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See detailUtilisation de la nystatine dans la candidose oropharyngée au CHU de Liège
Vercheval, Christelle ULiege; GILLET, Manon ULiege; Koch, Nathan ULiege et al

in Journal de Pharmacie de Belgique (2019)

Le Groupe de Gestion de l’Antibiothérapie du Centre Hospitalier Universitaire de Liègea souligné une utilisation importante et nonjustifiée de nystatine sous forme de bain debouche. Devant ce constat ... [more ▼]

Le Groupe de Gestion de l’Antibiothérapie du Centre Hospitalier Universitaire de Liègea souligné une utilisation importante et nonjustifiée de nystatine sous forme de bain debouche. Devant ce constat, nous avons réalisé une revue de la littérature sur l’efficacité et l’innocuité de la nystatine dans la candidose oropharyngée (COP) et nous partageons dans cet article quelques recommandations pratiques institutionnelles. La COP est une infection fongique fréquente avec un bon pronostic si elle est diagnostiquée et traitée de manière appropriée. La nystatine sous forme de pastille ou de suspension buvable est recommandée comme traitement alternatif en cas de COP bénigne par la Société Américaine des Maladies Infectieuses. Néanmoins, la littérature évaluant l’efficacité et la sécurité de la nystatine dans la COP est pauvre. En Belgique, la nystatine est commercialisée sous forme de suspension buvable et sous forme de matière première. Aucun consensus national n’est disponible sur la formulation, le dosage ou encore la durée de traitement de la nystatine en cas de COP. Au CHU de Liège, il a été décidé d’arrêter la préparation de bain de bouche à base de nystatine et de privilégier l’utilisation d’une suspension de nystatine en cas de COP bénigne. [less ▲]

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See detailProcalcitonin-guided antibiotic treatment in patients with positive blood cultures: A patient-level meta-analysis of randomized trials.
Meier, Marc A.; Branche, Angela; Neeser, Olivia L. et al

in Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2018)

Background: Whether procalcitonin (PCT)-guided antibiotic management in patients with positive blood cultures is safe remains understudied. We performed a patient level meta-analysis to investigate ... [more ▼]

Background: Whether procalcitonin (PCT)-guided antibiotic management in patients with positive blood cultures is safe remains understudied. We performed a patient level meta-analysis to investigate effects of PCT-guided antibiotic management in patients with bacteremia overall and stratified based on type of pathogen. Methods: We extracted and analysed individual data of 523 patients with positive blood cultures included in 13 trials (7 studies evaluating patients with acute respiratory illnesses, 6 studies patients with sepsis), in which patients were randomly assigned to receive antibiotics based on PCT levels (PCT group) or a control group. The main efficacy endpoint was duration of antibiotic treatment. The main safety endpoint was mortality within 30 days. Results: Mean duration of antibiotic therapy for 253 patients who received PCT guided treatment was significantly shorter compared to 270 control patients (-2.86 days (95%CI -4.88 to -0.84, p=0.006). Mortality was similar in both arms (16.6% vs 20.0%, p=0.263). In subgroup analyses by type of pathogen, we noted a trend of shorter mean antibiotic durations in the PCT arm for patients infected with gram positive organisms or Escherichia coli and significantly shorter treatment for subjects with pneumococcal bacteremia (-4.52 days [95%CI -7.40 to -1.64, p=0.002). In analysis by site of infection, antibiotics exposure was shortened in PCT group subjects with Streptococcus pneumoniae respiratory infection and those with Escherichia coli urogenital infections. Conclusion: This meta-analysis of patients with bacteremia receiving PCT-guided antibiotic management demonstrates lower antibiotic exposure without an apparent increase in mortality. Few differences were demonstrated in subgroup analysis stratified by type or site of infection but notable for decreased exposure in patients with pneumococcal pneumonia and E Coli urogenital infections. [less ▲]

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See detailDecontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial.
Wittekamp, Bastiaan H.; Plantinga, Nienke L.; Cooper, Ben S. et al

in JAMA: Journal of the American Medical Association (2018), 320(20), 2087-2098

Importance: The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to ... [more ▼]

