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Proceedings of Réanimation 2017, the French Intensive Care Society International Congress

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Annals of Intensive Care20177 (Suppl 1) :7

https://doi.org/10.1186/s13613-016-0224-7

  • Published:

.

.

P144 Post traumatic cerebral thrombophlebitis: prospective study about 15 cases

Chtara Kamilia1, Kais Regaieg2, Olfa Turki1, Najeh Baccouch2, Hedi Chelly1, Mabrouk Bahloul1, Mounir Bouaziz1
1Réanimation polyvalente, Faculté de médecine de Sfax, Sfax, Tunisia; 2Réanimation polyvalente, CHU Habib Bourguiba, Sfax, Tunisia
Correspondence: Chtara Kamilia - kamilia.chtaraelaoud@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P144

Introduction Head injury is a rare but possible etiology of cerebral thrombophlebitis. The diagnosis should be considered especially in front of open head injuries extended to venous sinuses. The MR angiography is the gold standard for early diagnosis.

Patients and methods This is a descriptive prospective study of all trauma patients hospitalized in the intensive care unit of the University Hospital Habib Bourguiba Sfax over a period of 6 years between January 2010 and June 2016 and in whom the diagnosis of cerebral venous thrombophlebitis has been confirmed by angiography CT or MR angiography.

Results During the period study, 15 patients were included. The median age of patients was 29 [17–49] years. All patients were male, victims of poly trauma following an accident of traffic. In admission, SAPSII was 31 [24–52] and SOFA was 4 [2–8]. We have noted the presence of a serious head injury in 15 patients, extended open skull fractures of the venous sinus in 9 patients. A related chest trauma was present in 12 patients and abdominal trauma in 4 patients, trauma of the pelvis and/or members were present in 7 patients. All patients underwent mechanical ventilation. The diagnosis of cerebral venous thrombosis was confirmed by cerebral angiography CT in 9 patients and cerebral MR angiography in 6 patients. 7 patients have presented secondary pulmonary embolism. All patients did not show a contraindication against anticoagulation at diagnosis of thrombophlebitis. The thrombophilia (antithrombin III, protein C and S, homocysteine, and antiphospholipid, gene mutation factors II and V) as well as for anti-neutrophil cytoplasmic antibodies were negative in all patients. The outcome was favorable in 13 patients. Two patients were died due to a state of refractory septic shock.

Discussion Post traumatic cerebral thrombophlebitis is a rare thrombotic vascular disease. It must be mentioned especially with presence of extensive skull fractures in open sinuses. Venous MR angiography is the gold standard. The treatment is based on anticoagulation curative dose. Its prescription can be complicated in these cases associated with traumatic intracranial hemorrhage.

Conclusion Head injury is a rare but possible etiology of cerebral thrombophlebitis. Other prospective studies are needed to better understand the path physiology and the prognosis of these thromboses.

Competing interests None.

P145 Pain measurement in mechanically ventilated patients with traumatic brain injury: behavioral pain tools versus analgesia/nociception index—preliminary results

Ali Jendoubi1, Ahmed Abbes,1, Houda Belhaouane,1, Oussama Nasri,1, Layla Jenzri,1, Salma Ghedira2, Mohamed Houissa2
1Anesthesia and Intensive Care, Charles Nicolle Teaching Hospital, Tunis, Tunisia; 2 Intensive care, Charles Nicolle Hospital, Tunis, Tunisia
Correspondence: Ali Jendoubi - jendoubi_ali@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P145

Introduction Pain is highly prevalent in critically ill trauma patients especially those with a traumatic brain injury (TBI). Behavioral pain tools such as the Behavioral pain scale (BPS), and critical care pain observation tool (CPOT) are recommended for sedated non-communicative patients. The analgesia nociception index (ANI) assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The primary aim is to evaluate the effectiveness of ANI in detecting pain in TBI patients. The secondary aim was to evaluate the impact of Norepinephrine use on ANI effectiveness, and to determine the correlation between ANI and BPS.

Patients and methods We performed a prospective observational study in 21 deeply sedated TBI patients. Exclusion criteria were non-sinus cardiac rhythm; presence of pacemaker; atropine or isoprenaline treatment; neuromuscular blocking agents and major cognitive impairment. HR, blood pressure and ANI were continuously recorded using the Physiodoloris® device at rest (T1), during (T2) and after the end (T3) of the painful stimulus (tracheal suctioning).

Results In total, 100 observations were scored. Patients’ characteristics were resumed in Fig. 1. ANI was significantly lower at T2 (Med (min–max) 54.5 (22–100)) compared with T1 (90.5 (50–100), p < 0.0001) and T3 (82 (36–100), p < 0.0001). Similar results were found in the subgroups of patients with (65 measurements) or without (35) Norepinephrine. During procedure, A negative linear relationship was observed between ANI and BPS (r2 = −0.469, p < 0.001). At the threshold of 50, the sensitivity and specificity of ANI to detect patients with BPS ≥ 5 were 73 and 62%, respectively with a negative predictive value of 86%.
Fig. 1
Fig. 1

Baseline demographic and clinical characteristics. Values are expressed as mean ± standard deviation (SD); n (%) or median [interquartile range]. EDH extradural haemorrhage SDH subdural haemorrhage, SAH subarachnoid hemorrhage

Discussion

Conclusion ANI is effective in detecting pain in deeply sedated critically ill TBI patients, including those patients treated with Norepinephrine.

Competing interests None.

P146 The prognosis of cervical spine trauma in elderly subjects in surgical intensive care

Kamal Belkadi1, Ma Bouhouri2, Youness Harti3, Afak Nsiri2, Khalid Khaleq4, Driss Hamoudi2, Rachid Harrar2
1Anesthesie reanimation, chu ibn rochd, Casablanca, Morocco; 2Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco; 3Anesthésie réanimation, CHU Ibn Rochd Casa, Casablanca, Morocco; 4Service d’accueil des urgences, Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Kamal Belkadi - kamal.belkadi@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P146

Introduction The aim of our study was to assess the prognostic factors of cervical spine trauma in elderly subjects admitted in the surgical intensive care unit.

Patients and methods We conducted a retrospective, and single-center study over 16 years (January 2000–January 2016) in Ibn Rochd hospital, we included all patients aged over 65 years with isolated cervical spine trauma, operated and non-operated, admitted in surgical intensive care, the death risk factors were searched by uni and multivariate analysis.

Results 198 patients were collected, the average age was 69.4 ± 3.9 years, with a male predominance 70.2%, the main causes were road accidents (50.5%) and fall (34.3%), 68.2% had a complete form (Frankel A), 75.7% were operated. The death rate in our study was 55%. The prognostic factors in univariate analysis were: hypertension, heart disease, fall injury, surgical delay >10 h; independent factors of death in multivariate analysis: heart disease and fall injury.

Conclusion The cervical spine trauma in elderly patients hospitalized in intensive care unit is poor prognosis.

Competing interests None.

P147 Interest of the urine antigen testing for Legionella pneumophila in the management of severe acute pneumonia: practice survey and analysis of performance in intensive care unit

Camille Thieffry1, Frédéric Wallet2, Erika Parmentier-Decrucq1, Raphaël Favory1, Daniel Mathieu1, Julien Poissy1
1Pôle de réanimation, hôpital salengro, C.H.R.U. - Lille, Avenue Oscar Lambret, Lille, France, Lille, France; 2 Centre de biologie pathologie génétique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
Correspondence: Julien Poissy - julien_poissy@hotmail.fr

Annals of Intensive Care 2017, 7(Suppl 1):P147

Introduction Legionnaire’s disease is a rare but severe acute pneumonia with a difficult definitive diagnosis. Legionella’s urine antigen testing is a quick, sensitive and specific test, widely prescribed in the case of an acute and severe community-acquired pneumonia. However, its overall contribution to the diagnosis of atypical pneumonia remains unknown in daily practice. The aims of this study were to evaluate the usefulness of this test in a “real life” utilization and to identify potential clinical markers of legionnaire’s disease in order to optimize its prescription. Legionnaire’s disease is a rare but severe acute pneumonia with a difficult definitive diagnosis. Legionella’s urine antigen testing is a quick, sensitive and specific test, widely prescribed in the case of an acute and severe community-acquired pneumonia. However, its overall contribution to the diagnosis of atypical pneumonia remains unknown in daily practice. The aims of this study were to evaluate the usefulness of this test in a “real life” utilization and to identify potential clinical markers of legionnaire’s disease in order to optimize its prescription.

Patients and methods We conducted a retrospective, monocentric and observational study. All the prescriptions of the urine antigen testing where monitored in the intensive care department and the emergency room admitting severe patients, in our University Teaching Hospital, from January 1st 2013 to December 31st 2015. Qualitative variables were compared by a Fischer’s exact test, and quantitative variables by a Mann–Whitney test. All tests were bilateral, and p ≤ 0.05 was considered as significant. ROC curves were determined for the variables of interest.

Results During the period of the survey, 1142 urinary tests were performed in 1002 patients. Three tests were positive for 0.26% of patients. Only 569 patients suffered from an actual pneumonia. Other patients suffered mostly from acute bronchitis (137 cases), and exacerbation of chronic obstructive pulmonary disease (123 cases). The characteristics of the 3 patients suffering from legionnaire’s disease differed significantly compared to the other kinds of acute pneumonia for: the need for invasive mechanical ventilation (100 vs 34.96% of patients; p = 0.043), PaO2/FiO2 ratio (107.5 vs 274.5; p = 0.0107), duration of mechanical ventilation (27.5 vs 2.5 days; p = 0.0062), natremia (129.5 vs 138 mmol/l; p = 0.0125), Creatine Phospho-Kinase level (16,125 vs 106UI; p = 0.0225) and Serum Glutamat Oxalacetat Transaminase (251 vs 35UI; p = 0.0157). We determined ROC curves for these last biological variables. Natremia: better threshold = 131, Se/Sp = 100/84.2%, AUC = 0.92. SGOT: better threshold = 191, Se/Sp = 100/89.6%, AUC = 0.9. CPK: better threshold 195, Se/Sp = 100/66.5, AUC = 0.88.

Discussion Urine antigen testing for Legionnaire’s disease appears to be over-prescribed in many cases with a very poor level of positivity in our cohort. However, it could be limited to patients exhibiting a pneumonia, and among them to patients with the classical biological perturbations described in this disease, which have excellent diagnostic performance. This targeted strategy would present an important benefit in term of costs.

Conclusion Our results show that a better selection in the patients who could benefit of this test is mandatory. Simples markers in routine testings could help the clinician to adapt his prescription, optimizing this test’s efficiency.

Competing interests None.

P148 Staphylococcal community-acquired urinary tract infection in the emergency department: a sign for acute infective endocarditis?

Thomas Lafon1, Philippe Vignon2, Emmanuelle Begot2, Alexandra Appert3, Mathilde Hadj3, Paul Claverie3, Morgan Matt4, Olivier Barraud5, Bruno François6
1Inserm cic 1435/urgences/samu, Centre Hospitalier Universitaire de Limoges, Limoges, France; 2Service de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges, Limoges, France; 3Urgences/samu, Centre Hospitalier Universitaire de Limoges, Limoges, France; 4Service de maladies infectieuses, Centre Hospitalier Universitaire de Limoges, Limoges, France; 5Bactériologie-virologie-hygiène/umr-s 1092, Centre Hospitalier Universitaire de Limoges, Limoges, France; 6Inserm cic1435/service de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges, Limoges, France
Correspondence: Thomas Lafon - thomas.lafon@chu-limoges.fr

Annals of Intensive Care 2017, 7(Suppl 1):P148

Introduction Urinary tract infection is a frequent cause of admission at the Emergency Department (ED). Most prevalent bacteria are usually gram-negative bacilli and Staphylococcus aureus (Sa) is rarely evidenced (2.5%) except in hospital-acquired infections due to urinary catheter [1]. Bacteriuria can be observed in Sa infective endocarditis (IE) because of the metastatic properties of Sa. We hypothesized that presence of Sa in the urine could be related to Staphylococcal bacteremia associated with unsuspected IE and not only the expression of a “usual” urinary tract infection.

Patients and methods This is a descriptive single-center study conducted over a 10 year-period in the Teaching Hospital of Limoges. All patients admitted to the ED with Sa (both MSSA and MRSA) isolated from their urine cultures were retrospectively analyzed. Data were collected from the database of the microbiology department and the patient medical charts. We secondarily searched if a Sa IE had been documented in patients with Sa isolated from their blood cultures in order to establish a link between IE and presence of Sa in the urine. We used modified Dukes criteria as diagnostic criteria of IE [2].

Results Between 2005 and 2015, 420,000 patients were admitted in the ED. Out of the 204 records analyzed, 174 patients whose urine culture grew Sa were excluded because they had a urinary catheter (n = 75) or sterile blood cultures (n = 99). Finally, 30 patients were studied (17 men; median age: 73 years; diabetes: n = 7; mitral valvular disease: n = 2, aortic valvular disease: n = 2) (Table 1). Reasons for admission were markedly heterogeneous and fever accounted for 14 cases. Echocardiography was performed in 25 patients with a median delay of 6.5 days (range: 0–23 days) and IE was confirmed in 21 of them. Only three cases of IE have been diagnosed in the ED because of a fever and valvular murmur (n = 2) but no patient was admitted to the ED for IE suspicion. Other initially suspected diagnoses were prostatitis, pneumonia or appendicitis and not related to any type of infection in 26% of the cases. The origin of Sa bacteremia was cutaneous in 67% of the cases. During the hospital stay, 70% of the patients presented secondary sites of Sa infection in addition to the urinary tract (arthritis, splenic abcess, cerebral hematoma). Among 21 patients presenting with an IE, 8 died within 7 days, and total hospital mortality reached 50%.
Table 1

Patients characteristics

Characteristics

n (%)

Median age (year)

63

Heart murmur

5 (24)

Congenital heart valve defect

19 (90)

Mitral localization

19 (90)

Abuse (drug, alcohol…)

4 (19)

Microbiology

 

 MSSA

20 (95)

 MRSA

1 (5)

Origin

 

 Skin

14 (67)

 Unknown

7 (33)

Complications

 

 Central nervous system

9 (43)

 Visceral abscesses

2 (9.5)

 Septic arthritis

9 (43)

 Skin and eye petechiae

9 (43)

Death

8 (38)

Conclusion This case series suggests that IE should be ruled out when Sa bacteriuria is evidenced, irrespective of the clinical presentation. This could question the reality of isolated community-acquired urinary tract infections due to Sa.

