The changing clinical aspects of infective endocarditis: descriptive review of 90 episodes in a French teaching hospital and risk factors for death.

OBJECTIVE: We wanted to describe the epidemiological aspects of infective endocarditis (IE) in a French hospital and identify the prognostic factors. METHODS: We reviewed the clinical, echocardiographic and microbiological features, and the outcome of 89 patients (90 episodes, median age 60 years) with IE over 18 months. Logistic regression analysis was used to identify prognostic factors for death. RESULTS: A native valve was involved in 68 cases (75.5%); in 7 of these the patient was an intravenous drug user. A prosthetic valve was involved in 22 cases (24.5%); 5 of these were of early onset. Diagnosis was definite in 87% of cases. Median time to diagnosis was 3 days. Twenty-five patients (28%) were immunocompromised. A portal of entry, usually cutaneous, was identified in 65% of cases. Sixty-two percent of patients had an underlying heart disorder, usually degenerative. The infection involved the left heart in more than 75% of cases. One or more vegetations were detected in 75% of cases. The median size of vegetation was 15 mm. Isolated agents were mainly staphylococci (n=40 (44%), including 12 coagulase-negative isolates), and streptococci (n=23 (25%), including 7 enterococci). In 11 cases (12%), cultures remained negative. Nineteen episodes were nosocomial and Staphylococcus aureus was implicated in 11 of them. Fifty percent of patients had at least one complication: heart failure (n=42), kidney failure (n=44), embolism (n=35), septic shock (n=19). Surgery was performed in 49 cases (54%) due to heart failure (n=19), cerebral embolism (n=12), and/or severe valve lesions (n=27). Eighteen patients died, 10 of whom were infected with S. aureus. Nosocomial IE (P=0.0008), heart failure (P=0.004) and prosthetic valve (P=0.01), but not S. aureus were independently associated with death. CONCLUSIONS: S. aureus was the main microorganism isolated in our patients. However, it was not independently predictive of fatal outcome.

Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versus piperacillin-susceptible organisms.

We sought to determine the epidemiological characteristics of patients in an intensive care unit (ICU) who developed ventilator-associated pneumonia (VAP) caused by piperacillin-resistant Pseudomonas aeruginosa (PRPA; n=34) or piperacillin-susceptible P. aeruginosa (PSPA; n=101). According to univariate analysis, the factors associated with the development of PRPA VAP were presence of an underlying fatal medical condition, immunocompromised status, longer previous hospital stay, less-severe illness at the time of ICU admission, duration of mechanical ventilation before onset of VAP, number of classes of antibiotic received, and previous exposure to imipenem or fluoroquinolone. Multivariate logistic regression analysis identified the following significant independent factors: presence of an underlying fatal medical condition (odds ratio [OR], 5.6), previous fluoroquinolone use (OR, 4.6), and initial disease severity (OR, 0.8). We concluded that the clinical characteristics of patients who develop PRPA VAP differ from those of patients who develop PSPA VAP. Restricted fluoroquinolone use is the sole independent risk factor for PRPA VAP that is open to medical intervention.

Is it possible to cure mediastinitis in patients with major postcardiac surgery complications?

BACKGROUND: The prognosis for mediastinitis after cardiac operation has improved during the last two decades, but most series do not include patients who already have a major postoperative complication when the infection developed. METHODS: Our 9-year prospective study of 371 consecutive patients with mediastinitis compared the characteristics of patients admitted to the intensive care unit primarily for mediastinitis with those who developed mediastinitis after intensive care unit admission for severe postoperative organ failure. RESULTS: We identified 323 (87%) primary and 48 (13%) secondary mediastinitis patients. The incubation time for mediastinitis was longer for secondary mediastinitis patients, despite similar initial operations. Staphylococcus aureus was responsible for approximately 60% of the episodes in both groups; however, the incidence of methicillin resistance was 2.5 times higher in secondary mediastinitis patients (p < 0.0001). The mediastinitis cure rate was similar for both groups. However, intensive care unit mortality (63% versus 21%), duration of mechanical ventilation (40 versus 9 days), and length of intensive care unit stay (53 versus 28 days) were significantly higher for secondary mediastinitis patients (p < 0.0001). CONCLUSIONS: The presence of a prior major postoperative complication does not alter the cure rate of mediastinal infections, but does greatly reduce the survival rate.

