Biomedical subjects

Jean-Ralph Zahar

Publications and source records attributed to Jean-Ralph Zahar.

At least 19 recordsLinked to original sources

PubMed2006

[Infections caused by multiresistant bacteria].

Bacterial resistance to antibiotics is enhanced by antimicrobial selection pressure by antibiotics and the crossed transmission. Multiresistant bacteria (MRB) are involved in 1/5 of nosocomial infections and the 3/4 of the MRB are meticillin resistant Staphylococcus aureus and extended-spectrum-beta-lactamase-producing Enterobacteriaceae. The epidemic diffusion of these strains is still poorly controlled in our hospitals. The fight against the diffusion of these bacteria requires not only to screen patients harbouring antibiotic-resistant bacteria and respect hygiene measures, but also actions aiming at reducing the weight of selection pressure by antibiotics.

Anti-Bacterial Agents↗

PubMed2006

Inappropriate prescribing of aminoglycosides: risk factors and impact of an antibiotic control team.

OBJECTIVES: Many factors are involved in the appropriate use of aminoglycosides, such as modalities of administration, drug levels monitoring and duration of treatment. We assessed prospectively the impact of an antibiotic control team on the appropriateness of prescriptions. METHODS: After a first observational audit assessing the appropriateness of prescriptions, and issuing updated recommendations, we performed an interventional audit, where an antibiotic control team provided counselling when prescriptions were considered inappropriate. Appropriateness of prescriptions, clinical outcomes of patients and medical costs were compared between the two periods. RESULTS: One hundred consecutive prescriptions were analysed in each period, and 32% of prescriptions were modified by the control team. As compared with the observational period, prescriptions in the intervention period were more appropriate with regard to treatment duration (73% versus 56%, P = 0.01) and drug levels monitoring (61% versus 40%, P = 0.05), and the median treatment duration was shorter (4 versus 6 days, P = 0.0002). Independent factors associated with appropriate treatment duration were hospitalization in intensive care unit [adjusted odds ratio (aOR), 4.46; 95% confidence interval (CI), 1.60-12.46], polymicrobial infection (aOR, 3.97; 1.32-11.92) and antibiotic control team intervention (aOR, 2.49; 1.27-4.87). The intervention period was associated with lower rate of nephrotoxicity (15% versus 4%, P = 0.01) and lower direct medical costs (4,039.4 Euros per 100 persons treated). CONCLUSIONS: Aminoglycoside use was frequently associated with excessive treatment duration and incorrect drug level monitoring. Reinforcing practice guidelines through direct counselling improved the appropriateness of prescriptions.

Aged↗

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

Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids.

BACKGROUND: Pleural empyema is an increasingly reported complication of pneumonia in children. Microbiological diagnostic tests for empyema by culture frequently have false-negative results due to previous administration of antibiotics. Molecular diagnosis by broad-range 16S ribosomal DNA (rDNA) polymerase chain reaction (PCR) and rapid pneumococcal antigen detection are reliable tools, but their diagnostic value has not been clearly established for pleural fluid samples. Pneumococcal antigen detection has only been validated for urine and cerebrospinal fluid samples. METHODS: Over 4 years, pleural fluid specimens were collected from 78 children with pleural empyema. Standard culture, pneumococcal antigen detection by latex agglutination (Pastorex; Bio-Rad) and immunochromatographic testing (Binax NOW Streptococcus pneumoniae), and 16S rDNA PCR were performed on these specimens. Pneumococcal identification by 16S rDNA PCR and sequencing was confirmed by pneumolysin PCR. RESULTS: Of the 78 cases of pleural empyema, 60 (77%) were microbiologically documented by culture or 16S rDNA PCR. Of the 40 pneumococcal empyema cases, 17 (43%) were only diagnosed by PCR and 23 with PCR and culture. The sensitivity and specificity of the latex antigen detection (with the use of culture and/or PCR as the test standard) were 90% and 95%, respectively. The immunochromatographic test detected pneumococcal antigens in 3 additional specimens for which latex agglutination results were negative, thereby increasing the sensitivity of antigen detection. CONCLUSIONS: Pneumococcal antigen detection in pleural fluid specimens from children provides a rapid and sensitive method of diagnosis of pneumococcal empyema, which can be confirmed by specific pneumolysin PCR when culture results are negative. Broad-range 16S rDNA PCR has value in detecting bacterial agents responsible for culture-negative pleural empyema.

