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Biomedical subjects

Jean Carlet

Publications and source records attributed to Jean Carlet.

At least 19 recordsLinked to original sources
PubMed2006

Highly sensitive and efficient computer-assisted system for routine surveillance for surgical site infection.

OBJECTIVES: Surveillance of surgical site infections (SSIs) is effective in reducing the rates of these complications, but it is extremely time-consuming and, consequently, underused. We determined the sensitivity and specificity of a computer-assisted surveillance system, compared with a conventional method involving review of medical records, and the time saved with the computer-assisted system. METHOD: A prospective study was conducted from January 1 to December 31, 2001. With the computer-assisted method, screening for SSIs relied on identification in the laboratory database of positive results of microbiological tests of surgical-site specimens; confirmation was obtained via computer-generated questionnaires completed by the surgeon in charge of the patient. In the conventional method, SSIs were identified by exhaustive chart review. The time spent on surveillance was recorded for both methods. SETTING: A 25-bed gastrointestinal surgery unit in a tertiary care hospital. PATIENTS: A total of 766 consecutive patients who underwent gastrointestinal surgery. RESULTS: The sensitivity of the computer-assisted method was 84.3% (95% confidence interval, 0.66-0.94); the specificity was 99.9%. For the 807 surgical procedures in the study, 197 had an SSI identified by culture of a surgical-site specimen. After elimination of 63 duplicate cultures with positive results, 134 questionnaires were sent to the surgeons, who confirmed 27 SSIs. The conventional method identified 32 SSIs. The computer-assisted method required 60% less time than the conventional method (90 hours vs 223 hours). CONCLUSION: Surveillance for SSIs using computer-assisted, laboratory-based screening and case confirmation by surgeons is as efficient as and far less time-consuming than the conventional method of chart review. This method permits routine surveillance for SSIs with reliable accuracy.

Computer Systems↗
PubMed2006

Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission.

OBJECTIVE: To describe triage decisions and subsequent outcomes in octogenarians referred to an ICU. DESIGN AND SETTING: Prospective observational study in the medical ICU in a tertiary nonuniversity hospital. PARTICIPANTS: Cohort of 180 patients aged 80 years or over who were triaged for admission. MEASUREMENTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model score, and mortality were recorded. Self-sufficiency (Katz Index of Activities of Daily Living) and quality of life (modified Perceived Quality of Life scale and Nottingham Health Profile) were measured 1year after triage. RESULTS: In 132 patients (73.3%) ICU admission was refused, including 79 (43.8%) considered too sick to benefit. Factors independently associated with refusal were nonsurgical status, age older than 85 years, and full unit. Greater self-sufficiency was associated with ICU admission. Hospital mortality was 30/48 (62.5%), 56/79 (70.8%), 9/51 (17.6%), and 0/2 in the admitted, too sick to benefit, too well to benefit, and family/patient refusal groups, respectively; 1-year mortality was 34/48 (70.8%), 69/79 (87.3%), 24/51 (47%), and 0/2, respectively. Self-sufficiency was unchanged by ICU stay. Quality of life (known in only 28 patients) was significantly poorer for isolation, emotional, and mobility domains compared to the French general population matched on sex and age. CONCLUSIONS: More than two-thirds of patients aged over 80 years referred to our ICU were denied admission. One year later self-sufficiency was not modified and quality of life was poorer than in the general population. These results indicate a need to discuss patient preferences before triage decisions.

Aged, 80 and over↗
PubMed2006

Excess risk of death from intensive care unit-acquired nosocomial bloodstream infections: a reappraisal.

