Summary
Delayed defecation is common in patients on intensive care. We aimed to determine factors associated with time to defecation after admission to intensive care and in turn its association with ...length of stay and mortality. We studied 396 adults admitted to one of five intensive care units in whom at least 2 days’ invasive ventilation was anticipated during an expected stay of at least 3 days. The median (IQR range) time to defecate by the 336 out of 396 (84%) patients who did so before intensive care discharge was 6 (4‐8 1–18) days. Defecation was independently associated with five factors, hazard ratio (95%CI), higher values indicating more rapid defecation: alcoholism, 1.32 (1.05–1.66), p = 0.02; laxatives before admission, 2.35 (1.79–3.07), p < 0.001; non‐invasive ventilation, 0.54 (0.36–0.82), p = 0.004; duration of ventilation, 0.78 (0.74–0.82), p < 0.001; laxatives after admission, 1.67 (1.23–2.26), p < 0.001; and enteral nutrition within 48 h of admission, 1.43 (1.07–1.90), p = 0.01. Delayed defecation was associated with prolonged intensive care stay but not mortality.
The spectrum of community-acquired pneumonia (CAP) due to
Chlamydophila psittaci
ranges from mild, self-limited CAP, to acute respiratory failure. We performed a retrospective study of 13 consecutive ...patients with CAP due to
C. psittaci
and 51 patients with legionellosis admitted in one intensive care unit (ICU) (1993–2011). As compared to patients with legionellosis, patients with psittacosis were younger (median age 48 38–59 vs. 60 50–71 years,
p
= 0.007), less frequently smokers (38 vs. 79 %,
p
< 0.001), with less chronic disease (15 vs. 57 %,
p
= 0.02), and longer duration of symptoms before admission (median 6 5–13 vs. 5 3–7 days,
p
= 0.038). They presented with lower Simplified Acute Physiology Score II (median 28 19–38 vs. 39 28–46,
p
= 0.04) and less extensive infiltrates on chest X-rays (median 2 1–3 vs. 3 3–4 lobes,
p
= 0.007). Bird exposure was mentioned in 100 % of psittacosis cases, as compared to 5.9 % of legionellosis cases (
p
< 0.0001). Extrapulmonary manifestations, biological features, and mortality (15.4 vs. 21.6 %,
p
= 0.62) were similar in both groups. In conclusion, severe psittacosis shares many features with severe legionellosis, including extrapulmonary manifestations, biological features, and outcome. Psittacosis is an important differential diagnosis for legionellosis, especially in cases of bird exposure, younger age, and more limited disease progression over the initial few days.
The optimal timing of cardiac surgery in infective endocarditis (IE) remains debated: Early surgery decreases the risk of embolism, and heart failure, but is associated with an increased rate of ...positive valve culture. To determine the determinants, and the consequences, of positive valve culture when cardiac surgery is performed during the acute phase of IE, we performed a retrospective study of adult patients who underwent cardiac surgery for definite left-sided IE (Duke Criteria), in two referral centres. During the study period (2002–2016), 148 patients fulfilled inclusion criteria. Median age was 65 years interquartile range, 53–73, male-to-female ratio was 2.9 (110/38). Cardiac surgery was performed after 14 days 5–26 of appropriate antibiotics. Valve cultures returned positive in 46 cases (31.1%). Factors independently associated with positive valve culture were vegetation size ≥ 10 mm (OR 2.83 1.16–6.89,
P
= 0.022) and < 14 days of appropriate antibacterial treatment before surgery (OR 4.68 2.04–10.7,
P
< 0.001). Positive valve culture was associated with increased risk of postoperative acute respiratory distress syndrome (37.0% vs. 15.7%,
P
= 0.008) but was associated neither with an increased risk of postoperative relapse nor with the need for additional cardiac surgery. Duration of appropriate antibacterial treatment and vegetation size are independently predictive of positive valve culture in patients operated during the acute phase of IE. Positive valve culture is associated with increased risk of postoperative acute respiratory distress syndrome.
The aim of our study was to compare the features at diagnosis in patients with ornithosis to patients with avian acute hypersensitivity pneumonitis (HP). Clinical, biological and radiological ...differences could potentially help clinicians to distinguish these diseases.
We conducted a retrospective study on patients admitted from 2000 to 2016 in three hospitals. Ornithosis was diagnosed based on a positive polymerase chain reaction for Chlamydophila psittaci on respiratory samples and/or a seroconversion while HP was diagnosed on the basis of at least one positive serum precipitin.
Twelve patients with HP and 13 patients with ornithosis were identified. Compared to HP, ornithosis occurred more frequently in males (P=0.047), with less previous respiratory diseases (P=0.01), shorter symptom duration (P=0.03), less frequently bilateral crackles (P=0.004), more severe disease requiring more frequently intensive care admission (P=0.005), higher CRP values (P=0.005) and more profound lymphopenia (P=0.02). Ground glass shadowing on CT scan (P=0.001) or bronchiectasis (P=0.03) were more frequently noted in patients with HP.
Our results suggest that patients with ornithosis and HP have important differences in their clinical, biological, and radiological presentation.
