Rationale: Acute exacerbations of COPD (AECOPDs) leading to hospitalization in intensive care units (ICU) for the most severe cases. The aim of the current study was to assess over 22 years the evolution of AECOPDs changes in the management practices and the impact on main outcomes. Methods: 1,816 patients admitted for AECOPDs were included prospectively between 1997 and 2018 in the Outcomerea French database from 32 ICUs. Evaluation of time trends were performed using a mixed model and time series analyses. Results: There was overtime a significant reduction in the prescription of corticosteroids (- 4.7%/year, p<.01) and antibiotics (-5.8%/year, p<.01), without these changes being correlated with the evolution of mortality in ICU in a time series analysis. The proportion of patients treated with Invasive Mechanical Ventilation (IMV) also gradually declined (-3.7%/year, p=.01) with this time a significant correlation between variations of use of IMV and variations of deaths in ICU in the time series analysis. Rate of NIV failures decreased over time (-6.2%/year, p<.01) with a diffusion of NIV for facilitating IMV weaning (+8.1%/year, p<.01). There was a significant shortening of length of stay in ICU (-3.2%/year, p<.01) and total duration of hospital stays (-2.6%/year, p<.01). We observed an improvement of the prognosis (-4.1%/year of deaths in ICU, p=0.03; -4.2 %/year of deaths in hospital post-ICU stay, p=0.02 and -4,98%/year of 90-day mortality, p=0.02). Conclusions: Lengths of stay decreased with a better prognosis of AECOPD in ICU. The management of ventilatory support has improved. Prescriptions for corticosteroids and antibiotics have been reduced.

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a very frequent in intensive care unit (ICU). However, there are few data and conflicting results about corticosteroids therapy for critically ill patients with an AECOPD. Methods: In this observational longitudinal cohort study, from OutcomeReaTM database with 32 french ICU centres participating, we assessed the impact of corticosteroids therapy at admission (daily dose ≥ 0.5 mg/kg of prednisone during the first 24 hours in ICU) on a composite criteria including death and invasive mechanical ventilation at day 28 after admission in ICU using an inverse probability of treatment weight estimator (IPTW), on patients in ICU for an AECOPD. Results: We included 1,247 patients of which 31,4% was treated by a corticosteroid therapy at admission. Corticosteroids had a protector effect on the main composite endpoint (RR = 0.69 [0.49; 0.98], p=0.038). For the subgroup of patients with a very severe COPD, this protective effect was not found (RR = 1,20 [0.58; 2.52], p=0.620). There was no significant impact of corticosteroids on failures of NIV, on lengths of stay in ICU or in hospital or on ventilation durations. Nosocomial infectious had the same prevalence in the two groups of patients. But the maximum systolic blood pressure and the levels of urea was higher and the glycaemic disorders more frequent when patient received corticosteroids. Conclusion: A corticosteroids administration at admission in ICU to patients with AECOPD had a protective effect on death or invasive mechanical ventilation at Day 28. Studies on doses to use or the profile of patients to treat are needed.

Severe malaria accounts for approximately 10% of all cases of imported malaria in France; cases are mainly due to Plasmodium fakiparum, while other Plasmodium species are possible but uncommon (P. vivax, P. knowlesi, P. nzalariae, and P. ovate). On the basis of WHO criteria for endemic areas, the French criteria defining severe imported malaria in adults have been progressively adapted to the European healthcare level. Management of severe imported malaria is a diagnostic and treatment emergency and must be initially conducted in the intensive care unit. Anti-infective treatment is now based on intravenous artesunate, which must be available in every hospital of the country likely to receive severe imported malaria patients. Intravenous quinine is thus used as a second-line treatment and is restricted to limited indications. Critical care management of organ failure is essential, particularly in patients presenting with very severe malaria. To date, no adjunctive therapy (including exchange transfusion) has demonstrated clear beneficial effects. (C) 2018 Elsevier Masson SAS. All rights reserved.

