Stéphane Soubrier

First-generation fluoroquinolone use and subsequent emergence of multiple drug-resistant bacteria in the intensive care unit*

Objective:The objective of this study was to determine the relationship between fluoroquinolone (FQ) use and subsequent emergence of multiple drug-resistant bacteria (MRB) in the intensive care unit (ICU). Design:The authors conducted a prospective observational cohort study and a case control study. Setting:The study was conducted in a 30-bed ICU. Methods:All immunocompetent patients hospitalized for >48 hrs who did not receive antibiotics before ICU admission were eligible during a 15-month period. Routine MRB screening was performed at ICU admission and weekly thereafter. This screening included tracheal aspirate and nasal, anal, and axilla swabs. Univariate and multivariate analyses were used to determine risk factors for MRB emergence in the ICU. In addition, a case control study was performed to determine whether FQ use is associated with subsequent emergence of MRB. Results:Two hundred thirty-nine patients were included; 108 ICU-acquired MRB were isolated in 77 patients. FQ use and longer duration of antibiotic treatment were identified as independent risk factors for MRB occurrence (odds ratio [95% confidence interval [CI] = 3.3 [1.7–6.5], 1.1 [1.0–1.2]; p < .001; respectively). One hundred thirty-five (56%) patients received FQ; matching was successful for 72 (53%) of them. Number of MRB (40 vs. 15 per 1,000 ICU days; p = .019) and percentage of patients with MRB (40% vs. 22%; OR [95% CI] = 1.5 [1.0–2.4]; p = .028) were significantly higher in cases than in controls. Although methicillin-resistant Staphylococcus aureus (26% vs. 12%; OR [95% CI] = 1.6 [.6–2.9]; p = .028) and extending-spectrum &bgr;-lactamase-producing Gram-negative bacilli (11% vs. 1%; OR [95% CI] = 4.7 [0.7–30.2]; p = .017) rates were higher in cases than in controls, ceftazidime or imipenem-resistant Pseudomonas aeruginosa (15% vs. 8%), Acinetobacter baumannii (1% vs. 5%), and Stenotrophomonas maltophilia (2% vs. 1%) rates were similar (p > .05) in case and control patients. Conclusion:FQ use and longer duration of antibiotic treatment are independently associated with MRB emergence. Reducing antimicrobial treatment duration and restricting FQ use could be suggested to control MRB spread in the ICU.

Moderate-to-Vigorous Physical Activity among Children: Discrepancies in Accelerometry-Based Cut-off Points

Objective: To highlight the discrepancies in accelerometry cut‐off points of moderate‐to‐vigorous physical activity (MVPA) according to the definitions of Puyau et al. (MVPAP) and Trost et al. (MVPAT).

Multiple-drug-resistant bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease: Prevalence, risk factors, and outcome.

Objective:To determine prevalence, risk factors, and effect on outcome of multiple-drug–resistant (MDR) bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease. Design:Prospective, observational, cohort study. Setting:Thirty-bed medical intensive care unit (ICU) in a university hospital. Methods:All chronic obstructive pulmonary disease patients with acute exacerbation who required intubation and mechanical ventilation for >48 hrs were eligible during a 4-yr period. Patients with pneumonia or other causes of acute respiratory failure were not eligible. In all patients, quantitative tracheal aspirate was performed at ICU admission (positive at 106 colony-forming units [cfu]/mL). MDR bacteria were defined as methicillin-resistant Staphylococcus aureus, ceftazidime- or imipenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and extended-spectrum &bgr;-lactamase–producing Gram-negative bacilli. All patients received empirical antibiotic treatment at ICU admission. Univariate and multivariate analyses were used to determine variables associated with MDR bacteria and variables associated with ICU mortality. Results:A total of 857 patients were included, and 304 bacteria were isolated (≥106 cfu/mL) in 260 patients (30%), including 75 MDR bacteria (24%) in 69 patients (8%). When patients with MDR bacteria were compared with patients without MDR bacteria, previous antimicrobial treatment (odds ratio [OR], 2.4; 95% confidence interval [95% CI], 1.2–4.7; p = .013) and previous intubation (OR, 31; 95% CI, 12–82; p < .001) were independently associated with MDR bacteria. When patients with bacteria other than MDR or patients with no bacteria were used as a reference group, these risk factors were still independently associated with MDR bacteria. Although ICU mortality rate was higher in patients with MDR bacteria than in patients without MDR bacteria (44% vs. 25%; p = .001; OR, 2.3; 95% CI, 1.4–3.8), MDR bacteria were not independently associated with ICU mortality. Inappropriate initial antibiotic treatment (88% vs. 5%; p = <.001; OR, 6.7; 95% CI, 3.8–12) and ventilator-associated pneumonia (23% vs. 5%; p = <.001; OR, 1.3; 95% CI, 1–1.8) rates were significantly higher in patients with MDR bacteria than in patients with bacteria other than MDR. Inappropriate initial antibiotic treatment was independently associated with increased ICU mortality (OR, 7.1; 95% CI, 1.9–30; p = .003). Conclusion:MDR bacteria are common in patients with acute exacerbation of chronic obstructive pulmonary disease requiring intubation and mechanical ventilation. Previous antimicrobial treatment and previous intubation are independent risk factors for MDR bacteria. Although MDR bacteria are not independently associated with ICU mortality, inappropriate initial antibiotic treatment is an independent risk factor for ICU mortality in these patients. Further studies are needed to determine whether broad-spectrum antibiotic treatment is cost-effective in these patients.

