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1.  Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance 
Critical Care  2013;17(6):R265.
Introduction
Several guidelines recommend initial empirical treatment with two antibiotics instead of one to decrease mortality in community-acquired pneumonia (CAP) requiring intensive-care-unit (ICU) admission. We compared the impact on 60-day mortality of using one or two antibiotics. We also compared the rates of nosocomial pneumonia and multidrug-resistant bacteria.
Methods
This is an observational cohort study of 956 immunocompetent patients with CAP admitted to ICUs in France and entered into a prospective database between 1997 and 2010.
Patients with chronic obstructive pulmonary disease were excluded. Multivariate analysis adjusted for disease severity, gender, and co-morbidities was used to compare the impact on 60-day mortality of receiving adequate initial antibiotics and of receiving one versus two initial antibiotics.
Results
Initial adequate antibiotic therapy was significantly associated with better survival (subdistribution hazard ratio (sHR), 0.63; 95% confidence interval (95% CI), 0.42 to 0.94; P = 0.02); this effect was strongest in patients with Streptococcus pneumonia CAP (sHR, 0.05; 95% CI, 0.005 to 0.46; p = 0.001) or septic shock (sHR: 0.62; 95% CI 0.38 to 1.00; p = 0.05). Dual therapy was associated with a higher frequency of initial adequate antibiotic therapy. However, no difference in 60-day mortality was found between monotherapy (β-lactam) and either of the two dual-therapy groups (β-lactam plus macrolide or fluoroquinolone). The rates of nosocomial pneumonia and multidrug-resistant bacteria were not significantly different across these three groups.
Conclusions
Initial adequate antibiotic therapy markedly decreased 60-day mortality. Dual therapy improved the likelihood of initial adequate therapy but did not predict decreased 60-day mortality. Dual therapy did not increase the risk of nosocomial pneumonia or multidrug-resistant bacteria.
doi:10.1186/cc13095
PMCID: PMC4056004  PMID: 24200097
2.  Mortality associated with timing of admission to and discharge from ICU: a retrospective cohort study 
Background
Although the association between mortality and admission to intensive care units (ICU) in the "after hours" (weekends and nights) has been the topic of extensive investigation, the timing of discharge from ICU and outcome has been less well investigated. The objective of this study was to assess effect of timing of admission to and discharge from ICUs and subsequent risk for death.
Methods
Adults (≥18 years) admitted to French ICUs participating in Outcomerea between January 2006 and November 2010 were included.
Results
Among the 7,380 patients included, 61% (4,481) were male, the median age was 62 (IQR, 49-75) years, and the median SAPS II score was 40 (IQR, 28-56). Admissions to ICU occurred during weekends (Saturday and Sunday) in 1,708 (23%) cases, during the night (18:00-07:59) in 3,855 (52%), and on nights and/or weekends in 4,659 (63%) cases. Among 5,992 survivors to ICU discharge, 903 (15%) were discharged on weekends, 659 (11%) at night, and 1,434 (24%) on nights and/or weekends. After controlling for a number of co-variates using logistic regression analysis, admission during the after hours was not associated with an increased risk for death. However, patients discharged from ICU on nights were at higher adjusted risk (odds ratio, 1.54; 95% confidence interval, 1.12-2.11) for death.
Conclusions
In this study, ICU discharge at night but not admission was associated with a significant increased risk for death. Further studies are needed to examine whether minimizing night time discharges from ICU may improve outcome.
