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Background Therapeutic failure is a frequent issue in the management of post-operative peritonitis. Objectives A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients. Patients and methods Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses. Results Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17–3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05–8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03–1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36–11.49) and diabetes (OR 6.95; 95% CI 1.34–36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13–3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02–5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21–7.01). No specific risk factors were identified for microbiological failure. Conclusions Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.

In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid. In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis. Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered. GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.

Background Bacterial respiratory infections (BRI) are major complications contributing to increased morbidity and mortality after lung transplantation (LT). This study analyzed epidemiology and outcome of 175 consecutive patients developing BRI in ICU after LT between 2006 and 2012. Methods Three situations were described: colonization determined in donors and recipients, pneumonia and tracheobronchitis during the first 28 postoperative days. Severity score, demographic, bacteriologic and outcome data were collected. Results 26% of donors and 31% of recipients were colonized. 92% of recipients developed BRI, including at least one episode of pneumonia in 19% of recipients. Only 21% of recipients developed BRI with an organism cultured from the donor’s samples, while 40% of recipients developed BRI with their own bacteria cultured before LT. Purulent sputum appears to be an important factor to discriminate tracheobronchitis from pneumonia. When compared to patients with tracheobronchitis, those with pneumonia had longer durations of mechanical ventilation (13 [3–27] vs 3 [29], p = 0.0005) and ICU stay (24 [16–34] vs 14 [9-22], p = 0.002). Pneumonia was associated with higher 28-day (11 (32%) vs 9 (7%), p = 0.0004) and one-year mortality rates (21 (61%) vs 24 (19%), p ≤ 0.0001). Conclusions These data confirm the high frequency of BRI right from the early postoperative period and the poor prognosis of pneumonia after LT.

International audience; Background: Fungus-positive respiratory samples (FPRS) are common in the intensive Care unit (ICU) and are usually considered to correspond to colonization. The management of FPRS during the early postoperative course after lung transplantation (LT) remains unclear. The epidemiology, clinical consequences, and prognosis of FPRS were assessed in LT recipients.Methods: Over a 6-year period, we analyzed the postoperative ICU course of 176 LT recipients with a specific focus on microbiological results of routine respiratory samples and clinical course. The outcomes during the ICU stay at day 28 and at 1 year were compared in patients with or without FPRS. Results are expressed as median and interquartile range.Results: In the pretransplantation period, Candida spp were reported in 17% of patients. No routine post-LT antifungal prophylaxis was initiated. In the post-LT period, at least 1 FPRS was observed in 69% of patients (93% Candida spp, 7% Aspergillus spp). Double LT (odds ratio = 4.15, 95% confidence interval [1.67-11.80], P = .0007) was the only risk factor associated with Candida spp in respiratory samples. Antifungal therapy was administered in 58% of patients with post-LT Candida-positive samples. Candida spp in post-LT respiratory samples were not associated with increased ICU, 28-day, or 1-year mortality rates.Conclusion: A high prevalence of FPRS is reported after LT, mainly with Candida spp. The lack of association between post-LT FPRS and mortality and morbidity suggests avoiding antifungal therapy in the absence of clinical signs of invasive infection.

In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid.In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis.Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered.GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.

BACKGROUND Multidrug-resistant (MDR) bacteria are a growing concern worldwide. The aim of this study was to describe the epidemiology and risk factors of MDR bacteria detected in respiratory invasive samples during hospitalization in the intensive care unit (ICU) after lung transplantation (LT). METHODS This study was based on a retrospective analysis of 176 patients hospitalized in the ICU after LT in 2006-2012. Respiratory invasive samples were performed according to a routine protocol. MDR pathogens were defined according to in vitro susceptibility tests. RESULTS A total of 1176 bacteria were cultured. Susceptibility testing was performed on 1046 strains and 404 (39%) MDR were detected in 90 (51%) patients. Pseudomonas aeruginosa, coagulase-negative staphylococci, and Enterobacteriaceae (mainly Enterobacter species) were the most common MDR pathogens. On multivariate analysis, an ICU stay >14 days, presence of a tracheostomy, and previous exposure to broad-spectrum antibiotics were associated with MDR acquisition (odds ratio [OR] 3.7; 95% confidence interval [1.69-8.12]; OR 3.28 [1.05-10.28]; and OR 2.25 [1.17-4.34], respectively). We consistently observed an increasing emergence of resistance to several antibiotics, from week 1 to week 4 of ICU hospitalization: for ticarcillin, piperacillin-tazobactam, ceftazidime, imipenem/cilastatin, amikacin, and ciprofloxacin in P. aeruginosa; and for piperacillin-tazobactam, cefepime, and amikacin in Enterobacteriaceae. CONCLUSION A large proportion of MDR bacteria are detected on respiratory invasive samples in LT patients, and the risk of their emergence is mainly determined by the previous exposure to broad-spectrum antibiotics and the length of ICU stay. Adequate treatment requires broad-spectrum empiric antibiotic therapy.

Obese patients could be more susceptible to mechanical ventilation (MV)-induced lung injury than non-obese patients due to weight-dependent changes in lung properties. The aim of this study was therefore to evaluate the pulmonary effects of 2 hours low VT MV in a diet-induced obese mice model, with VT calculated on either the actual body weight (VTaw) or the ideal body weight (VTiw) . First, we hypothesized that a MV with VTaw would be associated with altered lung mechanics and an increased lung inflammation. Second, we hypothesised that a MV with a VTiw would preserve lung mechanics and limit lung inflammation. We analyzed lung mechanics and inflammation using bronchoalveolar lavage (BAL) cell counts, flow cytometry tissue analysis and histology. Lung mechanics and inflammation were comparable in control and obese mice receiving VTiw. By contrast, obese mice receiving VTaw had significantly more alterations in lung mechanics, BAL cellularity and lung influx of monocytes as compared to control mice. Their monocyte expression of Gr1 and CD62L was also increased. Alveolar neutrophil infiltration was significantly increased in all obese mice as compared to controls. In conclusion, our findings suggest that protective MV with a VTaw is deleterious, with a marked alteration in lung mechanics and associated lung inflammation as compared to lean mice. With VTiw, lung mechanics and inflammation were close to that of control mice, except for an increased alveolar infiltrate of polymorphonuclear neutrophils. This inflammation might be attenuated by a blunted recruitment of inflammatory cells associated with obesity.