Importance: The effects of chlorhexidine (CHX) mouthwash, selective oropharyngeal decontamination (SOD), and selective digestive tract decontamination (SDD) on patient outcomes in ICUs with moderate to high levels of antibiotic resistance are unknown. Objective: To determine associations between CHX 2%, SOD, and SDD and the occurrence of ICU-acquired bloodstream infections with multidrug-resistant gram-negative bacteria (MDRGNB) and 28-day mortality in ICUs with moderate to high levels of antibiotic resistance. Design, Setting, and Participants: Randomized trial conducted from December 1, 2013, to May 31, 2017, in 13 European ICUs where at least 5% of bloodstream infections are caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Patients with anticipated mechanical ventilation of more than 24 hours were eligible. The final date of follow-up was September 20, 2017. Interventions: Standard care was daily CHX 2% body washings and a hand hygiene improvement program. Following a baseline period from 6 to 14 months, each ICU was assigned in random order to 3 separate 6-month intervention periods with either CHX 2% mouthwash, SOD (mouthpaste with colistin, tobramycin, and nystatin), or SDD (the same mouthpaste and gastrointestinal suspension with the same antibiotics), all applied 4 times daily. Main Outcomes and Measures: The occurrence of ICU-acquired bloodstream infection with MDRGNB (primary outcome) and 28-day mortality (secondary outcome) during each intervention period compared with the baseline period. Results: A total of 8665 patients (median age, 64.1 years; 5561 men [64.2%]) were included in the study (2251, 2108, 2224, and 2082 in the baseline, CHX, SOD, and SDD periods, respectively). ICU-acquired bloodstream infection with MDRGNB occurred among 144 patients (154 episodes) in 2.1%, 1.8%, 1.5%, and 1.2% of included patients during the baseline, CHX, SOD, and SDD periods, respectively. Absolute risk reductions were 0.3% (95% CI, -0.6% to 1.1%), 0.6% (95% CI, -0.2% to 1.4%), and 0.8% (95% CI, 0.1% to 1.6%) for CHX, SOD, and SDD, respectively, compared with baseline. Adjusted hazard ratios were 1.13 (95% CI, 0.68-1.88), 0.89 (95% CI, 0.55-1.45), and 0.70 (95% CI, 0.43-1.14) during the CHX, SOD, and SDD periods, respectively, vs baseline. Crude mortality risks on day 28 were 31.9%, 32.9%, 32.4%, and 34.1% during the baseline, CHX, SOD, and SDD periods, respectively. Adjusted odds ratios for 28-day mortality were 1.07 (95% CI, 0.86-1.32), 1.05 (95% CI, 0.85-1.29), and 1.03 (95% CI, 0.80-1.32) for CHX, SOD, and SDD, respectively, vs baseline. Conclusions and Relevance: Among patients receiving mechanical ventilation in ICUs with moderate to high antibiotic resistance prevalence, use of CHX mouthwash, SOD, or SDD was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB compared with standard care. Trial Registration: ClinicalTrials.gov Identifier: NCT02208154. [less ▲]

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See detailProcalcitonin-guided antibiotic therapy algorithms for different types of acute respiratory infections based on previous trials
Schuetz, P.; Bolliger, R.; Merker, M. et al

in Expert Review of Anti-Infective Therapy (2018), 16(7), 555-564

Introduction: Although evidence indicates that use of procalcitonin to guide antibiotic decisions for the treatment of acute respiratory infections (ARI) decreases antibiotic consumption and improves ... [more ▼]

Introduction: Although evidence indicates that use of procalcitonin to guide antibiotic decisions for the treatment of acute respiratory infections (ARI) decreases antibiotic consumption and improves clinical outcomes, algorithms used within studies had differences in PCT cut-off points and frequency of testing. We therefore analyzed studies evaluating procalcitonin-guided antibiotic therapy and propose consensus algorithms for different respiratory infection types. Areas covered: We systematically searched randomized-controlled trials (search strategy updated on February 2018) on procalcitonin-guided antibiotic therapy of ARI in adults using a pre-specified Cochrane protocol and analyzed algorithms from 32 trials that included 10,285 patients treated in primary care settings, emergency departments (ED), and intensive care units (ICU). We derived consensus algorithms for use of procalcitonin by the type of ARI including community-acquired pneumonia, bronchitis, chronic obstructive pulmonary disease or asthma exacerbation, sepsis, and post-operative sepsis due to respiratory infection. Consensus algorithm recommendations differ with regard to timing of treatment (i.e. timing of initiation in low-risk patients or discontinuation in high-risk patients) and procalcitonin cut-off points for the recommendation/strong recommendation to discontinue antibiotics (≤ 0.25/≤ 0.1 µg/L in ED and inpatients, ≤ 0.5/≤ 0.25 µg/L in ICU patients, and reduction by ≥ 80% from peak levels in sepsis patients). Expert commentary: Our proposed algorithms may facilitate safe and efficient implementation of procalcitonin-guided antibiotic protocols in diverse healthcare settings. Still, the decision about initiation and cessation of antibiotic treatment remains a clinical decision based on the patient assessment and the severity of illness and use of procalcitonin should not delay empirical treatment in high risk situations. © 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group. [less ▲]

