Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versus piperacillin-susceptible organisms.

We sought to determine the epidemiological characteristics of patients in an intensive care unit (ICU) who developed ventilator-associated pneumonia (VAP) caused by piperacillin-resistant Pseudomonas aeruginosa (PRPA; n=34) or piperacillin-susceptible P. aeruginosa (PSPA; n=101). According to univariate analysis, the factors associated with the development of PRPA VAP were presence of an underlying fatal medical condition, immunocompromised status, longer previous hospital stay, less-severe illness at the time of ICU admission, duration of mechanical ventilation before onset of VAP, number of classes of antibiotic received, and previous exposure to imipenem or fluoroquinolone. Multivariate logistic regression analysis identified the following significant independent factors: presence of an underlying fatal medical condition (odds ratio [OR], 5.6), previous fluoroquinolone use (OR, 4.6), and initial disease severity (OR, 0.8). We concluded that the clinical characteristics of patients who develop PRPA VAP differ from those of patients who develop PSPA VAP. Restricted fluoroquinolone use is the sole independent risk factor for PRPA VAP that is open to medical intervention.

Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of the usefulness of bronchoalveolar lavage and the protected specimen brush.

PURPOSE: To compare the usefulness of specimens recovered using a protected specimen brush and those recovered by bronchoalveolar lavage in the diagnosis of nosocomial pneumonia occurring in intubated patients undergoing ventilation, we performed both procedures in patients suspected of having pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. PATIENTS AND METHODS: Twenty-one patients (16 men and five women) with an average age of 57 +/- 12 years were studied. They had been receiving mechanical ventilation for 8 +/- 6 days before inclusion in the trial. The clinical suspicion for nosocomial bacterial pneumonia was high in these patients. Fiberoptic bronchoscopy was performed in each patient. Bronchoscopy specimens were obtained by a protected specimen brush and by bronchoalveolar lavage, and were then processed for quantitative bacterial and fungal culture using standard methods. Total cell counts were performed on an aliquot of resuspended original lavage fluid. Differential cell counts were made on at least 500 cells. In addition, 300 cells were examined at high-power magnification and the percentage of cells containing intracellular microorganisms and the average number of extracellular organisms per oil-immersion field were determined. RESULTS: Quantitative culture of specimens recovered using the protected specimen brush were positive (more than 10(3) colony-forming units [cfu]/ml) in five of five patients with subsequently confirmed pneumonia, and negative (less than 10(3) cfu/ml) in 13 of 13 patients without bacterial pneumonia, but results were not available until 24 to 48 hours after the procedure. Quantification of intracellular organisms in cells recovered by lavage was also useful in distinguishing patients with pneumonia (more than 25 percent of cells with intracellular organisms in five of five patients) from those without pneumonia (less than 15 percent of cells with intracellular organisms in all cases), and results were available immediately. In contrast, quantitative culture of lavage fluid and differential cell counts were of little value in identifying infected patients. CONCLUSION: The protected specimen brush and microscopic identification of intracellular organisms in cells recovered by lavage yield useful and complementary information, and together permit rapid and specific treatment of most patients with nosocomial pneumonia.

Incidence and morbidity of cytomegaloviral infection in patients with mediastinitis following cardiac surgery.

To determine the incidence and morbidity of infections with CMV associated with mediastinitis after conventional cardiac surgery, 115 consecutive adult patients with mediastinitis were evaluated with viral cultures of blood and urine. Shedding of CMV was seen in 29 patients (25 percent) within a mean period of 37 +/- 22 days after cardiopulmonary bypass. Viremia was documented in 79 percent (23) of these 29 patients. Acute renal failure and enzymatic abnormalities (AST and LDH) were significantly more common in patients with virologically proven infection with CMV (p less than 0.05). In patients who survived the initial period of bacterial infection, major differences in their clinical course were observed according to their virologic status. After the 15th day of hospitalization following the débridement, the persistence of local infection was more frequent (p less than 0.05) and the mortality was higher (p less than 0.01) in CMV-infected patients. Moreover, the mean duration of hospitalization in the ICU for survivors was 69 +/- 36 days in viral shedders, compared with 48 +/- 27 days in nonshedders (p less than 0.05). Infection with CMV in mediastinitis occurs frequently and is associated with persistence of local infection, prolonged hospitalization, and increased late mortality.

