Interest of a simple on-line screening registry for measuring ICU burden related to an influenza pandemic.

INTRODUCTION: The specific burden imposed on Intensive Care Units (ICUs) during the A/H1N1 influenza 2009 pandemic has been poorly explored. An on-line screening registry allowed a daily report of ICU beds occupancy rate by flu infected patients (Flu-OR) admitted in French ICUs. METHODS: We conducted a prospective inception cohort study with results of an on-line screening registry designed for daily assessment of ICU burden. RESULTS: Among the 108 centers participating to the French H1N1 research network on mechanical ventilation (REVA) - French Society of Intensive Care (SRLF) registry, 69 ICUs belonging to seven large geographical areas voluntarily participated in a website screening-registry. The aim was to daily assess the ICU beds occupancy rate by influenza-infected and non-infected patients for at least three weeks. Three hundred ninety-one critically ill infected patients were enrolled in the cohort, representing a subset of 35% of the whole French 2009 pandemic cohort; 73% were mechanically ventilated, 13% required extra corporal membrane oxygenation (ECMO) and 22% died. The global Flu-OR in these ICUs was only 7.6%, but it exceeded a predefined 15% critical threshold in 32 ICUs for a total of 103 weeks. Flu-ORs were significantly higher in University than in non-University hospitals. The peak ICU burden was poorly predicted by observations obtained at the level of large geographical areas. CONCLUSIONS: The peak Flu-OR during the pandemic significantly exceeded a 15% critical threshold in almost half of the ICUs, with an uneven distribution with time, geographical areas and between University and non-University hospitals. An on-line assessment of Flu-OR via a simple dedicated registry may contribute to better match resources and needs.

Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial.

BACKGROUND: Reduced duration of antibiotic treatment might contain the emergence of multidrug-resistant bacteria in intensive care units. We aimed to establish the effectiveness of an algorithm based on the biomarker procalcitonin to reduce antibiotic exposure in this setting. METHODS: In this multicentre, prospective, parallel-group, open-label trial, we used an independent, computer-generated randomisation sequence to randomly assign patients in a 1:1 ratio to procalcitonin (n=311 patients) or control (n=319) groups; investigators were masked to assignment before, but not after, randomisation. For the procalcitonin group, antibiotics were started or stopped based on predefined cut-off ranges of procalcitonin concentrations; the control group received antibiotics according to present guidelines. Drug selection and the final decision to start or stop antibiotics were at the discretion of the physician. Patients were expected to stay in the intensive care unit for more than 3 days, had suspected bacterial infections, and were aged 18 years or older. Primary endpoints were mortality at days 28 and 60 (non-inferiority analysis), and number of days without antibiotics by day 28 (superiority analysis). Analyses were by intention to treat. The margin of non-inferiority was 10%. This trial is registered with ClinicalTrials.gov, number NCT00472667. FINDINGS: Nine patients were excluded from the study; 307 patients in the procalcitonin group and 314 in the control group were included in analyses. Mortality of patients in the procalcitonin group seemed to be non-inferior to those in the control group at day 28 (21.2% [65/307] vs 20.4% [64/314]; absolute difference 0.8%, 90% CI -4.6 to 6.2) and day 60 (30.0% [92/307] vs 26.1% [82/314]; 3.8%, -2.1 to 9.7). Patients in the procalcitonin group had significantly more days without antibiotics than did those in the control group (14.3 days [SD 9.1] vs 11.6 days [SD 8.2]; absolute difference 2.7 days, 95% CI 1.4 to 4.1, p<0.0001). INTERPRETATION: A procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical patients in intensive care units could reduce antibiotic exposure and selective pressure with no apparent adverse outcomes. FUNDING: Assistance Publique-Hôpitaux de Paris, France, and Brahms, Germany.

Important questions asked by family members of intensive care unit patients.