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See detailLiver transplantation in Jehovah’s Witnesses: a single center-experience
VANDERMEULEN, Morgan ULiege; MEURISSE, Nicolas ULiege; DAMAS, Pierre ULiege et al

Conference (2018, March 15)

For religious reasons most of the Jehovah's witnesses (JW) refuse infusions of any blood product, including autologous or homologous pre-donated blood, platelets, fresh frozen plasma. However, they may ... [more ▼]

For religious reasons most of the Jehovah's witnesses (JW) refuse infusions of any blood product, including autologous or homologous pre-donated blood, platelets, fresh frozen plasma. However, they may accept solid organ transplantation. The authors report their experience of liver transplantation (LT) in JW over a 20-year period. [less ▲]

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See detailLiver transplantation in Jehovah's witnesses
VANDERMEULEN, Morgan ULiege; MEURISSE, Nicolas ULiege; DAMAS, Pierre ULiege et al

in Acta Gastro-Enterologica Belgica (2018, January), 81(1), 30

Introduction: Liver transplantation (LT) is a major surgical procedure with large dissections and sutures of large vessels in patients with high portal hypertension and low levels of platelets and ... [more ▼]

Introduction: Liver transplantation (LT) is a major surgical procedure with large dissections and sutures of large vessels in patients with high portal hypertension and low levels of platelets and coagulation factors. In consequence, LT often requires large amounts of blood products. For religious reasons, most Jehovah's witnesses (JW) refuse infusions of any blood product, including autologous or homologous pre-donated blood, platelets, fresh frozen plasma, coagulation factor concentrates, or human albumin. However, they may accept solid organ transplantation, including LT. Aim: The authors developed experience in abdominal and oncological surgery in JW and present here their results with LT in JW patients. Methods: Over a 20-year period, 22 LT (16 DBD, 2DCD, and 4 LRLT with JW living donors) were performed in 21 JW patients and were analyzed retrospectively. All patients received perioperative iron supplementation and erythropoietin. Two patients had percutaneous spleen embolization to increase platelet level. Anti-fibrinolytic (aprotinin or tranexamic acid) was administrated during LT and meticulous surgical hemostasis was achieved, helped by argon beam coagulation. Continuous circuit cell salvage and reinfusion whereby scavenged blood was maintained in continuity with the patient's circulation, was used in all patients. Veno-venous bypass was avoided during LT to minimize the coagulation disorders. Results: There were 10 male and 11 female patients whose mean age was 48 years (ranges: 6-70). Indications for LT were HCV with (3) or without (1) HCC, PBC (2), PSC (1), HBV (2), autoimmune hepatitis (1), antitrypsin deficiency (1), sarcoidosis (2), amyloidosis (3), polycystic liver disease (1), alcoholic cirrhosis with HCC (1), cryptogenic (3), hepatic artery thrombosis (1). At transplant, mean pre-operative hematocrit was 41% (ranges: 22-50), mean platelet level was 140x103/mm3 (ranges: 33-355), and mean INR was 1.25 (ranges: 0.84- 2.18).One LRLT recipient died at day 11 from aspergillosis and anemia, and another DBD recipient at day 28 due to complications after hepatic artery thrombosis. One patient finally accepted to be transfused for severe anemia. The mean hospital stay was 31 days (10-137). Kaplan-Maier patient survival was 85%, 72%, 72% at 5, 10 and 15 years, respectively Conclusions: According to the authors' experience, LT may be successful in selected and prepared JW patients who should not be a priori excluded from this life saving procedure. The indications for LT in JW were quite different from the common indications for LT, with a low rate of alcoholic cirrhosis. The experience with this particular group of patients helped the team to reduce transfusion needs in the non-JW patients. [less ▲]