Fiberoptic bronchoscopy in ventilated patients. Evaluation of cardiopulmonary risk under midazolam sedation.

One hundred seven acutely ill ventilated patients were prospectively studied to ascertain the severity and frequency of alterations in gas exchange and hemodynamic parameters during brief bronchoscopy. Sedation was performed using midazolam (0.1 mg/kg IV) without topical anesthesia. An average decline in PaO2 of 26 percent was observed at the end of the procedure, compared to the baseline value, and this was associated with a mild increase in PaCO2 in spite of the use of a special adapter. Alterations in mean systolic blood pressure appeared to be modest, consisting of a 10 percent decrease from the control level, related to sedation, and a 10 percent rise from baseline during the procedure, associated with a concomitant mild tachycardia. At that time, central hemodynamic measurements performed in a subset of 31 patients showed a significant increase in cardiac output associated with higher pulmonary wedge pressure. Fourteen patients developed hypoxemia of less than 60 mm Hg on FIO2 adjusted to 0.8. Of the ten risk factors univariately associated with hypoxemia, only the presence of ARDS (p less than 0.001) and "fighting" the ventilator during the procedure (p less than 0.05) remained significant after stepwise logistic regression. Attempts to prevent hypoxemia in critically ill patients should focus on inducing complete sedation, with careful attention to hemodynamic status, or providing maximal levels of oxygen to the ventilator (or both).

Long-term outcome and quality of life of patients requiring multidisciplinary intensive care unit admission after cardiac operations.

Patients with organ failure or severe infection after cardiac operations may require prolonged stays in the intensive care unit. This study examined long-term mortality and determined quality of life for surviving patients in this group. This observational cohort study was conducted at Bichat Hospital, Paris, an academic tertiary care center. The study group consisted of 116 consecutive patients who underwent cardiac operations and were transferred to the multidisciplinary intensive care unit between January 1986 and December 1987. Patients referred for mediastinitis were automatically excluded. Respiratory failure (88.8%) and hemodynamic instability (81.9%) were the main causes of transfer; an infection was present in 23.3% of patients at entry into the intensive care unit. Twenty-seven patients (23.3%) died in the intensive care unit. Presurgical New York Heart Association functional class, postoperative bacteremia before admission to the intensive care unit, and severity of illness on admission to the intensive care unit were independent predictors of death in the intensive care unit. After an average follow-up of 81 months (range 70 to 93 months), 69% of the patients alive at transfer from the intensive care unit were still alive. Preoperative New York Heart Association functional class was the only long-term independent prognostic factor. Quality of life, as evaluated by the Nottingham Health Profile, was good for more than 70% of the survivors and was not influenced by any recorded variables, with the exception of age.

Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients.

To evaluate the accuracy of clinical judgment in the diagnosis and treatment of nosocomial pneumonia in ventilated patients, we studied 84 patients suspected of having nosocomial pneumonia because of the presence of a new pulmonary infiltrate and purulent tracheal secretions. We prospectively evaluated the accuracy of diagnostic predictions and therapeutic plans independently formulated by a team of physicians aware of all clinical, radiologic and laboratory data, including the results of Gram-stained bronchial aspirates. Definite (n = 51) or probable (n = 33) diagnoses could be established in all patients by strict histopathologic and/or bacteriologic criteria. Only 27/84 patients were diagnosed as having pneumonia. Organisms responsible for pneumonias were identified by quantitative cultures of samples obtained using a protected specimen brush or pleural fluid cultures. Four hundred eight predictions were made for the 84 studied patients. Clinical diagnoses for patients subsequently diagnosed as having pneumonia were accurate in 81/131 cases (62 percent). Furthermore, only 43/131 (33 percent) therapeutic plans proposed for these patients represented effective therapy. Common causes of inappropriate treatment included failure to diagnose pneumonia (50 plans), failure to effectively treat highly resistant organisms (21 plans), and failure to treat all organisms in cases of polymicrobial pneumonia (14 plans). Therapeutic plans formulated for patients without pneumonia included the unnecessary use of antibiotics in 45/277 cases (16 percent). These findings indicate that the use of clinical criteria alone does not permit the accurate diagnosis of nosocomial pneumonia in ventilated patients, and commonly results in inappropriate or inadequate antibiotic therapy for these patients.

