Case Report: Severe Community-Acquired Pneumonia in Réunion Island due to Acinetobacter baumannii.

Acinetobacter baumannii (Ab) is a well-known nosocomial pathogen that has emerged as a cause of community-acquired pneumonia (CAP) in tropical regions. Few global epidemiological studies of CAP-Ab have been published to date, and no data are available on this disease in France. We conducted a retrospective chart review of severe cases of CAP-Ab admitted to intensive care units in Réunion University Hospital between October 2014 and October 2022. Eight severe CAP-Ab cases were reviewed. Median patient age was 56.5 years. Sex ratio (male-to-female) was 3:1. Six cases (75.0%) occurred during the rainy season. Chronic alcohol use and smoking were found in 75.0% and 87.5% of cases, respectively. All patients presented in septic shock and with severe acute respiratory distress syndrome. Seven patients (87.5%) presented in cardiogenic shock, and renal replacement therapy was required for six patients (75.0%). Five cases (62.5%) presented with bacteremic pneumonia. The mortality rate was 62.5%. The median time from hospital admission to death was 3 days. All patients received inappropriate initial antibiotic therapy. Acinetobacter baumannii isolates were all susceptible to ceftazidime, cefepime, piperacillin-tazobactam, ciprofloxacin, gentamicin, and imipenem. Six isolates (75%) were also susceptible to ticarcillin, piperacillin, and cotrimoxazole. Severe CAP-Ab has a fulminant course and high mortality. A typical case is a middle-aged man with smoking and chronic alcohol use living in a tropical region and developing severe CAP during the rainy season. This clinical presentation should prompt administration of antibiotic therapy targeting Ab.

Duration of Invasive Mechanical Ventilation before Veno-Venous ExtraCorporeal Membrane Oxygenation for Covid-19 related Acute Respiratory Distress Syndrome: The experience of a tertiary care center.

Background: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is an efficient ventilatory support in patients with refractory Covid-19-related Acute Respiratory Distress Syndrome (ARDS), however the duration of invasive mechanical ventilation (IMV) before ECMO initiation as a contraindication is still controversial. The aim of this study was to investigate the impact of prolonged IMV prior to VV-ECMO in patients suffering from refractory Covid-19-related ARDS. Methods: This single-center retrospective study included all patients treated with VV-ECMO for refractory Covid-19-related ARDS between January 1, 2020 and May 31, 2022. The impact of IMV duration was investigated by comparing patients on VV-ECMO during the 7 days (and 10 days) following IMV with those assisted after 7 days (and 10 days). The primary endpoint was in-hospital mortality. Results: Sixty-four patients were hospitalized in the ICU for Covid-19-related refractory ARDS requiring VV-ECMO. Global in-hospital mortality was 55 %. Median duration of IMV was 4 [2; 8] days before VV-ECMO initiation. There was no significant difference in in-hospital mortality between patients assisted with IMV pre-VV-ECMO for a duration of ≤7 days (≤10 days) and those assisted after 7 days (and 10 days) ((p = 0.59 and p = 0.45). Conclusion: This study suggests that patients assisted with VV-ECMO after prolonged IMV had the same prognosis than those assisted earlier in refractory Covid-19-related ARDS. Therefore, prolonged mechanical ventilation of more than 7-10 days should not contraindicate VV-ECMO support. An individual approach is necessary to balance the risks and benefits of ECMO in this population.

Severe leptospirosis in tropical and non-tropical areas: A comparison of two french, multicentre, retrospective cohorts.

