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Alain Lepape

Publications and source records attributed to Alain Lepape.

18 recordsLinked to original sources
PubMed2006

Human CD4+CD25+ regulatory T lymphocytes inhibit lipopolysaccharide-induced monocyte survival through a Fas/Fas ligand-dependent mechanism.

Although it is known that septic shock induces immunosuppression, the mechanism for this phenomenon is not well understood. Monocytes play a central role in septic shock pathophysiology, which is also characterized by an increased proportion of natural regulatory T (Treg) cells. We therefore investigated whether Treg could be involved in the decreased monocyte expression of CD14 and HLA-DR observed during septic shock. We demonstrated that human Treg inhibit LPS-induced retention of monocyte CD14. Because loss of CD14 is a hallmark of monocyte apoptosis, this suggests that Treg inhibit monocyte survival. This effect was largely mediated through the release of a soluble mediator that was not identical with either IL-10 or IL-4. The Fas/FasL pathway participated in the effect as it was blocked by anti-FasL Abs and reproduced by Fas agonist and recombinant soluble FasL. Furthermore, expression of FasL was much higher on Treg than on their CD25(-) counterparts. Collectively, these results indicate that Treg act on monocytes by inhibiting their LPS-induced survival through a proapoptotic mechanism involving the Fas/FasL pathway. This may be an important mechanism for septic shock-induced immunosuppression and may offer new perspectives for the treatment of this deadly disease.

CD4 Antigens↗
PubMed2006

Persisting low monocyte human leukocyte antigen-DR expression predicts mortality in septic shock.

OBJECTIVE: The immediate overwhelming release of inflammatory mediators in septic shock is rapidly followed by strong anti-inflammatory responses inducing a state of immunosuppression. The patients who survive the initial hyper-inflammatory step of septic shock but subsequently die may be those who do not recover from immunosuppression. We assessed whether a low monocyte human leukocyte antigen-DR (mHLA-DR) expression, proposed as a marker of immunosuppression, is an independent predictor of mortality in patients who survived the initial 48 h of septic shock. DESIGN AND SETTING: Prospective observational study performed in two adult intensive care units at a university hospital. PATIENTS: 93 consecutive patients with septic shock. MEASUREMENTS AND RESULTS: At days 1-2, mHLA-DR values (determined by flow cytometry) were not significantly different between survivors and non-survivors. A sharp difference became highly significant at days 3-4 when survivors had increased their values, while non-survivors had not (43% vs. 18%, percentage of HLA-DR positive monocyte, p < 0.001). Multivariate logistic regression analysis revealed that low mHLA-DR (< 30%) at days 3-4 remained independently associated with mortality after adjustment for usual clinical confounders, adjusted odds ratio (CI): 6.48 (95% CI: 1.62-25.93). CONCLUSION: The present preliminary results show that mHLA-DR is an independent predictor of mortality in septic shock patients. Being a marker of immune failure, low mHLA-DR may provide a rationale for initiating therapy to reverse immunosuppression. After validation of the current results in multicenter studies, mHLA-DR may help to stratify patients when designing a mediator-directed therapy in a time-dependent manner.

Aged↗
PubMed2006

Systemic transcriptional analysis in survivor and non-survivor septic shock patients: a preliminary study.

The second phase of septic shock is characterized by an anti-inflammatory state and patients rapidly develop features consistent with immunosuppression. The mechanisms sustaining this disease step are far from being well understood. The objective of the present study was to perform a genome-wide survey of mRNA expression in septic shock patients in order to investigate the bases of sepsis-induced immunoparalysis. We used Affymetrix HG-U133A oligonucleotide arrays to compare systemic gene expression patterns of survivors and non-survivors after the first 24 h of the syndrome (n = 38 patients). Supervised analysis identified a set of 28 genes efficiently discriminating non-survivors from survivors with a sensitivity of 100% and a specificity of 86%. The microarray findings were confirmed by qRT-PCR and the ability of the selected probe sets to function as a classifier of outcome was verified with an independent set of additional microarray analyses. Noteworthy, of gene overexpressed in survivors, many are known to participate in innate immunity (cytokine, chemokine receptor, effectors of the Toll-receptor pathways). It supports the hypothesis that restoration of inflammatory/immune functions is a key step for survival after septic shock. The consistency of our results into the context of sepsis-induced immunoparalysis tends to indicate that blood transcriptional profiling is a valuable approach not only for patients stratification but also to identity new genes possibly involved in sepsis pathophysiology.

