Cher(e)s ami(e)s


A l'occasion de cette nouvelle année, notre groupe progresse.

l'application e-rhea est finie!!!et doit être lancée dans des sites pilotes dès la semaine prochaine pour une extension progressive à tous les centres

les caractéristiques de l'application sont révolutionnaires et nous permettent non seulement de saisir les données pour la base de données communes mais aussi de:
- créer un recueil des données par centre
- générer de nouvelles données à saisir et les implémenter automatiquement dans tous les centres
- adosser des essais randomisés de facon très aisés ouverts à ceux qui souhaite y participer
- permettent des saisies locales de pages spécifiques

et tout cela avec des options maximales de sécurité acceptée par la CNIL.

par ailleurs l'association OUTCOMEREA ouvre un nouveau centre de traitement des données à l'intérieur de l'UMR 1137 université Paris Diderot Inserm (equipe 5: DeSCID: decision science in Infectious Diseases) ou de nouveaux étudiants de licence, master, thèse pourront être dirigés par
ceux d'entre nous qui possède une Hdr.

enfin, l'activité de recherche se poursuit:

voici quelques uns des papiers recemment publiés

Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance. Adrie C, Schwebel C, Garrouste-Orgeas M, Vignoud L, Planquette B, Azoulay E, Kallel H, Darmon M, Souweine B, Dinh-Xuan AT, Jamali S, Zahar JR, Timsit JF; This article was written on behalf of the Outcomerea Study Group. Crit Care. 2013 Nov 7;17(6):R265. [Epub ahead of print]

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events. Zahar JR, Garrouste-Orgeas M, Vesin A, Schwebel C, Bonadona A, Philippart F, Ara-Somohano C, Misset B, Timsit JF. Intensive Care Med. 2013 Dec;39(12):2153-60. doi: 10.1007/s00134-013-3071-0. Epub 2013 Aug 31.


Safety of intrahospital transport in ventilated critically ill patients: a multicenter cohort study*.
Schwebel C, Clec'h C, Magne S, Minet C, Garrouste-Orgeas M, Bonadona A, Dumenil AS, Jamali S, Kallel H, Goldgran-Toledano D, Marcotte G, Azoulay E, Darmon M, Ruckly S, Souweine B, Timsit JF; OUTCOMEREA Study Group. Crit Care Med. 2013 Aug;41(8):1919-28. doi: 10.1097/CCM.0b013e31828a3bbd.

Pseudomonas aeruginosa ventilator-associated pneumonia. predictive factors of treatment failure.
Planquette B, Timsit JF, Misset BY, Schwebel C, Azoulay E, Adrie C, Vesin A, Jamali S, Zahar JR, Allaouchiche B, Souweine B, Darmon M, Dumenil AS, Goldgran-Toledano D, Mourvillier BH, Bédos JP; OUTCOMEREA Study Group. Am J Respir Crit Care Med. 2013 Jul 1;188(1):69-76. doi: 10.1164/rccm.201210-1897OC.

, d'autres sont acceptés (correction des dysnatrémies: Darmon et al Shock 2014) ou très avancés dans le processus éditorial....

je vous (nous) souhaite à tous une excellente année 2014 et des lendemains qui chantent!!!

amicalement

Jean-Francois

Crit Care. 2013 Nov 7;17(6):R265. [Epub ahead of print]

Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance.

INTRODUCTION:Several guidelines recommend initial empirical treatment with two antibiotics instead of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit (ICU) admission. We compared the impact on 60-day mortality of using one or two antibiotics. We also compared the rates of nosocomial pneumonia and multidrug-resistant bacteria.

METHODS:This is an observational cohort study of 956 immunocompetent patients with CAP admitted to ICUs in France and entered into a prospective database between 1997 and 2010.Patients with chronic obstructive pulmonary disease were excluded. Multivariate analysis adjusted for disease severity, gender, and co-morbidities was used to compare the impact on 60-day mortality of receiving adequate initial antibiotics and of receiving one versus two initial antibiotics.

RESULTS:Initial adequate antibiotic therapy was significantly associated with better survival (subdistribution hazard ratio (sHR), 0.63; 95% confidence interval (95% CI), 0.42 to 0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95% CI, 0.005 to 0.46; p = 0.001) or septic shock (sHR: 0.62; 95% CI 0.38 to 1.00; p = 0.05). Dual therapy was associated with a higher frequency of initial adequate antibiotic therapy. However, no difference in 60-day mortality was found between monotherapy (β-lactam) and either of the two dual-therapy groups (β-lactam plus macrolide or fluoroquinolone). The rates of nosocomial pneumonia and multidrug-resistant bacteria were not significantly different across these three groups.

CONCLUSIONS:Initial adequate antibiotic therapy markedly decreased 60-day mortality. Dual therapy improved the likelihood of initial adequate therapy but did not predict decreased 60-day mortality. Dual therapy did not increase the risk of nosocomial pneumonia or multidrug-resistant bacteria.

Am J Respir Crit Care Med. 2013 Jul 1;188(1):69-76. doi: 10.1164/rccm.201210-1897OC.

Pseudomonas aeruginosa ventilator-associated pneumonia. predictive factors of treatment failure.

