Automated surveillance in French ICUs: is it feasible? Results from a survey in French ICUs participating in a surveillance network.

A survey was undertaken to evaluate the level of computerization in intensive care units (ICUs) within a French network dedicated to the surveillance of healthcare-associated infections, antimicrobial use (AMU) and antimicrobial resistance (AMR) in ICUs (REA-REZO). Ninety-eight ICUs responded, and patient records were computerized in 57%, antimicrobial prescriptions were computerized in 59% and AMR epidemiology was computerized in 72%. AMU and AMR feedback was provided to the ICU itself for 77% and 65% of ICUs, respectively, and feedback was provided to the national surveillance for 79% and 65% of ICUs, respectively. This study suggests that the level of computerization in ICUs requires further improvement.

Protracted viral shedding and viral load are associated with ICU mortality in Covid-19 patients with acute respiratory failure.

BACKGROUND: Protracted viral shedding is common in hospitalized patients with COVID-19 pneumonia, and up to 40% display signs of pulmonary fibrosis on computed tomography (CT) after hospital discharge. We hypothesized that COVID-19 patients with acute respiratory failure (ARF) who die in intensive care units (ICU) have a lower viral clearance in the respiratory tract than ICU patients discharged alive, and that protracted viral shedding in respiratory samples is associated with patterns of fibroproliferation on lung CT. We, therefore, conducted a retrospective observational study, in 2 ICU of Lyon university hospital. RESULTS: 129 patients were included in the study, of whom 44 (34%) died in ICU. 432 RT-PCR for SARS-CoV-2 were performed and 137 CT scans were analyzed. Viral load was significantly higher in patients deceased as compared to patients alive at ICU discharge (p < 0.001), after adjustment for the site of viral sampling and RT-PCR technique. The median time to SARS-CoV-2 negativation on RT-PCR was 19 days [CI95 %:15-21] in patients alive at ICU discharge and 26 days [CI95 %:17-infinity] in non-survivors at ICU discharge. Competitive risk regression identified patients who died in ICU and age as independent risk factors for longer time to SARS-CoV-2 negativation on RT-PCR, while antiviral treatment was independently associated with shorter time. None of the CT scores exploring fibroproliferation (i.e., bronchiectasis and reticulation scores) were significantly associated with time to SARS-CoV-2 negativation. CONCLUSIONS: Viral load in respiratory samples is significantly lower and viral shedding significantly shorter in ICU survivors of COVID-19 associated acute respiratory failure. Protracted viral shedding is unrelated to occurrence of fibrosis on lung CT.

Spontaneous decolonization during hospitalization in intensive care unit patients colonized by extended-spectrum beta-lactamase-producing Enterobacterales.

This study aimed to analyse the frequency of occurrence of spontaneous decolonization in intensive care unit patients colonized by extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) in order to assess the added value of continuing weekly ESBL-E rectal carriage screening in these patients. In total, 49,468 weekly rectal screening samples taken from 20,846 patients over 12 years were included. Among the 4280 ESBL-E carriers, only 109 patients (2.5%) could be considered decolonized at the end of their hospitalization with at least three consecutive negative samples. Overall, 7957 samples (16.1%) were requested for patients already identified as ESBL-E carriers. Avoiding unnecessary weekly screening following positive ESBL-E colonization results could decrease nursing and laboratory work loads.

A case of bacteriemic mediastinitis due to Prevotella buccae after cardiac surgery.

Mediastinitis is a well-known complication of open-heart surgery. Strictly anaerobic bacteria are rarely found in this condition, unlike in descending mediastinitis. We report the case of a mediastinitis due to Prevotella buccae after surgical replacement of the aortic valve and triple coronary artery bypass in an immunocompetent 76 year-old man. The bacteria were found in pure culture on blood samples and surgical samples. This case emphasizes the need to perform anaerobic cultures in case of sternal wound infection after open-heart surgery.

In vitro activity of temocillin against extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae strains isolated from urinary tract infections in France.