During severe malaria, both in endemic and non-endemic areas, cerebral malaria is strongly associated with mortality and morbidity. The main mechanisms of cerebral malaria combine sequestration of parasitized red blood cells in brain capillaries, production of cytokines, immune cell/platelet accumulation, and release of microparticules, finally resulting in endothelial lesions of the blood brain barrier, which contribute to various brain injuries (oedema, ischemia, haemorrhages). The neurological clinical findings range from simple delirium to profound coma. Fundoscopy, reflect of the brain microcirculation, is now currently realized in endemic areas, and should be recommended during imported cerebral malaria. Likewise, cerebral imaging should be systematically realized in patients with cerebral malaria. Intravenous artesunate is now firmly established as the treatment of choice for severe malaria worldwide in adults, children and during pregnancy. General care and supportive treatment are crucially important and supportive treatment of cerebral malaria should be better standardized. Finally, experimental and clinical research has a key role in cerebral malaria, so as to identify possible therapeutic targets in order to develop innovative therapies.

Chlamydophila pneumoniae (CP) and Mycoplasma pneumoniae (MP) patients could require intensive care unit (ICU) admission for acute respiratory failure.

Introduction. - Artesunate and other artemisinin derivatives are used in various infectious and non-infectious diseases. We aimed to analyze available data on artesunate and artemisinin derivatives activity in humans and their potential clinical benefits in non-malarial indications. Material and methods. - Literature review performed on PubMed and the Cochrane Library databases using the PRISMA method. We analyzed studies published in English from January 2008 to August 2017 using the same indicators of drug efficacy. Results. - We included 19 studies performed in humans (1 meta-analysis, 1 literature review, 4 randomized controlled trials, 3 prospective controlled trials, 3 prospective uncontrolled trials, 2 exploratory phase 1 or 2 trials, 1 case series, and 4 case reports). Artesunate and artemisinin derivatives demonstrated efficacy in the treatment of schistosomiasis in combination with praziquantel (P = 0.003). Artesunate monotherapy was less effective than praziquantel alone (P < 0.001) probably because its activity only affects the early stages of Schistosoma parasites. Artesunate monotherapy could be interesting as a chemoprophylactic drug against schistosomiasis (P < 0.001). Findings seem promising but are still controversial in the treatment of multidrug-resistant CMV infections. Studies do not conclude on artesunate and artemisinin derivatives efficacy in the treatment of cervix, breast, colorectal, and lung cancers. Conclusion. - Artesunate and artemisinin derivatives in combination with praziquantel were effective against schistosomiasis, and could be used as a chemoprophylactic drug alone. They could be interesting as anti-CMV and anti-tumor treatment. Additional trials in humans are required to assess the efficacy of artesunate and artemisinin derivatives in diseases other than malaria. (C) 2018 Elsevier Masson SAS. All rights reserved.

The article highlights the French clinical guidelines for the management of adult patients with acute infectious encephalitis.

En France, le paludisme grave d’importation concerne environ 12 a 14 % des acces palustres et implique tres majoritairement Plasmodium falciparum . A partir de la definition du paludisme grave de l’Organisation mondiale de la sante utilisee en zone d’endemie palustre, la definition francaise du paludisme grave d’importation de l’adulte a ete adaptee aux donnees et au contexte europeens. La prise en charge du paludisme grave est une urgence diagnostique et therapeutique qui doit etre realisee initialement en reanimation. Le traitement curatif du paludisme grave d’importation repose maintenant sur l’artesunate intraveineux (IV) qui doit etre disponible dans chaque hopital susceptible de recevoir ces patients. Des lors, la quinine IV devient un traitement de seconde ligne reserve a quelques circonstances. La prise en charge symptomatique des defaillances d’organes est primordiale, notamment au cours des formes les plus severes. Enfin, aucun traitement adjuvant n’a prouve, a ce jour, son efficacite en pratique clinique.