BACKGROUND: Overall rates of bloodstream infection (BSI) are often used as quality indicators in intensive care units (ICUs). We investigated whether ICU-acquired BSI increased mortality (by > or = 10%) after adjustment for severity of infection at ICU admission and during the pre-BSI stay. METHODS: We conducted a matched, risk-adjusted (1:n), exposed-unexposed study of patients with stays longer than 72 h in 12 ICUs randomly selected from the Outcomerea database. RESULTS: Patients with BSI after the third ICU day (exposed group) were matched on the basis of risk-exposure time and mortality predicted at admission using the Three-Day Recalibrated ICU Outcome (TRIO) score to patients without BSI (unexposed group). Severity was assessed daily using the Logistic Organ Dysfunction (LOD) score. Of 3247 patients with ICU stays of >3 days, 232 experienced BSI by day 30 (incidence, 6.8 cases per 100 admissions); among them, 226 patients were matched to 1023 unexposed patients. Crude hospital mortality was 61.5% among exposed and 36.7% among unexposed patients (P<.0001). Attributable mortality was 24.8%. The only variable associated with both BSI and hospital mortality was the LOD score determined 4 days before onset of BSI (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.03-1.16; P = .0025). The adjusted OR for hospital mortality among exposed patients (OR, 3.20; 95% CI, 2.30-4.43) decreased when the LOD score determined 4 days before onset of BSI was taken into account (OR, 3.02; 95% CI, 2.17-4.22; P<.0001). The estimated risk of death from BSI varied considerably according to the source and resistance of organisms, time to onset, and appropriateness of treatment. CONCLUSIONS: When adjusted for risk-exposure time and severity at admission and during the ICU stay, BSI was associated with a 3-fold increase in mortality, but considerable variation occurred across BSI subgroups. Focusing on BSI subgroups may be valuable for assessing quality of care in ICUs.

Calibration↗
PubMed2006

[Antibiotic strategy during septic shock].

Septic shock remains a true challenge to modern therapeutics. The quality and earliness of antibiotic administration are both fundamental elements. Treatment should be individually adapted to each patient. The pharmacokinetic indicators and predicted resistance of the bacteria targeted determine the choice of treatment, often empirical. Radical treatment of the source of infection, especially by surgery, should be combined with antibiotic treatment whenever possible.

Anti-Bacterial Agents↗
PubMed2006

Sepsis in European intensive care units: results of the SOAP study.

OBJECTIVE: To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units. DESIGN: Cohort, multiple-center, observational study. SETTING: One hundred and ninety-eight intensive care units in 24 European countries. PATIENTS: All new adult admissions to a participating intensive care unit between May 1 and 15, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, comorbid diseases, and clinical and laboratory data were collected prospectively. Patients were followed up until death, until hospital discharge, or for 60 days. Of 3,147 adult patients, with a median age of 64 yrs, 1,177 (37.4%) had sepsis; 777 (24.7%) of these patients had sepsis on admission. In patients with sepsis, the lung was the most common site of infection (68%), followed by the abdomen (22%). Cultures were positive in 60% of the patients with sepsis. The most common organisms were Staphylococcus aureus (30%, including 14% methicillin-resistant), Pseudomonas species (14%), and Escherichia coli (13%). Pseudomonas species was the only microorganism independently associated with increased mortality rates. Patients with sepsis had more severe organ dysfunction, longer intensive care unit and hospital lengths of stay, and higher mortality rate than patients without sepsis. In patients with sepsis, age, positive fluid balance, septic shock, cancer, and medical admission were the important prognostic variables for intensive care unit mortality. There was considerable variation between countries, with a strong correlation between the frequency of sepsis and the intensive care unit mortality rates in each of these countries. CONCLUSIONS: This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsis and the intensive care unit mortality in the various countries. In addition to age, a positive fluid balance was among the strongest prognostic factors for death. Patients with intensive care unit acquired sepsis have a worse outcome despite similar severity scores on intensive care unit admission.

APACHE↗
PubMed2006

Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: a national multiple-center risk-factor study.

OBJECTIVE: Heatstroke requires active body cooling and organ failure supportive care. Although heat waves are expected to recur over the next decades, little is known about the risk factors for mortality in heatstroke patients. We examined the prognosis and risk factors for hospital mortality in patients with heatstroke admitted to an intensive care unit (ICU) during the heat wave in France in August 2003. DESIGN: A questionnaire was sent to the physicians leading an ICU in France to identify the patients admitted with heatstroke during August 2003. Data included demographics, factors predisposing to heatstroke, severity during the first day in the ICU, air conditioning in the ICU, and hospital mortality. Risk factors for mortality were determined in multivariate Cox proportional hazards analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were obtained for 345 patients. Hospital mortality was 62.6%. Occurrence of heatstroke at home or in a healthcare facility rather than in a public location, high Simplified Acute Physiology Score II, high body temperature, prolonged prothrombin time, use of vasoactive drugs within the first day in the ICU, and patient management in an ICU without air conditioning were independently associated with an increased risk of death. CONCLUSIONS: Mortality of patients admitted to the ICU with heatstroke is high. Predictors of mortality are available within the first 24 hrs after admission. Furthermore, in this study, air conditioning in the ICU was associated with improved outcome.