Problem pathogens (Pseudomonas aeruginosa and Acinetobacter).

A number of factors have been suspected of or identified as increasing the risk for pneumonia or colonization of the lower respiratory tract by Pseudomonas and/or Acinetobacter spp. in the intensive care unit (ICU), including advanced age, chronic lung disease, immunosuppression, surgery, use of antimicrobial agents, presence of such invasive devices as endotracheal and gastric tubes, and type of respiratory equipment. However, there is little doubt that of all these factors, extended ICU care because of severe underlying disease, prolonged respiratory therapy with mechanical ventilation, and prior antimicrobial therapy are the most important. Because the only factor amenable to prevention in this setting is antimicrobial therapy, avoiding unnecessary antibiotics should be a high priority in the management of such patients. Crude mortality rates of 30% to 75% have been reported for nosocomial pneumonia caused by Pseudomonas and/or Acinetobacter spp., with the highest rates reported in ventilator-dependent patients. It is therefore clear that the prognosis associated with this type of infection is considerably worse than that associated with infection caused by other gram-negative or gram-positive bacteria. Because bactericidal synergy against Pseudomonas and Acinetobacter spp. has been shown when carbenicillin and an aminoglycoside are combined, the use of an effective beta-lactam (piperacillin, ticarcillin, ceftazidime, or imipenem) and aminoglycoside combination remains the preferred therapeutic approach when possible. Future research efforts should also aim to improve our ability to diagnose and exclude infection in the ICU setting to avoid administering unnecessary antibiotics to patients without true pulmonary infection.

[Splenic involvement in infectious endocarditis. Association for the Study and Prevention of Infectious Endocarditis]. / Les atteintes spléniques au cours des endocardites infectieuses. Association pour l'étude et la prévention de l'endocardite infectieuse.

INTRODUCTION: Splenic involvement in the course of endocarditis consists in either splenic infarct or abscess. Pathophysiological examinations suggest the existence of a continuum between the two types of lesion. Signs and symptoms are usually poor or aspecific. Current incidence and diagnostic methods are rarely reported in recent medical literature. EXEGESIS: We report a retrospective study conducted from a questionnaire that was circulated to nine French medical units. Two hundred and twenty five patients with infectious endocarditis according to Duke university criteria were included in the study. The existence of splenic lesions was investigated in 153 patients (68%). Splenic involvement was documented in 35 patients. Diagnostic methods were: abdominal echography (n = 77), abdominal CT scan (n = 40), and both techniques (n = 36). The incidence of splenic lesions was 9%, 35% and 36%, respectively. Among patients investigated using both diagnostic techniques, splenic abnormalities were detected by CT scan in 13 cases and by echography in six cases. Splenic abscess was suspected in nine patients by combining suggestive clinical course and radiological abnormalities, but was definitively evidenced in only four patients (surgery, n = 2, post-mortem examination, n = 2) presenting with large lesions (> or = 8 cm) associated with aortic endocarditis. All other 26 cases were categorized as splenic infarcts; however, diagnosis was confirmed in only two cases (surgery n = 1, autopsy n = 1). CONCLUSION: These data suggest that: 1) the incidence of splenic involvement during endocarditis is approximately 35%, 2) CT scan is probably superior to echography for spleen screening, and 3) incidence of abscess requiring specific surgery is very low, inferior to 2%.

Fatal aortic Myceliophthora thermophila infection in a patient affected by cystic medial necrosis.

A 22-year-old Italian woman developed fungal aortitis after cardiac surgery for aortic insufficiency. She experienced two episodes of septic embolization and subsequently underwent replacement of the aortic root and initial ascending aorta by a homograft. The lumina of the ascending aorta, aortic arch and the origin of the innominate artery were completely filled with vegetation. From the involved tissue the phaeoid thermophilic hyphomycete Myceliophthora thermophila (Apinis) van Oorschot was isolated in pure culture. This is the second report of isolation of this fungus from humans and the first isolation of a human pathogenic strain of M. thermophila causing fatal vasculitis in a patient affected by cystic medial necrosis. A detailed morphological description of the isolate is also provided.