Antigens, Bacterial↗

PubMed2006

[Meningitis caused by Enterococcus faecalis during disseminated anguilluliasis].

INTRODUCTION: Disseminated anguilluliasis is a serious disease requiring early diagnosis and treatment. The occurrence of bacterial complications, especially meningeal, is generally due to Gram-negative bacteria from the gastrointestinal tract. CASE: A 52-year-old man from Guadeloupe, treated for T-lymphoma during the previous year by polychemotherapy, was hospitalized for meningitis. Culture of the cerebrospinal fluid and the bronchoalveolar lavage both showed Enterococcus faecalis. Strongyloides stercoralis were also found in the stool and bronchoalveolar lavage. Outcome under treatment was favorable. DISCUSSION: This case reminds us of the usefulness of presumptive routine ivermectin treatment for all patients exposed to any immunosuppression treatment and ever having lived in a tropical area and thus possibly infected by chronic but silent anguilluliasis, even in the absence of parasitological certainty.

Amoxicillin↗

PubMed2006

Bloodstream infection in adults with sickle cell disease: association with venous catheters, Staphylococcus aureus, and bone-joint infections.

Although well documented in children with sickle cell disease (SCD), the incidence, cause, and outcome of bloodstream infection (BSI) are poorly defined in adults with SCD. Through a 5-year retrospective analysis of a cohort of 900 patients followed at our institution, we identified 56 episodes of BSI in 47 patients. The incidence rate of BSI was 1.2 episodes per 100 patient-years. As compared to the patients followed in the cohort, those with BSI were more likely to be younger (p = 0.001), to have Hb-S disease (p = 0.008), severe disease (p = 0.001), or additional immunosuppression (p = 0.05). BSI was hospital-acquired in 46% of cases and mainly associated with venous catheters (41%) and Staphylococcus aureus (34%). Pneumococci were rarely identified (10.7%). Despite an adequate duration of antibiotic therapy, the course of BSI was marked by a high frequency of associated bone-joint infection. Bone-joint infection was noted in 18 patients (32% of episodes) and occurred either during the initial BSI episode (13 patients) or 1-6 months after BSI resolution (5 patients). Factors associated with the occurrence of bone-joint infection were previous osteonecrosis (relative risk, 2.5; 95% confidence interval, 1.2-5.3) and S. aureus infection (relative risk, 3.8; 95% confidence interval, 1.8-8.4). In conclusion, BSI is a rare event in adults with SCD compared to children. It mainly occurs in those with a severe underlying disease and a venous catheter. These patients have a high risk of associated bone-joint infection and therefore must be closely monitored.

Adult↗

PubMed2006

Candida colonization of the respiratory tract and subsequent pseudomonas ventilator-associated pneumonia.

BACKGROUND: Recovery of Candida from the respiratory tract of a critically ill patient receiving mechanical ventilation (MV) usually indicates colonization rather than infection of the respiratory tract. However, interactions between Candida and bacteria, particularly Pseudomonas, have been reported. Thus, Candida colonization of the respiratory tract may predispose to bacterial ventilator-associated pneumonia (VAP). METHODS: In a multicenter study of immunocompetent critically ill patients receiving MV for > 2 days, we compared the incidence of pneumonia in patients with and without (exposed/unexposed) respiratory-tract Candida colonization, matched on study center, admission year, and MV duration. RESULTS: Over the 4-year study period, of the 803 patients meeting study inclusion criteria in the six study centers, 214 patients (26.6%) had respiratory tract Candida colonization. Candida albicans was the most common species (68.7%), followed by Candida glabrata (20.1%) and Candida tropicalis (13.1%). Extrapulmonary Candida colonization was more common in exposed patients (39.7% vs 8.3%, p = 0.01). Exposed patients had longer ICU and hospital stays but similar mortality to unexposed patients. The matched exposed/unexposed nested cohort study identified bronchial Candida colonization as an independent risk factor for pneumonia (24.1% vs 17.6%; adjusted odds ratio [OR], 1.58; 95% confidence interval [CI], 0.94 to 2.68; p = 0.0860); the risk increase was greatest for Pseudomonas pneumonia (9% vs 4.8%; adjusted OR, 2.22; 95% CI, 1.00 to 4.92; p = 0.049). CONCLUSIONS: Candida colonization of the respiratory tract is common in patients receiving MV for > 2 days and is associated with prolonged ICU and hospital stays, and with an increased risk of Pseudomonas VAP.

