Publications by authors named "Olivier Mimoz"

113 Publications

Regarding Use of Povidone Iodine to Reduce Nasopharyngeal Viral Load in Patients With COVID-19-Reply.

JAMA Otolaryngol Head Neck Surg 2021 Apr 29. Epub 2021 Apr 29.

Emergency Department, University Hospital of Poitiers, Poitiers, France.

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http://dx.doi.org/10.1001/jamaoto.2021.0684DOI Listing
April 2021

Ultrasound-guided catheterization and infectious risk in obese ICU patients.

Intensive Care Med 2021 Mar 27. Epub 2021 Mar 27.

INSERM, IAME, University of Paris, 75006, Paris, France.

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http://dx.doi.org/10.1007/s00134-021-06382-6DOI Listing
March 2021

Continuous Pneumatic Regulation of Tracheal Cuff Pressure to Decrease Ventilator-associated Pneumonia in Trauma Patients Who Were Mechanically Ventilated: The AGATE Multicenter Randomized Controlled Study.

Chest 2021 Mar 13. Epub 2021 Mar 13.

Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, France; Université de Poitiers, Faculté de Médecine, Poitiers, France; INSERM U1070, Pharmacologie des Agents anti-infectieux, France. Electronic address:

Background: Ventilator-associated pneumonia (VAP) is the most frequent health care-associated infection in severely ill patients, and aspiration of contaminated oropharyngeal content around the cuff of the tracheal tube is the main route of contamination.

Research Question: Is continuous regulation of tracheal cuff pressure using a pneumatic device superior to manual assessment three times daily using a portable manometer (routine care) in preventing VAP in patients with severe trauma?

Study Design And Methods: In this open-label, randomized controlled superiority trial conducted in 13 French ICUs, adults (age ≥ 18 years) with severe trauma (Injury Severity Score > 15) and requiring invasive mechanical ventilation for ≥ 48 h were enrolled. Patients were randomly assigned (1:1) via a secure Web-based random number generator in permuted blocks of variable sizes to one of two groups according to the method of tracheal cuff pressure control. The primary outcome was the proportion of patients developing VAP within 28 days following the tracheal intubation, as determined by two assessors masked to group assignment, in the modified intention-to-treat population. This study is closed to new participants.

Results: A total of 434 patients were recruited between July 31, 2015, and February 15, 2018, of whom 216 were assigned to the intervention group and 218 to the control group. Seventy-three patients (33.8%) developed at least one episode of VAP within 28 days following the tracheal intubation in the intervention group compared with 64 patients (29.4%) in the control group (adjusted subdistribution hazard ratio, 0.96; 95% CI, 0.76-1.20; P = .71). No serious adverse events related to the use of the pneumatic device were noted.

Interpretation: Continuous regulation of cuff pressure of the tracheal tube using a pneumatic device was not superior to routine care in preventing VAP in patients with severe trauma.

Clinical Trial Registration: ClinicalTrials.gov; No.: NCT02534974; URL: www.clinicaltrials.gov.
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http://dx.doi.org/10.1016/j.chest.2021.03.007DOI Listing
March 2021

Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial.

Lancet Infect Dis 2021 Feb 1. Epub 2021 Feb 1.

Service des Urgences et SAMU 86 Centre 15, CHU de Poitiers, France; Université de Poitiers, UFR de Médecine-Pharmacie, Poitiers, France; INSERM U1070, Pharmacologie des Agents Anti-Infectieux, Poitiers, France. Electronic address:

Background: Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure.

Methods: We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov, NCT03757143.

Findings: 1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02-0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6-69·4] h vs 30·0 [16·6-52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group.

Interpretation: For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time.

Funding: Becton Dickinson.

Translations: For the Chinese, Portuguese, Spanish, Turkish and Russian translations of the abstract see Supplementary Materials section.
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http://dx.doi.org/10.1016/S1473-3099(20)30738-6DOI Listing
February 2021

Obesity and risk of catheter-related infections in the ICU. A post hoc analysis of four large randomized controlled trials.

Intensive Care Med 2021 Apr 1;47(4):435-443. Epub 2021 Feb 1.

University of Paris, INSERM, IAME, 75006, Paris, France.

Purpose: Obesity increases the risk of nosocomial infection, but data regarding the role of body mass index (BMI) in catheter related infections are scarce. We used the data gathered from four randomized, controlled trials (RCTs) to investigate the association between body mass index (BMI) and intravascular catheter infections in critically ill obese patients.

Methods: Adult obese patients who required short-term central venous, arterial or dialysis catheter insertion in the intensive care unit (ICU) were analyzed. The association between BMI and major catheter-related infection (MCRI), catheter-related bloodstream infection (CRBSI) and catheter tip colonization was estimated using univariate and multivariate marginal Cox models. Exploratory analysis using dressing disruptions was added.

Results: A total of 2282 obese patients and 4275 catheters from 32 centers were included in this post-hoc analysis. Overall, 66 (1.5%) MCRI, 43 (1%) CRBSI and 399 (9.3%) catheter colonizations were identified. The hazard ratio (HR) for MCRI, CRBSI and colonization increased with BMI. After adjustment for well-known infection risk factors, the BMI ≥ 40 group had an increased risk for MCRI (HR 1.88, 95% CI 1.13-3.12, p = 0.015), CRBSI (HR 2.19, 95% CI 1.19-4.04, p = 0.012) and colonization (HR 1.44, 95% CI 1.12-1.84, p = 0.0038) compared to the BMI < 40 group. The mean dressing disruption per catheter was increased in the BMI ≥ 40 group (2.03 versus 1.68 in the BMI < 40 group, p = 0.05).