Aged↗
PubMed2005

Longitudinal study of cytokine and immune transcription factor mRNA expression in septic shock.

Success in treating severe sepsis will require relevant tools to monitor the patient immunoinflammatory status. This study aimed to investigate the feasibility of measuring a panel of immunological mediator mRNAs in whole blood and to study their prognostic values in septic shock patients. At the onset of shock, compared to healthy volunteers, mRNA levels in septic shock patients were increased for IL-10, IL-1beta, and high mobility group B1 (HMGB1) and decreased for transforming growth factor beta 1, the Th1, and Th2 transcription factors, T-bet and GATA-3, respectively. Single parameter analysis highlighted an increased expression of IL-10 and HMGB1 mRNA in nonsurvivors and a significant rise over time of GATA3 in survivors. Combining the expression levels of four genes, hierarchical cluster analysis showed that up to 95% of the patients with a similar outcome displayed transcriptional similarities. These results illustrate both the potential of whole blood mRNA quantification assays and the interest of a multiparametric strategy to better stratify septic patients.

Aged↗
PubMed2005

Messenger RNA expression of major histocompatibility complex class II genes in whole blood from septic shock patients.

OBJECTIVE: The decreased expression of human leukocyte antigen (HLA)-DR on monocytes is proposed as a major feature of sepsis-induced immunodepression. The objective of the present study was to investigate, in whole blood from septic shock patients, the messenger RNA (mRNA) expression of a gene panel, which is essential to ensure major histocompatibility complex class II protein structure, transport, and peptide loading. DESIGN: The authors conducted a cohort study. SETTING: This study was conducted in intensive care units at a university hospital. SUBJECTS: The study included septic shock patients (n = 41) and healthy volunteers (n = 15). MEASUREMENTS AND MAIN RESULTS: Using quantitative reverse transcriptase-polymerase chain reaction, we found that the highly polymorphic HLA-DRB1 and nonpolymorphic-DRA mRNA levels were significantly decreased in whole blood from patients with septic shock compared with healthy volunteer both on days 1-3 and 4-10 after the onset of shock. This profile was also observed for genes encoding the invariant chain, the transcription factor class II transactivator (CIITA), and the enzymes involved in the peptide loading cathepsin S, HLA-DMA, and -DMB. The monocyte surface expression of HLA-DR measured by flow cytometry was significantly correlated with the whole-blood mRNA levels of HLA-DRB1 and -DRA and to a lesser extent with the other CIITA-regulated genes HLA-DMA and invariant chain. The correlation between HLA-DRB mRNA and cell-surface expression levels was also observed in a small subset of purified monocyte samples. Regarding the temporal relationship, a significant increase of whole-blood HLA-DRA, -DMA, -DMB, invariant chain, and CIITA mRNA level was observed in survivors (p = .001), whereas expressions remained low in nonsurvivors. CONCLUSIONS: A global transcriptional down regulation of a gene panel required for MHC II-restricted antigen presentation may occur in the course of septic shock. Our results suggest that the transcriptional resumption of CIITA-regulated genes might contribute to the recovery of membrane HLA-DR expression observed in survivors. These results obtained at the mRNA level support previous reports describing the loss of monocyte HLA-DR at the protein level and thus confirm the potential of measuring monocyte HLA-DR in septic patient followup.

Adult↗
PubMed2005

Both percentage of gammadelta T lymphocytes and CD3 expression are reduced during septic shock.

OBJECTIVE: The mechanisms involved during sepsis-induced immunosuppression are far from being extensively established. The objective of the present study was to investigate whether two characteristics of T cells were altered in this situation: the percentage of circulating gammadelta T lymphocytes and the level of CD3 expression on T lymphocytes. DESIGN: Observational study. SETTING: Adult intensive care units in a university hospital. PATIENTS: Patients with septic shock (n = 21) and healthy individuals (n = 21). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In patients, we first observed the decreased percentage of gammadelta T lymphocytes in peripheral blood (1% [0.7-3.1], median [interquartile range]) in comparison with healthy individuals (3.5% [2.1-4.8]). Regarding CD3, we measured a highly significant decrease of its expression on both alphabeta and gammadelta T lymphocytes from patients (p < .005), whereas the CD3 mean fluorescence intensities ratio (gammadelta/alphabeta) was not affected: 2.2 [2.1-2.4] and 2.1 [1.9-2.3] in healthy individuals and septic patients, respectively. The magnitude in the decrease of CD3 expression was thus similar in alphabeta and gammadelta cells, suggesting a common down-regulation mechanism for both T-cell lineages. CONCLUSIONS: Combined with a reduced percentage of monocytes expressing human leukocyte antigen-DR, a reduced CD3 expression may be involved in the failure of antigen presentation depicted after septic shock, whereas the diminished percentage of circulating gammadelta T cells could be partly responsible for the elevated incidence of secondary infections. These two observations constitute additional pieces of the complex puzzle of sepsis-induced immunosuppression.

