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Background Group A Streptococcus is responsible for severe and potentially lethal invasive conditions requiring intensive care unit (ICU) admission, such as streptococcal toxic shock-like syndrome (STSS). A rebound of invasive group A streptococcal (iGAS) infection after COVID-19-associated barrier measures has been observed in children. Several intensivists of French adult ICUs have reported similar bedside impressions without objective data. We aimed to compare the incidence of iGAS infection before and after the COVID-19 pandemic, describe iGAS patients’ characteristics, and determine ICU mortality associated factors. Methods We performed a retrospective multicenter cohort study in 37 French ICUs, including all patients admitted for iGAS infections for two periods: two years before period (October 2018 to March 2019 and October 2019 to March 2020) and a one-year after period (October 2022 to March 2023) COVID-19 pandemic. iGAS infection was defined by Group A Streptococcus isolation from a normally sterile site. iGAS infections were identified using the International Classification of Diseases and confirmed with each center's microbiology laboratory databases. The incidence of iGAS infections was expressed in case rate. Results Two hundred and twenty-two patients were admitted to ICU for iGAS infections: 73 before and 149 after COVID-19 pandemic. Their case rate during the period before and after COVID-19 pandemic was 205 and 949/100,000 ICU admissions, respectively ( p  < 0.001), with more frequent STSS after the COVID-19 pandemic (61% vs. 45%, p  = 0.015). iGAS patients ( n  = 222) had a median SOFA score of 8 (5–13), invasive mechanical ventilation and norepinephrine in 61% and 74% of patients. ICU mortality in iGAS patients was 19% (14% before and 22% after COVID-19 pandemic; p  = 0.135). In multivariate analysis, invasive mechanical ventilation (OR = 6.08 (1.71–21.60), p  = 0.005), STSS (OR = 5.75 (1.71–19.22), p  = 0.005), acute kidney injury (OR = 4.85 (1.05–22.42), p  = 0.043), immunosuppression (OR = 4.02 (1.03–15.59), p  = 0.044), and diabetes (OR = 3.92 (1.42–10.79), p  = 0.008) were significantly associated with ICU mortality. Conclusion The incidence of iGAS infections requiring ICU admission increased by 4 to 5 after the COVID-19 pandemic. After the COVID-19 pandemic, the rate of STSS was higher, with no significant increase in ICU mortality rate.

IntroductionCritically ill patients often require enteral nutrition, but the optimal feeding strategy—continuous or intermittent—remains uncertain. While continuous enteral nutrition ensures steady nutrient delivery, it may inhibit key metabolic and cellular processes such as autophagy and ketogenesis. Intermittent enteral nutrition, by mimicking fasting periods, could activate protective pathways, potentially improving clinical outcomes. However, evidence for its efficacy and safety in intensive care units (ICUs) is limited. This study evaluates the clinical and metabolic impacts of fasting intervals during intermittent enteral nutrition compared with continuous enteral nutrition in critically ill patients.Methods and analysisWe designed a multicenter, randomised, open-label trial across nine French ICUs, enrolling adult patients requiring mechanical ventilation and vasopressor support. Participants will receive either intermittent or continuous enteral nutrition for 7 days, with the primary endpoint being the change in the Sequential Organ Failure Assessment (SOFA) score from Day 1 to Day 7 or ICU discharge. Secondary endpoints include nutritional intake, metabolic markers, gastrointestinal tolerance, ICU-acquired infections and mortality rates. Quality of life will be assessed at discharge. A total of 174 patients will be included. Descriptive statistics will summarise group characteristics, with the Student’s t-test or the Mann-Whitney U test depending on data distribution for SOFA score change, and regression for confounders. Secondary endpoints will be analysed using regression, χ2 or Fisher’s exact test, as appropriate.Ethics and disseminationThe study protocol was approved by a French ethics committee on 24 October 2023 (Comité de Protection des Personnes Ile de France 1, Paris, France, number SI 23.03427.000435). Patients are included after providing informed consent. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberRegistered on clinicaltrials.gov on 26 March 2023 (NCT06330610).

