Cobalamin c deficiency associated with antifactor h antibody-associated hemolytic uremic syndrome in a young adult.

BACKGROUND: Thrombotic microangiopathy (TMA) syndromes are characterized by the association of hemolytic anemia, thrombocytopenia and organ injury due to arteriolar and capillary thrombosis. CASE PRESENTATION: We report the first case of adult onset cobalamin C (Cbl C) disease associated with anti-factor H antibody-associated hemolytic uremic syndrome (HUS). A 19-year-old woman was admitted to the nephrology department owing to acute kidney failure, proteinuria, and hemolytic anemia with schizocytes. TMA was diagnosed and plasma exchanges were started in emergency. Exhaustive analyses showed 1) circulating anti factor H antibody and 2) hyperhomocysteinemia, hypomethioninemia and high levels of methylmalonic aciduria pointing towards Clb C disease. Cbl C disease has been confirmed by methylmalonic aciduria and homocystinuria type C protein gene sequencing revealing two heterozygous pathogenic variants. The kidney biopsy showed 1) intraglomerular and intravascular thrombi 2) noticeable thickening of the capillary wall with a duplication aspect of the glomerular basement membrane and a glomerular capillary wall IgM associated with Cbl C disease related TMA. We initiated treatment including hydroxycobalamin, folinic acid, betaine and levocarnitine and Eculizumab. Rituximab infusions were performed allowing a high decrease in anti-factor H antibody rate. Six month after the disease onset, Eculizumab was weaning and vitaminotherapy continued. Outcome was favorable with a dramatic improvement in kidney function. CONCLUSION: TMA with renal involvement can have a complex combination of risk factors including anti-FH autoantibody in the presence of cblC deficiency.

[Security of hospital infusion practices: From an a priori risk analysis to an improvement action plan]. / Sécurisation de la perfusion en milieu hospitalier : de l'analyse de risques a priori au plan d'action d'amélioration des pratiques.

OBJECTIVES: Infusion in care units, and all the more in intensive care units, is a complex process which can be the source of many risks for the patient. Under cover of an institutional approach for the improvement of the quality and safety of patient healthcare, a risk mapping infusion practices was performed. METHODS: The analysis was focused on intravenous infusion situations in adults, the a priori risk assessment methodology was applied and a multidisciplinary work group established. RESULTS: Forty-three risks were identified for the infusion process (prescription, preparation and administration). The risks' assessment and the existing means of control showed that 48% of them would have a highly critical patient security impact. Recommendations were developed for 20 risks considered to be most critical, to limit their occurrence and severity, and improve their control level. An institutional action plan was developed and validated in the Drug and Sterile Medical Devices Commission. CONCLUSION: This mapping allowed the realization of an exhaustive inventory of potential risks associated with the infusion. At the end of this work, multidisciplinary groups were set up to work on different themes and regular quarterly meetings were established to follow the progress of various projects. Risk mapping will be performed in pediatric and oncology unit where the risks associated with the handling of toxic products is omnipresent.

[Investigation of hospital epidemics and guidelines for the management of suspected cases of measles and invasive meningococcal disease]. / Investigation d'une épidémie hospitalière et règles de prise en charge des cas suspects de rougeole ou d'infection invasive à méningocoque en établissement de soins.

Outbreaks of infectious diseases within healthcare institutions must be detected early and controlled. Hospitals should develop a plan for coordinating all hospital components to respond to these critical situations. The knowledge of the different steps in an outbreak investigation can help identify the source of ongoing outbreaks and prevent additional cases. Outbreak investigation is based on a multidisciplinary approach and is an opportunity for research, training and program considerations.

Impact of short term use of interdialytic 60% ethanol lock solution on tunneled silicone catheter dysfunction.

