RESUMEN
INTRODUCTION: Fever treatment is commonly applied in patients with sepsis but its impact on survival remains undetermined. Patients with respiratory and haemodynamic failure are at the highest risk for not tolerating the metabolic cost of fever. However, fever can help to control infection. Treating fever with paracetamol has been shown to be less effective than cooling. In the SEPSISCOOL pilot study, active fever control by external cooling improved organ failure recovery and early survival. The main objective of this confirmatory trial is to assess whether fever control at normothermia can improve the evolution of organ failure and mortality at day 60 of febrile patients with septic shock. This study will compare two strategies within the first 48 hours of septic shock: treatment of fever with cooling or no treatment of fever. METHODS AND ANALYSIS: SEPSISCOOL II is a pragmatic, investigator-initiated, adaptive, multicentre, open-label, randomised controlled, superiority trial in patients admitted to the intensive care unit with febrile septic shock. After stratification based on the acute respiratory distress syndrome status, patients will be randomised between two arms: (1) cooling and (2) no cooling. The primary endpoint is mortality at day 60 after randomisation. The secondary endpoints include the evolution of organ failure, early mortality and tolerance. The target sample size is 820 patients. ETHICS AND DISSEMINATION: The study is funded by the French health ministry and was approved by the ethics committee CPP Nord Ouest II (Amiens, France). The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04494074.
Asunto(s)
Sepsis , Choque Séptico , Humanos , Choque Séptico/terapia , Choque Séptico/complicaciones , Respiración Artificial , Proyectos Piloto , Fiebre/terapia , Fiebre/complicaciones , Sepsis/complicaciones , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Multicéntricos como AsuntoRESUMEN
The development of biomarkers able to predict the occurrence of nosocomial infection could help manage preventive strategies, especially in medical patients whose degree of acquired immunosuppression may be variable. We hypothesized that the NO fraction present in the airways (upper and lower) of critically ill patients under mechanical ventilation could constitute such a biomarker. We conducted an observational proof-of-concept study in a medical intensive care unit of a teaching hospital. Forty-five patients (26 men; 72 [25th-75th percentiles] years [56-82]; Simplified Acute Physiology Score II, 63 [50-81], 14 infected) under mechanical ventilation (>3 days) underwent on day 1 and day 3 of their stay: nasal and exhaled (partitioned in bronchial and alveolar sources) bedside NO measurements, determination of urine NO end products and plasma cytokine (IL-6, IL-10) concentrations, and Sequential Organ Failure Assessment score calculation. Nosocomial infection incidence was recorded during the 15 subsequent days. Fifteen patients (33%) acquired a nosocomial infection (16 infections, 15 ventilator-associated pneumonia and 1 bacteremia). Nasal NO was the only marker significantly different between patients with and without subsequent infection (day 1, 52 ppb [20-142] vs. 134 [84-203], P = 0.038; day 3, 98 ppb [22-140] vs. 225 [89-288], P = 0.006, respectively). Nasal NO fraction 148 ppb or less at day 3 had an 80% sensitivity, a 70% specificity, and an odds ratio of 2.7 (95% confidence interval, 1.9-3.8) to predict acquisition of nosocomial infection. Nonsurvivors had a higher IL-6 concentration on day 3 (P = 0.014), whereas their nasal NO fractions were not significantly different. Nasal NO seems to be a relatively sensitive and specific biomarker of subsequent nosocomial infection acquisition (at least for ventilator-associated pneumonia), which warrants confirmation in a multicenter trial.
Asunto(s)
Pruebas Respiratorias , Infección Hospitalaria/metabolismo , Óxido Nítrico/análisis , Respiración Artificial/efectos adversos , Heridas y Lesiones/metabolismo , Anciano , Anciano de 80 o más Años , Área Bajo la Curva , Biomarcadores , Bronquios , Cuidados Críticos , Infección Hospitalaria/diagnóstico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/etiología , Femenino , Humanos , Huésped Inmunocomprometido , Interleucina-10/sangre , Interleucina-6/sangre , Masculino , Persona de Mediana Edad , Cavidad Nasal , Óxido Nítrico/orina , Proyectos Piloto , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Sensibilidad y Especificidad , Heridas y Lesiones/complicaciones , Heridas y Lesiones/terapiaAsunto(s)
Inhibidores de la Angiogénesis/efectos adversos , Enfermedad Iatrogénica , Mieloma Múltiple/tratamiento farmacológico , Neumonía/inducido químicamente , Talidomida/análogos & derivados , Anciano de 80 o más Años , Inhibidores de la Angiogénesis/administración & dosificación , Progresión de la Enfermedad , Esquema de Medicación , Resultado Fatal , Femenino , Humanos , Lenalidomida , Masculino , Persona de Mediana Edad , Neumonía/diagnóstico , Neumonía/terapia , Talidomida/administración & dosificación , Talidomida/efectos adversos , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
We report a case of non-ventilator-associated nosocomial pneumonia and septicemia due to Dolosigranulum pigrum, a rare gram-positive opportunistic pathogen. The organism was isolated from bronchoalveolar lavage fluid and blood of a debilitated patient. D. pigrum was identified after 16S rRNA gene sequencing.