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Jean Chastre

Publications and source records attributed to Jean Chastre.

At least 19 recordsLinked to original sources
PubMed2007

Early predictors for infection recurrence and death in patients with ventilator-associated pneumonia.

OBJECTIVE: Early recognition of predictors of unfavorable evolution of ventilator-associated pneumonia (VAP) might prompt therapeutic measures that might improve outcome. The objective of this study was to describe resolution of VAP variables and to determine early predictors of VAP recurrence and death. DESIGN AND SETTING: Description of the natural course of VAP resolution and multivariable analyses of predictors of VAP recurrence and death by day 28 after VAP onset based on the 401 patients included in the PNEUMA trial, a multiple-center, randomized study comparing 8 vs. 15 days of antibiotics for microbiologically proven VAP. Every patient included in that trial had received appropriate empirical antibiotics. MEASUREMENTS AND MAIN RESULTS: By day 28 after VAP onset, 27% of patients had VAP recurrence and 18% had died. On day 8 after VAP onset, predictors of VAP recurrence included intensive care unit admission Simplified Acute Physiology Score II (odds ratio [OR], 1.02), radiologic score (OR, 1.17), temperature (OR, 1.34), nonfermenting Gram-negative bacilli (OR, 2.00) or methicillin-resistant Staphylococcus aureus (OR, 2.50) as pathogens responsible for VAP, and mechanical ventilation dependency (OR, 2.08). Day 8 predictors of 28-day death were age (OR, 1.06), female sex (OR, 2.30), Sepsis-Related Organ Failure Assessment score (OR, 1.26), and nonfermenting Gram-negative bacilli (OR, 2.83) as pathogens responsible for VAP. However, the duration of antimicrobial therapy (8 vs. 15 days) was not associated with any of the studied adverse outcomes. CONCLUSIONS: For patients benefiting from appropriate empirical antibiotics for VAP, early predictors of infection recurrence or death included demographic characteristics, such as age or female sex, disease severity at VAP onset, nonfermenting Gram-negative bacilli or methicillin-resistant S. aureus as VAP-causative pathogens, prolonged mechanical ventilation dependency, persistent fever, and severity of lung injury. Future studies should attempt to determine whether specific diagnostic or therapeutic strategies could markedly improve VAP outcomes when early criteria for treatment failure are present.

APACHE↗
PubMed2007

Mortality among patients admitted to intensive care units during weekday day shifts compared with "off" hours.

OBJECTIVE: To determine whether mortality rates among intensive care unit (ICU) patients differ according to the time of ICU admission, we compared the death rates for patients admitted during weekday day shifts and off hours (from 6:30 pm to 8:29 am the next day for night shifts, from Saturday 1:00 pm to Monday 8:29 am for weekends, and from 8:30 am to 8:29 am the following morning for public holidays). METHODS: Retrospective cohort study of data collected prospectively from 23 ICUs located in the Paris metropolitan region, France. Between January 2000 and December 2003, 51,643 patients were admitted to these ICUs. Patients were grouped according to their day and time of admission and compared using univariable and multivariable analyses. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 51,643 patients admitted to ICUs, 33,857 (65.6%) were admitted during off hours. These latter patients were less critically ill than those admitted during day shifts, had fewer failed organs, required fewer support procedures, and their crude in-hospital mortality was lower (20.7 vs. 24.5%, p < .0001). After adjustment for initial disease severity, in-hospital mortality was not higher for off-hours admissions than weekday day admissions and even remained slightly lower (adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.98). CONCLUSIONS: Admission during off hours is common. In our ICUs, off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate.

APACHE↗
PubMed2006

Impact of piperacillin resistance on the outcome of Pseudomonas ventilator-associated pneumonia.

