OBJECTIVE:The passive leg raising maneuver (PLR) for fluid responsiveness testing relies on cardiac output (CO) measurements or invasive measurements of arterial pressure (AP) whereas the initial hemodynamic management during shock is often based solely on brachial cuff measurements. We assessed PLR-induced changes in noninvasive oscillometric readings to predict fluid responsiveness. STUDY DESIGN:Multicentre interventional study. PATIENTS AND METHODS:In ICU sedated patients with circulatory failure, AP (invasive and noninvasive readings) and CO measurements were performed before, during PLR (trunk supine, not modified) and after 500-mL volume expansion. Areas under the ROC curves (AUC) were determined for fluid responsiveness (>10% volume expansion-induced increase in CO) prediction. RESULTS:In 112 patients (19% with arrhythmia), changes in noninvasive systolic AP during PLR (noninvasiveΔ(PLR)SAP) only predicted fluid responsiveness (cutoff 17%, n=21, positive likelihood ratio [LR] of 26 [18-38]), not unresponsiveness. If PLR-induced change in central venous pressure (CVP) was at least of 2 mm Hg (n=60), suggesting that PLR succeeded in altering cardiac preload, noninvasiveΔ(PLR)SAP performance was good: AUC of 0.94 [0.85-0.98], positive and negative LRs of 5.7 [4.6-6.8] and 0.07 [0.009-0.5], respectively, for a cutoff of 9%. Of note, invasive AP-derived indices did not outperform noninvasiveΔ(PLR)SAP. CONCLUSION:Regardless of CVP (i.e., during "blind PLR"), noninvasiveΔ(PLR)SAP more than 17% reliably identified fluid responders. During "CVP-guided PLR", in case of sufficient change in CVP, noninvasiveΔ(PLR)SAP performed better (cutoff of 9%). These findings, in sedated patients who had already undergone volume expansion and/or catecholamines, have to be verified during the early phase of circulatory failure (before an arterial line and/or a CO measuring device is placed).

OBJECTIVE:We aimed to investigate the prognosis of HIV-infected patients with acute neurological complications at the highly active antiretroviral therapy (HAART) era. METHODS:We performed a retrospective study in HIV-infected patients admitted to a medical ICU with neurological complications between 2001 and 2008. RESULTS:Among the 210 studied patients (median [interquartile range] CD4-cell count: 80 [18-254]/μL; HIV viral load: 4.8 [2-5.3] log₁₀/mL), 40 (19%) had unknown HIV status at admission. Neurological complications consisted in delirium (45%), coma (39%), seizures (32%) and/or intracranial hypertension (21%). Admission diagnoses were AIDS-defining CNS disease for 88 (42%) patients, non-AIDS-defining CNS disease for 45 (21%), and systemic disease with neurological signs for 77 (37%). Seizures (p=0.003), focal deficit (p<0.001) and intracranial hypertension (p<0.001) were more frequently observed in patients with AIDS-defining CNS disease. Factors independently associated with ICU mortality (29.5%) were intracranial hypertension [odds ratio (OR), 5.09; 95% confidence interval (95% CI), 2.17-11.91], vasopressor use [OR, 3.92; 95% CI, 1.78-8.60] and SAPS II score [per 10-point increment, OR, 1.59; 95% CI, 1.31-1.93]. CONCLUSIONS:Prognosis of HIV-infected patients with neurological complications depends rather on clinical presentation than on HIV-related parameters. Intracranial hypertension symptoms at admission have a major impact on outcome.

The passive leg raising maneuver (PLR) with concomitant measurement of invasive arterial pressure (AP) or cardiac output (CO) changes are used to test volume responsiveness. The initial hemodynamic evaluation of shocked patients often relies on the sole non-invasive measurement of AP. We assessed the performance of PLR-induced changes in oscillometric measurements of systolic, mean and pulse AP (ΔplrSAP, ΔplrMAP and ΔplrPP).