RATIONALE:The predictive factors of treatment failure for ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa (PA) remain uncertain.OBJECTIVES:To describe PA-VAP recurrence prognosis and to identify associated risk factors in a large cohort of intensive care unit patients with PA-VAP.METHODS:From the multicenter OUTCOMEREA database (1997-2011), PA-VAP onset and recurrence were recorded. All suspected cases of VAP were confirmed by a positive quantitative culture of a respiratory sample. Multidrug-resistant PA strains were defined by the resistance to two antibiotics among piperacillin, ceftazidime, imipenem, colistine, and fluoroquinolones (FQ). An extensively resistant PA was defined by resistance to piperacillin, ceftazidime, imipenem, and FQ. A treatment failure was defined as a PA-VAP recurrence or by the death occurrence.MEASUREMENTS AND MAIN RESULTS:A total of 314 patients presented 393 PA-VAP. Failure occurred for 112 of them, including 79 recurrences. Susceptible, multidrug resistant, and extensively resistant PA represented 53.7%, 32%, and 14.3% of the samples, respectively. Factors associated with treatment failure were age (P = 0.02); presence of at least one chronic illness (P = 0.02); limitation of life support (P = 0.0004); a high Sepsis-Related Organ Failure Assessment score (P < 0.0001); PA bacteremia (P = 0.003); and previous use of FQ before the first PA-VAP (P = 0.0007). The failure risk was not influenced by the strain resistance profile or by the biantibiotic treatment, but decreased in case of VAP treatment that includes FQ (subdistribution hazard ratio, 0.5 [0.3-0.7]; P = 0.0006). However, the strain resistance profile slowed down the intensive care unit discharge hazard (subdistribution hazard ratio, 0.6 [0.4-1.0]; P = 0.048).CONCLUSIONS:Neither resistance profile nor biantibiotic therapy decreased the risk of PA-VAP treatment failure. However, the profile of PA resistance prolonged the length of stay. Better evaluation of the potential benefit of an initial treatment containing FQ requires further randomized trials.

Crit Care Med. 2013 Aug;41(8):1919-28. doi: 10.1097/CCM.0b013e31828a3bbd.

Safety of intrahospital transport in ventilated critically ill patients: a multicenter cohort study*.

OBJECTIVES:To describe intrahospital transport complications in critically ill patients receiving invasive mechanical ventilation.DESIGN:Prospective multicenter cohort study.SETTING:Twelve French ICUs belonging to the OUTCOMEREA study group.PATIENTS:Patients older than or equal to 18 years old admitted in the ICU and requiring invasive mechanical ventilation between April 2000 and November 2010 were included.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Six thousand two hundred forty-two patients on invasive mechanical ventilation were identified in the OUTCOMEREA database. The statistical analysis included a description of demographic and clinical characteristics of the cohort, identification of risk factors for intrahospital transport and construction of an intrahospital transport propensity score, and an exposed/unexposed study to compare complication of intrahospital transport (excluding transport to the operating room) after adjustment on the propensity score, length of stay, and confounding factors on the day before intrahospital transport. Three thousand and six intrahospital transports occurred in 1,782 patients (28.6%) (1-17 intrahospital transports/patient). Transported patients had higher admission Simplified Acute Physiology Score II values (median [interquartile range], 51 [39-65] vs 46 [33-62], p < 10) and longer ICU stay lengths (12 [6-23] vs 5 [3-11] d, p < 10). Post-intrahospital transport complications were recorded in 621 patients (37.4%). We matched 1,659 intrahospital transport patients to 3,344 nonintrahospital transport patients according to the intrahospital transport propensity score and previous ICU stay length. After adjustment, intrahospital transport patients were at higher risk for various complications (odds ratio = 1.9; 95% CI, 1.7-2.2; p < 10), including pneumothorax, atelectasis, ventilator-associated pneumonia, hypoglycemia, hyperglycemia, and hypernatremia. Intrahospital transport was associated with a longer ICU length of stay but had no significant impact on mortality.CONCLUSIONS:Intrahospital transport increases the risk of complications in ventilated critically ill patients. Continuous quality improvement programs should include specific procedures to minimize intrahospital transport-related risks.

Crit Care. 2012 Dec 19;16(6):R236. [Epub ahead of print]

Efficacy of renal replacement therapy in critically ill patients: a propensity analysis.

INTRODUCTION: Although renal replacement therapy (RRT) is a common procedure in critically ill patients with acute kidney injury (AKI), its efficacy remains uncertain. Patients who receive RRT usually have higher mortality rates than those who do not. However, many differences exist in severity patterns between patients with and those without RRT and available results are further confounded by treatment selection bias since no consensus on indications for RRT has been reached so far. Our aim was to account for these biases to accurately assess RRT efficacy, with special attention to RRT timing.METHODS:We performed a propensity analysis using data of the French longitudinal prospective multicenter Outcomerea database. Two propensity scores for RRT were built to match patients who received RRT to controls who did not despite having a close probability of receiving the procedure. AKI was defined according to RIFLE criteria. The association between RRT and hospital mortality was examined through multivariate conditional logistic regression analyses to control for residual confounding. Sensitivity analyses were conducted to examine the impact of RRT timing.RESULTS:Among the 2846 study patients, 545 (19%) received RRT. Crude mortality rates were higher in patients with than in those without RRT (38% vs 17.5%, P < 0.001). After matching and adjustment, RRT was not associated with a reduced hospital mortality. The two propensity models yielded concordant results.CONCLUSIONS:In our study population, RRT failed to reduce hospital mortality. This result emphasizes the need for randomized studies comparing RRT to conservative management in selected ICU patients, with special focus on RRT timing.