Aged↗
PubMed2006

Applying the concept of healthcare-associated infections to hematology programs.

Infection is a leading cause of mortality in hematology. Although data on nosocomial infections are available, little is known about events falling into the broader category of healthcare-associated infections. Our aim was to evaluate the incidence and causes of healthcare-associated infections in hematology patients, comparatively with nosocomial infections. Using predefined criteria, we classified 223 infectious episodes in 137 patients for their association with healthcare and nosocomial occurrence. Of the 223 infectious episodes, 204 (91%) were healthcare associated, 94/223 (42%) were also nosocomial, and 9% were community-acquired. Healthcare-associated infections should be preferred to nosocomial infections--which underestimates half of the healthcare-associated infections--as quality indicators for preventive programs.

Adolescent↗
PubMed2005

Predicting whether the ICU can help older patients: score needed.

Because the need for intensive care exceeds its availability in several countries, intensivists must admit those patients most likely to benefit. Intensive care unit admissions of elderly patients will increase substantially in the near future. Decreased self sufficiency and quality of life are common after hospitalization in older patients and they may require discharge to a nursing home, although some patients feel that life in a nursing home would be worse than dying. We have much to learn about matching the use of life-supporting treatments to the health-related values of older patients. A specific outcome-prediction score for older patients would help improve quality of care.

Aged, 80 and over↗
PubMed2005

Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.

OBJECTIVE: To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. DESIGN: Observational, prospective, multiple-center study. SETTING: Four university hospitals and seven primary-care hospitals in France. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. CONCLUSIONS: ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.

Female↗
PubMed2004

Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003.

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.

Decision Making↗
PubMed2004

New method of classifying infections in critically ill patients.

OBJECTIVE: To develop a systematic classification describing the contribution made by infection to the outcome from sepsis. CONTEXT: The emergence of effective therapies for sepsis means that accurate methods of risk assessment are of increasing importance. Although there are well-validated instruments for describing risk factors in the host, the contribution made by the infection is less well served. DESIGN AND METHODS: A systematic literature review of the English language literature published during the last 30 yrs of studies describing the outcome of infections, categorized by micro-organism and site of infection. RESULTS: We surveyed 510 published articles including 55,854 clinical infections, and we generated specific risk codes for bacteremia, meningitis, pneumonia, skin and soft tissue infections, peritonitis, and urinary tract infections. Both the nature of the organisms and the site of infection have a significant impact on survival from sepsis, and there is a significant interaction between them. CONCLUSION: We have described a novel approach to permit a better assessment of the contribution made by the infection to mortality in patients with sepsis or septic shock.

Communicable Diseases↗
PubMed2004

Epidemiology and control of antibiotic resistance in the intensive care unit.

PURPOSE OF REVIEW: Resistance to antibiotics is very high in the intensive care units of many countries, although there are several exceptions. Some infections are becoming extremely difficult to treat. The risk of cross-transmission of those strains is very high. This review focuses on recent data (2003 to the present) that may help understanding and dealing with this serious public health problem. RECENT FINDINGS: Intensive care units can be considered as 'factories' for creating, disseminating and amplifying resistance to antibiotics, for many reasons: importation of resistant microorganisms at admission, selection of resistant strains with an extensive use of broad-spectrum antibiotics, cross-transmission of resistant strains via the hands or the environment. Some national programs can be considered as failures, as in the UK and the USA. Other countries have been able to maintain a low level of resistance (Scandinavian countries, Netherlands, Switzerland, Germany, Canada). There is clearly an 'inoculum effect' above which preventive measures become poorly efficient. Several preventive measures have been proposed including preventive isolation, systematic screening at admission, local, national or international antibiotic guidelines, antibiotic prescriptions advice by infectious-disease teams, antibiotic prevention with selective digestive decontamination, antibiotic strategies such as 'cycling', or rather, for some authors, the use of an 'à la carte' antibiotic strategy which could be considered as a 'patient-to-patient antibiotic rotation'. SUMMARY: There is obviously an international concern regarding the level of resistance to antibiotics in the intensive-care-unit setting. A strong program including prevention of cross-transmission and better usage of antibiotics seems to be needed in order to be successful. We do not know if this kind of program will enable countries with a very high endemic level of resistance to decrease the level in future years.