Nosocomial pneumonia in patients with acute respiratory distress syndrome.

To describe the epidemiologic and microbial aspects of ventilator-associated pneumonia (VAP) in patients with acute respiratory distress syndrome (ARDS), we prospectively evaluated 243 consecutive patients who required mechanical ventilation (MV) for > or = 48 h, 56 of whom developed ARDS as defined by a Murray lung injury score > 2.5. We did this with bronchoscopic techniques when VAP was clinically suspected, before any modification of existing antimicrobial therapy. For all patients, the diagnosis of pneumonia was established on the basis of culture results of protected-specimen brush (PSB) (> or = 10(3) cfu/ml) and bronchoalvelolar lavage fluid (BALF) (> or = 10(4) cfu/ml) specimens, and direct examination of cells recovered by bronchoalveolar lavage (BAL) (< or = 5% of infected cells). Thirty-one (55%) of the 56 patients with ARDS developed VAP for a total of 41 episodes, as compared with only 53 (28%) of the 187 patients without ARDS for a total of 65 episodes (p = 0.0005). Only 10% of first episodes of VAP in patients with ARDS occurred before Day 7 of MV, as compared with 40% of the episodes in patients without ARDS (p = 0.005). All but two patients with ARDS who developed VAP had received antimicrobial treatment (mostly with broad-spectrum antibiotics) before the onset of infection, as compared with only 35 patients without ARDS (p = 0.004). The organisms most frequently isolated from patients with ARDS and VAP were methicillin-resistant Staphylococcus aureus (23%), nonfermenting gram-negative bacilli (21%), and Enterobacteriaceae (21%). These findings confirm that microbiologically provable VAP occurs far more often in patients with ARDS than in other ventilated patients. Because these patients are often treated with antibiotics early in the course of the syndrome, the onset of VAP is frequently delayed after the first week of MV, and is then caused mainly by methicillin-resistant S. aureus and other multiresistant microorganisms.

Ventilator-associated pneumonia caused by potentially drug-resistant bacteria.

To determine risk factors for ventilator-associated pneumonia (VAP) caused by potentially drug-resistant bacteria such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, and/or Stenotrophomonas maltophilia, 135 consecutive episodes of VAP observed in a single ICU over a 25-mo period were prospectively studied. For all patients, VAP was diagnosed based on results of bronchoscopic protected specimen brush (> or = 10(3) cfu/ml) and bronchoalveolar lavage (> or = 10(4) cfu/ml) specimens. Seventy-seven episodes were caused by "potentially resistant" bacteria and 58 episodes were caused by "other" organisms. According to logistic regression analysis, three variables among potential factors remained significant: duration of mechanical ventilation (MV) > or = 7 d (odds ratio [OR] = 6.0), prior antibiotic use (OR = 13.5), and prior use of broad-spectrum drugs (third-generation cephalosporin, fluoroquinolone, and/or imipenem) (OR = 4.1). Distribution of the 245 causative bacteria was analyzed according to four groups defined by prior duration of MV (< 7 or > or = 7 d) and prior use or lack of use (within 15 d) of antibiotics. Although 22 episodes of early-onset VAP in patients receiving no prior antibiotics were caused by antibiotic-susceptible bacteria, 84 episodes of late-onset VAP in patients receiving prior antibiotics were mainly caused by potentially resistant bacteria. Differences in the potential efficacies (ranging from 100% to 11%) against microorganisms of 15 antimicrobial regimens were studied according to classification into these four groups. These findings may provide a more rational basis for selecting the initial therapy of patients suspected of having VAP.

Predicting the outcome in elderly patients of hospital admission for acute care in Paris, France: construction and initial validation of a simplex index.