The use of hydroxocobalamin has long been advocated for treating suspected cyanide poisoning after smoke inhalation. Intravenous hydroxocobalamin has however been shown to cause oxalate nephropathy in a single-center study. The impact of hydroxocobalamin on the risk of acute kidney injury (AKI) and survival after smoke inhalation in a multicenter setting remains unexplored.

Background Post-extubation stridor is a common complication of endotracheal intubation in ICU. This study aimed to assess whether a series of pre-extubation upper airway ultrasound measurements using shear wave elastography (SWE) could help in detecting post-extubation stridor. Methods A prospective observational study (NCT05611437) was conducted between 2022 and 2024, which consecutively included 150 adults ICU patients intubated for more than 24 h, without prior surgical or neurological upper airway disease nor swallowing disorders. SWE measurements were performed in the 24 h before extubation. The occurrence of post-extubation stridor, dysphonia and swallowing disorders were assessed within 72 h. Results 125 participants were included in the final analysis. A total of 2,625 ultrasound images were obtained, with 81% deemed interpretable. Post-extubation stridor occurred in 9% of patients and was independently associated with sepsis at admission (OR 8.98; 95%CI 1.3–62.1). No differences were observed between upper airway ultrasound in patients with or without stridor. Stridor was associated with higher rates of dysphonia (82% vs. 23%), swallowing disorders (36% vs. 11%), and extubation failure (46% vs. 10%). Swallowing disorders were independently associated with the duration of mechanical ventilation (OR 1.10; 95% CI 1.04–1.17). Dysphonia was associated with female sex (OR 3.23; 95%CI 1.24–8.37), sternothyroid muscle stiffness (OR 1.11; 95%CI 1.04–1.18), and days of mechanical ventilation (OR 1.09; 95%CI 1.02–1.15). Conclusion Oropharyngeal SWE is feasible in critically ill patients before extubation, but was not predictive of post-extubation stridor. Further studies are needed to explore its role in predicting post-extubation upper airway complications.

PurposeData on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality.MethodsA 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up).ResultsAmong the 306 included patients, 126 (41.2%; 95% CI 35.6–46.9) died and 180 (58.8%; 95% CI 53.3–64.3) survived during the follow-up period [13 (3–24) days], including 51/180 patients (28.3%, 95% CI 21.9–35.5) who eventually required limb amputations, with a median number of 3 (1–4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02–1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69–0.99); p = 0.034] and platelet counts [HR 0.77 (0.60–0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68–4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28–0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06–3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis.ConclusionPurpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation.Trials registrationNCT03216577.

Background Neisseria meningitidis is the leading responsible bacterium of Purpura Fulminans (PF) accounting for two thirds of PF. Skin biopsy is a simple and minimally invasive exam allowing to perform skin culture and polymerase chain reaction (PCR) to detect Neisseria meningitidis . We aimed to assess the sensitivity of skin biopsy in adult patients with meningococcal PF. Methods A 17-year multicenter retrospective cohort study including adult patients admitted to the ICU for a meningococcal PF in whom a skin biopsy with conventional and/or meningococcal PCR was performed. Results Among 306 patients admitted for PF, 195 had a meningococcal PF (64%) with a skin biopsy being performed in 68 (35%) of them. Skin biopsy was performed in median 1 day after the initiation of antibiotic therapy. Standard culture of skin biopsy was performed in 61/68 (90%) patients and grew Neisseria meningitidis in 28 (46%) of them. Neisseria meningitidis PCR on skin biopsy was performed in 51/68 (75%) patients and was positive in 50 (98%) of them. Among these 50 positive meningococcal PCR, five were performed 3 days or more after initiation of antibiotic therapy. Finally, skin biopsy was considered as contributive in 60/68 (88%) patients. Identification of the meningococcal serogroup was obtained with skin biopsy in 48/68 (71%) patients. Conclusions Skin biopsy with conventional culture and meningococcal PCR has a global sensitivity of 88% and should be systematically considered in case of suspected meningococcal PF even after the initiation of antimicrobial treatment.