Usefulness of quantitative cultures of BAL fluid for diagnosing nosocomial pneumonia in ventilated patients.

STUDY OBJECTIVE: To evaluate the role of quantitative cultures of BAL for diagnosing nosocomial pneumonia in mechanically ventilated patients. DESIGN: Cohort study. SETTING: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center. PATIENTS: A total of 141 episodes of suspected lung infection in 84 consecutive patients mechanically ventilated for 48 h or more. MEASUREMENTS AND RESULTS: Microbiologic findings obtained using BAL were compared with those obtained with protected specimen brush (PSB) samples and their operating characteristics were determined. The level of qualitative agreement between BAL and PSB specimen cultures was high, with 83% of the organisms isolated in PSB specimens being recovered simultaneously from BAL fluid. In addition, the results of quantitative BAL and PSB cultures were significantly correlated (rho = 0.46, p < 0.0001). Fifty-seven cases of pneumonia were diagnosed based on the following criteria: PSB sample yielding > or = 10(3) cfu/mL of at least one microorganism and/or > or = 5% of cells containing intracellular bacteria on direct examination of BAL. The operating characteristics of BAL fluid cultures were determined using different ways to report the results and over a range of values. The discriminative value of 10(4) cfu/mL was found to be an optimal threshold, with a sensitivity of 82% (95% confidence interval [CI], 76 to 88) and a specificity of 84.5% (95% CI, 79 to 90). CONCLUSIONS: These results indicate that BAL fluid cultures can offer a sensitive and specific means to diagnose pneumonia in ventilated patients and may provide relevant information about the causative pathogens.

Osseointegration of macroporous calcium phosphate ceramics having a different chemical composition.

Calcium phosphate macroporous ceramics are biocompatible for bone surgery. Their osseointegration is, however, sometimes very poor. To measure the effect of the calcium phosphate content of the ceramic on its osseointegration, macroporous ceramics, differing in their chemical composition, were implanted into sheep femurs. The ceramics were composed of different percentages of hydroxyapatite (HA) and beta-tricalcium phosphate (beta-TCP). All other characteristics were the same. Results were assessed histologically with image analysis and showed significant differences in the amount of bone formed at the contact of the different ceramics. Ceramics containing beta-TCP induced better osseointegration than pure HA ceramics.

Is it possible to cure mediastinitis in patients with major postcardiac surgery complications?

BACKGROUND: The prognosis for mediastinitis after cardiac operation has improved during the last two decades, but most series do not include patients who already have a major postoperative complication when the infection developed. METHODS: Our 9-year prospective study of 371 consecutive patients with mediastinitis compared the characteristics of patients admitted to the intensive care unit primarily for mediastinitis with those who developed mediastinitis after intensive care unit admission for severe postoperative organ failure. RESULTS: We identified 323 (87%) primary and 48 (13%) secondary mediastinitis patients. The incubation time for mediastinitis was longer for secondary mediastinitis patients, despite similar initial operations. Staphylococcus aureus was responsible for approximately 60% of the episodes in both groups; however, the incidence of methicillin resistance was 2.5 times higher in secondary mediastinitis patients (p < 0.0001). The mediastinitis cure rate was similar for both groups. However, intensive care unit mortality (63% versus 21%), duration of mechanical ventilation (40 versus 9 days), and length of intensive care unit stay (53 versus 28 days) were significantly higher for secondary mediastinitis patients (p < 0.0001). CONCLUSIONS: The presence of a prior major postoperative complication does not alter the cure rate of mediastinal infections, but does greatly reduce the survival rate.

Closed drainage using Redon catheters for local treatment of poststernotomy mediastinitis.

