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1.
Minerva Anestesiol ; 81(4): 405-18, 2015 Apr.
Article in English | MEDLINE | ID: mdl-25220548

ABSTRACT

BACKGROUND: Aim of this study was to evaluate the epidemiology and outcomes of hospital-acquired bloodstream infections (HA-BSI) in Greek intensive care units (ICU). METHODS: Secondary analysis of data from 29 ICU collected during the EUROBACT study, a large prospective, observational, multination survey of HA-BSI. First episodes of HA-BSI acquired in the ICU or within 48 hours prior to admission were recorded. RESULTS: Gram-negative bacteria predominated namely Acinetobacter sp, Klebsiella sp, Pseudomonas sp (73.3% of monomicrobial infections) followed by Gram-positive cocci (18.3%); fungi (7.6%) and anaerobes (0.8%). Overall 73.3% of isolates were multidrug resistant (MDR), 47.1% extensively resistant (XDR) and 1.2% pan-drug resistant (PDR). Carbapenems were the most frequent empirically prescribed antibiotics, while colistin was the most frequently adequate; for both, calculated mean total daily doses were suboptimal. Overall 28-day all-cause mortality was 33.3%. In the multivariate analysis, factors adversely affecting outcome were higher SOFA score at HA-BSI onset (OR 1.19; 95% CI 1.08-1.31, P=0.0006), need for renal supportive therapy (OR 2.75; 95% CI 1.35-5.59, P=0.0053), and for vasopressors/inotropes (OR 2.68; CI 1.18-6.12, P=0.02); adequate empirical treatment had a protective effect (OR 0.48; CI 0.24-0.95, P=0.03). CONCLUSION: TIMELY administration of adequately dosed treatment regimens and early ICU admission of critically ill patients could help in improving outcomes.


Subject(s)
Cross Infection/epidemiology , Cross Infection/microbiology , Drug Resistance, Microbial , Hematologic Diseases/epidemiology , Hematologic Diseases/microbiology , Adult , Aged , Aged, 80 and over , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/therapeutic use , Antifungal Agents/therapeutic use , Critical Illness , Cross Infection/therapy , Female , Greece/epidemiology , Hematologic Diseases/therapy , Hospital Mortality , Humans , Intensive Care Units , Male , Middle Aged , Prospective Studies , Treatment Outcome
2.
Intensive Care Med ; 39(9): 1574-83, 2013 Sep.
Article in English | MEDLINE | ID: mdl-23765237

ABSTRACT

PURPOSE: To assess physician decisions about ICU admission for life-sustaining treatments (LSTs). METHODS: Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV). RESULTS: The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13-0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10-0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04-3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23-0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively. CONCLUSIONS: Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.


Subject(s)
Attitude of Health Personnel , Intensive Care Units , Practice Patterns, Physicians' , Renal Replacement Therapy , Respiration, Artificial , Triage , Aged, 80 and over , Decision Making , Female , Humans , Male
3.
Rev Mal Respir ; 26(9): 998-1002, 2009 Nov.
Article in French | MEDLINE | ID: mdl-19953048

ABSTRACT

BACKGROUND: Mucormycosis is a rare fungal infection occurring most frequently in immunocompromised patients. The pathogens are filamentous fungi, order of Mucorales. Disseminated mucormycosis is a severe, life treating disease. Early diagnosis is a major determinant for prognosis, however, it remains difficult. The management consists in an early antifungal therapy using lipid formulation of amphotericin B associated with an extensive surgical debridement. Despite this therapeutic of choice, the mortality of disseminated mucormycosis remains high. OBSERVATION: We report the case of disseminated mucormycosis in a 25 years old woman 9 months after a pulmonary transplantation. The clinical presentation included pulmonary and thyroid localization and the pathogen was Absidia corymbifera. The patient survived thanks to a large surgical debridement, and an early antifungal bitherapy by lipid formulation of amphotericin B and posaconazole. CONCLUSION: The re-emergence and the high mortality of mucormycosis in solid organ transplant receiver show the necessity to find new therapeutic approaches. Posaconazole associated with liposomal amphotericin B could be an interesting option to treat disseminated mucormycosis and improve their outcome.


Subject(s)
Absidia , Lung Diseases, Fungal/diagnosis , Lung Transplantation , Mucormycosis/diagnosis , Opportunistic Infections/diagnosis , Thyroid Diseases/diagnosis , Adult , Amphotericin B/administration & dosage , Antifungal Agents/administration & dosage , Combined Modality Therapy , Debridement , Female , Humans , Lung Diseases, Fungal/surgery , Mucormycosis/drug therapy , Mucormycosis/surgery , Opportunistic Infections/drug therapy , Opportunistic Infections/surgery , Thyroid Diseases/surgery , Triazoles/administration & dosage
4.
Am J Transplant ; 9(9): 2166-71, 2009 Sep.
Article in English | MEDLINE | ID: mdl-19681829

ABSTRACT

Fifty-eight solid organ transplant recipients with zygomycosis were studied to assess the presentation, radiographic characteristics, risks for extra-pulmonary dissemination and mortality of pulmonary zygomycosis. Pulmonary zygomycosis was documented in 31 patients (53%) and developed a median of 5.5 months (interquartile range, 2-11 months) posttransplantation. In all, 74.2% (23/31) of the patients had zygomycosis limited to the lungs and 25.8% (8/31) had lung disease as part of disseminated zygomycosis; cutaneous/soft tissue (50%, 4/8) was the most common site of dissemination. Pulmonary disease presented most frequently as consolidation/mass lesions (29.0%), nodules (25.8%) and cavities (22.6%). Patients with disseminated disease were more likely to have Mycocladus corymbifer as the causative pathogen. The mortality rate at 90 days after the treatment was 45.2%. In summary, pulmonary zygomycosis is the most common manifestation in solid organ transplant recipients with zygomycosis, and disseminated disease often involves the cutaneous/soft tissue sites but not the brain.