Purpose Continuous veno-venous haemofiltration (CVVH) directly connected to extracorporeal membrane oxygenation (ECMO) may ensure better blood flow and allow prolonged circuit life. The objective of this study was to assess circuit life of CVVH connected to ECMO and to a dialysis catheter. Materials and methods In this prospective observational study, patients receiving CVVH via ECMO were compared to time-matched patients receiving CVVH via a conventional dialysis catheter. CVVH circuit life and the safety and efficacy of the two CVVH procedures were analysed. Time to event was estimated using Kaplan-Meier analysis and compared using the log-rank test. Results Seventeen patients were included in each group, with 43 sessions in the ECMO group and 56 sessions in the DC group. Median CVVH circuit life was 48 [21–72] vs 20 [6–39] hours in the ECMO and DC groups, respectively (relative risk of termination of the session: 2.4, 95% CI [1.41–3.9], log rank P = 0.0009). CVVH blood flow was higher in the ECMO group. Despite higher anticoagulant doses in the catheter group, the circuit clotting rate was lower in the ECMO group. Effluent volume was slightly higher in the ECMO group (39 ml/kg/h [33–47] vs 34 ml/kg/h [32–39]), but with no biological impact. CVVH via ECMO was well tolerated with no major drawbacks. Conclusions In patients requiring ECMO, CVVH connected to ECMO instead of DC could be proposed as an alternative approach, allowing more stable blood flow and prolonged CVVH circuit life.

Background Post-operative infections are a major complication after lung transplantation (LT). Early bacterial pneumonia worsens the prognosis of LT. Procalcitonin (PCT) has been proposed as an early and rapid laboratory marker of infection and sepsis. PCT could be a useful biomarker of pulmonary infection after LT, but the early kinetics of PCT in this setting are unknown. We evaluated the kinetics of PCT and the impact of respiratory tract infection on PCT concentrations. Methods Over a 12-month period, PCT concentrations were determined daily in each patient admitted to our ICU for LT. Epidemiologic, clinical, laboratory and outcome data were obtained. A diagnosis of respiratory tract infection was suspected on clinical examination and confirmed by microbiologic culture. Results Twenty-six consecutive patients were included and 397 blood samples were obtained (13 [range 4 to 66] samples per patient). Plasma PCT reached a peak in the first 24 hours post-transplantation (5.72 [0.11 to 93.8] ng/ml), with a progressive decline over the first 7 post-operative days. Doubling of plasma PCT levels after an initial decrease was significantly associated with respiratory tract infection in transplanted patients (RR = 4.2 95% CI [1.95 to 9.03]). Conclusions A non-specific increase in PCT values was observed during the first week post-LT. In combination with microbiologic cultures, PCT assays may be useful after the first post-operative week as an aid in the diagnosis of bacterial pulmonary infection.

Perioperative complications following bariatric surgery (BS) have been poorly analysed and their management is not clearly assessed. The associated frequency of ICU admission is difficult to estimate. Among surgical complications, digestive perforations are the most frequent. The most common postoperative complications of sleeve gastrectomy are fistulas, but bleeding on the stapling line is also commonly reported. Complication rates are higher after Roux-en-Y gastric bypass, mainly due to anastomotic leaks. Medical complications are mainly thromboembolic or respiratory complications. All these surgical and medical complications are not easily detected; clinical signs can be atypical or insidious, often resulting in delayed management. Respiratory signs can be predominant and lead erroneously to pulmonary or thromboembolic diseases. Diagnostic criteria are based on minor clinical signs, tachycardia being probably the most frequent one. Lately, complications are revealed by haemodynamic instability, respiratory failure or renal dysfunction and radiographic findings. Management decision according to these abnormal signs is based on a combined multidisciplanary approach including surgical and/or endoscopic procedures and medical care, depending on the nature and severity of the surgical complication. Medical management is based on supportive ICU care of organ dysfunctions, curative anticoagulation if required, nutritional support, and appropriate anti-infective therapy. Pharmacological data are limited in morbidly obese patients and the appropriate doses are debated, especially for anti-infective agents. Complicated BS cases have a poor outcome, probably largely related to delayed diagnosis and reoperation.

International audience; OBJECTIVES: First evaluation of the transpulmonary thermodilution technique by the PiCCO2 device to assess cardiac index and pulmonary edema during the postoperative course after single-lung transplantation.DESIGN: Prospective observational study.SETTINGS: Intensive care unit, university hospital (single center).PARTICIPANTS: Single-lung transplant patients.INTERVENTIONS: The authors compared cardiac index measured by PiCCO2 and pulmonary artery catheter and assessed pulmonary edema using extravascular lung water index and pulmonary vascular permeability index measured by PiCCO2.MEASUREMENTS AND MAIN RESULTS: A Bland-Altman method was used to compare cardiac index measured by PiCCO2 and pulmonary artery catheter. Extravascular lung water index and pulmonary vascular permeability index were compared according to the PaO/FiO ratio with a threshold value of 150 mmHg. Ten single-lung transplant patients were included. Cardiac index measured by PiCCO2 and pulmonary artery catheter were 3.3 L/min/m (2.9-3.6) and 2.5 L/min/m (2.2-3.0). Bias for cardiac index was 0.71 L/min/m (-0.03; 1.44) and limit of agreements were -0.03 and 1.44 L/min/m. Extravascular lung water index was 12 mL/kg (11-16) and pulmonary vascular permeability index was 2.3 (2.0-3.1), consistent with pulmonary edema. Extravascular lung water index was higher in the group of PaO/FiO ratio ≤150 mmHg compared with the group of PaO/FiO ratio >150 mmHg (17 v 12 mL/kg, p = 0.04), whereas pulmonary vascular permeability index only tended to be higher (3.1 v 2.1, p = 0.06).CONCLUSION: PiCCO2 device systematically overestimated cardiac index compared with pulmonary artery catheter. However, it might be useful to assess pulmonary edema in acute respiratory failure after single-lung transplantation.