BACKGROUND: Leptospirosis is an anthropozoonosis that occurs worldwide but is more common in tropical regions. Severe forms may require intensive care unit (ICU) admission. Whether the clinical patterns and outcomes differ between tropical and non-tropical regions with similar healthcare systems is unclear. Our objective here was to address this issue by comparing two cohorts of ICU patients with leptospirosis managed in mainland France and in the overseas French department of Réunion, respectively. METHODOLOGY/PRINCIPAL FINDINGS: We compared two retrospective cohorts of patients admitted to intensive care for severe leptospirosis, one from Reunion Island in the Indian Ocean (tropical climate) and the other from metropolitan France (temperate climate). Chi-square and Student's t tests were used for comparisons. After grouping the two cohorts, we also performed multiple correspondence analysis and hierarchical clustering to search for distinct clinical phenotypes. The Réunion and Metropolitan France cohorts comprised 128 and 160 patients respectively. Compared with the Réunion cohort, the metropolitan cohort had a higher mean age (42.5±14.1 vs. 51.4±16.5 years, p<0.001). Severity scores, length of stay and mortality did not differ between the two cohorts. Three phenotypes were identified: hepato-renal leptospirosis (54.5%) characterized by significant hepatic, renal and coagulation failure, with a mortality of 8.3%; moderately severe leptospirosis (38.5%) with less severe organ failure and the lowest mortality rate (1.8%); and very severe leptospirosis (7%) manifested by neurological, respiratory and cardiovascular failure, with a mortality of 30%. CONCLUSIONS/SIGNIFICANCE: The outcomes of severe leptospirosis requiring ICU admission did not differ between tropical and temperate regions with similar healthcare access, practices, and resources, despite some differences in patient characteristics. The identification of three different clinical phenotypes may assist in the early diagnosis and management of severe leptospirosis.

The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality. DESIGN: This was a retrospective and observational study. SETTING: The study was conducted at a University hospital. PARTICIPANTS: This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. METHODS: The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. RESULTS: A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. CONCLUSIONS: In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.

C-reactive protein: An easy marker for early differentiation between leptospirosis and dengue fever in endemic area.

In tropical regions, leptospirosis and dengue fever (DF) are infectious diseases of epidemiological importance and have overlapping symptomatic features. The objective of this study was to identify the factors associated to diagnosing leptospirosis that differentiate it to DF at the initial hospital evaluation. A multicenter retrospective study was conducted comparing confirmed leptospirosis to DF cases. Clinical/laboratory findings were compiled at hospital admission on Reunion Island between 2018 and 2019. Multivariable logistic regression was used to identify the predictors of leptospirosis. In total, 98 leptospirosis and 673 DF patients were included with a mean age of 47.8 (±17.1) and 48.9 (±23.3) years, respectively. In the multivariate analyses, the main parameters associated with leptospirosis were: i) increased neutrophil counts, ii) C-reactive protein values, iii) the absence of prolonged partial thromboplastin time, and iv) a decrease of platelets. The most discriminating parameter was C-reactive protein (CRP). With a threshold of 50mg/L, CRP taken alone had a sensitivity of 94% and a specificity of 93.5%. The positive and negative likelihood ratios were 14.5 and 0.06, respectively. In the setting of an early presumptive diagnosis, we found that an increased CRP value (>50 mg/L) could help diagnose leptospirosis and aid the decision process for hospital surveillance and/or a potential antibiotic treatment regimen.

Valproic acid as adjuvant treatment for convulsive status epilepticus: a randomised clinical trial.

BACKGROUND: Generalised convulsive status epilepticus (GCSE) is a medical emergency. Guidelines recommend a stepwise strategy of benzodiazepines followed by a second-line anti-seizure medicine (ASM). However, GCSE is uncontrolled in 20-40% patients and is associated with protracted hospitalisation, disability, and mortality. The objective was to determine whether valproic acid (VPA) as complementary treatment to the stepwise strategy improves the outcomes of patients with de novo established GCSE. METHODS: This was a multicentre, double-blind, randomised controlled trial in 244 adults admitted to intensive care units for GCSE in 16 French hospitals between 2013 and 2018. Patients received standard care of benzodiazepine and a second-line ASM (except VPA). Intervention patients received a 30 mg/kg VPA loading dose, then a 1 mg/kg/h 12 h infusion, whilst the placebo group received an identical intravenous administration of 0.9% saline as a bolus and continuous infusion. Primary outcome was proportion of patients discharged from hospital by day 15. The secondary outcomes were seizure control, adverse events, and cognition at day 90. RESULTS: A total of 126 (52%) and 118 (48%) patients were included in the VPA and placebo groups. 224 (93%) and 227 (93%) received a first-line and a second-line ASM before VPA or placebo infusion. There was no between-group difference for patients hospital-discharged at day 15 [VPA, 77 (61%) versus placebo, 72 (61%), adjusted relative risk 1.04; 95% confidence interval (0.89-1.19); p = 0.58]. There were no between-group differences for secondary outcomes. CONCLUSIONS: VPA added to the recommended strategy for adult GCSE is well tolerated but did not increase the proportion of patients hospital-discharged by day 15. TRIAL REGISTRATION NO: NCT01791868 (ClinicalTrials.gov registry), registered: 15 February 2012.