OBJECTIVES: Relatives often lack important information about intensive care unit patients. High-quality information is crucial to help relatives overcome the often considerable situational stress and to acquire the ability to participate in the decision-making process, most notably regarding the appropriate level of care. We aimed to develop a list of questions important for relatives of patients in the intensive care unit. DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter study. Questions asked by relatives of intensive care unit patients were collected from five different sources (literature, panel of 28 intensive care unit nurses and physicians, 1-wk survey of nurses and 1-wk survey of physicians in 14 intensive care units, and in-depth interviews with 14 families). After a qualitative analysis (framework approach and thematic analysis), questions were rated by 22 relatives and 14 intensive care unit physicians, and the ratings were analyzed using principal component analysis and hierarchical clustering. RESULTS: The five sources produced 2,135 questions. Removal of duplicates and redundancies left 443 questions, which were distributed among nine predefined domains using a framework approach ("diagnosis," "treatment," "prognosis," "comfort," "interaction," "communication," "family," "end of life," and "postintensive care unit management"). Thematic analysis in each domain led to the identification of 46 themes, which were reworded as 46 different questions. Ratings by relatives and physicians showed that 21 of these questions were particularly important for relatives of intensive care unit patients. CONCLUSION: This study increases knowledge about the informational needs of relatives of intensive care unit patients. This list of questions may prove valuable for both relatives and intensive care unit physicians as a tool for improving communication in the intensive care unit.

Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome.

INTRODUCTION: Fluid responsiveness prediction is of utmost interest during acute respiratory distress syndrome (ARDS), but the performance of respiratory pulse pressure variation (ΔRESPPP) has scarcely been reported. In patients with ARDS, the pathophysiology of ΔRESPPP may differ from that of healthy lungs because of low tidal volume (Vt), high respiratory rate, decreased lung and sometimes chest wall compliance, which increase alveolar and/or pleural pressure. We aimed to assess ΔRESPPP in a large ARDS population. METHODS: Our study population of nonarrhythmic ARDS patients without inspiratory effort were considered responders if their cardiac output increased by >10% after 500-ml volume expansion. RESULTS: Among the 65 included patients (26 responders), the area under the receiver-operating curve (AUC) for ΔRESPPP was 0.75 (95% confidence interval (CI95): 0.62 to 0.85), and a best cutoff of 5% yielded positive and negative likelihood ratios of 4.8 (CI95: 3.6 to 6.2) and 0.32 (CI95: 0.1 to 0.8), respectively. Adjusting ΔRESPPP for Vt, airway driving pressure or respiratory variations in pulmonary artery occlusion pressure (ΔPAOP), a surrogate for pleural pressure variations, in 33 Swan-Ganz catheter carriers did not markedly improve its predictive performance. In patients with ΔPAOP above its median value (4 mmHg), AUC for ΔRESPPP was 1 (CI95: 0.73 to 1) as compared with 0.79 (CI95: 0.52 to 0.94) otherwise (P = 0.07). A 300-ml volume expansion induced a ≥ 2 mmHg increase of central venous pressure, suggesting a change in cardiac preload, in 40 patients, but none of the 28 of 40 nonresponders responded to an additional 200-ml volume expansion. CONCLUSIONS: During protective mechanical ventilation for early ARDS, partly because of insufficient changes in pleural pressure, ΔRESPPP performance was poor. Careful fluid challenges may be a safe alternative.

Screening and decolonization: does methicillin-susceptible Staphylococcus aureus hold lessons for methicillin-resistant S. aureus?

Methicillin-susceptible Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) have few structural differences, but their epidemiologies differ profoundly in terms of colonization, infection, and transmission. We compare strategies for controlling hospital infection due to MSSA and MRSA. Despite the straightforward epidemiology of MSSA, the effectiveness of screening and decolonization was established only recently. The optimal strategy for controlling MRSA spread and infection remains debated. Many data need to be acquired, given the complexity of MRSA epidemiology, the entanglement between collective and individual objectives, and the challenges faced when adjusting for confounders. However, studies have consistently demonstrated that screening is useful in high-risk units to identify the reservoir and to initiate contact precautions. In an endemic setting, the contribution of MRSA decolonization to cross-transmission limitation is probably small in comparison to the impact of precautions. Screening and decolonization may be effective in decreasing the MRSA infection risk in carriers.

Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit.

