Three cases of cutaneous mucormycosis with Lichtheimia spp. (ex Absidia/Mycocladus) in ICU. Possible cross-transmission in an intensive care unit between 2 cases.

Mucormycoses are rare but emerging diseases with poor prognosis caused by ubiquitous fungi from the environment. In November 2008, our teaching hospital experienced three cutaneous mucormycosis due to Lichtheimia spp. (ex Absidia/Mycocladus) in the intensive care and orthopaedic units. Environmental and epidemiological investigations suggested a possible cross-transmission of L. ramosa between two patients in intensive care. This is the first report of possible person-to-person transmission of mucormycosis species. These cases show the ineffectiveness of hydro-alcoholic solutions against spores and underline the need to respect standard precautions to prevent fungi dissemination.

[Resuscitation after three hours of cardiac arrest with severe hypothermia following a toxic coma]. / Récupération sans séquelle après trois heures d'arrêt cardiaque en hypothermie à 22 degrees C au décours d'un coma toxique.

We report the case of a 37-year-old woman who survived from severe hypothermia (rectal temperature: 22 degrees C) and prolonged cardiac arrest with asystole after benzodiazepine and tricyclic antidepressant poisoning. Basic-cardiopulmonary resuscitation and mechanical ventilation was started by a French Mobile Intensive-Care unit. Spontaneous circulation was restored at 25 degrees C under epinephrin after three hours of chest compression from home to the intensive-care unit and rewarming with extracorporeal circulation. The patient was discharged at day 13 without any neurological deficit. The discussion focuses on the benefit of extracorporeal-membrane oxygenation (ECMO) as extracorporeal circulation device through femoral access, the differential diagnosis between death and recoverable cardiac arrest and neuroprotection.

[Should presumptive meningoencephalitis treatment in adults be active against Mycoplasma pneumoniae?]. / Le traitement de première intention d'une méningoencéphalite de l'adulte doit-il tenir compte de Mycoplasma pneumoniae?

INTRODUCTION: Meningoencephalitis is the most common central nervous system complication caused by Mycoplasma pneumoniae. Its frequency is probably underestimated. OBJECTIVE: The study's aim was to determine the retrospectively incidence of M. pneumoniae meningoencephalitis among other cases of encephalitis diagnosed in infectiology, neurology and ICU at the Clermont-Ferrand University hospital in 2004 and 2005. DESIGN: A case of meningoencephalitis was defined by encephalopathy (altered level of consciousness and/or change in personality), with one or more of the following symptoms: fever, seizure, focal neurological findings, meningitis, electroencephalography or neuroimaging findings consistent with encephalitis. Tumor and hematoma diagnosed by scan were excluded. M. pneumoniae was considered as a possible cause when patients had positive serological test (IgM Elisa) and/or positive PCR results for the CSF. RESULTS: Four (8.3%) patients among 48 cases of encephalitis could have been caused by M. pneumoniae. All except one convulsed initially. Pneumopathy was found in two patients. All received a specific treatment later. Antibiotics seemed to influence evolution in only two patients. These 4 cases appeared during an epidemic between November 2004 and August 2005: 48 hospitalized adults had positive serological test for M. pneumoniae in 2005 and 15 in 2004, whereas the number of tests was the same in 2004 and in 2005. CONCLUSIONS: M. pneumoniae should be investigated as a cause of meningoencephalitis if initial tests are negative, if patients have respiratory symptoms and in case of epidemic. Presumptive treatment of meningoencephalitis should include an antibiotic active against M. pneumoniae.

Comparison of tolerance of facemask vs. mouthpiece for non-invasive ventilation.