Purpose In acute respiratory distress syndrome (ARDS) and acute lung injury (ALI), a conservative fluid management strategy improves lung function but could jeopardize extrapulmonary organ perfusion. The objective was to evaluate the diagnostic accuracy of echocardiography to predict tolerance of negative fluid balance (NFB) in patients with ARDS/ALI. Materials and Methods A prospective and observational study in an adult intensive care unit of a university hospital was conducted. All hemodynamically stable patients with ARDS/ALI were included. Echocardiography was performed before NFB and again after 24 hours. Tolerance of NFB was evaluated by the presence of hypotension, acute kidney injury, or need for fluid expansion. The 2 patient groups (tolerating and not tolerating NFB) were compared. Results Forty-five patients were included. Median age (Q1-Q3) was 58 (52-66) years, and the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen was 205 (163-258) mm Hg. Negative fluid balance was 1950 (1200-2200) mL within 24 hours in the tolerant group. Complications of NFB were observed in 35% cases. After univariate and multivariate logistic regression analyzes, 2 criteria was independently associates with poor tolerance: mitral inflow E wave to early diastolic mitral annulus velocities ratio (E/Ea ratio; odds ratio, 2.02 [1.02-4.02]; P = .04) and weight gain (odds ratio, 1.2 [1.03-1.4]; P = .02). The area under receiver operating characteristic curves was 0.74 for E/Ea and 0.77 for weight gain. Conclusions The ratio of E/Ea accurately predicted tolerance of NFB in patients with ARDS/ALI.

Postoperative peritonitis (PP) is associated with a high rate of multi-drug-resistant micro-organisms. The role of Pseudomonas aeruginosa in this condition has never been assessed. We evaluated the risk factors and prognosis for PP caused by P. aeruginosa.Patients hospitalized in the intensive care unit (ICU) after re-operation for PP were identified prospectively. Analyses were performed retrospectively. Specific risk factors were investigated by comparing P. aeruginosa PP with PP having other causes. The main outcome endpoint was death in the hospital.We found 55 P. aeruginosa PP among the 349 cases of PP (16%) in the ICU over 14 years. Factors associated with the presence of P. aeruginosa in peritoneal fluid culture were Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.02-1.09; p=0.004) and respiratory failure (OR 2.3; 95% CI 1.26-4.16; p=0.006). These criteria performed poorly in predicting P. aeruginosa PP. Such infections were associated with a higher hospital mortality rate, but not after adjustment for the severity score. Adequate antibiotic therapy comprising two antibiotics effective against P. aeruginosa was associated with a lower mortality rate for P. aeruginosa PP in the ICU.The prevalence of P. aeruginosa PP is not high. Risk factors do not allow accurate prediction of the infection. Our data suggest two drugs effective against P. aeruginosa should be considered for treating these infections.

Metabolic disorders and fluid overload are indications of continuous renal replacement therapy (CRRT) including continuous venovenous hemofiltration in patients on extracorporeal membrane oxygenation (ECMO). Direct connection of CRRT machine to the ECMO circuit provides many advantages. Nevertheless, because pressures in CRRT lines relate to ECMO blood flow, high ECMO blood flow may be associated with high pressures in CRRT lines. Thus, management of CRRT pressure lines becomes challenging. We evaluated a protocol for managing high CRRT pressures. Connections were performed according to a standardized protocol to maintain CRRT lines in the correct pressure ranges without modifying ECMO settings or inhibiting pressure alarms. To achieve this goal, the way of connecting of CRRT lines was adapted following a standardized protocol. Connection was first attempted between pump and oxygenator in the 12 patients. In five cases, high pressures in CRRT lines were successfully managed by changing the connection segment. Continuous renal replacement therapy parameters were within target levels and reduction of serum creatinine was 37%. In conclusion, management of high pressures in CRRT lines induced by ECMO could be achieved without modifying ECMO blood flow or inhibiting CRRT alarms. Iterative stops were avoided allowing efficient procedures.

Background De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI. Methods All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital. Results Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53 %), and no de-escalation was reported in 96 patients (47 %) (escalation in 65 [32 %] and unchanged regimen in 31 [15 %]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95 % CI 4.02–22.97) and empiric use of vancomycin (OR 3.39, 95 % CI 1.46–7.87), carbapenems (OR 2.64, 95 % CI 1.01–6.91), and aminoglycosides (OR 2.31 95 % CI 1.08–4.94). The presence of NFGNB (OR 0.28, 95 % CI 0.09–0.89) and the presence of MDR bacteria (OR 0.21, 95 % CI 0.09–0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95 % CI 1.34–5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95 % CI 1.16–1.42), and age (HR 1.03, 95 % CI 1.01–1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176). Conclusions De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.

