J. Trouillet

To describe the epidemiologic and microbial aspects of ventilator-associated pneumonia (VAP) in patients with acute respiratory distress syndrome (ARDS), we prospectively evaluated 243 consecutive patients who required mechanical ventilation (MV) for > or = 48 h, 56 of whom developed ARDS as defined by a Murray lung injury score > 2.5. We did this with bronchoscopic techniques when VAP was clinically suspected, before any modification of existing antimicrobial therapy. For all patients, the diagnosis of pneumonia was established on the basis of culture results of protected-specimen brush (PSB) (> or = 10(3) cfu/ml) and bronchoalvelolar lavage fluid (BALF) (> or = 10(4) cfu/ml) specimens, and direct examination of cells recovered by bronchoalveolar lavage (BAL) (< or = 5% of infected cells). Thirty-one (55%) of the 56 patients with ARDS developed VAP for a total of 41 episodes, as compared with only 53 (28%) of the 187 patients without ARDS for a total of 65 episodes (p = 0.0005). Only 10% of first episodes of VAP in patients with ARDS occurred before Day 7 of MV, as compared with 40% of the episodes in patients without ARDS (p = 0.005). All but two patients with ARDS who developed VAP had received antimicrobial treatment (mostly with broad-spectrum antibiotics) before the onset of infection, as compared with only 35 patients without ARDS (p = 0.004). The organisms most frequently isolated from patients with ARDS and VAP were methicillin-resistant Staphylococcus aureus (23%), nonfermenting gram-negative bacilli (21%), and Enterobacteriaceae (21%). These findings confirm that microbiologically provable VAP occurs far more often in patients with ARDS than in other ventilated patients. Because these patients are often treated with antibiotics early in the course of the syndrome, the onset of VAP is frequently delayed after the first week of MV, and is then caused mainly by methicillin-resistant S. aureus and other multiresistant microorganisms.

Abstract The in situ inflammatory response developing in the human lung during a localized bacterial infection was studied in 15 patients with unilateral community-acquired pneumonia (CAP). The local response in the involved lung was compared with that in the contralateral, noninvolved lung as well as with the systemic blood response. Eight healthy volunteers served as control subjects. Concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), and interleukin-6 (IL-6) were measured by ELISA in bronchoalveolar lavage (BAL) fluids (n = 15), serum (n = 15), and alveolar macrophage and monocyte culture supernatants (n = 8). The concentrations of TNF-alpha, IL-beta and IL-6 in BAL fluid were significantly higher in the involved lung than in the paired noninvolved lung (p &amp;lt; or = 0.01) or in healthy subjects (p &amp;lt; or = 0.02, p &amp;lt; or = 0.01, and p &amp;lt; or = 0.001, respectively). Serum IL-6 concentrations were higher in patients than in control subjects, whereas IL-1 beta and TNF-alpha concentrations did not differ in the two groups. Alveolar macrophages from the involved lung spontaneously released higher concentrations of IL-1 beta, IL-6, and TNF-alpha (p &amp;lt; or = 0.05) than did macrophages from the noninvolved lung, which served as controls. However, macrophages were hyporesponsive in terms of cytokine production to further stimulation by lipopolysaccharide (LPS) in the noninvolved and involved lung compared with controls, whereas peripheral blood monocytes were not.(ABSTRACT TRUNCATED AT 250 WORDS)

We have undertaken this retrospective study to determine factors associated with in-hospital mortality and morbidity in 80 adult patients with severe Streptococcus pneumoniae meningitis. Clinical characteristics at admission of patients infected with susceptible (n = 54) and nonsusceptible (n = 17) strains to penicillin G were similar: age: 51 +/- 19 versus 58 +/- 15 yr (p = 0.16); Simplified Acute Severity Score (SAPS II): 39 +/- 14 versus 41 +/- 11 (p = 0.68); and Glasgow Coma Score: 8 +/- 3 versus 9.5 +/- 3 (p = 0.21), respectively. In-hospital mortality was 25% (20/80), with one death among the 17 patients (6%) infected with a nonsusceptible strain (p = 0.03). High-dose dexamethasone was used in 22 cases. By multivariate analysis, three factors were independently associated with death: platelet count < 100 G/L (adjusted odds ratio [aOR] = 32.7; 95% CI = 3.2 to 332.5; p = 0.0032), arterial pH > 7.47 (aOR = 33.1; 95% CI = 3.4 to 319.7; p = 0.0025), and mechanical ventilation (aOR = 48.8; 95% CI = 2.6 to 901.5; p = 0.009). When adjusting for the identified prognostic factors, corticosteroids significantly reduced the risk of death (aOR = 0.069; 95% CI = 0.005 to 0.9; p = 0.048). Only SAPS II was predictive of adverse outcome (death or neurologic deficit). We conclude that in intubated patients with S. pneumoniae meningitis, hyperventilation should be used with caution. Nonsusceptibility to penicillin G is not associated with a worse outcome. High-dose corticosteroids may be beneficial in the most severely ill patients.

Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d'Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/-) and 6 a low level of proof (Grade 2+/-). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.