The purpose of this investigation was to characterize the management and prognosis of severe
Pneumocystis jirovecii
pneumonia (PJP) in human immunodeficiency virus (HIV)-negative patients. An ...observational cohort study of HIV-negative adults with PJP documented by bronchoalveolar lavage (BAL) through Gomori–Grocott staining or immunofluorescence, admitted to one intensive care unit (ICU) for acute respiratory failure, was undertaken. From 1990 to 2010, 70 patients (24 females, 46 males) were included, with a mean age of 58.6 ± 18.3 years. The mean Simplified Acute Physiology Score (SAPS)-II was 36.9 ± 20.4. Underlying conditions included hematologic malignancies (
n
= 21), vasculitis (
n
= 13), and solid tumors (
n
= 13). Most patients were receiving systemic corticosteroids (
n
= 63) and cytotoxic drugs (
n
= 51). Not a single patient received trimethoprim–sulfamethoxazole as PJP prophylaxis. Endotracheal intubation (ETI) was required in 42 patients (60.0 %), including 38 with acute respiratory distress syndrome (ARDS). In-ICU mortality was 52.9 % overall, reaching 80.9 % and 86.8 %, respectively, for patients who required ETI and for patients with ARDS. In the univariate analysis, in-ICU mortality was associated with SAPS-II (
p
= 0.0131), ARDS (
p
< 0.0001), shock (
p
< 0.0001), and herpes simplex virus (HSV) or cytomegalovirus (CMV) on BAL (
p
= 0.0031). In the multivariate analysis, only ARDS was associated with in-ICU mortality (odds ratio OR 23.4 4.5–121.9,
p
< 0.0001). PJP in non-HIV patients remains a serious disease with high in-hospital mortality. Pulmonary co-infection with HSV or CMV may contribute to fatal outcome.
Purpose
The reduction in acquired infections (AI) due to methicillin-resistant
Staphylococcus aureus
(MRSA) with the mupirocin/chlorhexidine (M/C) decontamination regimen has not been well studied in ...intubated patients. We performed post hoc analysis of a prior trial to assess the impact of M/C on MRSA AI and colonization.
Methods
We conducted a multicenter, placebo-controlled, randomized, double-blind study with the primary aim to reduce all-cause AI. The two regimens used topical polymyxin and tobramycin (P/T), nasal mupirocin with chlorhexidine body wash (M/C), or corresponding placebos for each regimen were administered according to a 2 × 2 factorial design. Participants were intubated patients in the intensive care units of three French university hospitals. The patients enrolled in the study (
n
= 515) received either active P/T (
n
= 130), active M/C (
n
= 130), both active regimens (
n
= 129), or placebos only (
n
= 126) for the period of intubation and an additional 24 h. The incidence and incidence rates (per 1,000 study days) of MRSA AI were assessed. Due to the absence of a statistically significant interaction between the two regimens, analysis was performed at the margins by comparing all patient receiving M/C (
n
= 259) to all patients not receiving M/C (
n
= 256), and all patients receiving P/T (
n
= 259) to all patients not receiving P/T (
n
= 256).
Results
Incidence odds ratio (OR) 0.39, 95 % confidence interval (CI) (0.16–0.96),
P
= 0.04 and incidence rates incidence rate ratio (IRR) 0.41, 95 % CI 0.17–0.97,
P
= 0.05 of MRSA AI were significantly lower with the use of M/C. We also observed an increase in the incidence (OR 2.50, 95 % CI 1.01–6.15,
P
= 0.05) and the incidence rate (IRR 2.90, 95 % CI 1.20–8.03,
P
= 0.03) of MRSA AI with the use of P/T.
Conclusion
Among our study cohort of intubated patients, the use of M/C significantly reduced MRSA AI.
To assess the use of procalcitonin (PCT) for the diagnosis of infection in a medical ICU.
Prospective, observational study.
Seventy-seven infected patients and 24 patients with systemic inflammatory ...response syndrome (SIRS) due to other causes. Seventy-five patients could be classified into sepsis (n = 24), severe sepsis (n = 27) and septic shock (n = 24), and 20 SIRS patients remained free from infection during the study. Plasma PCT and C-reactive protein (CRP) levels were evaluated within 48 h of admission (day 0), at day 2 and day 4.
As compared with SIRS, PCT and CRP levels at day 0 were higher in infected patients, regardless of the severity of sepsis (25.2 +/- 54.2 ng/ml vs 4.8 +/- 8.7 ng/ml; 159 +/- 92 mg/l vs 71 +/- 58 mg/l, respectively). At cut-off values of 2 ng/ml (PCT) and 100 mg/l (CRP), sensitivity and specificity were 65% and 70% (PCT), 74% and 74% (CRP). PCT and CRP levels were significantly more elevated in septic shock (38.5 +/- 59.1 ng/ml and 173 +/- 98 mg/l) than in SIRS (3.8 +/- 6.9 ng/ml and 70 +/- 48 mg/l), sepsis (1.3 +/- 2.7 ng/ml and 98 +/- 76 mg/l) and severe sepsis (9.1 +/- 18. 2 ng/ml and 145 +/- 70 mg/l) (all p = 0.005). CRP, but not PCT, levels were more elevated in severe sepsis than in SIRS (p<0.0001). Higher PCT levels in the patients with four dysfunctional organs and higher PCT and CRP levels in nonsurvivors may only reflect the marked inflammatory response to septic shock.
In this study, PCT and CRP had poor sensitivity and specificity for the diagnosis of infection. PCT did not clearly discriminate SIRS from sepsis or severe sepsis.
Leptospirosis has a highly variable clinical presentation, which may be related to different infecting serovars, host factors, or a combination of these. This study investigated retrospectively 34 ...consecutive patients with serologically confirmed leptospirosis admitted during the period 1992–2002. On admission, the most frequent symptoms were fever (100%), headache (75%), myalgia (55%), arthralgia (45%) and vomiting (39%). Pertinent laboratory findings included lymphopenia (85%), thrombocytopenia (75%), elevated liver enzymes (87%) and renal abnormalities (proteinuria, 77%; haematuria, 58%; elevated serum creatinine, 53%). The study confirmed the variable clinical and biological symptoms of leptospirosis, and indicated that lymphopenia is a common feature of leptospirosis cases.
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