Introduction No studies have compared ventilator-associated pneumonia (VAP) and non-VAP following cardiac surgery (CS). The aim of this study was to assess the incidence, clinical and microbiologic features, treatment characteristics and prognosis of postoperative pneumonia following CS with a special focus on non-VAP. Methods This was a retrospective cohort study based on a prospectively collected database. We compared cases of non-VAP and VAP following CS observed between January 2005 and December 2012. Statistical analysis consisted of bivariate and multivariate analysis. Results A total of 257 (3.5%) of 7,439 consecutive CS patients developed postoperative pneumonia, including 120 (47%) cases of non-VAP. Patients with VAP had more frequent history of congestive heart failure (31% vs. 17%, P = 0.006) and longer duration of cardiopulmonary bypass (105 vs 76 min, P Pseudomonas aeruginosa (20.2%) and Haemophilus spp (20.2%), except for a lower proportion of Methicillin-susceptible S. aureus in the non-VAP group (3.2% vs 7.9%, P = 0.03). In the intensive care unit, patients with non-VAP had lower sequential organ failure assessment scores than patients with VAP (8 ± 3 versus 9 ± 3, P = 0.004). On multivariate analysis, in-hospital mortality was similar in both groups (32% in the non-VAP group and 42% in the VAP group, adjusted Odds Ratio (aOR): 1.4; 95% confidence intervals (CI): 0.7-2.5; P = 0.34) and appropriate empiric antibiotic therapy was associated with a reduction of in-hospital mortality (aOR: 0.4; 95% CI: 0.2-1; P = 0.05). Piperacillin/tazobactam or imipenem monotherapy constituted appropriate empiric therapy in the two groups, with values reaching 93% and 95% with no differences between VAP and non-VAP cases. Conclusions Intensive care patients with VAP are more severely ill than non-VAP patients following CS. Nevertheless, patients with non-VAP and VAP following CS have similar outcomes. This study suggests that the empiric antibiotic regimen in patients with pneumonia following CS should include at least a broad-spectrum antibiotic targeting non-fermenting Gram-negative bacilli, regardless of the type of pneumonia, and targeting S. aureus in VAP patients.

Purpose The management of bronchial fistula associated with acute lung injury raises two major concerns: (1) high ventilation pressures are necessary for lung recruitment but detrimental for fistula healing, and (2) adequate lung recruitment is prevented by large air leak. Primary surgical closure of bronchial fistula should be attempted but is rarely successful during mechanical ventilation. We sought to evaluate the efficacy of extracorporeal membrane oxygenation associated with lung-protective ventilation in case of failure of conventional management. Description Arteriovenous extracorporeal membrane oxygenation was initiated by femorofemoral cannulation. A stepwise increase of extracorporeal membrane oxygenation output and a decrease of mechanical ventilation settings were simultaneously performed, aiming at lung-protective ventilation. Evaluation During a 1-year period, this protocol management was used in 5 patients with refractory respiratory failure associated with bronchial fistula after thoracic operations. This strategy allowed fistula healing in 3 patients. Conclusions If correctly timed, extracorporeal membrane oxygenation can provide a therapeutic bridge to lung-protective ventilation and allow bronchial fistula healing in case of refractory respiratory failure.

The search for new molecules to fight Pseudomonas aeruginosa is of paramount importance. Carbon monoxide (CO) is known to act as an effective inhibitor of the respiratory chain in P. aeruginosa, but the practical use of this gas as an antibacterial molecule is hampered by its toxicity and difficulty to manipulate. Here, we show that a water-soluble CO releaser (CORM-3) possesses bactericidal properties against laboratory and antibiotic-resistant P. aeruginosa. CORM-3 reduced the bacterial count by 4 logs 180 min after in vitro treatment. CORM-3-treated bacteria had a lower O(2) consumption than vehicle-treated bacteria, and the decrease in O(2) consumption temporally preceded the bactericidal action of CORM-3. These results support the hypothesis that the antimicrobial effect of CORM-3 is mediated by an interaction of CO liberated by the carrier with the bacterial respiratory chain. The antibacterial effect occurred at concentrations of CORM-3 that are 50-fold lower than toxic concentrations for eukaryotic cells. CORM-3 treatment compared to vehicle treatment decreased bacterial counts in the spleen and increased survival in immunocompetent and immunosuppressed mice following P. aeruginosa bacteremia. Our results suggest that CORMs could form the basis for developing a new therapeutic strategy against P. aeruginosa-induced infection.

The toxic effect of high concentrations of CO gas in living organisms is coherently typified at biochemical levels by the high affinity of CO for hemoglobin and cytochromes, heme-dependent proteins that are indispensable for oxygen transport and mitochondrial respiration. However, the basal production of CO during heme degradation and the ability of heme oxygenase-1 (HO-1) to increase CO availability pose the question of how this gaseous molecule interacts with metal centers within the intracellular milieu to serve as one of the most unconventional signaling mediators. Emerging evidence indicates that the diverse and multifaceted beneficial effects exerted by "low concentrations" of CO cannot be explained solely by the activation of classic prototypic targets (i.e., guanylate cyclase/potassium channels) but entails the dynamic and concerted activation/inhibition of a group of CO-responsive proteins. As the complexity of the temporal and spatial action of CO is progressively being appreciated, this review aims to (a) highlight the current knowledge on certain metal-containing proteins that interact directly with CO; (b) analyze the latest notions on their functional role in response to CO; and finally (c) propose a rational view on the mode these CO targets may interrelate with and be regulated by the HO/CO pathway.

