Hypothermia for bacterial meningitis--reply Mourvillier, Bruno; Wolff, Michel
JAMA : the journal of the American Medical Association,
2014-Apr-02, Volume:
311, Issue:
13
Journal Article
Given that ventilator-associated pneumonia (VAP) causes substantial morbidity, mortality and costs, prevention of this infectious process is a major challenge.
This study provides an update on the ...prevention of VAP, focusing on the ability of preventive measures to improve patient outcomes and concentrating wherever possible on the data published within the past 5 years. Particular attention is being paid to the latest approach to facilitate the implementation of those prevention measures known as 'care bundles'.
Several preventive measures have been shown to reduce the rate of VAP but many less have demonstrated an impact on patient outcomes (noninvasive positive pressure ventilation, sedation and weaning protocols, selective digestive and oral decontamination and endotracheal tube with drainage of subglottic secretions). Patients at risk must be approached with a bundle of preventive measures. Beyond the theoretical frame, a great deal of attention must be given to the factors that might improve adherence to those preventive measures. Future clinical trials testing new strategies in preventing VAP should have patient outcomes (i.e. a reduction in the length under mechanical ventilation, in the duration of stay in healthcare settings or in antibiotic consumption) as primary end-points rather than VAP rates.
Blackwater fever (BWF) is a severe clinical syndrome, characterized by intravascular hemolysis, hemoglobinuria, and acute renal failure that is classically seen in European expatriates chronically ...exposed to Plasmodium falciparum and irregularly taking quinine. BWF virtually disappeared after 1950, when chloroquine superseded quinine. We report 21 cases of BWF seen in France from 1990 through 1999 in European expatriates who lived in sub-Saharan Africa. All patients had macroscopic hemoglobinuria, jaundice, and anemia. Acute renal failure occurred in 15 patients (71%), 7 of whom required dialysis. The presumed triggers of BWF were halofantrine (38%), quinine (24%), mefloquine (24%), and halofantrine or quinine (14%). Glucose-6-phosphate dehydrogenase (G6PD) activity was normal in the 14 patients who underwent this test. Low-level P. falciparum parasitemia was found in 8 patients. All 21 patients survived. Our data and 13 cases reported in the literature suggest a resurgence of classic BWF among Europeans living in Africa and a need to discuss attendant therapeutic implications.
Summary Background Listeriosis is a severe foodborne infection and a notifiable disease in France. We did a nationwide prospective study to characterise its clinical features and prognostic factors. ...Methods MONALISA was a national prospective observational cohort study. We enrolled eligible cases declared to the National Reference Center for Listeria (all microbiologically proven) between Nov 3, 2009, and July 31, 2013, in the context of mandatory reporting. The outcomes were analysis of clinical features, characterisation of Listeria isolates, and determination of predictors of 3-month mortality or persisting impairment using logistic regression. A hierarchical clustering on principal components was also done for neurological and bacteraemic cases. The study is registered at ClinicalTrials.gov , number NCT01520597. Findings We enrolled 818 cases from 372 centres, including 107 maternal–neonatal infections, 427 cases of bacteraemia, and 252 cases of neurolisteriosis. Only five (5%) of 107 pregnant women had an uneventful outcome. 26 (24%) of 107 mothers experienced fetal loss, but never after 29 weeks of gestation or beyond 2 days of admission to hospital. Neurolisteriosis presented as meningoencephalitis in 212 (84%) of 252 patients; brainstem involvement was only reported in 42 (17%) of 252 patients. 3-month mortality was higher for bacteraemia than neurolisteriosis (hazard ratio HR 0·54 95% CI 0·41–0·69, p<0·0001). For both bacteraemia and neurolisteriosis, the strongest mortality predictors were ongoing cancer (odds ratio OR 5·19 95% CI 3·01–8·95, p<0·0001), multi-organ failure (OR 7·98 4·32–14·72, p<0·0001), aggravation of any pre-existing organ dysfunction (OR 4·35 2·79–6·81, p<0·0001), and monocytopenia (OR 3·70 1·82–7·49, p=0·0003). Neurolisteriosis mortality was higher in blood-culture positive patients (OR 3·67 1·60–8·40, p=0·002) or those receiving adjunctive dexamethasone (OR 4·58 1·50–13·98, p=0·008). Interpretation The severity of listeriosis is higher than reported elsewhere. We found evidence of a significantly reduced survival in patients with neurolisteriosis treated with adjunctive dexamethasone, and also determined the time window for fetal losses. MONALISA provides important new data to improve management and predict outcome in listeriosis. Funding Programme Hospitalier Recherche Clinique, Institut Pasteur, Inserm, French Public Health Agency.
