Sébastien Prin

Serum procalcitonin elevation in critically ill patients at the onset of bacteremia caused by either gram negative or gram positive bacteria

BackgroundIn the ICU, bacteremia is a life-threatening infection whose prognosis is highly dependent on early recognition and treatment with appropriate antibiotics. Procalcitonin levels have been shown to distinguish between bacteremia and noninfectious inflammatory states accurately and quickly in critically ill patients. However, we still do not know to what extent the magnitude of PCT elevation at the onset of bacteremia varies according to the Gram stain result.MethodsReview of the medical records of every patient treated between May, 2004 and December, 2006 who had bacteremia caused by either Gram positive (GP) or Gram negative (GN) bacteria, and whose PCT dosage at the onset of infection was available.Results97 episodes of either GN bacteremia (n = 52) or GP bacteremia (n = 45) were included. Procalcitonin levels were found to be markedly higher in patients with GN bacteremia than in those with GP bacteremia, whereas the SOFA score value in the two groups was similar. Moreover, in the study population, a high PCT value was found to be independently associated with GN bacteremia. A PCT level of 16.0 ng/mL yielded an 83.0% positive predictive value and a 74.0% negative predictive value for GN-related bacteremia in the study cohort (AUROCC = 0.79; 95% CI, 0.71–0.88).ConclusionIn a critically ill patient with clinical sepsis, GN bacteremia could be associated with higher PCT values than those found in GP bacteremia, regardless of the severity of the disease.

Procalcitonin kinetics within the first days of sepsis: relationship with the appropriateness of antibiotic therapy and the outcome

IntroductionManagement of the early stage of sepsis is a critical issue. As part of it, infection control including appropriate antibiotic therapy administration should be prompt. However, microbiological findings, if any, are generally obtained late during the course of the disease. The potential interest of procalcitonin (PCT) as a way to assess the clinical efficacy of the empirical antibiotic therapy was addressed in the present study.MethodsAn observational cohort study including 180 patients with documented sepsis was conducted in our 15-bed medical intensive care unit (ICU). Procalcitonin measurement was obtained daily over a 4-day period following the onset of sepsis (day 1 (D1) to D4). The PCT time course was analyzed according to the appropriateness of the first-line empirical antibiotic therapy as well as according to the patient outcome.ResultsAppropriate first-line empirical antibiotic therapy (n = 135) was associated with a significantly greater decrease in PCT between D2 and D3 (ΔPCT D2–D3) (-3.9 (35.9) vs. +5.0 (29.7), respectively; P < 0.01). In addition, ΔPCT D2–D3 was found to be an independent predictor of first-line empirical antibiotic therapy appropriateness. In addition, a trend toward a greater rise in PCT between D1 and D2 was observed in patients with inappropriate antibiotics as compared with those with appropriate therapy (+5.2 (47.4) and +1.7 (35.0), respectively; P = 0.20). The D1 PCT level failed to predict outcome, but higher levels were measured in the nonsurvivors (n = 51) when compared with the survivors (n = 121) as early as D3 (40.8 (85.7) and 21.3 (41.0), respectively; P = 0.04). Moreover, PCT kinetics between D2 and D3 were also found to be significantly different, since a decrease ≥ 30% was expected in the survivors (log-rank test, P = 0.04), and was found to be an independent predictor of survival (odds ratio = 2.94; 95% confidence interval 1.22 to 7.09; P = 0.02).ConclusionsIn our study in an ICU, appropriateness of the empirical antibiotic therapy and the overall survival were associated with a greater decline in PCT between D2 and D3. Further studies are needed to assess the utility of the daily monitoring of PCT in addition to clinical evaluation during the early management of sepsis.

Candida spp. airway colonization could promote antibiotic-resistant bacteria selection in patients with suspected ventilator-associated pneumonia

