Virginie Lemiale

Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive care unit: a multicenter study

IntroductionCommunity-acquired pneumonia (CAP) account for a high proportion of ICU admissions, with Streptococcus pneumoniae being the main pathogen responsible for these infections. However, little is known on the clinical features and outcomes of ICU patients with pneumococcal pneumonia. The aims of this study were to provide epidemiological data and to determine risk factors of mortality in patients admitted to ICU for severe S. pneumoniae CAP.MethodsWe performed a retrospective review of two prospectively-acquired multicentre ICU databases (2001-2008). Patients admitted for management of severe pneumococcal CAP were enrolled if they met the 2001 American Thoracic Society criteria for severe pneumonia, had life-threatening organ failure and had a positive microbiological sample for S. pneumoniae. Patients with bronchitis, aspiration pneumonia or with non-pulmonary pneumococcal infections were excluded.ResultsTwo hundred and twenty two patients were included, with a median SAPS II score reaching 47 [36-64]. Acute respiratory failure (n = 154) and septic shock (n = 54) were their most frequent causes of ICU admission. Septic shock occurred in 170 patients (77%) and mechanical ventilation was required in 186 patients (84%); renal replacement therapy was initiated in 70 patients (32%). Bacteraemia was diagnosed in 101 patients. The prevalence of S. pneumoniae strains with decreased susceptibility to penicillin was 39.7%. Although antibiotherapy was adequate in 92.3% of cases, hospital mortality reached 28.8%. In multivariate analysis, independent risk factors for mortality were age (OR 1.05 (95% CI: 1.02-1.08)), male sex (OR 2.83 (95% CI: 1.16-6.91)) and renal replacement therapy (OR 3.78 (95% CI: 1.71-8.36)). Co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not influence outcome.ConclusionsIn ICU, mortality of pneumococcal CAP remains high despite adequate antimicrobial treatment. Baseline demographic data and renal replacement therapy have a major impact on adverse outcome.

338 Causes and hospital mortality in a large cohort of out-of-hospital cardiac arrest

Background The great majority of successfully resuscitated out-of-hospital cardiac arrest (OHCA) patients will subsequently die during their ICU and hospital stay. Several studies have previously described the main causes of OHCA but the impact of aetiology on the outcome and the timing and value of diagnostic procedures such as coronary angiogram remains controversial. Methods We analysed the causes of cardiac arrest in a prospective database from a tertiary reference. We compared the mortality observed in the subgroups of patients with a cardiac or a non-cardiac cause of arrest. Results 983 patients were admitted from January 2000 to August 2008.In patients without an obvious non-cardiac cause of arrest, a coronary angiogram followed if necessary by a coronary angioplasty was performed at admission. The median age was 58 years (range 84.39) and 74% were male. Past or current cigarette smoking was noted in 54%, hypertension in 35% and hypercholesterolemia in 23%. The causes of OHCA were an acute coronary syndrome (ACS=Gr1) in 389 pts (40%), primary ventricular arrhythmia (VT-FV=Gr2) in 154 pts (16%), cardiac failure (=Gr3) in 35 pts (3%), acute respiratory failure (=Gr4) in 186 pts (19%), neurological failure (=Gr5) in 41 pts (4%), unknown (=Gr6) in 71 pts (7%) and others causes(=Gr7) in 104 pts (11%). Overall, the mortality rate of the entire cohort was 68%; mortality rates observed in each subgroup are displayed in the figure. Download : Download full-size image

Hairy Cell Leukemia with Pulmonary Infiltrates

We report a case of acute respiratory failure and cutaneous rash in a 44-year-old woman treated for hairy cell leukemia. She was admitted to the ICU at the time of neutropenia recovery. She was at high risk for infection, most notably with intracellular pathogens (i.e., Legionella, Mycoplasma, Chlamydia, tuberculosis, and invasive fungal infections), but no pathogen was recovered. Her skin rash was a hypersensitivity reaction to cladribine, and her dyspnea was related to cardiogenic pulmonary edema and, possibly, cladribine hypersensitivity. The case of this patient illustrates the diagnostic challenges raised by ICU patients with hematological malignancies. Possible diagnoses in our patient were selective immune deficiency related to hairy cell leukemia, cladribine toxicity, heart failure with pulmonary edema, acute lung injury during neutropenia recovery, and infection. She improved within a few days with diuretic therapy and cladribine discontinuation.

336 Outcome after immediate invasive strategy in out-of-hospital cardiac arrest

Background According to the most recent guidelines, patients resuscitated from a cardiac arrest due to an acute coronary syndrome (ACS) should undergo an immediate coronary angiography with a subsequent percutaneous coronary intervention (PCI) if indicated. However, the outcome of this strategy and the value of the ECG in this setting are controversial. The aim of our study is to describe the results of such a strategy and to analyze the value of the ECG in a large cohort of patients resuscitated from an out-of-hospital cardiac arrest (OHCA). Methods A coronary angiogram was performed in all survivors of an OHCA referred to a tertiary center if there was no obvious non-cardiac cause of arrest. ECG changes noted on the electrocardiogram recorded after the return of spontaneous circulation were classified in 3 patterns (Group 1: ST segment elevation, Group 2: ST segment depression, conduction anomalies or negative T waves, Group 3: non-specific changes or normal). Results 669 OHCA patients were admitted between January 2003 and August 2008. A coronary angiogram was performed in 372 (56%) ST segment elevation was noted in 112 patients (30%), ST depression or negative T waves in 183 (49%) and non-specific changes or normal ECG in 77 (21%). PCI was performed in 156 patients (42%). PCI was more frequently performed in patients with ST elevation (90/112, 80%) than in the other groups (Group 2: 52/183, 28% Group 3: 14/77, 18%, p Conclusions Our results suggest that an immediate coronary angiography with subsequent PCI is associated with a low mortality rate, particularly in patients with ST segment elevation. Further analyses will investigate the exact impact of such a strategy in all subsets of OHCA patients.