BACKGROUND: Ventilator-associated pneumonia (VAP), the most common hospital-acquired infection in intensive care units, increases mortality and health care costs. We describe the long-term impact of a multifaceted program for decreasing VAP rates that markedly improved compliance with 8 targeted preventive measures. METHODS: We compared VAP rates during a 45-month baseline period and a 30-month intervention period in a cohort of patients who received mechanical ventilation for > 48 h. VAP was diagnosed on the basis of quantitative cultures of distal specimens. VAP incidence density rates were expressed as total VAP episodes over total mechanical ventilation duration and as first VAP episodes over mechanical ventilation duration at VAP or hospital discharge. We used segmented regression analysis and a Cox proportional hazard model to assess the impact of the program on first VAP occurrence. RESULTS: Baseline and intervention VAP rates were 22.6 and 13.1 total VAP episodes over total mechanical ventilation duration per 1000 ventilation-days, respectively, and 26.1 and 14.9 first VAP episodes over mechanical ventilation duration at VAP or hospital discharge per 1000 procedure-days, respectively (P < .001). VAP rates decreased by 43% in both statistical analyses and remained significant after adjustment for confounders (Cox adjusted hazard ratio, 0.58; 95% confidence interval, 0.46-0.72; P < .001). Daily VAP hazard rates on ventilation days 5, 10, and 15 were 2.6%, 3.5%, and 3.4%, respectively, during the baseline period and 1.4%, 2.3%, and 2%, respectively, during the intervention period. CONCLUSION: Our preventive program produced sustained VAP rate decreases in the long term. However, VAP rates remained substantial despite high compliance with preventive measures, suggesting that eliminating VAP in the intensive care unit may be an unrealistic goal.

A multifaceted program to prevent ventilator-associated pneumonia: impact on compliance with preventive measures.

OBJECTIVE: To determine the effect of a 2-yr multifaceted program aimed at preventing ventilator-acquired pneumonia on compliance with eight targeted preventive measures. DESIGN: Pre- and postintervention observational study. SETTING: A 20-bed medical intensive care unit in a teaching hospital. PATIENTS: A total of 1649 ventilator-days were observed. INTERVENTIONS: The program involved all healthcare workers and included a multidisciplinary task force, an educational session, direct observations with performance feedback, technical improvements, and reminders. It focused on eight targeted measures based on well-recognized published guidelines, easily and precisely defined acts, and directly concerned healthcare workers' bedside behavior. Compliance assessment consisted of five 4-wk periods (before the intervention and 1 month, 6 months, 12 months, and 24 months thereafter). MEASUREMENTS AND MAIN RESULTS: Hand-hygiene and glove-and-gown use compliances were initially high (68% and 80%) and remained stable over time. Compliance with all other preventive measures was initially low and increased steadily over time (before 2-yr level, p < .0001): backrest elevation (5% to 58%) and tracheal cuff pressure maintenance (40% to 89%), which improved after simple technical equipment implementation; orogastric tube use (52% to 96%); gastric overdistension avoidance (20% to 68%); good oral hygiene (47% to 90%); and nonessential tracheal suction elimination (41% to 92%). To assess overall performance of the last six preventive measures, using ventilator-days as the unit of analysis, a composite score for preventive measures applied (range, 0-6) was developed. The median (interquartile range) composite scores for the five successive assessments were 2 (1-3), 4 (3-5), 4 (4-5), 5 (4-6), and 5 (4-6) points; they increased significantly over time (p < .0001). Ventilator-acquired pneumonia prevalence rate decreased by 51% after intervention (p < .0001). CONCLUSIONS: Our active, long-lasting program for preventing ventilator-acquired pneumonia successfully increased compliance with preventive measures directly dependent on healthcare workers' bedside performance. The multidimensional framework was critical for this marked, progressive, and sustained change.

Epidemiology, management, and risk factors for death of invasive Candida infections in critical care: a multicenter, prospective, observational study in France (2005-2006).

OBJECTIVE: To describe the evolving epidemiology, management, and risk factors for death of invasive Candida infections in intensive care units (ICUs). DESIGN: Prospective, observational, national, multicenter study. SETTING: One hundred eighty ICUs in France. PATIENTS: Between October 2005 and May 2006, 300 adult patients with proven invasive Candida infection who received systemic antifungal therapy were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred seven patients (39.5%) with isolated candidemia, 87 (32.1%) with invasive candidiasis without documented candidemia, and 77 (28.4%) with invasive candidiasis and candidemia were eligible. In 37% of the cases, candidemia occurred within the first 5 days after ICU admission. C. albicans accounted for 57.0% of the isolates, followed by C. glabrata (16.7%), C. parapsilosis (7.5%), C. krusei (5.2%), and C. tropicalis (4.9%). In 17.1% of the isolates, the causative Candida was less susceptible or resistant to fluconazole. Fluconazole was the empirical treatment most commonly introduced (65.7%), followed by caspofungin (18.1%), voriconazole (5.5%), and amphotericin B (3.7%). After identification of the causative species and susceptibility testing results, treatment was modified in 86 patients (31.7%). The case fatality ratio in ICU was 45.9% and did not differ significantly according to the type of episode. Multivariate analysis showed that factors independently associated with death in ICU were type 1 diabetes mellitus (odds ratio [OR] 4.51; 95% confidence interval [CI] 1.72-11.79; p = 0.002), immunosuppression (OR 2.63; 95% CI 1.35-5.11; p = 0.0045), mechanical ventilation (OR 2.54; 95% CI 1.33-4.82; p = 0.0045), and body temperature >38.2 degrees C (reference, 36.5-38.2 degrees C; OR 0.36; 95% CI 0.17-0.77; p = 0.008). CONCLUSIONS: More than two thirds of patients with invasive candidiasis in ICU present with candidemia. Non-albicans Candida species reach almost half of the Candida isolates. Reduced susceptibility to fluconazole is observed in 17.1% of Candida isolates. Mortality of invasive candidiasis in ICU remains high.