OBJECTIVE: To develop a simple index able to identify at an early stage those elderly patients at high risk of requiring discharge to a residential or nursing home after admission to hospital for acute care. For these patients, early discharge planning might lead to a more effective management and reduce the length of hospitalisation. DESIGN, SETTING, AND PATIENTS: This was a prospective study conducted in two teaching hospitals in Paris, France. A total of 510 consecutive patients was included. They were aged 75 years or more and had been admitted to acute medical care units through the emergency department. MEASUREMENTS: Demographic data, social support, physical disability, mental disability, and pathologic status were assessed shortly after admission (within 24-48 hours). MAIN OUTCOME MEASURES: Outcome of hospitalisation was defined as discharge to home or residential/nursing home. RESULTS: The index, developed by multiple logistic regression, included six variables: the wish of patients' principal career about their returning home after acute hospitalisation, presence of a chronic condition, ability to perform toileting, ability to know the name of the hospital or the city, their age, and their living arrangements. The sensitivity of the index in identifying patients at high risk of requiring discharge to a residential/nursing home was 74.4%, the specificity 63.8% the positive predictive value was 57.8%, and the negative predictive value was 80.6%. CONCLUSIONS: The simple index, using data available very early in the course of hospitalisation, provides an accurate prediction of the hospitalisation outcome. The performance of the index should be tested in other populations and the practical benefits of risk screening should be assessed in a controlled trial to evaluate whether the intervention is useful and without any adverse effects.

Usefulness of quantitative cultures of BAL fluid for diagnosing nosocomial pneumonia in ventilated patients.

STUDY OBJECTIVE: To evaluate the role of quantitative cultures of BAL for diagnosing nosocomial pneumonia in mechanically ventilated patients. DESIGN: Cohort study. SETTING: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center. PATIENTS: A total of 141 episodes of suspected lung infection in 84 consecutive patients mechanically ventilated for 48 h or more. MEASUREMENTS AND RESULTS: Microbiologic findings obtained using BAL were compared with those obtained with protected specimen brush (PSB) samples and their operating characteristics were determined. The level of qualitative agreement between BAL and PSB specimen cultures was high, with 83% of the organisms isolated in PSB specimens being recovered simultaneously from BAL fluid. In addition, the results of quantitative BAL and PSB cultures were significantly correlated (rho = 0.46, p < 0.0001). Fifty-seven cases of pneumonia were diagnosed based on the following criteria: PSB sample yielding > or = 10(3) cfu/mL of at least one microorganism and/or > or = 5% of cells containing intracellular bacteria on direct examination of BAL. The operating characteristics of BAL fluid cultures were determined using different ways to report the results and over a range of values. The discriminative value of 10(4) cfu/mL was found to be an optimal threshold, with a sensitivity of 82% (95% confidence interval [CI], 76 to 88) and a specificity of 84.5% (95% CI, 79 to 90). CONCLUSIONS: These results indicate that BAL fluid cultures can offer a sensitive and specific means to diagnose pneumonia in ventilated patients and may provide relevant information about the causative pathogens.

[Nosocomial pneumonia in intensive care units]. / Pneumopathies nosocomiales en réanimation.

Nosocomial pneumonia is associated with substantial morbidity and mortality. Patients treated with mechanical ventilation have the highest risk for developing this intensive care unit acquired infection. Gram-negative bacilli are the predominant organisms responsible for pneumonia in this setting. However, Staphylococcus aureus has recently emerged as a significant isolate. Nosocomial pneumonia is difficult to diagnose clinically in ventilated patients because fever, lung infiltrate on chest X-ray, leukocytosis are frequent in severely ill patients under mechanical ventilation whatever lung infection is present or not and because lower respiratory tract of such patients is colonized by potentially pathogenic bacteria independently of the presence of true lung infection; thus, different diagnostic strategies are proposed. Our personal bias is that using bronchoscopic techniques to obtain bronchoalveolar lavage and protected-brush specimens permits us to devise a therapeutic strategy that is superior to one based only on clinical evaluation. Measures for prevention of nosocomial infection are essential to decrease the incidence of nosocomial pneumonia and the emergence of multiresistant pathogens.

Long-term outcome and quality of life of patients requiring multidisciplinary intensive care unit admission after cardiac operations.