Competing interests None.

References
  1. 1.

    Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis Off Publ Infect Dis Soc Am. 2000;30(4):633–8.

     
  2. 2.

    Ekkelenkamp MB, Verhoef J, Bonten MJ. Quantifying the relationship between Staphylococcus aureus bacteremia and S. aureus bacteriuria: a retrospective analysis in a tertiary care hospital. Clin Infect Dis Off Publ Infect Dis Soc Am. 2007;44(11):1457–9.

     

P149 The infectious tricuspid endocarditis in ICU: clinical features, management and outcome

Amira Jamoussi1, Amira Ben Jazia1, Takoua Marhbène1, Dhouha Lakhdhar1, Jalila Ben Khelil1, Mohamed Besbes1
1Medical icu, Hospital Abderrahmen Mami De Pneumo-Phtisiologie, Ariana, Tunisia
Correspondence: Amira Jamoussi - dr.amira.jamoussi@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P149

Introduction Since the outbreak scourge of intravenous drug addiction in Tunisia, we are witnessing the emergence of cases of infectious tricuspid endocarditis (ITE). This pathology should be studied because it requires specific medical and surgical management. The aim of the study was to describe the clinical features, management and outcome of ITE in intensive care unit.

Patients and methods This was a retrospective study from January 2009 to December 2014. We enrolled patients who were hospitalized in intensive care unit and had ITE. We recorded baseline characteristics, management and outcome.

Results During the study period, we collected 10 cases of ITE making an incidence rate of 3 cases for 1000 patient admissions. They were divided into 8 men and 2 women. The median age was of 37.5 years. The main reasons of ICU admission was acute respiratory failure (80%), among them 5 required mechanical ventilation. Hemodynamic failure was present in 3 cases.

The median SAPS II was of 33 [19–90]. The median APACHE II was of 17 [7–53]. Different contributing factors were identified: intravenous drug abuse (6 patients), a central venous catheter (1 patient) and a pacemaker (1 patient).

All patients underwent transesophageal echocardiography showing one or several vegetations on native tricuspid valve. No associated left endocarditis was found.

Blood cultures were positive in 8 cases of which 5 contained 2 different micro-organisms. The identified micro-organisms were: Meticillin Resistant Staphylococcus aureus (n = 6), Meticillin Sensitive Staphylococcus aureus (n = 3), coagulase-negative staphylococcus (n = 2), Enterobacter cloacae (n = 1), and candida famata (n = 1). Occurring complications were hospital-acquired infections (n = 5), septic pulmonary embolism (n = 4), withdrawal syndrome (5 cases), acute renal failure (n = 2) and atrioventricular block (n = 2).

Medical treatment consisted of a double antibiotic treatment. Surgical treatment was required in 7 patients: tricuspid valve replacement by bioprosthesis (6 cases) and valvuloplasty (1 case).

The average length of stay was of 31.3 days [2–56]. ITE had recurred on bioprotheses in two patients after intravenous drug resumption; they underwent surgery again and one of them died.

In hospital mortality was of 30%. The outcome was favorable in 7 patients.

Conclusion The ITE in ICU is a severe disease with frequent complications and in hospital mortality reaches 30%. The most frequent incriminated micro-organism is Meticillin Resistant Staphylococcus aureus. It often requires medical and surgical treatment. Intravenous drug addiction remains the most common cause and worsens the prognosis by the risk of recurrence.

Competing interests None.

P150 Microbiological mapping of community-acquired intra-abdominal infections (IAI) and indicator of local antibiotherapy appropriateness with French national guidelines

Julien Goutay1, Caroline Blazejewski2, Isabelle Joly-Durand3, Isabelle Pirlet4, Marie Pierre Weillaert5, Sebastien Beague2
1Interne en anesthésie réanimation, C.H. Régional Universitaire de Lille (CHRU de Lille), Lille, France; 2Réanimation polyvalente, Hospital Center De Dunkerque, Dunkerque, France; 3Equipe opérationnelle d’hygiene, Hospital Center De Dunkerque, Dunkerque, France; 4Service de chirurgie digestive, Hospital Center De Dunkerque, Dunkerque, France; 5Laboratoire, Hospital Center De Dunkerque, Dunkerque, France
Correspondence: Julien Goutay - julien.goutay@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P150

Introduction French guidelines for community-acquired IAI underline the importance of establishing antibiotherapy protocols based on regular analysis of microbiological data; and of systematic site infection cultures to determine microbial sensitivity to antibiotics. Our study describes microbial population involved in our community-acquired IAI and defines an annual follow-up indicator of probabilistic antibiotherapy inadequacy to microbial sensitivity.

Materials and methods We conducted a retrospective, monocentric, observational study from January the 1st 2014 to December the 31st 2015. All community-acquired IAI in adults were included. Exclusion criteria were: cirrhosis and peritoneal dialysis. Initial probabilistic antibiotherapy and total antibiotherapy duration were left to the discretion of the physician in charge. Results of intra-abdominal cultures (IAC) were analyzed. Three microbial groups were defined: (A) A-group: wild-type bacteria strains treated with adequat antibiotherapy; (B) B-group: antibiotic resistant bacteria treated with adequat antibiotherapy; (C) C-group: multi-drug resistant bacteria treated with inadequat antibiotherapy. A Chi square analysis was performed on SPSS software (IBM).

Results 98 community-acquired IAI were included: 54 (55%) had positive IAC with 133 bacteria; 34 (35%) didn’t have intra-abdominal swab; 10 (10%) had sterile cultures. Predominant strains were Gram-negative bacteria (76/133 (57%)). More represented bacteria were Escherichia Coli (50/133 (38%)) and Bacteroïdes fragilis (16/133 (12%)). 127/133 (95%) bacteria belong to A- and B-groups. B-group importance increased significantly between 2015 and 2016. C-group characteristics were comparable over the 2 years. Initial antibiotherapy was inadequate with French guidelines in 38/98 (39%) cases and with microbial antibiotic susceptibility in 6/133 (4.5%) cases (C-group). Average antibiotherapy duration was 11.3 days. Antibiotic treatment duration was too long according to French guidelines for 65/98 (67%) patients.

Discussion Our microbial population in community-acquired IAI is similar to national studies with a lowest resistance rate (C-group under 10%). Probabilistic antibiotherapy proposed by French guidelines is appropriated to our microbial ecology. Antibiotherapy duration is unconformed with guidelines in 67% cases. Peroperative swabs are frequently missing (35%). Non-compliance with French guidelines highlights the importance to formalize our local procedure. This formalization at any stage (surgical, medical and biological cares) seems essential to improve our standard of care. C-group rate could be used as a real-time feedback to adapt our protocol continuously.

Conclusion The goal of our study is to improve local standard of care by offering a formalization of community-acquired IAI management procedure. C-group rate seems to be a good follow-up indicator of probabilistic antibiotherapy inadequacy to microbial sensitivity, allowing an optimization of our protocol in real-time.

Competing interests None.

Reference
  1. 1.

    Montravers et al. Recommandations Formalisées d’Experts «Prise en charge des infections intra-abdominales», Octobre 2015.

     

P151 The resumption of peritonitis in surgical intensive care unit

Ma Bouhouri1, Kamal Belkadi2, Soufi Aziz1, Khalid Khaleq3, Afak Nsiri1, Driss Hamoudi1, Rachid Harrar1
1Reanimation des urgences chirurgicale, chu ibn rochd, Casablanca, Morocco; 2Anesthesie reanimation, chu ibn rochd, Casablanca, Morocco; 3Service d’accueil des urgences, Chu Ibn Rochd, Casablanca, Morocco
Correspondence: Kamal Belkadi - kamal.belkadi@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P151

Introduction The resumption of peritonitis is a serious complication of abdominal and pelvic surgery. It’s a medical and surgical emergency, the prognosis depends on the speed, the quality of the care, and the underlying terrain and etiology.

Patients and methods We conducted a descriptive analytic retrospective study over a period of 5 years (January 2011–June 2016) 60 cases of peritonitis hospitalized in surgical intensive care unit.

Results The average age of our patients was 44.36 years with a sex ratio of 1.5 (36H/24F). The most frequent risk factors were: factors relating to the ground, and factors related to the initial peritonitis.

Clinical signs were dominated by fever (75%), abdominal pain (52%). The period of the average recovery was 8.2 days. The decision of the surgical revision was based on a clinical, biological and radiological criteria.

40 patients in our series, 67% of cases were taken on clinical and biological criteria while 15 patients 25% were taken on radiological criteria. In 8% of the remaining cases, the potential severity of the clinical and biological state in association with an inconclusive ultrasound, led to reoperation.

The therapeutic treatment was based on a perioperative resuscitation, treatment of organ failure, empirical antibiotic therapy and by midline laparotomy surgery. Bacteriological samples performed intraoperatively allowed to have the following bacteriological profile: predominance of BGN (79%) dominated by E. coli (28%) followed by Klebsiella pneumoniae (21%), Acinetobacter and Enterococcus baumanii (12%). The multimicrobien character was found in 55%. The E. coliKlebsiella pneumoniae association was the most frequent (37%).

The anastomotic dehiscence was the direct cause of the most common surgical revision found intraoperative (62%). The average hospital stay was 8 days. The mortality rate was 61%. The main prognostic factors in our study emerged in the univariate analysis were: kidney failure, the number of organ failure, a TP <50% the needs of ventilation and the use of catecholamines.

Discussion Mortality is variable depending on the studies, between 25 and 60%.

Conclusion The diagnosis often difficult. Only effective and early therapeutic management reduces mortality remains high in recent years despite the various advances in the field of surgery and reanimation.

Competing interests None.

P152 Prognostic factors in intra abdominal sepsis: a prospective study

Reda Hafiane1, Khalid Khaleq1, Khalid Hattabi2, Mohamed Aziz Bouhouri1, Afak Nsiri1, Driss Hammoudi1, Abdelaziz Fadil2, Rachid Al Harrar1
1Service de réanimation des urgences chirurgicales, CHU IBN ROCHD de Casablanca, casablanca, Morocco; 2Service des urgences viscérales, CHU Ibn Rochd de casablanca, Casablanca, Morocco
Correspondence: Reda Hafiane - hafiane.reda89@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P152

Introduction Intra- abdominal sepsis represents a life threatening condition. Its manifestations are non specific and can quickly lead to multi organ failure if not treated correctly. Patient’s assessment is essential in order to adjust the therapy. The aim of our study is to highlight the prognostic factors in this situation.

Patients and methods It’s a prospective observational study performed during 6 months (02/2016–08/2016) in visceral emergency operating rooms.

Inclusion criteria: adults admitted with intra-abdominal infectious disease diagnosed with biological and radiological means.

Studied parameters: demographic data, co morbidities, number of organ failure, type of anesthesia, intraoperative incidents and evolution. Results were analyzed using SPSS software, prognostic factors were extracted with univariate then multivariate analysis. Significant results were noted.

Results During this period, we admitted 302 patients, the mean age: 41.14 ± 17 years. Male predominance was noticed in our population: 69.9%. The mortality rate was: 13.2%.

The main prognostic factors were reported in the attached Table 2.
Table 2

Main prognostic factors in intra abdominal sepsis

Variable

Hazard ratio unadjusted

p

Hazard ratio adjusted

p

Age

1.047

0.001

1.032

0.009

Sex

3.25

0.001

0.068

0.47

High hemoglobin

0.68

0.01

0.33

0.52

creatinine

1.11

0.001

1.16

0.001

Pesence of clammy skin

14.74

0.001

77

0.05

Urea

37.34

0.01

37

0.25

Hemodynamic instability

26

0.001

1.27

0.834

Use of vasoactive drugs

29

0.001

34

0.001

Operating time

1.018

0.0001

1.014

0.001

Discussion Many significant prognostic factors were identified: Age, existence of hemodynamic failure with renal involvement, long operative time and the use of vasoactive drugs.

A high hemoglobin level at the admission was a protective factor.

The presence of respiratory distress, the sex and the presence of yeasts were not significant factors in our study.

Conclusion Intra abdominal sepsis is causing quickly a multi organ dysfunction syndrome leading to death. Therefore, our priority is to stop this sepsis with the help of the surgeon and the efficient use of antibiotics.

Competing interests None.

P153 Community acquired intra abdominal sepsis: concerning 302 cases

Reda Hafiane1, Khalid Khaleq1, Khalid Hattabi2, Mohamed Aziz Bouhouri1, Afak Nsiri1, Driss Hammoudi1, Khalid Zerouali3, Abdelaziz Fadil2, Rachid Al Harrar1
1Service de réanimation des urgences chirurgicales, CHU IBN ROCHD de Casablanca, casablanca, Morocco; 2 Service des urgences viscérales, CHU Ibn Rochd de casablanca, Casablanca, Morocco; 3Service de microbiologie, CHU Ibn Rochd de casablanca, Casablanca, Morocco
Correspondence: Reda Hafiane - hafiane.reda89@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P153

Introduction Intra abdominal sepsis is a dangerous condition causing a high mortality rate even with surgery and post operative care improvement.

The aim of the study is to assess the bacteriological and epidemiological profile of this population.

Patients and methods It’s a prospective observational study performed during 6 months (02/2016–08/2016) in visceral emergency operating rooms.

Inclusion criteria: adults admitted with intra-abdominal infectious disease diagnosed with biological and radiological means.

Exclusion criteria: post operative peritonitis and deceased patients before their admittance.

Studied parameters: demographic data (gender, age…), the time management, co morbidities, number of organ failure, intraoperative incidents and postoperative evolution.

Results During this period, we admitted 302 patients, the mean age: 41.14 ± 17 years. Male predominance was noticed in our population: 69.9%.

