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The optimal isolation time of COVID-19 patients in intensive care unit (ICU) is debated. We investigated the impact of two different COVID-19 patient isolation time strategies on healthcare workers (HCW) contamination, intensity of nursing care and potential associated adverse events. We prospectively included all consecutive COVID-19 patients and HCW in our ICU in the first two pandemic waves (March to May 2020 and August to November 2020). Specific isolation measures for COVID-19 patients were released after two negative RT-PCR assays in the first wave and 14 days after the onset of symptoms in the second wave. Contamination of HCW was assessed at the end of each pandemic wave by combining both a RT-PCR assay and a serological test. Overall, 117 COVID-19 patients and 73 HCW were included. Despite an earlier release from isolation after ICU admission in the second than in the first wave [6 (4-8) vs. 15 (11-19) days, < 0.01], the proportion of HCW with a positive serological test (16 vs. 17%, = 0.94) or with a positive RT-PCR assay (3 vs. 5%, = 0.58) was not different between the two waves. Although a lower nurse-to-bed ratio, the intensity of nursing care was higher in the second than in the first wave. A longer isolation time was associated with accidental extubation (OR = 1.18, 95%CI:1.07-1.35, = 0.005) but neither with ventilator-associated pneumonia nor with dysglycemia. A shorter isolation time of COVID-19 patients in ICU was not associated with higher HCW contamination, while a longer isolation time seemed to be associated with higher accidental extubation.

Background Pneumonia is one of the major complications of drowning, but the optimal empirical antibiotic treatment is not clearly defined. Multidrug-resistant (MDR) bacteria and fungi have been identified in a recent series of freshwater drowning-associated pneumonia. However, microbial data in seawater drowning are scarce. The objective of the study is to describe the microorganisms isolated in early respiratory specimens obtained from seawater drowning-associated pneumonia and to provide their antibiotic susceptibility pattern. Methods All patients admitted for seawater drowning between 2003 and 2013 to two intensive care units, from the region in France with the highest drowning rate, were retrospectively included. Demographics, antimicrobial therapy and microbiological data from respiratory samples collected within the first 48 h after admittance were analyzed. Results Seventy-four drowned patients were included, of which 36 (49%) were diagnosed by the clinician as having early pneumonia. Concerning the overall population, the median simplified acute physiology score (version 2) was 45 (30–65), and the mortality was 26%. Twenty-four respiratory samples from different patients were obtained within the first 48 h. Sixteen were positive. The main microorganisms found were Enterobacteriaceae ( Enterobacter spp., Klebsiella spp. and Escherichia coli ) and Gram-positive aerobic cocci ( Streptococcus pneumonia and Staphylococcus aureus) with a low rate of antimicrobial resistance. No MDR bacteria or fungi were identified. However, among the positive respiratory samples collected, 5/16 (31%) grew bacteria with natural resistance to amoxicillin–clavulanate, the first-line antibiotic commonly used in our cohort. Resistance was only found among Gram-negative bacteria and from respiratory samples of patients with a higher drowning grade at admission ( p  = 0.01). Conclusions This 10-year descriptive study, the largest cohort to date, provides early respiratory samples from seawater drowning patients. The microorganisms retrieved were either mostly part of the human oro-pharyngeal flora or Enterobacteriaceae and displayed low rates of antimicrobial resistance. Respiratory samples should nonetheless be collected at admittance to the ICU to avoid inappropriate treatment. Empiric use of cephalosporin could be restricted to severe patients or if Gram-negative bacilli are found after direct examination.

T cell activation as well as unresponsiveness has been described in separate studies in sepsis. Our aim was to establish the coexistence of both T cell fate in human sepsis. This is a cross-sectional study of 48 patients presenting with severe sepsis or septic shock and 15 healthy controls. Cytofluorometric techniques were used to quantify T cell activation, apoptosis, proliferation, expression of costimulatory molecules, and cytokine secretion. Patients with sepsis were characterized by a significant increase in the percentage of activated T cell subsets, as measured using CD69 marker, compared with healthy controls (P<.05). T cell proliferation as measured through Ki67 expression was obvious in infected patients for both CD4 and CD8 T cell subsets compared with controls (P≤.006). T cell subset apoptosis as measured using Hoechst dye was also increased in infected patients compared with controls (P≤.002). CD4 T cell proliferation was correlated with interleukin 2 secretion (R2=0.84, P<.001), whereas up-regulation of CD4 T cell apoptosis was correlated with CTLA-4 expression (R2=0.24, P=.001). No such similar relationship was observed for CD8+ T cells. Concomitant T cell proliferation and T cell apoptosis are observed in human sepsis, being related to a different pathway.

