Improvement in process of care and outcome in patients requiring intensive care unit admission for community acquired pneumonia

BMC Infectious Diseases

Olivier Leroy²  Nicolas Boussekey²  Arnaud Chiche²  Agnès Meybeck²  Pierre Yves Delannoy²  Serge Alfandari²  Patrick Devos³  Cécile Journaux²  Hugues Georges¹ 

[1] Service de réanimation médicale, Hôpital chatiliez, 135 rue du Président Coty, BP 619, 59208, Tourcoing, cedex, France;Intensive Care Unit, Hôpital chatiliez, 135 rue du Président Coty, BP 619, 59208, Tourcoing, cedex, France;Department of Biostatistics, Centre Hospitalier Universitaire de Lille, 59000, Lille, France

关键词: Combination therapy;    Antimicrobial therapy;    Intensive care unit;    Severe community acquired pneumonia;   

Others  :  1148618
DOI  :  10.1186/1471-2334-13-196

 received in 2012-11-20, accepted in 2013-04-24,  发布年份 2013

【 摘 要 】

Background

The present study was performed to assess the prognosis of patients admitted to the intensive care unit (ICU) for community acquired pneumonia (CAP) after implementation of new processes of care.

Methods

Two groups of patients with CAP were admitted to a 16-bed multidisciplinary ICU in an urban teaching hospital during two different periods: the years 1995–2000, corresponding to the historical group; and 2005–2010, corresponding to the intervention group. New therapeutic procedures were implemented during the period 2005–2010. These procedures included a sepsis management bundle derived from the Surviving Sepsis Campaign, use of a third-generation cephalosporin and levofloxacin as the initial empirical antimicrobial regimen, and noninvasive mechanical ventilation following extubation.

Results

A total of 317 patients were studied: 142 (44.8%) during the historical period and 175 (55.2%) during the intervention period. Sequential Organ Failure Assessment scores were higher in patients in the intervention group (7.2 ± 3.7 vs 6.2 ± 2.8; p=0.008). Mortality changed significantly between the two studied periods, decreasing from 43.6% in the historical group to 30.9% in the intervention group (p < 0.02). A restrictive transfusion strategy, use of systematic postextubation noninvasive mechanical ventilation in patients with severe chronic respiratory or cardiac failure patients, less frequent use of dobutamine and/or epinephrine in patients with sepsis or septic shock, and delivery of a third-generation cephalosporin associated with levofloxacin as empirical antimicrobial therapy were independently associated with better outcomes.

Conclusion

Positive outcomes in ICU patients with CAP have significantly increased in our ICU in recent years. Many new interventions have contributed to this improvement.

