Deux approches différentes sont possibles pour faire le diagnostic et prendre en charge les pneumopathies acquises sous ventilation (PAV). La stratégie clinique également appelée « non-invasive » permet, grâce à des prélèvements simples et peu onéreux, d'identifier les malades réellement atteints de PAV en prenant le risque de traiter inévitablement un certain nombre de malades par excès qui ne seraient que seulement porteurs d'une colonisation des voies aériennes. Cette approche qui a le mérite de la rapidité et de la facilité de mise en œuvre dès que l'on suspecte une PAV est difficilement compatible avec un contrôle rationnel de la prescription des antibiotiques. Une stratégie microbiologique, dite « invasive » fondée sur une antibiothérapie guidée par le résultat d'un examen direct d'un prélèvement au mieux réalisé par une bronchoscopie, (lavage bronchoalvéolaire ou brosse télescopique protégée), permet de limiter le nombre de malades traités par excès tout en adaptant la thérapeutique aux résultats de la culture quantitative. L'intérêt de ce type de stratégie a pu être démontré. Two strategies are available for the diagnosis and therapeutic management of ventilator-associated pneumonia (VAP). One based on clinical evaluation (also called noninvasive strategy) is safe, cheap and easy to use. However, this approach obviously leads to an excessive use of antibiotics due to the treatment of signs and symptoms suggesting lung infection, but frequently due to other infections or non-infectious inflammatory process. A microbiological strategy (or invasive) based on direct examination of protected brush or brochoalveolar lavage specimens obtained via a fiberoptic bronchoscopy permits to accurately select patients with VAP with a rapid identification of organisms responsible for infection. This strategy allowing the reduction of unnecessary antimicrobial regiments has been proven to be efficient.
Iseganan, an antimicrobial peptide, is active against aerobic and anaerobic gram-positive and gram-negative bacteria as well as fungi and yeasts. The drug has shown little resistance in vitro and to be safe and well tolerated in 800 patients with cancer treated for up to 6 wk.To determine the efficacy of iseganan for the prevention of ventilator-associated pneumonia (VAP).Mechanically ventilated patients in the United States and Europe were randomized to oral topical iseganan or placebo (1:1) and treated six times per day while intubated for up to 14 d. Patients were eligible if randomized within 24 h of intubation and estimated to survive and remain mechanically ventilated for 48 h or more. The primary efficacy endpoint of the study was VAP measured among survivors at Day 14.A total of 709 patients were randomized and received at least one dose of study drug. The two groups were comparable at baseline except iseganan-treated patients were, on average, 3 yr older. The rate of VAP among survivors at Day 14 was 16% (45/282) in patients treated with iseganan and 20% (57/284) in those treated with placebo (p = 0.145). Mortality at Day 14 was 22.1% (80/362) in the iseganan group compared with 18.2% (63/347) in the placebo group (p = 0.206). No pattern of excess adverse events in the iseganan group compared with placebo was observed.Iseganan is not effective in improving outcome in patients on prolonged mechanical ventilation.
To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in patients at risk for ventilator-associated pneumonia and to describe risk factors for P. aeruginosa ventilator-associated pneumonia.Prospective, observational study.ICUs at 56 sites in 11 countries across four regions: the United States (n = 502 patients), Europe (n = 495), Latin America (n = 500), and Asia Pacific (n = 376).Adults intubated and mechanically ventilated for 48 hours to 7 days, inclusive.None (local standard of care).Ventilator-associated pneumonia prevalence as defined by local investigators were 15.6% (293/1,873) globally, 13.5% in the United States, 19.4% in Europe, 13.8% in Latin America, and 16.0% in Asia Pacific (p = 0.04). Corresponding P. aeruginosa ventilator-associated pneumonia prevalences were 4.1%, 3.4%, 4.8%, 4.6%, and 3.2% (p = 0.49). Of 50 patients with P. aeruginosa ventilator-associated pneumonia who underwent surveillance testing, 19 (38%) had prior P. aeruginosa colonization and 31 (62%) did not (odds ratio, 7.99; 95% CI, 4.31-14.71). Of predefined risk factors for multidrug resistance (hereafter, risk factors), the most frequent in all patients were antimicrobial therapy within 90 days (51.9% of enrolled patients) and current hospitalization of more than or equal to 5 days (45.3%). None of these risk factors were significantly associated with P. aeruginosa ventilator-associated pneumonia by multivariate logistic regression. Risk factors associated with prior P. aeruginosa colonization were antimicrobial therapy within 90 days (odds ratio, 0.46; 95% CI, 0.29-0.73) and high proportion of antibiotic resistance in the community or hospital unit (odds ratio, 1.79; 95% CI, 1.14-2.82).Our findings suggest that ventilator-associated pneumonia remains a common ICU infection and that P. aeruginosa is one of the most common causative pathogens. The odds of developing P. aeruginosa ventilator-associated pneumonia were eight times higher in patients with prior P. aeruginosa colonization than in uncolonized patients, which in turn was associated with local resistance.