Pathophysiology of cardiac arrest corresponds to an ischemia-reperfusion syndrome with deep impairment of microcirculation. Muscular tissue oxygen saturation (StO2) is a noninvasive method of evaluation of microcirculation. Our study was aimed at assessing the prognosis value of muscular StO2 in patients admitted for out-of-hospital cardiac arrest (OHCA) and treated with hypothermia. We conducted a prospective bicentric observational study including OHCA patients treated with therapeutic hypothermia. Baseline StO2, derived variables (desaturation and resaturation slopes), and lactate levels were compared at different times between patients with good and poor outcomes. Prognosis was assessed by the Cerebral Performance Category (CPC) score at 6 months after admission (CPC 1-2, good outcome; CPC 3-5, poor outcome). Forty-four patients were included, 17 good and 27 poor outcomes at 6 months. At admission, StO2 and lactate levels were lower in good outcome patients. Desaturation and resaturation slopes did not differ between groups. After an OHCA treated with therapeutic hypothermia, StO2 was correlated with outcome. Further research is needed to better understand the pathophysiological process underlying our results.

Listeriosis is a severe foodborne infection and a notifiable disease in France. We did a nationwide prospective study to characterise its clinical features and prognostic factors. MONALISA was a national prospective observational cohort study. We enrolled eligible cases declared to the National Reference Center for Listeria (all microbiologically proven) between Nov 3, 2009, and July 31, 2013, in the context of mandatory reporting. The outcomes were analysis of clinical features, characterisation of Listeria isolates, and determination of predictors of 3-month mortality or persisting impairment using logistic regression. A hierarchical clustering on principal components was also done for neurological and bacteraemic cases. The study is registered at ClinicalTrials.gov, number NCT01520597. We enrolled 818 cases from 372 centres, including 107 maternal–neonatal infections, 427 cases of bacteraemia, and 252 cases of neurolisteriosis. Only five (5%) of 107 pregnant women had an uneventful outcome. 26 (24%) of 107 mothers experienced fetal loss, but never after 29 weeks of gestation or beyond 2 days of admission to hospital. Neurolisteriosis presented as meningoencephalitis in 212 (84%) of 252 patients; brainstem involvement was only reported in 42 (17%) of 252 patients. 3-month mortality was higher for bacteraemia than neurolisteriosis (hazard ratio [HR] 0·54 [95% CI 0·41–0·69], p<0·0001). For both bacteraemia and neurolisteriosis, the strongest mortality predictors were ongoing cancer (odds ratio [OR] 5·19 [95% CI 3·01–8·95], p<0·0001), multi-organ failure (OR 7·98 [4·32–14·72], p<0·0001), aggravation of any pre-existing organ dysfunction (OR 4·35 [2·79–6·81], p<0·0001), and monocytopenia (OR 3·70 [1·82–7·49], p=0·0003). Neurolisteriosis mortality was higher in blood-culture positive patients (OR 3·67 [1·60–8·40], p=0·002) or those receiving adjunctive dexamethasone (OR 4·58 [1·50–13·98], p=0·008). The severity of listeriosis is higher than reported elsewhere. We found evidence of a significantly reduced survival in patients with neurolisteriosis treated with adjunctive dexamethasone, and also determined the time window for fetal losses. MONALISA provides important new data to improve management and predict outcome in listeriosis. Programme Hospitalier Recherche Clinique, Institut Pasteur, Inserm, French Public Health Agency.

