Investigation of a nosocomial outbreak of extended-spectrum beta-lactamase VEB-1-producing isolates of Acinetobacter baumannii in a hospital setting.

A nosocomial outbreak of epidemiologically related VEB-1 extended-spectrum beta-lactamase-producing isolates of Acinetobacter baumannii occurred in 33 patients in an intensive care unit. A case-control study identified previous treatment with third-generation cephalosporins as the only risk factor for A. baumannii acquisition. Rationale for antibiotic use should be strengthened.

[Prognosis of severe community-acquired pneumonia in alcoholic patients hospitalized in intensive care]. / Pronostic des pneumopathies communautaires graves chez des patients éthyliques chroniques hospitalisés en réanimation.

INTRODUCTION: The purpose of our study was to determine prognosis factors of alcoholic patients hospitalised in an intensive care unit with severe community-acquired pneumonia (SCAP). METHOD: Chronic alcoholism was defined by intake of pur alcohol more than 36 g per day for more than one year and severe community-acquired pneumonia by the criteria of the American Thoracic Society. RESULTS: 50 patients were included. Mortality rate was 48% in the department and 68% at two months after dismissal from intensive care. 1 Yen percent of patients were admitted in a state of shock (100% mortality). The most frequent pathogen was Streptococus pneumoniae (38%). The major complications were: 24% acute respiratory distress syndrome (ARDS), 18% multi-organ failure, 48% disseminated intravascular coagulopathy (DIC), 48% pulmonary superinfection. Antibiotherapy was not conform to current guidelines in 20% of cases and hence led to 90% death. DISCUSSION: Mortality rate was higher than in other studies. Bad prognosis factors were identified: severe state on admission, shock on admission or subsequently, non adapted initial antibiotherapy, Child's score B and C, Streptococus pneumoniae, complications: ARDS, superinfections, coagulopathy, multi organ failure.

[Lung infection by Mycobacterium szulgai]. / Infection pulmonaire à Mycobacterium szulgai.

BACKGROUND: Mycobacterium szulgai is an uncommon atypical mycobacterium human pathogen. CASE REPORT: The clinical manifestations and radiographic findings in a 31-year-old woman were strongly suggestive of pulmonary tuberculosis. The mode of transmission could not be determined. Mycobacterium szulgai was identified. The patient was treated with antituberculosis antibiotics and the clinical course was favorable. DISCUSSION: Mycobacterium szulgai is an atypical mycobacterrium difficult to identify. Its epidemiological features are unknown. This potential pulmonary pathogen is rarely described in the literature. Most cases have involved pulmonary, bone and joint or skin infections in immunodepressed patients. M. szulgai is relatively susceptible to classic antituberculosis antibiotics although standard regimens have not been established. Our patient required intensive care for mechanical ventilation.

Colchicine poisoning: report of a fatal case with body fluid and post-mortem tissue analysis by high-performance liquid chromatography.

A case involving a suicide by the ingestion of colchicine tablets is presented. Liquid chromatography has been used to measure the drug level in blood and in post-mortem tissues of the patient (a 42-year-old man). Plasma concentration 24 h after ingestion was 4.5 ng/mL. On autopsy, the kidney showed the highest concentration (396 ng/g). High concentrations were also found in the liver (347 ng/g) and heart (334 ng/g). Low concentrations were detected in the lung (58 ng/g), muscle (10 ng/g) and brain (5 ng/g).

Dobutamine improves gastrointestinal mucosal blood flow in a porcine model of endotoxic shock.

