Durability of antimicrobial activity of antibiotic-impregnated external ventricular drains: a prospective study.

BACKGROUND: Antibiotic-impregnated external ventricular drains (AI-EVDs) have a debated efficacy in clinical studies. OBJECTIVES: Our aim was to assess the durability of antimicrobial activity of AI-EVDs used in clinical settings. METHODS: From April 2017 to January 2018, all consecutive AI-EVDs (Bactiseal™) inserted in adult patients were prospectively included. After removal, each AI-EVD was cultured and assessed for antimicrobial activity on both internal and external sides of AI-EVDs. Catheters were each challenged with a single Staphylococcus strain [MSSA, MRSA or methicillin-resistant Staphylococcus epidermidis (MRSE)]. MS was used to measure residual concentrations of rifampicin and clindamycin. RESULTS: Sixty-five AI-EVDs were included (56 patients). Among these, 21 were challenged with MSSA, 23 with MRSA and 21 with MRSE. Five ventriculostomy-related colonizations (9%) and two ventriculostomy-related infections (4%) occurred. Staphylococcus was the main bacterium responsible for colonization (4/5). AI-EVD inhibition decreased significantly against MRSA and MRSE according to duration of catheterization (for external and internal sides, P < 0.02) and overall volume of CSF drained (P < 0.005 for both sides against MRSE, P < 0.005 for external side against MRSA), but not against MSSA. Clindamycin concentration was not correlated with duration of catheterization or CSF volume drained, but <20% of initial concentration was recovered even after 5 days of AI-EVD dwelling. Conversely, rifampicin concentration showed a rapid and significant decline correlated to duration and CSF volume (P < 0.001 and P = 0.03, respectively). CONCLUSIONS: Antimicrobial activity of AI-EVDs dropped quickly in vivo. Antimicrobial impregnation did not prevent AI-EVD colonization by susceptible strains in 9% of the cases.

Secondary Insults and Adverse Events During Intrahospital Transport of Severe Traumatic Brain-Injured Patients.

BACKGROUND: Our aim was to assess the occurrence of secondary insults (SIs) or adverse events (AEs) during intrahospital transport (IHT) of severe traumatic brain injury (TBI) patients for head computed tomography (CT) scanning. METHODS: A prospective study based on severe TBI patients admitted from June 2011 through June 2013 in a level I trauma center. Patients received an IHT to perform a control CT scan in the first 3 days following trauma. The occurrence of SIs and AEs was assessed during the IHT for a control CT scan. The frequency of SIs was compared to the periods "before," "during," and "after" IHT. SI was defined by an intracranial pressure (ICP) >30 mmHg, a cerebral perfusion pressure (CPP) <50 mmHg, systolic blood pressure (SBP) <90 mmHg, or saturation pulse O2 (SpO2) <90 % for more than five consecutive minutes. An AE was defined as failures of hardware or ventilator asynchrony requiring therapeutic intervention during transport. In addition, we assessed the therapeutic benefit of a CT scan control. RESULTS: The final analysis included 31 patients and 31 IHTs. The median duration of IHT was 29 min [25;37]. SIs occurred in 16 patients (52 %) during transport, whereas it was observed in 4 patients (13 %) before (p = 0.002) and 4 patients (13 %) after IHT (p = 0.001). Twenty-four AEs occurred during transport of 19 patients (61 %). One patient benefited from hematoma evacuation after implementation of control CT. CONCLUSION: IHT carries significant SIs and AEs in severe TBI patients. To improve a risk/benefit ratio favorable for patients, a program focusing on IHT complications regarding therapeutic impact of control CT scan is needed.

Clinical, biological, and microbiological pattern associated with ventriculostomy-related infection: a retrospective longitudinal study.

