Éditeur(s) : HAL CCSD American Medical Association (AMA)
Résumé : International audience
IMPORTANCE Although frequently used in treating intensive care unit (ICU) patients with sepsis, empirical antifungal therapy, initiated for suspected fungal infection, has not been shown to improve outcome. OBJECTIVE To determine whether empirical micafungin reduces invasive fungal infection (IFI)-free survival at day 28. DESIGN, SETTING, AND PARTICIPANTS Multicenter double-blind placebo-controlled study of 260 nonneutropenic, nontransplanted, critically ill patients with ICU-acquired sepsis, multiple Candida colonization, multiple organ failure, exposed to broad-spectrum antibacterial agents, and enrolled between July 2012 and February 2015 in 19 French ICUs. INTERVENTIONS Empirical treatment with micafungin (100mg, once daily, for 14 days) (n = 131) vs placebo (n = 129). MAIN OUTCOMES AND MEASURES The primary end pointwas survival without proven IFI 28 days after randomization. Key secondary end points included new proven fungal infections, survival at day 28 and day 90, organ failure, serum (1-3)-beta-D-glucan level evolution, and incidence of ventilator-associated bacterial pneumonia. RESULTS Among 260 patients (mean age 63 years; 91 [35%] women), 251 (128, micafungin group; 123, placebo group) were included in the modified intent-to-treat analysis. Median values were 8 for Sequential Organ Failure Assessment (SOFA) score, 3 for number of Candida-colonized sites, and 99 pg/mL for level of (1-3)-beta-D-glucan. On day 28, there were 82 (68%) patients in the micafungin group vs 79 (60.2%) in the placebo group who were alive and IFI free (hazard ratio [HR], 1.35 [95% CI, 0.87-2.08]). Results were similar among patients with a (1-3)-beta-D-glucan level of greater than 80 pg/mL (n = 175; HR, 1.41 [95% CI, 0.85-2.33]). Day-28 IFI-free survival in patients with a high SOFA score (> 8) was not significantly different when compared between the micafungin vs placebo groups (HR, 1.69 [95% CI, 0.96-2.94]). Use of empirical micafungin decreased the rate of new invasive fungal infection in 4 of 128 patients (3%) in the micafungin group vs placebo (15/123 patients [12%]) (P =.008). CONCLUSIONS AND RELEVANCE Among nonneutropenic critically ill patients with ICU-acquired sepsis, Candida species colonization at multiple sites, and multiple organ failure, empirical treatment with micafungin, compared with placebo, did not increase fungal infection-free survival at day 28.
ISSN: 0098-7484

hal-01405822
https://hal-univ-rennes1.archives-ouvertes.fr/hal-01405822
DOI : 10.1001/jama.2016.14655
PUBMED : 27706483

Éditeur(s) : HAL CCSD BioMed Central
Résumé : International audience
BACKGROUND: In the context of recent guidelines on invasive candidiasis (IC), how French intensive care units (ICUs) are managing IC? METHODS: This is a prospective observational multicenter cohort study. During 1 year (2012-2013), 87 French ICUs enrolled consecutive patients with suspected or proven IC (SIC or PIC) and receiving systemic antifungal therapy (SAT). Data were collected up to 28 days after inclusion. RESULTS: We studied 835 patients, 291 with PIC and 544 with SIC. At SAT initiation, patients with SIC were significantly more severe (SAPS II 50.1 ± 18.7 vs. 46.2 ± 18.0). Severe sepsis or septic shock prompted to initiate empiric SAT in 70 % of SIC. Within 4 days in median, the initial SAT was modified in 49 % of patients with PIC vs. 33 % patients with SIC. Modifications were most often motivated by mycological results, and de-escalation was the most frequent change. Regarding compliance to IC management guidelines, echinocandin was used for 182 (62.5 %) patients with PIC, and 287 (52.7 %) of those with SIC; central venous catheter was removed in 87 (54.3 %) of patients with candidaemia, and 43 of the remaining patients received echinocandin; and de-escalation was undertaken after 5 days of SAT in 142 patients, after 10 days in 13 patients. As 20.6 % of SIC were secondarily documented, 403/835 (48 %) patients had finally a proven IC. Candida albicans was the main pathogen (65.3 %), then Candida glabrata (15.9 %). The 28-day mortality rates were 40.0 % in candidaemia, 25.4 % in cIAI, and 26.7 % in deep-seated candidiasis. In the overall population of patients with proven IC, four independent prognostic factors were identified: immunosuppression (Odds Ratio (OR) = 1.977: 1.03-3.794 95 % confidence interval (CI), p = 0.04), age (OR = 1.035; 1.017-1.053 95 % CI; p  extless 0.001), SAPS extgreater46 on ICU admission (OR = 2.894; 1.81-4.626 95 % CI; p  extless 0.001), and surgery just before or during ICU stay (OR = 0.473; 0.29-0.77 95 % CI; p  extless 0.001). CONCLUSION: When SAT is initiated in French ICUs, the IC is ultimately proven for 48 % of patients. Empiric SAT is initiated in severely ill ICU patients. The initial SAT is often adapted, with de-escalation to fluconazole when possible. Mortality rate remains high
ISSN: 2110-5820