Main emergencies are reported in the attached Table 3. Concerning the bacteriological profile: we had 121 positive samplings. Enterobacterias were the most frequent strain. E coli was predominant: 43%, Enterococcus faecalis: 25%, Streptococcus (viridians and acidominimus): 14%, we had 1 case of Acinetobacter baumanii resistant to imipenem. 6 cases of yeasts were found (Candida albicans).
Table 3

Main emergencies with epidemiological profile

Disease

Number (n)

Sex ratio (M/F)

Age (years)

Time management (days)

Number of organ failure (n)

APACHE II score

Number of deaths (n)

Peptic perforation peritonitis

48

47

42.5

1.54

1

10

1

Appendicitis

100

1.43

31.7

2.95

0

7

0

intestinal perforation peritonitis

18

0.63

36

5.6

3

19

6

Biliary peritonitis

10

0.43

62.2

7.2

2

16

4

Post traumatic peritonitis

6

6

25

3.1

3

15

2

Necrotizing fasciitis

28

13

55.9

20

0

12

0

Antibiotic use was: Ampicilline: 44%, Ceftriaxone 41%, metronidazole: 76% and tazocilline: 4%.

Discussion In our context, community acquired intra abdominal sepsis leads to a high death rate. We noticed relevant parameters: a late time management, high gravity scores, some surgical procedures not directed by supervisors. Therefore, we have to establish therapeutic protocols tailored to each disease in order to improve patients’ management and help to reduce the mortality rate.

Conclusion Early diagnosis and care for intra abdominal sepsis represent a major way to prevent complications. Bacteriological proof is necessary to adjust post operative antibiotherapy.

Competing interests None.

P154 Conformity of antibiotic prescribing in emergency room

Fatma Kaaniche Medhioub1, Rania Allela2, Najla Ben Algia3, Samar Cherif4
1Faculté de médecine de Sfax, Sfax, Tunisia; 2Hopital régional mahres, Faculté de médecine de Sfax, Sfax, Tunisia; 3Intensive care, hopital régional Gafsa, Sfax, Tunisia; 4Intensive care, hopital régional mahres, Sfax, Tunisia
Correspondence: Fatma Kaaniche Medhioub - fatma_kaaniche@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P154

Introduction The development of bacterial resistance is a major public health problem due to unreasonable use of antibiotics. The introduction of appropriate antibiotic therapy has a positive impact on patient survival and a significant economic impact. The objective of this study is to evaluate the compliance of antibiotics prescribed in emergencies.

Patients and methods Prospective study conducted on 1 year (01/01/2015–31/12/2015). We have included patients admitted to the emergency with hyperthermia (>38°), hypothermia (<36°) or two criteria of systemic inflammatory response syndrome. Were collected in the emergency department: history, presence of prior antibiotic therapy, demographic and clinical characteristics at admission, prescription of antibiotics in emergencies and its modalities and the discharge diagnosis. During hospitalization were collected: the introduction, modification or discontinuation of the antibiotic, the reasons for this change and certainty diagnosis. The compliance analysis of antibiotic therapy was performed by an expert group (two infectiologists, a bacteriologist and an emergency doctor) with regard to the current recommendations. Two groups were defined and compared: group of patients receiving complies antibiotic therapy and group with antibiotics considered improper. The criteria associated with non-compliance were sought.

Results Four hundred and twenty-two patients were enrolled. The final diagnosis retained an infectious etiology in 356 patients (84%). The mean age was 62.4 ± 18 years. Blood cultures were taken in 370 cases (87.7%). Infectious sites were most often lung (52%) and urine (32%). Severe sepsis was diagnosed in 14 patients (3.3%). A complies prescription was found in 335 patients (79.4%). Antibiotic therapy was started in 302 patients (71.5%) at the emergency and classified complies with 234 (55.4%). Among the 68 patients (16.1%) with an illegal antibiotic, it was continued in 24 (35.3%) during hospitalization. Among 120 patients (28.4%) did not receive antibiotics, this attitude was classified complies in 115 patients (95.8%). Non-compliance was related to the presence of antibiotics in the last 3 months and the presence of renal failure.

Conclusion Particular attention should be paid to the antibiotic prescription in patients subject to prior exposure to these. Dose adjustments should be respected in cases of renal failure. Regular evaluation of the antibiotic prescription in the emergency is necessary.

Competing interests None.

P155 Pulmonary resections’ bacterial cartography

Mohamed Taoufik Slaoui1, Souhail Boubia2, Y. Hafiani1, A. Khaoudi1, R. Cherkab1, W. Elallam1, C. Elkettani1, L. Barrou.1, M. Ridaii2
1Anesthesia service surgical resuscitation, chu ibn rochd, Casablanca, Morocco; 2 Thoracic surgery, chu ibn rochd, Casablanca, Morocco
Correspondence: Mohamed Taoufik Slaoui - dr.t.slaoui@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P155

Introduction The study of the bacterial cartography in thoracic surgery is extremely important for the treatment of post-operative infections due to the severity of the underlying pathology, the fragility of patients after surgery in addition to the choice of the empiric antibiotic therapy.

Materials and methods We led a prospective study following all the patients who underwent a pulmonary resection surgery for a period of 7 months from January to July 2016, jointly with the microbiology department, CHU Ibn Rochd, Casablanca. The bronchial secretions were collected by a protected distal bronchial sample using a (Combicath) after the intubation.

Results During the period of the study, 92 patients underwent a pulmonary resection, 65% for a neoplastic pathology.

The medium age was 43 years ±8 and 58% of our sample were male. 48% of our patients had smoking habits and 16 of them had pulmonary tuberculosis, 12 had repeated respiratory infections. The antibiotics used in pre-operative: 58% of beta-lactams; 22% of fluoroquinolones; 5% of macrolides.

Moreover, 60% of our patients were classified ASA1.

Of the 92 obtained samples, 22 were positive (23.9%). The most frequently observed germs were the Acinetobacter baumannii (8.7%), Pseudomonas aeruginosa (6.5%), Klebsiella pneumoniae (4.3%), Staphylococcus aureus (4.3%). The Acinetobacter baumannii was the most resistant germ (60% sensibility to carbapenem).

These patients were followed until their D30 after surgery, 12 of them developed a post-operative pneumonitis with 4 cases of multi-resistant Acinetobacter Baumanii, 2 of which deceased.

Conclusion Pneumonitis after pulmonary resection are common and severe that’s why it is necessary to establish a global prevention strategy mainly based on general patricians and pneumologists’ awareness concerning the choice of the prescribed antibiotics, in order to avoid the spread of multi-resistant germs.

Competing interests None.

P156 The Acinetobacter baumannii (AB) in the severe burns

Rihi El Mehdi1
1Intensive care unit, IBN ROCHD, Casablanca, Morocco
Correspondence: Rihi El Mehdi - mehdi_44@hotmail.fr

Annals of Intensive Care 2017, 7(Suppl 1):P156

Introduction Infection is a major cause of morbidity and mortality in burned. The bacterial ecology varies among centers. Despite the progress in the management of severe burned, mortality remains very high. The aim of this study is to establish the pathogenic profile of AB in this population.

Materials and methods Single-center retrospective study of 7 months, including any serious burned hospitalized for more than 48 h in intensive care, and who benefited from bacteriological samples during his stay.

Infectivity was retained on a range of clinical and biological arguments (CDC criteria) changed). They excluded all burned died for non-infectious causes, and patients with isolated settlement.

Results Sixty-two (72) patients were infected by the AB during our study period. The sex ratio (M/F) was 1.7 and the mean age was 39 ± 23 years. Nosocomial pneumonia was present in 61.11% of cases. Urinary tract infection was present in 18.05% of cases. Bacteremia was present in 12.5% of cases. Skin infection was present 8.33% of cases. The resistance profile was marked by 100% of cases of resistance to third-generation cephalosporins (C3G), 88% of cases of resistance to fluoro-quinolones (FQ), 74% of cases of resistance to imipenem and 64, 28% of cases of resistance to tigecycline.

Conclusion The incidence of infection with Acinetobacter baumannii in our unit remains high compared to that of intensive care units. Colonization and infection by the AB are significantly associated with increased length of stay, and mortality, and given the gravity of hospitalized patients, failure to comply with hygiene and abusive use of antibiotic prophylaxis.

Competing interests None.

Reference
  1. 1.

    Coignard B, Lepoutre A, Desenclos JC. Lessons learned from implementing a mandatory notification of hospital acquired infections in France [cited June 11, 2006]. Lyon, France.

     

P157 Clinical impact of extended-spectrum β-lactamase producing Enterobacteriaceae colonization on pneumonia in ICU

Caroline Schimpf1, Assaf Mizrahi2, Benoît Pilmis2, Alban Le Monnier2, Kelly Tiercelet1, Mélanie Cherin3, Cédric Bruel1, Francois Philippart1
1Réanimation, Groupe Hospitalier Paris Saint-Joseph, Paris, France; 2Unité de microbiologie clinique et dosages des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris, France; 3Réanimation polyvalente adulte, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
Correspondence: Francois Philippart - fphilippart@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P157

Introduction ESBL are enzymes mostly found in Enterobacteriaceae and confer resistance to all beta lactams antibiotics except cefoxitin and carbapenems. Recently, a significant increase in the rate of ESBL-related infections in ICU makes difficult the choice of empiric antibiotic therapy, especially in patients colonized by extended-spectrum β-lactamase producing Enterobacteriaceae (ESBLe) [1]. Notably, very few data are currently available regarding the role of ESBLe colonization on further pneumonia involving the same bacteria [2]. The aim of our study was to describe the incidence of ESBLe infections among ESBLe-colonized ICU patients.

Patients and methods This study was conducted retrospectively from January 1st 2011 to May 1st 2016, in our intensive care department. All admitted ESBLe-colonized patients who develop an infection during their ICU stay have been included in the study. The only exclusion criterion was an antibiotic treatment for an ESBLe infection at ICU admission.

Results During the period of the study, 386 stays were associated with an ESBLe colonization in 384 patients. 148 infections were diagnosed in patients colonized by ESBLe, among which 78 pneumonias. In 18 cases (23%) the ESBLe was involved in the pulmonary infection (PN-ESBLe+) and was the only responsible bacterium in 66% of cases. The ESBLe was the same in screening and pneumonia in 15 cases (83%). The PN-ESBLe+ was associated with septic shock in 9 (50%) cases, acute respiratory distress syndrome in 2 (11%) cases and neurologic failure in 7 (39%) cases. Episodes were ventilator-associated pneumonia in 56% (10 cases) of PN-ESBLe+ and 52% (31 cases) of PN-ESLBe-. The most common pathogens involved were Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae in both groups. Comparing groups (PN-ESBLe+ or PN-ESLBe−), only the notion of prior antibiotic therapy within 30 days (OR 3.9 [1.07–18.3]; p = 0.03) and colonization by ESBL Klebsiella pneumoniae (OR 4.04 [1.02–16.1]; p = 0.04) were more frequent in PN-ESBLe+. At least one empiric antibiotic was effective on the ESBLe in 83% of cases. In vitro antibiotic susceptibility tests demonstrate 100% efficiency of the association of piperacillin/tazobactam and amikacin on ESBLe involved in pneumonia.

Mortality at day 28 was 24% for PN-ESBLe+ and 44% for PN-ESBLe−. Hospital mortality was 53 and 38% respectively (p = NS).

Among 70 extra-pulmonary infections, ESLBe take part in 30 (43%) cases. The involvement of ESBLe was significantly lower in pneumonia than in other infections (p = 0.01).

Discussion Due to the single center character of our study, results cannot be extrapolated to the whole ICU population. Nevertheless, the observed incidence of colonizing ESBLe in our study is close enough from others studies. This point consolidates reflection about ICU pneumonia empiric treatment.

Conclusion The involvement of colonizing-ESBLe in ICU pneumonia is rare in our population and significantly lower than in other infections. Identified risk factors for PN-ESBLe + are a prior antibiotic therapy within 30 days and colonization with K. pneumoniae. Alternative associations to carbapenem remain efficient in all cases of pneumonia in our ICU and should probably be kept in mind.

Competing interests None.

References
  1. 1.

    Bretonniere C, Leone M, Milesi C, Allaouchiche B, Armand-Lefevre L, Baldesi O, et al. Strategies to reduce curative antibiotic therapy in intensive care units (adult and paediatric). Intensive Care Med 2015;41(7):1181–96.

     
  2. 2.

    Depuydt PO, Vandijck DM, Bekaert MA, Decruyenaere JM, Blot SI, Vogelaers DP, et al. Determinants and impact of multidrug antibiotic resistance in pathogens causing ventilator-associated-pneumonia. Crit Care 2008;12(6):R142.

     

P158 Risk factors of resistance for Gram negative bacilli responsible for ICU: acquired bacteremia—analysis of a large French ICU network

Sébastien Bailly1, Jc Lucet2, Alain Lepape3, François L’hériteau4, Martine Aupée5, Caroline Bervas6, Sandrine Boussat7, Anne Berger-Carbonne8, Anaïs Machut9, Anne Savey10, Jean-François Timsit11, REA-RAISIN Study group
1Iame team 5, INSERM UMR 1137, Paris, France; 2Hygiène hospitalière, Hôpital Bichat-Claude Bernard (AP-HP), Paris, France; 3Réanimation, Hospices Civils De Lyon, Lyon, France; 4Médecine interne, Hôpital Bichat-Claude Bernard (AP-HP), Paris, France; 5Hygiène hospitalière, C.H.U de Rennes, Rennes, France; 6Pharmacie, CHU - Hôpitaux de Bordeaux, Bordeaux, France; 7Réanimation, CHRU Nancy, Nancy, France; 8Dgos, Ministère des Affaires sociales et de la Santé, Paris, France; 9Cclin sud est, Hospices Civils De Lyon, Lyon, France; 10Cclin, Hospices Civils De Lyon, Lyon, France; 11 Réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard, Paris, France
Correspondence: Sébastien Bailly - sbailly@chu-grenoble.fr

Annals of Intensive Care 2017, 7(Suppl 1):P158

Introduction Immediate adequate treatment of ICU-acquired Gram negative bacilli (GNB) bloodstream infections (BSI) improves patients’ prognosis. Risk factors of resistance of GNB-BSIs should be better assessed.