ObjectiveCandida spp. airway colonization could promote development of ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa, a potentially multidrug-resistant (MDR) bacteria, and worsen the outcome of VAP regardless of pathogen. We therefore address the question of the risk of MDR bacteria isolation within the airway of patients with suspected VAP, whether Candida spp. is present or not.Design and settingProspective observational study in a teaching hospital.Patients and methodsConsecutive patients with suspected VAP were included. Respiratory tract secretions were seeded on specific medium for yeast isolation in addition to standard culture. Outcome as well as presence of MDR bacteria were assessed according to fungal colonization.Results323 suspected VAP were analysed. Among these, 181 (56xa0%) cases presented with Candida spp. airway colonization. Colonized and noncolonized patients were similar regarding baseline characteristics, prior exposure to antibiotics and VAP severity. However, mortality rate was greater in patients with fungal airway colonization than in those without (44.2 versus 31.0xa0%, respectively; pxa0=xa00.02). In addition, MDR bacteria isolation was 31.5xa0% in patients with Candida spp. colonization versus 23.2xa0% in those without (pxa0=xa00.13). Moreover, Candida spp. airway colonization was one independent risk factor for MDR bacteria isolation [odds ratio (OR)xa0=xa01.79, 95xa0% confidence interval 1.05–3.05; pxa0=xa00.03], in addition to the time elapsed between intensive care unit (ICU) admission and VAP suspicion.ConclusionsIn patients with suspected VAP, Candida spp. airway colonization is frequent and associated with increased risk for MDR bacteria isolation. This could worsen outcome and should therefore be considered when choosing an empiric antibiotic therapy.

Suffering among carers working in critical care can be reduced by an intensive communication strategy on end-of-life practices

PurposeBurnout syndrome (BOS) has frequently been reported in healthcare workers, and precipitating factors include communication problems in the workplace and stress related to end-of-life situations. We evaluated the effect of an intensive communication strategy on BOS among caregivers working in intensive care (ICU).MethodsLongitudinal, monocentric, before-and-after, interventional study. BOS was evaluated using the Maslach Burnout Inventory (MBI) and depression using the Centre for Epidemiologic Studies Depression Scale (CES-D) in 2007 (period 1) and 2009 (period 2). Between periods, an intensive communication strategy on end-of-life practices was implemented, based on improved organisation, better communication, and regular staff meetings.ResultsAmong 62 caregivers in the ICU, 53 (85%) responded to both questionnaires in period 1 and 49 (79%) in period 2. We observed a significant difference between periods in all three components of the MBI (emotional exhaustion, pxa0=xa00.04; depersonalization pxa0=xa00.04; personal accomplishment, pxa0=xa00.01). MBI classified burnout as severe in 15 (28%) caregivers in period 1 versus 7 (14%) in period 2, pxa0<xa00.01, corresponding to a 50% risk reduction. Symptoms of depression as evaluated by the CES-D were present in 9 (17%) caregivers in period 1 versus 3 (6%) in period 2, pxa0<xa00.05, corresponding to a risk reduction of almost 60%.ConclusionThe implementation of an active, intensive communication strategy regarding end-of-life care in the ICU was associated with a significant reduction in the rate of burnout syndrome and depression in a stable population of caregiving staff.

Serum procalcitonin for the early recognition of nosocomial infection in the critically ill patients: a preliminary report

BackgroundThe usefulness of procalcitonin (PCT) measurement in critically ill medical patients with suspected nosocomial infection is unclear. The aim of the study was to assess PCT value for the early diagnosis of bacterial nosocomial infection in selected critically ill patients.MethodsAn observational cohort study in a 15-bed intensive care unit was performed. Seventy patients with either proven (n = 47) or clinically suspected but not confirmed (n = 23) nosocomial infection were included. Procalcitonin measurements were obtained the day when the infection was suspected (D0) and at least one time within the 3 previous days (D-3 to D0). Patients with proven infection were compared to those without. The diagnostic value of PCT on D0 was determined through the construction of the corresponding receiver operating characteristic (ROC) curve. In addition, the predictive value of PCT variations preceding the clinical suspicion of infection was assessed.ResultsPCT on D0 was the best predictor of proven infection in this population of ICU patients with a clinical suspicion of infection (AUROCC = 0.80; 95% CI, 0.68–0.91). Thus, a cut-off value of 0.44 ng/mL provides sensitivity and specificity of 65.2% and 83.0%, respectively. Procalcitonin variation between D-1 and D0 was calculated in 45 patients and was also found to be predictive of nosocomial infection (AUROCC = 0.89; 95% CI, 0.79–0.98) with a 100% positive predictive value if the +0.26 ng/mL threshold value was applied. Comparable results were obtained when PCT variation between D-2 and D0, or D-3 and D0 were considered. In contrast, CRP elevation, leukocyte count and fever had a poor predictive value in our population.ConclusionPCT monitoring could be helpful in the early diagnosis of nosocomial infection in the ICU. Both absolute values and variations should be considered and evaluated in further studies.