INTRODUCTION: Ethanol lock (EL) is used to reduce catheter infections, but its impact on dialysis catheter dysfunction has not been studied. METHODS: We analyzed the rate of dialysis silicone catheter dysfunction after an interdialytic 60% EL in an open prospective controlled non crossover cohort study, with each patient being his or her own control. The study was divided into three consecutive 2-week periods: the pre- and post-intervention periods, in which interdialytic standard locks (SL) were used, and the intervention period, in which one EL was instilled during the first week, and two consecutively in the second week. We analyzed the rate of catheter dysfunction (exchange, use of fibrinolytic, reversing the lines, difficulty in instilling or withdrawing fluid) after EL or SL. RESULTS: In 30 patients, 90 EL were instilled. The rate of catheter dysfunction increased during the EL period (2 - 13%, p < 0.001), and between the two consecutive dialysis sessions before and after EL (p < 0.05). It decreased between the two consecutive dialysis sessions after EL and the following dialysis session after an SL (p < 0.05). No catheter was removed. The urea reduction ratio did not differ in dialysis after an SL and after an EL (0.77 vs. 0.73, p = 0.17). CONCLUSION: Short term EL is associated with a transient increase in catheter dysfunction, without resulting in catheter removal or decreasing dialysis efficiency.

Multidrug-resistant Klebsiella pneumoniae outbreak after endoscopic retrograde cholangiopancreatography.

BACKGROUND AND STUDY AIMS: Infection is a recognized complication of endoscopic retrograde cholangiopancreatography (ERCP). We describe the epidemiologic and molecular investigations of an outbreak of ERCP-related severe nosocomial infection due to KLEBSIELLA PNEUMONIAE producing extended-spectrum beta-lactamase (ESBL). PATIENTS AND METHODS: We conducted epidemiologic and molecular investigations to identify the source of the outbreak in patients undergoing ERCP. We carried out reviews of the medical and endoscopic charts and microbiological data, practice audits, surveillance cultures of duodenoscopes and environmental sites, and molecular typing of clinical and environmental isolates. RESULTS: Between December 2008 and August 2009, 16 patients were identified post-ERCP with KLEBSIELLA PNEUMONIAE that produced extended-spectrum beta-lactamase type CTX-M-15. There were 8 bloodstream infections, 4 biliary tract infections, and 4 cases of fecal carriage. The microorganism was isolated only from patients who had undergone ERCP. Environmental investigations found no contamination of the washer-disinfectors or the surfaces of the endoscopy rooms. Routine surveillance cultures of endoscopes were repeatedly negative during the outbreak but the epidemic strain was finally isolated from one duodenoscope by flushing and brushing the channels. Molecular typing confirmed the identity of the clinical and environmental strains. Practice audits showed that manual cleaning and drying before storage were insufficient. Strict adherence to reprocessing procedures ended the outbreak. CONCLUSIONS: The endoscopes used for ERCP can act as a reservoir for the emerging ESBL-producing K. PNEUMONIAE. Regular audits to ensure rigorous application of cleaning, high-level disinfection, and drying steps are crucial to avoid contamination.

[Role of indoor endotoxins in asthma symptoms]. / Rôle des endotoxines de l'environnement intérieur dans les symptômes asthmatiques.

INTRODUCTION: Endotoxin is a collective term designating a characteristic group of chemical constituents of the outer membrane of Gram negative bacteria, the lipopolysaccharides (LPS). BACKGROUND: LPS provocation tests in healthy subjects (50 microg) induce asthma-like airflow obstruction with a neutrophilic inflammatory influx, similar to reactions observed in non-atopic asthma. Asthmatic subjects show the same reaction with smaller doses of LPS (20 microg), revealing higher sensitivity to LPS than normal subjects. Low levels (2 microg) of LPS do not induce either airflow obstruction or bronchial hyperreactivity. Among exposed workers, particularly in agriculture, endotoxin is the most significant component of the bioaerosol that is associated with airway disease. In clinical studies, exposure to LPS is associated with severe asthma. Conversely, epidemiological studies, in both urban and rural areas, assessing the relationship between exposure to LPS and asthma and asthma- related symptoms are inconsistent. PERSPECTIVES: Longitudinal epidemiological studies, especially in farm children, may confirm the putative protective effects of LPS with respect to atopic asthma. CONCLUSION: Exposure to indoor LPS is frequently associated with asthma and asthma-like symptoms in current studies. Their definitive role needs to be confirmed by birth cohort studies currently under way that should define the controversial protective effect of LPS with respect to atopic asthma in farming populations.

[Hepatorenal syndrome]. / Syndrome hépatorénal.