Purpose Lung volumes, especially functional residual capacity (FRC), are decreased in acute respiratory distress syndrome (ARDS). Positive end-expiratory pressure (PEEP) contributes to increased end-expiratory lung volume (EELV) and to improved oxygenation, but differentiating recruitment of previously nonaerated lung units from distension of previously open lung units remains difficult. This study evaluated simple methods derived from bedside EELV measurements to assess PEEP-induced lung recruitment while monitoring strain. Methods Prospective multicenter study in 30 mechanically ventilated patients with ARDS in five university hospital ICUs. Two PEEP levels were studied, each for 45 min, and EELV (nitrogen washout/washin technique) was measured at both levels, with the difference (Δ) reflecting PEEP-induced lung volume changes. Alveolar recruitment was measured using pressure-volume (PV) curves. High and low recruiters were separated based on median recruitment at high PEEP. Minimum predicted increase in lung volume computed as the product of ΔPEEP by static compliance was subtracted from ΔEELV as an independent estimate of recruitment. Estimated and measured recruitments were compared. Strain induced by PEEP was also calculated from the same measurements. Results FRC was 31 ± 11% of predicted. Median [25th–75th percentiles] PEEP-induced recruitment was 272 [187–355] mL. Estimated recruitment correlated with recruited volume measured on PV curves (ρ = 0.68), with a slope close to identity. The ΔEELV/FRC ratio differentiated high from low recruiters (110 [76–135] vs. 55 [23–70]%, p  = 0.001). Strain increase due to PEEP was larger in high recruiters ( p  = 0.002). Conclusion PEEP-induced recruitment and strain can be assessed at the bedside using EELV measurement. We describe two bedside methods for predicting low or high alveolar recruitment during ARDS.

The primary end point when treating acute shock is to restore blood circulation, mainly by reaching macrocirculatory parameters. However, even if global haemodynamic goals can be achieved, microcirculatory perfusion may remain impaired, leading to cellular hypoxia and organ damage. Interestingly, few methods are currently available to measure the adequacy of organ blood flow and tissue oxygenation. The rise in tissue partial pressure of carbon dioxide (CO 2 ) has been observed when tissue perfusion is decreased. In this regard, tissue partial pressure of CO 2 has been proposed as an early and reliable marker of tissue hypoxia even if the mechanisms of tissue partial pressure in CO 2 rise during hypoperfusion remain unclear. Several technologies allow the estimation of CO 2 content from different body sites: vascular, tissular (in hollow organs, mucosal or cutaneous), and airway. These tools remain poorly evaluated, and some are used but are not widely used in clinical practice. The present review clarifies the physiology of increasing tissue CO 2 during hypoperfusion and underlines the specificities of the different technologies that allow bedside estimation of tissue CO 2 content.

Cutaneous manifestations of miliary tuberculosis are extremely rare. We describe a 62-year-old woman with leukopenia who developed infiltrated dermal-hypodermal and ulcerative cutaneous lesions during the course of miliary tuberculosis. Miliary tuberculosis was diagnosed when Mycobacterium tuberculosis bacilli were isolated by cultures of the bronchoalveolar lavage fluid and blood and when acid-fast bacilli were detected on histopathologic examination of hepatic, pulmonary, and cutaneous biopsy specimens. With the increasing incidence of immunocompromised patients, unusual presentations of tuberculosis may be observed more often. Acute miliary tuberculosis of the skin is an exceptional manifestation that is due to acute hematogenous dissemination of M. tuberculosis to the skin. We describe a patient who had unusual cutaneous manifestations of miliary tuberculosis.

Diffuse alveolar haemorrhage (DAH) complicating primary catastrophic anti-phospholipid syndrome (CAPS) was diagnosed in a 50-year-old female patient. Treatment strategies are limited for this often life-threatening autoimmune disease that requires aggressive immunosuppression. In the absence of clinically validated treatment strategies, high-dose steroids associated with plasma exchange and eventually intravenous immunoglobulins were used to manage the disease. Its severity prompted the initiation of rituximab that was administered weekly for four consecutive weeks. Anticoagulation therapy, on the other hand, needed to be discontinued due to the major haemorrhagic episodes. This combination treatment provided an effective control of the CAPS-associated DAH and helped achieve clinical remission.