Bacteremia↗
PubMed2003

A continuous quality-improvement program reduces nosocomial infection rates in the ICU.

OBJECTIVE: To assess the impact of a continuous quality-improvement program on nosocomial infection rates. DESIGN AND SETTING: Prospective single-center study in the medical-surgical ICU of a tertiary care center. PATIENTS. We admitted 1764 patients during the 5-year study period (1995-2000); 55% were mechanically ventilated and 21% died. Mean SAPS II was 37+/-21 points and mean length of ICU stay was 9.7+/-16.1 days. INTERVENTIONS: Implementation of an infection control program based on international recommendations. The program was updated regularly according to infection and colonization rates and reports in the literature. MEASUREMENTS AND RESULTS: Prospective surveillance showed the following rates per 1000 procedure days: ventilator-associated pneumonia (VAP) 8.7, urinary tract infection (UTI) 17.2, central venous catheter (CVC) colonization 6.1, and CVC-related bacteremia and 2.0; arterial catheter colonization did not occur. In the 5 years following implementation of the infection control program there was a significant decline in the rate per patient days of UTI, CVC colonization, and CVC-related bacteremia but not VAP. Between the first and second 2.5-year periods the time to infection increased significantly for UTI and CVC-related colonization. CONCLUSIONS: A continuous quality-improvement program based on surveillance of nosocomial infections in a nonselected medical-surgical ICU population was associated with sustained decreases in UTI and CVC-related infections.

Cross Infection↗
PubMed2003

Fatal septic shock caused by Corynebacterium D2.

BACKGROUND: Septic shock remains one of the leading causes of mortality in critically ill patients. Optimal management depends on prompt diagnosis with identification of the causative organisms to allow appropriate antibiotic therapy. PATIENT: We report the first case of septic shock caused by Corynebacterium D2, a micro-organism that can cause encrusted cystitis and pyelitis of transplanted kidneys or, more rarely, native kidneys. Diagnosis rests on identification of risk factors, positive urine cultures, and computed tomography results. Despite optimal treatment our patient died with persistent encrusted pyelitis. CONCLUSIONS: Corynebacterium D2 is known to cause chronic inflammation of the bladder and proximal urinary tract but can also cause severe septic shock in immunocompetent patients.

Aged↗
PubMed2003

Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes.

OBJECTIVE: To assess the appropriateness of ICU triage decisions. DESIGN. Prospective descriptive single-center study. SETTING: Ten-bed, medical-surgical ICU in an acute-care 460-bed, tertiary care hospital. PATIENTS: All patients triaged for admission were entered prospectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases, admission diagnoses, Mortality Probability Model (MPM0) score, information available to ICU physicians, and mortality were recorded. Of the 334 patients (96% medical), 145 (46.4%) were refused. Reasons for refusal were being too-sick-to-benefit (48, 14%) and too-well-to-benefit (93, 28%). Factors independently associated with refusal were patient location, ICU physician seniority, bed availability, patient age, underlying diseases, and disability. Hospital mortality was 23% and 27% for patients admitted to our ICU and other ICUs, respectively, and 7.5% and 60% for patients too well and too sick to benefit, respectively. In the multivariate Cox model, McCabe = 1 [hazard ratio (HR), 0.44 (95% CI, 0.24-0.77), P=0.001], living at home without help (HR, 0.440, 95% CI, 0.28-0.68, P=0.0003), and immunosuppression (HR, 1.91, 95% CI, 1.09-3.33, P=0.02) were independent predictors of hospital death. Neither later ICU admission nor refusal was associated with cohort survival. MPM0 was not associated with hospital mortality. CONCLUSIONS: Refusal of ICU admission was related to the ability of the triaging physician to examine the patient, ICU physician seniority, patient age, underlying diseases, self-sufficiency, and number of beds available. Specific training of junior physicians in triaging might bring further improvements. Scores that are more accurate than the MPM0 are needed.

Decision Making↗