Patients with organ failure or severe infection after cardiac operations may require prolonged stays in the intensive care unit. This study examined long-term mortality and determined quality of life for surviving patients in this group. This observational cohort study was conducted at Bichat Hospital, Paris, an academic tertiary care center. The study group consisted of 116 consecutive patients who underwent cardiac operations and were transferred to the multidisciplinary intensive care unit between January 1986 and December 1987. Patients referred for mediastinitis were automatically excluded. Respiratory failure (88.8%) and hemodynamic instability (81.9%) were the main causes of transfer; an infection was present in 23.3% of patients at entry into the intensive care unit. Twenty-seven patients (23.3%) died in the intensive care unit. Presurgical New York Heart Association functional class, postoperative bacteremia before admission to the intensive care unit, and severity of illness on admission to the intensive care unit were independent predictors of death in the intensive care unit. After an average follow-up of 81 months (range 70 to 93 months), 69% of the patients alive at transfer from the intensive care unit were still alive. Preoperative New York Heart Association functional class was the only long-term independent prognostic factor. Quality of life, as evaluated by the Nottingham Health Profile, was good for more than 70% of the survivors and was not influenced by any recorded variables, with the exception of age.

Mortality due to ventilator-associated pneumonia or colonization with Pseudomonas or Acinetobacter species: assessment by quantitative culture of samples obtained by a protected specimen brush.

Ventilator-associated pneumonia (VAP) due to multiresistant pathogens is associated with a high death rate. We analyzed the relationship between VAP due to Pseudomonas or Acinetobacter species and death by comparing the outcomes for patients colonized with these pathogens (bacterial counts of < 10(3) cfu/mL) with those for patients with pneumonia due to these pathogens (bacterial counts of > or = 10(3) cfu/mL). Samples were obtained systematically with a protected specimen brush when pneumonia was suspected. Clinical characteristics at admission to our intensive care unit and clinical features at the time of suspicion of VAP were not significantly different between colonized patients and those with VAP. Mortality rates were 29% among colonized patients and 73% among patients with VAP (P < .001). These results demonstrate a relationship between a high mortality rate and the development of pneumonia due to multiresistant, nonfermenting, gram-negative bacilli ( > or = 10(3) cfu/mL) in the lower airways of patients receiving ventilatory support.

Diagnosis of pulmonary infections in mechanically ventilated patients.

The optimal management strategy for ventilator-dependent patients who develop symptoms suggestive of lung infection remains controversial. Proponents of the empirical approach prefer to treat most patients with fever and pulmonary infiltrates with one or more new antibiotics, even if it may be difficult (1) to determine whether pneumonia has developed in such patients, (2) in case of infection, to precisely identify the responsible microorganisms and thereby select the optimal antimicrobial treatment, and (3) to avoid resorting to broad-spectrum drug coverage in patients without true infection. Our personal bias is that using bronchoscopic techniques to obtain protected specimen brush and bronchoalveolar lavage specimens from the affected area in the lung permits to devise a therapeutic strategy superior to the one based only on clinical evaluation. These bronchoscopic techniques, when they are performed before new antibiotics are administered, enable physicians to identify most patients who need immediate treatment and select optimal therapy, in a manner that is safe and well tolerated by patients. Furthermore, they frequently permit the clinician to withhold antimicrobial treatment in patients without infection, minimizing the risk of the emergence of resistant microorganisms in the intensive care unit. In patients with clinical evidence of severe sepsis, the initiation of antibiotic therapy should not, however, be delayed while awaiting bronchoscopy, and patients should be given immediate treatment with antibiotics. In that case, "simplified" non-bronchoscopic diagnostic procedures might allow obtaining reliable distal pulmonary secretions for quantitative cultures on a 24-hour basis just before the initiation of a new antimicrobial therapy.

Nosocomial pneumonia and mortality among patients in intensive care units.