BACKGROUND: The impact of antibiotic resistance on the outcome of infections due to Gram-negative bacilli, especially Pseudomonas, remains highly controversial. STUDY OBJECTIVE, DESIGN, AND PATIENTS: We evaluated the impact of piperacillin resistance on the outcomes of Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) for patients who had received appropriate empiric antibiotics before enrollment in the PNEUMA trial, a multicenter randomized study comparing 8 vs 15 days of antibiotics. RESULTS: Despite similar characteristics at intensive care unit (ICU) admission, patients infected with piperacillin-resistant Pseudomonas strains were more acutely ill at VAP onset and had a higher 28-day mortality rate (37 vs 19%; P = 0.04) than those with piperacillin-susceptible Pseudomonas VAP. Factors associated with 28-day mortality retained by multivariable analysis were: age (OR: 1.07; 95% CI: 1.03-1.12); female gender (OR: 4.00; 95% CI: 1.41-11.11); severe underlying comorbidities (OR: 2.73; 95% CI: 1.02-7.33); and SOFA score (OR: 1.17; 95% CI: 1.03-1.32), but piperacillin resistance did not reach statistical significance (OR: 2.00; 95% CI: 0.72-5.61). The VAP recurrence rates, either superinfection or relapse, and durations of mechanical ventilation and ICU stay did not differ as a function of Pseudomonas-resistance status. CONCLUSIONS: For patients with Pseudomonas VAP benefiting from appropriate empiric antibiotics, piperacillin resistance was associated with increased disease severity at VAP onset and higher 28-day crude mortality; however, after controlling for confounders, piperacillin-resistance was no longer significantly associated with 28-day mortality. The VAP recurrence rates and durations of ICU stay and mechanical ventilation did not differ for susceptible and resistant strains.

Aged↗
PubMed2006

Use of quantitative cultures and reduced duration of antibiotic regimens for patients with ventilator-associated pneumonia to decrease resistance in the intensive care unit.

Ventilator-associated pneumonia is responsible for approximately half of the infections acquired in the intensive care unit and represents one of the principal reasons for the prescription of antibiotics in this setting. Invasive diagnostic methods, including bronchoalveolar lavage and/or protected specimen bronchial brushing, could improve the identification of patients with true bacterial pneumonia and facilitate decisions of whether to treat. These techniques also permit rapid optimization of the choice of antibiotics in patients with proven bacterial infection, once the results of respiratory tract cultures become available, based on the identity of the specific pathogens and their susceptibility to specific antibiotics, to avoid prolonged use of a broader spectrum of antibiotic therapy than is justified by the available information. Because unnecessary prolongation of antibiotic therapy for patients with true bacterial infection may lead to the selection of multidrug-resistant microorganisms without improving clinical outcome, efforts to reduce the duration of therapy for nosocomial infections are also warranted. An 8-day regimen can probably be standard for patients with ventilator-associated pneumonia. Possible exceptions to this recommendation include immunosuppressed patients, patients who are bacteremic or whose initial antibiotic therapy was not appropriate for the causative microorganism(s), and patients whose infection is with very difficult-to-treat microorganisms and show no improvement in clinical signs of infection.

Anti-Infective Agents↗
PubMed2006

Novel and innovative strategies to treat ventilator-associated pneumonia: optimizing the duration of therapy and nebulizing antimicrobial agents.

Ventilator-associated pneumonia (VAP) is responsible for approximately half of the infections acquired in the intensive care unit (ICU) and represents one of the principal reasons for prescribing antibiotics in this setting. Because unnecessary prolongation of antimicrobial therapy and insufficient dosing of antibiotics at the site of infection in patients with true bacterial infection may lead to the selection of multidrug-resistant microorganisms without improving clinical outcome, efforts to reduce the duration of therapy and optimize pulmonary penetration of antimicrobial agents are warranted. An 8-day regimen can probably be standard for patients with VAP. Possible exceptions to this recommendation include immunosuppressed patients, those whose initial antimicrobial treatment was not appropriate for the causative microorganism(s), and patients whose infection was caused by very difficult-to-treat microorganisms and had no improvement in clinical signs of infection. Nebulizing concentration-dependent antibiotics such as aminoglycosides during mechanical ventilation can markedly increase tissue penetration in foci of pneumonia as compared with intravenous administration. The superiority in terms of pulmonary penetration and antibacterial efficacy of this route of administration was demonstrated in a model of ventilated piglets with and without bronchopneumonia.

Administration, Inhalation↗
PubMed2006

Ventilator-associated pneumonia: what is new?