BACKGROUND: Our aim was to describe the pattern of ventriculostomy-related infection (VRI) development using a dynamic approach. STUDY DESIGN: Retrospective longitudinal study. METHODS: We analyzed the files of 449 neurosurgical patients who underwent placement of external ventricular drain (EVD). During the study period, CSF sampling was performed on a daily base setting. VRI was defined as a positive CSF culture resulting in antibiotic treatment. For VRI patients, we arbitrary defined day 0 (D0) as the day antibiotic treatment was started. In these patients, we compared dynamic changes in clinical and biological parameters at four pre-determined time points: (D-4, D-3, D-2, D-1) with those of D0. For all CSF-positive cultures, we compared CSF biochemical markers' evolution pattern between VRI patients and the others, considered as a control cohort. RESULTS: Thirty-two suffered from VRI. Peripheral white blood cell count did not differ between D-4-D0. Median body temperature, CSF cell count, median Glasgow Coma Scale, CSF protein, and glucose concentrations were significantly different between D-4, D-3, D-2, and D0. At D0, 100 % of CSF samples yielded organisms in culture. The physician caring for the patient decided to treat VRI based upon positive CSF culture in only 28 % (9/32) of cases. In the control cohort, CSF markers' profile trends to normalize, while it worsens in the VRI patients. CONCLUSIONS: We showed that clinical symptoms and biological abnormalities of VRI evolved over time. Our data suggest that VRI decision to treat relies upon a bundle of evidence, including dynamic changes in CSF laboratory exams combined with microbiological analysis.

Spigelian hernia: CT findings and clinical relevance.

OBJECTIVE: The purpose of our study was to evaluate the clinical relevance of preoperative CT in distinguishing between the two subtypes of spigelian hernia (SH). MATERIALS AND METHODS: We reviewed retrospectively the CT images of 35 patients. The patients were divided into two groups on the basis of the SH subtype: interstitial SH group (n = 15) and subcutaneous SH group (n = 20). Clinical characteristics of patients and CT findings were analyzed. Bowel ischemia on surgery was also noted. RESULTS: Sixteen right hernias and 19 left hernias were observed. Fifteen interstitial SH (43%) and 20 subcutaneous SH (57%) were found. No type of content showed a statistically significant association with one or other subtype of SH. Nine of the 26 patients presenting with SH with SB content showed signs of SBO on CT. Closed-loop SBO on CT was present in 5 of the 26 patients with SB content. An interstitial SH was observed in all of these 5 patients (p = 0.039). Surgery was performed on 10 patients. Bowel ischemia was found on surgery in 4 patients and showed no statistically significant association with a particular subtype of SH (p = 0.6). CONCLUSION: Our study shows the importance of performing CT in SH. CT provides the diagnosis of SH, shows SH content, and demonstrates the presence of SBO or closed-loop SBO. Moreover, the distinction between the two subtypes of SH on CT appears to be of clinical relevance since closed-loop SBO is statistically associated with interstitial SH and the optimal surgical approach may differ.

Suspicion of penetrating cardiac injury: Curing or caring?

Identifying penetrating cardiac injury in hemodynamically stable patients can be challenging especially when the patient has no signs of cardiac tamponade and no pericardial effusion identified on transthoracic echocardiography. In this case report, we discuss both penetrating cardiac injuries diagnosis algorithm and treatment strategies. At present, it is difficult to refer to general guidelines transposable from one center to another. We report the paramount importance of multidisciplinary management with experienced teams to face any possible pitfalls in traumatology especially in the context of penetrating cardiac injury.

Multidrug-Resistant Staphylococcus epidermidis Ventriculostomy-Related Infection Successfully Treated by Intravenous Ceftaroline after Failure of Daptomycin Treatment.

BACKGROUND: Ventriculostomy-related infection with multidrug-negative strains are challenging to treat. We report the use of new antibiotics in such a case. CASE DESCRIPTION: We report the case of a neurosurgical intensive care unit patient who developed ventriculostomy-related infection with a multidrug-resistant Staphylococcus epidermidis. Vancomycin, recommended in such cases, was not used due to high minimal inhibitory concentrations and concerns for lack of pharmacokinetic/pharmacodynamic target attainment. Daptomycin and ceftaroline remained the only treatment options. Daptomycin was shown microbiologically ineffective after 10 treatment days, with undetectable cerebrospinal fluid (CSF) concentration. Ceftaroline, a novel beta-lactam agent to which the strain showed susceptibility, was thus used. Serum and CSF samples were assessed for antibiotic concentrations. Our results show that CSF bacterial clearance was obtained after 6 days of such treatment. Serum and CSF samplings showed low penetration ratios (2.6%-4.8%), probably due to mild inflammatory CSF profile, with CSF concentration at minimal inhibitory concentration level. CONCLUSIONS: We observed than even in the case of mild meningeal inflammation, ceftaroline penetration in CSF, although moderate, enabled efficient bacterial clearance and clinical efficacy, in adjunction to correct ventriculoperitoneal shunt management.

