Community-acquired pneumonia and positive urinary antigen tests: Factors associated with targeted antibiotic therapy.

BACKGROUND: The use of rapid microbiological tests is supported by antimicrobial stewardship policies. Targeted antibiotic therapy (TAT) for community-acquired pneumonia (CAP) with positive urinary antigen test (UAT) has been associated with a favorable impact on outcome. We aimed to determine the factors associated with TAT prescription. PATIENTS AND METHODS: We conducted a retrospective multicenter study including all patients presenting with CAP and positive UAT for Streptococcus pneumoniae or Legionella pneumophila from January 2010 to December 2013. Patients presenting with aspiration pneumonia, coinfection, and neutropenia were excluded. CAP severity was assessed using the Pneumonia Severity Index (PSI). TAT was defined as the administration of amoxicillin for pneumococcal infection and either macrolides or fluoroquinolones (inactive against S. pneumoniae) for Legionella infection. RESULTS: A total of 861 patients were included, including 687 pneumococcal infections and 174 legionellosis from eight facilities and 37 medical departments. TAT was prescribed to 273 patients (32%). Four factors were found independently associated with a lower rate of TAT: a PSI score≥4 (OR 0.37), Hospital A (OR 0.41), hospitalization in the intensive care unit (OR 0.44), and cardiac comorbidities (OR 0.60). Four other factors were associated with a high rate of TAT: positive blood culture for S. pneumoniae (OR 2.32), Hospitals B (OR 2.34), E (OR 2.68), and H (OR 9.32). CONCLUSION: TAT in CAP with positive UAT was related to the hospitals as well as to patient characteristics.

Antimicrobial stewardship program and quality of antibiotic prescriptions.

OBJECTIVE: National recommendations have been issued to define which optimal organization in hospitals could improve the quality of antibiotic prescription. Our aim was to check whether there was a link between applying these national recommendations and the quality of antibiotic prescriptions. PATIENTS AND METHODS: A prospective study was carried out in three French regional hospitals (A to C), to assess how recommendations were applied. Hospital organization was measured with the ICATB score (antimicrobial stewardship index) and the appropriateness of antibiotic prescription was assessed by an audit during 1 week by two investigators, who shadowed physicians during bedside visits, in various medical and surgical departments. RESULTS: There was a considerable difference in the organization of these three hospitals in terms of computerized prescriptions, formulary restriction, availability of recommendations, and antibiotic consumption defined as delivered daily-dose. Institution A had strictly followed recommendations for hospital organization, but these were less observed in institution B and C. The prevalence of antibiotic treatment was comparable in the three hospitals, and concerned over 25% of patients. In institution A, 60% of antibiotic prescriptions were inadequate, 23% were not appropriate and 17% were optimal. In institution B, these figures reached 36%, 34%, and 34%, while in institution C they reached 25%, 55%, and 20%, respectively. CONCLUSION: There is no clear link between applying national recommendations for antibiotic prescription and optimization of hospital organization and the quality of antibiotic prescriptions.

Continuous noninvasive measurement of aortic blood flow in critically ill patients with a new esophageal echo-Doppler system.

PURPOSE: Determination of aortic blood flow (ABF) using esophageal Doppler has been proposed as a low invasive hemodynamic monitoring method. The esophageal echo-Doppler Dynemo 3000 (Sometec Inc., Paris, France) system, recently available on the market, is an original device measuring simultaneously, and at the same anatomic level, aortic diameter, and blood flow velocity. Until now, this material has been used exclusively for peroperative monitoring. The objectives of the study were to assess the feasibility and reliability of use for continuous measurements of ABF in hemodynamically compromised intensive care unit patients; and to compare ABF values and its change induced by preload manipulation with the cardiac output (CO) values measured simultaneously by the standard thermodilution method. MATERIALS AND METHODS: Sixty simultaneous measurements of ABF and CO were performed in 22 intensive care unit patients. In 16 hypovolemic patients, Doppler and thermodilution measurements were repeated after fluid replacement. RESULTS: Applicability of the method was 84.6% (failure of the echo-Doppler method in 4 of 26 eligible patients). Coefficient of variation of echo-Doppler-derived ABF was 3.25 +/- 2.26%. Interobserver variability was 3.3 +/- 1.6%. Close linear relationship was found between ABF and CO (r = 0.92). Average ABF/CO ratio was 73 +/- 10%, but significant variation was observed after fluid replacement. CONCLUSIONS: The echo-Doppler Dynemo 3000 system allows reliable continuous measurements of ABF in intensive care unit patients, both easily and safely.