Au cours du paludisme grave chez l'enfant en zone d'endémie, les coinfections ont fait l'objet de plusieurs études, et semblent aggraver le pronostic. En revanche, au cours du paludisme d'importation de l'adulte, les données sur l'épidémiologie et l'impact de ces coinfections sont rares. Les objectifs de notre étude sont de décrire les coinfections communautaires au cours des accès palustres graves (APG) d'importation chez l'adulte, et d'identifier les facteurs associés à leur survenue. Étude multicentrique observationnelle dans 52 centres de réanimation en France, ancillaire d'une étude rétrospective (2000–2006) et d'une étude prospective (2006–2010). Un APG était défini selon les critères de l'OMS 2000 adaptés au paludisme d'importation. Une coinfection communautaire était définie comme une infection diagnostiquée dans les 48 heures suivant l'admission en réanimation. Les données cliniques et démographiques étaient collectées à partir des dossiers standardisés. Les facteurs associés aux coinfections communautaires étaient identifiés par analyses uni- et multi-variées. La fusion des 2 bases a permit de colliger 555 patients admis en réanimation pour APG d'importation. L'âge moyen était de 44 ans, la population était majoritairement masculine (69 %). Tous les patients étaient traités par quinine intraveineuse. Cent-dix-neuf patients (21 %) ont présenté au moins une coinfection, dont 42 (35 %) communautaire et 77 (65 %) nosocomiale. Parmi les coinfections communautaires, on retrouvait 18 pneumopathies (43 %), 13 bactériémies (31 %), et 5 infections urinaires (12 %). Les principaux germes identifiés étaient Escherichia coli (n = 7), Streptococcus pneumoniae (n = 5), Pseudomonas aeruginosa (n = 4), et des streptocoques autres (n = 4). En analyse multivariée, 3 variables présentes à l'admission étaient indépendamment associées à la présence d'une coinfection communautaire le sexe masculin (OR 3,41, IC 95 % [1,75–6,78]), une détresse respiratoire définie par le critère OMS modifié (OR 2,96, IC 95 % [1,42–6,08]) et une acidose définie par le critère OMS (OR 2,33, IC 95 % [1,04–5,07]). La mortalité intrahospitalière était de 9 % (n = 55) sur l'ensemble de la cohorte sans différence significative entre les patients présentant une coinfection communautaire versus le reste de la cohorte. Sur une large population d'adulte admis en réanimation pour un APG d'importation, 21 % présentent au moins une coinfection, dont 1/3 d'origine communautaire, notamment des pneumopathies et des bactériémies. En analyse multivariée, le sexe masculin, la présence d'une détresse respiratoire ou d'une acidose sont associées à la survenue d'un coinfection communautaire. Ces données peuvent contribuer orienter le clinicien à identifier les patients les plus à risque et à optimiser leur traitement.

In France, severe imported malaria concerns around 12-14% of the malaria episodes, mainly due to Plasmodium falciparum. From the WHO definition of severe malaria in endemic areas, the French definition of severe imported malaria has been elaborated considering an European context. Severe malaria is a diagnostic and therapeutic emergency and the initial management must be conducted in intensive care unit. The curative treatment of severe malaria is based on intravenous artesunate, which now must be available everywhere in France. Consequently, intravenous quinine is a second line treatment, with some residual indications. Management of organ dysfunctions in intensive care unit remains crucial, particularly during the most severe forms of imported malaria. Currently, no adjunctive therapy has proved its effectiveness in clinical practice.

Purpose: The objectives of our study were to describe the outcome of patients with malignancies treated for acute respiratory distress syndrome (ARDS) with noninvasive ventilation (NIV) and to evaluate factors associated with NIV failure.Methods: Post hoc analysis of a multicenter database within 20 years was performed. All patients with malignancies and Berlin ARDS definition were included. Noninvasive ventilation use was defined as NIV lasting more than 1 hour, whereas failure was defined as a subsequent requirement of invasive ventilation. Conditional backward logistic regression analyses were conducted.Results: A total of 1004 met the Berlin definition of ARDS. Noninvasive ventilation was used in 387 patients (38.6%) and NIV failure occurred in 71%, with an in-hospital mortality of 62.7%. Severity of ARDS defined by the partial pressure arterial oxygen and fraction of inspired oxygen ratio (odds ratio [OR], 2.20; 95% confidence interval [CI], 1.15-4.19), pulmonary infection (OR, 1.81; 95% Cl, 1.08-3.03), and modified Sequential Organ Failure Assessment (SOFA) score (OR, 1.13; 95% Cl, 1.06-1.21) were associated with NIV failure. Factors associated with hospital mortality were NIV failure (OR, 2.52; 95% CI, 1.56-4.07), severe ARDS as compared with mild ARDS (OR, 1.89; 95% CI, 1.05-1.19), and modified SOFA score (OR, 1.12; 95% Cl, 1.05-1.19).Conclusion: Noninvasive ventilation failure in ARDS patients with malignancies is frequent and related to ARDS severity, SOFA score, and pulmonary infection-related ARDS. Noninvasive ventilation failure is associated with in-hospital mortality. (C) 2016 Elsevier Inc. All rights reserved.