OBJECTIVES: Temocillin was introduced in 2015 in the French guidelines for the treatment of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae urinary tract infections. Little susceptibility data is available. We investigated the in vitro activity of temocillin against ESBL-producing Enterobacteriaceae isolated from samples of cytobacteriological examinations of urine. MATERIAL AND METHODS: Susceptibility testing was performed on 157 ESBL-producing E. coli and 95 ESBL-producing K. pneumoniae strains using the disk diffusion method. MICs of resistant strains were measured with the Etest method. RESULTS: Using current breakpoints, 71.3% of E. coli strains and 77.9% of K. pneumoniae strains were classified as susceptible. However, diameter and MIC breakpoints vary by country, and we reported discordance of clinical categorization between diameters and MIC determination for some strains. The measure of diameters was also sometimes difficult because of contaminating colonies within the inhibition zone. CONCLUSION: We highlighted difficulties related to the determination of temocillin susceptibility, such as culture of resistant colonies in the inhibition zone and discordance of clinical categorizations obtained with the disk diffusion method or the Etest method. Overall, 42% of tested Enterobacteriaceae had a diameter or MIC close to the current breakpoints; thus, it is necessary to determine the MIC for these strains before considering the clinical use of this molecule.

Characteristics and outcome of patients with newly diagnosed advanced or metastatic lung cancer admitted to intensive care units (ICUs).

BACKGROUND: Although patients with advanced or metastatic lung cancer have poor prognosis, admission to the ICU for management of life-threatening complications has increased over the years. Patients with newly diagnosed lung cancer appear as good candidates for ICU admission, but more robust information to assist decisions is lacking. The aim of our study was to evaluate the prognosis of newly diagnosed unresectable lung cancer patients. METHODS: A retrospective multicentric study analyzed the outcome of patients admitted to the ICU with a newly diagnosed lung cancer (diagnosis within the month) between 2010 and 2013. RESULTS: Out of the 100 patients, 30 had small cell lung cancer (SCLC) and 70 had non-small cell lung cancer. (Thirty patients had already been treated with oncologic treatments.) Mechanical ventilation (MV) was performed for 81 patients. Seventeen patients received emergency chemotherapy during their ICU stay. ICU, hospital, 3- and 6-month mortality were, respectively, 47, 60, 67 and 71%. Hospital mortality was 60% when invasive MV was used alone, 71% when MV and vasopressors were needed and 83% when MV, vasopressors and hemodialysis were required. In multivariate analysis, hospital mortality was associated with metastatic disease (OR 4.22 [1.4-12.4]; p = 0.008), need for invasive MV (OR 4.20 [1.11-16.2]; p = 0.030), while chemotherapy in ICU was associated with survival (OR 0.23, [0.07-0.81]; p = 0.020). CONCLUSION: This study shows that ICU management can be appropriate for selected newly diagnosed patients with advanced lung cancer, and chemotherapy might improve outcome for patients with SCLC admitted for cancer-related complications. Nevertheless, tumors' characteristics, numbers and types of organ dysfunction should be taken into account in the decisional process before admitting these patients in ICU.

A promising new test to detect Streptococcus pneumoniae urinary antigen.

BACKGROUND: Streptococcus pneumoniae is the main etiology of community-acquired pneumonia (CAP). A quick detection of urinary antigen helps in obtaining a documented result in case of Streptococcus pneumoniae CAP. METHODS: We compared the BinaxNOW®S. pneumoniae test with the new urinary antigen Sofia®S. pneumoniae FIA. We examined 133 urine samples. RESULTS: Of the 133 included and tested non-concentrated urine samples, BinaxNOW® and Sofia® tests yielded 122 and 113 negative results and 11 and 20 positive results, respectively. The overall agreement between the tests was good. CONCLUSION: This new test enabled the diagnosis of seven additional cases (7/133=5.2%). The improved detection with Sofia® may be due to the immunofluorescence method used by this new test as compared with the colorimetric method used by BinaxNOW®. Sofia® also offers the advantage of being connected to the laboratory information system (LIS) allowing an automated traceability.