OBJECTIVE: To evaluate the role that nosocomial pneumonia plays in the outcome of intensive care unit (ICU) patients. DESIGN: Cohort study. SETTING: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center. PATIENTS: A total of 1978 consecutive patients admitted to the ICU for at least 48 hours. MAIN OUTCOME MEASURES: Various parameters known to be strongly associated with death of ICU patients were recorded: age, location before admission to the ICU, diagnostic categories, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiologic Score, McCabe score, number and type of dysfunctional organs, and the development of nosocomial bacteremia and nosocomial urinary tract infection. These variables and the presence or absence of nosocomial pneumonia were compared between survivors and nonsurvivors and entered into a stepwise logistic regression model to evaluate their independent prognostic roles. RESULTS: Nosocomial pneumonia developed in 328 patients (16.6%) whose mortality was 52.4% compared with 22.4% for patients without ICU-acquired pneumonia (P < .001), APACHE II score (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.06 to 1.10; P < .001), number of dysfunctional organs (OR = 1.54; 95% CI, 1.36 to 1.74; P < .001), nosocomial pneumonia (OR = 2.08; 95% CI, 1.55 to 2.80; P < .001), nosocomial bacteremia (OR = 2.51; 95% CI, 1.78 to 3.55; P < .001), ultimately or rapidly fatal underlying disease (OR = 1.76; 95% CI, 1.38 to 2.25; P < .001), and admission from another ICU (OR = 1.30; 95% CI, 1.01 to 1.68; P =.04) were significantly associated with mortality. CONCLUSION: These data suggest that, in addition to the severity of underlying medical conditions and nosocomial bacteremia, nosocomial pneumonia independently contributes to ICU patient mortality.

Closed drainage using Redon catheters for local treatment of poststernotomy mediastinitis.

BACKGROUND: Continuous irrigation has been used worldwide for the treatment of acute poststernotomy mediastinitis. However, its high rate of failure led to the development of new methods, among them closed drainage with Redon catheters. METHODS: We evaluated the results obtained with Redon catheters in 70 patients, and compared them to those obtained in 38 patients treated with continuous irrigation. RESULTS: The two treatment groups were not different for age, type of cardiac operation, and initial severity of illness. Local failure of Redon catheter drainage occurred less frequently (20 of 38 versus 9 of 70 patients; p = 0.0001). This reduced failure rate was mainly attributable to a lower incidence of superinfections (10 of 38 versus 2 of 70 patients; p = 0.0002), but also to a lower incidence of primary failure (10 of 38 versus 7 of 70 patients; p = 0.026). Mortality was significantly decreased (15 of 38 versus 12 of 70 patients; p = 0.01). The other major advantage of this technique was the simplicity of its use. CONCLUSIONS: The technique using Redon catheters should be considered an effective and convenient treatment of acute poststernotomy mediastinitis.

Diagnosis and treatment of nosocomial pneumonia in patients in intensive care units.

The optimal management strategy for ventilator-dependent patients who develop symptoms suggestive of lung infection remains controversial. Our personal bias is that using bronchoscopic techniques to obtain protected-brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. These bronchoscopic techniques, when they are performed before new antibiotics are administered, enable physicians to identify most patients who need immediate treatment and to select optimal therapy, in a form that is safe and well tolerated by patients. Furthermore, they frequently permit physicians to withhold antimicrobial treatment from patients without infection, thereby minimizing the risk of emergence of resistant microorganisms in the intensive care unit. Despite many advances in antimicrobial therapy, successful treatment of patients with nosocomial pneumonia remains a complex undertaking, and ultimately further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

Role of quantitative cultures of endotracheal aspirates in the diagnosis of nosocomial pneumonia.

To assess the reliability of quantitative cultures of endotracheal aspirates (EA) to diagnose ventilator-associated pneumonia, fiberoptic bronchoscopy was used to study 57 episodes of suspected lung infection in 39 patients with no recent changes in antimicrobial chemotherapy. A total of 19 cases (33%) of pneumonia were diagnosed based on the following criteria: protected specimen brush (PBS) sampling yielding > or = 10(3) cfu/ml of at least one microorganism and/or > or = 5% of cells containing intracellular bacteria on direct examination of bronchoalveolar lavage (BAL). The operating characteristics of EA cultures were calculated over a range of cutoff values (from 10(3) to 10(7) cfu/ml), and the threshold of 10(6) cfu/ml appeared to be the most accurate, with a sensitivity of 68% and a specificity of 84%. Microorganisms cultured from EA samples correlated weakly with those obtained using PSB specimens (rho = 0.32), with only 49 microorganisms among 123 (40%) found in both samples. These latter results and the relatively low sensitivity of the technique indicate that EA quantitative cultures are of limited value for the diagnosis of pneumonia in ventilated patients when fiberoptic techniques are available.