Materials and methods Data from a large French national ICU network were explored during a 10-year period (2005–2014). Patients with a GNB-BSI were included and were divided into two groups according to the resistance (R) profile (BSI due to a R isolate or not). The following three groups were considered: (1) all GNB-BSI including Pseudomonas spp., Acinetobacter spp., Stenotrophomonas spp. and Enterobacteriacae (Eb) for which the following R were considered: ticarcillin (Pseudomonas spp., Acinetobacter spp., Stenotrophomonas spp.); ceftazidime (cefta) (P. aeruginosa (PA), Acinetobacter spp., Stenotrophomonas spp.), third generation cephalosporin (3GC) (Eb) and imipenem (all GNB, during the period 2011–2014 only), (2) PA cefta R from 2005 to 2014 and (3) Eb species resistant to 3GC from 2005 to 2014. Univariable hierarchical logistic models with two levels (random center and region effects) were used to select variables associated with resistance using a p value threshold of 0.2. Selected variables were further introduced in multivariable analyses using a hierarchical model with two random effects.

Results From 265,035 patients admitted in an annual median of 158 French ICUs, 9553 experienced an ICU-acquired (>48 h.) BSI, 5062 (53%) BSI due to GNB, including 1764 (35%) BSI due to R isolates. PA was identified in 1167 (23%) BSIs (480 (41%) R) and Eb in 3298 (65%) BSIs (1226 (34%) R). The median annual incidences of R GNB BSIs/10,000 ICU patients were: 68 for all R GNB BSI, 41 for Eb 3GC-R BSIs and 9.2 for PA cefta-R BSI. There was a significant increase of annual incidence for all GNB R and Eb 3GC-R BSI.

Independent factors associated with all R GNB BSI were: 1) ICU variables: percentage of patients with an immunosuppression other than neutropenia (7.9–14%: OR 1.23; 95% CI, [1.04–1.46]; >14%: 1.31 [1.09–1.57]); percentage of resistant GNB the previous year (55–66%: 1.87 [1.59–2.2]; >66%: 2.93 [2.43–3.53]) and 2) patient-variables: antimicrobial therapy at ICU admission (1.79 [1.55–2.08]); presence of an invasive device (CVC or intubation) (1.99 [1.25–3.16]) before infection; and one protective factor: trauma at ICU admission (0.76 [0.65–0.89]). The year effect was significant both for all R GNB and 3GC-R Eb but not for R PA. This effect was more pronounced for 3GC-R Eb, with an increase in the risk of R from 2005 to 2014 (Fig. 2). The duration from ICU admission to infection was the main risk factor of R for all BGN and sub-groups (Eb and PA): the probability of having a BSI due to a R strain increased with the time in ICU before infection (Fig. 3). ICU-based random effect remains significant indicating major impact of local epidemiology.
Fig. 2
Fig. 2

Evolution of the risk to have a BSI due to a resistant strain according to the year of ICU admission

Fig. 3
Fig. 3

Days from ICU admission to infection

Limitation The absence of information about antibiotic consumption may partly explain the remaining significant center random effect in the final models.

Conclusion The duration from ICU admission to BSI was a main risk factor for a resistant isolate in GNB BSI. Resistance rates increased over time, especially for 3GC-R Eb and were highly dependent of local previous epidemiology.

Competing interests None.

P159 Sepsis at ICU admission due to extended-spectrum β-lactamase producing enterobacteriaceae among colonized patients: prevalence, risk factors and prognosis

Keyvan Razazi1, Jérémy Rosman1, Nicolas de Prost1, Guillaume Carteaux1, Chloe Jansen2, Jean Winoc Decousser3, Christian Brun-Buisson1, Armand Mekontso Dessap1
1Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 2Cepi, Hospital Henri Mondor, Créteil, France; 3Microbiologie, Hôpital Henri Mondor, Créteil, France
Correspondence: Jérémy Rosman - jeremy.rosman@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P159

Introduction Prevalence of Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) carriers dramatically increases all over the world with a spread to the community. The increasing prevalence of ESBL-PE carriage at Intensive Care Unit (ICU) admission raises important questions on empiric therapy strategies in patients presenting with infection, which may include the use of a carbapenem as first-line therapy. Data on ESBL-PE sepsis at ICU admission among colonized patients are lacking.

Patients and methods We prospectively assessed between 2009 and 2015 the prevalence, risk factors and prognosis of ESBL-PE sepsis among ESBL-PE carriers at ICU admission. The following data were collected: demographic characteristics, which included sex, age, simplified acute physiology score (SAPS II), location before ICU admission, antibiotic exposure, surgery during the previous year, presence of underlying disease, Charlson comorbidity index, presence of indwelling devices and outcomes.

Results A total of 597 patients had ESBL-PE carriage detected at admission, corresponding to 9.5% of admitted patients. Among these patients, 325 patients had sepsis at ICU admission. Fifty patients (15.4%) had ESBL-PE related sepsis at ICU admission. ESBL-PE infection included 23 (46%) urinary tract infections, 14 (28%) pulmonary infections, 9 (18%) abdominal infections and 4 (8%) other infections. All but two ESBL-PE pneumonia cases were hospital-acquired (86%) while community-acquired ESBL-PE urinary tract infection was not uncommon (12/36 = 33%).

By multivariable analysis, prior urinary tract disease [OR 3.0 (1.1–8.0)], hospital-acquired sepsis at admission [OR 2.9 (1.4–5.7)], treatment with fluoroquinolone within the past 3 months [OR 2.8 (1.2–6.4)] past ESBL-PE infection [OR 2.8 (1.2–6.5)] were independent predictive factors for ESBL-PE sepsis at admission, whereas a pulmonary source of sepsis [OR 0.30 (0.15–0.61)] was protective. The final model showed a good calibration (chi2 = 3.7, p = 0.45) and discrimination (area under the curve = 0.85). Patients with ESBL-PE related sepsis had more often septic shock and bacteraemia at admission. ESBL-PE related sepsis was also more often associated with more frequent inadequate empirical therapy (68 vs 87%, p < 0.001). However, mortality did not differ significantly between patients with ESBL-PE infection and others (20 vs 22%).

Conclusion At ICU admission, ESBL-PE related sepsis was relatively infrequent among colonized patients. Our predictive factors for ESBL-PE may help choosing empiric therapy for sepsis among ESBL-PE carriers at ICU admission. The study did not show a significant association between ESBL-PE infection at admission and mortality.

Competing interests None.

Reference
  1. 1.

    Goulenok T, Ferroni A, Bille E, Lécuyer H, Join-Lambert O, Descamps P, Nassif X, Zahar JR. Risk factors for developing ESBL E. coli: can clinicians predict infection in patients with prior colonization? Hosp Infect. 2013;84(4):294–9.

     

P160 Carbapenemase-producing Enterobacteriaceae: experience of a Tunisian intensive care unit

Amira Ben Jazia1, A. M’rad1, Zouhour Ouali2, Manel Barghouth1, Y Blel1, N Brahmi1
1Department of intensive care and toxicology, Centre d’Assistance Médicale Urgente, Tunis, Tunisia; 2Department of biology, Centre d’Assistance Médicale Urgente, Tunis, Tunisia
Correspondence: A. M’rad - mrad.aymen@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P160

Introduction Carbapenemase-producing Enterobacteriaceae (CPEc) are increasingly reported worldwide and constitutes a real challenge antibiotic for clinicians to preserve the bacterial ecology. Its incidence has remarkably increased in our intensive care unit during the last 5 years.

This work aims to focus on the impact of CPEc increasing in our intensive care unit.

Patients and methods A retrospective and descriptive study conducted in a Tunisian intensive care unit, including all hospitalized patients infected by an Enterobacteriaceae. We have determined annual incidence of CPEc from January 2008 to December 2015.

Results One thousand two hundred and three episodes of Enterobacteriaceae infections were eligible in 748 patients (324 male/424 female) aged between 14 and 88 years.

The global prevalence of CPEc across study period was 4.48% (54/1203).The prevalence of CPEc in each site was respectively of 23% in hemocultures, 18% in coproculture, 12% in catheters, 3.3% in respiratory tract, and 3% in urinary tract.

The overall incidence of (CPEc) increased from 0.69% (1/144) in 2008 to 7.77% (15/193) in 2015 (Fig. 4).
Fig. 4
Fig. 4

CPEc increasing from 2011 to 2015

Conclusion

Our study confirms the rapid spread of CPEc in Tunisian hospital and the urgent need for a well-structured and coordinated national surveillance plan in order to limit their dissemination.

Competing interests None.

P162 Extended spectrum beta lactamase producing enterobacteriacae (ESBL-PE) infections in ICU

Achille Kouatchet1, Rafael Mahieu2, Emmanuel Weiss3, David Schnell4, Jean-Ralph Zahar5
1Service de Réanimation médicale et Médecine hyperbare, Centre Hospitalier Universitaire d’Angers, Angers, France; 2Réanimation médicale, Centre Hospitalier Universitaire d’Angers, Angers, France; 3Département d’anesthésie-réanimation, Hôpital Beaujon, Boulevard du Général Leclerc, Clichy, France, Clichy, France; 4Réanimation médicale, CHU de Strasbourg, Strasbourg, France; 5Laboratoire de bacteriologie-virologie-hygiene, Hôpital Avicenne, Bobigny, France
Correspondence: Achille Kouatchet - ackouatchet@chu-angers.fr

Annals of Intensive Care 2017, 7(Suppl 1):P162

Introduction The ESBL spread has a major consequence in term of antibiotic choices. Carbapenem antibiotic are regarded as the most effective treatment. However numbers of authors suggest that alternatives antibiotics (i.e. noncarbapenems) could be used in ESBL-PE infections. There are some conflicting data regarding the use of alternatives in case of ESBL-PE infections. Moreover as far as we know, there are no data in ICU.

Objectives the aim of this study was to describe ESBL-PE infections in ICU and therapeutic options chosen in these specific situations.

Patients and methods Prospective multicentric observational cohort study conducted in volunteers ICU. All consecutive patients hospitalized in ICU with ESBL-PE infection according to CDC definitions were included. Severity of illness was defines according to bone criteria, SAPS II and SOFA. Demographic datas, empirical and definitive antibiotic therapy (ET and DT), clinical evolution, and outcome were recorded. In vitro antimicrobial susceptibility testing was performed by the disk diffusion method or the Vitek 2 system according to the guidelines of the Antibiogram Committee of the French Microbiologic society.

Results During the study period 146 patients with ESBL-PE infection met eligibility criteria with respectively a median age and SAPS II score of 63 (51–74) and 50 (38–70). The median SOFA Score at first day of antibiotic therapy and ICU admission were 7 (4–11) and 7 (5–11) respectively. The most frequent site of infection were respiratory tract (45%), urinary tract (20%) and abdominal (17%). The most frequent isolated species were: Escherichia coli (43%), Klebsiella sp (37%) and Enterobacter sp (18%). Respectively 50, 23 and 27% patients had septic shock, severe sepsis and sepsis according to Bone criteria.

Among ESBL-PE, 98.6% were carbapenem and 46.5 were BLBI sensitive. Among the whole population, 47 (48%) patients received a carbapenems as ET. 66 (68%) received a DT with carbapenems and 31 (32%) patients received an alternative DT. The most frequent reasons for maintaining carbapenems as DT were: Antibiotic susceptibility tests (38% of cases), severity level (33% of cases) immunosuppression (8% of cases). The Median length of ICU stay after infection was respectively 12 (6–27) and 11 (7–16) days for carbapenems and alternatives DT (p = 0.1). The D28 mortality was 24% for patients with carbapenems DT and 24% for patients with alternatives DT (p = 0.02).

Surprisingly, there were no differences between the 2 groups (carbapenems vs alternatives) in term of severity.

Conclusion Alternatives are frequently used for ESBL-PE infections in ICU. In our cohort 31 (32%) patients received antibiotics other than carbapenems regardless of the severity.

Competing interests None.

P163 Extended-spectrum beta-lactamase-producing enterobacteriaceae cross-transmission in the absence of private room in intensive care unit

Margaux Artiguenave1, Paktoris-Papine Sophie1, Florence Espinasse2, Faten El Sayed3, Aurélien Dinh4, Cyril Charron1, Guillaume Geri5, Antoine Vieillard-Baron1, Xavier Repessé1
1Réanimation médico-chirurgicale, Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France; 2Equipe opérationnelle d’hygiène hospitalière, Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France; 3Service de microbiologie, Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France; 4Equipe mobile de microbiologie, Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Boulogne-Billancourt, France; 5Réanimation Médicale, Hôpital Cochin, Paris, France
Correspondence: Xavier Repessé - xavier.repesse@aphp.fr

Annals of Intensive Care 2017, 7(Suppl 1):P163

Introduction Multidrug micro-organisms are responsible for longer hospitalisations and poorer outcomes in intensive care unit (ICU). The transmission of extended-spectrum beta-lactamase producing enterobacteriaceae (ESBL-PE) is prevented by the application of additional contact precautions, mainly relying on isolation in a private room and hand hygiene with waterless alcohol-based solution. Contact isolation cannot be achieved in our 12-bed ICU only composed of two twin bedrooms. We aimed at reporting the ESBL-PE acquisition in this peculiar architectural form of ICU and at studying the impact of twin bedrooms on ESBL-PE cross-transmission.

Patients and methods An observational and non-interventional study was prospectively conducted in the 12-bed ICU of a university hospital Ambroise Paré (Boulogne-Billancourt, France). Inclusion criteria were: (1) adult patients and (2) a period of hospitalisation allowing the patient to be nursed by at least two paramedical teams. Characteristics of patients at admission (age, sex, SAPSII) and clinical data during hospital stay (duration of mechanical ventilation, duration of ICU stay, outcome) were prospectively collected. Microbiological data concerning ESBL-PE imported and acquired carriage were monitored by rectal swabs collected at admission and once weekly every Monday for the whole duration of the ICU stay. ESBL imported carriage was defined as a first screening positive for ESBL whereas ESBL acquired carriage as a negative first screening at admission followed by at least one positive rectal swan. Mechanistic of a potential cross-transmission was studied following a three-step process consisting in (1) identifying patients considered as possible ESBL sources (index patients) for transmission, (2) classifying each ESBL strain according to the CTXm 1 and 9 groups and (3) diagnosing potential cross-transmission by gene sequencing of remaining cases of possible transmission.

