Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study.

BACKGROUND: No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock. PATIENTS AND METHODS: This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset). RESULTS: Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5-47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14-65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis. CONCLUSION: Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics. Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

Urinary tract infection with Corynebacterium urealyticum in South Africa.

Corynebacterium urealyticum has been well documented as a urinary pathogen in Europe. The purpose of this study was to investigate the incidence and clinical relevance of Corynebacterium urealyticum as a urinary pathogen in a predominantly Third World population (South Africa) and to attempt to increase the isolation rate by culturing urine specimens on a selective medium. Two methods were used to isolate Corynebacterium urealyticum from urine specimens. Blood agar plates from routine urine cultures of 7,912 urine specimens were incubated for 48 hours and 1,281 specimens were cultured on a selective medium as well as on routine media. The antimicrobial susceptibility of all isolates of Corynebacterium urealyticum was tested. The yield of Corynebacterium urealyticum on blood agar was three isolates in three patients (0.038% of 7,912), all of whom had pyuria, alkaline urine and risk factors for Corynebacterium urealyticum infection. Use of selective media increased the yield of Corynebacterium urealyticum to 15 of 1,281 specimens (1.17%), however 73% of these urine samples yielded other pathogens and none had an alkaline pH which could not be attributed to the presence of another urealytic pathogen. All isolates were susceptible to vancomycin and 92.6% susceptible to norfloxacin. The pathogenic potential of Corynebacterium urealyticum was confirmed in South African patients, but the incidence of infection was low. The use of a selective medium is therefore not cost-effective in all cases but could be used selectively on the basis of typical urine findings and patient criteria.

Spread of non-typable multiply resistant Haemophilus influenzae in a South African hospital.

In July 1987 non-typable Haemophilus influenzae strains resistant to both ampicillin and chloramphenicol were isolated from the endotracheal aspirate of two children with pneumonia at Baragwanath Hospital, Johannesburg, South Africa. A study was therefore undertaken to determine the carriage rates of Haemophilus influenzae strains in the nasopharynx of children and staff in the index ward and in three control wards. Using a disc diffusion and an agar dilution method the susceptibility was determined of 100 isolates to ampicillin, chloramphenicol, erythromycin, rifampicin, amoxicillin/clavulanic acid, gentamicin, cefaclor, cefotaxime, tetracycline, sulphamethoxazole, trimethoprim and trimethoprim/sulphamethoxazole (1:19). The overall carriage rate of Haemophilus influenzae on admission was 76%. In the index ward, children carrying multiply resistant strains differed from the other children in that there was a longer mean duration of hospitalization, a lower proportion of males, and a higher proportion who had previously received antibiotics. All ampicillin resistant strains were shown to produce beta-lactamase. Only four isolates belonged to serotype b, of which three were ampicillin resistant and chloramphenicol sensitive while one was resistant to both drugs. Nasopharyngeal spread of resistant non-typable strains of Haemophilus influenzae was demonstrated to affect the management of paediatric patients in the hospital.