OBJECTIVE: To test the hypothesis that saline solution plus dobutamine increases gastrointestinal mucosal perfusion better than saline solution alone in a model of endotoxic shock. DESIGN: Prospective, randomized, unblinded study. SETTING: Animal research laboratory affiliated with a university teaching hospital. SUBJECTS: Twelve female pigs, weighing 30 to 32 kg. INTERVENTIONS: Animals were anesthetized, and their lungs were mechanically ventilated. Catheters were inserted into the right atrium, pulmonary artery, and carotid artery for blood sampling and blood pressure and cardiac output measurements. A tonometer and a laser Doppler probe were placed in the lumen of the stomach and the ileum for determination of mucosal acid-base status and measurement of mucosal blood flow. Group 1 animals (n = 6) received an infusion (T = 0 min) of 150 mcirog/kg Escherichia coli endotoxin and normal saline solution (0.3 mL/kg/min). Group 2 animals (n = 6) received an infusion of endotoxin and were resuscitated with the same method as used in group 1, but an infusion of dobutamine (5 microg/kg/min) was begun at T = 60 mins, and continued for the duration of the experiment. MEASUREMENTS AND MAIN RESULTS: Both experimental regimens produced shock, with decreased mean arterial pressure and systemic vascular resistance, without change in cardiac output and oxygen delivery. Endotoxin plus saline infusion decreased gastrointestinal mucosal blood flow to <60% of baseline and decreased gastrointestinal pH. In contrast, gastrointestinal mucosal blood flow returned to baseline values, and intramucosal pH tended to normalize by the end of the saline solution plus dobutamine resuscitative protocol. CONCLUSION: Compared with saline solution alone, saline solution plus dobutamine increased blood flow to the gastrointestinal mucosa, and may have partially improved oxygenation.

The contrasting effects of dobutamine and dopamine on gastric mucosal perfusion in septic patients.

To test the hypothesis whether or not dobutamine or dopamine infusion increases gastric mucosal perfusion, a prospective randomized crossover trial was conducted on 10 septic patients in the intensive care unit of a university hospital. Systemic hemodynamic, oxygen transport, and gastric perfusion assessed by gastric intramucosal pH and laser Doppler flowmetry were measured at baseline and after administration of dobutamine or dopamine (5 micrograms/kg/min). Both increased oxygen transport. In response to dobutamine, gastric mucosal blood flow increased (+32 +/- 14% from baseline; p < 0.05), gastric tonometered PCO2 and gastric arterial PCO2 difference decreased (58 +/- 7 versus 52 +/- 7 mm Hg; p < 0.05; 16.8 +/- 7.0 versus 10.5 +/- 7.2 mm Hg; p < 0.05), and intramucosal pH increased (7.23 +/- 0.05 versus 7.29 +/- 0.06; p < 0.05). In response to dopamine, gastric mucosal blood flow decreased (-28 +/- 8% from baseline; p < 0.05), gastric tonometered PCO2, gastric-arterial PCO2 difference, and calculated intramucosal pH were unchanged (58 +/- 7 versus 61 +/- 9 mm Hg, ns; 16.8 +/- 7.0 versus 18.9 +/- 8.4 mm Hg, ns; 7.24 +/- 0.05 versus 7.21 +/- 0.06, ns). We speculated that despite an oxygen transport increase, dobutamine and dopamine have affected differently gastric mucosal perfusion in septic patients.

Skeletal muscle microvascular blood flow and oxygen transport in patients with severe sepsis.

To compare skeletal muscle microvascular blood flow at rest and during reactive hyperemia in septic patients, a prospective, controlled trial was conducted on 16 patients with severe sepsis and a control group of 10 patients free of infection in the intensive care unit of a university hospital. Systemic hemodynamics, whole-body oxygen transport, and skeletal muscle microvascular blood flow at rest and during reactive hyperemia were measured. Reactive hyperemia was produced by arrest of leg blood flow with a pneumatic cuff; on completion of the 3 min ischemic phase the occluding cuff was rapidly deflated to 0. Hemodynamic and oxygen-derived variables were determined invasively. Skeletal muscle microvascular blood flow data were obtained using a laser Doppler flowmetry technique and values expressed in millivolts. Whole-body oxygen delivery in septic patients was increased compared with control subjects. Resting skeletal muscle blood flow was decreased in septic patients compared with control subjects (233 +/- 52 versus 394 +/- 93 mV; p < 0.05). Peak flow during reactive hyperemia was also decreased in septic patients compared with control subjects (380 +/- 13 versus 2,033 +/- 853 mV; p < 0.05). Cyclic variation in blood flow (vasomotion) was observed in control subjects but not in septic patients. Skeletal muscle microvascular perfusion is altered in patients with severe sepsis despite normal or elevated whole-body oxygen delivery. These microvascular abnormalities may further compromise tissue nutrient flow and may contribute to the development of organ failure in septic patients.