Breast Implants and Bilateral Tension Pneumothorax Following Blunt Chest Trauma.

A 38-year-old woman was admitted to our trauma centre with a complete left pneumothorax. The chest tube implementation procedure was aborted quickly because of a very difficult dissection (subcutaneous emphysema over two voluminous breast implants). The patient was transferred to the imaging room without chest tube insertion due to respiratory and haemodynamic stability. During transfer, the patient presented with cardiac arrest due to tension pneumothorax. The time benefit with the use of immediate total body computed tomography has been reported. A simple and rapid initial imaging assessment including chest and pelvic X-rays and four-chamber view and 'swing technique' ultrasound protocol enables the appropriate emergency decisions. While this diagnostic approach is time consuming, it nevertheless allows a reduction in the time needed to initiate life-saving interventions for the most severe patients. This case reminds us that even if patients are stable, drainage of a complete pneumothorax under mechanical ventilation should not be delayed, especially in case of technical difficulties.

Multidrug-Resistant Acinetobacter baumannii Ventriculostomy-Related Infection, Treated by a Colistin, Tigecycline, and Intraventricular Fibrinolysis.

BACKGROUND: Acinetobacter baumannii meningitis and ventriculitis are difficult issues, because of the low diffusion of antibiotics in the cerebrospinal fluid and bacterial multidrug resistance. The presence of an infected intraventricular hematoma, constituting an equivalent of undrained abscess, may promote biofilm formation and failure of medical treatment. CASE DESCRIPTION: In this case of ventriculostomy-related infection after ventricular hemorrhage, Acinetobacter baumannii was sensitive only to colistin and tigecycline. Despite a combination therapy involving intraventricular injections of colistin, we observed clinical and bacteriologic failure. Therefore, at day 4 of antibiotic therapy, we performed intraventricular fibrinolysis, which dissolved the clot, enabling sterilization of the cerebrospinal fluid after 48 hours. CONCLUSION: This clinical case suggests the usefulness of intraventricular fibrinolysis to lyse the clot and optimize the action of antibiotics.

Prediction of Early Intracranial Hypertension After Severe Traumatic Brain Injury: A Prospective Study.

OBJECTIVE: This study aimed to assess the reliability of clinical features, noninvasive transcranial Doppler-related pulsatility index (PI) calculation, and optic nerve sheath diameter (ONSD) measured by ultrasound (US) and initial computed tomography (CT) scan (Marshall CT scan classification) in predicting the occurrence of early (<24 hours) high intracranial pressure (EHICP) (>20 mm Hg) after severe traumatic brain injury (TBI). METHODS: We conducted an observational prospective study in a level 1 trauma center. Patients were measured simultaneously for PI and US ONSD in the triage zone. Patients were categorized into 2 groups: those who had EHICP after TBI (EHICP+) and those who did not (EHICP-). RESULTS: Fifty-four patients were included; 32 were categorized as EHICP+ and 22 as EHICP-. PI >1.4 did not correlate with EHICP+ patients (69% vs. 46%, P = 0.09). US ONSD measurement was higher in the EHICP+ group (6.25; range, 6-6.95 vs. 5.7; range, 5.2-6.4; P = 0.005). The area under the receiver operating characteristic curve for US ONSD as a predictor of developing EHICP was 0.73 (95% confidence interval [CI], 0.59-0.86). CT ONSD measurement was higher in the EHICP+ group (6.71; range, 6.35-7.87 vs. 6.25; range, 5.8-6.93; P = 0.04). The area under the receiver operating characteristic curve for CT ONSD measurement as a predictor for EHICP+ was 0.67 (95% CI, 0.53-0.81). The diffuse injury III and IV categories in the Marshall CT scan classification were associated with the occurrence of EHICP (P = 0.004). CONCLUSIONS: None of the clinical features or noninvasive tools assessed in this study enabled clinicians to strictly ascertain EHICP. Further studies are needed to establish their potential role before intracranial pressure probe insertion.