doi:10.1186/1472-6963-11-321
PMCID: PMC3269385  PMID: 22115194
3.  Scorpion Envenomation Among Children: Clinical Manifestations and Outcome (Analysis of 685 Cases) 
Our objective was to characterize both epidemiologically and clinically manifestations after severe scorpion envenomation and to define simple factors indicative of poor prognosis in children. We performed a retrospective study over 13 years (1990–2002) in the medical intensive care unit (ICU) of a university hospital (Sfax-Tunisia). The diagnosis of scorpion envenomation was based on a history of scorpion sting. The medical records of 685 children aged less than 16 years who were admitted for a scorpion sting were analyzed. There were 558 patients (81.5%) in the grade III group (with cardiogenic shock and/or pulmonary edema or severe neurological manifestation [coma and/or convulsion]) and 127 patients (18.5%) in the grade II group (with systemic manifestations). In this study, 434 patients (63.4%) had a pulmonary edema, and 80 patients had a cardiogenic shock; neurological manifestations were observed in 580 patients (84.7%), 555 patients (81%) developed systemic inflammatory response syndrome (SIRS), and 552 patients (80.6%) developed multi-organ failure. By the end of the stay in the ICU, evolution was marked by the death in 61 patients (8.9%). A multivariate analysis found the following factors to be correlated with a poor outcome: coma with Glasgow coma score ≤ 8/15 (odds ratio [OR] = 1.3), pulmonary edema (OR = 2.3), and cardiogenic shock (OR = 1.7). In addition, a significant association was found between the development of SIRS and heart failure. Moreover, a temperature > 39°C was associated with the presence of pulmonary edema, with a sensitivity at 20.6%, a specificity at 94.4%, and a positive predictive value at 91.7%. Finally, blood sugar levels above 15 mmol/L were significantly associated with a heart failure. In children admitted for severe scorpion envenomation, coma with Glasgow coma score ≤ 8/15, pulmonary edema, and cardiogenic shock were associated with a poor outcome. The presence of SIRS, a temperature > 39°C, and blood sugar levels above 15 mmol/L were associated with heart failure.
doi:10.4269/ajtmh.2010.10-0036
PMCID: PMC2963974  PMID: 21036842
4.  Post-traumatic pulmonary embolism in the intensive care unit 
Annals of Thoracic Medicine  2011;6(4):199-206.
OBJECTIVE:
To determine the predictive factors, clinical manifestations, and the outcome of patients with post-traumatic pulmonary embolism (PE) admitted in the intensive care unit (ICU).
METHODS:
During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each trauma patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study period, all trauma patients admitted to our ICU were classified into two groups. The first group included all patients with confirmed PE; the second group included patients without clinical manifestations of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or its branches.
RESULTS:
During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%). The mean delay of development of PE was 11.3 ± 9.3 days. Eight patients (24%) developed this complication within five days of ICU admission. On the day of PE diagnosis, the clinical examination showed that 13 patients (38.2%) were hypotensive, 23 (67.7%) had systemic inflammatory response syndrome (SIRS), three (8.8%) had clinical manifestations of deep venous thrombosis (DVT), and 32 (94%) had respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (4%). The mean ICU stay was 31.6 ± 35.7 days and the mean hospital stay was 32.7 ± 35.3 days. The mortality rate in the ICU was 38.2% and the in-hospital mortality rate was 41%. The multivariate analysis showed that factors associated with poor prognosis in the ICU were the presence of circulatory failure (Shock) (Odds ratio (OR) = 9.96) and thrombocytopenia (OR = 32.5).Moreover, comparison between patients with and without PE showed that the predictive factors of PE were: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2/FiO2 < 200 mmHg, the presence of spine fracture, and the presence of meningeal hemorrhage.
CONCLUSION:
Despite the high frequency of DVT in post-traumatic critically ill patients, symptomatic PE remains, although not frequently observed, because systematic screening is not performed. Factors associated with poor prognosis in the ICU are the presence of circulatory failure (shock) and thrombocytopenia. Predictive factors of PE are: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2/FiO2 < 200, the presence of a spine fracture, and the presence of meningeal hemorrhage. Prevention is highly warranted.
doi:10.4103/1817-1737.84773
PMCID: PMC3183636  PMID: 21977064
Anticoagulation; ICU; predictive factors; pulmonary embolism; trauma patients
5.  Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations 
Aim:
To determine factors associated with poor outcome in children suffering traumatic head injury (HI).
Materials and Methods:
A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians.
Results:
There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41).