This prospective, single centre, randomised, cross-over study compares patient tolerance of the facemask and mouthpiece for delivery of non-invasive ventilation in an intensive care unit. Twenty-seven patients with acute respiratory failure were scheduled for two 45-min sessions of non-invasive ventilation with facemask and mouthpiece. The order of the sessions was chosen at random. Nurses and patients assessed the tolerance of both techniques using a visual analogue scale. The time spent by nurses and the changes in respiratory parameters were recorded. The facemask was better tolerated than the mouthpiece; all the cases of non-invasive ventilation withdrawal (n = 5) occurred with mouthpieces (p = 0.026). Less nursing time was required using the facemask for the 22 patients who underwent both procedures (p = 0.01). However, the difference in tolerance scores was not significant. Non-invasive ventilation with both facemask and mouthpiece improved the P(a)o(2)/F(i)o(2) ratio, increased the pH and decreased the P(a)co(2). Only non-invasive ventilation with the facemask lowered the respiratory rate. The facemask appears to be a better initial choice for non-invasive ventilation when compared to mouthpiece, but both can be effective.

[Effect of bronchial drainage on the improvement in gas exchange observed in ventral decubitus in ARDS]. / Influence du drainage bronchique dans l'amélioration des échanges gazeux observée en décubitus ventral au cours du SDRA.

OBJECTIVES: A bronchial secretion draining effect is frequently suggested as a mechanism for oxygenation improvement during prone positioning (PP) in patients with acute respiratory distress syndrome (ARDS). Nevertheless, it has never really been evaluated. The aim of this study was to search for an interrelationship between the volume of the bronchial secretion and the improvement of the PaO2/FIO2 ratio during prone positioning, with NO inhalation or not. STUDY DESIGN: Open prospective clinical study. PATIENTS: The study included 15 consecutive patients with severe ARDS (PaO2/FIO2 < 200 after alveolar recruitment, Murray score > 2.5). METHODS: They were returned to the prone position for 4 hours (h0-h4) combined with an inhalation of 5 ppm NO during 1 hour (h2-h3). Tracheal suction were performed hourly between h-2 and h6 and weighed on a precision scale from h-1 to h6. Haemodynamic, blood gas and respiratory compliance were recorded at h0, h2, h3, h4 and h6. RESULTS: No significant haemodynamic changes were observed in the various phases. Compared with the baseline condition at h0, PP and PP + NO respectively improved PaO2/FIO2 by 102 +/- 62% at h2 (P < 0.005) and 156 +/- 79% at h3 (P < 0.005/h0 and < 0.01/h2). 14/15 patients responded to PP and 15/15 to PP + NO (gain in PaO2/FIO2 > 10%). Concerning secretions, we collected 3.0 +/- 7.5 g, 4.4 +/- 6.1 g, 1.7 +/- 1.4 g and 1.7 +/- 1.6 between h-2 and h0, h0 and h2, h2 and h4, h4 and h6. Individual assessments showed no relationship between the PaO2/FIO2 evolution at any time and the quantity of secretions obtained during the first 2 hours in the prone position. Six patients presented secretions of less than 1 g between h0 and h2, and for whom the improvement in oxygenation was higher than average (115 +/- 53% at h2). CONCLUSION: In patients with little or moderate secretions, the improvement observed in oxygenation, with or without NO, does not depend on their volume.

Decreased susceptibility to extended-spectrum cephalosporins of a penicillin-susceptible Streptococcus pneumoniae in meningitis.

A 69-year-old woman was admitted to the hospital with meningitis due to Streptococcus pneumoniae. The strain was susceptible to penicillin but intermediate to cefotaxime. In Europe the decrease of susceptibility generally pertains more to penicillin than to cefotaxime. Such a strain is perhaps a forewarning of the existence of high-level cephalosporin-resistant strains. Despite the possible detection of the resistance by oxacillin disk, it underlines the need to determine the MICs of different beta-lactams without delay and to choose the most efficient treatment.

[Snake bite by European vipers. A multicenter study of tolerance to Viperfav, a new intravenous antivenom]. / Envenimations par vipères européennes. Etude multicentrique de tolérance du Viperfav, nouvel antivenin par voie intraveineuse.