The impact of high level cephalosporin resistance due to Enterobacteriaceae harbouring a type I-inducible chromosomal β-lactamase on the outcome of ventilator-associated pneumonia (VAP) remains unknown. A retrospective cohort study was conducted in two intensive care units (ICUs) over a four-year period to identify factors prognostic of VAP caused by high level AmpC (HL-AmpC)-producing Enterobacteriaceae. The study included 75 patients, who developed VAP due to Enterobacteriaceae harbouring a type I-inducible chromosomal β-lactamase. One-third of these VAP episodes were due to HL-AmpC-producing Enterobacteriaceae. Demographic and clinical characteristics at ICU admission were similar for patients, regardless of Enterobacteriaceae susceptibility, but those who developed VAP due to HL-AmpC-producing Enterobacteriaceae received antibiotics more frequently before its onset and had higher disease severity and organ dysfunction scores. Enterobacter spp. were the major HL-AmpC-producing micro-organisms responsible for VAP. VAP due to HL-AmpC-producing Enterobacteriaceae is rare. High level cephalosporin resistance was not associated with higher day 28 mortality, despite its association with more severe disease at VAP onset.

Les complications neurologiques des endocardites infectieuses sont fréquentes et ont une importance particulière car elles sont souvent inaugurales, peuvent mettre en jeu le pronostic vital et modifier sensiblement la prise en charge. Elles doivent être recherchées devant tout signe neurologique focal ou trouble de conscience inexpliqué. Les accidents vasculaires ischémiques par embolie d’une végétation constituent la principale complication neurologique des endocardites. Ils sont plus fréquents en cas d’endocardite à Staphylococcus aureus et de grosses végétations supérieures à 10mm et mobiles. Le diagnostic repose au mieux sur l’imagerie cérébrale par résonance magnétique avec injection. Les hémorragies cérébrales résultent de plusieurs mécanismes mais imposent en général d’éliminer un anévrisme mycotique rompu. D’autres complications infectieuses (méningite, abcès) peuvent nécessiter une modification du traitement anti-infectieux. En cas de complication neurologique et d’indication chirurgicale urgente au cours d’une endocardite infectieuse, le délai d’intervention doit être discuté au cas par cas ; mais plusieurs études récentes ont rapporté que la chirurgie de remplacement valvulaire est réalisable à la phase aiguë d’un accident vasculaire ischémique sans risque majeur d’aggravation neurologique.

Objective. - Comparison of treatments initiated during invasive candidiasis in intensive care units with current French guidelines.Study design. - Prospective, observational, French multicenter study (October 2005-May 2006).Patients and methods. - Selection of patients with Candida species identification and in vitro antifungal susceptibility determination. The empiric treatments instituted before the microbiologic documentation of infection and the curative treatments instituted after identification of the causative Candida and determination of its susceptibility were collected and compared with treatments proposed by the French clinical practice guidelines (2004) for the management of patients with invasive candidiasis.Results. - One hundred and eighty-six patients were studied. Invasive candidiasis was due to fluconazole-resistant or susceptible-dose dependent Candida in 18.3% of patients, without any significant influence of a previous treatment with azoles. Empiric and curative treatments were both in accordance with recommendations for 47% of patients. Recommendations were mainly not respected when proposed therapy was amphotericin B that disappeared from therapeutics used in ICU. Finally, 16.9% of episodes of invasive candidiasis, for which fluconazole was the recommended treatment, were due to fluconazole-resistant or susceptible-dose dependent Candida.Conclusion. - The support of French ICU physicians to current French guidelines was observed in 47% of cases. The infrequent use of amphotericin B must be emphasized. The nonnegligible incidence of fluconazole-resistant or susceptible-dose dependent Candida sp., particularly in patients without any prior exposition to azole agents, and the inability to predict this resistance should lead to propose a revision of 2004 guidelines. (C) 2008 Elsevier Masson SAS. Tous droits reserves.

La prescription d'antibiotique et l'évaluation de la réponse au traitement sont une pratique quotidienne en réanimation. Lors d'une infection bactérienne, l'hôte, la bactérie, le site infecté et l'antibiotique sont les déterminants de l'évolution du processus infectieux. La définition de l'échec de l'antibiothérapie doit donc être adaptée, en termes de critère et de délai, selon la combinaison de ces éléments, dont chacun peut par conséquent être impliqué dans l'échec (défenses de l'hôte, résistance bactérienne, accessibilité du site, schéma thérapeutique adapté). Seule une démarche rigoureuse permet, après avoir confirmé le diagnostic et éliminé un certain nombre de faux échecs, de systématiquement envisager et déterminer le mécanisme en cause.