Aged↗

PubMed2005

Is methicillin resistance associated with a worse prognosis in Staphylococcus aureus ventilator-associated pneumonia?

BACKGROUND: Excess mortality associated with methicillin resistance in patients with Staphylococcus aureus ventilator-associated pneumonia (SA-VAP), taking into account such confounders as treatment adequacy and time in the intensive care unit (ICU), have not been adequately estimated. METHODS: One hundred thirty-four episodes of SA-VAP entered in the Outcomerea database were studied. Patients from whom methicillin-resistant S. aureus (MRSA) was recovered were compared with those from whom methicillin-susceptible S. aureus (MSSA) was recovered, stratified for duration of stay in the ICU at the time of VAP diagnosis and adjusted for confounders (severity at admission, characteristics at VAP diagnosis, and treatment adequacy). RESULTS: Treatment was adequate within 24 h after VAP diagnosis for 86% of the 65 MSSA-infected patients and 77% of the 69 MRSA-infected patients (P = .2). Polymicrobial VAP was more commonly associated with MSSA than with MRSA (49.2% vs. 25.7%; P = .01). MRSA infection was associated with a lower prevalence of coma at hospital admission and a higher rate of use of central venous lines and fluoroquinolones during the first 48 h of the ICU stay. The rates of shock, recurrence, and superinfection were similar in both groups. The crude hospital mortality rate was higher for MRSA-infected patients than for MSSA-infected patients (59.4% vs. 40%; P = .024). This difference disappeared after controlling for time in the ICU before VAP and parameters imbalanced at ICU admission (odds ratio [OR], 1.23; 95% confidence interval [CI], 0.49-3.12; P = .7) and remained unchanged after further adjustments for initial treatment adequacy and polymicrobial VAP (OR, 0.98; 95% CI, 0.36-2.66). CONCLUSIONS: Differences in patient characteristics, initial ICU treatment, and time in the ICU confounded estimates of excess death due to MRSA VAP. After careful adjustment, methicillin resistance did not affect ICU or hospital mortality rates.

Aged↗

PubMed2005

A chromosomally integrated bacteriophage in invasive meningococci.

Cerebrospinal meningitis is a feared disease that can cause the death of a previously healthy individual within hours. Paradoxically, the causative agent, Neisseria meningitidis, is a common inhabitant of the human nasopharynx, and as such, may be considered a normal, commensal organism. Only in a small proportion of colonized people do the bacteria invade the bloodstream, from where they can cross the blood-brain barrier to cause meningitis. Furthermore, most meningococcal disease is caused by bacteria belonging to only a few of the phylogenetic groups among the large number that constitute the population structure of this genetically variable organism. However, the genetic basis for the differences in pathogenic potential remains elusive. By performing whole genome comparisons of a large collection of meningococcal isolates of defined pathogenic potential we brought to light a meningococcal prophage present in disease-causing bacteria. The phage, of the filamentous family, excises from the chromosome and is secreted from the bacteria via the type IV pilin secretin. Therefore, this element, by spreading among the population, may promote the development of new epidemic clones of N. meningitidis that are capable of breaking the normal commensal relationship with humans and causing invasive disease.

Base Sequence↗

PubMed2005

Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death. A prospective multicenter study.

STUDY OBJECTIVES: More than two thirds of family members visiting intensive care unit (ICU) patients have symptoms of anxiety or depression during the first days of hospitalization. Identifying determinants of these symptoms would help caregivers support families at patient discharge or when death is imminent. DESIGN AND SETTING: Prospective multicenter study including 78 ICUs (1184 beds) in France. PARTICIPANTS: Family members completed the Hospital Anxiety and Depression Scale on the day of patient discharge or death to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression. RESULTS: Three hundred fifty-seven patients were included in the study, and 544 family members completed the Hospital Anxiety and Depression Scale. Symptoms of anxiety and depression were found in 73.4% and 35.3% of family members, respectively; 75.5% of family members and 82.7% of spouses had symptoms of anxiety or depression (P = .007). Symptoms of depression were more prevalent in family members of nonsurvivors (48.2%) than of survivors (32.7%) (P = .008). The multivariate model identified 3 groups of factors associated with symptoms: (1) patient-related: severity as assessed by the Simplified Acute Physiology Score II (odds ratio [OR] 1.017 per point) and patient age (OR 0.984 per year) predicted anxiety, and Simplified Acute Physiology Score II (OR, 1.015 per point), patient death (OR 2.092), and patient age (OR 0.981) predicted depression; (2) family-related: the spouse predicted anxiety (OR 2.085); and (3) ICU-related: a room with more than 1 bed (OR 1.539) predicted depression. CONCLUSION: The prevalence of symptoms of anxiety and depression remains high at the end of the ICU stay, whether the patient is well enough to be discharged or is near death.