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See detailAcidose métabolique à trou anionique élevé (acidose pyroglutamique) induite par une prise chronique de paracétamol
TCHOUGANG NONO, Joël ULiege; MISTRETTA, Virginie ULiege; Noirot, Isabelle ULiege et al

in Revue Médicale de Liège (2018), 73(1), 39-42

Acetaminophen is the most consumable analgesic in the world in the form of medical prescription or selfmedication. It is one of the active ingredients most often involved in voluntary poisoning. Lethal ... [more ▼]

Acetaminophen is the most consumable analgesic in the world in the form of medical prescription or selfmedication. It is one of the active ingredients most often involved in voluntary poisoning. Lethal dose of acetaminophen classically induces acute hepatic failure on hepatic necrosis. Chronic intake of sub-lethal doses (i.e. near recommended therapeutic doses) of acetaminophen in the presence of certain risk factors may be responsible for another much less recognized pathological manifestation: severe metabolic acidosis with an increased anion gap due to the accumulation of 5-oxoproline or pyroglutamic acid. [less ▲]

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See detailVariation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.
Huijben, Jilske A.; Volovici, Victor; Cnossen, Maryse C. et al

in Critical Care (2018), 22(1), 90

BACKGROUND: General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of ... [more ▼]

BACKGROUND: General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. METHODS: We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. RESULTS: The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36-40 mmHg (4.8-5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30-35 mmHg (4-4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). CONCLUSIONS: Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome. [less ▲]

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See detailHighly standardized quadriceps dynamometry of critically ill adults at bedside: a step towards individualized rehabilitation.
ROUSSEAU, Anne-Françoise ULiege; KELLENS, Isabelle ULiege; Freycenon, Gaelle et al

in Acta Anaesthesiologica Belgica (2018), 69

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See detailNew Modalities for the Administration of Inhaled Nitric Oxide in Intensive Care Units After Cardiac Surgery or for Neonatal Indications: A Prospective Observational Study.
Gaudard, Philippe; Barbanti, Claudio; Rozec, Bertrand et al

in Anesthesia and Analgesia (2018), 126(4), 1234-1240

BACKGROUND: Nitric oxide (NO) has a well-known efficacy in pulmonary hypertension (PH), with wide use for 20 years in many countries. The objective of this study was to describe the current use of NO in ... [more ▼]

BACKGROUND: Nitric oxide (NO) has a well-known efficacy in pulmonary hypertension (PH), with wide use for 20 years in many countries. The objective of this study was to describe the current use of NO in real life and the gap with the guidelines. METHODS: This is a multicenter, prospective, observational study on inhaled NO administered through an integrated delivery and monitoring device and indicated for PH according to the market authorizations. The characteristics of NO therapy and ventilation modes were observed. Concomitant pulmonary vasodilator treatments, safety data, and outcome were also collected. Quantitative data are expressed as median (25th, 75th percentile). RESULTS: Over 1 year, 236 patients were included from 14 equipped and trained centers: 117 adults and 81 children with PH associated with cardiac surgery and 38 neonates with persistent PH of the newborn. Inhaled NO was initiated before intensive care unit (ICU) admission in 57%, 12.7%, and 38.9% with an initial dose of 10 (10, 15) ppm, 20 (18, 20) ppm, and 17 (11, 20) ppm, and a median duration of administration of 3.9 (1.9, 6.1) days, 3.8 (1.8, 6.8) days, and 3.1 (1.0, 5.7) days, respectively, for the adult population, pediatric cardiac group, and newborns. The treatment was performed using administration synchronized to the mechanical ventilation. The dose was gradually decreased before withdrawal in 86% of the cases according to the usual procedure of each center. Adverse events included rebound effect for 3.4% (95% confidence interval [CI], 0.9%-8.5%) of adults, 1.2% (95% CI, 0.0%-6.7%) of children, and 2.6% (95% CI, 0.1%-13.8%) of neonates and methemoglobinemia exceeded 2.5% for 5 of 62 monitored patients. Other pulmonary vasodilators were associated with NO in 23% of adults, 95% of children, and 23.7% of neonates. ICU stay was respectively 10 (6, 22) days, 7.5 (5.5, 15) days, and 9 (8, 15) days and ICU mortality was 22.2%, 6.2%, and 7.9% for adults, children, and neonates, respectively. CONCLUSIONS: This study confirms the safety of NO therapy in the 3 populations with a low rate of rebound effect. Gradual withdrawal of NO combined with pulmonary vasodilators are current practices in this population. The use of last-generation NO devices allowed good compliance with recommendations. [less ▲]

