26 research outputs found
Cytomegalovirus reactivation in ICU patients
No full textInternational audienceApproximately 20 years have passed since we reported our results of histologically proven cytomegalovirus (CMV) pneumonia in non-immunocompromised ICU patients. Even if there are more recent reports suggesting that CMV may worsen the outcomes for ICU patients, there is no definite answer to this question: is CMV a potential pathogen for ICU patients or is it simply a bystander? We will describe the pathophysiology of active CMV infection and the most recent insights concerning the epidemiological aspects of these reactivations. Cytomegalovirus can be pathogenic by a direct organ insult (such as for the lung), by decreasing host defences against other microorganisms and/or by enhancing the body's inflammatory response (as in acute respiratory distress syndrome). The incidence of active CMV infection is dependent on the diagnostic method used. Using the most sophisticated available biological tools, the incidence can reach 15-20 % of ICU patients (20-40 % in ICU patients with positive CMV serology). In adequately powered cohorts of patients, active CMV infection appears to be associated with worse outcomes for mechanically ventilated ICU patients. There is no absolute direct proof of a negative impact of active CMV infection on the health outcomes of mechanically ventilated patients. Prospective randomized trials are lacking. Future trials should examine the potential benefits for health outcomes of using antiviral treatments. Such treatments could be prophylactic, pre-emptive or used only when there is an end-organ disease. Cytomegalovirus infection may affect health outcomes for ICU patients. Additional prospective trials are necessary to confirm this hypothesis
Pseudomonas aeruginosa multi résistant et mortalité chez les patients sous ventilation mécanique en réanimation
No full textThèse présentée sous la forme d'une "thèse article"Contexte : La combinaison d’une résistance accrue aux antibiotiques et d’une diminution de la découverte de nouvelles molécules antibiotiques est une préoccupation sérieuse dans le domaine de la réanimation. Cependant, le lien entre la résistance bactérienne et le pronostic reste controversé. Pseudomonas aeruginosa (Pa) est le principal agent pathogène à l’origine des pneumonies acquises sous ventilation mécanique (PAVM), or il devient de plus en plus résistant aux antibiotiques. Le but de notre étude était donc d’évaluer la relation entre les épisodes de PAVM à Pa multi-résistant et la mortalité à J30.Méthodes : à partir d’une base de données longitudinales française multicentrique prospective (2010-2016), les données physiologiques et descriptives correspondant à des épisodes de PAVM à Pa ont recueillis. Le caractère multi-résistant était défini comme une non-sensibilité à au moins un agent dans trois classes d’antibiotiques ou plus. Pour analyser si les épisodes multi-résistants étaient associés à une mortalité hospitalière à J30, nous avons effectué une analyse de survie multivariée en utilisant le modèle de fragilité non linéaire multivarié.Résultats : au total, 230 patients ont présenté 286 épisodes de PAVM à Pa. Un maximum de trois épisodes par patient a été observé. 73 épisodes étaient multi-résistant et 213 étaient sensible. Dans le modèle multivarié, les facteurs associés indépendamment à la mortalité à J30 incluaient l’âge (HR, 1.02, 95% CI, 1.01-1.04, p=0.0064), l’hospitalisation dans les 6 mois précédant le premier épisode (HR, 2.31, 95% CI, 1.50-3.60, p=0.0002), l’insuffisance rénale chronique (HR, 2.34, 95% CI, 1.15-4.77, p=0.0196) et la récidive d’une PAVM à Pa (HR, 2.29, 95% CI, 1.79-4.87, p=0.032). Finalement, le caractère multi-résistant de Pa lors de la PAVM n’était pas associé à une augmentation de la mortalité (HR, 0.87, 95% CI, 0.52-1.45, p=0.59).Conclusion : cette étude n’identifie pas de relation entre le profil de résistance de Pseudomonas aeruginosa et la mortalité
Effet du décubitus ventral en ventilation spontanée sur l'oxygénation dans l'insuffisance respiratoire aiguë liée au SARS-CoV-2