SARS-CoV-2 with Panton-Valentine leukocidin-producing Staphylococcus aureus healthcare-associated pneumonia in the Indian Ocean.

At this time, the literature reports only one case of superinfection with Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus in a patient with severe acute respiratory distress syndrome secondary to coronavirus 2 (SARS-CoV-2) pneumonia. Here we report the first two cases of PVL-producing S. aureus healthcare-associated pneumonia in patients hospitalized for SARS-CoV-2 pneumonia in the Indian Ocean region. The two isolated strains of S. aureus were found to belong to the ST152/t355 clone, a known PVL-producing S. aureus clone that circulates in Africa and is responsible for infections imported into Europe. Our two cases reinforce the hypothesis that SARS-CoV-2 infection favors the occurrence of PVL-producing S. aureus pneumonia. Production of PVL should be searched in patients returning from the Indian Ocean region who present with severe SARS-CoV-2 pneumonia complicated by superinfection with S. aureus even in the case of late onset healthcare-associated pneumonia.

Effect of antibiotic therapy on the prognosis of ventilator-associated pneumonia caused by Stenotrophomonas maltophilia.

BACKGROUND: Ventilator-associated pneumonia (VAP) caused by Stenotrophomonas maltophilia is poorly described in the literature. However, it has been shown to be associated with increased morbidity and mortality. Probabilistic antibiotic therapy against S. maltophilia is often ineffective as this pathogen is resistant to many antibiotics. There is no consensus at present on the best therapeutic strategy to adopt (class of antibiotics, antibiotic combination, dosage, treatment duration). The aim of this study was to evaluate the effect of antibiotic therapy strategy on the prognosis of patients with VAP caused by S. maltophilia. RESULTS: This retrospective study evaluated all consecutive patients who developed VAP caused by S. maltophilia between 2010 and 2018 while hospitalized in the intensive care unit (ICU) of a French university hospital in Reunion Island, in the Indian Ocean region. A total of 130 patients with a median Simplified Acute Physiology Score II of 58 [43-73] had VAP caused by S. maltophilia after a median duration of mechanical ventilation of 12 [5-18] days. Ventilator-associated pneumonia was polymicrobial in 44.6% of cases, and ICU mortality was 50.0%. After multivariate Cox regression analysis, the factors associated with increased ICU mortality were older age (hazard ratio (HR): 1.03; 95% CI 1.01-1.04, p = 0.001) and high Sequential Organ Failure Assessment score on the day of VAP onset (HR: 1.08; 95% CI 1.03-1.14, p = 0.002). Appropriate antibiotic therapy, and in particular trimethoprim-sulfamethoxazole, was associated with decreased ICU mortality (HR: 0.42; 95% CI 0.24-0.74, p = 0.003) and decreased hospital mortality (HR: 0.47; 95% CI 0.28-0.79, p = 0.04). Time to start of appropriate antibiotic therapy, combination therapy, and duration of appropriate antibiotic therapy had no effect on ICU mortality (p > 0.5). CONCLUSION: In our study, appropriate antibiotic therapy, and in particular trimethoprim-sulfamethoxazole, was associated with decreased ICU and hospital mortality in patients with VAP caused by S. maltophilia.

Case Report: Refractory Shock due to Fulminant Dengue Myocarditis Treated with Venoarterial Extracorporeal Membrane Oxygenation: A Report of Four Cases.

Dengue disease is found worldwide and has been spreading exponentially in the past decades. Severe forms affect about 2% of patients, sometimes leading to organ failure. Recent studies have shown that fulminant dengue myocarditis is more common than previously thought, and fatal cases have been reported. The treatment of fulminant dengue myocarditis remains supportive and is very challenging in cases of cardiogenic shock. Here, we describe four cases presenting with fulminant dengue myocarditis treated with extracorporeal membrane oxygenation, among two survived.

Acute severe asthma requiring invasive mechanical ventilation in the era of modern resuscitation techniques: A 10-year bicentric retrospective study.