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See detailInhaled sevoflurane sedation in the intensive care unit. A case report and narrative literature review
Hubert, Julien ULiege; PIRET, Sonia ULiege; SERPE, Philippe ULiege et al

in Acta Anaesthesiologica Belgica (2018), 69(1), 55-59

This article aims at reviewing, in recent literature, the interest and good practice of using volatile sedation with sevoflurane in an intensive care setting. Although rarely used in the intensive care ... [more ▼]

This article aims at reviewing, in recent literature, the interest and good practice of using volatile sedation with sevoflurane in an intensive care setting. Although rarely used in the intensive care unit (ICU) compared to intravenous sedation, inhaled sedation may be a good alternative to insure comfort to ICU patients. Current literature demonstrates that sevoflurane, administrated through a specifically designed device, the AnaConDa, provides safe and good quality sedation to those patients. Long-term inhaled sevoflurane sedation (ISS) (>96 hours) would be associated to lower agitation, improved pain control, and lower mortality than intravenous sedation. The properties of sevoflurane may be of further advantage in specific intensive care situations such as bronchospasm, postoperative sedation after cardiothoracic surgery, or in agitated patients due to alcohol or other drugs withdrawal. Other studies suggest superiority of ISS in case of pulmonary arterial hypertension, chronic obstructive pulmonary disease, and acute respiratory distress syndrome. We here illustrate our literature review with a case of severe bronchospasm successfully managed using ISS. © Acta Ancesthesiologica Belgica, 2018. [less ▲]

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See detailComparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP)
Vincent, Jean-Louis; Lefrant, J.-Y.; Kotfis, K. et al

in Intensive Care Medicine (2018), 44(3), 337-344

Purpose: To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time. Methods: We reviewed all epidemiological data, including comorbidities, types and ... [more ▼]

Purpose: To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time. Methods: We reviewed all epidemiological data, including comorbidities, types and severity of organ failure, interventions, lengths of stay and outcome, for patients from the Sepsis Occurrence in Acutely ill Patients (SOAP) study, an observational study conducted in European intensive care units in 2002, and the Intensive Care Over Nations (ICON) audit, a survey of intensive care unit patients conducted in 2012. Results: We compared the 3147 patients from the SOAP study with the 4852 patients from the ICON audit admitted to intensive care units in the same countries as those in the SOAP study. The ICON patients were older (62.5 ± 17.0 vs. 60.6 ± 17.4 years) and had higher severity scores than the SOAP patients. The proportion of patients with sepsis at any time during the intensive care unit stay was slightly higher in the ICON study (31.9 vs. 29.6%, p = 0.03). In multilevel analysis, the adjusted odds of ICU mortality were significantly lower for ICON patients than for SOAP patients, particularly in patients with sepsis [OR 0.45 (0.35–0.59), p < 0.001]. Conclusions: Over the 10-year period between 2002 and 2012, the proportion of patients with sepsis admitted to European ICUs remained relatively stable, but the severity of disease increased. In multilevel analysis, the odds of ICU mortality were lower in our 2012 cohort compared to our 2002 cohort, particularly in patients with sepsis. © 2018, The Author(s). [less ▲]

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See detailEffect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: A patient-level meta-analysis of randomized trials
Wirz, Y.; Meier, M. A.; Bouadma, L. et al

in Critical Care (2018), 22(1), 191

Background: The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized ... [more ▼]

Background: The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection. Methods: For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the "procalcitonin-guided" group) or the current standard of care (the "controls"). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay. Results: Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001). Conclusion: Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration. © 2018 The Author(s). [less ▲]

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See detailImpact of a VAP bundle in Belgian intensive care units
Jadot, L.; Huyghens, L.; De Jaeger, A. et al

in Annals of Intensive Care (2018), 8(1), 65

Background: In order to decrease the incidence of ventilator-associated pneumonia (VAP) in Belgium, a national campaign for implementing a VAP bundle involving assessment of sedation, cuff pressure ... [more ▼]