Chronic exposure to particulate air pollution is associated with lung function impairment. To determine the molecular mechanism(s) of this phenomenon, we investigated, in an alveolar human epithelial cell line (A549), whether diesel exhaust particles (DEPs), a main component of particulate air pollution, modulates the expression and activity of the matrix metalloprotease (MMP)-1, a collagenase involved in alveolar wall degradation. Interaction of DEPs with cigarette smoke, which also produces structural and functional lung alterations, was also investigated. A noncytotoxic concentration of DEPs induced an increase in MMP-1 mRNA and protein expression and activity in A549 cells without modifying the expression of the MMP inhibitors TIMP-1 and -2. This effect was not potentiated when cells were coexposed to noncytotoxic concentrations of cigarette smoke condensate. DEP-induced MMP-1 was associated with increased ERK 1/2 phosphorylation and upregulation of expression and activity of the NADPH oxidase analog NOX4. Cell transfection with a NOX4 small interfering RNA prevented these phenomena, showing the critical role of a NOX4 ERK 1/2 pathway in DEP-induced MMP-1 expression and activity. Similar results to those observed in A549 cells were obtained in another human lung epithelial cell line, NCI-H292. Furthermore, experiments in mice intratracheally instilled with DEPs confirmed the in vitro findings, showing the induction of NOX4 and MMP-1 protein expression in alveolar epithelial cells. We conclude that alveolar alterations secondary to MMP-1 induction could explain lung function impairment associated with exposure to particulate pollution.

Postoperative peritonitis (POP) is a common surgical complication after bariatric surgery (BS). We assessed the importance of positive fungal cultures in these cases of POP admitted to the intensive care unit. Clinical features and outcome were compared in 25 (41%) Candida-positive patients (6 (22%) fluconazole-resistant Candida glabrata) and 36 patients without Candida infection. Candida infections were more commonly isolated in late-onset peritonitis and were often associated with multidrug-resistant bacteria. Risk factors for intensive care unit mortality (19.6%) were diabetes and superobesity. Candida infections, including fluconazole-resistant strains, are common in POP after BS. These data encourage the empirical use of a broad-spectrum antifungal agent.

International audience; AIMS: Carbon monoxide (CO) delivered in a controlled manner to cells and organisms mediates a variety of pharmacological effects to the extent that CO-releasing molecules (CO-RMs) are being developed for therapeutic purposes. Recently, ruthenium-based CO-RMs have been shown to posses important bactericidal activity. Here we assessed the effect of fast CO releasers containing ruthenium (Ru(CO)(3)Cl(glycinate) [CORM-3] and tricarbonyldichlororuthenium(II) dimer [CORM-2]) and a novel slow manganese-based CO releaser ([Me(4)N][Mn(CO)(4)(thioacetate)(2)] [CORM-371]) on O(2) consumption and growth of Pseudomonas aeruginosa (PAO1). We then compared these effects with the action elicited by sodium boranocarbonate (CORM-A1), which lacks a transition metal but liberates CO with a rate similar to CORM-371. RESULTS: CORM-2, CORM-3, and, to a lesser extent, CORM-371 exerted a significant bactericidal effect and decreased O(2) consumption in PAO1 in vitro. The effect appeared to be independent of reactive oxygen species production, but in the case of metal-containing compounds it was prevented by the thiol donor N-acetylcysteine. In contrast, CORM-A1 was bacteriostatic rather than bactericidal in vitro eliciting only a moderate and transient decrease in O(2) consumption. INNOVATION: None of the tested CO-RMs was toxic to murine macrophages or human fibroblasts at the concentration impairing PA01 growth but only ruthenium-containing CO-RMs showed potential therapeutic properties by increasing the survival of mice infected with PA01. CONCLUSION: CO carriers inhibit bacterial growth and O(2) consumption in vitro, but transition metal carbonyls appear more powerful than compounds spontaneously liberating CO. The nature of the metal in CO-RMs also modulates the anti-bacterial effect, with ruthenium-based CO-RMs being efficacious both in vitro and in vivo.

Introduction La de-escalade antibiotique (DA) est recommandee dans le cadre du bon usage de l’antibiotherapie (AB). Cette DA n’est pas toujours realisable. L’objectif et d’analyser dans une population de malades de reanimation pris en charge pour une peritonite postoperatoire (PPO) les facteurs limitant la DA. Materiel et methodes Entre 1999 et 2011, tous les pts admis en reanimation pour PPO ont ete inclus prospectivement dans une base de donnee et analyses. Les donnees suivantes ont ete recueillies : demographie, maladies de fond, scores de gravite IGS II et SOFA au moment du diagnostic, conditions de la chirurgie initiale et de la reprise, microbiologie (identification et sensibilite des germes isoles, presence de bacteries multi-resistantes [BMR]). Les modifications de l’AB probabiliste ont ete segmentees en deux categories : DA, absence de DA (non-DA) en cas de traitement stable ou elargi. Les facteurs associes a une non-DA ont ete analyses en analyse univariee puis par regression logistique. Les resultats sont presentes en moyennes ± ET et proportions. Les comparaisons statistiques ont ete faites par test- t de Student et Chi 2 . Une valeur de p Resultats Au total, 206 pts, 117 (57 %) hommes, 61 ± 17 ans, 62 (30 %) avec une maladie de fond fatale a un an ont ete pris en charge ; 120 (58 %) pts recevaient une AB au moment du diagnostic. A la reprise, l’IGS II etait de 45 ± 14 et le SOFA 7 ± 3 ; 173 (84 %) pts avaient une infection polymicrobienne et 72 (35 %) pts etaient porteurs de BMR (43 bacilles a Gram negatif et 54 cocci a Gram positif). Quarante-cinq (22 %) pts ont recu une AB probabiliste par monotherapie, 74 (36 %) bitherapie, 87 (42 %) tritherapie ou plus. Les principaux agents utilises ont ete la piperacilline/tazobactam ( n = 127, 62 %), les aminosides ( n = 92, 44 %), la vancomycine ( n = 80, 39 %), les antifongiques ( n = 69, 33 %) et l’imipenem ( n = 50, 24 %). L’AB probabiliste etait adaptee chez 137 (66 %) pts. Les modifications de l’AB probabiliste ont ete effectuees chez 178 (86 %) pts avec une DA chez 117 (77 %) pts, et une non-DA (traitement stable ou elargi) chez 89 (43 %) pts. Les principales modifications ont ete un arret de la piperacilline/tazobactam ( n = 78, 38 %), de l’imipenem ( n = 31, 15 %), des aminosides ( n = 75, 36 %), de la vancomycine ( n = 52, 25 %) et des antifongiques ( n = 26, 13 %). L’analyse univariee des facteurs associes a une non-DA est presentee dans le Tableau 1 . En analyse multivariee, les facteurs associees a une non-DA sont la presence de BMR (OR : 3,959 [1,759–9,215], p = 0,001), la presence de bacilles a Gram negatif non fermentants (3,239 [1,171–9,46], p = 0,0261) et une AB probabiliste par monotherapie (2,127 [1,266–8,012], p = 0,014) tandis que les facteurs defavorables a une non-DA (donc associes a une DA) etaient une AB probabiliste par vancomycine (0,355 [0,148–0,815], p = 0,0165) et une AB probabiliste adaptee (0,127 [0,056–0,276], p Discussion Tout comme dans les pneumopathies acquises sous ventilation mecanique [1] , les facteurs limitant la DA sont essentiellement lies a des germes difficiles a traiter comme les BMR et les bacilles a Gram negatif non fermentants. L’AB probabiliste par vancomycine peut etre tres souvent arretee.