Natural history of ventriculostomy-related infection under appropriate treatment and risk factors of poor outcome: a retrospective study.

OBJECTIVEThe authors aimed to describe the natural history of ventriculostomy-related infections (VRIs) under appropriate treatment and to assess risk factors for poor outcome.METHODSAll patients older than 18 years in whom an external ventricular drain (EVD) had been implanted and who had developed a VRI requiring treatment were included in this retrospective study. D0 was defined as the first day of antibiotic administration. Clinical and biological parameters were compared each day beginning with D1 and ending with D10 to those of D0. The authors defined D0 in a control group as the day a CSF culture came back positive, without any sign of infection. The authors then searched for poor prognostic factors in the VRI group.RESULTSAmong 567 patients requiring an EVD between January 2007 and October 2017, 39 developed a VRI. Most were monomicrobial infections, and 47 microbes were responsible (45% were gram-positive cocci). Clinical parameters differed significantly from the control group during the first 2 days and then returned to baseline. The CSF parameters differed significantly from the control group for a longer period, returning to baseline after 5 days. CSF sterilization occurred in a median time of 2 days. An intrathecal route or EVD exchange was not associated with a poor outcome. No clinical or biological parameter between D3 and D5 was linked to outcome.CONCLUSIONSClinical status improved faster than CSF parameters (before and after D5, respectively). Some CSF parameters remained abnormal until D10. Body temperature and microbiological cultures normalized faster than other parameters.

The multistep road to ventilator-associated lung abscess: A retrospective study of S.aureus ventilator-associated pneumonia.

OBJECT: We observed some cases of lung abscess (LA) in ICU patients suffering S.aureus ventilator-associated pneumonia (S.aureus-VAP). We aimed to assess which of the host and/or bacteria-related features are associated with LA. METHODS: We conducted a retrospective study from January 2009 to July 2013 in a trauma surgical ICU within a teaching hospital. All adult patients presenting with S.aureus-VAP were included. We compared two groups of patients according to the formation or not of LA concomitantly to S.aureus-VAP. RESULTS: Seventy-nine S.aureus-VAP patients, predominantly males (85%) of rather young age (mean [SD]: 35yr [21-64]) with severe trauma (initial Simplified Acute Score II = 42 [32-52]) related-ICU admission, were included. Among them, 10 (14%) developed LA. Patient's characteristics significantly associated with LA development were: a younger age (p = 0.003), road traffic accidents admission (p = 0.017), head injury (p = 0.002), lower Glasgow Coma Scale (p = 0.009), blunt chest trauma (p = 0.01) pneumothorax (p = 0.01) and lung contusions (p = 0.002). No microbiological factors were significantly associated with LA formation. Abscesses were mostly bilateral, ≥5 cm of diameter and with a posterior location. CONCLUSIONS: Our results do not favor a specific virulence of S.aureus, but rather highlight the role of multiple insults to the lung, promoting LA formation. Despite a similar severity score, patients with LA had more serious trauma, combining severe both chest and head insults.

A multi-faceted strategy to reduce ventilation-associated mortality in brain-injured patients. The BI-VILI project: a nationwide quality improvement project.