Background: In order to decrease the incidence of ventilator-associated pneumonia (VAP) in Belgium, a national campaign for implementing a VAP bundle involving assessment of sedation, cuff pressure control, oral care with chlorhexidine and semirecumbent position, was launched in 2011–2012. This report will document the impact of this campaign. Methods: On 1 day, once a year from 2010 till 2016, except in 2012, Belgian ICUs were questioned about their ventilated patients. For each of these, data about the application of the bundle and the possible treatment for VAP were recorded. Results: Between 36.6 and 54.8% of the 120 Belgian ICUs participated in the successive surveys. While the characteristics of ventilated patients remained similar throughout the years, the percentage of ventilated patients and especially the duration of ventilation significantly decreased before and after the national VAP bundle campaign. Ventilator care also profoundly changed: Controlling cuff pressure, head positioning above 30° were obtained in more than 90% of cases. Oral care was more frequently performed within a day, using more concentrated solutions of chlorhexidine. Subglottic suctioning also was used but in only 24.7% of the cases in the last years. Regarding the prevalence of VAP, it significantly decreased from 28% of ventilated patients in 2010 to 10.1% in 2016 (p ≤ 0.0001). Conclusion: Although a causal relationship cannot be inferred from these data, the successive surveys revealed a potential impact of the VAP bundle campaign on both the respiratory care of ventilated patients and the prevalence of VAP in Belgian ICUs encouraging them to follow the guidelines. © 2018, The Author(s). [less ▲]

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See detailEffect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis
Schuetz, Philipp; Wirz, Yannick; Sager, Ramon et al

in Lancet Infectious Diseases (2018), 18(1), 95-107

Background In February, 2017, the US Food and Drug Administration approved the blood infection marker procalcitonin for guiding antibiotic therapy in patients with acute respiratory infections. This meta ... [more ▼]

Background In February, 2017, the US Food and Drug Administration approved the blood infection marker procalcitonin for guiding antibiotic therapy in patients with acute respiratory infections. This meta-analysis of patient data from 26 randomised controlled trials was designed to assess safety of procalcitonin-guided treatment in patients with acute respiratory infections from different clinical settings. Methods Based on a prespecified Cochrane protocol, we did a systematic literature search on the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, and pooled individual patient data from trials in which patients with respiratory infections were randomly assigned to receive antibiotics based on procalcitonin concentrations (procalcitonin-guided group) or control. The coprimary endpoints were 30-day mortality and setting-specific treatment failure. Secondary endpoints were antibiotic use, length of stay, and antibiotic side-effects. Findings We identified 990 records from the literature search, of which 71 articles were assessed for eligibility after exclusion of 919 records. We collected data on 6708 patients from 26 eligible trials in 12 countries. Mortality at 30 days was significantly lower in procalcitonin-guided patients than in control patients (286 [9%] deaths in 3336 procalcitonin-guided patients vs 336 [10%] in 3372 controls; adjusted odds ratio [OR] 0·83 [95% CI 0·70 to 0·99], p=0·037). This mortality benefit was similar across subgroups by setting and type of infection (pinteractions>0·05), although mortality was very low in primary care and in patients with acute bronchitis. Procalcitonin guidance was also associated with a 2·4-day reduction in antibiotic exposure (5·7 vs 8·1 days [95% CI −2·71 to −2·15], p<0·0001) and a reduction in antibiotic-related side-effects (16% vs 22%, adjusted OR 0·68 [95% CI 0·57 to 0·82], p<0·0001). Interpretation Use of procalcitonin to guide antibiotic treatment in patients with acute respiratory infections reduces antibiotic exposure and side-effects, and improves survival. Widespread implementation of procalcitonin protocols in patients with acute respiratory infections thus has the potential to improve antibiotic management with positive effects on clinical outcomes and on the current threat of increasing antibiotic multiresistance. Funding National Institute for Health Research. © 2018 Elsevier Ltd [less ▲]

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See detailManagement of Respiratory Infections with Use of Procalcitonin: Moving toward More Personalized Antibiotic Treatment Decisions.
Wirz, Yannick; Branche, Angela; Wolff, Michel et al

in ACS Infectious Diseases (2017), 3(12), 875-879

Due to overlap of clinical findings and low sensitivity of bacterial diagnostic tests, differentiation between bacterial and viral respiratory tract infections remains challenging, ultimately leading to ... [more ▼]