Tracking hypotension and dynamic changes in arterial blood pressure with brachial cuff measurements.

BACKGROUND: Arterial cannulation is strongly recommended during shock. Nevertheless, this procedure is associated with significant risks and may delay other emergent procedures. We assessed the discriminative power of brachial cuff oscillometric noninvasive blood pressure (NIBP) for identifying patients with an invasive mean arterial blood pressure (MAP) below 65 mm Hg or increasing their invasive MAP after cardiovascular interventions. METHODS: This prospective study, conducted in three intensive care units, included adults in circulatory failure who underwent 45 degrees passive leg raising, 300 mL fluid loading, and additional 200 mL fluid loading. The collected data were four invasive and noninvasive MAP measurements at each study phase. RESULTS: Among 111 patients (50 septic, 15 cardiogenic, and 46 other source of shock), when averaging measurements of each study phase, NIBP measurements accurately predicted an invasive MAP lower than 65 mm Hg: area under the receiver operating characteristic curve 0.90 (95% CI: 0.71-1), positive and negative likelihood ratios 7.7 (95% CI: 5.4-11) and 0.31 (95% CI: 0.22-0.44) (cutoff 65 mm Hg). For identifying patients increasing their invasive MAP by more than 10%, the area under the receiver operating characteristic curve was 0.95 (95% CI: 0.92-0.96); positive and negative likelihood ratios (cutoff 10%) were 25.7 (95% CI: 10.8-61.4) and 0.26 (95% CI: 0.2-0.34). CONCLUSIONS: NIBP measurements have a good discriminative power for identifying hypotensive patients and performed even better in tracking MAP changes, provided that one averages four NIBP measurements.

Acute disseminated encephalomyelitisin the intensive care unit:clinical features and outcome of 20 adults.

OBJECTIVE: Because acute disseminated encephalomyelitis (ADEM) is a rare disease in adults admitted to the intensive care unit (ICU), we describe its characteristics and patient outcomes. DESIGN AND SETTING: A retrospective (2000-2006), observational, multicenter study was conducted in seven medical ICUs. Clinical, biological and neuroimaging features of patients diagnosed with ADEM were evaluated. Functional prognosis was graded using the modified Rankin (mR) scale. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: At ICU admission, the 20 patients' median (25th-75th percentile) Glasgow coma score (GCS) was 7 (4-13), temperature 39 (38-39) degrees C. Six (30%) patients had seizures, 17 (85%) had a motor deficit and 14 (70%) required mechanical ventilation. Fifteen (75%) patients had cerebrospinal fluid pleocytocis. All patients had white-matter lesions on their magnetic resonance images. All patients received high-dose steroids. Five (25%) patients died. Fourteen (70%) patients were able to walk without assistance (mR3] had significantly lower GCS (4 (3-4) vs. 12 (7-13), p=0.002) and more frequent seizures [4 (67%) vs. 2 (14%), p=0.02] at admission. CONCLUSIONS: Unlike previous reports, our results showed that ADEM requiring ICU admission is a severe disease causing high mortality, and 35% of the patients had persistent functional sequelae. Intensivists should be aware of ADEM's clinical features to initiate appropriate immunomodulating therapy.

High prevalence of carriage of methicillin-resistant Staphylococcus aureus at hospital admission in elderly patients: implications for infection control strategies.

BACKGROUND: Despite contact isolation precautions for patients with methicillin-resistant Staphylococcus 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 1100-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.

Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units.

OBJECTIVE: To evaluate the effectiveness of screening strategy and contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA). DESIGN AND SETTING: Prospective observational cohort from 1 February 1995 to 31 December 2001 in three intensive care units (45 beds) in a French teaching hospital. PATIENTS: 8,548 patients admitted to the three ICUs had nasal screening on ICU admission and weekly thereafter. Contact precautions were used in MRSA-positive patients. The following variables were collected: age, gender, severity score, length of stay, workload, and colonization pressure (percentage of patient-days with an MRSA to the number of patient-days in the unit). Alcohol-based handrub solution was introduced in July 2000. We compared the period before this (P1) with that thereafter (P2). RESULTS: Of the 8,548 admitted patients 554 (6.5%) had MRSA at ICU admission, and 456 of the 7,515 (6.1%) exposed patients acquired MRSA. Acquisition incidence decreased from 7.0% in P1 to 2.8% in P2. Independent variables associated with MRSA acquisition were: age (adjusted odds ratio 1.013), severity score (1.047), length of ICU stay (1.015), colonization pressure (1.019), medical ICU (1.58), and P2 (0.49). CONCLUSIONS: MRSA control in these ICUs characterized by a high prevalence of MRSA at admission was achieved via multiple factors, including screening, contact precautions, and use of alcoholic handrub solution. Our results after adjustment of risk factors for MRSA acquisition and the steady improvement in MRSA over several years strengthen these findings. MRSA spreading can be successfully controlled in ICUs with high colonization pressure.

Prevalence and risk factors for carriage of methicillin-resistant Staphylococcus aureus at admission to the intensive care unit: results of a multicenter study.

BACKGROUND: Detection of methicillin-resistant Staphylococcus aureus (MRSA) carriers on admission to the intensive care unit (ICU) is an important component of strategies for controlling the spread of MRSA. METHODS: A prospective multicenter study was conducted in 14 French ICUs for 6 months. All patients were screened within 24 hours after admission, using nasal and cutaneous swabs In addition, clinical samples were obtained. Patient data collected on ICU admission included presence of immunosuppression; history of hospital stay, surgery, antimicrobial treatments, or previous colonization with MRSA; chronic health evaluation and McCabe scores; reason for admission; whether the patient was transferred from another ward; severity of illness; presence of skin lesions; and invasive procedures. Risk factors for MRSA carriage at ICU admission were estimated, and significantly associated variables were used to develop a predictive score for MRSA carriage. A cost-benefit analysis was then performed. RESULTS: Of the 2347 admissions with MRSA screening, 162 (6.9%; range, 3.7%-20.0% among ICUs) were positive for MRSA, of whom 54.3% were detected through screening specimens only. Of the 2310 first admissions (vs repeat admissions) to the ICU, 96 were newly identified MRSA carriers. Factors associated with MRSA carriage in the multivariate analysis were age older than 60 years, prolonged hospital stay in transferred patients, history of hospitalization or surgery, and presence of open skin lesions in directly admitted patients. Only universal screening detected MRSA carriage with acceptable sensitivity. A cost-benefit analysis confirmed that universal screening and preventive isolation were beneficial. CONCLUSIONS: The prevalence of MRSA carriage on admission to the ICU is high in this endemic setting. Screening for MRSA on admission is useful to identify the imported cases and should be performed in all ICU-admitted patients.

Impact of HAART advent on admission patterns and survival in HIV-infected patients admitted to an intensive care unit.

BACKGROUND: Several studies found increased survival times and decreased hospitalization rates since the introduction of highly active antiretroviral therapy (HAART). OBJECTIVE: To examine the impact of HAART on admission patterns and survival of HIV-infected patients admitted to an intensive care unit (ICU). DESIGN: Prospective observational cohort study. SETTING AND SUBJECTS: All HIV-infected patients admitted from 1 January 1995 to 30 June 1999, to an infectious diseases ICU located in Paris. MAIN OUTCOME MEASURES: ICU utilization and admission patterns, and survival. RESULTS: A total of 426 HIV-related admissions were included. Sepsis increased from 16.3% to 22.6% from the pre- to the post-HAART era, whereas AIDS-related admissions decreased from 57.7% to 37% (P < 0.05). No significant difference in ICU utilization was found. In both periods, half of the patients were not on antiretroviral treatment at ICU admission. In-ICU mortality was 23%, without significant difference between the study periods. By multivariable analysis, in-ICU mortality was significantly associated with SAPS II > 40, Omega score > 75 and mechanical ventilation; and long-term survival with admission in the HAART era and AIDS at ICU admission. Cumulative survival rates after ICU discharge were 85.3% and 70.8% after 12 and 24 months, respectively. CONCLUSIONS: HAART had little impact on ICU utilization by HIV-infected patients. After the introduction of HAART AIDS-related conditions decreased and sepsis increased as reasons for ICU admission. Whereas ICU survival was dependent on usual prognostic markers, long-term survival was clearly dependent on HIV disease stage and HAART availability. In both study periods, at least a half of the HIV infected patients were not on anti-retroviral treatment at the time of ICU admission.