The hepatorenal syndrome (HRS) is an acute functional renal failure due to renal arterial vasoconstriction occurring in cirrhotic patients with vascular dysfunction. The renal arterial vasoconstriction is the result of diffuse arteriole vasodilatation. There are two types of HRS, which can be differentiated according to the course and the stage of the renal failure; they have a different prognosis. Liver transplantation remains the standard treatment. Maintenance medical therapy is mainly based on vasopressin analogues. The interest of both dialysis and portosystemic intrahepatic shunt techniques remains to be determined. The prognosis of HRS is poor and in the absence of treatment, onset is usually followed by rapid fatal outcome.

Successful control of a hospital-wide vancomycin-resistant Enterococcus faecium outbreak in France.

We describe the control of a hospital-wide vancomycin-resistant Enterococcus faecium (VRE) outbreak in a 2,000-bed university hospital located on three different sites in Clermont-Ferrand, France. From January 2004 to April 2007, 220 VRE cases were identified. Overall, 28 different wards had at least one case. All of the strains expressed a high level of resistance to vancomycin and to teicoplanin carried by the vanA gene. Pulsed-field gel electrophoresis (PFGE) analysis of the strains revealed that they were clonally related. Control measures consisted of implementing a strategy of VRE screening by rectal swab, reinforcing hand hygiene practices and taking contact precautions. Recommendations for a restricted use of specific antibiotics were sent to each physician. Alcohol-based handrubs were provided throughout the hospital and the staff underwent training for their use. Compliance with contact precautions, including the use of clean non-sterile gloves and single-use gowns, was reinforced. VRE cases were assigned systematically to a single-bed room. In October 2007, no new VRE carriage has been detected for 7 months and no clinical samples had been VRE-positive for 10 months. In conclusion, a hospital-wide VRE outbreak was successfully controlled by a strategy based on routine screening, the reinforcement of hand hygiene and taking barrier precautions.

Is treatment with N-acetylcysteine to prevent contrast-induced nephropathy when using bicarbonate hydration out of date?

AIMS: Chronic renal failure (CRF) is a major risk factor for contrast-induced nephropathy (CIN) and could be prevented by bicarbonate hydration. The effect of N-acetylcysteine (NAC) in preventing CIN in patients treated by bicarbonate hydration has never been investigated. METHODS: Patients admitted for cardiac angiography from January 2002 to November 2004, with stable CRF (glomerular filtration rate (GFR) < 56 ml/min, Cockcroft-Gault formula) were included in a prospective, randomized, double-blind study comparing the efficacy of oral NAC + bicarbonate hydration vs oral placebo + bicarbonate hydration to prevent CIN. NAC 1,200 mg twice daily or placebo was given on Day -1 and Day 0 (Day 0 = cardiac angiography). A 1.4% bicarbonate solution (1 ml/ kg/h) was administered 12 hours before and after cardiac angiography. The overall CIN incidence on Day 2 was defined by one or more of the following criteria: increase in serum creatinine > 44.2 micromol/l, increase in serum creatinine > 25% or decrease in GFR > 5 ml/ min. RESULTS: Between NAC group (n = 28) and placebo group (n = 32) there was no difference in baseline demographics (age, sex ratio, weight, arterial hypertension, diabetes), in Day 0 characteristics (serum creatinine, GFR, hematocrit, protidemia) and in Day 0 cardiac angiography procedure (diagnostic or interventional, number of stents, type and volume of contrast media infused). The overall incidence of CIN in the NAC and placebo groups was 7.1 vs 9.3% (p = 1), respectively, and the rates of the observed criteria a, b, and c were 0 vs 6.3% (p = 0.49), 3.5 vs 6.3% (p = 1), and 7.1 vs 9.3% (p = 1). CONCLUSION: In CRF patients undergoing cardiac angiography, the use of bicarbonate hydration is associated with a very low incidence of CIN. In these conditions, on the basis of our results, we cannot draw any meaningful conclusion on the effect of NAC on the prevention of CIN.

[Intra-alveolar haemorrhage without renal damage as the initial presenting feature of Goodpasture's syndrome: case report and review of literature]. / Hémorragie intra-alvéolaire isolée révélant un syndrome de Goodpasture sans atteinte rénale : à propos d'une observation et revue de la littérature.

Isolated pulmonary involvement in Goodpasture's syndrome is exceptionally described. We report a 36-year-old woman with pulmonary haemorrhage and review 28 additional cases of the literature. In fact, these patients had often mild urine abnormalities and constant glomerular lesions. Antiglomerular basement membrane antibodies testing should be systematically ordered in patients presenting with alveolar haemorrhage. Goodpasture's syndrome without renal abnormality could be an early stage of the disease with a better prognosis.