No full textIntroduction : le décubitus ventral (DV) vigile est utilisé chez les patients en ventilation spontanée pour la gestion de l’insuffisance respiratoire aiguë secondaire au SARS-CoV-2.Objectifs : amélioration de l’oxygénation et diminution du travail respiratoire pendant le DV.Méthodes : du 1er octobre 2020 au 15 janvier 2021, 18 patients admis pour une pneumonie à SARS-Cov-2 avec une hypoxémie définie par un PaO2 : FiO2 < 300 mmHg sous oxygénothérapie à haut débit nasal ont été inclus dans 4 unités de réanimations à Marseille (France). Ils ont été placés selon une séquence randomisée en schéma croisés en DV et en décubitus dorsal (DD) pendant deux heures entrecoupées d’une période de washout de 2 heures. Nous avons relevé les gazométries artérielles, les données cliniques, la dyspnée et l’inconfort. L’effort inspiratoire a été estimé par les courbes de pressions œsophagiennes (Pes). Le produit pression-temps simplifié et la pression transpulmonaire ont été mesurés. Nous avons aussi enregistré le CO2 expiré et calculé l’espace mort physiologique.Résultats : 17 patients ont été analysés. 1 patient est sorti d’étude avant le début de l’expérience. Le PaO2 : FiO2 médian était de 93 [IQR : 73-126] mmHg à l’inclusion, il était majoré à 208 [IQR : 114-226] mmHg à la fin du DV et avait baissé à 91 [IQR : 64-120] mmHg en fin de DD (p=0,0004). 65% des patients (n=11) ont été classés comme répondeurs dans le groupe DV. La fréquence respiratoire était significativement diminuée en fin de DV en comparaison au DD (respectivement 21 cycles/min [19-22] et 28 cycles/min [20-33], p= 0,0008). Il n’y avait pas de différence significative de PaCO2, d’ETCO2 ni d’espace mort physiologique entre la fin du DD et la fin du DV, de même que sur la valeur du produit pression-temps simplifié, le delta(Δ) de Pes, le delta de pression transpulmonaire dynamique et l’intensité de la dyspnée. Il y a eu une augmentation de l’inconfort de 2[IQR : 1.8-4.0] à 3.1[IQR : 2.5-6.2] p= 0.0232 pendant le DV, sans majoration de la douleur. Conclusion : dans les insuffisances respiratoires aiguës secondaires au SARS-CoV-2, en comparaison au DD, le DV améliore l’oxygénation, réduit la fréquence respiratoire sans modifier le ΔPes, le travail respiratoire, la PaCO2 et l’espace mort
Fatal Septic Shock Triggered by Donor Transmitted Varicella Zoster Virus Reinfection 3 Days After Lung Transplantation
No full textInternational audienc
Cytomegalovirus reactivation enhances the virulence of Staphylococcus aureus pneumonia in a mouse model
No full textInternational audienceObjectives: Cytomegalovirus (CMV) reactivation in intensive care unit patients may increase mortality and favour bacterial pneumonia. We developed a murine model to compare the severity of staphylococcal pneumonia after CMV reactivation and in CMV-negative mice. Methods: Balb/c mice were primo-infected with murine cytomegalovirus (MCMV n = 90) or received saline (control n = 90). After latency, all mice underwent caecal ligation and puncture to trigger MCMV reactivation in MCMV primary-infected mice. Surviving animals received an intra-nasal inoculation with methicillin-susceptible Staphylococcus aureus (MSSA) to induce pneumonia. Mortality, lung bacterial count, histology and interferon-alpha and gamma serum levels were compared in MCMV reactivated and control mice 2, 5 and 15 days after pneumonia. Results: AfterMSSA pneumonia, MCMV mice showed a trend towards a higher mortality (9.4% versus 0%; p 0.09) and a higher weight loss (2.2 (0.6-4.1 g) versus 0.7 (-0.3 to 1.3 g); p 0.005). The lung bacterial countwas higher in MCMV mice 2 days (5 x 10(3) (10(3) to 3 x 10(5)) versus 10(2) (0 to 4 x 10(2)) CFU/lung; p 0.007) and 5 days (2.5 x 10(4) (1.6 x 10(4) to 6.5 x 10(5)) versus 15 (10-40) CFU/lung; p 0.005) after MSSA pneumonia. 8/40 (20%) MCMV mice developed lung abscesses compared to 0% in control (p 0.011). Interferon-alpha serum levels 2 days after staphylococcal pneumonia were higher in MCMV mice. Conclusions: MCMV reactivation decreased lung bacterial clearance and favoured the development of staphylococcal abscessing pneumonia. CMV reactivation may be responsible for a higher susceptibility to bacterial sepsis. (C) 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved
Evaluation of Almitrine Infusion During Veno-Venous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome in Adults
No full textMultidrug-resistant Pseudomonas aeruginosa and mortality inmechanically ventilated ICU patients
