BackgroundMultiplex polymerase chain reaction (mPCR) enables recovery of viruses from airways of patients with community-acquired pneumonia (CAP), although their clinical impact remains uncertain.MethodsAmong consecutive adult patients who had undergone a mPCR within 72 hours following their admission to one intensive care unit (ICU), we retrospectively included those with a final diagnosis of CAP. Four etiology groups were clustered: bacterial, viral, mixed (viral-bacterial) and no etiology. A composite criterion of complicated course (hospital death or mechanical ventilation > 7 days) was used. A subgroup analysis compared patients with bacterial and viral-bacterial CAP matched on the bacterial pathogens.ResultsAmong 174 patients (132 men [76 %], age 63 [53–75] years, SAPSII 38 [27;55], median PSI score 106 [78;130]), bacterial, viral, mixed and no etiology groups gathered 46 (26 %), 53 (31 %), 45 (26 %) and 30 (17 %) patients, respectively. Virus-infected patients displayed a high creatine kinase serum level, a low platelet count, and a trend toward more frequent alveolar-interstitial infiltrates. A complicated course was more frequent in the mixed group (31/45, 69 %), as compared to bacterial (18/46, 39 %), viral (15/53, 28 %) and no etiology (12/30, 40 %) groups (p < 0.01). In multivariate analysis, the mixed (viral-bacterial) infection was independently associated with complicated course (reference: bacterial pneumonia; OR, 3.58; CI 95 %, 1.16–11; p = 0.03). The subgroup analysis of bacteria-matched patients confirmed these findings.ConclusionsViral-bacterial coinfection during severe CAP in adults is associated with an impaired presentation and a complicated course.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1517-9) contains supplementary material, which is available to authorized users.

Venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) are lifesaving supports that are more and more frequently used in critically ill patients. Despite of major technological improvements observed during the last 20 years, ECMO-associated hemolysis is still a complication that may arise during such therapy. Hemolysis severity, directly appreciated by plasma free hemoglobin concentration, may be present with various intensity, from a nonalarming and tolerable hemolysis to a highly toxic one. Here, we propose a review dedicated to extracorporeal membrane oxygenation (ECMO)-associated hemolysis, with a particular emphasis on pathophysiology, prevalence, and clinical consequences of such complication. We also focus on laboratory assessment of hemolysis and on the limits that have to be known by clinicians to prevent and manage hemolytic events.

BackgroundInfectious complications are a major cause of morbidity and mortality after heart transplantation (HT). However, the epidemiology and outcomes of these infections in the recent population of adult heart transplant recipients have not been investigated.MethodsWe conducted a single-center retrospective study on infectious complications occurring within 180 days following HT on consecutive heart transplant recipients, from January 2011 to June 2015 at Bichat University Hospital in Paris, France. Risk factors for non-viral infections occurring within 8, 30 and 180 days after HT were investigated using competing risk analysis.ResultsOverall, 113 patients were included. Fifty-eight (51%) HTs were high-priority allocations. Twenty-eight (25%) patients had an extracorporeal membrane oxygenation (ECMO) support at the time of transplantation. Ninety-two (81%) patients developed at least one infection within 180 days after HT. Bacterial and fungal infections (n = 181 episodes) occurred in 80 (71%) patients. The most common bacterial and fungal infections were pneumonia (n = 95/181 episodes, 52%), followed by skin and soft tissue infections (n = 26/181, 14%). Multi-drug-resistant bacteria were responsible for infections in 21 (19%) patients. Viral infections were diagnosed in 44 (34%) patients, mostly Cytomegalovirus infection (n = 39, 34%). In multivariate subdistribution hazard model, prior cardiac surgery (subdistribution hazard ratio sHR = 2.7 [95% CI 1.5–4.6] p < 0.01) and epinephrine or norepinephrine at the time of HT (sHR = 2.3 [95% CI 1.1–5.2] p  = 0.04) were significantly associated with non-viral infections within 8 days after HT. Prior cardiac surgery (sHR = 2.5 [95% CI 1.4–4.4] p < 0.01), recipient age over 60 years (sHR = 2.0 [95% CI 1.2–3.3] p < 0.01) and ECMO following HT (sHR = 1.7 [95% CI 1.0–2.8] p = 0.04) were significantly associated with non-viral infection within 30 days after HT, as well as within 180 days after HT.ConclusionThis study confirmed the high rate of infections following HT. Recipient age, prior cardiac surgery and ECMO following HT were independent risk factors for early and late bacterial and fungal infections.Electronic supplementary materialThe online version of this article (10.1186/s13613-019-0490-2) contains supplementary material, which is available to authorized users.