Results From June 2014 to April 2015, 550 patients were admitted in the ICU, among which 470 followed the inclusion criteria. The rate of ESBL colonization at admission was 13.2% (n = 62), mainly with Escherichia coli. Two hundred and twenty-one non-colonized patients were screened at least twice. The incidence of ESBL acquisition was 4.1% (9 patients on 221), also mainly with Escherichia coli. Mortality did not differ between ESBL carriers and non-carriers. In univariate analysis, ESBL acquisition was associated with the Injury Global Score II (IGSII) and the Sequential Organ Failure Assessment (SOFA) at admission, the need for catecholamine and the ICU length of stay (LOS). In multivariate analysis, ICU LOS and IGSII at admission were the strongest risk factor for ESBL acquisition. The nine ESBL-acquired carriers had one to three index patients defined as a patient hospitalized who shared at least 1 day hospitalization. The CTXm grouping of the ESBL strains excluded a cross-transmission for 4 patients. The gene sequencing did it for 3 others and confirmed a cross-transmission in only two patients (0.8%). The cross-transmission emanated from the same source of a CTXm 1 ESBL-producing E. coli. This patient shared 1 day in a different unit with the first acquired carrier and 2 days in the same unit with the other. No case of cross-transmission in the same room was observed.

Conclusion The rate of 13.2% of ESBL carriage on admission was comparable to other rates in French ICUs (15%). Despite the absence of contact isolation, the incidence of ESBL acquisition was 4.1% which is actually lower than transmission rates previously published in other ICUs. A cross-transmission concerned two ESBL-acquired carriers only and resulted from the same index patient during short shared hospitalizations of 1 day in a different unit and 2 days in the same unit. Our results question whether the contact isolation in private rooms plays a major role for the prevention of ESBL cross-transmission in ICU, although the external validity of our results could be questionable.

Competing interests None.

P164 Prevalence of colonization with extended spectrum B-lactamase producing bacteria and subsequent ICU acquired infection in French Guiana

Hatem Kallel1, Claire Mayence1, Stéphanie Houcke1, Pascal Guegueniat1, Didier Hommel1
1Intensive care unit, Hospital, Cayenne, French Guiana
Correspondence: Hatem Kallel - kallelhat@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P164

Introduction Bacterial resistance to antibiotics is a common problem worldwide. In South America, this prevalence is reported to be the highest in the world. However, in French Guyana, there is no data on the epidemiology of colonization and infection caused by extended spectrum B-lactamase producing enterobacteriaceae (ESBL-PE). We conducted this study to investigate the prevalence of colonization with ESBL-PE and subsequent ICU acquired infection in French Guiana.

Materials and methods A 24 months (January 2014 to December 2015) observational study in a 14 beds ICU in a general hospital. Our unit, is the sole and the referral one of all French Guiana department.

Results Over the study period, 670 patients were admitted to ICU and 603 of them (90%) were hospitalized more than 48 h. The mean occupancy rate was 82.5 ± 20.6% and the mean colonization index (with ESBL-PE) was de 37 ± 18.1%. The mean age was 43.4 ± 21.1 years. The sex-Ratio (M/F) was 1.3. The mean IGS II calculated at admission to ICU was 44.6 ± 24.2. The most recorded organ failures at admission to ICU were respiratory and hemodynamic ones (56.7 and 37.2% respectively). At admission to ICU, 44.2% of patients presented active infection and 57.3% received antibiotics. Multidrug resistant (MDR) bacteria carriage was found in 88 patients (13.4%) at ICU admission and was acquired in ICU in 89 other patients (13.4%). The most isolated MDR bacteria at admission were ESBL producing E coli and K. pneumoniae. However, the most isolated MDR bacteria during ICU stay were ESBL producing K. pneumoniae and E cloacae. During the ICU stay, 98 patients (14.6%) had presented 147 episodes of ICU acquired infections (ICU-AI). Over the 177 patients carrying MDR bacteria, 159 (89.8%) carried ESBL-PE and 66 developed ICU-AI. ESBL-PE caused 21.2, 37.5, 20, and 66.7% of 1st, 2nd, 3rd and 4th ICU-AI episodes respectively. Statistical analysis didn’t show any link between ESBL-PE carriage and a first episode of ICU-AI caused by ESBL-PE.

Conclusion Our study show a high prevalence of ESBL-PE bacteria carriage at admission in our ICU. ESBL-PE carriage was not associated to higher prevalence of ICU-AI caused by the same microorganism. This finding can help to reduce the inappropriate use of carbapenems in such conditions.

Competing interests None.

P165 On-line hemofiltration versus conventional hemofiltration in septic shock patients: clinical safety and effectiveness

Kaouther Dhifaoui1, Zied Hajjej1, Amira Fatnassi1, Walid Sellami1, Iheb Labbene1, Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospital of Tunis, Tunisia, Tunis, Tunisia
Correspondence: Zied Hajjej - hajjej_zied@hotmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P165

Introduction The implementation of hemofiltration (HF) as a renal replacement therapy in septic shock patients requires the supply of large quantities of replacement solutions. These solutions are either industrially prepared in autoclaved expensive plastic bags (conventional hemofiltration, CHF) or continuously provided in unlimited amounts at the dialysis machine directly from the water treatment plant to form the replacing solutions (on-line hemofiltration, OLHF).The aim of our study was to evaluate the safety and effectiveness of on-line hemofiltration compared to conventional hemofiltration in septic shock patients.

Patients and methods The investigative protocol was approved by the Institutional Ethics Authorities and all patients or their legally authorized representatives provided written informed consent. It was a prospective, randomized, clinical study, including septic shock patients with acute renal failure. Patients were randomized to receive either on-line hemofiltration (n = 8) or conventional hemofiltration (n = 25) for renal replacement therapy during 4 days. Hemodynamic monitoring was conducted by conventional devises, including: electrocardiogram and a radial arterial catheter for invasive arterial pressure every 6 h during period study. We collected serum samples also every 6 h (urea, potassium and sodium levels, troponin, hemoglobin, platelets, C-reactive protein and lactates).

Results The evolution of heart rate (HR), mean arterial pressure (MAP), biological markers were comparable between the two groups over time except a significant decrease in MAP in the OLHF group compared to CHF group only at H6 (P = 0.008) and H12 (P = 0.015) and a significant decrease in C-reactive protein level in the OLHF group at H48 (P = 0.02).

Conclusion On-line hemofiltration seems to be a safe and reliable method of renal replacement therapy in septic shock patients. It may be associated with attenuated pro-inflammatory cytokine profile (C-reactive protein).

Competing interests None.

P166 Usefulness of biological testing during renal replacement therapy in ICU patients

Fahmi Dachraoui1, Sabrine Nakkaa1, Abdelwaheb M’ghirbi1, Ali Adhieb1, Dhouha Ben Braiek1, Kmar Hraiech1, Ali Ousji1, Islem Ouanes1, Hammouda Zaineb1, Saousen Ben Abdallah1, Lamia Ouanes-Besbes1, Fekri Abroug1
1Réanimation polyvalente, CHU Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Fahmi Dachraoui - dachraoui.fahmi@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P166

Introduction Clinical and biological monitoring of efficacy and safety of RRT sessions is thought useful and in many ICUs biological testing at mid RRT session and at its end is routinely performed. The aim of the present study is to evaluate the impact of laboratory tests performed during RRT session on clinical decision making and treatment alteration.

Patients and methods Retrospective study including all consecutive patients hospitalized in the medical ICU of the University Hospital Monastir, Tunisia between January 2015 and September 2016, requiring intermittent hemodialysis performed in the ICU. For each patient we collected demographic characteristics (age, sex, SAPS III, diagnosis, comorbidities), indication of the RRT, clinical and biological parameters before, during and at the end of RRT session. Based on the patient monitoring records during each RRT session we identified therapeutic interventions started before the end of the RRT session in the light of the results of laboratory tests performed during the session (usually in the middle the session): infusion of glucose, potassium, transfusion, extension of the session.

Results During the study period, 370 patients were admitted to the ICU. Of these 24 patients required acute hemodialysis. The median age of these patients were 54 years (IQR = 31), 53% of them were female. The main comorbidities were hypertension, diabetes, chronic renal failure (CRF) with preserved diuresis, respectively in 55, 38 and 36%. ¾ of the patients included were in septic shock and had median SAPS III score of 92 (IQR = 34). Anuria, pulmonary oedema, hyperkalemia, and acidosis indicated RRT sessions respectively in 47.1, 24.5, 8.8, 9.8 and 9.8%. Results of laboratory tests performed during RRT sessions prompted a specific attitude in the following rates: infusion of glucose in 35.7%, addition of potassium in 22%, and extension of the session duration 15.2%.

Conclusion The practice of laboratory tests during the RRT sessions seems useful since it could impact clinical decision making in more than one-third of sessions.

Competing interests None.

P167 Feasibility of regional citrate anticoagulation for membrane-based therapeutic plasma exchange in ICU

Simon Klein1, Mattéo Miquet1, Jean-Marc Thouret1, Vincent Peigne1
1Réanimation, Centre Hospitalier Métropole-Savoie, Chambéry, France
Correspondence: Vincent Peigne - vincentpeigne@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P167

Introduction Therapeutic plasma exchange (TPE) is crucial for the management of auto-immune diseases like thrombotic thrombocytopenic purpura or myasthenia gravis. TPE is performed either by centrifugation, with specific machines which are not routinely available in ICUs, or by using specific plasma separation membranes with widely spread in ICUs hemofiltration machines. Regional citrate anticoagulation for TPE is well established with centrifugation but has been seldom described for membrane TPE. We are reporting the experience of our ICU in this field.

Patients and methods Retrospective study including all patients who received TPE with citrate regional anticoagulation between 2013 and 2016 in an 18-bed ICU. TPE is performed solely in the ICU in our institution.

Results 26 patients were included. TPE was required for thrombotic microangiopathy (13 patients), vasculitis (6 patients), hyperviscosity syndrome (2 patients), Guillain–Barré syndrome (2 cases) and others (3 patients). Mean SAPS2 score was 32 [standard deviation (SD) 16.6]. 281 TPE were performed, with a mean number of 10.5 (SD 11.5; range 2–57) TPE per patients. Coagulation of the circuit of TPE occurred in 10 (38%) patients. Coagulation of the circuit occurred in 10.3% (29/281) of the TPE. Minor adverse events have been reported in two patients: one had a rash during the first TPE (no recurrence during the 56 next TPEs) and the other had paresthesia during the first two TPEs (the calcium infusion was increased and there had been no recurrence during the 25 next TPEs). No serious adverse events related to citrate were observed.

Conclusion Regional anticoagulation with citrate allowed us to perform TPE in 26 patients, without significant adverse events. The rate of circuit coagulation was 10.3% per TPE.

Competing interests None.

P168 Modelization of the cost-effectiveness of anti-thrombin to reduce the incidence of membrane thrombosis during continuous hemofiltration

Vincent Peigne1, Jean-Louis Daban2, Mathieu Boutonnet2, Bernard Lenoir3
1Réanimation, Centre hospitalier Métropole Savoie, Chambéry, France; 2Réanimation, Hôpital d’Instruction des Armées Percy, Clamart, France; 3Département d’anesthésie-réanimation, Hôpital d’Instruction des Armées Percy, Clamart, France
Correspondence: Vincent Peigne - vincentpeigne@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P168

Introduction A reduced incidence of membrane thrombosis after injection of Anti-thrombin (AT) has been reported in septic patients with acquired deficit in AT undergoing continuous hemofiltration. As this strategy was routinely performed in our unit until 2012, we investigated its cost-effectiveness.

Patients and methods Data about the use of hemofiltration, the consumption of AT and hemofiltration devices during 2011 (period with routine use of AT) and 2012 (period with use of AT only if a membrane thrombosis occurred) were extracted from the administrative database of the institution. A decisional tree was built to modelize the impact of AT on the consumption of hemofiltration devices and blood products. The decisional tree took into account the probability of membrane thrombosis with and without AT and the probability of transfusion after membrane thrombosis. Costs were obtained from the pharmacy of the institution (AT, hemofiltration devices) and from the literature (blood products).

Results During 2011, 77 days of hemofiltration were performed, with the use of 45 doses of AT (23,202€) and 76 hemofiltration devices (11,632€). During 2012, 76 (−1%) days of hemofiltration were performed, with the use of 5 (−89%) doses of AT (2578€) and 85 (+10%) hemofiltration devices (13,443€). The mean cost of 1 day of hemofiltration decreased from 449€ to 211€ with the diminution of the use of AT.

According to the decisional tree, AT was almost never cost-effective. The only circumstances associated with a benefit for the use of AT was the association of a probability of thrombosis with AT inferior to 0.1, of a probability of thrombosis without AT equal 1, of a probability of transfusion after thrombosis equal 1 and a cost of transfusion of 424€. In these extremely favorable circumstances, AT could decrease the daily cost of hemofiltration of 2.22–19.30€.

Discussion The model has several limits: the losses of utility related to transfusion and to interruption of hemofiltration due to thrombosis were not taken into account; the cost of AT measurement was not estimated; the work load of changing a membrane and of transfusion after membrane thrombosis was not analyzed.

Conclusion Our results suggest that anti-thrombin is not cost-effective to reduce the costs of hemofiltration related to membrane thrombosis.

Competing interests None.