PURPOSE: We assessed outcomes in brain-injured patients after implementation of a multi-faceted approach to reduce respiratory complications in intensive care units. METHODS: Prospective nationwide before-after trial. Consecutive adults with acute brain injury requiring mechanical ventilation for ≥24 h in 20 French intensive care units (ICUs) were included. The management of invasive ventilation in brain-injured patients admitted between 1 July 2013 and 31 October 2013 (4 months) was monitored and analysed. After the baseline period (1 November 2013-31 December 2013), ventilator settings and decision to extubate were selected as targets to hasten weaning from invasive ventilation. During the intervention period, low tidal volume (≤7 ml/kg), moderate positive end-expiratory pressure (PEEP, 6-8 cm H2O) and an early extubation protocol were recommended. The primary endpoint was the number of days free of invasive ventilation at day 90. Comparisons were performed between the two periods and between the compliant and non-compliant groups. RESULTS: A total of 744 patients from 20 ICUs were included (391 pre-intervention; 353 intervention). No difference in the number of invasive ventilation-free days at day 90 was observed between the two periods [71 (0-80) vs. 67 (0-80) days; P = 0.746]. Compliance with the complete set of recommendations increased from 8 (2%) to 52 (15%) patients after the intervention (P < 0.001). At day 90, the number of invasive ventilation-free days was higher in the 60 (8%) patients whose care complied with recommendations than in the 684 (92%) patients whose care deviated from recommendations [77 (66-82) and 71 (0-80) days, respectively; P = 0.03]. The mortality rate was 10% in the compliant group and 26% in the non-compliant group (P = 0.023). Both multivariate analysis [hazard ratio (HR) 1.78, 95% confidence interval (95% CI) 1.41-2.26; P < 0.001] and propensity score-adjusted analysis (HR 2.25, 95% CI 1.56-3.26, P < 0.001) revealed that compliance was an independent factor associated with the reduction in the duration of mechanical ventilation. CONCLUSIONS: Adherence to recommendations for low tidal volume, moderate PEEP and early extubation seemed to increase the number of ventilator-free days in brain-injured patients, but inconsistent adoption limited their impact. Trail registration number: NCT01885507.

From the Skin to the Brain: Pathophysiology of Colonization and Infection of External Ventricular Drain, a Prospective Observational Study.

Ventriculostomy-related infection (VRI) is a serious complication of external ventricular drain (EVD) but its natural history is poorly studied. We prospectively tracked the bacteria pathways from skin towards ventricles to identify the infectious process resulting in ventriculostomy-related colonization (VRC), and VRI. We systematically sampled cerebrospinal fluid (CSF) on a daily basis and collected swabs from both the skin and stopcock every 3.0 days for microbiological analysis including in 101 neurosurgical patient. Risk factors for positive event defined as either VRC or VRI were recorded and related to our microbiological findings. A total of 1261 CSF samples, 473 skin swabs, and 450 stopcock swabs were collected. Skin site was more frequently colonized than stopcock (70 (60%) vs 34 (29%), p = 0.023), and earlier (14 ±1.4 vs 24 ±1.5 days, p<0.0001). Sixty-one (52%) and 32 (27%) skin and stopcock sites were colonized with commensal bacteria, 1 (1%) and 1 (1%) with pathogens, 8 (7%) and 1 (1%) with combined pathogens and commensal bacteria, respectively. Sixteen positive events were diagnosed; a cutaneous origin was identified in 69% of cases. The presence of a pathogen at skin site (6/16 vs 4/85, OR: 11.8, [2.5-56.8], p = 0.002) and CSF leakage (7/16 vs 6/85, OR 10 [2.4-41.2], p = 0.001)) were the two independent significant risk factors statistically linked to positive events occurrence. Our results suggest that VRC and VRI mainly results from an extra-luminal progression of pathogens initially colonizing the skin site where CSF leaks.

Certainty in categorical judgment of size.

The certainty of judgment (or self-confidence) has been traditionally studied in relation with the accuracy. However, from an observer's viewpoint, certainty may be more closely related to the consistency of judgment than to its accuracy: consistent judgments are objectively certain in the sense that any external observer can rely on these judgments to happen. The regions of certain vs. uncertain judgment were determined in a categorical rating experiment. The participants rated the size of visual objects on a 5-point scale. There was no feedback so that there were no constraints of accuracy. Individual data was examined, and the ratings were characterized by their frequency distributions (or categories). The main result was that the individual categories always presented a core of certainty where judgment was totally consistent, and large peripheries where judgment was inconsistent. In addition, the geometry of cores and boundaries exhibited several phenomena compatible with the literature on visual categorical judgment. The ubiquitous presence of cores in absence of accuracy constraints provided insights about objective certainty that may complement the literature on subjective certainty (self-confidence) and the accuracy of judgment.