In patients treated by venoarterial extracorporeal membrane oxygenation, early severe background abnormalities on standard electroencephalography provide important information on neurologic outcome. The lack of sleep transients on continuous electroencephalography reflects the severity of brain dysfunction and might represent an additional prognostic marker.

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BackgroundOxacillin and cloxacillin are the most frequently used penicillins for the treatment of severe methicillin-susceptible Staphylococcus aureus infections in intensive care units (ICUs), especially endocarditis. International recommendations do not suggest any adaptation of the dosage in case of renal impairment. We wanted to assess the risk factors for overdosing in ICU and the related observed side effects.MethodsAll patients with a therapeutic drug monitoring of oxa- or cloxacillin between 2008 and 2014 were included. The target range of trough concentration for total antibiotic activity was considered to be 20–50 mg/L. Data concerning the infection, the given treatment, the renal function, and the attributed side effects of overdosing were collected. A logistic regression model was used to compute the measured trough concentrations.ResultsSixty-two patients were included in this study. We found a median trough plasma concentration of 134.3 mg/L (IQR 65.3–201 mg/L). Ten patients (16.1%) reached the target concentration; all other patients (83.9%) were overdosed. Eleven patients (17.7%) experienced neurological side effects attributed to a high antibiotic concentration, i.e. persistent coma and delirium. When adjusted on the dosage used, the risk of overdosing was significantly associated with a creatinine clearance <10 mL/min (with or without hemodialysis).ConclusionWith the suggested dose of 12 g/day for cloxacillin treatment in case of endocarditis and severe infections occurring in ICU, 83.9% of patients are largely overdosed. Considering the observed side effects, doses should be accurately monitored and reduced, particularly when renal replacement therapy is needed.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0255-8) contains supplementary material, which is available to authorized users.

RationaleThe impact of prevention strategies and risk factors for early-onset (EOP) versus late-onset (LOP) ventilator-associated pneumonia (VAP) are still debated.ObjectivesTo evaluate, in a multicenter cohort, the risk factors for EOP and LOP, as the evolution of prevention strategies.Methods7,784 patients with mechanical ventilation (MV) for at least 48 hours were selected into the multicenter prospective OUTCOMEREA database (1997–2016). VAP occurring between the 3rd and 6th day of MV defined EOP, while those occurring after defined LOPs. We used a Fine and Gray subdistribution model to take the successful extubation into account as a competing event.Measurements and main resultsOverall, 1,234 included patients developed VAP (EOP: 445 (36%); LOP: 789 (64%)). Male gender was a risk factor for both EOP and LOP. Factors specifically associated with EOP were admission for respiratory distress, previous colonization with multidrug-resistant Pseudomonas aeruginosa, chest tube and enteral feeding within the first 2 days of MV. Antimicrobials administrated within the first 2 days of MV were all protective of EOP. ICU admission for COPD exacerbation or pneumonia were early risk factors for LOP, while imidazole and vancomycin use within the first 2 days of MV were protective factors. Late risk factors (between the 3rd and the 6th day of MV) were the intra-hospital transport, PAO2-FIO2<200 mmHg, vasopressor use, and known colonization with methicillin-resistant Staphylococcus aureus. Among the antimicrobials administered between the 3rd and the 6th day, fluoroquinolones were the solely protective one.Contrarily to LOP, the risk of EOP decreased across the study time periods, concomitantly with an increase in the compliance with bundle of prevention measures.ConclusionVAP risk factors are mostly different according to the pneumonia time of onset, which should lead to differentiated prevention strategies.