OBJECTIVES: To evaluate the tolerance and the effectiveness of i.v. Viperfav, a new antivenom containing F(ab')2 fragments of equine antibodies, for the treatment of European viper envenomed patients. STUDY DESIGN: Open, multicentre field trial, associated with a cohort study. PATIENTS: The study included 46 patients of either gender, nine aged less then 10 years, eight between 10 and 15 years, and 28 adults, who sustained a moderate or severe viper envenomation (Grade 2 or 3). METHOD: At the inclusion, a single infusion of Viperfav was given. Depending on the clinical course, up to four additional infusions were to have been administered at 4-hour intervals. To evaluate tolerance, all symptoms were recorded. There were three effectiveness evaluation criterion (duration of hospitalisation, course of the severity grade, recovery (sequelae)) and one subjective criteria (value of the antivenom as ascertained by investigators). RESULTS: In the 46 included patients, 79 infusions were administrated. Concerning tolerance, six mild symptoms were associated to the antivenom infusions. No severe reaction occurred. The mean duration of hospitalisation was 4 days 19 hours +/- 13 hours. A severity grade decrease by at least one point was observed in 35 patients, and all were discharged without sequelae. For the investigators the antivenom was inefficient in only two patients (grade 3 with tissue lesions). CONCLUSIONS: In comparison with literature data (5 to 10% of severe reactions attributable to the antivenom), the tolerance of Viperfav can be considered as satisfactory. As all criteria were in favour of a positive benefit to risk ratio, the authors recommend the use of Viperfav i.v. for the grade 2 and 3 envenomations instead of the current less purified antivenom, which can only be administered by the intramuscular route.

Combined nitric oxide inhalation, prone positioning and almitrine infusion improve oxygenation in severe ARDS.

PURPOSE: To determine the efficacy and side effects of prone positioning (PP) and nitric oxide (NO) inhalation, alone, associated, or combined with i.v. almitrine for the treatment of hypoxaemia in severe acute respiratory distress syndrome (ARDS). METHODS: Over a period of 20 months, 27 consecutive critically ill patients with severe ARDS (Murray score > 2.5, PaO2/FiO2 < 170 after alveolar recruitment) were prospectively and randomly included. They inhaled NO for two hours at concentrations of 5 and 10 ppm for one hour each (H0-H2). One hour later, they were returned to the prone position for four hours (H3-H7). During the last two hours in this position (H5-H7), they were assigned to further inhalation of 10 ppm NO (Group B, n = 9) or to no further inhalation (Group A, n = 9). In group C (n = 9), the procedure for group B was combined with perfusion of 16 mg.kg-1.min-1 almitrine throughout the study. RESULTS: Compared with control values, two hours NO inhalation improves PaO2/FiO2 and shunt effect by +28% and -9%, PP by +88% and -27%, PP + almitrine by +132% and -28%, NO + almitrine by +153 and -28%, PP + NO by +94% and -29%, NO + PP + almitrine by +327 and -48%. NO inhalation reduces pulmonary vascular resistance. Other haemodynamic parameters remain unchanged, whatever the treatment. NO inhalation improves PaO2/FiO2 by over 20% in 50% of the patients and PP is effective in 78% of the cases. CONCLUSION: Prone Position improves PaO2/FiO2 significantly more than NO alone but less than PP + almitrine or NO + almitrine. The best results are obtained with the association of NO + Prone position + Almitrine.

[Primary antiphospholipid syndrome of fatal course and osteoarticular cytosteatonecrosis]. / Syndrome primaire des antiphospholipides d'évolution fatale et cytostéatonécrose ostéoarticulaire.

The antiphospholipid syndrome produces acute occlusions of arteries and veins. This syndrome can cause a multiple organ systems failure whose outcome is often fatal. The authors report a case of the primary, antiphospholipid syndrome characterized by this fatal outcome, a so-called "devastating" syndrome following pulse steroids. In this patient, the antiphospholipid antibodies had been found after presenting bone-marrow fat necrosis, which led to extensive lesions of knees, hips and shoulders. Damage to the cell membranes in necrotic lesions might have promoted the immune response against phospholipids. The potential risks of pulse doses of steroids in the antiphospholipid syndrome are documented by the present observation, which also suggests that antiphospholipid antibodies should be determined in cases of fat necrosis of all origins.