Introduction La transplantation pulmonaire (TP) est grevee d’une grande morbi-mortalite notamment en periode peri-operatoire. La survenue de certains evenements precoces per- et post-operatoire, pourrait impacter sur la mortalite notamment au cours des 30 premiers jours post-operatoires. Nous avons donc souhaite decrire ces evenements et evalue leur impact sur le pronostic a court terme des patients transplantes. Patients et methodes Analyse retrospective monocentrique de 173 TP consecutives realisees entre 2006 et 2011. L’objectif principal de cette etude est d’evaluer l’impact sur la mortalite au cours des 30 jours post-transplantation de la survenue : – en per-operatoire d’une importante instabilite hemodynamique definie par une expansion volemique superieure a 2500 mL ou de forte dose de catecholamines (noradrenaline superieure a 2,5 mg/h ou associee a dobutamine ou adrenaline), d’une hypoxemie prolongee (SpO2 inferieure a 90 % pendant plus de 30 minutes) et du recours a une circulation extra corporelle (CEC) ; – en post-operatoire d’une epuration extra renale (EER) ou d’une transfusion massive (superieure a 5 culots globulaires) precoce (durant les 72 heures suivant la greffe). Les variables qualitatives ont ete analysees grâce au test au test du Chi2. Les odds ratio (OR) et les intervalles de confiance a 95 % ont ete calcules. Une valeur de p Resultats Sur 173 dossiers, 143 ont pu etre analyses. L’anesthesie generale dure en moyenne 376 min (± 119).L’intervention est realisee sous CEC dans 21 % des cas. II y a recours a de fortes doses de catecholamines et a une expansion volemique dans 32,2 et 71 % des patients. Une EER et une transfusion massive post-operatoire sont necessaires dans 11,9 et 10,1 % des cas respectivement. Le taux de mortalite dans notre cohorte est de 13,4 % au cours des 30 jours post-transplantation. Les principaux facteurs de risque de mortalite retrouves sont les fortes doses de catecholamines per-operatoire (OR 3,73 [1,34–10,4] p = 0,0086), un recours precoce a l’EER (OR 9,69 [3,06–3065] p Discussion Dans notre cohorte, plus d’un patient sur huit decede lors du premier mois post-operatoire. Cette etude a permis d’identifier une population a haut risque de mortalite marquee notamment par la necessite de fortes doses de catecholamines, d’une transfusion massive ou d’une EER precoces.

Introduction Les pneumopathies postoperatoires (PPO) apres chirurgie cardiaque surviennent frequemment chez des patients qui sont en ventilation spontanee. Cependant, les etudes evaluant les PPO apres chirurgie cardiaque n’ont essentiellement evalue que les patients developpant une pneumopathie acquise sous ventilation mecanique (PAVM). Le but de cette etude etait d’evaluer les caracteristiques des PPO apres chirurgie cardiaque en portant une attention plus particuliere sur les pneumopathies acquises en ventilation spontanee (PAVS) et la microbiologie. Materiel et methodes Etude retrospective, monocentrique menee de janvier 2005 a decembre 2012, a partir d’une base de donnee colligee de maniere prospective. Ont ete evalues consecutivement tous les patients operes d’une chirurgie cardiaque developpant une PPO dans les 7 premiers jours. Comparaison des caracteristiques des PAVS a celles des PAVM. CEERB Paris Nord (IRB 00006477). Resultats Durant la periode 7439 patients ont eu une chirurgie cardiaque ; 255 (3,5 %) ont developpe une PPO et parmi eux 120 (47 %) ont eu une PAVS. Les germes les plus frequemment isoles etaient des enterobacteries (39 % dans le groupe PAVS et 44 % dans le groupe PAVM, p = 0,5) et Pseudomonas aeruginosa (22 % dans le groupe PAVS contre 26 % dans le groupe PAVM, p = 0,5). L’antibiotherapie probabiliste initiale la plus frequemment utilisee etait l’association piperacilline/tazobactam et amikacine (70 %) sans difference entre les 2 groupes (p = 0,9). La proportion d’antibiotherapie probabiliste adaptee etait similaire entre les 2 groupes (88 % dans le groupe PAVS contre 89 % dans le groupe PAVM, p = 0,6). La sensibilite des germes aux associations d’antibiotiques etait similaire dans les 2 groupes (PAVS et PAVM respectivement) : amoxicilline/acide clavulanique (58 % contre 50 %, p = 0,4) ; Cephalosporine de 3e generation (76 % contre 70 %, p = 0,3) ; piperacilline/tazobactam (95 % contre 93 %, p = 0,4) ; piperacilline/tazobactam/amikacine (98 % contre 98 %, p = 0,8). Malgre un score SOFA plus bas a l’admission en reanimation dans le groupe des PAVS (5 ± 2 vs 7 ± 3, p Discussion Il y a peu de differences entre les PAVM et les PAVS. Le type de germe isole et le pronostic sont similaires, suggerant qu’ils dependent plus du terrain du patient que du type d’acquisition de la PPO (PAVS/PAVM). Les germes retrouves sont essentiellement des bacilles a Gram negatif avec une forte proportion de Pseudomonas aeruginosa qui doit etre pris en compte dans le traitement empirique des PPO precoces.