[Cost/effectiveness comparison of the vaccine campaign and reduction of sick leave, after vaccination against influenza among the Clermont-Ferrand University Hospital staff]. / Comparaison coût/bénéfice de la campagne vaccinale et de la réduction de l'absentéisme, après vaccination contre la grippe du personnel du CHU de Clermont-Ferrand.

OBJECTIVE: The aim of this study was to compare the cost of vaccination for the Clermont-Ferrand University hospital (CHU) personnel and the cost of sick leave among vaccinated and non-vaccinated employees in 2003, 2004, and 2005. DESIGN: The study included 7256 CHU staff (medical and non-medical personnel). The cost of sick leave was calculated on the basis of short-term disease (four to nine days) over the three months of the epidemic season in 2004, 2005, and 2006. RESULTS: In 2005, the overall cost of vaccination was 4.02 euros per vaccinated employee. Over the three years, the total sick leave reached 804 days for employees vaccinated against 5670 for non-vaccinated employees. In 2003, 2004, and 2005, the vaccinal coverage was 13, 20.5, and 30.1%, the mean duration of sick leave was 0.16, 0.17, and 0.18 day among vaccinated staff, and 0.26, 0.39, and 0.34 day among non-vaccinated staff corresponding to a benefit per vaccinated employee of 5, 26, and 20 euros, respectively for each year. The total benefit for the institution was 86,458 euros (4630+38,168+43,660). If the vaccinated rate of 75% recommended by the Haute Autorité de santé (HAS) had been reached, the additional benefit would have been 250,193 euros (33,157+152,256+65,180). CONCLUSIONS: The number of sick leave days and the related cost were approximately twice less important for vaccinated employees, economically justifying this vaccination including a period of weak epidemic, as checked over three consecutive years.

ICU survival and need of renal replacement therapy with respect to AKI duration in critically ill patients.

BACKGROUND: Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU mortality. DESIGN: Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day. SETTING: 23 French ICUs. PATIENTS: Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015. INTERVENTION: None. RESULTS: A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (n = 559), 27.69% (n = 327) and 26.26% (n = 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (P < 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery [CSHR 0.54 (95% CI 0.46-0.63), P < 0.01]. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI. CONCLUSIONS: Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.

Pseudomonas aeruginosa and Pseudomonas putida outbreak associated with contaminated water outlets in an oncohaematology paediatric unit.

This paper describes an outbreak of Pseudomonas aeruginosa and Pseudomonas putida that occurred in an oncohaematology paediatric unit between January and April 2005. Eight children had nosocomial infections due to P. aeruginosa (N=5) or P. putida (N=3), which were recovered from central venous catheter blood cultures (N=4), the catheter exit site alone (N=2), or the catheter exit site and the catheter tip (N=2). Subsequent investigation showed that contaminated water outlets represented the possible source of spread. Studies of nursing and environmental cleaning practices revealed two modes of catheter contamination. A reduction in the size of the catheter dressing at the exit site gave less protective cover during showers, and a detergent-disinfectant diluted with tap water had contaminated perfusion bottles. Repetitive intergenic consensus polymerase chain reaction indicated two discrete patterns for P. aeruginosa and one for P. putida. The water network was chlorinated, and disposable seven-day filters were fitted on all taps and showers. Due to the deleterious effects of chlorination on the water network and the cost of the weekly filter change, a water loop producing microbiologically controlled water was installed. In addition, the concentration of the detergent-disinfectant was increased and refillable sprayers were replaced with ready-to-use detergent-disinfectant solution for high-risk areas. Following these measures, no Pseudomonas spp. have since been isolated in clinical or environmental samples from the ward.

Centropontine myelinolysis after correction of hyponatremia: role of associated hypokalemia.