Purpose
To assess whether invasive and non-invasive blood pressure (BP) monitoring allows the identification of patients who have responded to a fluid challenge, i.e., who have increased their ...cardiac output (CO).
Methods
Patients with signs of circulatory failure were prospectively included. Before and after a fluid challenge, CO and the mean of four intra-arterial and oscillometric brachial cuff BP measurements were collected. Fluid responsiveness was defined by an increase in CO ≥10 or ≥15 % in case of regular rhythm or arrhythmia, respectively.
Results
In 130 patients, the correlation between a fluid-induced increase in pulse pressure (Δ
500ml
PP) and fluid-induced increase in CO was weak and was similar for invasive and non-invasive measurements of BP:
r
² = 0.31 and
r
² = 0.29, respectively (both
p
< 0.001). For the identification of responders,
invasive
Δ
500ml
PP was associated with an area under the receiver-operating curve (AUC) of 0.82 (0.74–0.88), similar (
p
= 0.80) to that of
non-invasive
Δ
500ml
PP AUC of 0.81 (0.73–0.87). Outside large gray zones of inconclusive values (5–23 % for
invasive
Δ
500ml
PP and 4–35 % for
non-invasive
Δ
500ml
PP, involving 35 and 48 % of patients, respectively), the detection of responsiveness or unresponsiveness to fluid was reliable. Cardiac arrhythmia did not impair the performance of
invasive
or
non-invasive
Δ
500ml
PP. Other BP-derived indices did not outperform Δ
500ml
PP.
Conclusions
As evidenced by large gray zones, BP-derived indices poorly reflected fluid responsiveness. However, in our deeply sedated population, a high increase in invasive pulse pressure (>23 %) or even in non-invasive pulse pressure (>35 %) reliably detected a response to fluid. In the absence of a marked increase in pulse pressure (<4–5 %), a response to fluid was unlikely.
The cases of 48 adult patients with tuberculous meningitis who were admitted to an intensive care unit (ICU) between 1982 and 1993 were reviewed. An underlying disease was present in 24 patients ...(50%), including 10 with human immunodeficiency virus infection. Forty-seven patients were referred to the ICU because of neurological deterioration; 22 were comatose at admission. Forty-six patients received antituberculous treatment; 36 required mechanical ventilatory support, and 16 underwent neurosurgery. Thirty-one patients died within 4 months after admission, and the remaining 17 were alive at a I-year follow-up. Univariate prognostic analysis selected three variables, all assessed at admission, associated with outcome: time to onset of treatment of ⩾3 days (P = .003), coma (P = .006), and simplified acute physiology score of >11 (P = .03). Thus, the outcome of tuberculous meningitis is mainly determined by the clinical stage at admission and the delay in starting treatment. These findings underscore the need to initiate early therapy as soon as the diagnosis of tuberculous meningitis is suspected.
Ceftazidime-avibactam (CAZ-AVI) is a recently approved β-lactam-β-lactamase inhibitor combination with the potential to treat serious infections caused by carbapenem-resistant organisms. Few patients ...with such infections were included in the CAZ-AVI clinical trials, and clinical experience is lacking. We present a case series of patients with infections caused by carbapenem-resistant Enterobacteriaceae (CRE) or Pseudomonas aeruginosa (CRPa) who were treated with CAZ-AVI salvage therapy on a compassionate-use basis. Physicians who had prescribed CAZ-AVI completed a case report form. We used descriptive statistics to summarize patient characteristics and treatment outcomes. We used the Wilcoxon rank sum test and Fisher's exact test to compare patients by treatment outcome. The sample included 36 patients infected with CRE and two with CRPa. The most common infections were intra-abdominal. Physicians categorized 60.5% of patients as having life-threatening infections. All but two patients received other antibiotics before CAZ-AVI, for a median of 13 days. The median duration of CAZ-AVI treatment was 16 days. Twenty-five patients (65.8%) concurrently received other antibiotics to which their pathogen was nonresistant in vitro Twenty-eight patients (73.7%, 95% confidence interval CI, 56.9 to 86.6%) experienced clinical and/or microbiological cure. Five patients (20.8%) with documented microbiological cure died, whereas 10 patients (71.4%) with no documented microbiological cure died (P = 0.01). In three-quarters of cases, CAZ-AVI (alone or combined with other antibiotics) cured infections caused by carbapenem-resistant organisms, 95% of which had failed previous therapy. Microbiological cure was associated with improved survival. CAZ-AVI shows promising clinical results for infections for which treatment options are limited.
