Archive for February 12, 2013

Critical care management and outcome of severe Pneumocystis pneumonia in patients with and without HIV infection.

Crit Care. 2008;12(1):R28.

Monnet X, Vidal-Petiot E, Osman D, Hamzaoui O, Durrbach A, Goujard C, Miceli C, Bourée P, Richard C.

Source

AP-HP, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, Le Kremlin-Bicêtre, F-94270, France. xavier.monnet@bct.aphp.fr

Erratum in

Crit Care. 2009;13(2)407.

Abstract

BACKGROUND:

Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status.

METHODS:

We retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital.

RESULTS:

The yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis.

CONCLUSION:

The yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2374632/pdf/cc6806.pdf

February 12, 2013 at 8:23 pm

Impact of Clinical Guidelines in the Management of Severe HospitalAcquired Pneumonia*

CHEST 2005; 128:2778 –2787

Guy W. Soo Hoo, MD, MPH; Y. Eugenia Wen, MD; Trung V. Nguyen, DO; and Matthew Bidwell Goetz, MD

Study objectives

To asses the impact of locally developed antimicrobial treatment guidelines in the initial empiric treatment of ICU patients with severe hospital-acquired pneumonia (HAP).

Design

Observational cohort study with preguideline and postguideline data collection.

Patients

A total of 48 preguideline patients with 56 episodes of severe HAP defined by the

National Nosocomial Infections Surveillance (NNIS) compared with 58 guideline-treated

(GUIDE) patients with 61 episodes of severe HAP.

Results

The two groups were similar in terms of mean (SD) age (IS group, 67.7  9.6 years; GUIDE group, 68.0  11.5 years) and simplified acute physiology score (NNIS group, 12.9  3.9; GUIDE group, 12.6  3.1) at the HAP diagnosis, and the proportion of the most frequent isolates (ie, Pseudomonas and methicillin-resistant Staphylococcus aureus). There was wide variation in initial antibiotic use in NNIS-treated patients, with cefotaxime, ceftazidime, and piperacillin being the most common agents compared with all of the GUIDE patients who received an imipenem-cilastin-based regimen. Vancomycin use was similar in both groups. The GUIDE patients had a higher percentage of adequately treated patients (81% vs 46%, respectively; p < 0.01) with a lower mortality rate at 14 days (8% vs 23%, respectively; p 0.03). A lower mortality rate was also noted at the end of 30 days and the end of hospitalization but was not statistically significant. Appropriate imipenem use (as defined by the guidelines) occurred in 74% of the cases, and there was no increase in the number of imipenem-resistant organisms isolated during the course of the study.

Conclusions

These guidelines represent a successful implementation of a “deescalation” approach, because the recommended empiric therapy with broad-spectrum antibiotics was switched to therapy with narrower spectrum agents after 3 days. Based on our experience, this approach improves the adequacy of antibiotic treatment, with improvement in short-term survival and without increasing the emergence of resistant organisms

PDF

https://journal.publications.chestnet.org/data/Journals/CHEST/22032/2778.pdf

February 12, 2013 at 8:21 pm

Acute Respiratory Failure in Patients with Severe Community-acquired Pneumonia

Am. J. Respir. Crit. Care Med. Nov. 1999  V.160 N.S 1585-1591

A Prospective Randomized Evaluation of Noninvasive Ventilation

MARCO CONFALONIERI, ALFREDO POTENA, GIORGIO CARBONE, ROSSANA DELLA PORTA,

ELIZABETH A. TOLLEY, and G. UMBERTO MEDURI

Unità Operativa di Pneumologia, Ospedale Civile di Piacenza, Piacenza, Italy; Unità di Terapia Intensiva Respiratoria, Divisione di Fisiopatologia Respiratoria, Arcispedale S. Anna, Ferrara, Italy; Medicina d’Urgenza, Ospedale Gradenigo, Torino, Italy; Unità di Terapia Intensiva Respiratoria, Ospedale Maggiore di Crema, Crema, Italy; and Memphis Lung Research Program, Department of Medicine, Pulmonary and Critical Care Division, University of Tennessee, Memphis, Tennessee

In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p 5 0.03), and duration of intensive care unit (ICU) stay (1.8 6 0.7 d versus 6 6 1.8 d; p 5 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p 5 0.04) and improved 2-mo survival (88.9% versus 37.5%; p 5 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD. Confalonieri M, Potena A, Carbone G, Della Porta R, Tolley EA, Meduri GU. Acute respiratory failure in patients with severe community-acquired pneumonia: a prospective randomized evaluation of noninvasive ventilation.

PDF

http://ajrccm.atsjournals.org/content/160/5/1585.full.pdf+html

February 12, 2013 at 8:19 pm


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