BACKGROUND: Pneumococcal infections remain the main cause of overwhelming post-splenectomy infections, and purpura fulminans may develop in almost 20% of patients with overwhelming post-splenectomy infection. We aimed at describing the impact of asplenia/hyposplenia on the clinical features and the outcomes of adult patients admitted to the intensive care unit (ICU) for pneumococcal purpura fulminans. METHODS: A 17-year national multicenter retrospective cohort study included adult patients admitted to 55 French ICUs for an infectious purpura fulminans from 2000 to 2016. Patients with pneumococcal purpura fulminans were analyzed according to the absence or presence of asplenia/hyposplenia. RESULTS: Among the 306 patients admitted to the ICU for purpura fulminans, 67 (22%) had a pneumococcal purpura fulminans, of whom 34 (51%) had asplenia (n = 29/34, 85%) or hyposplenia (n = 5/34, 15%) and 33 (49%) had eusplenia. The prevalence of pneumococcal purpura fulminans was seven times higher in asplenic/hyposplenic patients compared to eusplenic patients with purpura fulminans (n = 34/39, 87% vs. n = 33/267, 12%; p \\textless 0.001). The median time interval between the occurrence of asplenia/hyposplenia and ICU admission was 20 [9-32] years. Pneumococcal vaccine coverage was 35% in asplenic/hyposplenic patients. Purpura was more frequently reported before ICU admission in asplenic/hyposplenic patients (n = 25/34, 73% vs. n = 13/33, 39%; p = 0.01). The rate of bacteremia did not differ between asplenic/hyposplenic and eusplenic patients (n = 31/34, 91% vs n = 27/33, 82%; p = 0.261). SAPS II (60 ± 14 vs. 60 ± 18; p = 0.244) and SOFA (13 [1-5] vs. 14 [1-4, 6]; p = 0.48) scores did not differ between asplenic/hyposplenic and eusplenic patients. There were no significant differences between asplenic/hyposplenic and eusplenic patients regarding the rate of limb amputation (n = 9/34, 26% vs. 15/33, 45%; p = 0.11) and hospital mortality (n = 20/34, 59% vs. n = 15/33, 45%; p = 0.27). CONCLUSIONS: Half of pneumococcal purpura fulminans episodes occurred in asplenic or hyposplenic patients. Pneumococcal vaccine coverage was reported in one third of asplenic/hyposplenic patients. Half of pneumococcal purpura fulminans episodes occurred more than 20 years after splenectomy. Outcomes of pneumococcal purpura fulminans did not show significant differences between patients with or without asplenia or hyposplenia, although the small number of patients included limited our power to detect potential differences between groups.

Long-term health-related quality of life (HR-QOL) of patients surviving the acute phase of purpura fulminans (PF) has not been evaluated. This was a French multicenter exposed-unexposed cohort study enrolling patients admitted in 55 intensive care units (ICUs) for PF from 2010 to 2016. Adult patients surviving the acute phase of PF (exposed group) were matched 1:1 for age, sex, and Simplified Acute Physiology Score II with septic shock survivors (unexposed group). HR-QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36) questionnaire, the Hospital Anxiety and Depression (HAD) scale, the Impact of Event Scale-Revised (IES-R), and the activity of daily living (ADL) and instrumental ADL (IADL) scales. The primary outcome measure was the physical component summary (PCS) of the SF-36 questionnaire. Thirty-seven survivors of PF and 37 of septic shock were phone-interviewed at 55 (interquartile range [IQR], 35-83) months and 44 (IQR, 35-72) months, respectively, of ICU discharge (P = .23). The PCS of the SF-36 was not significantly different between exposed and unexposed patients (median, 47 [IQR, 36-53] vs 54 [IQR, 36-57]; P = .18). There was also no significant difference between groups regarding the mental component summary of the SF-36, and the HAD, IES-R, ADL and IADL scales. Among the 37 exposed patients, those who required limb amputation (n = 12/37 [32%]) exhibited lower PCS (34 [IQR, 24-38] vs 52 [IQR, 42-56]; P = .001) and IADL scores (7 [IQR, 4-8] vs 8 [IQR, 7-8]; P = .021) compared with nonamputated patients. Long-term HR-QOL does not differ between patients surviving PF and those surviving septic shock unrelated to PF. Amputated patients have an impaired physical HR-QOL but a preserved mental health. NCT03216577.

Keywords: Purpura fulminans, Neisseria meningitidis, Streptococcus pneumoniae, Septic shock, Meningitis