Adult↗

PubMed2005

Contribution of blinded, protected quantitative specimens to the diagnostic and therapeutic management of ventilator-associated pneumonia.

OBJECTIVE: Sampling techniques for microbiological diagnosis of ventilator-associated pneumonia (VAP) remain debated, and it is unclear to what extent invasive diagnostic techniques impact the management of patients. DESIGN: A prospective observational study of 68 first episodes of suspected pneumonia in which specimens were obtained blindly (endotracheal aspirate [EA] and blinded protected telescoping catheter [PTC]) and via bronchoscopy (directed PTC bronchoscopy and BAL), and in sequence, and the results were provided to the attending physicians in the same order. Therapeutic plans resulting at each step were examined, and their adequacy was assessed using quantitative BAL fluid culture as the diagnostic standard. PARTICIPANTS: Sixty-eight patients with clinically suspected VAP hospitalized in two ICUs in a tertiary care university hospital. RESULTS: There were 35 patients (51%) with VAP confirmed by BAL fluid culture (13 early onset and 22 late onset). EA specimens grew organisms (light growth or more) in all BAL-confirmed VAP cases and 59% of nonconfirmed cases, whereas the sensitivity and specificity of blinded PTC quantitative cultures were 77% and 97%, and did not differ from those of directed PTC cultures (77% and 94%, respectively). Antibiotic therapy based on the clinical severity and likelihood of VAP, Gram stain results, and early blinded PTC culture results was adequate in 54% (19 of 35 VAP patients) within 2 h of sampling and 80% (28 of 35 patients) within 24 h; therapy was revised in only 3 more patients following BAL culture results. New antibiotics were introduced within the first 24 h in 14 of 33 nonconfirmed episodes (42%), and antibiotics were withheld or withdrawn within 48 h in 23 episodes (70%); three of these patients-with both blinded PTC and BAL growing organisms below the threshold-had early subsequently confirmed pneumonia with the same organism. CONCLUSIONS: A therapeutic approach guided by quantitative cultures of blinded specimens helps achieve early adequate management of approximately 90% of patients suspected of having VAP.

Bronchoalveolar Lavage Fluid↗

PubMed2004

Outcome of severe adult thrombotic microangiopathies in the intensive care unit.

OBJECTIVE: Thrombotic microangiopathies, namely thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, are uncommon microvascular occlusive diseases. Despite the dramatic improvement in the outcome by exogenous plasma supply, either through plasma infusion or through plasma exchange, patients frequently require support in the intensive care unit. In the present study, we evaluated the outcome of a large cohort of patients with severe thrombotic microangiopathies. DESIGN: A retrospective multicenter study from January 1998 to June 2001. SETTING: Fourteen French university hospital medical intensive care units. PATIENTS: Sixty three adult patients with severe thrombotic microangiopathies. MEASUREMENTS AND RESULTS: Of the 63 patients, 19 had a clinical presentation of thrombotic thrombocytopenic purpura, 18 had hemolytic uremic syndrome and 26 had combined neurologic and renal failures. Infections were the main etiology associated with thrombotic microangiopathies. The mortality rate was 35%. Of the survivors, all achieved complete remission. Whereas neurologic failure assessed through the Glasgow coma scale was an independent predictor of mortality [HR=0.845 (CI 95%: 0.759-0.940), P=0.002], renal impairment did not appear to be an adverse prognostic factor. The use of plasma exchange was independently associated with survival [HR=0.269 (CI 95%: 0.104-0.691), P=0.006]. CONCLUSIONS: Thrombotic microangiopathies with severe organ dysfunctions leading to hospitalization in the intensive care unit are associated with high mortality. Neurologic impairment appears to be the main adverse prognostic factor correlated to mortality, and the study confirms the importance of plasma exchange in the treatment of high-risk patients.

Adult↗

PubMed2004

Practices in non-neutropenic ICU patients with Candida-positive airway specimens.