BACKGROUND: Patients with severe hyponatremia have a high risk for centropontine myelinolysis (CPM) during treatment, but the incidence rate and risk factors have not been well-assessed. METHODS: This study was conducted in a medical intensive care unit (ICU) of a university teaching hospital. All patients with a serum sodium concentration < 120 mmol/l and a serum osmolality level < 250 mosmol/kg upon ICU admission were enrolled in this prospective study and were included if they underwent a baseline brain computerized tomography scan (CT scan) and a follow-up brain magnetic resonance imaging 1 month after admission. The diagnosis of CPM was based on cerebral magnetic resonance imaging findings, i.e. T1-weighted images with T2-weighted images showing hyperintense signal in the corresponding areas which were not apparent on the initial cerebral CT scan. RESULTS. Of the 22 patients included, 12 were considered as having acute hyponatremia and 8 were chronic alcoholics. In 12 patients, the increase in serum sodium level was < 12 mmol/I in any 24-hour period. CPM was diagnosed in 7/22 patients (31.8%) and was asymptomatic in 4 of them. CPM was present in 4 patients with acute hyponatremia and in 4 chronic alcoholics. It was associated with a lower baseline potassium level (p = 0.05) and NaCl administration during the first 24 hours (p = 0.005). However, non-acute hyponatremia, chronic alcoholism and rapid correction of serum sodium did not appear as risk factors. CONCLUSION: The incidence rate of CPM following severe hyponatremia is high and can develop even when there is a slow correction of serum sodium level. Hypokalemia is a predisposing factor.

Outbreak of colonization and infection with vancomycin-resistant Enterococcus faecium in a French university hospital.

An outbreak of infection with vancomycin-resistant Enterococcus faecium occurred at Hotel-Dieu Hospital (Clermont-Ferrand, France). A case-control study was performed in the infectious diseases and hematology units of the hospital. Urinary catheter use (odds ratio [OR], 12 [95% confidence interval {CI}, 1.5-90]; P<.02), prior exposure to a third-generation cephalosporin (OR, 22 [95% CI, 3-152]; P=.002), and prior exposure to antianaerobials (OR, 11 [95% CI, 1.5-88]; P<.02) were independently predictive of vancomycin-resistant Enterococcus faecium carriage.

[Impact study of an active antiflu vaccination programme on the Clermont-Ferrand Teaching Hospital staff]. / Etude d'impact d'une campagne active de vaccination antigrippale du personnel hospitalier du CHU de Clermont-Ferrand. achamoux@chu-clermontferrand.fr

OBJECTIVE: Protecting health care units from influenza epidemics has a double purpose: to decrease the mortality rate of patients at risk and to reduce work-leave in medical staff. An annual vaccination appears to be the most effective prevention against influenza. In France however the vaccinal coverage of health workers does not exceed 15%. METHOD: In the 2003-2004 winter, the department of occupational health and the nosocomial disease committee of the Clermont-Ferrand Teaching Hospital initiated an active vaccination campaign. Three joint actions were carried out: date and place of vaccination sessions were individually addressed to every healthcare worker, meetings on prevention of influenza were held, as well as vaccination sessions on the work place in exposed units. RESULTS: Significant results were noted: vaccination rate increased 2.6 fold compared to the previous year (4.8 to 12.6%) and a vaccinal coverage rate of 29% in the exposed units. COMMENTS: The results even if far from national objectives encourage the pursuit of the campaigns promoting information and vaccination on the work place. The high frequency of reported postinjection adverse effects (1 out of 3) should be taken into account in future information campaign.

Migration of plasticizers from PVC medical devices: Development of an infusion model.

Alternatives to DEHP plasticizers are used in various PVC medical devices (MD) for infusion. As they are able to migrate from these MDs into infused solutions, they may come into contact with patient. Different and specific clinical parameters influence their migration in at-risk situations such as infusion. In contrast to the regulations for Food Contact Materials (MCDA), there is currently no acceptable migration limits for the use of these plasticizers in clinical situations. In order to assess their migration, and thus control the risks linked to these MDs, we developed a migration model for the plasticizers in MDs. To this end, we applied a cross-disciplinary methodological process similar to that used in the food-processing industry, taking into account the MDs' conditions of use in clinical practice. The simulation model is simple and includes the following conditions: MD should be tested with a dynamic method that respects our established clinical assumption (2 L of infused solutions via 13 dm(2) of plasticized PVC), at a temperature of 25 °C and during 24 h of contact, using a 50/50 (v/v) ethanol/water simulant. This model could be proposed as a tool for the safety evaluation of the patients' exposure risk to plasticizers from PVC medical devices for infusions.

Hemoperitoneum in patients receiving hemodialysis.