BACKGROUND: Continuous irrigation has been used worldwide for the treatment of acute poststernotomy mediastinitis. However, its high rate of failure led to the development of new methods, among them closed drainage with Redon catheters. METHODS: We evaluated the results obtained with Redon catheters in 70 patients, and compared them to those obtained in 38 patients treated with continuous irrigation. RESULTS: The two treatment groups were not different for age, type of cardiac operation, and initial severity of illness. Local failure of Redon catheter drainage occurred less frequently (20 of 38 versus 9 of 70 patients; p = 0.0001). This reduced failure rate was mainly attributable to a lower incidence of superinfections (10 of 38 versus 2 of 70 patients; p = 0.0002), but also to a lower incidence of primary failure (10 of 38 versus 7 of 70 patients; p = 0.026). Mortality was significantly decreased (15 of 38 versus 12 of 70 patients; p = 0.01). The other major advantage of this technique was the simplicity of its use. CONCLUSIONS: The technique using Redon catheters should be considered an effective and convenient treatment of acute poststernotomy mediastinitis.

Predicting the outcome in elderly patients of hospital admission for acute care in Paris, France: construction and initial validation of a simplex index.

OBJECTIVE: To develop a simple index able to identify at an early stage those elderly patients at high risk of requiring discharge to a residential or nursing home after admission to hospital for acute care. For these patients, early discharge planning might lead to a more effective management and reduce the length of hospitalisation. DESIGN, SETTING, AND PATIENTS: This was a prospective study conducted in two teaching hospitals in Paris, France. A total of 510 consecutive patients was included. They were aged 75 years or more and had been admitted to acute medical care units through the emergency department. MEASUREMENTS: Demographic data, social support, physical disability, mental disability, and pathologic status were assessed shortly after admission (within 24-48 hours). MAIN OUTCOME MEASURES: Outcome of hospitalisation was defined as discharge to home or residential/nursing home. RESULTS: The index, developed by multiple logistic regression, included six variables: the wish of patients' principal career about their returning home after acute hospitalisation, presence of a chronic condition, ability to perform toileting, ability to know the name of the hospital or the city, their age, and their living arrangements. The sensitivity of the index in identifying patients at high risk of requiring discharge to a residential/nursing home was 74.4%, the specificity 63.8% the positive predictive value was 57.8%, and the negative predictive value was 80.6%. CONCLUSIONS: The simple index, using data available very early in the course of hospitalisation, provides an accurate prediction of the hospitalisation outcome. The performance of the index should be tested in other populations and the practical benefits of risk screening should be assessed in a controlled trial to evaluate whether the intervention is useful and without any adverse effects.

The changing clinical aspects of infective endocarditis: descriptive review of 90 episodes in a French teaching hospital and risk factors for death.

OBJECTIVE: We wanted to describe the epidemiological aspects of infective endocarditis (IE) in a French hospital and identify the prognostic factors. METHODS: We reviewed the clinical, echocardiographic and microbiological features, and the outcome of 89 patients (90 episodes, median age 60 years) with IE over 18 months. Logistic regression analysis was used to identify prognostic factors for death. RESULTS: A native valve was involved in 68 cases (75.5%); in 7 of these the patient was an intravenous drug user. A prosthetic valve was involved in 22 cases (24.5%); 5 of these were of early onset. Diagnosis was definite in 87% of cases. Median time to diagnosis was 3 days. Twenty-five patients (28%) were immunocompromised. A portal of entry, usually cutaneous, was identified in 65% of cases. Sixty-two percent of patients had an underlying heart disorder, usually degenerative. The infection involved the left heart in more than 75% of cases. One or more vegetations were detected in 75% of cases. The median size of vegetation was 15 mm. Isolated agents were mainly staphylococci (n=40 (44%), including 12 coagulase-negative isolates), and streptococci (n=23 (25%), including 7 enterococci). In 11 cases (12%), cultures remained negative. Nineteen episodes were nosocomial and Staphylococcus aureus was implicated in 11 of them. Fifty percent of patients had at least one complication: heart failure (n=42), kidney failure (n=44), embolism (n=35), septic shock (n=19). Surgery was performed in 49 cases (54%) due to heart failure (n=19), cerebral embolism (n=12), and/or severe valve lesions (n=27). Eighteen patients died, 10 of whom were infected with S. aureus. Nosocomial IE (P=0.0008), heart failure (P=0.004) and prosthetic valve (P=0.01), but not S. aureus were independently associated with death. CONCLUSIONS: S. aureus was the main microorganism isolated in our patients. However, it was not independently predictive of fatal outcome.