OBJECTIVE: To examine practices of French intensivists regarding the management of mechanically ventilated patients with Candida-positive airway specimens but no major risk factors for immunodepression. Design : Closed-item questionnaire with a clinical vignette. SETTING: 564 French intensive care units (ICUs). PARTICIPANTS: 198 intensivists who have a special interest in infectious diseases and who answered the questionnaire (response rate, 35.1%). INTERVENTION: None. MEASUREMENTS AND RESULTS: The respondents recommended bronchoalveolar lavage (62.6% of respondents), protected distal sampling and protected specimen brush (59.1%), transbronchial biopsy (38.9%), and tracheal aspiration (12.1%) for the diagnosis of candidal pneumonia. A positive airway specimen was felt by most respondents (83.3%) to indicate colonisation; 66.7% of respondents recommended tests for systemic candidiasis in this situation, and 56.5% serial sampling to compute the colonisation index. Azole derivatives were the preferred antifungal medications. The clinical vignette described a patient with chronic obstructive lung disease who required mechanical ventilation for an acute exacerbation and who had a tracheal aspirate positive for Candida. Responses varied widely, with 37.8% of respondents diagnosing clinically insignificant colonisation but 24.2% recommending antifungal treatment and 61.6% serial testing to assess the Candida colonisation index. Intensivists with greater experience with severely immunocompromised patients were more aggressive in their diagnostic management. CONCLUSIONS: Wide variations occur among practices of French intensivists regarding Candida-positive airway specimens in patients without major risk factors for immunodepression. Additional studies are needed to improve our understanding of the links between Candida colonisation and infection and to determine the indications for pre-emptive antifungal treatment in non-neutropenic critically ill patients.

Antifungal Agents↗

PubMed2004

[Control scale of antibiotic prescriptions in intensive care].

THE PROBLEM TO BE SOLVED: The improvement in the prescription of antibiotics (PA) is currently one of the stages necessary for the management of bacterial resistances. Patients admitted to intensive care, because of an acute affection or fragile territory, are frequently administered an antibiotic. The inappropriate nature of the PA is noted in 30 to 50% of cases. The inadequacy of the initial antibiotic therapy leads to an excessive increase in mortality and morbidity. THE DEVELOPMENT OF A CONTROL TOOL: In order to improve our habits and help the prescribers, a panel of experts discussed the subject of the prescription of antibiotics during the 3rd day of the Outcomerea Group. At the end of this meeting, practical guidelines together with a scale for the control of the prescription of antibiotics had been established. COMMENTS: We targeted our discussion on the importance of empirical treatment and the need to document the infectious episode. Moreover, we discussed the choice of the antibiotic molecule and the crucial need to reassess the treatment set-up. We also approach the place of combinations of antibiotics and their indications in our units as well as the optimal duration of the treatments.

Anti-Bacterial Agents↗

PubMed2003

[Audit on antibiotic prescriptions in a department of infectious diseases].

OBJECTIVES: France is one of the countries that prescribe the most antibiotics. The inappropriate use of antibiotics participates in the emergence of multi-resistant bacteria. This study was aimed at assessing the adequation of antibiotic prescriptions in a hospital department of internal medicine-infectious diseases. METHODS: Over a two-month period, all the antibiotics treatments were analysed prospectively. The adequation of the treatments was analysed at first with regard to the various consensus conferences of the French-speaking Society of infectious diseases (Société de pathologie infectieuse de langue française (Spilf)) and then with regard to the bacteriological results. RESULTS: One hundred and five prescriptions were analysed during the study period. Thirty-five percent of prescriptions were inadequate with regard to the criteria used. In 22 cases the prescription was excessive, in 8 cases it was unjustified and in 5 cases it was inappropriate. Moreover, in univariate analysis, 3 factors were correlated with inadequation: prescriptions drawn-up by a non-infectious disease practitioner (OR =3.45, IC 95% 1.34-9.09, p=0.008), prescriptions drawn-up by junior in the department (OR =4.10, IC 95% 1.54-11.08, p=0.003) and prescriptions pour respiratory infections (OR=2.58, IC 95% 1.03-6.48, p =0.04). CONCLUSION: This study conducted in a department of infectious diseases reveals the persisting high rate of inappropriate prescriptions, confirming the need to develop control and retro-control strategies regarding the prescription of antibiotics in order to control the diffusion of multi-resistant bacteria.

Adolescent↗

PubMed2003

Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited.