Infectious encephalitis is a severe disease leading to a high mortality and morbidity. The most frequent causes include Herpes simplex virus, Varicella Zoster virus, Listeria monocytogenes, and Mycobacterium tuberculosis. Urgent treatment is required (anti-infective therapy and nonspecific supportive care). The aim of this study was to define treatment strategy, empirical and after microbiological documentation at 48hours, through a systematic literature review.

PURPOSE:The prognosis of critically ill cancer patients has improved recently. Controversies remain as regard to the specific prognosis impact of neutropenia in critically ill cancer patients. The primary objective of this study was to assess hospital outcome of critically ill neutropenic cancer patients admitted into the ICU. The secondary objective was to assess risk factors for unfavorable outcome in this population of patients and specific impact of neutropenia.METHODS:We performed a post hoc analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centers in France and Belgium. Neutropenia was defined as a neutrophil count lower than 500/mm(3).RESULTS:Among the 1,011 patients admitted into the ICU during the study period 289 were neutropenic at the time of admission. Overall, 131 patients died during their hospital stay (hospital mortality 45.3 %). Four variables were associated with a poor outcome, namely allogeneic transplantation (OR 3.83; 95 % CI 1.75-8.35), need for mechanical ventilation (MV) (OR 6.57; 95 % CI 3.51-12.32), microbiological documentation (OR 2.33; CI 1.27-4.26), and need for renal replacement therapy (OR 2.77; 95 % CI 1.34-5.74). Two variables were associated with hospital survival, namely age younger than 70 (OR 0.22; 95 % CI 0.1-0.52) and neutropenic enterocolitis (OR 0.37; 95 % CI 0.15-0.9). A case-control analysis was also performed with patients of the initial database; after adjustment, neutropenia was not associated with hospital mortality (OR 1.27; 95 % CI 0.86-1.89).CONCLUSION:Hospital survival was closely associated with younger age and neutropenic enterocolitis. Conversely, need for conventional MV, for renal replacement therapy, and allogeneic hematopoietic stem cell transplantation (HSCT) were associated with poor outcome.

Aim: Low survival rate was previously described after cardiac arrest in cancer patients and may challenge the appropriateness of intensive care unit (ICU) admission after return of spontaneous circulation (ROSC). Objectives of this study were to report outcome and characteristics of cancer patients admitted to the ICU after cardiac arrest.Methods: A retrospective chart review in seven medical ICUs in France, in 2002-2012. We studied consecutive patients with malignancies admitted after out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA).Results: Of 133 included patients of whom 61% had solid tumors, 48 (36%) experienced OHCA and 85 (64%) IHCA. Cardiac arrest was related to the malignancy or its treatment in 47% of patients. Therapeutic hypothermia was used in 51(41%) patients. The ICU mortality rate was 981133 (74%). Main causes of ICU death were refractory shock or multiple organ failure (n = 64, 48%) and neurological injury (n = 27, 20%); 42 (32%) patients died in ICU after treatment-limitation decisions. Twenty-four (18%) patients were discharged alive from the hospital. Overall 6-month survival rate was 14% (181133,95% confidence interval, 8-21%). Survival rates at ICU discharge and after 6 months did not differ significantly across type of malignancy or between the OHCA and IHCA groups, and neither were they significantly different from those in matched controls who had cardiac arrest but no malignancy.Conclusions: Even if low, the 6-month survival rate of 14% observed in cancer patients admitted to the ICU after cardiac arrest and ROSC may support the admission of these patients to the ICU and may warrant an initial full-code ICU management. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

We wanted to assess the diagnostic accuracy of urinary dipstick testing in excluding catheter-associated urinary tract infection (CAUTI) in intensive care unit (ICU) patients with fever or hypothermia.

hoc septique compliquant un paludisme a Plasmodium falciparum associe a une parasitemie faible chez une femme enceinte F. Boissier a,∗, C. Vermersch a, S. Spagnolo a, F. Bruneel b, C. Brun-Buisson a, N. de Prost a a Service de reanimation medicale, hopital Henri-Mondor, 51, avenue de Lattre-de-Tassigny, 94010 Creteil, France b Service de reanimation medico-chirurgicale, centre hospitalier de Versailles, Le Chesnay, France