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most frequent intensive care unit (ICU)-acquired infection among patients receiving mechanical ventilation. Failure to initiate appropriate and adequate therapy (i.e., the etiologic organism is sensitive to the therapeutic agent, the dose is optimal, and the route of administration is correct) promptly in patients with VAP has been associated consistently with higher mortality rates. However, effective antimicrobial therapy for patients with true VAP can be achieved while avoiding excessive antibiotic use and the emergence of multidrug-resistant strains in the ICU. METHOD: Review of the pertinent English-language literature. RESULTS: Antimicrobial therapy for patients with VAP should follow a two-stage process. The first stage is identifying true pneumonia rapidly and starting therapy with an empirical regimen that is likely to be appropriate. In general, this requires using broad-spectrum antibiotics in all patients in whom there is a possibility that the etiologic pathogen could be difficult to treat (e.g., multi-drug-resistant pathogen). The second stage focuses on trying to achieve this objective without overusing and abusing antibiotics and combines a number of steps, such as stopping therapy in patients with a low probability of the disease, streamlining treatment once the etiologic agent is known, switching to monotherapy after three to five days, and shortening the duration of therapy to seven or eight days, as dictated by the patient's clinical response to therapy and information about the bacteriology of the infection. CONCLUSION: Although such a strategy seems a logical way to manage patients with VAP, data are still needed to determine how best to achieve this process.

Anti-Bacterial Agents↗
PubMed2006

Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia, despite initially appropriate antibiotic therapy.

OBJECTIVE: To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) on length of stay in the intensive care unit (ICU) for patients with ventilator-associated pneumonia (VAP) and to control for the effect of initially inappropriate antibiotic treatment on outcomes by focusing only on persons who were given appropriate antibiotic therapy for their infection. DESIGN: Retrospective analysis of pooled, patient-level data from multiple clinical trials in VAP. SETTING: Multiple ICUs in France. SUBJECTS: Persons with bronchoscopically confirmed VAP due to either MRSA or methicillin-susceptible S. aureus (MSSA) and who received initially appropriate antibiotic treatment. All persons with MRSA VAP received vancomycin (15 mg/kg intravenously, twice daily). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared patients with MRSA VAP to persons with MSSA VAP. ICU length of stay represented the primary end point and ICU-free days served as a secondary end point. We recorded information regarding multiple confounders, including demographics, reasons for ICU admission and mechanical ventilation (MV), severity of illness at both ICU admission and time of diagnosis of VAP, and duration of mechanical ventilation before and following the onset of VAP. The final cohort included 107 patients, and one third of cases were due to MRSA. Despite receiving initially appropriate antibiotic treatment, median ICU length of stay was significantly longer for persons with MRSA infection (33 days vs. 22 days; p=.047). The median number of ICU-free days was concomitantly lower in MRSA VAP (0 days vs. 5 days; p=.011). Survival analysis employing a Cox proportional hazards model identified several predictors of remaining in the ICU: Pao2/Fio2 ratio at diagnosis of VAP, duration of MV before VAP, duration of MV after diagnosis of VAP, and reason for MV. Additionally, infection with MRSA as opposed MSSA doubled the probability of needing continued ICU care (hazard ratio, 2.08; 95% confidence interval, 1.09-3.95; p=.025). CONCLUSIONS: MRSA VAP independently prolongs the duration of ICU hospitalization, and in turn, increases overall costs, even for patients initially given appropriate antibiotic treatment. Confronting the adverse impact of MRSA will require efforts that address more than the initial antibiotic prescription.

Anti-Bacterial Agents↗
PubMed2006

New diagnostic and prognostic markers of ventilator-associated pneumonia.

PURPOSE OF REVIEW: The purpose of this review is to analyze the potential advantages and drawbacks of using biomarkers of bacterial infection for the diagnosis and prognosis of ventilator-associated pneumonia. RECENT FINDINGS: Whereas procalcitonin and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) have both greater diagnostic accuracies than most commonly used clinical parameters and other biomarkers of infection, such as C-reactive protein, they can be increased in noninfectious conditions or remain low in patients with true infection. Furthermore, these assays cannot determine the causative organisms and associated patterns of antibiotic susceptibility. SUMMARY: Procalcitonin and sTREM-1 should be used only as a complementary tool, to reinforce the usual diagnostic work-up. However, serial serum procalcitonin and sTREM-1 measurements may provide an opportunity to change the treatment early in the course of patients with ventilator-associated pneumonia, either to intensify treatment when their levels stay high, or to avoid unnecessary prolonged courses of antibiotics when their levels rapidly decrease. Whether procalcitonin and/or sTREM-1 guidance can reduce antibiotic use in such a setting will require additional studies, but such a strategy appears promising.