[Rhabdomyolysis in severe acute asthma]. / Rhabdomyolyse au cours d'un asthme aigu grave.

A case is reported of a 74-year-old man who developed rhabdomyolysis during treatment for status asthmaticus. This patient had a history of asthma. He was admitted after a cardiac arrest during a severe asthma attack. Continuous muscle relaxation (4 mg.h-1 of pancuronium for 10 days; total dose 960 mg) was required to carry out mechanical ventilation. Bronchodilators and high doses of steroids (300 mg.day-1 of methylprednisolone for 10 days) were also given. After the administration of muscle relaxant had been discontinued, the patient displayed a severe, predominantly proximal, quadriplegia as well as a raised blood creatinine kinase concentration. The urine was brown coloured over a 24 h period. Rhabdomyolysis was confirmed by muscle biopsy. The patient recovered over a period of one month. This case is discussed in the light of some other similar reports in the literature. It seems that the combination of muscle relaxant with high doses of steroids is to be incriminated.

Selective digestive decontamination by erythromycin-base in a polyvalent intensive care unit.

OBJECTIVE: To study the effect of selective digestive tract decontamination by erythromycin-base on the incidence of carriage and infection with MR Enterobacteriaceae producing an extended spectrum beta-lactamase (ESB). DESIGN: After a 10-week prospective survey to ascertain the baseline incidence in two bays (1 and 3) of the same ICU, bay 1 was compared with bay 3 during a further survey of 6 months. The patients in bay 1 received erythromycin-base. SETTING: Two non-contiguous bays, 1 and 3, of 4 beds, in the same polyvalent ICU of a university hospital. PATIENT: Consecutive patients with unit stay longer than 2 days; 34 patients were included during the control period, 43 in bay 1 (decontamination) and 46 in bay 3 (control) during the trial period. INTERVENTION: Erythromycin-base, 1 g t.i.d. in powder form administered by gastric tube to patients in bay 1 from admission to discharge. MEASUREMENTS AND RESULTS: Digestive tract carriage was monitored by cultures of gastric and rectal swab specimens, sampled twice a week. Enterobacteriaceae were isolated on Drigalski agar with incorporated ceftazidime (4 mg/l). In bay 1 there was a decrease in ESB producing Enterobacteriaceae (23% vs 10%, p = 0.0004) from rectal swab, especially in K. pneumoniae (15% vs 2%, p = 10(-5)), during the decontamination period in comparison to the control period. During the trial period the only differences observed between bays 1 and 3 were in the gastric samples: K. pneumoniae were less often isolated in bay 1 than in bay 3 (0% vs 3%, p = 0.03). Intestinal carriage with multiresistant Enterobacteriaceae occurred in 28% patients in bay 1 and 30% patients in bay 3 during the trial period (p = 0.79). Erythromycin-base did not delay the carriage by patients in bay 1 (log rank test p = 0.42). CONCLUSION: Erythromycin-base was not effective in preventing digestive tract carriage due to Enterobacteriaceae resistant to third generation cephalosporin by production of chromosomal cephalosporinase. The decrease in isolates containing K. pneumoniae in bay 1 cannot be definitively attributed to erythromycin-base, since the number of this species in bay 3 was low.

Clinical and bacteriological study of nosocomial infections due to Enterobacter aerogenes resistant to imipenem.

Enterobacter aerogenes strains resistant to imipenem were isolated in 10 patients, 7 of whom had received imipenem-cilastatin. The strains were differentiated by biotype, antibiotype, and plasmid content. All of the strains overproduced a chromosomal cephalosporinase and lost a major outer membrane protein with a size of about 40 kDa. In 5 of the 10 patients, E. aerogenes strains resistant to extended-spectrum cephalosporin were isolated during the same stay. In three patients, the similarity between the imipenem-susceptible and -resistant strains suggests the occurrence of mutation and reversion in vivo. The combination imipenem-cilastatin has been critically important for use with multiresistant strains of Enterobacter spp., but its use increases the risk of selection of imipenem-resistant strains.

Treatment of a meningitis due to an Enterobacter aerogenes producing a derepressed cephalosporinase and a Klebsiella pneumoniae producing an extended-spectrum beta-lactamase.