A fatal endocarditis case due to an emerging bacterium: Moraxella nonliquefaciens.

Moraxella nonliquefaciens is a Gram-negative coccobacillus considered as a commensal organism from the upper respiratory tract, with low pathogenic potential. The phenotypical conventional identification is difficult and the matrix-assisted laser desorption/ionization time-of-flight technology has increased the resolution of identification of this bacterium. We report a fatal case of endocarditis due to M. nonliquefaciens whose identification was confirmed by 16S rRNA, and we review the literature on this pathogen in endocarditis.

Diagnosis of primary antibody and complement deficiencies in young adults after a first invasive bacterial infection.

OBJECTIVES: Screening for primary immunodeficiencies (PIDs) in adults is recommended after two severe bacterial infections. We aimed to evaluate if screening should be performed after the first invasive infection in young adults. METHODS: Eligible patients were retrospectively identified using hospital discharge and bacteriology databases in three centres during a 3-year period. Eighteen to 40-year-old patients were included if they had experienced an invasive infection with encapsulated bacteria commonly encountered in PIDs (Streptococcus pneumoniae (SP), Neisseria meningitidis (NM), Neisseria gonorrhoeae (NG), Haemophilus influenzae (HI), or group A Streptococcus (GAS)). They were excluded in case of general or local predisposing factors. Immunological explorations and PIDs diagnoses were retrieved from medical records. Serum complement and IgG/A/M testings were systematically proposed at the time of study to patients with previously incomplete PID screening. RESULTS: The study population comprised 38 patients. Thirty-six had experienced a first invasive episode and a PID was diagnosed in seven (19%): two cases of common variable immunodeficiency revealed by SP bacteraemia, one case of idiopathic primary hypogammaglobulinaemia, and two cases of complement (C6 and C7) deficiency revealed by NM meningitis, one case of IgG2/IgG4 subclasses deficiency revealed by GAS bacteraemia, and one case of specific polysaccharide antibody deficiency revealed by HI meningitis. Two patients had previously experienced an invasive infection before the study period: in both cases, a complement deficiency was diagnosed after a second NM meningitis and a second NG bacteraemia, respectively. CONCLUSION: PID screening should be considered after a first unexplained invasive encapsulated-bacterial infection in young adults.

Colonization pressure as a risk factor of ICU-acquired multidrug resistant bacteria: a prospective observational study.

The primary objective of this study was to evaluate the impact of colonization pressure on intensive care unit (ICU)-acquired multidrug resistant bacteria (MDRB). All patients hospitalized for more than 48 h in the ICU were included in this prospective observational study. MDRB were defined as methicillin resistant Staphylococcus aureus, Pseudomonas aeruginosa resistant to ceftazidime or imipenem, Gram-negative bacilli producing extended-spectrum beta-lactamases (ESBL), and all strains of Acinetobacter baumannii and Stenotrophomonas maltophilia. Colonization pressure was daily calculated in the three participating ICUs. Univariate and multivariate analyses were used to determine risk factors for ICU-acquired MDRB. Two hundreds and four (34%) of the 593 included patients acquired an MDRB during their ICU stay. Multivariate analysis identified colonization pressure as an independent risk factor for ICU-acquired MDRB (OR (95% CI) 4.18 (1.03-17.01), p = 0.046). Other independent risk factors for ICU-acquired MDRB were mechanical ventilation (3.08 (1.28-7.38), p = 0.012), and arterial catheter use (OR, 3.04 (1.38-6.68), p = 0.006). ICU-acquired MDRB were associated with increased mortality, duration of mechanical ventilation, and ICU stay. However, ICU-acquired MDRB was not independently associated with ICU-mortality. Colonization pressure is an independent risk factor for acquiring MDRB in the ICU.

Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial.