Aged↗
PubMed2004

The Th2 response as monitored by CRTH2 or CCR3 expression is severely decreased during septic shock.

The shift of T lymphocytes toward a Th2 profile during septic shock has been established on the basis of in vitro cytokine production. In the present study, the Th2 response was investigated at the level of cell surface marker expression (whole blood flow cytometry). In 58 patients with septic shock, we observed a reduced CRTH2 (chemoattractant receptor-homologous molecule expressed on Th2 cells) expression on Th2 lymphocytes and regulatory T cells in comparison with 39 healthy volunteers. Eosinophils, which constitutively express CRTH2 in healthy individuals, also exhibited low levels of CRTH2 in patients. In addition, eosinophil CCR3 expression (eotaxin receptor, type 2 chemokine) was strongly correlated with CRTH2, suggesting thus an extended modulation of Th2 related molecules. Importantly, the persistence over time of low levels of CRTH2 or CCR3 expression was found in nonsurvivors. We hypothesize that the restoration of CRTH2/CCR3 expression may be an indicator for optimal recovery after septic shock.

Aged↗
PubMed2004

The anti-inflammatory response dominates after septic shock: association of low monocyte HLA-DR expression and high interleukin-10 concentration.

The diminished expression of HLA-DR on monocytes has been proposed as a reliable marker of immunosuppression occuring during septic shock. The objective of the present observational study was to establish the time-dependent relation between plasma cytokines interleukin (IL)-10, transforming growth factor (TGF)-beta1, tumor necrosis factor (TNF)-alpha and monocyte HLA-DR expression in 38 adult patients with septic shock. All patients (mortality at 28 days: 42%, mean admission SAPS II score: 54) had decreased HLA-DR expression. This expression was significantly lower in non-survivors at all time points. All patients had elevated IL-10 concentrations, the highest values were found in non-survivors. IL-10 was the sole cytokine to significantly correlate with HLA-DR expression (r: -0.6, p<0.001). TNF and TGF values did not provide any prognostic information. TGF levels from septic patients were even found to be decreased in comparison with normal values which suggested that IL-10 is likely more important than TGF regarding the immunosuppressive properties of septic patients' plasma. This preliminary work showed that, at the systemic level, the anti-inflammatory response dominated after septic shock. Monocyte HLA-DR expression and IL-10 measurement deserve to be determined in parallel in a larger longitudinal study. They might constitute helpful indicators for staging patients and making a decision about whether to institute a therapy with molecules able of reversing sepsis-induced immunosuppression.

Aged↗
PubMed2004

Compliance with guidelines on antibiotic prophylaxis in total hip replacement surgery: results of a retrospective study of 416 patients in a teaching hospital.

OBJECTIVE: To assess compliance of anesthesiologist practices in antibiotic prophylaxis during total hip replacement (THR) surgery with the French Society of Anesthesiology and Intensive Care consensus-based guidelines. DESIGN: Retrospective review of medical records. Compliance of anesthesiologist practices with the guidelines was assessed according to antibiotic prophylaxis use, antimicrobial agent, dosage of first injection, time from first dose to incision, and total duration of antibiotic prophylaxis. SETTING: Orthopedic surgery wards in a 2,200-bed French teaching hospital. PATIENTS: A random sample of 416 patients undergoing THR from January 1999 to December 2000. RESULTS: Three hundred eighty-six (93%) of the sampled medical records were usable. Antibiotic prophylaxis was used for 366 (95%) of the patients. Total duration of prophylaxis did not exceed 48 hours in 98% (359 of 366) of the patients. Drug selection complied with national guidelines in 259 (71%) of the patients. Dosage and timing of the first injection were appropriate in 98% (290 of 296) and 80% (236 of 296) of the patients, respectively, who received one of the recommended antibiotics. Overall, 53% (203 of 386) of the patients met all five criteria. In multivariate analysis, there was a significant anesthesiologist effect on overall compliance with the guidelines (likelihood ratio chi-square with 9 degrees of freedom, 25.7; P < .01). Undergoing surgery during 2000 was the only patient characteristic associated with an increased rate of appropriate practices (adjusted OR, 1.56; CI95 1.02-2.38). CONCLUSION: The overall compliance rate should be improved by disseminating the guidelines and the results of this study following audit and feedback.