PURPOSE: Patients with acute severe asthma (ASA) may in rare cases require invasive mechanical ventilation (IMV). However, recent data on this issue are lacking. MATERIALS AND METHODS: In this retrospective and bicentric study conducted on a 10 year period, we investigate the in-hospital mortality in patients with ASA requiring IMV. We compare this mortality to that of patients with other types of respiratory distress using a standardized mortality ratio (SMR) model. RESULTS: Eighty-one episodes of ASA requiring IMV were evaluated. Factors significantly associated with in-hospital mortality were cardiac arrest on day of admission, cardiac arrest as the reason for intubation, absence of decompensation risk factors, need for renal replacement therapy on day of admission, and intubation in pre-hospital setting. Non-survivors had higher SAPS II, SOFA, creatinine and lactate levels as well as lower blood pressure, pH, and HCO3 on day of admission. In-hospital mortality was 15% (n = 12). Compared to a reference population of 2,670 patients, the SMR relative to the SAPS II was very low at 0.48 (95% CI, 0.25-0.84). The only factor independently associated with in-hospital mortality was cardiac arrest on day of admission. In-hospital mortality was 69% in patients with cardiac arrest on day of admission and 4% in others (p < 0.01). Salvage therapies were given to 7 patients, sometimes in combination with each other: ECMO (n = 6), halogenated gas (n = 1) and anti-IL5 antibody (n = 1). Death occurred in only 2 of these 7 patients, both of whom had cardiac arrest on day of admission. CONCLUSION: Nowadays, the mortality of patients with ASA requiring IMV is low. Death is due to multi-organ failure, with cardiac arrest on day of admission being the most important risk factor. In patients who did not have cardiac arrest on day of admission the mortality is even lower (4%) which allows an aggressive management.

A comprehensive strategy for the early treatment of COVID-19 with azithromycin/hydroxychloroquine and/or corticosteroids: Results of a retrospective observational study in the French overseas department of Réunion Island.

BACKGROUND: This study aimed to evaluate the prognosis of COVID-19 patients in Reunion Island, with a particular focus on the management of patients with hypoxemic pneumonia. METHODS: This retrospective observational study was conducted from 11 March to 17 April 2020 at the only hospital authorized to manage patients with COVID-19 in Reunion Island. RESULTS: Over the study period, 164 out of 398 patients (41.2%) infected with COVID-19 were admitted to Félix Guyon University Hospital. Of these, 36 (22%) developed hypoxemic pneumonia. Patients with hypoxemic pneumonia were aged 66 [56-77] years, 69% were male and 33% had hypertension. Ten patients (27.8%) were hospitalized in intensive care unit (ICU). Hydroxychloroquine/azithromycin treatment was associated with a lower ICU admission rate (P=0.008). None of the 6 patients treated with corticosteroids were hospitalized in ICU (P=0.16). There were no deaths at follow up (minimum 80 days). CONCLUSIONS: Despite the risk profile of COVID-19 patients with severe hypoxemic pneumonia, the mortality rate of the disease in Reunion Island was 0%. This may be due to the care bundle used in our hospital (early hospitalisation, treatment with hydroxychloroquine/azithromycin and/or corticosteroids, non-invasive respiratory support, etc).

Postpandemic Influenza Mortality of Venovenous Extracorporeal Membrane Oxygenation-Treated Patients in Reunion Island: A Retrospective Single Center Study.

OBJECTIVES: The aim of the present study was to assess the post-pandemic mortality of influenza in patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) in Reunion Island, France, by comparing the incidence with other patients undergoing VV-ECMO. DESIGN: Retrospective, descriptive, and single-center cohort study. The primary outcome was the standardized mortality ratio for influenza based on the quartiles of the Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score (RESP Score) in the reference population of patients undergoing VV-ECMO. SETTING: Intensive care unit (ICU), Felix Guyon Hospital, University Teaching Hospital of La Réunion, La Réunion, France. PARTICIPANTS: Consecutive patients on ECMO with positive polymerase chain reaction for influenza. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-seven consecutive patients were hospitalized in the ICU with a positive influenza polymerase chain reaction from January 2013 to December 2017. Twenty-four influenza patients underwent ECMO including 18 patients with VV-ECMO. During this period, 72 patients requiring VV-ECMO were hospitalized in the ICU. The overall mortality rate of influenza patients on VV-ECMO was 61% versus 46% for non-influenza patients. The standardized mortality ratio per quartile of RESP Score was 1.28 (95% confidence interval 0.61-2.35). CONCLUSIONS: In Reunion, the mortality of patients undergoing VV-ECMO for severe influenza is not lower than the expected mortality of all patients undergoing VV-ECMO.

