years, anticipated death within 5 years, immunosuppression, shock, mechanical ventilation, bilateral pulmonary involvement, bacteremia, neutrophil count <3500/mm3, total serum protein level <45 g/l, serum creatinine >15 mg/l, non-aspiration pneumonia, ineffective initial therapy and complications. Multivariate analysis selected only 5 factors significantly associated with prognosis: anticipated death within 5 years, shock, bacteremia, non-pneumonia-related complications and ineffective initial therapy.ConclusionThe effectiveness of the initial therapy appears to be the most significant prognosis factor and, as the one and only related to the initial medical intervention, suggests a need for permanent optimization of our antimicrobial strategies.

Severe community-acquired pneumonia in ICUs: prospective validation of a prognostic score.

ObjectiveTo determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively.DesignCombined retrospective and prospective clinical study over two periods: January 1987–December 1992 and January 1993–December 1994.SettingFour medical ICUs in the north of France.PatientsDerivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index.ResultsIn the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (−0.37), grading of sepsis ≥11 (−0.2), antimicrobial combination (−0.01), Glasgow score >12+mechanical ventilation (MV) (+0.09), serum creatinine ≥15 mg/l (+0.22), chest involvement shown by X-ray ≥3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score ≥12 (+0.49), neutrophil count ≤3500/mm3 (+0.52), acute organ system failure score ≥2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patients points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of ≥2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98.ConclusionThis index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).

Hospital-acquired pneumonia: risk factors, clinical features, management, and antibiotic resistance.

Purpose of review The aim of this review is to summarize recent developments regarding risks factors, clinical features, management and antimicrobial resistance, and prevention of hospital-acquired pneumonia. Recent findings Risk factors for hospital-acquired pneumonia developing in specific ICUs (neurologic and cardiovascular surgery) were reported. Characteristics of pneumonia acquired in general wards but requiring ICU admission were studied. Analysis of the impact of reintubation on pneumonia occurrence demonstrated that only reintubation after accidental extubation increases the risk. Early administration of adequate antibiotic(s), associated with a deescalating strategy, remains the only measure directly amenable to modification by clinicians that decreases the infection-related mortality. Numerous data emphasized the recommendation that guidelines for hospital-acquired pneumonia therapy should be updated and customized to local patterns to improve the level of adequacy of antimicrobial treatment. A 8-day treatment regimen could be proposed when pneumonia is not caused by a nonfermenting, gram-negative bacilli. In cases of pneumonia caused by methicillin-resistant Staphylococcus aureus, linezolid, compared with vancomycin, significantly increases the rates of cure and survival. Semirecumbent positioning in all eligible patients, sucralfate rather than H2 antagonists in patients at low to moderate risk of gastrointestinal bleeding, and, in selected patients, aspiration of subglottic secretions and oscillating beds are the measures proposed to prevent the development of ventilator-associated pneumonia. Conversely, the routine or indiscriminate use of selective digestive decontamination is not recommended. Summary In our opinion, the optimization of the length of treatment and the reduction of mortality with linezolid in staphylococcal pneumonia are two major recent developments.

Effect of hospital-acquired ventilator-associated pneumonia on mortality of severe community-acquired pneumonia

PURPOSE The purpose of this article is to evaluate, using two pairwise case-control studies, attributable mortality linked to hospital-acquired ventilator-associated pneumonia (HA-VAP) complicating the intensive care unit (ICU) stay of patients exhibiting severe community-acquired pneumonia (CAP). MATERIALS AND METHODS Over an 11-year period, 498 patients with severe CAP were collected. Among them, 43 exhibited HA-VAP. In a first case-control study, these patients were matched with control on the basis of six confounding variables known to be general ICU prognosis factors. In a second case-control study, six variables specifically linked to CAP prognosis were used for matching. RESULTS In the two case-control studies, each case patient was matched with one control patient. In the first analysis, success of matching was achieved in 198 of 258 (77%) variables used for matching. In the second analysis, matching was successful for 242 of 258 (94%) confounding variables used. Eighteen patients died, compared with, respectively, 6 (P = .003) and 7 (P = .01) controls. Attributable mortality of HA-VAP was similar in the two pairwise analyses, respectively, 28% (risk ratio = 3.0; 95% confidence interval, 1.32 to 6.82) and 26% (risk ratio = 2.57; 95% confidence interval, 1.2 to 5.52). CONCLUSION When confounding factors were controlled, HA-VAP appeared to increase mortality of severe CAP requiring ICU admission.

Hospital-Acquired Pneumonia in Critically Ill Patients

AbstractStudy objectives: To identify, in patients experiencing hospital-acquired pneumonia (HAP), prognostic factors present at disease onset and build an algorithm capable of stratifying mortality risk upon HAP onset. Design: Observational cohort from January 1994 to December 2001. Setting: One intensive care unit (ICU) from a university-affiliated, urban teaching hospital. Patients: All consecutive patients exhibiting bacteriologically documented HAP either on ICU admission or during ICU stay. Interventions: Data collection and multivariate analysis using Chi-Square Automatic Interaction and Detection technique. Results: 168 patients were studied. The overall mean mortality rate was 49.4%. Upon onset of HAP, five independent variables allowed binary stratification of mortality risk. These consisted of underlying diseases (nonfatal versus ultimately and rapidly fatal diseases), Simplified Acute Physiology Score II (less than versus ≥37), platelet count (less than versus ≥150 000/mm3), chest x-ray involvement (1 versus >1 lobe), and PaO2/FiO2 (less than versus ≥167mm Hg). A branching algorithm consisting of these five variables identified patients with HAP at both low (<35%) and high (>75%) risk of mortality. Conclusion: Mortality in ICU patients with HAP may be predicted early, upon onset of HAP, by the cumulative use of prognostic factors in an algorithm.