【 授权许可】

   
2013 Georges et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A: Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med 2002, 28(2):108-121.
• [2]Woodhead M, Welch CA, Harrison DA, Bellingan G, Ayres JG: Community-acquired pneumonia on the intensive care unit: secondary analysis of 17,869 cases in the ICNARC Case Mix Programme Database. Crit Care 2006, 10(Suppl 2):S1. BioMed Central Full Text
• [3]Bartlett JG, Breiman RF, Mandell LA, File TM Jr: Community-acquired pneumonia in adults: guidelines for management, The Infectious Diseases Society of America. Clin Infect Dis 1998, 26(4):811-838.
• [4]Niederman MS, Mandell LA, Anzueto A, Bass JB, Broughton WA, Campbell GD: Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention.; American Thoracic Society. Am J Respir Crit Care Med 2001, 163(7):1730-1754.
• [5]Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC: Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007, 44(Suppl 2):S27-S72.
• [6]SPILF: Prise en charge des infections des voies respiratoires basses de l’adulte immunocompétent. Médecine et Maladies Infectieuses 2006, 36:235-244.
• [7]The Acute Respiratory Distress Syndrome Network Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med 2000, 342(18):1301-1308.
• [8]Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002, 288(7):862-871.
• [9]Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001, 345(19):1359-1367.
• [10]Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. New Eng J Med 1999, 340(6):409-417.
• [11]Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A: Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001, 344(10):699-709.
• [12]Girault C, Daudenthun I, Chevron V, Tamion F, Leroy J, Bonmarchand G: Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. Am J Respir Crit Care Med 1999, 160(1):86-92.
• [13]Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J: Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.; Surviving Sepsis Campaign Management Guidelines Committee. Crit Care Med 2004, 32(3):858-873.
• [14]Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE: A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997, 336(4):243-250.
• [15]1994 revisions to classification of functional capacity and objective assessment of patients with diseases of the heart. American Heart Association AHA medical/scientific statement Circulation 1994, 90(1):644-645.
• [16]Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE: APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981, 9(8):591-597.
• [17]Le Gall JR, Lemeshow S, Saulnier F: A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993, 270(24):2957-2963.
• [18]Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H: The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996, 22(7):707-710.
• [19]Nseir S, Favory R, Jozefowicz E, Decamps F, Dewavrin F, Brunin G: Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care 2008, 12(3):R62. BioMed Central Full Text
• [20]Guidelines for the Management of Adults with Hospital-acquired: Ventilator-associated, and Healthcare-associated Pneumonia Infectious Diseases Society of America; American Thoracic Society. Am J Respir Crit Care Med 2005, 171:388-416.
• [21]Yu M, Levy MM, Smith P, Takiguchi SA, Miyasaki A, Myers SA: Effect of maximizing oxygen delivery on morbidity and mortality rates in critically ill patients: a prospective, randomized, controlled study. Crit Care Med 1993, 21(6):830-838.
• [22]Cane RD: Hemoglobin: how muchis enough? Crit Care Med 1990, 18(9):1046-1047.
• [23]de Langue Française Cdceta-islirbSdPI: Médecine et Maladies Infectieuses. 1992, 22(sup 2):38-201.
• [24]Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y: Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 2000, 162(1):134-138.
• [25]Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C: Infectious Diseases Society of America Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003, 37(11):1405-1433.
• [26]Ruiz M, Ewig S, Torres A, Arancibia F, Marco F, Mensa J: Severe community-acquired pneumonia, Risk factors and follow-up epidemiology. Am J Respir Crit Care Med 1999, 160(3):923-929.
• [27]Moine P, Vercken JB, Chevret S, Chastang C, Gajdos P: Severe community-acquired pneumonia. Etiology, epidemiology, and prognosis factors. French Study Group for Community-Acquired Pneumonia in the Intensive Care Unit. Chest 1994, 105(5):1487-1495.
• [28]Welte T, Torres A, Nathwani D: Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax 2012, 67(1):71-79.
• [29]Drago L, Nicola L, Rodighiero V, Larosa M, Mattina R, De Vecchi E: Comparative evaluation of synergy of combinations of beta-lactams with fluoroquinolones or a macrolide in Streptococcus pneumoniae. J Antimicrob Chemother 2011, 66(4):845-849.
• [30]Olive D, Georges H, Devos P, Boussekey N, Chiche A, Meybeck A, Alfandari S, Leroy O: Severe pneumococcal pneumonia: impact of new quinolones on prognosis. BMC Infect Dis 2011, 11:66. BioMed Central Full Text
• [31]Mortensen EM, Restrepo MI, Anzueto A, Pugh J: The impact of empiric antimicrobial therapy with a beta-lactam and fluoroquinolone on mortality for patients hospitalized with severe pneumonia. Crit Care 2005, 10(1):R8.
• [32]Martin-Loeches I, Lisboa T, Rodriguez A, Putensen C, Annane D, Garnacho-Montero J: Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia. Intensive Care Med 2010, 36(4):612-620.
• [33]Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P: Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005, 33(11):2465-2470.
• [34]Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A: Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 2006, 173(2):164-170.
• [35]Corwin H, Gettinger A, Pearl R, Fink M, Levy M, Abraham E: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med 2004, 32(1):39-52.
• [36]Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K: Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008, 358(2):111-124.
• [37]Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med 2008, 36(1):296-327.
• [38]Leone M, Vallet B, Teboul JL, Mateo J, Bastien O, Martin C: Survey of the use of catecholamines by French physicians. Intensive Care Med 2004, 30(5):984-988.
• [39]De Backer D, Creteur J, Silva E, Vincent JL: Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best? Crit Care Med 2003, 31:1659-1667.