A case of nosocomial meningitis due to a Klebsiella pneumoniae producing a CAZ-5 extended-spectrum beta-lactamase and an Enterobacter aerogenes producing a derepressed cephalosporinase is reported. The intrathecal catheter incriminated was removed and a treatment with ceftazidime (4 g/24 h) and amikacin (1.5 g/24 h) was started. After 24 h ceftazidime was replaced by imipenem (2 then 4 g/24 h). This treatment failed to obtain cerebrospinal fluid sterilization; therefore the imipenem dosage was increased to 8 g/24 h and two intrathecal infusions of amikacin (50 mg) were carried out. Thereafter the patient recovered.

A case-control study of an outbreak of infections caused by Klebsiella pneumoniae strains producing CTX-1 (TEM-3) beta-lactamase.

In July 1984 Klebsiella pneumoniae producing beta-lactamase CTX-1(TEM-3) (K. pneumoniae-CTX-1) spread from an Intensive Care Unit (ICU) throughout the hospitals of Clermont-Ferrand, France, and were isolated in four other hospitals of the region. A retrospective case control study was conducted in the ICU to characterize the risk factors for nosocomial infection with this organism. The cases were the 74 patients who had had K. pneumoniae-CTX-1 isolated from one or more clinical samples between July 1984 and December 1987. They were compared with 74 controls for host risk factors, underlying disease, procedures and antibiotic treatment. The monthly incidence of infection/colonization varied from 0% to 14.6%. The mortality rate attributable to this organism was 0.26% during the study period. The duration of stay of cases was longer than that of controls. More cases than controls had ventilatory assistance. However, the predominant risk factor was emergency abdominal surgery. Before K. pneumoniae-CTX-1 was isolated, cases received quinolones and trimethoprim sulphamethoxazole more often than controls. However, only 15% of cases had received third generation cephalosporins while at the onset of K. pneumoniae-CTX-1 infection colonization, 32 patients were no longer being given antibiotics. The use of antibiotic prophylaxis by, for example, selective digestive tract decontamination should be considered in patients at high risk of infection.

[Potassium cyanide poisoning treated with hydroxocobalamin]. / Intoxication au cyanure de potassium traitée par l'hydroxocobalamine.

A fifteen-year-old girl, with a clean medical history, was admitted to the intensive care unit 90 minutes after ingestion of 2.5 g potassium cyanide. She had typical signs of severe cyanide poisoning including deep coma, circulatory failure, and major metabolic acidosis. Gastric lavage and antidotal treatment with 4 g hydroxocobalamin and 8 g sodium hyposulfite was administered without delay together with supportive treatment consisting of mechanical ventilation with FIO2, blood alkalinisation and administration of beta-stimulants. These measures led to a rapid clinical improvement. The ventilatory support was discontinued after 24 hours and the patient left the intensive care unit on the fourth day with only slightly impaired mental status. She survived despite a very high blood cyanide concentration (494 mumol.l-1 on admission) probably because of the rapid symptomatic and antidotal treatment.

[Pseudomonas cepacia septicemias: therapeutic difficulties]. / Septicémies à Pseudomonas cepacia: difficultés thérapeutiques.

From Summer 1983 to Summer 1986, 34 cases of septicemia due to Pseudomonas cepacia could be detected in several intensive care units in the university hospital in Clermont-Ferrand (France). Intravascular catheters can be involved in the inoculation of this bacterial agent: a previous respiratory tract infection or a drained abscess can be the portal of entry of the bacteremia. Three patients died from the septicemia and the overall prognosis of the intensive care patients looks significatively worsened. The removing of the catheters and drains, the opening of an infected collection were useful but not sufficient to overcome. The choice of a good antibiotic was not easy; only ceftazidime, minocycline and cotrimoxazole have a fair activity in vitro. We only assessed the good results of ceftazidime. Pseudomonas cepacia is also resistant for many antiseptics. The large use of disinfecting procedures in intensive care units promotes the diffusion of this bacteria.