Impact of previous sepsis on the accuracy of procalcitonin for the early diagnosis of blood stream infection in critically ill patients

BackgroundBlood stream infections (BSI) are life-threatening infections in intensive care units (ICU), and prognosis is highly dependent on early detection. Procalcitonin levels have been shown to accurately and quickly distinguish between BSI and noninfectious inflammatory states in critically ill patients. It is, however, unknown to what extent a recent history of sepsis (namely, secondary sepsis) can affect diagnosis of BSI using PCT.Methodsreview of the medical records of every patient with BSI in whom PCT dosage at the onset of sepsis was available between 1st September, 2006 and 31st July, 2007.Results179 episodes of either primary (n = 117) or secondary (n = 62) sepsis were included. Procalcitonin levels were found to be markedly lower in patients with secondary sepsis than in those without (6.4 [9.5] vs. 55.6 [99.0] ng/mL, respectively; p < 0.001), whereas the SOFA score was similar in the two groups. Although patients in the former group were more likely to have received steroids and effective antibiotic therapy prior to the BSI episode, and despite a higher proportion of candidemia in this group, a low PCT value was found to be independently associated with secondary sepsis (Odd Ratio = 0.33, 95% Confidence Interval: 0.16–0.70; p = 0.004). Additional patients with suspected but unconfirmed sepsis were used as controls (n = 23). Thus, diagnostic accuracy of PCT as assessed by the area under the receiver-operating characteristic curves (AUROCC) measurement was decreased in the patients with secondary sepsis compared to those without (AUROCC = 0.805, 95% CI: 0.699–0.879, vs. 0.934, 95% CI: 0.881–0.970, respectively; p < 0.050).ConclusionIn a critically ill patient with BSI, PCT elevation and diagnosis accuracy could be lower if sepsis is secondary than in those with a first episode of infection.

Impact of an intensive communication strategy on end-of-life practices in the intensive care unit

PurposeSince the 2005 French law on end of life and patients’ rights, it is unclear whether practices have evolved. We investigated whether an intensive communication strategy based on this law would influence practices in terms of withholding and withdrawing treatment (WWT), and outcome of patients hospitalised in intensive care (ICU).MethodsThis was a single-centre, two-period study performed before and after the 2005 law. Between these periods, an intensive strategy for communication was developed and implemented, comprising regular meetings and modalities for WWT. We examined medical records of all patients who died in the ICU or in hospital during both periods.ResultsIn total, out of 2,478 patients admitted in period 1, 678 (27%) died in the ICU and 823/2,940 (28%) in period 2. In period 1, among patients who died in the ICU, 45% died subsequent to a decision to WWT versus 85% in period 2 (pxa0<xa00.01). Among these, median time delay between ICU admission and initiation of decision-making process was significantly different (6–7xa0days in period 1 vs. 3–5xa0days in period 2, pxa0<xa00.05). Similarly, median time from admission to actual WWT decision was significantly shorter in period 2 (11–13xa0days in period 1 vs. 4–6xa0days in period 2, pxa0<xa00.05). Finally, median time from admission to death in the ICU subsequent to a decision to WWT was 13–15xa0days in period 1 versus 7–8xa0days in period 2, pxa0<xa00.05. Reasons for WWT were not significantly different between periods.ConclusionIntensive communication brings about quicker end-of-life decision-making in the ICU. The new law has the advantage of providing a legal framework.

Incidence and Predictors of New-Onset Atrial Fibrillation in Septic Shock Patients in a Medical ICU: Data from 7-Day Holter ECG Monitoring

Purpose We investigated incidence, risk factors for new-onset atrial fibrillation (NAF), and prognostic impact during septic shock in medical Intensive Care Unit (ICU) patients. Methods Prospective, observational study in a university hospital. Consecutive patients from 03/2011 to 05/2013 with septic shock were eligible. Exclusion criteria were age <18 years, history of AF, transfer with prior septic shock. Included patients were equipped with long-duration (7 days) Holter ECG monitoring. NAF was defined as an AF episode lasting >30 seconds. Patient characteristics, infection criteria, cardiovascular parameters, severity of illness, support therapies were recorded. Results Among 66 patients, 29(44%) developed NAF; 10 (34%) would not have been diagnosed without Holter ECG monitoring. NAF patients were older, with more markers of heart failure (troponin and NT-pro-BNP), lower left ventricular ejection fraction (LVEF), longer QRS duration and more nonsustained supra ventricular arrhythmias (<30s) on day 1 than patients who maintained sinus rhythm. By multivariate analysis, age (OR: 1.06; p = 0.01) and LVEF<45% (OR: 13.01, p = 0.03) were associated with NAF. NAF did not predict 28 or 90 day mortality. Conclusions NAF is common, especially in older patients, and is associated with low ejection fraction. We did not find NAF to be independently associated with higher mortality.