BACKGROUND: Many new mechanical ventilation modes are proposed without any clinical evaluation. "Dual-controlled" modes, such as AutoFlow™, are supposed to improve patient-ventilator interfacing and could lead to fewer alarms. We performed a long-term clinical evaluation of the efficacy and safety of AutoFlow during assist-controlled ventilation, focusing on ventilator alarms. METHODS: Forty-two adult patients, receiving mechanical ventilation for more than 2 days with a Drager Evita 4 ventilator were randomized to conventional (n = 21) or AutoFlow (n = 21) assist-controlled ventilation. Sedation was given using a nurse-driven protocol. Ventilator-generated alarms were exhaustively recorded from the ventilator logbook with a computer. Daily blood gases and ventilation outcome were recorded. RESULTS: A total of 403 days of mechanical ventilation were studied and 45,022 alarms were recorded over a period of 8074 hours. The course of respiratory rate, minute ventilation, F IO2 , positive end-expiratory pressure, Pa O2 /F IO2 , Pa CO2 , and pH and doses and duration of sedation did not differ between the 2 groups. Outcome (duration of mechanical ventilation, ventilator-associated pneumonia, course of Sequential Organ Failure Assessment score, or death) was not different between the 2 groups. The number of alarms per hour was lower with AutoFlow assist-controlled ventilation: 3.3 [1.5 to 17] versus 9.1 [5 to 19], P < 0.0001 (median [quartile range]). In multivariate analysis, a low alarm rate was associated with activation of AutoFlow and a higher midazolam dose. CONCLUSIONS: This first long-term clinical evaluation of the AutoFlow mode demonstrated its safety with regard to gas exchange and patient outcome. AutoFlow also allowed a very marked reduction in the number of ventilator alarms.

Introduction La transplantation pulmonaire (TP) est la seule option therapeutique des maladies pulmonaires parenchymateuses echappant aux traitements medicamenteux. Les infections pulmonaires, complications frequentes avec un pic d’incidence au cours du mois suivant la TP [1] , sont associees a une morbi-mortalite importante. Afin d’optimiser l’antibiotherapie probabiliste, il est important de bien connaitre les profils de resistance des bacteries responsables de ces infections. Le but de l’etude etait de decrire la frequence d’emergence des bacteries multi-resistantes (BMR) retrouvee sur les prelevements respiratoires au cours du premier mois suivant la TP et leurs facteurs de risque. Materiel et methodes Cette etude retrospective mono-centrique analyse 176 patients (pts) adultes ayant eu une TP sur une periode de 6 ans. Les donnees microbiologiques recoltees proviennent des prelevements respiratoires realises en reanimation au cours des 30 premiers jours (j) suivant la TP. Les BMR sont identifiees selon les recommandations internationales [2] . Les analyses statistiques sont realisees avec le test de Mann-Whitney, le Chi 2 et un modele de regression logistique. Resultats Sur les 1176 bacteries isolees, 404 (34 %) etaient des BMR retrouvees chez 90 pts (51 %) [principalement Pseudomonas aeruginosa (20 % des BMR), Enterobacter spp (19 %), Staphylococcus aureus (11 %) et Stenotrophomonas maltophilia (10 %)]. Les BMR ont emerge en mediane a j9 apres TP. Une correlation etait observee entre le temps depuis la TP et l’emergence des BMR ( r 2 : 0,59 ; p p = 0,0009), la presence d’une tracheotomie (OR : 3,28 [1,05–10,28] ; p = 0,039) et l’utilisation prealable d’un antibiotique a large spectre (OR : 2,25 [1,17–4,34] ; p = 0,016) etaient des facteurs de risque d’emergence de BMR. La sensibilite aux differents antibiotiques decroissait rapidement. La sensibilite globale au cefepime (FEP) diminuait de 81 % a 50 % pour tous les germes identifies entre la 1 e et la 4 e semaine d’hospitalisation en reanimation, la sensibilite a l’imipeneme (IPM) passait de 90 % a 48 %, celle de l’amikacine (AMK) de 85 % a 64 %, celle de la piperacilline–tazobactam (TZP) de 77 % a 50 % ( Fig. 1 ). Discussion Chez nos pts transplantes pulmonaires, une large proportion de BMR a emerge dans un delai median de 9 j. La duree d’hospitalisation en reanimation et la presence d’une antibiotherapie anterieure a large spectre etaient les principaux determinants de cette emergence. Au vu de ces resultats et pour un traitement adapte, une antibiotherapie a large spectre semble necessaire des la phase precoce.

Mid-term and long-term complications of bariatric surgery have been described. Nevertheless, data dealing with healthcare-related complications in the specific context of morbid obesity are scarce [1]. Benzodiazepines may be associated with serious adverse events, and they should be used with caution in obese patients because of modification of pharmacokinetic characteristics [2]. We aim to describe two cases of prolonged coma due to drug accumulation after repeated benzodiazepine administration.