PURPOSE: Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of this study was to compare NAVA and pressure support ventilation (PSV) in the early phase of weaning from mechanical ventilation. METHODS: A multicentre randomized controlled trial of 128 intubated adults recovering from acute respiratory failure was conducted in 11 intensive care units. Patients were randomly assigned to NAVA or PSV. The primary outcome was the probability of remaining in a partial ventilatory mode (either NAVA or PSV) throughout the first 48 h without any return to assist-control ventilation. Secondary outcomes included asynchrony index, ventilator-free days and mortality. RESULTS: In the NAVA and PSV groups respectively, the proportion of patients remaining in partial ventilatory mode throughout the first 48 h was 67.2 vs. 63.3 % (P = 0.66), the asynchrony index was 14.7 vs. 26.7 % (P < 0.001), the ventilator-free days at day 7 were 1.0 day [1.0-4.0] vs. 0.0 days [0.0-1.0] (P < 0.01), the ventilator-free days at day 28 were 21 days [4-25] vs. 17 days [0-23] (P = 0.12), the day-28 mortality rate was 15.0 vs. 22.7 % (P = 0.21) and the rate of use of post-extubation noninvasive mechanical ventilation was 43.5 vs. 66.6 % (P < 0.01). CONCLUSIONS: NAVA is safe and feasible over a prolonged period of time but does not increase the probability of remaining in a partial ventilatory mode. However, NAVA decreases patient-ventilator asynchrony and is associated with less frequent application of post-extubation noninvasive mechanical ventilation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02018666.

In vitro susceptibility to mecillinam of Escherichia coli strains isolated from the urine of pregnant women.

OBJECTIVES: Pivmecillinam is a safe beta-lactam for use in pregnancy. It has been widely used for the treatment of lower urinary tract infections (UTIs) in the Nordic countries where its efficacy, minor impact on the microbiota, and low level of resistance among the Escherichia coli strains have been proven. However, susceptibility data related to E. coli involved in asymptomatic bacteriuria and lower UTIs in pregnant women is lacking. We aimed to support the 2015 recommendations issued by the French Infectious Diseases Society (SPILF) on gestational UTI, with a particular focus on pivmecillinam. MATERIAL AND METHODS: Antimicrobial susceptibility testing was performed by 12 hospitals with a maternity department on 235 E. coli strains isolated from the urine of pregnant women. Susceptibility to mecillinam was tested by disk diffusion method using the 2015 recommendations of the antibiogram committee of the French microbiology society (CA-SFM). RESULTS: Global susceptibility to mecillinam was 86.4%. Susceptibility to mecillinam was 96.5% for strains susceptible to amoxicillin-clavulanic acid and 38.7% for resistant strains. All six extended-spectrum beta-lactamase-producing E. coli strains were susceptible to mecillinam. CONCLUSION: Given the efficacy and safety of pivmecillinam during pregnancy, it may be used for the documented treatment of asymptomatic bacteriuria and acute cystitis in pregnant women. It also represents an alternative for the treatment of multidrug-resistant bacterial infections.

Impact of a targeted isolation strategy at intensive-care-unit-admission on intensive-care-unit-acquired infection related to multidrug-resistant bacteria: a prospective uncontrolled before-after study.

Isolation of patients with multidrug resistant (MDR) bacteria is recommended to reduce cross-transmission of these bacteria. However, isolation of critically ill patients has several negative side effects. Therefore, we hypothesized that a targeted isolation strategy, based on the presence of at least one risk factor for MDR bacteria, would be not inferior to a systematic isolation strategy at intensive-care unit (ICU) admission. This prospective before-after study was conducted in a mixed ICU, during two 12-month periods, separated by a 1-month 'wash-out' period. During the before period, isolation was systematically performed in all patients at admission. During the after period, isolation was only performed in patients with at least one risk factor for MDR bacteria at admission. During the two periods, routine screening for MDR bacteria was performed at ICU admission, and isolation prescription was modified after receipt of screening result. Primary outcome was the percentage of patients with ICU-acquired infection (ICUAI) related to MDR bacteria, measured from ICU admission until ICU discharge or day 28, whatever happens first. A total of 1221 patients were included. No significant difference was found in ICUAI related to MDR bacteria (85 of 585 (14.5%) vs. 84 of 636 (13.2%) patients, risk difference, -1.3%, 95% confidence interval [-5.2 to 2.6%]) between the two periods, confirming the non-inferiority hypothesis. Our results suggest that targeted isolation of patients at ICU admission is not inferior to systematic isolation, regarding the percentage of patients with ICUAI related to MDR bacteria. Further randomized controlled multicentre studies are needed to confirm our results.