Mortality of critically ill patients with severe influenza starting four years after the 2009 pandemic.

Background: In Reunion Island, influenza is not considered a serious illness despite significant mortality in intensive care unit (ICU). We assess the post-pandemic mortality of influenza by comparing it to other community-acquired pneumonia in our ICU. Methods: Retrospective, descriptive, and single-centre cohort study. The main aim was to determine the standardized mortality ratio (SMR) for influenza based on the quartiles of the SAPSII score in the reference population of 954 patients hospitalized for community-acquired pneumonia. Another aim was to analyze the risk factors for mortality in influenza patients. Results: 127 consecutive patients were hospitalized in our ICU with a positive influenza PCR, from January 2013 to December 2017. The mortality rate of these patients was 31% (CI 95%: 23-39%). In patients hospitalized for community-acquired pneumonia, the SMR of patients with influenza was 1.24 (CI 95%: 0.89-1.70). At admission, thirty-nine patients (31%) had superinfections, in 17 caused by methicillin-susceptible Staphylococcus aureus. Need for renal replacement therapy (RR 2.53 [1.29-4.93]) or ECMO (RR 2.35 [1.16-4.74]) were associated with mortality. Twenty-four patients underwent ECMO, 17 with VV-ECMO. Conclusions: Mortality in patients with influenza pneumonia was higher than the expected mortality in community-acquired pneumonia. Although generally considered benign, influenza is a deadly infection in ICU patients in Reunion Island.

Acute respiratory distress syndrome in leptospirosis.

PURPOSE: Acute Respiratory Distress Syndrome is a major complication of leptospirosis, leading to the majority of fatalities. METHODS: Retrospective, descriptive and single-center cohort study. The primary outcome was the Standardized Mortality Ratio (SMR) for ARDS in leptospirosis based on the quartiles of the SAPS2 score in the reference population of 1683 patients hospitalized for ARDS. The second outcomes were to determine the risk factors of mortality of ARDS in leptospirosis and to describe the cases requiring Extracorporeal Membrane Oxygenation (ECMO). RESULTS: Of 172 leptospirosis patients from January 2004 to October 2017, 39 (23%) presented a moderate or severe ARDS with a mortality rate of 23% (9 cases). Among patients with ARDS, the SMR with regards to Simplified Acute Physiology Score II was 0.49 (CI95%: 0.21; 0.96). Risk factors associated with mortality found by bivariate analysis were Severity Acute Physiology Score II (p = 0.01), Sequential Organ Failure Assessment (p = 0.01), base excess (p = 0.002), kaliemia (p = 0.004), bilirubinemia (p = 0.01) and level of aspartate aminotransferase (p = 0.01). Eight patients underwent ECMO for refractory ARDS and six survived. CONCLUSIONS: Leptospirosis can induce serious but transient ARDS with a better prognosis than that of other causes of ARDS. Several patients have been successfully treated with ECMO.

Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study.

BACKGROUND: To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock. METHODS: Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied. RESULTS: A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37-0.60). Experts' adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55-0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively). CONCLUSIONS: Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.

Leptospirosis in ICU: A Retrospective Study of 134 Consecutive Admissions.

OBJECTIVES: Leptospirosis causes reversible multiple organ failure, and its mortality remains high. The aim of this study was to determine the mortality rate of leptospirosis in an ICU offering all types of organ support available nowadays and to compare it with mortality in bacterial sepsis. DESIGN: Retrospective, descriptive, and single-center cohort study. SETTINGS: The largest ICU of Reunion Island (Indian Ocean) in a teaching hospital. PATIENTS: Consecutive patients hospitalized in ICU for leptospirosis from January 2004 to January 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We report 134 cases of patients with leptospirosis hospitalized in ICU. The median age was 40 years (interquartile range, 30-52 yr), with a Simplified Acute Physiology Score II of 38 (27-50) and a Sequential Organ Failure Assessment score of 10 (8-12). Forty-one patients (31%) required mechanical ventilation and 76 (56%) required renal replacement therapy. The door-to-renal replacement therapy time was 0 (0-1) day after admission with a median urea of 25 mmol/L (17-32 mmol/L). Five patients required extracorporeal membrane oxygenation. The mortality rate was 6.0% (95% CI, 2.6-11.4). Among patients hospitalized for sepsis, the standardized mortality ratio of patients with leptospirosis with regards to Simplified Acute Physiology Score II was dramatically low: 0.40 (95% CI, 0.17 - 0.79). CONCLUSIONS: The mortality of severe leptospirosis is lower than for other bacterial infection, provided modern resuscitation techniques are available. Prompt organ support ensures very low mortality rates despite high severity scores.