P169 Vascular access sites for acute renal replacement in intensive care unit

Amira Ben Jazia1, Amira Jamoussi2, Takoua Merhbene3, Dhouha Lakhdhar4, Jalila Ben Khelil2, Mohamed Besbes2
1Medical ICU, Hospital Abderrahmen Mami De Pneumo-Phtisiologie, Ariana, Tunisia; 2Réanimation médicale, Hôpital Abderrahmen Mami, Ariana, Tunisia; 3Réanimation respiratoire, Hôpital Abderrahmen Mami de pneumo-phtisiologie, Ariana, Tunisia; 4Service de réanimation médicale, Centre d’assistance médicale-urgente, Tunis, Tunisia
Correspondence: Amira Ben Jazia - amira26juillet@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P169

Introduction Several temporary venous catheterizations are sometimes required for acute renal replacement therapy (RRT) in the intensive care unit (ICU). This study compares catheterizations in the femoral and jugular veins in terms of patient safety.

Materials and methods This was a descriptive retrospective review of dialysis sessions (DS) records monitoring performed in patients older than 17 years hospitalized in medical intensive care unit between April 2011 and December 2015.

A study of dialysis catheter, was conducted in critically ill adults requiring RRT was performed.

Catheter insertion site, catheter age and urea reduction ratio (URR) were analyzed.

Results URRs were analyzed from 330 dialysis sessions (n = 64 patients). The mean rate of URRs was 52.8 ± 12.4. Only 31.4% of dialysis sessions (DS) were efficient with URR ≥ 60.

This study analyzed 64 patients who underwent two different sites of catheterization: the femoral and jugular site.

The mean age of cathéters was 1.613 days.

No significant difference (P = 0.18) in the efficiency of (DS) was detected between sessions performed through femoral (n = 225; 68%) and jugular (n = 105; 32%) dialysis catheters.

Conclusion Femoral and internal jugular acute vascular access sites are both acceptable for RRT therapy in the ICU. The effectiveness of (DS) in the ICU is low (31.4%). An analysis of predictive factors of inefficiency of (DS) is expected to improve our results.

Competing interests None.

Reference
  1. 1.

    Ridel C, Baldea MC, Rondeaua E, Vinsonneaub C. La dose de dialyse en réanimation: existe-t-il vraiment un idéal? Dose of dialysis in intensive care unit.

     

P170 Renal replacement therapy protocol with regional citrate anticoagulation: observational study of efficacy with a new post-filter ionized calcemia target

Celine Derreumaux1, Thierry Seguin1, Jean-Marie Conil1
1Réanimation polyvalente, Hopital Rangueil, Toulouse, France
Correspondence: Celine Derreumaux - celine.derreumaux@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P170

Introduction In Intensive Care Unit (ICU), some patients suffering from acute kidney injury need renal replacement therapy (RRT). It requires the circuit anticoagulation, this could be done by a regional citrate method. Today, this is a recommended approach for the everyday care, even if the technique isn’t widespread yet [1]. The ionized calcemia dosing through the filter (“post-filter” ionized-calcemia) is used to monitor the technique efficacy, with a target of 0.25–0.35 mmol/L showing a good filter anticoagulation.

The objective of our study was the assessment of efficacy and safety of our regional citrate anticoagulation protocol, with a less restrictive post-filter ionized calcemia target (0.3–0.6 mmol/L). The main goal was the analysis of the circuit lifespan, considering a lifespan above 24 h, as well as the search of some clinical and biological factors affecting the technique efficacy. Moreover, we analyzed the side effects incidence of the protocol (hypernatremia, metabolic alcalosis), and their consequences. The study received the scientific ethical agreement of University Hospital of Toulouse, and is registered with number 18-0214.

Patients and methods 57 patients, admitted to one of the two University Hospital ICUs of Toulouse, needing a continuous RRT method, without any need for systemic heparin anticoagulation, and without severe hepatocellular failure, were included in the study. 103 filters included over a 1-year period were analyzed.

Results Results show a mean filter lifespan of 48 h, with a lifespan above 24 h for 85.4% of all filters. Coagulation was the cessation reason for 29.1% of filters, most of them before 24 h of the filter use. A value of post-filter ionized calcemia at day 1 below 0.54 mmol/L was the main factor influencing a filter lifespan above 24 h. An age older than 51 and a SAPS II severity score below 80 were other factors conditioning a filter lifespan of more than 24 h. Side effects of citrate were rare and didn’t have any clinical impact among our patients.

Discussion These results suggest that citrate used for anticoagulation in RRT could have an additional anti inflammatory effect through the induced hypocalcemia, as well as an energetic gain which could lead to a renal protection against ischemia–reperfusion mechanism [2]. Moreover, these results call into question the need of post-filter ionized calcemia dosing for the monitoring of citrate anticoagulation efficacy, since the method safety is monitored by the total-to-ionized calcium ratio.

Conclusion During continuous RRT in ICU, a regional citrate anticoagulation protocol with a non-restrictive post-filter ionized calcemia target seems to be efficient and could reduce side effects. These results need to be confirmed with a randomised control study.

Competing interests None.

References
  1. 1.

    KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney international Supplements, 2012.

     
  2. 2.

    Oudemans-van Straaten, HM et al. Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med, 2009;37(2):545–52.

     

P171 Impact of the use of an oXiris filter versus an AN69ST filter on the duration of hemofiltration in intensive care

Charlotte Kelway1, Valery Blasco1, Cyril Nafati1, Karim Harti1, Laurent Reydellet1, Jacques Albanese1
1RPPF, Hopital de la Timone, Marseille, France
Correspondence: Charlotte Kelway - chakel@hotmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P171

Introduction Continuous veno-venous haemofiltration (CVVH) is used to treat acute kidney injury in critically ill patients. To optimize its efficiency, CVVH requires effective anticoagulation. Systemic anticoagulation with standard heparin, the most used, can lead to major bleeding complications. Hemofilters that are able to adsorb heparin molecules on their surface such as AN69ST and oXiris membranes represent an alternative. The objective of this study was to compare these two types of filters in terms of duration, efficiency, dysfunctions and cost.

Materials and methods From October 2012 to May 2014, we conducted a retrospective, observational, and non-interventional study. All patients admitted in the intensive care unit needing CVVH were included. The primary endpoint was the filter lifespan: AN69ST versus oXiris. The secondary endpoint was the filter efficiency (urea reduction ratio: URR). The main analysis did not consider the anticoagulation type. We conducted a subgroup analysis taking into account the use or not of an anticoagulation.

Results 181 sessions in 93 patients were carried out using 386 filters representing 10,706 h of treatment. The mean AN69ST filter lifespan was 27 ± 20 h and 28 ± 22 h for oXiris filters (p > 0.05). There is no significant difference in terms of duration between the two filters. The subgroup analysis taking into consideration the use or not of anticoagulation did not show any difference either. The mean URR was 48 ± 23% in the AN69ST group and 44 ± 25% in the oXiris group (p > 0.05). Concerning the dysfunctions, there were no significant difference between the two filters. One hundred and seventy-six AN69ST filters were used for a total cost of 24,288 euros. Two hundred and ten oXiris filters were used for a total cost of 39,060 euros.

Conclusion The AN69ST and oXiris lifespans are not significantly different. They were as efficient in terms of blood epuration and had as many dysfunctions. The use of an oXiris filter rather than an AN69ST to extend the circuit’s lifespan in the same clinical conditions is not justified considering the extra cost generated.

Competing interests None.

References
  1. 1.

    Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2015;27(5);343–8.

     
  2. 2.

    Intensive Care Med 2012; 38(11):1818–25.

     
  3. 3.

    PLoS One 2014;9(5):e97187.

     

P172 Effects of early use of diuretics in patients at risk of acute renal failure and oliguria

Narjess Ben Aicha1, Khaoula Meddeb1, Ahmed Khedher1, Jihene Ayachi1, Nesrine Fraj1, Nesrine Sma1, Imed Chouchene1, Mohamed Boussarsar2
1Réanimation médicale, CHU Farhat Hached, Sousse, Tunisia; 2Réanimation médicale, CHU Farhat Hached. Research Laboratory N° LR14ES05. Faculty of Medicine, Sousse, Tunisia
Correspondence: Mohamed Boussarsar - hamadi.boussarsar@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P172

Introduction Because oliguria is a poor prognostic sign in patients with acute renal failure (ARF), diuretics are often used to increase urine output in patients with or at risk of ARF. From a pathophysiological point of view there are several reasons to expect that loop diuretics could have a beneficial effect on renal function. However, a review of literature shows that the use of loop diuretics in patients with ARF has been associated with inconclusive results despite the theoretical benefits [1].

To assess the adjunctive effect of diuretics, to alter the progression to kidney injury or failure, in patients at risk for acute renal failure.

Patients and methods This is a retrospective chart review of consecutive patients who developed ARF with oliguria in the intensive care unit. Chart abstractors were well trained residents. Two chart reviewers (senior intensivists) studied all the charts. An explicit protocol was used to precise all needed definitions. Uniform handling of data was ensured especially for conflicting, missing or unknown data. Oliguria was defined as urine output lower than 0.5 ml/kg/h for at least 3 h.

RIFLE score was assessed before and after urinary output normalisation. Therapeutic intervention to optimize pre-renal perfusion was described. Mean arterial blood pressure (MBP) before and after therapeutic initiation, oliguria duration, delay from oliguria onset to diuretic administration, delay from diuretic administration to urinary output normalisation were measured.

Results 23 patients were studied over a 2 years period. They were 63 [24, 87] median (IQR) aged, with diabetes mellitus, 22%; hypertension, 47.8%; cardiac failure, 32% and chronic respiratory failure, 43%. Chronic and obstructive kidney diseases were excluded. Median SAPS II was 37 [23, 75]. 80% were on mechanical ventilation.

RIFLE score before diuretics administration was assessed at oliguria onset as (patients without risk, zero; R, 69%; I, 17%; F, 10%; L, 4%; E, zero). Fluid resuscitation after oliguria onset was administered in 77% and vasopressors in 80%. Median (IQR) delay from oliguria onset to diuretic administration was 5 [0.5, 22] h while optimization of pre-renal hemodynamic disturbances was already achieved.

The median (IQR) MBP before and after therapeutic intervention was respectively, 74 [46, 100] and 95 [69, 110] mmHg. Median (IQR) delay from initiation of therapeutic intervention and MBP improvement was 1.5 [0, 3] h. The delay from diuretic administration to urinary output normalization was 3 [0.5, 27] h.

After resumption of diuresis, RIFLE score was assessed as (patients without risk, 74%; R, 17%; I, 8%; F, 1% L, zero; E, zero) (Fig. 5). Increased serum creatinine level, above 1.5 fold normal range, was observed only in 6 (26%) patients.
Fig. 5
Fig. 5

Progression of RIFLE score classes respectively from baseline to after therapeutic intervention

Conclusion Rapid optimization of pre-renal hemodynamic disturbances associated with short delay administration of diuretics could significantly alter the progression to kidney injury or failure in at risk acute renal failure ICU patients.

Competing interests None.

Reference
  1. 1.

    Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia. 2010;65(3):283–93. doi:10.1111/j.1365-2044.2009.06228.x. Epub 2010 Jan 19.

     

P173 Epidemiology and risk factors of Acinetobacter baumannii ventilator associated pneumonia

Walid Sellami1, Zied Hajjej1, Soumaya Ben Yedder2, Walid Samoud1, Bousselmi Radhouene1, Bousselmi Mariem3, Iheb Labbene1, Mustapha Ferjani1
1Department of critical care medicine and anesthesiology, Military Hospital of Tunis, Tunisia, Tunis, Tunisia; 2Department of critical care medicine and anesthesiology, Military hospital of tunis, tunisia, Tunis, Tunisia, Tunisia; 3Department of critical care medicine and anesthesiology, Military Hospital of Tunis, Tunisia, tunis, Tunisia
Correspondence: Walid Sellami - drsellamiwalid@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P173

Introduction The ventilator associated pneumonia (VAP) is a common and severe complication of assisted ventilation. It’s the leading cause of nosocomial infections in intensive care unit and remain responsible for a high morbidity and mortality because of the emergence of multi-drug resistant (MDR) bacterial agent such us Acinetobacter baumannii (AB). The aim of this study was to determine the incidence, risk factors and prognosis of AB VAP.

Patients and methods Retrospective study extending over a 5 year period (January 2010–January 2016) that included all patients over 18 years and ventilated more than 48 h and developing AB VAP. Patients were divided into two groups: one consisting of patients who developed VAP to AB and the second developed VAP to another bacterial pathogen.

Results One hundred and forty patients developed VAP. The incidence rate of AB VAP was 15.3% with a density of incidence of 20.3 per 1000 ventilator days. Age, male gender, the time between hospitalization and mechanical ventilation and the medical pathology were risk factors for developing AB VAP. AB was resistant to ceftazidime in 100%, to imipenem in 65%, tobramycin in 70% and netilmycin in 35.3%, rifampin in 85% with a sensitivity to colistin in 100% of cases. The resistance of this germ to imipenem increased from 35% in 2010 to 88.5% in 2016. The evolution of patients with AB VAP developed frequently septic shock compared to other patients (44 vs 19.3%; p = 0.038). The AB VAP mortality was higher (50 vs 33%; p = 0.03).

Conclusion The increasing incidence of multi-drug resistant AB VAP is responsible for a high morbidity and mortality. So we need to identify risk factors and to strengthen the means of prevention of hand contamination and cross transmission during invasive procedures.

Competing interests None.

P174 Incidence and risk factors of central line associated bloodstream infections and its risk factors in a Tunisian medical intensive care unit

Nesrine Sma1, Asma Ammar2, Khaoula Meddeb1, Asma Ben Cheikh2, Hend Ben Lakhal1, Jihene Ayachi1, Ahmed Khedher1, Nesrine Fraj1, Messaouda Khelfa1, Yamina Hamdaoui1, Imed Chouchene1, Nabiha Bouafia2, Mohamed Boussarsar3
1Réanimation médicale, CHU Farhat Hached, Sousse, Tunisia; 2Hospital hygiene unit, Farhat Hached Hospital, Sousse, Tunisia; 3Medical intensive care unit, Farhat Hached Hospital. Research Laboratory N° LR14ES05. Faculty of Medicine, Sousse, Tunisia
Correspondence: Mohamed Boussarsar - hamadi.boussarsar@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P174

Introduction Central line associated bloodstream infections (CLABSI) are among the serious hospital-acquired infections. The aim of this study is to determine the incidence of CLABSI, the pathogens and the risk factors that play a role in the development of BSI among patients followed in a Tunisian medical intensive care unit.