Late endocarditis-associated obstructive dysfunction of a tricuspid ball-cage-type valve. Doppler echocardiographic findings and therapeutic implications.

Thrombotic obstruction is rare in bacterial endocarditis involving prosthetic heart valves. A 45-year-old man who had three intracardiac, ball-cage-type prosthetic valves, presented with streptococcal septicemia. Major obstruction of the tricuspid Smeloff-Cutter valve and normal function of the two other prostheses were documented by Doppler echocardiography. Emergency replacement of the tricuspid valve alone was decided on the one basis of this echocardiographic diagnosis, and successfully performed. Operative findings confirmed the noninvasive findings.

[Evaluation of bidimensional echography in the etiological orientation of pericardial disease. Apropos of 39 anatomo-echographic comparisons]. / Evaluation de l'échographie bidimensionnelle dans l'orientation étiologique des maladies du péricarde. A propos de 39 confrontations anatomo-échographiques.

Echocardiography provides a firm diagnosis of pericardial effusion and evaluates its repercussions on the cardiac cavities. The images obtained with two-dimensional echocardiography are of such quality that the anatomical lesions can be analyzed, but the predictive value of this examination for the aetiological diagnosis has not yet been established. To investigate this point we have compared the images recorded in 39 episodes of pericardial disease with the corresponding anatomical data provided by surgery (n = 38)) or necropsy (n = 1) less than 48 hours after the ultrasonic examination. In one case, the purely solid nature of the pericardial content, suspected on the presence of an echo-filled cavity with adherent membranes, was confirmed at surgery. Conversely, the totally or partly liquid nature of the effusion was ascertained whenever the two pericardial membranes were separated by an echo-free cavity in at least one portion of the region examined, and there was no false-positive result (n = 38). The images obtained could be compared with the anatomical lesions in 28 out of 38 cases of partly or totally liquid pericarditis. The pericardial cavity was entirely echo-free in 12 of these cases, and this was confirmed by the anatomical examination, except in one case where epicardial nodules were found at surgery. Abnormal intrapericardial images were detected in the other 16 echocardiographic examinations, viz.: round masses in 2 cases, linear echoes in 2 cases and mattress-like deposits in 12 cases. In 9 of these 16 cases corresponding intrapericardial formations were discovered at surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of molsidomine during the cold test in stable coronary insufficiency under beta-blocker treatment]. / Effets de la molsidomine lors d'un test au froid chez l'insuffisant coronaire stable sous traitement bêtabloquant.

The heart rate, cardiac output, coronary sinus blood flow, systolic and end diastolic left ventricular pressures, femoral arterial pressure and coronary oxygen arterio-venous difference were measured in 12 patients with stable coronary artery disease without cardiac failure on long-term betablocker therapy, before and 45 minutes after 2 or 3 mg sublingual molsidomine. The measurements were repeated in 8 patients during a cold pressor test. Under basal conditions, molsidomine decreased the systolic and end diastolic left ventricular pressures, mean femoral arterial pressure, cardiac output and double product. The coronary oxygen arterio-venous difference was unchanged. Coronary sinus flow and myocardial oxygen consumption decreased. In the 2 patients who were given 3 mg molsidomine, a progressive reduction in systolic left ventricular pressure to 70% or less than its initial value, necessitated immediate treatment with volume expanders. During the cold pressor test before molsidomine the systolic and end diastolic left ventricular pressures, mean femoral arterial pressure and the double product increased. Coronary sinus flow was unchanged overall: it decreased in 6 patients, increased in 2 patients and remained the same in 1 patient. Coronary resistance increased in 6 patients and decreased in only one patient. During the cold pressor test after molsidomine there was a significant reduction in the increase of systolic left ventricular pressure, mean femoral artery pressure and double product. Coronary sinus blood flow increased in 5 patients and decreased in only one case. Coronary resistance decreased in half the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hospital discharge planning and length of hospital stay in elderly patients admitted through the emergency department]. / Orientation à la sortie de l'hôpital et durée de séjour hospitalier des personnes âgées admises par les urgences.