The clinical pulmonary infection score-original or modified-has been proposed for the diagnosis and management of ventilator-associated pneumonia. In 79 episodes of suspected pneumonia, we prospectively assessed the diagnostic accuracy of the physicians' clinical assessment of probability and of the modified clinical pulmonary infection score, both measured before (pretest) and after (post-test) incorporating gram stains results, using bronchoalveolar lavage fluid culture as the reference test. The pretest clinical estimate was inaccurate (sensitivity 50%, specificity 58%); the mean clinical pulmonary infection score at baseline was 6.5 +/- 1.3 (range, 3-9) and 5.9 +/- 1.7 (range, 3-9), respectively, for the 40 confirmed and the 39 nonconfirmed episodes (p = 0.07), and only slightly more accurate (sensitivity 60%, specificity 59%) than the clinical prediction. Incorporating the gram stain results of either directed or blind protected sampling increased the diagnostic accuracy (sensitivity and specificity of 85% and 49% and 78% and 56%, respectively) of the clinical score and increased the likelihood ratio for pneumonia of a score of more than six from 1.46 to 1.67 and 1.77. The clinical pulmonary infection score has low diagnostic accuracy; however, incorporating gram stains results into the score may help clinical decision making in patients with clinically suspected pneumonia.

Bronchoalveolar Lavage Fluid↗

PubMed2003

Bactericidal activity response of blood neutrophils from critically ill patients to in vitro granulocyte colony-stimulating factor stimulation.

OBJECTIVE: Neutrophil function impairment is common in nonneutropenic critically ill patients. Whether granulocyte colony-stimulating factor (G-CSF) may be useful for preventing nosocomial infection in these patients is debated. The response of blood neutrophils from critically ill patients to G-CSF was investigated in vitro. DESIGN AND SETTING: Prospective study, laboratory investigation in two intensive care units. PATIENTS: 52 critically ill patients without immunosuppression. MEASUREMENTS: Neutrophils obtained from 52 patients on the 5th day of their intensive care unit stay were incubated with and without G-CSF (1, 10, 100 ng/ml). Reactive oxygen species (ROS) release and bactericidal activity against Staphylococcus aureus and Pseudomonas aeruginosa were evaluated. Plasma cytokines (interleukin 10, tumor necrosis factor alpha, and G-CSF) were measured. RESULTS: Median values (25th-75th percentiles) indicated no stimulatory effect of G-CSF on neutrophil bactericidal activity against either organism: S. aureus, 100% (95-109) of the unstimulated condition with 1 ng/ml G-CSF, and P. aeruginosa, 102% (98-109) with 1 ng/ml G-CSF. However, wide interindividual variability was found, ranging from marked inhibition to marked stimulation. Similar variability was found for ROS release. No correlations were found between ROS release and bactericidal activities against either bacterial strain. Inhibition of neutrophil bactericidal activity by G-CSF was associated with significantly higher plasma interleukin 10 concentrations. Plasma G-CSF levels were significantly higher in patients whose neutrophil bactericidal activity was unresponsive to G-CSF, suggesting G-CSF receptor downregulation. CONCLUSIONS: The effect of G-CSF on in vitro neutrophil bactericidal activity varied widely, depending on endogenous levels of G-CSF and was not predictable based on severity scores.

Adult↗

PubMed2002

Impact of a family information leaflet on effectiveness of information provided to family members of intensive care unit patients: a multicenter, prospective, randomized, controlled trial.

Comprehension and satisfaction are relevant criteria for evaluating the effectiveness of information provided to family members of intensive care unit (ICU) patients. We performed a prospective randomized trial in 34 French ICUs to compare comprehension of diagnosis, prognosis, treatment, and satisfaction with information provided by ICU caregivers, in ICU patient family representatives who did (n = 87) or did not (n = 88) receive a family information leaflet (FIL) in addition to standard information. An FIL designed specifically for this study was delivered at the first visit of the family representative: it provided general information on the ICU and hospital, the name of the ICU physician caring for the patient, a diagram of a typical ICU room with the names of all the devices, and a glossary of 12 terms commonly used in ICUs. Characteristics of the ICUs, patients, and family representatives were similar in the two groups. The FIL reduced the proportion of family members with poor comprehension from 40.9% to 11.5% (p < 0.0001). In the representatives with good comprehension, the FIL was associated with significantly better satisfaction (21 [18 to 24, quartiles] versus 27 [24 to 29, quartiles], p = 0.01). These results indicate that ICU caregivers should consider using an FIL to improve the effectiveness of the information they impart to families.

Aged↗