Characteristics and outcomes of HIV-infected patients in the ICU: impact of the highly active antiretroviral treatment era.

OBJECTIVE: To examine whether the introduction of highly active antiretroviral therapy (HAART) has changed the rate of admission, the clinical spectrum, and the mortality of HIV-infected ICU patients. DESIGN: Observational study. SETTING: Infectious diseases ICU in a teaching hospital, Paris, France. PATIENTS: All HIV-infected patients admitted during a pre-HAART era (1995-1996; n=189) and a HAART era (1998-2000; n=236). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: At the HAART era, 79% of patients had derived no or little benefit from the availability of HAART at ICU admission: 44% had no history of antiretroviral (ARV) medications and 35% had failed to respond to ARV. As compared with the pre-HAART era, the rate of hospitalized HIV-infected patients requiring the ICU stay increased (HAART, 5.9% vs pre-HAART, 4.4%; p=0.004). The admission was more likely to occur through the emergency room (45 vs 29%, p=0.0004), and the patients to be foreigners (38.1 vs 28.6%; p=0.04). After adjustment for significant prognostic covariates (AIDS-related tumors at admission, CD4 count <50/mm(3), poor functional status (Knaus score C or D), SAPSII, and need for mechanical ventilation), ICU survival was unchanged (adjusted OR=0.613, 95% CI=0.312-1.206), but 3-month survival was significantly improved (adjusted OR=0.57; 95% CI=0.32-0.99; p=0.045). CONCLUSION: The number of HIV-infected patients admitted to the ICU remained high in the HAART era. Underutilization of HAART and limited access to health care are possible explanations. The ICU mortality has remained unchanged, but 3-month mortality has decreased.

Infective endocarditis in the intensive care unit: clinical spectrum and prognostic factors in 228 consecutive patients.

OBJECTIVE: To identify factors associated with in-hospital outcome of adult patients admitted to the ICU with infective endocarditis (IE). DESIGN AND SETTING: Retrospective study performed in the two medical ICUs of a teaching hospital. PATIENTS AND PARTICIPANTS: The charts of all 228 consecutive patients aged 18 years or older admitted with infective IE between January 1993 and December 2000 were reviewed. All patients satisfied the modified Duke's criteria for definite IE. MEASUREMENTS AND RESULTS: There were 146 episodes of native valve endocarditis and 82 of prosthetic valve endocarditis. Staphylococcus aureus was the predominant causative micro-organism. Most complications occurred early during the course of IE. One-half of the patients underwent cardiac surgery during the same hospitalization and had a better outcome than nonoperated patients. The overall in-hospital mortality rate was 45% (102/228). Multivariate analysis revealed the following clinical factors in patients with native valve IE as independently associated with outcome: septic shock (odds ratio 4.81), cerebral emboli (3.00), immunocompromised state (2.88), and cardiac surgery (0.475); in patients with prosthetic valve IE the factors were: septic shock (4.07), neurological complications (3.1), and immunocompromised state (3.46). CONCLUSIONS: IE still carries high morbidity and mortality rates for the subset of patients requiring ICU admission. Most complications occur early making the decision process for optimal medical and surgical management more difficult. Surgical treatment appears to improve in-hospital outcome.

[Non tuberculous mycobacterial diseases]. / Les mycobactéries non tuberculeuses.