Adult↗
PubMed2004

Increased percentage of CD4+CD25+ regulatory T cells during septic shock is due to the decrease of CD4+CD25- lymphocytes.

OBJECTIVE: The elevation of the percentage of regulatory CD4+CD25+ T lymphocytes (Treg) has been recently described during septic shock. The objective of the present study was to investigate whether this increased percentage was due to Treg proliferation. DESIGN: Observational study. SETTING: Adult intensive care units in a university hospital. SUBJECTS: Patients with septic shock (n = 54) and healthy individuals (n = 30). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In patients, we first confirmed the increased percentage of Treg among CD4+ lymphocytes in comparison with healthy individuals. Surprisingly, regarding absolute counting, we demonstrated that both T CD4+ lineages (CD25+ and CD25-) were diminished immediately after the onset of shock. Then, whereas Treg returned rapidly to healthy donors values, CD4+CD25- T lymphocytes remained dramatically reduced. Finally, Foxp3 (Treg-related gene) messenger RNA quantification enabled us to definitively rule out a lack of proliferation since it was not increased during shock. CONCLUSION: The increased percentage of Treg after shock is due not to their proliferation but to a decrease in CD4+CD25- T lymphocyte number. We hypothesize that it might be due to a resistance of Treg to apoptosis processes occurring during septic shock.

APACHE↗
PubMed2004

Clinical and therapeutic features of nonpostoperative nosocomial intra-abdominal infections.

OBJECTIVE: To compare the clinical, microbiological, and therapeutic features of nonpostoperative nosocomial intra-abdominal infections (non-PostopNAI) with community-acquired intra-abdominal infections (CAI). SUMMARY BACKGROUND DATA: Prospective (June 2000 through January 2001) consecutive case series analysis of patients operated for secondary nonpostoperative intra-abdominal infections collected in 176 study centers (surgical wards and intensive care units). PATIENTS AND METHODS: Clinical, microbiological, and therapeutic characteristics of CAI and non-PostopNAI infections were collected. Management of antibiotic therapy was decided by the attending physician. The efficacy of treatment was evaluated over a 30-day period after the index episode. RESULTS: Evaluatable observations (n = 1008) were collected (761 CAI and 247 non-PostopNAI), including 285 intensive care unit patients. When compared with CAI patients, non-PostopNAI patients presented an increased interval between admission to the surgical ward and operation (1.3 +/- 1.5 vs. 0.5 +/- 0.7 days in CAI patients; P < 0.001), increased proportions of underlying diseases, a more severe clinical condition as assessed by increased proportions of hospitalization in the intensive care unit (48% vs. 22% in CAI patients, P < 0.001) and a higher SAPS II score (34 +/- 15 vs. 24 +/- 14, P < 0.001). In non-PostopNAI patients, increased proportions of therapeutic failure (15% vs. 7% in CAI patients, P < 0.01) and of fatalities (12% vs. 4% in CAI patients, P < 0.001) were observed. CONCLUSIONS: Delayed diagnosis and increased severity are the main characteristics of non-PostopNAI infections. Microbiological features are quite similar in CAI and non-PostopNAI infections, suggesting that antibiotic therapy recommended for CAI infections could be applied to non-PostopNAI patients. Characteristics of non-PostopNAI patients should lead to identify them as a specific entity in clinical trials.

Abdomen↗
PubMed2003

Fast renal trapping of porcine luteinizing hormone (pLH) shown by 123I-scintigraphic imaging in rats explains its short circulatory half-life.