The characteristics of spontaneous aerobic Gram-negative bacillary meningitis (AGNBM) were determined in 40 adults requiring admission to an intensive care unit (ICU) during a 16-year period in ten French ICUs. Eight infections were hospital-acquired and most patients had predisposing factors, mainly chronic alcoholism and an immunocompromised status. Three immunosuppressed patients had disseminated strongyloidiasis. Gram's stain, cerebrospinal fluid and blood cultures were positive for 85%, 98% and 80% of cases, respectively. Escherichia coli (57%) and Klebsiella pneumoniae (17%) were the most frequent pathogens. In-ICU mortality was 38%. Spontaneous AGNBM is a rare complication of bacteraemia in adults. The severity of predisposing underlying diseases might explain the poor prognosis despite appropriate antimicrobial therapy.

AbstractBackground:Despite contact isolation precautions for patients with methicillin-resistantStaphylococcus aureus(MRSA), MRSA infections are increasing in many countries.Objective:To evaluate the role of a potential unrecognized reservoir of MRSA carried by patients in acute care wards, we determined the prevalence of MRSA at hospital admission, with special emphasis on screening-specimen yields.Setting:A 1,100-bed teaching hospital in Paris, France.Methods:Nasal screening cultures were performed at admission to a tertiary-care teaching hospital for patients older than 75 years.Results:MRSA was isolated from 63 (7.9%) of 797 patients. On the multivariate analysis, variables significantly associated with MRSA carriage were presence of chronic skin lesions (adjusted odds ratio [AOR], 5.10; 95% confidence interval [CI95], 2.52–10.33); transfer from a nursing home, rehabilitation unit, or long-term-care unit (AOR, 4.52; CI95, 2.23–9.18); and poor chronic health status (AOR, 1.80; CI95, 1.02–3.18). Without admission screening, 84.1% of MRSA carriers would have been missed at hospital admission and 76.2% during their hospital stay. Furthermore, 81.1% of days at risk for MRSA dissemination would have been spent without contact isolation precautions had admission screening not been performed.Conclusions:MRSA carriage at hospital admission is far more prevalent than MRSA-positive clinical specimens. This may contribute to failure of contact isolation programs. Screening cultures at admission help to identify the reservoir of unknown MRSA patients.

La protéine C activée recombinante humaine est une nouvelle thérapeutique ayant fait la preuve de son efficacité en termes de mortalité dans le sepsis sévère. Elle est indiquée en cas de sepsis sévère associé à deux dysfonctions d'organe. Ce traitement semble surtout indiqué en cas de défaillance hémodynamique et respiratoire, principalement au cours d'une infection communautaire, sans tenir compte du score apache II. La coagulation intra-vasculaire disséminée, en particulier au cours du purpura fulminans, est une bonne indication. L'administration doit être, soit précoce pour les infections fulminantes, soit rapide après évaluation de l'impact de la réanimation initiale ou de la chirurgie éventuelle, mais sans dépasser 48 heures après le début du sepsis. L'âge et l'obésité ne sont plus à priori des contre-indications. Le traitement n'est pas justifié chez des patients à risque accru de complication hémorragique ou avec une seule défaillance d'organe. L'intérêt de la protéine C activée recombinante est discutable chez les patients qui s'améliorent rapidement au point de n'avoir plus qu'une seule défaillance d'organe. Les patients pédiatriques, en l'absence d'étude d'efficacité spécifique ne devraient pas recevoir de traitement. L'utilisation de la protéine C activée conduit également à une réflexion globale sur la mise en œuvre très précoce de protocoles rigoureux pour optimiser le délai et la prise en charge du sepsis sévère.