Mycobacteria species other than members of Mycobacterium tuberculosis complex are called non tuberculous mycobacteria (NTM) or "atypical" mycobacteria. To date, about 80 mycobacterial species have been described. They are usually opportunistic pathogens with variable degrees of virulence. Tuberculosis is the commonest mycobacterial disease in the world, followed by leprosy and Buruli ulcer. Before the AIDS epidemic, NTM diseases were confined to the lungs (M. kansasii, M. intracellulare and M. avium), the skin (M. marinum) or cervical lymph nodes (M. scrofulaceum). The outbreak of AIDS epidemic has dramatically changed the epidemiology of NTM diseases. Between 25 to 50% of AIDS patients in Europe and USA are infected with NTM. NTM infections are usually disseminated in patients with profound immunodeficiency. The inflammatory response and the prognosis of NTM diseases depend on the immunological status and the NTM species. Diagnosis may be difficult, especially in AIDS patients in whom numerous diseases are often associated. Diagnostic criteria involve clinical, radiological, microbiological and pathological findings. Identification of Mycobacterium species in cultures is the gold standard. Pathological examination has several interests: it may reveal an NTM disease, it provides a more rapid assessment of the infection than cultures, and helps to evaluate the virulence of NTM species identified by cultures.

Personal decision-making criteria related to seasonal and pandemic A(H1N1) influenza-vaccination acceptance among French healthcare workers.

BACKGROUND: Influenza-vaccination rates among healthcare workers (HCW) remain low worldwide, even during the 2009 A(H1N1) pandemic. In France, this vaccination is free but administered on a voluntary basis. We investigated the factors influencing HCW influenza vaccination. METHODS: In June-July 2010, HCW from wards of five French hospitals completed a cross-sectional survey. A multifaceted campaign aimed at improving vaccination coverage in this hospital group was conducted before and during the 2009 pandemic. Using an anonymous self-administered questionnaire, we assessed the relationships between seasonal (SIV) and pandemic (PIV) influenza vaccinations, and sociodemographic and professional characteristics, previous and current vaccination statuses, and 33 statements investigating 10 sociocognitive domains. The sociocognitive domains describing HCWs' SIV and PIV profiles were analyzed using the classification-and-regression-tree method. RESULTS: Of the HCWs responding to our survey, 1480 were paramedical and 401 were medical with 2009 vaccination rates of 30% and 58% for SIV and 21% and 71% for PIV, respectively (p<0.0001 for both SIV and PIV vaccinations). Older age, prior SIV, working in emergency departments or intensive care units, being a medical HCW and the hospital they worked in were associated with both vaccinations; while work shift was associated only with PIV. Sociocognitive domains associated with both vaccinations were self-perception of benefits and health motivation for all HCW. For medical HCW, being a role model was an additional domain associated with SIV and PIV. CONCLUSIONS: Both vaccination rates remained low. Vaccination mainly depended on self-determined factors and for medical HCW, being a role model.

Acute Kidney Injury Network definition of contrast-induced nephropathy in the critically ill: incidence and outcome.

INTRODUCTION: Contrast-induced nephropathy (CIN) has been extensively studied in the ward but only scarcely in intensive care unit (ICU) patients, even if they may be particularly prone to develop or to worsen acute kidney insufficiency. We aimed to measure the incidence of CIN in a large ICU population using the Acute Kidney Injury Network (AKIN) definition and to investigate its impact on patients' outcome. METHODS: In this 3-year retrospective study, we included all patients undergoing, during their stay in our medical ICU, a contrast media-enhanced computed tomographic scan. Change in serum creatinine between baseline (24 hours before to 12 hours after contrast media injection) and its maximum value over the 96 hours after contrast media injection was recorded. Contrast-induced nephropathy was defined as a 44.2-µmol/L absolute or a 25% relative minimal increase in serum creatinine over 48, 72, or 96 hours and according to the stage 1 of the AKIN classification (at least 26.4 µmol/L or 50% increase over 48 hours). RESULTS: A total of 398 contrast-enhanced computed tomographic scans performed among 299 patients were analyzed. Incidence of CIN was 14% according to the AKIN definition and ranged from 8% (48-hour absolute definition) to 23% (96-hour relative definition). The need for renal replacement therapy and ICU mortality were significantly higher in case of CIN. After adjusting for other variables associated with ICU mortality, the occurrence of at least 1 CIN episode during the ICU stay (AKIN criteria) was independently associated with ICU mortality (odds ratio, 3.85; 95% confidence interval, 1.85-8.00). CONCLUSIONS: Even if incidence varied greatly depending on the definition, CIN appeared frequent in our critically ill patients. The AKIN definition, independently associated with ICU mortality, may allow unifying diagnostic criteria to further evaluate this condition that impacts morbidity and mortality.