BACKGROUND: Sugar moieties of gonadotropins play no primary role in receptor binding but they strongly affect their circulatory half-life and consequently their in vivo biopotencies. In order to relate more precisely hepatic trapping of these glycoproteic hormones with their circulatory half-life, we undertook a comparative study of the distribution and elimination of porcine LH (pLH) and equine CG (eCG) which exhibit respectively a short and a long half-life. This was done first by following half-lives of pLH in piglets with hepatic portal circulation shunted or not. It was expected that such a shunt would enhance the short half-life of pLH. Subsequently, scintigraphic imaging of both 123I-pLH and 123I-eCG was performed in intact rats to compare their routes and rates of distribution and elimination. METHODS: Native pLH or eCG was injected to normal piglets and pLH was tested in liver-shunted anaesthetized piglet. Blood samples were recovered sequentially over one hour time and the hormone concentrations were determined by a specific ELISA method. Scintigraphic imaging of 123I-pLH and 123I-eCG was performed in rats using a OPTI-CGR gamma camera. RESULTS: In liver-shunted piglets, the half-life of pLH was found to be as short as in intact piglets (5 min). In the rat, the half-life of pLH was also found to be very short (3-6 min) and 123I-pLH was found to accumulate in high quantity in less than 10 min post injection at the level of kidneys but not in the liver. 123I-eCG didn't accumulate in any organ in the rats during the first hour, plasma concentrations of this gonadotropin being still elevated (80%) at this time. CONCLUSION: In both the porcine and rat species, the liver is not responsible for the rapid elimination of pLH from the circulation compared to eCG. Our scintigraphic experiments suggest that the very short circulatory half-life of LH is due to rapid renal trapping.

Animals↗
PubMed2003

Family participation in care to the critically ill: opinions of families and staff.

BACKGROUND: Allowing family members to participate in the care of patients in intensive care units (ICUs) may improve the quality of their experience. No previous study has investigated opinions about family participation in ICUs. METHODS: Prospective multicenter survey in 78 ICUs (1,184 beds) in France involving 2,754 ICU caregivers and 544 family members of 357 consecutive patients. We determined opinions and experience about family participation in care; comprehension (of diagnosis, prognosis, and treatment) and satisfaction (Critical Care Family Needs Inventory) scores to assess the effectiveness of information to families and the Hospital Anxiety and Depression score for family members. RESULTS: Among caregivers 88.2% felt that participation in care should be offered to families. Only 33.4% of family members wanted to participate in care. Independent predictors of this desire fell into three groups: patient-related (SAPS II at ICU admission, OR 0.984); ICU stay length, OR 1.021), family-related (family member age, OR 0.97/year); family not of European descent, OR 0.294); previous ICU experience in the family, OR 1.59), and those related to emotional burden and effectiveness of information provided to family members (symptoms of depression in family members, OR 1.58); more time wanted for information, OR 1.06). CONCLUSIONS: Most ICU caregivers are willing to invite family members to participate in patient care, but most family members would decline.

Adult↗
PubMed2003

Calcitonin gene related peptide and N-procalcitonin modulate CD11b upregulation in lipopolysaccharide activated monocytes and neutrophils.

OBJECTIVE: Circulating levels of calcitonin gene related peptide (CGRP) and calcitonin precursors, including procalcitonin (PCT) and its free aminopeptide N-procalcitonin (N-PCT), have been found dramatically increased in septic patients. PCT is known to attenuate the chemotaxis of monocytes in response to chemoattractants. This study examined whether CGRP and N-PCT modulate the LPS-induced expression of CD11b, which is one of the major integrins involved in monocyte and neutrophil chemotaxis during a response to microbial infections. DESIGN AND SETTING: In vitro cell culture study in the immunology laboratory of a university hospital. PARTICIPANTS: Healthy volunteers. MEASUREMENTS AND RESULTS: We assessed the effects of N-PCT and CGRP on CD11b expression on monocytes and neutrophils after LPS (2 ng/ml) or fMLP (10(-8) M) challenges. We used a human whole blood model, and measurements were made by flow cytometry. Both peptides in a dose-dependent manner decreased the LPS- and fMLP-induced rise in CD11b in monocytes and neutrophils. As these peptides are thought to act by raising cAMP, we also mimicked their effects with the use of rolipram and forskolin and found similar results. CONCLUSIONS: These findings are in line with recent studies demonstrating anti-inflammatory properties for this family of peptides. CGRP and calcitonin precursors may function as factors suppressing the propagation of inflammation through the inhibition of several processes involved during a response to a bacterial stimulus.