A matched case-control study of toxoplasmosis after allogeneic haematopoietic stem cell transplantation: still a devastating complication.

Toxoplasmosis (TXP) is a life-threatening complication of allogeneic haematopoietic stem cell transplantation (AHSCT). Little is known about the risk factors and there is no consensus on prophylactic measures. To investigate the risk factors, we conducted a single-centre, retrospective matched case-control study among adults who underwent AHSCT from January 2006 to March 2015 in our hospital. TXP cases were identified from the prospectively maintained hospital's database. The 1:2 control population consisted of the two patients who received an AHSCT immediately before and after each case with similar donor relationship (related, unrelated) but who did not develop TXP. Risk factors were identified by conditional logistic regression. Clinical features and outcome of TXP were examined. Twenty-three (3.9%) cases of TXP (20 diseases, three infections) were identified among 588 AHSCT recipients. Twenty (87%) cases had a positive pre-transplant Toxoplasma gondii serology. In comparison with 46 matched control patients, risk factors were the absence of effective anti-Toxoplasma prophylaxis (odds ratio (OR) 11.95; 95% CI 3.04-46.88; p <0.001), high-grade (III-IV) acute graft-versus-host-disease (OR 3.1; 95% CI 1.04-9.23; p 0.042) and receipt of the tumour necrosis factor-α blocker etanercept (OR 12.02; 95% CI 1.33-108.6; p 0.027). Mortality attributable to TXP was 43.5% (n = 10). Non-relapse mortality rates during the study period of cases and controls were 69.6% (n = 16) and 17.4% (n = 8), respectively. Lung involvement was the dominant clinical feature (n = 14). Two cases were associated with graft failure, one preceded by haemophagocytic syndrome. Given TXP-related morbidity and attributable mortality, anti-Toxoplasma prophylaxis is essential for optimized management of seropositive AHSCT recipients.

No impact on long-term survival of prolonged ICU stay and re-admission for patients undergoing cytoreductive surgery with HIPEC.

BACKGROUND: Cytoreductive surgery (CRS) and Hyperthermic intraperitoneal chemotherapy (HIPEC) are promising new approaches of peritoneal metastases. However these surgical procedures are associated with a high morbidity rate thus intensive care (IC) management following serious complications may be warranted for these patients. The impact of the prolonged IC stay or re-admission on long-term survival remains unknown. METHODS: We retrospectively analysed 122 consecutive HIPEC procedures over a one year period (2010-2011) in a single academic hospital. We analysed complications that would lead to prolonged stay or re-admission into ICU and analysed long term follow-up in patients whether they required intensive care (ICU group) or not (Control group). RESULTS: ICU group represented 26.2% of the cohort mainly due to septic or haemorrhagic shock. Among them acute kidney injury and respiratory failure were present in 50% and 47% respectively. Cohort overall mortality rate was of 5.7%. Patients were followed for 4 years and survival analysis was performed adjusting for main confounding factors in a Cox survival model. Survival was not different between groups, with a median survival of 38 months [32; 44] vs. 33 months [26; 39] in the ICU group and Control group respectively. CONCLUSION: Prolonged stay or re-admission into ICU does not seem to statistically impact long term prognosis of patients undergoing CRS with HIPEC.