Due to overlap of clinical findings and low sensitivity of bacterial diagnostic tests, differentiation between bacterial and viral respiratory tract infections remains challenging, ultimately leading to antibiotic overuse in this population of patients. Addition of procalcitonin, a blood biomarker expressed by epithelial cells in response to bacterial infections, to the clinical assessment leads to a reduction in inappropriate antibiotic initiation. Procalcitonin also provides prognostic information about the resolution of illness, and significant decreases over time are a strong signal for the discontinuation of antibiotics. Current evidence from randomized trials indicates that procalcitonin-guided antibiotic stewardship results in a reduction in antibiotic use and antibiotic side effects, which importantly translates into improved survival of patients with respiratory infections. Inclusion of procalcitonin into antibiotic stewardship algorithms thus improves the diagnostic and therapeutic management of patients presenting with respiratory illnesses and holds great promise to mitigate the global bacterial resistance crisis. [less ▲]

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See detailSepsis prediction in critically ill patients by platelet activation markers on ICU admission: a prospective pilot study
LAYIOS, Nathalie ULiege; Delierneux, Céline ULiege; Hego, Alexandre ULiege et al

in Intensive Care Medicine Experimental (2017), 5(1), 32

Background: Platelets have been involved in both surveillance and host defense against severe infection. To date, whether platelet phenotype or other hemostasis components could be associated with ... [more ▼]

Background: Platelets have been involved in both surveillance and host defense against severe infection. To date, whether platelet phenotype or other hemostasis components could be associated with predisposition to sepsis in critical illness remains unknown. The aim of this work was to identify platelet markers that could predict sepsis occurrence in critically ill injured patients. Results: This single-center, prospective, observational, 7-month study was based on a cohort of 99 non-infected adult patients admitted to ICUs for elective cardiac surgery, trauma, acute brain injury and post-operative prolonged ventilation and followed up during ICU stay. Clinical characteristics and severity score (SOFA) were recorded on admission. Platelet activation markers, including fibrinogen binding to platelets, platelet membrane P-selectin expression, plasma soluble CD40L, and platelet-leukocytes aggregates were assayed by flow cytometry at admission and 48h later, and also at the time of sepsis diagnosis (Sepsis-3 criteria) and 7 days later for sepsis patients. Hospitalization data and outcomes were also recorded. Of the 99 patients, 19 developed sepsis after a median time of 5 days. SOFA at admission was higher; their levels of fibrinogen binding to platelets (platelet-Fg) and of D-dimers were significantly increased compared to the other patients. Levels 48h after ICU admission were no longer significant. Platelet-Fg % was an independent predictor of sepsis (P = 0.030). By ROC curve analysis cutoff points for SOFA (AUC=0.85) and Platelet-Fg (AUC=0.75) were 8 and 50%, respectively. The prior risk of sepsis (19%) increased to 50% when SOFA was above 8, to 46% when Platelet-Fg was above 50%, and to 87% when both SOFA and Platelet-Fg were above their cutoff values. By contrast, when the two parameters were below their cutoffs, the risk of sepsis was negligible (3.8%). Patients with sepsis had longer ICU and hospital stays and higher death rate. Conclusion: In addition to SOFA, platelet-bound fibrinogen levels assayed by flow cytometry within 24h of ICU admission help identifying critically ill patients at risk of developing sepsis. [less ▲]

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See detailReliability of a standardized protocol for bedside quadriceps strength measurement in critically ill patients
ROUSSEAU, Anne-Françoise ULiege; Freycenon, Gaëlle ULiege; KELLENS, Isabelle ULiege et al

in Intensive Care Medicine Experimental (2017, September), 5(S2), 327

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See detailMeasurement of pleural pressure swings with a fluid-filled esophageal catheter vs pulmonary artery occlusion pressure
VERSCHEURE, Sara ULiege; MASSION, Paul ULiege; GOTTFRIED, S et al

in Journal of Critical Care (2017), 37

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See detailImpact of the cumulated proteins and energy deficits on ICU patient’s outcome
PAGE, Isaline ULiege; Warnier, Stéphanie; NYS, Monique ULiege et al

in Annals of Intensive Care (2017, January), 7(Suppl1), 200

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