Cervical necrotizing fasciitis: clinical manifestations and management.

Forty-five cases of cervical necrotizing fasciitis are reported, and their clinical, bacteriologic, and therapeutic implications are considered. Fasciitis was of dental origin in 78% of cases, pharyngeal in 16%, and surgical or posttraumatic in 6%. The condition extended to the face in 22% of cases, to the lower part of the neck in 56%, and to the mediastinum in 40%. Soft-tissue cultures were positive in 78% of cases. Anaerobes were isolated along with aerobes in 49% of cases (mean, 2.2 isolates per patient) and in pure culture in 22%. Treatment included surgical debridement and drainage and the administration of antibiotics active against both anaerobic and gram-negative aerobic bacteria. Hyperbaric oxygen was used for adjunctive treatment. The bacteria involved did not affect clinical manifestations, extension, or mortality. The survival rate among our patients was 78%. Mortality was significantly higher among cases with mediastinal extension (44% vs. 7%; P < .01); thus the prompt recognition and drainage of sites of mediastinal extension are of critical importance. Other risk factors for death were an age of > 70 years, underlying diabetes, the development of septic shock within 24 hours after admission, and prolonged prothrombin time.

Sex steroid hormones in circulatory shock, sepsis syndrome, and septic shock.

METHODS: Estrone (E1), estradiol (E2), testosterone (T), FSH, and LH levels were daily measured during a ten day period in 50 critically ill patients (38 men, 12 post-menopausal women). Patients were separated into four groups: A) no circulatory failure, no sepsis, B) sepsis syndrome without circulatory failure, C) circulatory failure without sepsis syndrome, D) septic shock. Results of hormonal measurements were compared 1) among the 4 groups, 2) between male and female patients, 3) between septic and nonseptic patients. The potential for the infusion of the vasoactive drug dobutamine to induce sex hormonal changes was documented in ten additional septic shock patients by measuring cortisol, E1, and T at base-line and after dobutamine infusion. Changes in active renin and plasma renin activity (PRA) were used as indirect witness of the dobutamine-induced beta 2-stimulation. RESULTS: A dramatic increase in E1 and E2 levels was observed in women of groups B and D, and only in male patients of group D. In the septic patients, estrogen levels peaked at days 1 and 2 and trended to normal from day 6 after the onset of sepsis, while FSH and LH decreased. No difference was found between survivors and non-survivors. Whatever the group, male patients had low T levels throughout the study. Dobutamine induced a significant increase in active renin levels and a decrease in the regression slope between renin and PRA. Cortisol levels remained normal. No significant change in E1 and T was observed after dobutamine. CONCLUSIONS: High estrogen levels were specifically observed in patients with sepsis and septic shock, either males or females. Decreased LH and FSH levels were consistent with the negative feed-back effect of high estrogen levels on pituitary secretion. Circulating T levels were decreased in all male patients. We found no correlation between sequential estrogen levels and outcome. These levels were not modified by a dobutamine-induced beta-2 stimulation.

Carbon dioxide rebreathing method of cardiac output measurement during acute respiratory failure in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To compare measurement of cardiac output by the CO2 rebreathing method vs. the thermodilution cardiac output technique in the setting of acute respiratory failure in patients with chronic obstructive pulmonary disease. DESIGN: Prospective, comparative study of two methods in a consecutive sample. SETTING: Intensive care unit. PATIENTS: Twenty-five patients with chronic obstructive pulmonary disease with acute respiratory failure were studied. The patients were being mechanically ventilated and monitored with systemic and pulmonary artery catheters. MEASUREMENTS AND MAIN RESULTS: Cardiac output was determined, using both the thermodilution technique and an indirect CO2 Fick method. Veno-arterial CO2 content difference was calculated from an estimated mixed venous PCO2 obtained by an equilibrium CO2 rebreathing method and measured PaCO2. PCO2 was converted to content using the equation of the CO2 dissociation curve described by McHardy. A wide range of cardiac output was studied. There was a significant correlation between thermodilution and CO2 rebreathing methods (r2 = .92, p < .001). The mean difference between thermodilution and CO2 rebreathing methods was -0.06 L/min/m2, standard deviation for the bias was 0.028 L/min/m2, and 95% confidence interval for the bias was -0.120 to -0.001 L/min/m2. CONCLUSION: Our results suggest that the CO2 rebreathing method may be a reliable non-invasive technique to determine cardiac output in mechanically ventilated patients with chronic obstructive pulmonary disease.