Purpose Postoperative infectious complications are key issues following lung transplantation (LT). Fungal bronchial colonization (FBC) is reported in 40 to 80% of the cases and is usually considered as a complication. The risk factors, morbidity and mortality linked to FBC were assessed in a retrospective monocentric cohort of LT. Methods and Materials From 2006 to 2010, all consecutive LT performed in our institution were included. Demographic and microbiologic data during the first 30 postoperative days after LT were collected. The risk factors of developing FBC and its prognosis were assessed. Results Among 102 LT (emphysema 46%, idiopathic fibrosis 38%), FBC was reported after LT in 52% of the cases in a median delay of 3 [2-5 IQ] days after LT. Only one donor was colonized while 11 % of the recipients were colonized before LT. The main organisms involved in FBC were Candidas (78% of the cases, C albicans (54%), other Candidas species (24%)) while Aspergillus were reported in 9% of the cases. The risk factors associated with FBC are presented in the table 1 . Ischemic bronchitis was reported in 24% of the cases and all of them developed FBC. 75% of FBC were treated by antifungal therapy. Interestingly FBC did not have any impact on length of mechanical ventilation and mortality at day 30. Conclusions FBC is a frequent situation, especially in double LT. The links between ischemic bronchitis and FBC are not clear. FBC in these cases could be a consequence rather than a cause. In patients with identified risk factors (double LT, colonization of conservation liquid), a preemptive antifungal therapy could be discussed. Factors associated with fungal colonization Parameters Odds Ratio 95% IC p Double lung transplantation 3.93 1.49-10.40 0.0037 Hospitalisation >10 days 2.75 1.12-6.77 0.0214 ischemic bronchitis 10.06 2.77-36.66 0.0001 conservation liquid colonization 8.66 0.98-76.11 0.028

Introduction Les patients victimes de plaies thoraciques par arme blanche necessitent une prise en charge specifique en raison du risque vital potentiel mais de la dissociation souvent presente entre l’etat clinique et les lesions sous-jacentes. Cependant, aucune etude n’existe sur la necessite d’orienter systematiquement tous les patients, meme ceux dont la plaie ne semble pas penetrante, vers le dechocage d’un centre disposant de chirurgie thoracique. D’autre part, l’interet de la realisation systematique d’une tomodensitometrie (TDM) dans le bilan des lesions reste controverse par rapport a des radiographies de thorax (RT) repetees. Materiel et methodes Tous les patients adresses au dechocage pour suspicion de plaie thoracique par arme blanche penetrante ou non ont ete inclus de facon prospective de janvier 2009 a decembre 2011. Le motif de transfert annonce par le medecin transporteur en prehospitalier etait consigne puis ont ete recueillies les donnees suivantes : caracteristiques des plaies, leur caractere penetrant ou non, les donnees cliniques et biologiques en prehospitalier et lors de l’hospitalisation, la realisation d’une RT, d’une TDM et les lesions observees, la necessite d’un drainage percutane ou d’une intervention chirurgicale. Pour chaque TDM realisee etait consignee la presence de lesions non vues a la RT et une modification eventuelle de prise en charge therapeutique induite par ces lesions. Resultats Cent cinquante trois patients ont ete analyses. En cas de RT normale, la TDM permettait de diagnostic de lesions occultes dans 28,4 % des cas et celles-ci modifiaient la prise en charge chez 4,5 % des patients. En cas de RT anormale ou douteuse, de nouvelles lesions etaient observees dans 61,3 % des cas et 57,9 % de ces lesions modifiaient la prise en charge du patient. En analyse multivariee, les facteurs de risque de lesion modifiant la therapeutique etaient une plaie soufflante (p = 0,002), une plaie sus-claviculaire (p = 0,037) et une RT anormale (p Discussion Cette etude montre qu’une TDM est certainement utile en cas de plaie de l’aire abdomino-thoracique et probablement en cas de plaie sus-claviculaire et de radiographie de thorax anormale, car dans ces indications, de nouvelles lesions sont observees frequemment et modifient souvent la prise en charge des patients. En dehors de ces cas de figure, il semble que la TDM ne soit pas indispensable par rapport a une RT de controle. D’autre part, le tri des patients ne peut etre effectue de facon fiable en prehospitalier. Tous devraient donc etre adresses dans un centre qui dispose d’un service chirurgie thoracique.

Purpose Postoperative infectious complications are key issues following lung transplantation (LT). Early bacterial pneumonia (EBP) worsen prognosis of LT. Assessment of bacterial epidemiology of EBP is necessary to optimize treatment of EBP, thus improving LT outcome. Methods and Materials From 2006 to 2010, all consecutive LT performed in our institution were included. Demographic and microbiologic data during the first 30 postoperative days after LT were collected. Results 102 LT (emphysema 46%, idiopathic fibrosis 38%) were performed during the study period. Among 831 bacteriological cultures of bronchial aspirate, 307 were positive. Evolution of bacterial epidemiology during the first 2 weeks is presented in figure 1 . Donor colonization was associated with recipient infection with Methicilin-sensitive Staphylococcus aureus (MSSA) (OR=5,84; [1,87-18,27], p=0,0033) and Enterobacteria (0R=2,8; [1,15-6,83], p=0,037). Presence of purulent expectoration, contrary to fever, leukocyte count, chest X ray, impairment in lung function and CPIS scor, was associated with positive bacterial cultures (OR=1,99; IC [1,45-2,72] p=0,01). Interestingly, type of bacteria did not have any impact on mortality at day 30. Conclusions There is an evolution of bronchial bacterial epidemiology during the 2 weeks following LT with an increase in Pseudomonas aeruginosa proportion. Only purulent expectoration, but not other parameters currently used to diagnose post operative pneumonia, is associated with positive bacterial culture of bronchial aspiration. These findings highlight the challenging problems raised by the diagnosis of respiratory infection after LT.

Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection.

Background We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS). Methods In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP). Results Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45 ± 10 versus 63 ± 16 years; p