No full textInternational audienceBackground: The link between bacterial resistance and prognosis remains controversial. Predominant pathogen causing ventilator-associated pneumonia (VAP) is Pseudomonas aeruginosa (Pa), which has increasingly become multidrug resistant (MDR). The aim of this study was to evaluate the relationship between MDR VAP Pa episodes and 30-day mortality. Methods: From a longitudinal prospective French multicenter database (2010-2016), Pa VAP onset and physiological data were recorded. MDR was defined as non-susceptibility to at least 1 agent in 3 or more antimi-crobial categories. To analyze if MDR episodes were associated with greater in-hospital 30-day mortality, we performed a multivariate survival analysis using the multivariate nonlinear frailty model. Results: A total of 230 patients presented 286 Pa VAP. A maximum of 3 episodes per patient was observed; 73 episodes were MDR and 213 were susceptible. In the multivariate model, factors independently associated with 30-day mortality included hospitalization in the 6 months preceding the first episode (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.50-3.60; P = .0002), chronic renal failure (HR, 2.34; 95% CI, 1.15-4.77; P = .0196), and Pa VAP recurrence (HR, 2.29; 95% CI, 1.79-4.87; P = .032). Finally, MDR Pa VAP was not associated with death (HR, 0.87; 95% CI; 0.52-1.45; P = .59). Conclusions: This study did not identify a relationship between the resistance profile of Pseudomonas aerugi-nosa and mortality
Early Hepatic Dysfunction Is Associated with a Worse Outcome in Patients Presenting with Acute Respiratory Distress Syndrome: A Post-Hoc Analysis of the ACURASYS and PROSEVA Studies.
No full textBilirubin is well-recognized marker of hepatic dysfunction in intensive care unit (ICU) patients. Multiple organ failure often complicates acute respiratory distress syndrome (ARDS) evolution and is associated with high mortality. The effect of early hepatic dysfunction on ARDS mortality has been poorly investigated. We evaluated the incidence and the prognostic significance of increased serum bilirubin levels in the initial phase of ARDS.The data of 805 patients with ARDS were retrospectively analysed. This population was extracted from two recent multicenter, prospective and randomised trials. Patients presenting with ARDS with a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen < 150 mmHg measured with a PEEP ≥ 5 cm of water were included. The total serum bilirubin was measured at inclusion and at days 2, 4, 7 and 14. The primary objective was to analyse the bilirubin at inclusion according to the 90-day mortality rate.The 90-day mortality rate was 33.8% (n = 272). The non-survivors were older, had higher Sepsis-related Organ Failure Assessment (SOFA) score and were more likely to have a medical diagnosis on admission than the survivors. At inclusion, the SOFA score without the liver score (10.3±2.9 vs. 9.0±3.0, p<0.0001) and the serum bilirubin levels (36.1±57.0 vs. 20.5±31.5 μmol/L, p<0.0001) were significantly higher in the non-survivors than in the survivors. Age, the hepatic SOFA score, the coagulation SOFA score, the arterial pH level, and the plateau pressure were independently associated with 90-day mortality in patients with ARDS.Bilirubin used as a surrogate marker of hepatic dysfunction and measured early in the course of ARDS was associated with the 90-day mortality rate
Venovenous extracorporeal membrane oxygenation devices-related colonisations and infections
No full textInternational audienceBackground: Nosocomial infections occurring during extracorporeal membrane oxygenation (ECMO) support have already been reported, but few studied infections directly related to ECMO devices. This study aims to evaluate the rate of both colonisations and infections related to ECMO devices at the time of ECMO removal. Results: We included all consecutive adult patients treated with venovenous ECMO (VV-ECMO) for at least 48 h during a 34-month study. At the time of ECMO removal, blood cultures, swab cultures on insertion cannula site and intravascular cannula extremity cultures were systematically performed. Each ECMO device was classified according to the infectious status into three groups: (1) uninfected/uncolonised ECMO device, (2) ECMO device colonisation and (3) ECMO device infection. Ninety-nine patients underwent 103 VV-ECMO, representing 1472 ECMO days. The ECMO device infection rate was 9.7% (10 events), including 7 ECMO device-related bloodstream infections (6.8%). The ECMO device colonisation rate was 32% (33 events). No difference was observed between the three groups, regarding days of mechanical ventilation, ICU length of stay, ICU mortality and in-hospital mortality. We observed a longer ECMO duration in the ECMO device colonisation group as compared to the uninfected/uncolonised ECMO device group [12 (9-20 days) vs. 5 days (5-16 days), respectively, p < 0.05]. Conclusions: At the time of ECMO removal, systematic blood culture and intravascular extremity cannula culture may help to diagnose ECMO device-related infection. We reported a quite low infection rate related to ECMO device. Further studies are needed to evaluate the benefits of systematic strategies of cannula culture at the time of ECMO removal