Patients and methods All patients admitted for more than 48 h were included in the study over a 1-year period in an 8-bed medical ICU. The enrollment was based on clinical and laboratory diagnosis of BSI. Blood samples were collected from catheter hub of all patients for culture, followed by identification and antibiotic sensitivity testing of the isolates. For all subjects, age, sex, underlying diseases, SAPS II score, ICU length of stay, invasive procedures and their durations (mechanical ventilation, central catheterization, urinary catheterization) were recorded. Risk factors were evaluated by a multivariate logistic regression model.

Results Among a total of 237 admissions from September 15th 2015 to September 15th 2016, 163 (68.7) patients were eligible. One hundred twenty-five (76) patients had a central line. A total of 27 episodes of CLABSI were assessed in 23 (18.4) patients. The mean SPASII of patients with CLABSI was 33 ± 15.4. Their mean CHARLSON index was 1.8 ± 1.7, median duration of catheterization was 4 [1.5–7] days and 8 (34.8) had more than one catheterization attempt. The rate of CLABSI was 19.2/1000 catheter.days. Gram positive bacteremia was determined in 13% of BSI patients. Of these isolates, 3 were Staphylococci. Gram negative bacteremia was determined in 35% of these isolates, 4 were Acinetobacter baumannii, 3 were Klebsiella pneumonia and 1 was Proteus mirabilis and in 56% of cases BSI was diagnoses clinically. A univariate analysis identified ventilator-associated pneumonia, sedation, and longer interval between onset of CLABSIs and the duration of catheterization as risk factors of CLABSIs. In multivariate analysis, the independent factors of CLABSI which are the duration of catheterization (OR, 1.06; 95% CI, [1.003–1.139]; p = 0.042) and catheterization attempt number (OR, 1.99; 95% CI, [1.18–3.37]; p = 0.01). Thirteen (56.5) patients developed septic shock and they all died.

Discussion The rate of CLABSI in our ICU (19.2/1000 catheter.days) was higher compared with the mean rate of CLABSI in ICU reported by the NNIS system surveillance for 2004, which is 3.9/1000 catheter.days [1]. Duration of catheterization, frequent manipulation of catheter, catheter location, catheter type, underlying diseases, suppression of immune system, and types of fluids administered through the catheter are significant risk factors in development of BSIs [2]. In our study both duration of catheterization and number of attempts are independent factors for CLABSI.

Conclusion In a monocenter cohort, CLABSI had a moderate density rate but are associated with poor outcome. Identifying the risk factors is necessary to find solutions for this major health problem.

Competing interests None.

References
  1. 1.

    National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470–85.

     
  2. 2.

    Öztürk F, Gündeş S, Işık C. Prospective evaluation of the risk factors, etiology and the antimicrobial susceptibilities of the isolates in nosocomial bacteriemic patients. Mikrobiyol Bul.2008;42:17–27.

     

P175 Is prehospital endobronchial intubation a risk factor for subsequent ventilator associated pneumonia?

Timothée Trampont1, Thomas Lafon2, Thomas Daix3, Vincent Legarçon1, Paul Claverie1, Henri Hani Karam1, Nicolas Pichon3, Philippe Vignon3, Bruno François3
1Service urgences adultes/samu-smur, C.H.U de Limoges, Limoges, France; 2Services urgences adultes/samu-smur/inserm cic1435, C.H.U de Limoges, Limoges, France; 3Inserm cic 1435/réanimation polyvalente, C.H.U de Limoges, Limoges, France
Correspondence: Timothée Trampont - timothee.trampont@orange.fr

Annals of Intensive Care 2017, 7(Suppl 1):P175

Introduction According to some studies, field-intubated patients have 1.5–3 times greater risk of ventilator associated pneumonia (VAP). Endobronchial intubation (EI) can be unrecognized by the physicians and may result in complications such as atelectasis which in turn could increase the risk of VAP. The aim of our study was to confirm this hypothesis.

Patients and methods This monocentric retrospective study included all consecutive patients >18 years who underwent an out-of-hospital tracheal intubation before their admission to the intensive care unit (ICU) between January 2012 and December 2015. Exclusion criteria were suspected aspiration or pneumonia on admission, patients who died within the first 5 days of ICU stay, extubation in less than 48 h and underlying disease making radiological interpretation difficult for VAP diagnosis. VAP were divided into early onset (<7 days) and late onset (≥7 days) events and were independently diagnosed by two experienced intensivists who had no access to the initial chest X-ray performed to check the position of the tracheal tube, based on the Clinical Pulmonary Infection Score. Onset of ventilator associated tracheobronchitis (VAT) was also noted. Inadvertent endobronchial intubation was determined by another independent physician based on the interpretation of admission chest X-ray.

Results 397 patients were intubated out-of-hospital. Of the 284 patients excluded, 104 had an extubation in less than 48 h, 114 were died within the first 5 days, 22 had a suspicion of pneumonia, 28 a suspicion of aspiration and 8 an underlying disease making radiological interpretation difficult. Of the 121 patients included, 28 (23.1%) had an EI upon admission. No significant difference was observed between the EI and non-EI group for gender, age, SAPS2, comorbidities and diagnostic category (cardiorespiratory arrest, trauma, coma and cardiorespiratory failure). Early-onset VAP were diagnosed in 43% in the EI group and in 29% of non-EI patients (p = 0.085). Adding early onset VAT, the respiratory infection rate was 61% in the EI group and 44% in the non-EI group (p = 0.061) (Fig. 6). Late-onset VAP were observed in 8.6% in the non-EI group and 7.1% in the EI group, without difference between groups (p = 0.403). There was no inter-group difference in the duration of ventilation, duration of ICU stay and ICU mortality. Staphyloccocus aureus was the most prevalent pathogen in patients with early-onset VAP (23.1%, only one strain was methicillin-resistant).
Fig. 6
Fig. 6

Rate of early-onset VAP + VAT depending of the position of the tube

Conclusion This study found a high rate of inadvertent prehospital endobronchial intubation with a higher incidence of early-onset VAP. These results support the implementation of specific procedures to decrease the incidence of EI.

Competing interests None.

References
  1. 1.

    Bissinger U, Lenz G, Kuhn W. Unrecognized endobronchial intubation of emergency patients. Annals of Emergency Medicine. 1989;18(8):853–55.

     
  2. 2.

    Sitzwohl C, Langheinrich A, Schober A, et al. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010;341(nov091):c5943–c5943.

     

P176 Early versus late-onset ventilator-associated pneumonia: causative pathogens and resistance profiles

Hend Ben Lakhal1, Aymen M’rad1, Fatma Essafi1, Nasreddine Foudhaili1, Hafedh Thabet2, Youssef Blel1, Nozha Brahmi1
1Department of intensive care and toxicology, Centre d’Assistance Médicale Urgente, Tunis, Tunisia; 2Service de réanimation, centre d’assistance médicale-urgente, Tunis, Tunisia
Correspondence: A M’rad - mrad.aymen@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P176

Introduction Ventilator-associated pneumonia (VAP) is associated with increased hospital stay and high morbidity and mortality in critically ill patients. The classic dichotomy between early and late onset VAP is no longer helpful available. The aims of this study were to determine the incidence of multidrug-resistant pathogens in the first episodes of VAP and to assess potential differences in bacterial profiles of subjects with early-onset versus late-onset VAP.

Patients and methods Retrospective cohort study over a period of 18 months including all patients who had a first episode of VAP confirmed by positive culture. Subjects were distributed into 2 groups according to the number of intubation days: early-onset VAP (<5 days) or late-onset VAP (≥5 days).The primary endpoint was the nature of causative pathogens and their resistance profiles.

Results Sixty patients were included, 29 men and 31 women. The average age was 38 ± 16 years. The IGS 2 at admission was 40.5 [32; 44] APACHE 19 [15; 22]. Monomicrobial infections were diagnosed in of 46 patients (77%).Two different bacteria were isolated in 14 cases (13%). A. baumannii was the most frequently isolated in 53% (n = 32) of patients; followed by P. aeruginosa in 37% (n = 22), Enterobacteriaceae in 28% (n = 17) and S. aureus in 5% (n = 3). The isolated bacteria were multidrug-resistant in most cases (58/60). The VAP group comprised 36 episodes (60%) of early-onset VAP and 24 episodes (40%) of late-onset VAP. A. baumannii was isolated in 47% of early VAP (n = 17) versus 62% of late VAP (n = 15) (p = NS), P. aeruginosa in 36% of early VAP (n = 13) versus 37% of late VAP (n = 9) (p = NS) and Enterobacteriaceae in 30% of early VAP (n = 11) versus 25% of late VAP (n = 6) (p = NS). For the resistance profile of the different pathogens isolated, there was no difference between early and late onset VAP.

Conclusion According to new data from the literature, there were no microbiological differences in the prevalence of potential multidrug-resistant pathogens or in their resistance profiles associated with early-onset versus late-onset VAP.

Competing interests None.

P177 Nosocomial infection in the sever burns

Rihi El Mehdi1
1Intensive care unit, IBN ROCHD, Casablanca, Morocco
Correspondence: Rihi El Mehdi - mehdi_44@hotmail.fr

Annals of Intensive Care 2017, 7(Suppl 1):P177

Introduction The bacterial nosocomial infection is a major cause of morbidity and mortality in burned. The bacterial ecology in an ICU has a major impact in terms of morbidity and mortality, particularly in the center of burned or length of stay of patients is increased compared to a general intensive care.

Materials and methods We conducted an observational study spread over 7 months in ICU for severe burned burnt including any who have spent more than 48 h with nosocomial infection (modified CDC criteria), and in which all biological and bacteriological samples were taken. The different types of infections studied were: skin, urinary, lung and bloodstream infections. They excluded all patients belatedly supported or having stayed in other healthcare facilities.

Results One hundred twenty (120) patients showed nosocomial infection during this period. The sex ratio (M/F) was 1.7 and the mean age was 39 ± 23 years. Bacteremia was present in 44.84% of cases, followed by the urinary tract infection that was present in 21.21% of cases, followed by the cutaneous infection in 10.30% of cases, and last pulmonary infection in 9% of cases. Infection was polymicrobial in 14.5% of cases. The main bacteria identified were: Acinetobacter baumanii (43.45%) of which 74% is resistant to imipenem, Enterobacteriaceae (31.5%), Pseudomonas aeruginosa (24%) of which 83.25% is resistant to ceftazidime and 68.2% is resistant to imipenem, Enterococcus (16%) and Staphylococcus Aureus (14.29%).

Conclusion The incidence of nosocomial infection is very high compared to literature. The rate of resistance to common antibiotics is very high. A drastic management of antibiotics in our context, the selection of patients and the frequent use in the operating room for skincare allow a better management of these patients.

Competing interests None.

Reference
  1. 1.

    Wurtz R, Karajovic M, Dacumos E, Jovanovic B, Hanumadass M. Nosocomial infections in a burn intensive care unit. Burns. 1995;21:181–84.

     

P178 Ventilator acquired pneumonia: diagnosis treatment and bacterial ecology in a Moroccan intensive care unit

Hanane Ezzouine1, Mahmoud Kerrous1, Saad El Haoui1, Soufiane Ahdil1, Abdellatif Benslama1
1Anesthesiology and intensive care department, University Teaching Hospital IBN Rushd-Casablanca, Casablanca, Morocco
Correspondence: Hanane Ezzouine - ezzouinehanane@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P178

Introduction The management of ventilator acquired pneumonia is a diagnostic and therapeutic challenge. Antibiotic therapy is a key link. The objective of this work is to study the epidemiological, clinical patients who developed VAP during their stay in the Medical Intensive Care Unit of the CHU Ibn Rushd in Casablanca and are features of the bacterial ecology of VAP during the 2015.

Patients and methods It is a retrospective descriptive study and analytical spread over 1 year, from January 2015 to December 2015. Were included all patients with pneumonia Ventilator, with or without bacteraemia, after hospitalization for more than 48 h. Were collected clinical, biological, radiological, bacteriological and scalable patients included.

Results The average age of the patients was 42.19 years with a sex ratio (M/F) 1.47 APACHE II score average was 16.4, the average SAPSII was 31.12 and the average was 2.39 SOFA. 86.5% of patients were intubated on admission in intensive care. 3.5% were intubated within less than 5 days notice after admission and the average time to onset of VAP was 3.76 days. The VAP were early in 68.4% of cases. The average hospital stay of patients being 19.63 days. 73.68% in the sample used in our patients was bronchial aspiration. The most offending germs are 27.2% Acinetobacter baumannii, Pseudomonas aeruginosa 16.3%. 100% of patients received empirical antibiotic therapy chosen according to the ecology of the service. 77.4% died. 43.8% of deaths were directly related to VAP.

Conclusion Ventilator acquired pneumonia is main problem in our ICU. The bacteriological ecology must be usually known. In our unit Acinetobacter baumanii is the main germ associated.

Competing interests None.

P179 Determinants and prognostic factors of Acinetobacter baumannii ventilator-associated pneumonia

Khalid Abidi1, Tarek Dendane1, Ssouni Oussama1, Jihane Belayachi2, Naoufal Madani2, Redouane Abouqal2, Amine Ali Zeggwagh1
1Medical intensive care unit, Mohamed V University Hopital Ibn Sina, Rabat, Morocco; 2Service des urgences médicales hospitalières - ibn sina – université mohamed v – rabat, Hopital Ibn Sina, Rabat, Morocco
Correspondence: Tarek Dendane - tdendane@hotmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P179

Introduction Acinetobacter baumannii (AB) ventilator-associated pneumonia (VAP) is common in critically ill patients. The aims of this study were to describing the epidemiological characteristics of AB-VAP, to identify risk factors for acquisition and factors predictive of a poor outcome.

