Biomedical subjects

Jean-Louis Trouillet

Publications and source records attributed to Jean-Louis Trouillet.

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

Impact of antibiotic-resistant bacteria on the outcome of ventilator-associated pneumonia.

Since antibiotic resistance has become a worldwide concern, there has been an ongoing debate as to whether infections caused by resistant bacteria are associated with higher mortality. Because resistant strains do not appear to be more virulent, differences in outcome may principally relate to patients' characteristics before or at the time of infection onset, and to high rates of inappropriate empirical antimicrobial treatment prescribed for antibiotic-resistant infections. In two large series of severe Staphylococcus aureus and Pseudomonas aeruginosa ventilator-associated pneumonia, we recently demonstrated that antibiotic resistance does not significantly affect intensive care unit mortality of patients receiving appropriate initial antibiotics. However, antibiotic resistance was consistently found to increase hospital length of stay. Early identification of patients with risk factors favoring antibiotic-resistant infections should prompt the initiation of an empirical antibiotic regimen covering these highly resistant bacteria, which can usually be deescalated 48 to 72 hours later when the results of microbiological samples culture become available.

Anti-Bacterial Agents↗

PubMed2006

Native-valve infective endocarditis caused by Enterobacteriaceae: report on 9 cases and literature review.

Although the demographic characteristics of patients who develop infective endocarditis (IE) have changed over the last few decades, Enterobacteriaceae remain rarely responsible. We report the clinical and epidemiological characteristics of 9 patients with native-valve Enterobacteriaceae IE from 6 French medical intensive care units over a 10-y period and have identified 29 additional cases in the literature. Nearly a third of the 38 patients were immunocompromised and/or had previously known valvular heart disease. Salmonella spp. and Yersinia spp. were the most frequently isolated microorganisms reported in the literature. The overall mortality rate was 24% (9/38) and was lower for operated patients (10% (1/10)) compared to those who did not undergo valve surgery (31% (8/26)). Our results confirmed the rarity of native-valve endocarditis caused by Enterobacteriaceae, pathogens frequently responsible for nosocomial and community-acquired bacteraemias. This paradox may be explained by susceptibility to the bactericidal action of serum and the inability of these bacteria to colonize the endocardium.

Adult↗

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

Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units.

OBJECTIVE: To evaluate the effectiveness of screening strategy and contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA). DESIGN AND SETTING: Prospective observational cohort from 1 February 1995 to 31 December 2001 in three intensive care units (45 beds) in a French teaching hospital. PATIENTS: 8,548 patients admitted to the three ICUs had nasal screening on ICU admission and weekly thereafter. Contact precautions were used in MRSA-positive patients. The following variables were collected: age, gender, severity score, length of stay, workload, and colonization pressure (percentage of patient-days with an MRSA to the number of patient-days in the unit). Alcohol-based handrub solution was introduced in July 2000. We compared the period before this (P1) with that thereafter (P2). RESULTS: Of the 8,548 admitted patients 554 (6.5%) had MRSA at ICU admission, and 456 of the 7,515 (6.1%) exposed patients acquired MRSA. Acquisition incidence decreased from 7.0% in P1 to 2.8% in P2. Independent variables associated with MRSA acquisition were: age (adjusted odds ratio 1.013), severity score (1.047), length of ICU stay (1.015), colonization pressure (1.019), medical ICU (1.58), and P2 (0.49). CONCLUSIONS: MRSA control in these ICUs characterized by a high prevalence of MRSA at admission was achieved via multiple factors, including screening, contact precautions, and use of alcoholic handrub solution. Our results after adjustment of risk factors for MRSA acquisition and the steady improvement in MRSA over several years strengthen these findings. MRSA spreading can be successfully controlled in ICUs with high colonization pressure.

Adult↗

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↗

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↗

PubMed2004

Impact of methicillin resistance on outcome of Staphylococcus aureus ventilator-associated pneumonia.

The impact of methicillin resistance on morbidity and mortality of patients suffering from severe Staphylococcus aureus infections remains highly controversial. We analyzed a retrospective cohort of 97 patients with methicillin-susceptible and 74 patients with methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia (VAP). Initial empiric antibiotic therapy was appropriate for every patient. Patients with methicillin-resistant Staphylococcus aureus VAP were older, had higher disease-severity scores, and had been on mechanical ventilation longer at onset of VAP. Factors associated with 28-day mortality retained by multivariate logistic regression analysis were: age (odds ratio [OR] = 1.05, 95% confidence interval [CI], 1.02-1.08, p = 0.001) and Day 1 organ dysfunctions or infection (ODIN) score (OR = 1.90, 95% CI, 1.31-2.78, p = 0.001), but not methicillin resistance (OR = 1.72, 95% CI, 0.73-4.05, p = 0.22). The percentages of infection relapse or superinfection did not differ significantly between the two patient groups. In conclusion, after controlling for clinical and physiologic heterogeneity between groups, methicillin resistance did not significantly affect 28-day mortality of patients with Staphylococcus aureus VAP receiving appropriate antibiotics.

Age Distribution↗

PubMed2004

Estimation of left ventricular systolic function by single transpulmonary thermodilution.