Biomarkers↗
PubMed2005

A randomized double-blind trial of iseganan in prevention of ventilator-associated pneumonia.

RATIONALE: 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. OBJECTIVES: To determine the efficacy of iseganan for the prevention of ventilator-associated pneumonia (VAP). METHODS: 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. MEASUREMENTS AND MAIN RESULTS: 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. CONCLUSIONS: Iseganan is not effective in improving outcome in patients on prolonged mechanical ventilation.

Administration, Oral↗
PubMed2005

Antimicrobial treatment of hospital-acquired pneumonia.

This article highlights the importance of providing adequate empirical antibiotic therapy for hospital-acquired pneumonia and avoiding the excessive use of antibiotics. To meet these goals, a strategy for the management of suspected ventilator-associated pneumonia should include obtaining reliable pulmonary specimens for direct microscope examination and cultures before new antibiotics are administered.

Anti-Bacterial Agents↗
PubMed2005

Acute poststernotomy mediastinitis managed with debridement and closed-drainage aspiration: factors associated with death in the intensive care unit.

OBJECTIVE: The purpose of the study is to describe an intensive care unit's experience in the treatment of poststernotomy mediastinitis and to identify factors associated with intensive care unit death. METHODS: Over a 10-year period, 316 consecutive patients with mediastinitis occurring less than 30 days after sternotomy were treated in a single unit. First-line therapy was closed-drainage aspiration with Redon catheters. Variables recorded, including patient demographics, underlying disease classification, clinical and biologic data available at intensive care unit admission and day 3, and their association with intensive care unit mortality, were subjected to multivariate analyses. RESULTS: Intensive care unit mortality (20.3%) was significantly associated with 5 variables available at admission: age greater than 70 years (odds ratio, 2.70), operation other than coronary artery bypass grafting alone (odds ratio, 2.59), McCabe class 2/3 (odds ratio, 2.47), APACHE II score (odds ratio, 1.12 per point), and organ failure (odds ratio, 2.07). After introducing day 3 variables into the logistic regression model, independent risk factors for intensive care unit death were as follows: age greater than 70 years, operations other than coronary artery bypass grafting alone, McCabe class 2/3, APACHE II score, mechanical ventilation still required on day 3, and persistently positive bacteremia. For patients receiving mechanical ventilation for less than 3 days, mortality was very low (2.4%). In contrast, for patients receiving mechanical ventilation for 3 days or longer, mortality reached 52.8% and was associated with non-coronary artery bypass grafting cardiac surgery, persistently positive bacteremia, and underlying disease. CONCLUSIONS: In patients requiring intensive care for acute poststernotomy mediastinitis, age, type of cardiac surgery, underlying disease, and severity of illness at the time of intensive care unit admission were associated with intensive care unit death. Two additional factors (mechanical ventilation dependence and persistently positive bacteremia) were identified when the analyses were repeated with inclusion of day 3 patient characteristics.

Acute Disease↗
PubMed2005

Adverse effect on a referral intensive care unit's performance of accepting patients transferred from another intensive care unit.

OBJECTIVE: To determine whether observed and predicted mortality for intensive care unit (ICU) transfer admissions is different from non-ICU transfer admissions and how that might affect ICU performance evaluation. DESIGN, SETTING, AND PATIENTS: We retrospectively analyzed the charts of 3,416 patients admitted to our tertiary referral ICU from January 1995 to December 2001 and evaluated the effect on our performance (based on the Simplified Acute Physiology Score II risk model) of accepting patients transferred from another hospital's ICU. MAIN RESULTS: During the study period, 597 patients (17%) had been transferred from a non-ICU setting in another hospital (hospital transfer) and 408 (12%) from another hospital's ICU (ICU transfer). ICU mortality and standardized mortality ratios were significantly higher for ICU-transfer patients than for hospital-transfer or directly admitted patients: 34% vs. 23% vs. 17% (p < .0001) and 0.95 (95% confidence interval, 0.83-1.08), 0.82 (95% confidence interval, 0.71-0.95), and 0.62 (95% confidence interval, 0.55-0.68), respectively. ICU-transfer patients had 3.6-fold longer mean ICU stays and 1.9-fold longer durations of mechanical ventilation than directly admitted patients. Hospital-transfer (odds ratio = 1.89) and ICU-transfer patients (odds ratio = 2.41) had significantly higher mortality rates, even after adjustment for case mix and disease severity. Consequently, a benchmarking program adjusting only for these latter variables, but not admission source, would penalize our ICU by 39 excess deaths per 1,000 admissions as compared with another ICU admitting no transfer patients. Finally, patients transferred from the ward of another hospital had significantly higher mortality rates (odds ratio = 1.56) as compared with patients directly admitted from the ward of our hospital, confirming the "transfer effect" for this homogeneous patients' subgroup. CONCLUSIONS: Admission source remains a strong and independent predictor of ICU death, despite adjustment for case mix and disease severity at ICU admission. Specifically, accepting numerous ICU-transfer patients, for whom the probability of ICU death is the most underestimated by a system adjusting only for case mix and disease severity, can adversely affect the evaluation of referral centers' performance. Future benchmarking and profiling systems should evaluate and adequately account for the ICU-transfer factor to provide healthcare payers and consumers with more accurate and valid information on the true performance of referral centers.