In February, 2017, the US Food and Drug Administration approved the blood infection marker procalcitonin for guiding antibiotic therapy in patients with acute respiratory infections. This ...meta-analysis of patient data from 26 randomised controlled trials was designed to assess safety of procalcitonin-guided treatment in patients with acute respiratory infections from different clinical settings.
Based on a prespecified Cochrane protocol, we did a systematic literature search on the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, and pooled individual patient data from trials in which patients with respiratory infections were randomly assigned to receive antibiotics based on procalcitonin concentrations (procalcitonin-guided group) or control. The coprimary endpoints were 30-day mortality and setting-specific treatment failure. Secondary endpoints were antibiotic use, length of stay, and antibiotic side-effects.
We identified 990 records from the literature search, of which 71 articles were assessed for eligibility after exclusion of 919 records. We collected data on 6708 patients from 26 eligible trials in 12 countries. Mortality at 30 days was significantly lower in procalcitonin-guided patients than in control patients (286 9% deaths in 3336 procalcitonin-guided patients vs 336 10% in 3372 controls; adjusted odds ratio OR 0·83 95% CI 0·70 to 0·99, p=0·037). This mortality benefit was similar across subgroups by setting and type of infection (pinteractions>0·05), although mortality was very low in primary care and in patients with acute bronchitis. Procalcitonin guidance was also associated with a 2·4-day reduction in antibiotic exposure (5·7 vs 8·1 days 95% CI −2·71 to −2·15, p<0·0001) and a reduction in antibiotic-related side-effects (16% vs 22%, adjusted OR 0·68 95% CI 0·57 to 0·82, p<0·0001).
Use of procalcitonin to guide antibiotic treatment in patients with acute respiratory infections reduces antibiotic exposure and side-effects, and improves survival. Widespread implementation of procalcitonin protocols in patients with acute respiratory infections thus has the potential to improve antibiotic management with positive effects on clinical outcomes and on the current threat of increasing antibiotic multiresistance.
National Institute for Health Research.
Neurologic complications of endocarditis can influence diagnosis, therapeutic plans, and prognosis.
To describe how early cerebral magnetic resonance imaging (MRI) affects the diagnosis and ...management of endocarditis in hospitalized adults.
Single-center prospective study between June 2005 and October 2008. (ClinicalTrials.gov registration number: NCT00144885)
Tertiary care university hospital in France.
130 patients with endocarditis.
Cerebral MRI with angiography performed up to 7 days after admission and before any surgical intervention.
2 experts jointly established the endocarditis diagnostic classification (according to Duke-modified criteria) and therapeutic plans just before and after MRI and then compared them.
Endocarditis was initially classified as definite in 77 patients and possible in 50 and was excluded in 3. Sixteen patients (12%) had acute neurologic symptoms. Cerebral lesions were detected by MRI in 106 patients (82% 95% CI, 75% to 89%), including ischemic lesions in 68, microhemorrhages in 74, and silent aneurysms in 10. Solely on the basis of MRI results and excluding microhemorrhages, diagnostic classification of 17 of 53 (32%) cases of nondefinite endocarditis was upgraded to either definite (14 patients) or possible (3 patients). Endocarditis therapeutic plans were modified for 24 (18%) of the 130 patients, including surgical plan modifications for 18 (14%). Overall, early MRI led to modifications of diagnosis or therapeutic plan in 36 patients (28% CI, 20% to 36%).
Investigators did not assess whether the MRI-related changes in diagnosis and therapeutic plans improved patient outcomes or led to unnecessary procedures and increased costs.
Cerebral lesions were identified by MRI in many patients with endocarditis but no neurologic symptoms. The MRI findings affected both diagnostic classifications and clinical management plans.
French Ministry of Health.
PDF