A prospective study was organized in two teaching hospitals in Paris, including 426 elderly patients aged 75 and more, who had been hospitalized through the medical emergency department. The goal of the study was to assess the influence of difficulties of orientation at discharge on the length of stay, independently of other risk factors. The mean length of stay was 18.3 +/- 15.4 days. Orientation at discharge toward a social or a nursing care institution was associated with a 12 days longer mean length of stay than a home discharge. A longer length of stay was also associated with: a strictly social problem at admission, the diagnoses of dementia, confusion, social problem, fall or general health impairment, a short or long-term fatal prognosis, a poor mental status, refusal of home discharge as expressed by the referent person. Multivariate analysis showed that discharge toward a social or a nursing care institution was the first explanatory factor, explaining 12% of variance. These results suggest that the hospital discharge management has a major influence on the elderly length of hospital stay. Therefore, an interdisciplinary care management, including social and geriatric evaluation as soon as the patient is admitted at the emergency department, should be evaluated, in order to avoid problems of orientation that may occur at discharge.

[Splenic involvement in infectious endocarditis. Association for the Study and Prevention of Infectious Endocarditis]. / Les atteintes spléniques au cours des endocardites infectieuses. Association pour l'étude et la prévention de l'endocardite infectieuse.

INTRODUCTION: Splenic involvement in the course of endocarditis consists in either splenic infarct or abscess. Pathophysiological examinations suggest the existence of a continuum between the two types of lesion. Signs and symptoms are usually poor or aspecific. Current incidence and diagnostic methods are rarely reported in recent medical literature. EXEGESIS: We report a retrospective study conducted from a questionnaire that was circulated to nine French medical units. Two hundred and twenty five patients with infectious endocarditis according to Duke university criteria were included in the study. The existence of splenic lesions was investigated in 153 patients (68%). Splenic involvement was documented in 35 patients. Diagnostic methods were: abdominal echography (n = 77), abdominal CT scan (n = 40), and both techniques (n = 36). The incidence of splenic lesions was 9%, 35% and 36%, respectively. Among patients investigated using both diagnostic techniques, splenic abnormalities were detected by CT scan in 13 cases and by echography in six cases. Splenic abscess was suspected in nine patients by combining suggestive clinical course and radiological abnormalities, but was definitively evidenced in only four patients (surgery, n = 2, post-mortem examination, n = 2) presenting with large lesions (> or = 8 cm) associated with aortic endocarditis. All other 26 cases were categorized as splenic infarcts; however, diagnosis was confirmed in only two cases (surgery n = 1, autopsy n = 1). CONCLUSION: These data suggest that: 1) the incidence of splenic involvement during endocarditis is approximately 35%, 2) CT scan is probably superior to echography for spleen screening, and 3) incidence of abscess requiring specific surgery is very low, inferior to 2%.

[Nosocomial pneumonia in intensive care units]. / Pneumopathies nosocomiales en réanimation.

Nosocomial pneumonia is associated with substantial morbidity and mortality. Patients treated with mechanical ventilation have the highest risk for developing this intensive care unit acquired infection. Gram-negative bacilli are the predominant organisms responsible for pneumonia in this setting. However, Staphylococcus aureus has recently emerged as a significant isolate. Nosocomial pneumonia is difficult to diagnose clinically in ventilated patients because fever, lung infiltrate on chest X-ray, leukocytosis are frequent in severely ill patients under mechanical ventilation whatever lung infection is present or not and because lower respiratory tract of such patients is colonized by potentially pathogenic bacteria independently of the presence of true lung infection; thus, different diagnostic strategies are proposed. Our personal bias is that using bronchoscopic techniques to obtain bronchoalveolar lavage and protected-brush specimens permits us to devise a therapeutic strategy that is superior to one based only on clinical evaluation. Measures for prevention of nosocomial infection are essential to decrease the incidence of nosocomial pneumonia and the emergence of multiresistant pathogens.