Until recently, brain aspergillosis was almost always fatal, with a response rate to amphotericin B of < 10%. This study describes a retrospective analysis of eight consecutive cases of brain aspergillosis. All patients were immunosuppressed and five required mechanical ventilation. Antifungal treatment included amphotericin B (n = 7), itraconazole (n = 3), voriconazole (n = 2) and flucytosine (n = 1). Three (38%) patients survived following prolonged azole therapy after initial amphotericin B treatment, combined with a reduction in their immunosuppressive treatment. The prognosis of brain aspergillosis might be improved if immunosuppression could be reduced and prolonged oral azole therapy used.

The past 30 years have seen several advances in the management of brain abscess ( 1 Mathisen G.E. Johnson J.P. Brain abscess. Clin Infect Dis. 1997; 25: 763-779 Crossref PubMed Scopus (477) Google Scholar , 2 Whelan M.A. Hilal S.K. Computed tomography as a guide in the diagnosis and follow-up of brain abscesses. Radiology. 1980; 135: 663-671 PubMed Google Scholar , 3 Haimes A.B. Zimmerman R.D. Morgello S. et al. MR imaging of brain abscesses. AJR Am J Roentgenol. 1989; 152: 1073-1085 Crossref PubMed Scopus (187) Google Scholar ), which have been accompanied by a decline in mortality from 30% to 50% before 1980 to between 4% and 20% ( 4 Seydoux C. Francioli P. Bacterial brain abscesses factors influencing mortality and sequelae. Clin Infect Dis. 1992; 15: 394-401 Crossref PubMed Scopus (174) Google Scholar , 5 Mampalam T.J. Rosenblum M.L. Trends in the management of bacterial brain abscesses a review of 102 cases over 17 years. Neurosurgery. 1988; 23: 451-458 Crossref PubMed Scopus (224) Google Scholar , 6 Kaplan K. Brain abscess. Med Clin North Am. 1985; 69: 345-360 PubMed Google Scholar , 7 Chun C.H. Johnson J.D. Hofstetter M. Raff M.J. Brain abscess. A study of 45 consecutive cases. Medicine (Baltimore). 1986; 65: 415-431 Crossref PubMed Scopus (221) Google Scholar , 8 McClelland C.J. Craig B.F. Crockard H.A. Brain abscesses in Northern Ireland a 30 year community review. J Neurol Neurosurg Psychiatry. 1978; 41: 1043-1047 Crossref PubMed Scopus (54) Google Scholar ). There are few data, however, about the prognosis of brain abscess in critically ill patients who have been admitted to an intensive care unit (ICU).

Because of a high prevalence of Pseudomonas aeruginosa infections, we conducted an epidemiological study to assess the need for systematic surveillance, as well as the value of applying barrier precautions toP. aeruginosa carriers. From July 1997 to February 1998, we conducted a prospective cohort study in an 18-bed medical intensive care unit (ICU), which is part of the infectious diseases department in a 1200-bed tertiary-care teaching hospital. Rectal and oropharyngeal swabs were obtained on admission and twice weekly. Acquired strains were genotypically characterized by pulsed-field gel electrophoresis (PFGE). A risk factor analysis for carriage, colonization and infection was performed. Among 269 eligible patients, 116 (43%) were P. aeruginosa carriers, with 46 (17%) detected on admission and 70 (26%) who acquired carriage during their stay in ICU. Among these 70 patients, 29 became colonized (N=13) or developed infection (N=16). Conversely, in the 121 patients who remained free of carriage, no colonization or infection were detected. Genotyping analysis using PFGE was performed for 81/85 (95%) acquired strains in 67 patients. The same genotype I was observed for 58/81 (70%) of these strains issued from 47 patients, and a distinct genotype II affected two other patients (three strains). The last 20 strains were not genetically related. In a multivariate model, mechanical ventilation was associated with the acquisition of P. aeruginosa carriage. Antibiotics ineffective against P. aeruginosa significantly increased the risk of colonization or infection in ICU. Although several recent studies concluded that endogenous sources account for the majority of P. aeruginosa colonizations or infections, we conclude that epidemiology may vary according to the ICU, and that cross-colonization (i.e., exogenous source) may occur and warrant reinforced barrier precautions.