Blood pressure and arterial lactate level are early indicators of short-term survival in human septic shock.

OBJECTIVE: To identify early prognostic markers of septic shock among catheterization-derived hemodynamic and metabolic data. DESIGN: Prospective cohort study. SETTING: A medical intensive care unit in a university hospital. PATIENTS: Thirty-two consecutive patients with septic shock, separated into two groups according to short-term (10-day) evolution: 18 acute survivors and 14 fatalities. MEASUREMENTS: Usual hemodynamic and metabolic variables were measured at the onset of shock, i.e., when the catheter was inserted (T0), and 24 h later (T24). The values collected for each group at T0 and T24 and their 24-h changes were compared. RESULTS: On admission, no difference was found between acute survivors and eventual fatalities. After 24 h, fatalities presented with significantly lower mean arterial pressure (p <0.01), left ventricular stroke work index (p <0.05) and higher lactate levels (p <0.01) than acute survivors. Moreover, the 24-h changes of lactate and blood pressure were also of prognostic value (p <0.05). Oxygen delivery and oxygen consumption did not differ statistically between the two groups. At T24, a mean arterial pressure of less than 85 mmHg and a lactate level equal to or greater than 3.5 mmol/l were independently associated with poor survival (37.5% and 30.7%, respectively). Day 10 survival was only 12.5% when both criteria were present at T24. CONCLUSIONS: Changes in mean arterial pressure and arterial blood lactate within the first 24 h of treatment are strong prognostic indicators of short-term survival in patients with septic shock. After 24 h of treatment, maintenance of a mean blood pressure equal to or greater than 85 mmHg correlates with survival at day 10. Data suggest that early reductions in both cardiac function and vascular tone play a determining role in the hypotension observed in fatalities. Persistence of hyperlactatemia in hypotensive patients bodes particularly ill. Blood pressure and lactate level are simple bedside parameters that can enable the clinician to identify patients with a high risk of mortality.

[Prognosis of acute tuberculous respiratory distress syndrome. 4 cases]. / Pronostic du syndrome de détresse respiratoire aiguë tuberculeux. 4 observations.

OBJECTIVES: We examined the characteristics of 4 cases of adult respiratory distress syndrome in patients with tuberculosis in an attempt to improve prognosis. METHODS: Four new cases of adult respiratory distress syndrome were described together with a review of the cases reported in the literature. Inclusion criteria were the presence of the syndrome as defined according to the American-European consensus conference and the criteria described by Murray et al. and identification of the mycobacteria causing tuberculosis. RESULTS: A total of 52 cases were included in the study. The sex ratio was 0.71 and mean age 46 +/- 15 years. Eight patients had a past history of pulmonary tuberculosis. Alcoholism was the primary immunodepression factor observed (35%) followed by human immunodeficiency virus infection (13%). For 74% of the patients, the disease course lasted 7 days. The initial chest X-ray was suggestive of tuberculosis in 11. Intradermoreaction to tuberculin was positive in 2 out of 17 patients. Direct examination of non-invasive respiratory samples was positive in 44% for mycobacteria. Disseminated tuberculosis was seen in 64%. Anti-tuberculosis antibiotherapy was started on the first day of intensive care in 68% of the patients; rapid treatment was associated with better prognosis: 1.5 +/- 1.2 days versus 3 +/- 2.7 in fatal cases (p = 0.02). Adjuvant corticosteroid therapy was used in 46% of the cases and was apparently associated with unfavourable outcome: 74% mortality versus 58% without corticosteroids. Ventilatory assistance was required in 88% and associated with poor prognosis (13% survival versus 100% without assistance) (p < 10(-3)). Outcome was fatal in 36 cases (70%) with a mean delay of 9.7 +/- 10.8 days. CONCLUSION: The conditions required for improving the prognosis of adult respiratory distress syndrome in tuberculosis patients included suspecting tuberculosis in all cases of acute respiratory failure of unknown origin, particularly in the immunodepressed patient, and to avoid missing this diagnosis in case of a non-suggestive chest X-ray and a negative though exhaustive microbiology search. Adjuvant corticotherapy is uneffective and may be dangerous.