Aged↗
PubMed2005

Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients.

OBJECTIVE: To assess the impact of tracheotomy on sedative administration, sedation level, and autonomy of mechanically-ventilated intensive care unit (ICU) patients. DESIGN, SETTING, AND PATIENTS: In this observational study, the charts of all consecutive patients undergoing mechanical ventilation requiring tracheotomy over a 14-month period in our 18-bed tertiary care ICU were reviewed retrospectively. Patients' sedation levels (according to the Riker's 7-level sedation-agitation score) and intravenous (fentanyl and midazolam) and oral (clorazepate and haloperidol) sedative administration were measured daily during the 7 days before and after tracheotomy. We also recorded patients for whom chair positioning and oral alimentation became possible in the days following tracheotomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheotomy was performed on 72 (23.1%) of the 312 patients undergoing mechanical ventilation for > or = 48 hrs. After tracheotomy, median (25th, 75th percentiles) fentanyl and midazolam administration decreased from 866 (191, 1672) to 71 (3, 426) microg/(patient.day) and from 44 (16, 128) to 7 (1, 42) mg/(patient.day) (p < .001), respectively. Concomitant median time spent heavily sedated decreased from 7 (3, 17) to 1 (0, 6) hrs/day (p < .001), with no increase in agitation time. During the 7 days following tracheotomy, partial oral alimentation became possible for 35 patients (48.6%) and out-of-bed positioning became possible for 16 patients (22.2%). CONCLUSION: On the basis of these observations, we conclude that tracheotomized mechanically ventilated ICU patients required less intravenous sedative administration, spent less time heavily sedated, and achieved more autonomy earlier.

Algorithms↗
PubMed2005

The invasive (quantitative) diagnosis of ventilator-associated pneumonia.

Although appropriate antibiotics may improve survival in patients with bacterial pneumonia, use of empirical broad-spectrum antibiotics in patients without infection is potentially harmful, facilitating colonization and superinfection with multiresistant microorganisms. Invasive diagnostic methods, including bronchoalveolar lavage and/or protected-specimen bronchial brushing, could improve identification of patients with true bacterial pneumonia and facilitate decisions whether or not to treat, and thus clinical outcome. Bronchoalveolar lavage and/or protected-specimen bronchial brushing permit collecting distal pulmonary secretions with minimal or no upper-airway contamination, either through a fiberoptic bronchoscope or blindly using an endobronchial catheter that is wedged in the tracheobronchial tree. Due to the inevitable oropharyngeal bacterial contamination that occurs in the collection of all respiratory secretion samples, quantitative culture techniques are always needed to differentiate oropharyngeal contaminants present at low concentration from higher-concentration infecting organisms. Because even a few doses of a new antimicrobial agent can negate results of microbiologic cultures, pulmonary secretions in patients suspected of having developed pneumonia should always be obtained before new antibiotics are administered. Bronchoalveolar lavage may also provide useful clues for the diagnosis of other forms of respiratory failure, such as pulmonary hemorrhage or other types of infections, especially in immunocompromised patients.