Acute abdominal pain in chronic hemodialysis patients has well-known causes, including acute pancreatitis, mesenteric arterial insufficiency, or complicated duodenal ulcer. Others, such as hemoperitoneum, are far less common. Although hemoperitoneum occurs in patients receiving peritoneal dialysis, dialysis is seldom if ever the direct cause of the bleeding. Hemoperitoneum is often related to menses or ovulation, particularly to ovarian cyst rupture; therefore, it is more common in young women. In most cases, no specific treatment is required. Hemoperitoneum is rarely considered as the cause of acute abdominal pain in chronic hemodialysis patients. In this report of hemoperitoneum confirmed by emergency laparotomy in 3 women, bleeding was not related to gynecologic origin. All of the women were younger than age 50 and undergoing long-term hemodialysis. All patients had a history of acute abdominal pain associated with shock. The cause of bleeding was always an organ lesion: hepatic amyloidosis with suspected portal hypertension or sclerosing peritonitis and acute hemorrhagic pancreatitis. Coagulation abnormalities and the use of anticoagulants during hemodialysis sessions may have been aggravating factors in all three patients. Hemoperitoneum is difficult to diagnose, particularly in the minor forms, and consequently its incidence may be underestimated. Therefore, it should be considered whenever a chronic hemodialysis patient presents with persistent acute abdominal pain.

Growth factors and proinflammatory cytokines in the renal involvement of POEMS syndrome.

The POEMS syndrome is a multisystemic syndrome associated with plasma cell dyscrasia, characterized by the combination of polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes. Renal involvement in POEMS syndrome is rare (26 reported cases). It has been described as membranoproliferative glomerulonephritis-like lesions (MPGN-like), mesangiolytic glomerulonephritis, or thrombotic microangiopathy. Proinflammatory cytokines (TNF-alpha, IL-1, IL-6) have been implicated in the physiopathogenesis of POEMS syndrome, particularly when there is renal involvement. Growth factors (FGF-beta, TGF-beta, PDGF) have been implicated in renal lesions of the same histological type but of different origins. An increase in serum vascular endothelial growth factor (VEGF) has been reported in POEMS syndrome (20 of 22 cases). Circulating levels of these factors were determined in 4 patients with POEMS and renal involvement (3 MPGN-like, 1 MPGN-like, and mesangiolysis) and compared with those obtained in 4 patients with POEMS without clinical renal involvement and in 4 patients with primitive membranoproliferative glomerulonephritis (MPGN). TNF-alpha, IL-1beta, and IL-6 were determined with an immunoradiometric assay, and VEGF, PDGF, FGF-beta, and TGF-beta with an enzyme-linked immunosorbent assay. Among the patients with POEMS syndrome, there was no difference in proinflammatory cytokines and growth factors between those with or without renal involvement. VEGF is the only growth factor that differentiates MPGN in POEMS syndrome from primitive MPGN.

Septic shock in patients with the acquired immunodeficiency syndrome.

OBJECTIVE: To evaluate the prognosis of patients with septic shock admitted to an intensive care unit (ICU), according to their HIV serostatus. DESIGN: Retrospective study. SETTING: Medical ICU of a university hospital. PATIENTS: 76 patients with septic shock admitted to the same ICU, of whom 28 were HIV positive and 48 were HIV negative. MEASUREMENTS AND RESULTS: Severity scores, number and type of organ failures, and survival rates were assessed in the two groups of patients. Glasgow Coma Scale and general severity scores [Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score (SAPS)] were significantly worse in HIV-infected patients. The total number of organ failures was also higher in the HIV-positive group: 3.7 +/- 0.2 vs 3.1 +/- 0.2 in the HIV-negative group (p < 0.001). On day 28, 21 (46%) HIV-negative patients were dead compared to 26 (93%) patients in the HIV-positive group (p < 0.001). In the multivariate analysis, HIV infection was an independent risk factor for mortality, as were the SAPS score, use of mechanical ventilation, and the McCabe score. CONCLUSIONS: This study reports a considerable excess mortality in HIV-infected patients with septic shock. Although severity of illness was clearly much more pronounced in HIV-positive patients, retroviral infection was independently associated with death. Improving survival in HIV-positive patients with septic shock may require earlier diagnosis and treatment of the causative infection.