OBJECTIVE: The single-indicator transpulmonary thermodilution technique (PiCCO system) provides two derived indices of cardiac systolic function: the cardiac function index and the global ejection fraction. We used transesophageal echocardiography to compare theses indices with left ventricular fractional area of change only for patients with no isolated right ventricular dysfunction. (The global cardiac systolic function may be decreased despite preserved left ventricular function in this situation.) DESIGN: Prospective, open, clinical study. SETTING: Intensive care unit (ICU) in a university hospital. PATIENTS: Thirty-three mechanically ventilated patients. INTERVENTION: Left ventricular fractional area of change (LVFAC) was measured using transesophageal echocardiography. The cardiac function index (CFI) and the global ejection fraction (GEF) were determined from transpulmonary thermodilution-derived cardiac output and thoracic volumes. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography identified 3 patients with isolated right ventricular failure (PiCCO underestimated LVFAC in this situation). Significant correlations were established between LVFAC and CFI (r=0.87, n=30, p<0.0001) or GEF (r=0.82, n=30, p<0.0001). The mean differences between measured LVFAC and LVFAC estimated with CFI or GEF were 0.8+/-8.5% (range: -17 to 14%) and 0.8+/-9.0% (range: -21 to 19%), respectively. Area under the receiver operating characteristics curves for the estimation of LVFAC >/=40% using CFI or GEF was 0.92. CFI >4 and GEF >18% estimated LVFAC >/=40% with respective sensitivities of 86 and 88% and specificities of 88 and 79%. Significant correlations were established between changes of LVFAC and CFI/GEF over time. CONCLUSIONS: In mechanically ventilated ICU patients, PiCCO-derived cardiac function index and global ejection fraction provide reliable estimations of LV systolic function but may underestimate it in the cases of isolated right ventricular failure.

APACHE↗

PubMed2004

The impact of methicillin resistance on the outcome of poststernotomy mediastinitis due to Staphylococcus aureus.

The impact of methicillin resistance on morbidity and mortality among patients with severe Staphylococcus aureus infection remains highly controversial. We retrospectively analyzed patients with mediastinitis due to methicillin-susceptible S. aureus (MSSA; 145 patients) or methicillin-resistant S. aureus (MRSA; 73 patients) who were treated with closed drainage using Redon catheters. Initial empirical antibiotic therapy was appropriate for every patient. Patients with MRSA mediastinitis were older, had higher disease severity scores at admission to the intensive care unit (ICU), and had longer periods of MRSA incubation. Multivariate analysis revealed that ICU mortality was associated with age of > or =65 years, incubation time of < or =15 days, bacteremia, higher Acute Physiology and Chronic Health Evaluation II score, and receipt of mechanical ventilation > or =2 days after surgical debridement, but not with methicillin resistance. After adjustment, durations of mechanical ventilation and Redon catheter drainage were similar for both groups (for patients infected with MRSA, only the time to mediastinal effluent sterilization remained longer). Methicillin resistance did not significantly affect ICU mortality among patients with poststernotomy mediastinitis who benefited from optimal treatments.

Aged↗

PubMed2004

Clinical and autopsy diagnoses in the intensive care unit: a prospective study.

BACKGROUND: Autopsy rates have declined worldwide, but recent retrospective intensive care unit (ICU) data indicate major discrepancies between more than 25% of clinical and autopsy diagnoses. METHODS: We conducted a 3-year prospective study of all consecutive autopsies performed on patients who died in a university hospital medical-surgical ICU to determine how many might have benefited from a different level of care, had the autopsy diagnosis been made before death. All clinical diagnoses were compared with autopsy findings at monthly clinical-pathological meetings. Major and minor diagnostic discrepancies were categorized according to the criteria of Goldman et al. RESULTS: Of 1492 patients admitted to the ICU, 315 died, of whom 167 (53.0%) were autopsied. The most common reason (79.7%) for not obtaining an autopsy was family refusal. The mean +/- SD clinical characteristics were similar for autopsied vs nonautopsied patients, except for shorter length of ICU stay (13 +/- 17 vs 20 +/- 27 days, P =.006), shorter duration of mechanical ventilation (13 +/- 16 vs 19 +/- 25 days, P =.01), and lower percentage of postcardiac surgery patients (38.9% vs 50.0%, P =.05). Among the intensivists' 694 clinical diagnoses, 33 (4.8%) were refuted and 13 (1.9%) were judged incomplete by autopsy findings. Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others. Major diagnostic errors (class I and class II discrepancies) were made in 53 (31.7%) of 167 patients, with a high percentage of immunocompromised patients also observed among these. Similar percentages of patients with class I and class II errors vs other patients had undergone modern diagnostic techniques during their ICU stay. CONCLUSION: Even in the era of modern diagnostic technology, regular comparisons of clinical and autopsy diagnoses provide pertinent information that might improve future management of ICU patients.

Aged↗

PubMed2004

Acquisition of multidrug-resistant Pseudomonas aeruginosa in patients in intensive care units: role of antibiotics with antipseudomonal activity.

A matched case-control study was performed to identify risk factors for acquiring multidrug-resistant Pseudomonas aeruginosa (MDRPA) in intensive care unit (ICU) patients during a 2-year period. MDRPA was defined as P. aeruginosa with combined decreased susceptibility to piperacillin, ceftazidime, imipenem, and ciprofloxacin. Thirty-seven patients who were colonized or infected with MDRPA were identified, 34 of whom were matched with 34 control patients who had cultures that showed no growth of P. aeruginosa. Matching criteria were severity of illness and length of ICU stay, with each control patient staying in the ICU for at least as long as the time period between the corresponding case patient's admission to the ICU and the acquisition of MDRPA. Baseline demographic and clinical characteristics and the use of invasive procedures were similar for case patients and control patients. Multivariate analysis identified duration of ciprofloxacin treatment as an independent risk factor for MDRPA acquisition, whereas the duration of treatment with imipenem was of borderline significance. These data support a major role for the use of antibiotics with high antipseudomonal activity, particularly ciprofloxacin, in the emergence of MDRPA.

Aged↗