Influence of the rt-PA dose (1 mg/kg versus 1.5 mg/kg) and duration of administration on the patency of infarct-related coronary arteries in 81 patients.

This open study compared the efficacy and side effects of two dose regimens of intravenous rt-PA initiated before the fifth hour after the onset of myocardial infarction. The first 40 patients (group A) received 1 mg/kg of rt-PA infused over 90 minutes, including a 10-mg initial bolus. The following 41 patients (group B) received 1.5 mg/kg (20-mg initial bolus, 60% over 60 minutes and 40% over 120 minutes). Noninvasive clinical, electrocardiographic, and biochemical parameters of reperfusion were recorded systematically, along with serial measurements of fibrinogen and hemoglobin levels. Coronary arteriography and left ventriculography were performed at the 48th hour or earlier, on an emergency basis, in the absence of signs of reperfusion, or if there were clinical and ECG signs of rethrombosis. Patency of the infarct-related artery (TIMI grades 2 and 3) was achieved in 55% of the group A patients vs. 83% of the group B patients (p less than .01). Twelve emergency coronary arteriographies were performed in each group. No significant difference was observed in the ejection fraction (48% in group A vs. 52% in group B). The peak CPK level was similar in both groups, but the peak occurred earlier in group B (p less than .001). There was no statistically significant difference between the two dose regimens in terms of reduction in fibrinogen or plasminogen levels. Two deaths occurred in group A vs. one death in group B. No cerebrovascular accidents occurred in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of the replacement of intravenous trinitrin by oral trinitrin in the acute phase of myocardial infarction complicated by regressive left ventricular insufficiency]. / Existe-t-il un intérêt au relais de la trinitrine intraveineuse par la trinitrine per os à la phase aiguë de l'infarctus du myocarde, compliqué d'insuffisance ventriculaire gauche régressive?

Left ventricular failure is a common complication of the acute phase of myocardial infarction. The most appropriate current treatment, when an increase in preload is the predominant or sole feature, involves nitroglycerin by infusion combined in varying degrees with diuretics. The aim of this study was to assess the value of maintenance treatment following intravenous nitroglycerin based upon a long acting nitrate derivative designed to achieve a hemodynamic result. Twenty patients with a mean age of 62 and with left ventricular failure during the acute phase of a myocardial infarction were studied. They were all treated with IV nitroglycerin using an automatic pump syringe. Pulmonary artery diastolic pressure, cardiac output, blood pressure and heart rate were measured hourly for six hours then every 6 hours. When PADP fell to below 18 mmHg, maintenance treatment with placebo or long acting nitroglycerin was given double-blind (10 patients were given long acting nitroglycerin and 10 patients the placebo). Pulmonary artery pressures, blood pressure and heart rate were measured every 2 hours for 8 hours, then at 12 and 24 hours. No significant difference was found in heart rate, blood pressure, cardiac output nor PADP (10 +/- 3.5 mmHg cf. 12 +/- 2.8 mmHg; NS) between the two groups. In total, maintenance treatment with long acting nitrate derivatives following IV nitroglycerin for hemodynamic purposes in patients with an acute myocardial infarction complicated by regressive cardiac failure would no appear to be necessary.