Impact of prior statin therapy on the outcome of patients with suspected ventilator-associated pneumonia: an observational study.

IntroductionVentilator-associated pneumonia (VAP) is the most commonly acquired infection in intensive care units (ICU). Its outcome is related, at least in part, to the host’s response. Statins have anti-inflammatory effects and may thus improve the outcome. We aimed to assess the impact of prior statin use in the setting of VAP.MethodsA six-year cohort study was conducted in a French ICU at a teaching hospital. All of the patients with suspected VAP were included. Baseline characteristics, outcomes, statin exposure, and the description of suspected episodes were collected prospectively. The primary endpoint was 30-day mortality. Patients who were taking statins before admission to the ICU whether or not treatment was continued thereafter (‘previous users’ group) were compared to those without prior statin therapy (‘statin-naive’ group). A survival analysis using a Cox model was conducted in the whole cohort and in the subgroup of prior statin users.ResultsAmong the 349 patients included, 93 (26.6%) had taken statins. At baseline, these patients were at higher risk of complications than statin-naive ones (for example, older, more likely to be men and to have underlying diseases, greater simplified acute physiology score II (SAPS II)). There was, however, no difference regarding severity at the time VAP was suspected (sequential organ failure assessment (SOFA): 9.0 (4.0 to 16.0) versus 8.0 (4.0 to 17.0); Pu2009=u20090.11). Nonetheless, 30-day mortality in statin users was not different from that in statin-naive patients (35.5% versus 26.2%, respectively; adjusted hazard ratio (HR)u2009=u20091.23 (0.79 to 1.90) 95% confidence interval (CI); Pu2009=u20090.36). In contrast, after limiting analysis to prior statin users and adjusting for potential confounders, those who continued the treatment had better survival than those who did not (HRu2009=u20090.47; (0.22 to 0.97) 95% CI; Pu2009=u20090.04).ConclusionsStatin continuation in prior users could provide protective effects in patients with suspected VAP.

Significance of Prior Digestive Colonization With Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Patients With Ventilator-Associated Pneumonia.

Objectives:Ventilator-associated pneumonia is frequent in ICUs. Extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae are difficult-to-treat pathogens likely to cause ventilator-associated pneumonia. We sought to assess the interest of screening for extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae rectal carriage as a way to predict their involvement in ventilator-associated pneumonia. Design:A retrospective cohort study of patients with suspected ventilator-associated pneumonia in a medical ICU was conducted. Patients:Every patient admitted between January 2006 and August 2013 was eligible if subjected to mechanical ventilation for more than 48 hours. Each patient with suspected ventilator-associated pneumonia was included in the cohort. Active surveillance culture for extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae detection was routinely performed in all patients at admission and then weekly throughout the study period. Extended-spectrum &bgr;-lactamase colonization was defined by the isolation of at least one extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae from rectal swab culture. Interventions:None. Measurements and Main Results:Among 587 patients with suspected ventilator-associated pneumonia, 40 (6.8%) were colonized with extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae prior to the development of pneumonia. Over the study period, 20 patients (3.4%) had ventilator-associated pneumonia caused by extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae; of whom, 17 were previously detected as being colonized with extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae. Sensitivity and specificity of prior extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae colonization as a predictor of extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae involvement in ventilator-associated pneumonia were 85.0% and 95.7%, respectively. The positive and negative predictive values were 41.5% and 99.4%, respectively. The positive likelihood ratio was 19.8. Conclusions:Screening for extended-spectrum &bgr;-lactamase–producing Enterobacteriaceae digestive colonization by weekly active surveillance cultures could reliably exclude the risk of the involvement of such pathogens in patients with ventilator-associated pneumonia in low-prevalence area.