Impact of a high loading dose of amikacin in patients with severe sepsis or septic shock.

BACKGROUND: The therapeutic effect of aminoglycosides is highest and optimal when the peak plasma concentration (C max)/minimal inhibitory concentration (MIC) ratio is between 8 and 10. The French guidelines recommend to use high doses of aminoglycosides for empiric antibiotic therapy in patients suffering from severe sepsis or septic shock. In clinical practice, the recommended target is an amikacin C max between 60 and 80 mg/L, which corresponds to approximately 8 times the MIC breakpoint, as defined by the European Committee on Antimicrobial Susceptibility Testing. The aim of this study was to assess the incidence and impact on mortality of an amikacin concentration between 60 and 80 mg/L in patients suffering from severe sepsis or septic shock. METHODS: This was a prospective observational cohort study conducted in two intensive care units (ICU). Patients receiving amikacin at a loading dose of 30 mg/kg for severe sepsis or septic shock were enrolled in the cohort. The target C max for amikacin was between 60 and 80 mg/L, as recommended by French guidelines (i.e. C max/MIC breakpoint = 8-10). RESULTS: Over the study period, the amikacin C max was <60 mg/L, between 60 and 80 mg/L, and >80 mg/L in 20 (18.2%), 46 (41.8%) and 44 (40%) of the 110 selected patients, respectively. Mortality rate was 40, 28.3 and 56.8% in the groups of patients with C max < 60 mg/L, 60 mg/L < C max < 80 mg/L and C max > 80 mg/L, respectively. Following multivariate analysis, mortality rate was significantly lower in the group of patients with amikacin C max between 60 and 80 mg/L than in the group of patients with amikacin C max > 80 mg/L (P = 0.004). The multivariate analysis also revealed that the factors independently associated with a higher in-ICU mortality rate were age (P = 0.02) and norepinephrine dose (P = 0.0001). CONCLUSIONS: With a loading dose of 30 mg/kg of amikacin, concentration was potentially suboptimal (C max < 60 mg/L) in only 18.2% of patients. The pharmacodynamic target (60 mg/L < C max < 80 mg/L) recommended by French guidelines was reached in 41.8% of patients and was associated with reduced in-ICU mortality. But amikacin overexposure (i.e. C max > 80 mg/L) was frequent and potentially associated with increased mortality.

Prognosis of patients presenting extreme acidosis (pH <7) on admission to intensive care unit.

PURPOSE: The purpose was to determine prognosis of patients presenting extreme acidosis (pH <7) on admission to the intensive care unit (ICU) and to identify mortality risk factors. MATERIALS AND METHODS: We retrospectively analyzed all patients who presented with extreme acidosis within 24 hours of admission to a polyvalent ICU in a university hospital between January 2011 and July 2013. Multivariate analysis and survival analysis were used. RESULTS: Among the 2156 patients admitted, 77 patients (3.6%) presented extreme acidosis. Thirty (39%) patients suffered cardiac arrest before admission. Although the mortality rate predicted by severity score was 93.6%, death occurred in 52 cases (67.5%) in a median delay of 13 (5-27) hours. Mortality rate depended on reason for admission, varying between 22% for cases linked to diabetes mellitus and 100% for cases of mesenteric infarction (P = .002), cardiac arrest before admission (P < .001), type of lactic acidosis (P = .007), high Simplified Acute Physiology Score II (P = .008), and low serum creatinine (P = .012). CONCLUSIONS: Patients with extreme acidosis on admission to ICU have a less severe than expected prognosis. Whereas mortality is almost 100% in cases of cardiac arrest before admission, mortality is much lower in the absence of cardiac arrest before admission, which justifies aggressive ICU therapies.