Subject(s)
Lung Diseases, Fungal/drug therapy , Lung Diseases, Fungal/etiology , Organ Transplantation/adverse effects , Zygomycosis/drug therapy , Zygomycosis/etiology , Adult , Aged , Antifungal Agents/therapeutic use , Female , Humans , Male , Middle Aged , Postoperative Complications/drug therapy , Time Factors , Treatment Outcome
5.
Transfus Clin Biol ; 15(4): 154-9, 2008 Sep.
Article in French | MEDLINE | ID: mdl-18757224

ABSTRACT

OBJECTIVE: Few studies have shown that aged packed red blood cells (RBC) transfusion negatively influenced the outcome of ICU patients, probably related to storage lesions which could be decreased by leukodepletion of RBC. The purpose of this study was to evaluate the impact of aged leukodepleted-RBC pack, on the outcome of ICU patients. DESIGN: Retrospective, observational, cohort study in a Medical Intensive Care Unit. PATIENTS: Consecutive patients admitted during the years 2005 and 2006, and requiring a transfusion. We recorded patient's demographic data, number of RBC unit and age of each RBC, length of ICU, mortality during ICU stay. RESULTS: Five hundred and thirty-four patients were included with global mortality was 26.6%, length of stay in ICU six days (3-14) and SAPS II 48 (35-62). RBC equaling to 5.9 were transfused per patients (22.7%<14 days and 57.3%<21 days). The number of RBC was significantly higher in the dead patients group, but the rate of RBC stored less than 21 days was not different (54% versus 60%; p=0.21). In a multivariate logistic model, independent predictors of ICU death were SAPS II (OR=1.02 per point, p<0.001), number of RBC (OR=1.08 per RBC, p<0.001), length of stay in ICU (p<0.001). Similar results were obtained while introducing the age of RBC as time dependent covariates in a multivariate Cox's model. CONCLUSIONS: RBC transfused in our ICU are old. The ICU outcome is independently associated with the number of leucodepleted RBC transfused, but not with their age.


Subject(s)
Erythrocyte Aging/physiology , Erythrocyte Transfusion/methods , Erythrocytes/physiology , Aged , Comorbidity , Erythrocyte Transfusion/standards , Erythrocytes/cytology , Female , Humans , Intensive Care Units , Length of Stay , Male , Middle Aged , Retrospective Studies , Sepsis/mortality , Sepsis/therapy , Shock, Hemorrhagic/mortality , Shock, Hemorrhagic/therapy , Survival Analysis , Survivors
6.
Med Mal Infect ; 36(6): 299-303, 2006 Jun.
Article in French | MEDLINE | ID: mdl-16698210

ABSTRACT

Severe sepsis, which is related to a high mortality rate, requires a very specific antibiotic strategy, which must be adapted to each case. The appropriateness of empiric therapy is based on the delay before administration of the molecule, the bacterial resistance profile, and the kinetic and/or dynamic properties of the available antibiotics.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Anti-Infective Agents/therapeutic use , Infections/drug therapy , Anti-Infective Agents/pharmacokinetics , Drug Administration Schedule , Humans
7.
Diabetes Metab ; 31(2): 144-51, 2005 Apr.
Article in English | MEDLINE | ID: mdl-15959420

ABSTRACT

OBJECTIVE: In France, diabetic subjects were not allowed to dive. The principal risk is hypoglycemia during immersion. However scuba diving is allowed in many countries. To follow blood glucose changes, food intake and insulin adjustments in type 1 diabetic patients when diving, and to propose specific guidelines for such patients willing to practice recreational scuba diving. METHODS: Fifteen well-controlled (mean HbA1c: 7.2%) type 1 diabetic patients without complications were volunteer to dive under strict medical monitoring. They dove 8 times in 4 days in autumn at a depth of 20 meters, in 12 degrees C to 16 degrees C water. A strict protocol based on blood glucose was implemented to prevent hypoglycaemia. RESULTS: No case of hypoglycemia was observed and no faintness was reported underwater. Mean blood glucose before diving was 200 mg/dl (11 mmol/l). There was a mean fall in blood glucose of 40 mg/dl (2.2 mmol/l) during dives, a mean decrease in daily insulin doses by 19.3% on the last day. Daily energy intake was 3,225 Kcal in average. A continuous glucose monitoring (CGMS) was performed in one patient and showed a rather stable glycemia during immersion but a decrease within the 8 hours after. CONCLUSION: When respecting a strict protocol to prevent hypoglycaemia, the risk of hypoglycaemia appears quite low. We recommend an ideal glycemic goal of 200-250 mg/dl (11-13.75 mmol/l) before immersion, a higher reduction of insulin doses (-30%) and taking carbohydrates on board in any case. The present data have recently led the French diving federation (FESSM) to allow type 1 diabetic patients to dive with some restrictive qualification requirements: dives within the "safety curve" (no decompression curve), in above 14 degrees C water, depth limited to the median space range (6 to 20 meters), plus mandatory guidance by a diving instructor.


Subject(s)
Blood Glucose/metabolism , Diabetes Mellitus, Type 1/physiopathology , Diet, Diabetic , Dietary Carbohydrates , Diving/legislation & jurisprudence , Insulin/therapeutic use , Body Composition , Diabetes Mellitus, Type 1/blood , Diabetes Mellitus, Type 1/diet therapy , Diabetes Mellitus, Type 1/drug therapy , Energy Intake , France , Humans , Hypoglycemia/prevention & control , Hypoglycemic Agents/therapeutic use , Monitoring, Ambulatory
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