Prolonged stays in ICU have been associated with overconsumption of resources but little is known about their epidemiology. We aimed to identify predictors and prognostic factors of extended stays, studying a long-stay population.We present a retrospective cohort study between July 2000 and December 2013 comparing patients hospitalized in a medical ICU for ≥30 days (long-stay patients-LSP) with patients hospitalized for <30 days (short-stay patients-SSP). Admission characteristics were collected from the local database for every patient and evolution during the ICU stay was retrieved from LSP files.Among 8906 patients hospitalized in the ICU, 417 (4.7%) were LSP. At admission, male sex (adjusted odds-ratio (aOR) 1.4 [1.1; 1.7]), inpatient (aOR 2.0 [1.6; 2.4]) and in-ICU hospitalizations for respiratory (aOR 2.9 [1.6; 3.5]) or infectious diseases (aOR 1.6 [1.1; 2.5]) were all independently associated with a long stay in the ICU, while hospitalizations for metabolic (aOR 0.2 [0.1; 0.5]) or cardiovascular diseases (aOR 0.3 [0.2; 0.5]) were in favor of a short stay. In-ICU and in-hospital LSP mortality were 38.8% and 48.2%. Age (aOR 1.02 [1.00-1.04]), catecholamines (aOR 3.9 [1.9; 8.5]), renal replacement therapy (aOR 2.4 [1.3; 4.3]), primary disease-related complications (aOR 2.5 [1.4; 4.6]) and nosocomial infections (aOR 4.1 [1.8; 10.1]) were independently associated with mortality in LSP.LSP were highly comorbid patients mainly hospitalized for respiratory diseases. Their mortality was mostly related to nosocomial infections but the majority were discharged alive from the hospital.
Heart transplantation (HT) and ventricular assist devices (VAD) for the management of end-stage heart failure have not been directly compared. We compare the outcomes and use of resources with these 2 strategies in 2 European countries with different allocation systems. We studied 83 patients managed by VAD as the first option in Bad Oeynhausen, Germany (Group I) and 141 managed with either HT or medical therapy, as the first option, in Paris, France (Group II). The primary end-point was 2-year survival. Kaplan–Meier analyses were performed after the application of propensity score weights to mitigate the effects of non-random group assignment. The secondary end-points were resource utilization and costs. Subgroup analyses were performed for patients undergoing HT and patients treated with inotropes at the enrolment time. The Group I patients were more severely ill and haemodynamically compromised, and 28% subsequently underwent HT vs 55% primary HT in Group II, P < 0.001. The adjusted probability of survival was 44% in Group I vs 70% in Group II, P <0.0001. The mean cumulated 2-year costs were €281 361 ± 156 223 in Group I and €47 638 ± 35 061 in Group II, P < 0.0001. Among patients who underwent HT, the adjusted probability of survival in Group I (n = 23) versus Group II (n = 78) was 76% versus 68%, respectively (0.09), though it differed in the inotrope-treated subgroups (77% in Group I vs 67% in Group II, P = 0.04). HT should remain the first option for end-stage heart failure patients, associated with improved outcomes and better cost–effectiveness profile. VAD devices represent an option when transplant is not possible or when patient presentation is not optimal.
L’oxygénation par membrane extracorporelle (ECMO) veino-artérielle est devenue l’assistance de premier choix dans le choc cardiogénique réfractaire. Les procédures de sevrage de cette technique d’assistance cardiocirculatoire largement répandue ne sont pourtant pas standardisées. Le taux de mortalité après un sevrage de l’ECMO reste élevé, ce qui montre que de nombreuses questions ne sont pas résolues dans ce domaine. Le but de cette revue est de proposer une stratégie de sevrage de l’ECMO veino-artérielle à la lumière des données de la littérature.