Biomarkers↗
PubMed2003

[Epidemiology of Gram-positive infections in France: changing resistance].

CONTRIBUTION OF CLINICAL EPIDEMIOLOGY: Clinical epidemiology goes beyond simply counting cases of resistance. The goal is to collect clinical data contributing to an explication of epidemiological observations enabling a classification into 4 types of resistance. GRAM POSITIVE BACTERIA: Depending on the specialty, Gram positive bacteria are the cause of a variable percentage of clinical infections. In oncology and hematology, Gram-positive infections appear to be on the rise due to the increase in the number of coagulase-negative staphylococcal infections. The percentage appears to be unchanged in intensive care. Community-acquired streptococcal infections include a growing number caused by Streptococcus viridans, with the development of resistance and an aggravation of Streptococcus pneumoniae resistance. Nosocomial Gram-positive infections show that the increase in the number of meticillin-resistant Staphylococcus aureus infections is slowing down with the emergence of exceptional Staphylococcus aureus strains exhibiting intermediary resistance to glycopeptides. STREPTOCOCCUS VIRIDANS: Isolation of Streptococcus viridans is becoming increasingly frequent, particularly in immunodepressed patients or in patients with surgical conditions such as peritonitis. Several risk factors have been identified. In vitro glycopeptides and linezolide would have 100% activity against S. viridans. METICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA): Infections caused by MRSA strains are rather exceptional compared with simple colonization. All patients with suspected Staphylococcus aureus infections should not be treated as if they had a MRSA infection. STREPTOCOCCUS PNEUMONIA: Beta-lactame resistant pneumococci have shown some progression.

Anti-Bacterial Agents↗
PubMed2003

Marked elevation of human circulating CD4+CD25+ regulatory T cells in sepsis-induced immunoparalysis.

OBJECTIVE: Immunoparalysis has recently emerged as a possible cause explaining the failure of clinical trials in septic shock. Because human peripheral blood CD4+CD25+ T cells have been characterized as suppressor T cells, we hypothesized they might be increased in sepsis-induced immunoparalysis. DESIGN: Prospective, observational, clinical study. SETTING: Adult intensive care units in a university hospital. SUBJECTS: Patients with septic shock (n = 16) and healthy individuals (n = 36). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In patients with septic shock (mortality rate at 28 days, 56%; mean admission Simplified Acute Physiology Score II, 47), we first illustrated immunoparalysis by showing a severe diminished monocytic human leukocyte antigen (HLA)-DR expression. Afterward, compared with control values, we found in these patients a marked elevation of circulating CD4+CD25+ T cells that were also CD45RO+ and CD69- and overexpressed CTLA-4. Importantly, nonsurvivors (n = 9) presented prolonged lower monocytic HLA-DR expression and higher percentage of CD4+CD25+ T-suppressor T cells. CONCLUSIONS: These data support the concept that the persistence of a pronounced immunoparalysis after septic shock is associated with a poor outcome. Whether CD4+CD25+ T cells directly participate in sepsis-induced immunoparalysis remains to be investigated.

Abatacept↗
PubMed2003

Prevention of nosocomial infections in ICU. What is really effective?

In South East of France, about 20% of the ICU patients with a length of stay > or = 2 days will develop a nosocomial infection (NI) related to an invasive device. This elevated rates of NI (the most elevated in the hospital) are related to the usual severity of patients, the use of invasive devices such as indwelling arterial catheter, central venous catheter, intubation and bladder catheter. These two characteristics are associated with an important antimicrobial consumption and a subsequent selection of resistant bacteria. The techniques which could be used in the prevention of NI have now proved to be effective. They are hand disinfection, non sterile gloves utilization and a rationale use of mask, gowns. The application of these measures are known as Standard Precautions, recommended by the CDC. The specificity of prevention in ICU is questionable, since many measures can be applied in ICU, anesthesia or surgery. In the prevention of NI in ICU, without any doubt, the most important (but the most difficult to achieve) is the strict respect of standard precautions. To achieve this goal, the best investment is alcoholic hand rub. Among the specific measures, maximum barrier precaution for CVC insertion, reduction of indication and duration of invasive device exposure. The real challenge is to apply few effective measures, but accepted, associated with behavioural changes and whose compliance is measured.

Catheterization↗