Materials and methods A retrospective-prospective study was conducted at the Medical Intensive Care Unit of the University Hospital Ibn Sina, Rabat-Morocco from January 2013 to December 2015. They were included in the study that all patients developed VAP with identified germ. For identification of risk factors of acquisition of AB VAP, two groups of patients were compared: patients with AB VAP versus patients with VAP caused by other germs. To identify factors associated with mortality, two other groups were compared: Survivors versus died.

Results 122 patients presented VAP among which 60 were caused by Acinetobacter baumannii. Among isolates of AB, 8.3% were drug susceptible, and 16.7% were multidrug-resistant while 75% were extensively drug-resistant. They were Independent risk factors for acquisition of AB VAP in multivariate analysis: the presence of a central venous catheter before the occurrence of VAP, duration of prior hospitalization ≥4 days and ICU duration of stay ≥5 days. The mortality rate of AB VAP was 85%. The independent risk factors for poor outcome in multivariate analysis were: duration of antibiotic treatment >7 days, the reintubation and the presence of a previous hospitalization.

Discussion Our data were similar to those of the literature with a high incidence of VAP due to the AB (49%) and a high rate of resistance to this bacterium particularly to carbapenems. However, and compared to the literature, the VAP AB were responsible for a death rate much higher (85%).

Conclusion Our data were similar to those of the literature with a high incidence of VAP due to the AB (49%) and a high rate of resistance to this bacterium particularly to carbapenems. However, and compared to the literature, the VAP AB were responsible for a death rate much higher (85%).

Competing interests None.

P180 Ventilator-associated pneumonia in the elderly: a study of the prognosis

Hatem Ghadhoune1, Anis Chaari2, Guissouma Jihene1, Hend Allouche1, Insaf Trabelsi1, Habib Brahmi1, Mohamed Samet1, Hatem El Ghord1
1Réanimation médicale bizerte, Faculté de médecine de Tunis, Bizerte, Tunisia; 2Intensive care unit, King Hamad University Hospital, Muharraq, Bahrain
Correspondence: Hatem Ghadhoune - ghadhoune@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):P180

Introduction Ventilator-associated pneumonia (VAP) is common in critically-ill patients. In fact, 10–20% of patients requiring invasive mechanical ventilation develop this complication. The onset of VAP has been reported to be associated with increased mortality. However, data related to critically-ill elderly patients are scarce. The aim of this study is to assess the prognostic impact of VAP in critically-ill elderly patients.

Patients and methods Mono-center, retrospective study conducted from 01/012014 to 30/09/2015. All old patients (age ≥65 years) requiring mechanical ventilation were included. Two groups were compared: Patients who developed VAP (VAP (+) group) and those who did not develop VAP (VAP (−) group).

Results During the study period, 86 patients were included. The causes of admission in the intensive care unit (ICU) were shock (n = 30), acute respiratory failure (n = 41) and disturbed level of consciousness (n = 15). Diabetes mellitus, hypertension and chronic obstructive pulmonary disease were the most common comorbidities (44.2, 32.6 and 40.7% respectively). Mean age was 73.3 ± 6.5 years. Sex-ratio (M/F) was 1.8. Mean APACHE(II) score was 24 ± 9. The mean duration of mechanical ventilation was 10 ± 15 days. Thirty patients (34.9%) developed VAP. ICU-mortality was significantly higher in the VAP (+) group (90 vs 55.4%; p = 0.001). Multivariate analysis identified two independent factors predicting ICU mortality: Shock on admission (OR = 22.7, CI 95% [5.1–101.2], p < 0.001) and VAP (OR = 5.7, CI 95% [1.2–28.1], p = 0.033).

Conclusion VAP is common in critically-ill elderly patients and is associated with worse outcome. Therefore, preventing its onset is of paramount importance.

Competing interests None.

Reference
  1. 1.

    Magill SS, Li Q, Gross C, Dudeck M, Allen-Bridson K, Edwards JR. Crit Care Med. 2016 Aug 10. [Epub ahead of print].

     

P181 Epidemiologic characterization and prognosis factors of Acinetobacter baumannii ventilator-associated pneumonia

Ben Sik Ali Habiba1, Nouira Hajer2, Najla Tilouch2, Sondes Yaakoubi2, Oussama Jaoued2, Rim Gharbi2, Mohamed Fekih Hassen2, Souheil Elatrous2
1Réanimation médicale, EP taher sfar, Mahdia, Tunisia; 2Réanimation médicale, EPS Taher Sfar Mahdia, Mahdia, Tunisia
Correspondence: Mohamed Fekih Hassen - mohamed.fekihhassen@rns.tn

Annals of Intensive Care 2017, 7(Suppl 1):P181

Introduction Ventilator associated pneumonia (VAP) is the most frequent nosocomial infection in critically ill patients. It is associated with high mortality, prolonged mechanical ventilation, length of stay, and increased health-care costs. Among pathogens responsible of VAP, Acinetobacter baumannii which is characterized by its ability to spread in the hospital environment and to acquire resistance leading sometimes to therapeutic impasses is associated with a particularly high mortality reaching 30–75%.

Objective To describe the epidemiological characteristics of A. baumannii VAP, to determine their prognosis and identify factors associated with mortality.

Patients and methods It is a monocentric observational study conducted over a period of 13 years in a Tunisian intensive care unit (ICU) including mechanical ventilated patients for more than 48 h with confirmed A. baumannii VAP.

Results One hundred and twenty-three patients were included in the study. A. baumannii was responsible for 31% of VAP in our ICU. The VAP were late in 59% of cases. More than 90% of isolates pathogens were resistant to ticarcillin, piperacillin, piperacillin–tazobactam, ceftazidime and ciprofloxacin. Sixty percent of germs were sensitive to imipenem. Resistance to imipenem has increased consistently from 0% at the beginning of the study to 88% in 2015. All pathogens were susceptible to colistin. A. baumannii VAP was complicated by septic shock in 63% of cases. The median duration of mechanical ventilation and of ICU stay were 17 (IQR: 11–25) and 25 days (IQR: 17–41) respectively. The use of parenteral nutrition was the only factor associated with the occurrence of A. baumannii VAP resistant to imipenem (odds ratio 2.27, 95% CI [1.07–4.80], p = 0.033). ICU mortality was 45%. It was higher in patients with A. baumannii VAP resistant to imipenem (55 vs 39%, p > 0.05). In the multivariate analysis, the age, the use of renal replacement therapy and the occurrence of VAP relapse have been identified as factors associated with mortality.

Conclusion A. baumannii resistance to imipenem became threatening. The use of parenteral nutrition was the only factor associated with the occurrence of A. baumannii VAP resistant to imipenem. The choice of empiric antimicrobial for VAP caused by this pathogen must take in consideration the epidemiologic data of each country and each ICU. A. baumannii VAP was associated with high mortality. The age, the use of renal replacement therapy and the occurrence of VAP relapse have been identified as predictive of poor outcome.

Competing interests None.

P182 Admission in intensive care unit for severe adverse drug event: what finding?

Julien Arcizet1, Bertrand Leroy1, Caroline Abdulmalack2, Catherine Renzullo1, Maël Hamet2, Jean-Marc Doise2, Jérôme Coutet1
1Pharmacy unit, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône, France; 2Intensive care unit, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône, France
Correspondence: Julien Arcizet - julien.arcizet@ch-chalon71.fr

Annals of Intensive Care 2017, 7(Suppl 1):P182

Introduction Adverse drug events (ADE) remain a serious public health problem. They represent between 0.16 and 15.7% of hospital admissions and between 0.37 and 27.4% of intensive care unit (ICU) admissions. They are defined as any injury related to a drug, and include both adverse drug reactions, expected or not, but also underuse, overuse and misuse, unintended or undesired, preventable or not. Indeed, mortality from iatrogenic event would rise between 2.0 and 28.1%, whereas these ADE that resulted in ICU hospitalization could be prevented in 17.5–85.7% of cases. These unplanned admissions overload ICU, limit access to health care for other patients and have serious economic consequences for the health system. It is therefore necessary to study these ADE to know their main causes and attempt to find a solution to avoid them.

The main objectives of our study were to clinically and pharmaceutically analyze and stratify the different ADE leading to hospitalization in our ICU.

Patients and methods This is a monocentric prospective study, between June 2014 to January 2016, in medico-surgery ICU. From all admissions, we had included patients admitted in our hospital for involuntary ADE (plausible, likely and very likely causal). We had collected clinical aspects (Failure mode, IGSII score, mortality in ICU) and pharmaceutical aspect (number of drug, offending drugs) at daily medical staff meeting.

Results On 1545 admissions, 154 patients were hospitalized for unintended ADE. The average age was 70 years old [26; 95], with a men/women ratio equal to 1.8. The clinical severity IGSII score found was 51 [13; 120]. Average length of stay in ICU was 5.5 days [1; 28] on average in this unit. The main reasons of admission were: hematologic failure (in particular hemorrhagic) (29.9%), metabolic failure (19.5%), renal failure (11.0%), neurological failure (11.0%) and sepsis (10.4%). Respiratory, hepatic, hemodynamic failures and hypersensitivity reactions represented respectively less than 10% of cases. 34 patients (22%) included died during their stays in ICU. On average, 7.6 drugs were found in the usual treatment of the patient. 32.5% of this population had a known cognitive disorder and 62% of them self-management of their treatment. The main drugs involved were: furosemide (16.9%), metformin (13.0%), perindopril (9.1%), lysine acetylsalicylate (8.4%), warfarin (8.4%) and fluindione (7.8%). The most common drug families involved were: drugs of the cardiovascular system (33.8% of cases), anticoagulants and antiplatelet agents (31.8%), antidiabetics (16.9%) and psychotropic (13.6%).

Conclusion Hospitalizations in ICU for ADE are still too common despite their preventability for most cases. Many patients with known cognitive disorder manage their treatment themselves and this is probably one of the reasons of iatrogenic events. Anticoagulants and antiplatelet agents, by side effects, misuse, underuse or overuse are very often involved. The onset of kidney failure from dehydration and the continuation of nephrotoxic and antidiabetic treatment also remain one of the most common causes. Consequently, it is necessary to continue and develop primary, secondary and tertiary prevention strategies to prevent their appearance, to limit their consequences and to reduce recidivism.

Competing interests None.

P183 Prolonged intensive care unit stay: prognostic factors

Chaigar Mohammed Cheikh1, Zakaria Quechar1, Hanane Ezzouine1, Abdellatif Benslama1
1Anesthesiology and intensive care department, UNIVERSITY TEACHING HOSPITAL IBN RUSHD-CASABLANCA, Casablanca, Morocco
Correspondence: Chaigar Mohammed Cheikh - chaigarmed@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):P183

Introduction Intensive care unit (ICU) is usually identified as a place of acute care, concentrated over a short period. For many reasons, a prolonged stay in the ICU has a pejorative connotation for the intensivist physician. The aim of our study is to describe the epidemiological, clinical, paraclinical profile of patients hospitalized for a long time in ICU (over 15 days) and to identify the main prognostic factors and those that can predict the duration of stay in ICU.

Patients and methods We conducted a retrospective study, over a period of 5 years and 6 months (January 2010 to June 2015), enrolling patients whose length of stay was greater than or equal to 15 days in medical ICU of the UH Ibn Rochd of Casablanca. Statistical analysis was performed using SPSS 21.0.

Results We enrolled 151 patients witch correspond to 8.2% of all admissions. The sex ratio was 1.6, the average age was (43.2 ± 18.5 years). The majority of patients (75%) were transferred from the emergency department. Medical pathology was the main motive of admission (82.1% of cases). Means of severity scores were calculated as follows: APACHE III (56.2 ± 22.9), IGS III (40 ± 9.6), OSF (0.6 ± 0.7). The average length of stay was (42.2 ± 59.7 days). The incidence of nosocomial infection was 82.8%, the average day of onset was 9.34 ± 8.7 days. Pneumonia, bacteremia and vascular catheter infections were the main sites, Gram-Negative Bacilli were the most frequently identified, dominated by Acinetobacter baumanii (27.9%). Mechanical ventilation (91.4%) and vascular catheterization (84.1%) are the most used invasive devices. Antibiotics (92.1%), sedation (91.4%) and vasopressors (60.9%) were the main administrated treatments. The outcome was favorable in 37.7% of cases. Hemodynamic instability (64.2%) and respiratory complications (61.6%) were the complications most frequently observed, septic shock occurred in 49% of cases. Mortality rate was 55%. In univariate analysis, the variables that have emerged as risk factors of mortality were: sex, length of hospitalization, severity scores (APACHE III, IGS III, OSF), the Charlson comorbidity score adjusted to age, traumatic pathology, the occurrence of nosocomial infection, septic shock, hemodynamic instability, neurological worsening, use of vasopressors, and tracheostomy. In multivariate analysis: nosocomial infection (p = 0.04), hemodynamic worsening (p = 0.03), use of vasopressors (p < 0.01) and antibiotics (p < 0.01) appeared to be risk factors of mortality.

Conclusion Although patients hospitalized in ICU for more than 15 days are few, they represent a serious problem of care and an important part of the activity of intensive care (bed occupancy, care costs).

Competing interests None.

P184 Admissions and readmissions to the intensive care unit of patients with hematologic malignancies: a 5 years retrospective study

Magalie Joris1, Dimitri Titeca Beauport1, Loay Kontar1, Delphine Lebon2, Bérengère Gruson2, Michel Slama1, Jean-Pierre Marolleau2, Julien Maizel1
1Réanimation médicale, Centre Hospitalier Universitaire, Amiens, France; 2Hématologie clinique et thérapie cellulaire, Centre Hospitalier Universitaire, Amiens, France
Correspondence: Magalie Joris - joris.magalie@chu-amiens.fr

Annals of Intensive Care 2017, 7(Suppl 1):P184

Introduction Despite an improvement in prognosis of patients with hematologic malignancies for the last decade, mortality of such patients admitted to the intensive care unit (ICU) remains high. Yet, it seems that a first ICU stay does not modify prognosis of the malignancy. Until now, there is no data on readmission in the ICU of such patients and its effect on short and long term prognosis impact.

Patients and methods This retrospective, single-center study conducted on a 5 years period in the medical ICU from our university hospital included 265 patients with hematological malign