Effect of ventilator-associated tracheobronchitis on outcome in patients without chronic respiratory failure: a case-control study.

IntroductionOur objective was to determine the effect of ventilator-associated tracheobronchitis (VAT) on outcome in patients without chronic respiratory failure.MethodsThis was a retrospective observational matched study, conducted in a 30-bed intensive care unit (ICU). All immunocompetent, nontrauma, ventilated patients without chronic respiratory failure admitted over a 6.5-year period were included. Data were collected prospectively. Patients with nosocomial pneumonia, either before or after VAT, were excluded. Only first episodes of VAT occurring more than 48 hours after initiation of mechanical ventilation were studied. Six criteria were used to match cases with controls, including duration of mechanical ventilation before VAT. Cases were compared with controls using McNemars test and Wilcoxon signed-rank test for qualitative and quantitative variables, respectively. Variables associated with a duration of mechanical ventilation longer than median were identified using univariate and multivariate analyses.ResultsUsing the six criteria, it was possible to match 55 (87%) of the VAT patients (cases) with non-VAT patients (controls). Pseudomonas aeruginosa was the most frequently isolated bacteria (34%). Although mortality rates were similar between cases and controls (29% versus 36%; P = 0.29), the median duration of mechanical ventilation (17 days [range 3–95 days] versus 8 [3–61 days]; P < 0.001) and ICU stay (24 days [range 5–95 days] versus 12 [4–74] days; P < 0.001) were longer in cases than in controls. Renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.6–14.6; P = 0.004), tracheostomy (OR = 4, 95% CI = 1.1–14.5; P = 0.032), and VAT (OR = 3.5, 95% CI = 1.5–8.3; P = 0.004) were independently associated with duration of mechanical ventilation longer than median.ConclusionVAT is associated with longer durations of mechanical ventilation and ICU stay in patients not suffering from chronic respiratory failure.

Relationship between tracheotomy and ventilator-associated pneumonia: a case–control study

The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case–control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes·1,000 MV-days−1) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes·1,000 MV-days−1). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3–5)), antibiotic treatment (2.1 (1.1–3.2)) and tracheotomy (0.18 (0.1–0.3)) were associated with VAP. In summary, the present study demonstrates that tracheotomy is independently associated with decreased risk for ventilator-associated pneumonia.

Outcomes of ventilated COPD patients with nosocomial tracheobronchitis: a case-control study.

Abstract.Background:The aim of this study was to determine the impact of nosocomial tracheobronchitis (NTB) related to new bacteria on the outcome in patients with chronic obstructive pulmonary disease (COPD).Patients and Methods:A prospective observational case-control study was conducted in medical COPD patients requiring intubation and mechanical ventilation for more than 48 hours. Patients with nosocomial pneumonia were excluded. Six matching criteria were used, including the duration of mechanical ventilation before NTB occurrence.Results:81 matched case-control pairs were studied. Although the mortality rate was similar (40% vs 34%; p = 0.48), median duration of mechanical ventilation (20 vs 12 days; p = 0.015) and intensive care unit (ICU) stay (25 vs 18 days; p = 0.022) were higher in cases than in controls. NTB was independently associated with a longer than median period of mechanical ventilation among case and control patients (OR = 4.7 [95%CI = 2–10.9]; p < 0.001). In cases with appropriate antibiotic treatment compared with those who did not receive antibiotics, a shorter median duration of mechanical ventilation (12 vs 23 days; p = 0.006) and ICU stay (16 vs 29 days; p = 0.029) were observed.Conclusion:NTB is associated with an increased duration of mechanical ventilation and ICU stays. Further studies are required to determine whether antibiotics could improve the outcome of patients with NTB.

Physical activity and sedentary lifestyle in children as time-limited functions: Usefulness of the principal component analysis method

This study was designed to examine the hourly variation in and the interplay between physical activity and sedentary behavior (SB) in order to highlight key time periods for physical activity interventions for children. Data for physical activity and SB obtained with ActiGraph in 56 boys and 47 girls aged from 8 to 11 years. These data were divided into sixty minute-time samples for moderate-to-vigorous physical activity (MVPA) and SB, and analyzed using a principal component analysis (PCA) and correlation statistics. The PCA provides 10 factors which account for 80.4% of the inertia. Only two of these factors did not display competition between MVPA and SB. Contrary to some reports, a coefficient of correlation of —.68 (p,<10−4) was found between daily time spent at MVPA and SB. Some salient traits of children’s behaviors were shown through PCA. The results suggested that efficacy of interventions targeting the morning hours (07:00 AM–11:59 AM) and the afternoon period (02:00 PM–05:59 PM) warrants attention. H. Hubert, herve.hubert@univ-lille2.fr