Non-invasive measurement of cardiac output in patients with acute lung injury using the carbon dioxide rebreathing method.

STUDY OBJECTIVE: To compare measurement of cardiac output by the CO2 rebreathing method with the thermodilution cardiac output technique in mechanically ventilated patients with acute lung injury. DESIGN: Prospective study comparing two methods of cardiac output measurement in 22 consecutive patients with acute lung injury. SETTING: Intensive care unit of a university hospital. PATIENTS: Twenty-two mechanically ventilated patients with acute lung injury monitored with systemic and pulmonary artery catheters. MEASUREMENTS AND RESULTS: Cardiac output was determined using both the thermodilution technique and an indirect CO2 Fick method. Veno-arterial CO2 content difference was calculated from an estimated mixed venous CO2 tension obtained by an equilibrium CO2 rebreathing method and measured arterial CO2 tension. Carbon dioxide pressure was converted to content using the equation of the CO2 dissociation curve described by McHardy. A wide range of cardiac index was studied from 2.7-5.7 l/min/m2. There was a significant correlation between thermodilution and CO2 rebreathing methods (r2 = 0.82, p < 0.01). The mean difference between the CO2 rebreathing method and thermodilution was 0.05 l/min/m2, with a standard deviation for the bias of 0.38 l/min/m2. CONCLUSION: Our results suggest that the CO2 rebreathing method may be a reliable non-invasive technique to determine cardiac output in mechanically ventilated patients with acute lung injury.

Is steroid dependent Crohn's disease a separate entity?

Crohn's disease has been sometimes considered as a syndrome including different entities. In this prospect we tried to assess whether steroid dependent Crohn's disease could be a separate sub-group. Eighty five patients (mean follow-up: 6 years) with documented Crohn's disease were classified into 3 groups: 1--patients never treated with steroids (NS) (N = 37); 2--patients in whom steroids had been given but had been withdrawn (NSD) (N = 37); 3--patients dependent on continuous steroid therapy (SD) (N = 11). Ten variables were considered: age at onset, sex, CDAI, cumulative topography of lesions, extra-intestinal symptoms, albuminemia, ESR, surgical operations, annual frequency of relapses. Monofactorial analysis (analysis of variance and CHI2 test) showed group SD to be significantly different from group NS and in term of age at onset, CDAI, ESR, annual frequency of relapses, extra-intestinal symptoms, surgical operations. In contrast, a multivariate analysis of correspondences applied to the 3 groups and to 9 dichotomous variables showed that group SD is not a separate entity, but the limit of a continuum extending from group NS to group NSD. This was ascertained by a CHI2 test applied to the dichotomous variables. Thus, within the limits of this study Crohn's disease appears to be a homogeneous entity rather than a heterogeneous syndrome.

Age differences in performance at concentration: a pilot study.

24 subjects ranging in age from 5 to 65 years individually played Concentration in pictorial and verbal formats. Consistent with age-related declines in both general and visual processing, performance was poorest for the elderly subjects on both tasks; however, there was no evidence of children's precocity.

[Role of hyperbaric oxygenation in the treatment of acute anaerobic infections]. / Place de l'oxygénothérapie hyperbare dans le traitement des infections aiguës à germes anaérobies.

Hyperbaric oxygenation (HBO), as an adjuvant treatment in necrotizing soft tissues infections and in gas gangrene is reviewed, including its specific effects, experimental studies and clinical reports. With a global therapeutic management, considered as an emergency state, including surgery, antibiotic regimens and HBO, we can obtained 50% mortality and morbidity decrease with a more conservative surgery. Finally, favorable outcome is associated with early therapeutics and localization of the initial necrotizing infection.