Impact of the 13-valent pneumococcal conjugate vaccine on the incidence of pneumococcal meningitis in children.

The impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on the incidence of pneumococcal meningitis (PM) in children is unknown. To determine this impact, a descriptive multicentre retrospective cohort study was conducted from 2008 to 2013 in northern France. All laboratory-confirmed PM in children aged <18 years in all hospitals of the area with paediatric units were included. Two independent databases were used for exhaustive identification of cases: medical plus laboratory records at each hospital and discharge codes. The corrected incidence of PM was determined by a capture-recapture analysis using these two databases. Sixty-two cases were found over the 6-year period. A decrease of the PM corrected incidence was observed in the global population (P = 0·07), significant only for children aged <2 years, from 11·9/100 000 in 2008 in 1·9/100 000 in 2013 [6·4 fold-decrease, 95% confidence interval (CI) 1·4-41, P = 0·01] between years 2008 and 2013. When comparing the pre- and post-PCV13 periods, this decrease was still statistically significant for children aged <2 years [7·32/100 000 (95% CI 4·39-10·25) to 2·78/100 000 (95% CI 0·96-4·60), P = 0·01]. Only three (5%) cases of PM caused by vaccine serotypes could have been prevented. After the introduction of the PCV13 vaccine, a decrease in the incidence of PM cases in children in northern France was observed.

[Patient's course requiring NIPPV in Centre Hospitalier Lyon-Sud]. / Le parcours du patient nécessitant une VNI au centre hospitalier Lyon-Sud.

Non-invasive positive pressure ventilation (NIPPV) has become a major therapeutic of acute respiratory failure. Thanks to technical progress, its use has become widespread in intensive care units and now in emergency and pneumology departments, for indications recognized and validated as decompensation of chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema. Patients with this conditions transit in the hospital, from the emergency or pulmonology departments, sometimes through intensive care units. Knowledge of the NIPPV, its indications, contraindications, terms of use and surveillance requires trained teams. This training covers not only the technical but also the hardware, multiple ventilation modes, and interfaces. Other indications being evaluated, such as ventilation in the perioperative period, also require coordination between different actors. The establishment of a specific group of thinking and working around the NIPPV is clearly needed, allowing teams of hospital (emergency department, intensive care unit, pulmonology, anesthesia) to work together. This work deals with different areas: training, equipment, condition of receiving patients in the different services within the constraints of personnel and equipment. In this article, we trace the point of view of each of the professionals in this group and some of the actions implemented.

[Technical criteria of central venous catheters: Anaesthesiologist/intensivist and pharmacist opinions]. / Critères de choix d'un cathéter veineux central : points de vue de l'anesthésiste-réanimateur et du pharmacien.

INTRODUCTION: The lack of technical information from suppliers and from the literature, a wide variety of features and the absence of medical device reference document explain the difficulty for medical and pharmaceutical staffs to choose a central venous catheter (CVC). The aim of this study was to establish the specifications to choose a CVC according to the clinician needs. METHODS: An analysis of suppliers' technical documentation and a literature review was performed to identify criteria and to collect them in a questionnaire to conduct semi-structured interviews between 1 pharmacist and 5 anaesthesiologists/intensivists. With these interviews, the technical criteria were classified according to their importance in 3 levels. RESULTS: Thirteen technical criteria were identified after reading the technical documents and the literature. Among them, 8 were classified as "essential criteria" (level I) by the physicians: J-shaped guide, one clamp on each way, identified lumen, radiopacity, graduation every centimeter by 5 to 20 cm from the distal extremity, a length of 15 to 25 cm, a single-lumen catheter with a 14 to 16G way and a three-lumen catheter with 14 to 18G way. Finally, three criteria were classified as "intermediate criteria" (level II) and two as "optional criteria" (level III). CONCLUSIONS: This collaborative approach allowed to reference new medical devices according to the clinicians needs. These CVC are a mean to respect guidelines for physicians and nurses and to secure the patient's care.