hal-01259216
https://hal-univ-rennes1.archives-ouvertes.fr/hal-01259216
DOI : 10.1186/s13613-015-0103-7
PUBMED : 26743881

Éditeur(s) : HAL CCSD Elsevier Masson
Résumé : National audience
Introduction Les péritonites secondaires à levures représentent une part importante des candidoses profondes et de leur traitement. Peu d’outils sont disponibles afin de prédire au mieux les patients susceptible d’avoir une culture du liquide péritonéal positive. L’étude AMARCAND II (10/202–09/2013) a analysé les patients de réanimation recevant un traitement antifongique pour un candidose invasive prouvée ou suspectée. L’analyse des patients ayant un traitement probabiliste pour péritonite à levure suspectée est présentée ici. Patients et méthodes Cent soixante-douze patients parmi les 835 inclus ont été analysés. Les patients ayant une documentation mycologique (groupe D) ont été comparés à ceux ayant une culture à levure négative (groupe ND). La performance du Candida score [1] et du Peritonitis score [2] ont été évalués dans cette population de candidose profonde suspectée. Résultats Parmi les 172 patients, 51 ont eu une péritonite documentée à levure et 121 un culture à levure négative. Les caractéristiques des groupes sont présentées dans le Tableau 1. L’AUC du Peritonitis score était de 0,63 [0,54–0,72] contre 0,40 [0,31–0,49] pour le Candida score, p = 0,005. Pour un Peritonitis score ≥ 3, la sensibilité était de 39,2 %, la spécificité de 81,8 %, la VPP de 47,6 % et la VPN de 76,2 %. Le Candida score ne permettait pas de classer les patients atteints de péritonite à levure. Discussion Peu d’éléments permettent de différencier les patients qui vont avoir une infection documentée des autres. La localisation sus-mésocolique de l’infection et l’antibiothérapie de plus de 48 heures sont les éléments les plus fiables retrouvés. Le Peritonitis score reste intéressant dans ce contexte mais le Candida score n’a aucune utilité
ISSN: 2352-5800

hal-01244999
https://hal-univ-rennes1.archives-ouvertes.fr/hal-01244999
DOI : 10.1016/j.anrea.2015.07.329

Éditeur(s) : HAL CCSD BioMed Central
Résumé : International audience
IntroductionFever is associated with a poor outcome in severely brain-injured patients, and its control is one of the therapies used in this condition. But, fever suppression may promote infection, and severely brain-injured patients are frequently exposed to infectious diseases, particularly ventilator-associated pneumonia (VAP). Therefore, we designed a study to explore the role of a fever control protocol in VAP development during neuro-intensive care.MethodsAn observational study was performed on severely brain-injured patients hospitalized in a university ICU. The primary goal was to assess whether fever control was a risk factor for VAP in a prospective cohort in which a fever control protocol was applied and in a historical control group. Moreover, the density of VAP incidence was compared between the two groups. The statistical analysis was based on a competing risk model multivariate analysis.ResultsThe study included 189 brain-injured patients (intervention group, n¿=¿98, and historical control group, n¿=¿91). The use of a fever control protocol was an independent risk factor for VAP (hazard ratio 2.73, 95% confidence interval [1.38, 5.38; P¿=¿0.005]). There was a significant increase in the incidence of VAP in patients treated with a fever control protocol (26.1 versus 12.5 VAP cases per 1000 days of mechanical ventilation). In cases in which a fever control protocol was applied for >3 days, we observed a higher rate of VAP in comparison with the rate among patients treated for ¿3 days.ConclusionFever control in brain-injured patients was a major risk factor for VAP occurrence, particularly when applied for >3 days.
ISSN: 1364-8535

hal-01118640
https://hal-univ-rennes1.archives-ouvertes.fr/hal-01118640
PUBMED : 25498970
DOI : 10.1186/s13054-014-0689-4
PUBMEDCENTRAL : PMC4279880