[Antifungal treatment for suspected or proved candidiasis in the critically ill]. / Traitements antifongiques en réanimation au cours des infections fongiques invasives documentées ou suspectées.

OBJECTIVE: Describe systemic antifungal therapy in non-neutropenic adult patients in intensive care unit (ICU). PATIENTS AND METHOD: A prospective, observational study was conducted during the first half of 2010 in the 7 ICU in a hospital with medical consultant on antimicrobial therapy. All non-neutropenic consecutive adult patients receiving systemic antifungal therapy for documented or suspected invasive fungal infection (IFI) apart from aspergillosis were included. RESULTS: Out of 1502 patients admitted in ICU, 104 (7 %) underwent systemic antifungal therapy, including 30 (29 %) for a documented IFI and 74 (71 %) for a suspected IFI. Candida albicans was identified in 23 (77 %) of the IFI and 45/52 (86 %) of the broncho-pulmonary and/or urinary colonizations in suspected IFI. Echinocandin was significantly more prescribed in patients with a documented infection (19/30 patients) and fluconazole in patients with a suspected infection (48/74 patients). The first line therapy was primarily stopped after recovery (11/30 patients) or de-escalation (9/30 patients) in documented infections, and for lack of indication (34/74 patients) or due to recovery (21/74 patients) in suspected infections after on average of 7 days of treatment. CONCLUSION: For ICU non-neutropenic adult patients in our center, antifungal therapy is prescribed two times out of three for suspected, unproved infections, in most cases with fluconazole. Documented infections were more often treated by echinocandin with secondary de-escalation. An interventional prospective study to assess the role of antifungal pre-emptive or empirical therapy is necessary.

[Right atrial thrombus--a complication of central venous catheters]. / Thrombus auriculaire droit---une complication des voies veineuses centrales.

We describe the development, in three days, of a pediculate mass hanging on the right atrial lateral wall in a 39-year-old woman with a subclavian venous catheterization. She was a current smoker and alcoholic but without drug addict. The hypothesis of a non valvular right atrial infective endocarditis was considered at first, but subsequent events directed the diagnosis towards a thrombus, which was resorbed by heparin. We discuss the incidence, the complications, the treatment and the differential diagnosis of thrombus caused by a central venous catheter. The prevention of right atrial thrombus caused by a central venous catheter depends on the position of the central venous catheter tip, either in the superior vena cava or at the superior vena cava-right atrium junction. A more distal position is a frequent source of thrombotic and embolic complications.

[Pneumococcal infections in intensive care. Retrospective 8 year study]. / Infections à pneumocoques en réanimation. Etude rétrospective sur 8 ans.

OBJECTIVE: The aim of this study was to analyze the clinical presentations and severity of S. pneumoniae infections requiring hospitalization in an intensive care unit and evaluate the incidence and severity of infections caused by penicillin-resistant strains. PATIENTS AND METHODS: This retrospective study reviewed cases in our intensive care unit from January 1989 through December 1996 including all patients with pneumococcal infection. RESULTS: The study included 102 patients, mean age 59.6 years. Pneumonia was the most frequent (83 cases) followed by bacteriemia (31 cases) and meningitis (15 cases). Mortality was high (43%) and influenced by age, simplified severity score, and presence of shock at admission. Antibiotic resistance appeared in 1991 and increased over the years reaching, in 1996: 24% for penicillin, 38% for macrolides, 20% for sulfamides, 19% for tetracyclins, and 14% for phenicols. Penicillin-resistance was not found to modify clinical expression nor severity of infection. Amoxicillin and third-generation cephalosporins were the most widely used antibiotics. CONCLUSION: Pneumococcal infections in intensive care patients are severe with high mortality. The emergence of more and more resistant strains has little clinical consequence on severity or treatment.

[Descending necrotizing mediastinitis. A diagnosis not to be ignored]. / La médiastinite descendante nécrosante. Un diagnostic à ne pas méconnaître.

BACKGROUND: Acute descending posterior mediastinitis is a very serious condition which can develop after common ear-nose-throat infections. Clinical manifestations are typical and must be recognized rapidly for early diagnosis. CASE REPORTS: We report two cases. In the first case, a 28-year-old man had a retropharyngeal abscess which fistulized into the left pleural cavity. Three operations were necessary to achieve cure and favorable outcome. In the second case, mediastinitis was diagnosed in a 39-year-old patient following a throat infection. Despite early surgery, outcome was fatal due to development of pericarditis and tamponnade. DISCUSSION: These two cases illustrate the variable course of descending mediastinitis and emphasize the importance of early medicosurgical cure. Treatment is based on intravenous antibiotics using a combination of 2 or 3 drugs at high doses in association with emergency surgery and extensive mediastinal washings. Despite well-conducted treatment, descending necrotizing mediastinitis may lead to a fatal outcome.