Anti-Bacterial Agents↗
PubMed2005

Conference summary: ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP), which is usually defined as an infection occurring greater than 48 hours after hospital admission in a patient requiring mechanical ventilation, is an entity that should be viewed as a subcategory of health-care-associated pneumonia, which includes any patient who was hospitalized in an acute care hospital for 2 or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving mechanical ventilation. In contrast to infections of other frequently involved organs (eg, urinary tract and skin), for which mortality is low, the mortality rate for VAP ranges from 20% to 50% and can reach 70% in some specific settings or when lung infection is caused by high-risk pathogens and/or when initial antibiotic therapy is inappropriate. Although the attributable mortality rate for VAP is still debated, it has been shown that these infections prolong both the duration of ventilation and the duration of ICU stay. These prolonged hospitalizations underscore the considerable financial burden imposed by the development of VAP. The causes of VAP are many and may vary by hospital, patient population, and type of ICU, emphasizing the need for timely, local surveillance data. In many cases infection is caused by multiple-drug-resistant pathogens. Risk factors for such resistant microorganisms are the duration of mechanical ventilation, prior antibiotic treatment, and contact with the health care system. Preventive measures should be guided with regard to a full understanding of pathogenesis and epidemiology. Because respiratory-tract colonization of ICU patients is generally very complex, corresponding to a mix of self-colonization and cross-transmission, only a multifaceted and multidisciplinary program can be effective. Antimicrobial therapy of patients with VAP should follow a 2-stage process. The first stage involves administering broad-spectrum antibiotics to avoid inappropriate treatment in patients with true bacterial pneumonia. The second stage focuses on trying to achieve this objective without over-using and abusing antibiotics, combining a number of different steps, such as stopping therapy in patients with a low probability of the disease, streamlining treatment once the etiologic agent is known, switching to monotherapy after days 3-5, and shortening duration of therapy to 7-8 days, as dictated by the patient's clinical response to therapy and information about the bacteriology of the infection.

Drug Resistance, Multiple↗
PubMed2004

Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia.

We investigated the value of procalcitonin kinetics as a prognostic marker during ventilator-associated pneumonia (VAP). This prospective, observational study was conducted in a medical intensive care unit in a university hospital. All consecutive patients with microbiologically proven VAP who survived 3 days after its diagnosis were included and grouped according to clinical outcome: favorable or unfavorable, defined as death, VAP recurrence, or extrapulmonary infection requiring antibiotics before Day 28. Serum procalcitonin levels were measured on Days 1, 3, and 7 for all patients. Among the 63 patients included, 38 had unfavorable outcomes. On Day 1, they were more critically ill than patients with a favorable outcome. Serum procalcitonin levels decreased during the clinical course of VAP but were significantly higher from Day 1 to Day 7 in patients with unfavorable outcomes. Multivariate analyses retained serum procalcitonin levels on Days 1, 3, and 7 as strong predictors of unfavorable outcome. Based on these data, procalcitonin could be a prognostic marker of outcome during VAP.

Biomarkers↗
PubMed2004

Infective endocarditis in the intensive care unit: clinical spectrum and prognostic factors in 228 consecutive patients.

OBJECTIVE: To identify factors associated with in-hospital outcome of adult patients admitted to the ICU with infective endocarditis (IE). DESIGN AND SETTING: Retrospective study performed in the two medical ICUs of a teaching hospital. PATIENTS AND PARTICIPANTS: The charts of all 228 consecutive patients aged 18 years or older admitted with infective IE between January 1993 and December 2000 were reviewed. All patients satisfied the modified Duke's criteria for definite IE. MEASUREMENTS AND RESULTS: There were 146 episodes of native valve endocarditis and 82 of prosthetic valve endocarditis. Staphylococcus aureus was the predominant causative micro-organism. Most complications occurred early during the course of IE. One-half of the patients underwent cardiac surgery during the same hospitalization and had a better outcome than nonoperated patients. The overall in-hospital mortality rate was 45% (102/228). Multivariate analysis revealed the following clinical factors in patients with native valve IE as independently associated with outcome: septic shock (odds ratio 4.81), cerebral emboli (3.00), immunocompromised state (2.88), and cardiac surgery (0.475); in patients with prosthetic valve IE the factors were: septic shock (4.07), neurological complications (3.1), and immunocompromised state (3.46). CONCLUSIONS: IE still carries high morbidity and mortality rates for the subset of patients requiring ICU admission. Most complications occur early making the decision process for optimal medical and surgical management more difficult. Surgical treatment appears to improve in-hospital outcome.

Cardiac Surgical Procedures↗