Conclusions:
A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.
doi:10.4103/0974-2700.82206
PMCID: PMC3132359  PMID: 21769206
Acute head injury; children; Glasgow coma scale score; intensive care unit; multivariate analysis; prognosis; trauma
6.  Isolated traumatic head injury in children: Analysis of 276 observations 
Background:
To determine predictive factors of mortality among children after isolated traumatic brain injury.
Materials and Methods:
In this retrospective study, we included all consecutive children with isolated traumatic brain injury admitted to the 22-bed intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). Basic demographic, clinical, biochemical, and radiological data were recorded on admission and during ICU stay.
Results:
There were 276 patients with 196 boys (71%) and 80 girls, with a mean age of 6.7 ± 3.8 years. The main cause of trauma was road traffic accident (58.3%). Mean Glasgow Coma Scale score was 8 ± 2, Mean Injury Severity Score (ISS) was 23.3 ± 5.9, Mean Pediatric Trauma Score (PTS) was 4.8 ± 2.3, and Mean Pediatric Risk of Mortality (PRISM) was 10.8 ± 8. A total of 259 children required mechanical ventilation. Forty-eight children (17.4%) died. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 24 (OR: 10.98), neurovegetative disorder (OR: 7.1), meningeal hemorrhage (OR: 2.74), and lesion type VI according to Marshall tomographic grading (OR: 13.26).
Conclusion:
In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic injuries. Short-term prognosis is influenced by demographic, clinical, radiological, and biochemical factors. The need to put preventive measures in place is underscored.
doi:10.4103/0974-2700.76831
PMCID: PMC3097575  PMID: 21633564
Acute head injury; children; intensive care unit; motor-vehicle crash; prognosis; trauma
7.  Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome 
Annals of Thoracic Medicine  2010;5(2):97-103.
OBJECTIVE:
To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU.
METHODS:
During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed.
RESULTS:
During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3.
Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 ratio <300 and the absence of pharmacological prevention of venous thromboembolism.
CONCLUSION:
Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 < 300 and the absence of pharmacological prevention of venous thromboembolism.
doi:10.4103/1817-1737.62473
PMCID: PMC2883205  PMID: 20582175
ICU; predictive factors; prophylactic anticoagulation; pulmonary embolism
8.  Correlation between antibiotic use and changes in susceptibility patterns of Pseudomonas aeruginosa in a medical-surgical intensive care unit 
Context:
Multiple surveillance programmes have reported a decline in antibiotic susceptibility of P. aeruginosa.
Aim:
Our study aimed to study the relationship between the use of antipseudomonal drugs and the development of resistance of P. aerogenosa to these drugs.
Setting and Design:
Our study is retrospective. It was conducted in a medical surgical intensive care unit during a five-year period (January 1st, 1999 to December 31, 2003), which was divided into 20 quarters. We had monitored the use of antipseudomonal agents and the resistance rates of P. aeruginosa to these drugs.
Statistical Methods:
The associations between use and resistance were quantified using non-partial and partial correlation coefficients according to Pearson and Spearman.
Results:
Over the study period, the most frequently used antipseudomonal agent was Imipenem (152 ± 46 DDD/1000 patients-day) and the resistance rate of P. aeruginosa to Imipenem was 44.3 ± 9.5% (range, 30 and 60%). In addition, Imipenem use correlated significantly with development of resistance to Imipenem in the same (P < 0.05) and in the following quarter (P < 0.05); and Ciprofloxacin use correlated significantly with resistance to Ciprofloxacin in the following quarter (P < 0.05). However, use of Ceftazidime or Amikacine had no apparent association with development of resistance.
Conclusion:
We conclude that the extensive use of imipenem or ciprofloxacin in intensive care units may lead to the emergence of imipenem- and ciprofloxacin-resistant strains of P. aeruginosa and that antibiotic prescription policy has a significant impact on P. aeruginosa resistance rates in an intensive care unit.
doi:10.4103/0972-5229.40945
PMCID: PMC2760919  PMID: 19826586
Ciprofloxacin; use; imipenem; P. aeruginosa; resistance

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