Conclusions: Using the largest dataset ever collected from large multicentric RCTs, we showed that patients with BMI ≥ 40 had an increased risk for intravascular catheter infections. Targeted prevention measures should focus on this population with a particular attention to catheter care and dressing disruption.
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http://dx.doi.org/10.1007/s00134-020-06336-4DOI Listing
April 2021

Local signs at insertion site and catheter-related bloodstream infections: an observational post hoc analysis using individual data of four RCTs.

Crit Care 2020 12 14;24(1):694. Epub 2020 Dec 14.

University of Paris, INSERM, IAME, 75006, Paris, France.

Background: Little is known on the association between local signs and intravascular catheter infections. This study aimed to evaluate the association between local signs at removal and catheter-related bloodstream infections (CRBSI), and which clinical conditions may predict CRBSIs if inflammation at insertion site is present.

Methods: We used individual data from four multicenter randomized controlled trials in intensive care units (ICUs) that evaluated various prevention strategies for arterial and central venous catheters. We used multivariate logistic regressions in order to evaluate the association between ≥ 1 local sign, redness, pain, non-purulent discharge and purulent discharge, and CRBSI. Moreover, we assessed the probability for each local sign to observe CRBSI in subgroups of clinically relevant conditions.

Results: A total of 6976 patients and 14,590 catheters (101,182 catheter-days) and 114 CRBSI from 25 ICUs with described local signs were included. More than one local sign, redness, pain, non-purulent discharge, and purulent discharge at removal were observed in 1938 (13.3%), 1633 (11.2%), 59 (0.4%), 251 (1.7%), and 102 (0.7%) episodes, respectively. After adjusting on confounders, ≥ 1 local sign, redness, non-purulent discharge, and purulent discharge were associated with CRBSI. The presence of ≥ 1 local sign increased the probability to observe CRBSI in the first 7 days of catheter maintenance (OR 6.30 vs. 2.61 [> 7 catheter-days], p = 0.02).

Conclusions: Local signs were significantly associated with CRBSI in the ICU. In the first 7 days of catheter maintenance, local signs increased the probability to observe CRBSI.
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http://dx.doi.org/10.1186/s13054-020-03425-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737269PMC
December 2020

Risk factors and events in the adult intensive care unit associated with pain as self-reported at the end of the intensive care unit stay.

Crit Care 2020 12 7;24(1):685. Epub 2020 Dec 7.

Unité de recherche EA3279, Aix-Marseille Université, Marseille, France.

Background: The short-term and long-term consequences of the most frequent painful procedures performed in the ICU are unclear. This study aimed to identify the risk factors associated with pain-related discomfort perceived by critically ill patients during the whole ICU stay as self-reported by patients at the end of their ICU stay.

Methods: The study involved 34 ICUs. Adult patients who survived an ICU stay of 3 calendar days or more were eligible for inclusion. Discomforts, including the pain-related discomfort, were assessed using the French 18-item questionnaire on discomfort in ICU patients, the "Inconforts des Patients de REAnimation" (IPREA). Patients scored each item from 0 (minimal discomfort) to 10 (maximal discomfort). Associations between patient characteristics at ICU admission, life support therapies and main potentially painful procedures performed during the ICU stay and pain-related discomfort scores assessed at the end of the ICU stay were analyzed.

Results: Patients with complete IPREA questionnaires (n = 2130) were included. The median pain-related discomfort score was 3 (IQR 0-5). From the univariate analysis, pain-related discomfort scores were negatively correlated with age and positively correlated with ICU stay duration; surgical patients reported significant higher pain-related discomfort scores than medical patients; chest drain insertion, chest drain removal, use of bladder catheter, central venous catheter (CVC) insertion, complex dressing change, and intra-hospital transport were associated with pain-related discomfort scores. From the multivariate analyses using generalized estimating equations models, only age, chest drain removal, use of a bladder catheter, CVC insertion, and intra-hospital transport were the main risk factors associated with pain-related discomfort scores.

Conclusion: Patients who underwent chest drain removal, bladder catheter, CVC insertion, and intra-hospital transport during their ICU stay reported higher pain-related discomfort scores (with respect to the whole ICU stay and assessed at the end of their ICU stay) than patients who did not experience these events. This study may pave the way for further targeted studies aiming at investigating a causal link between these common procedures in the ICU and adult critically ill patients' perceptions of their ICU stay regarding recalled pain.

Trial Registration: Clinicaltrials.gov Identifier NCT02442934, retrospectively registered on May 13, 2015.
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http://dx.doi.org/10.1186/s13054-020-03396-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722444PMC
December 2020

Ultrasound guidance and risk for central venous catheter-related infections in the ICU. A post hoc analysis of individual data of three multi-centric randomized trials.

Clin Infect Dis 2020 Dec 5. Epub 2020 Dec 5.

University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France.

Background: Ultrasound (US) guidance is frequently used in critically ill patients for central venous catheter (CVC) insertion. The effect of US on infectious risk remains controversial and randomized-controlled trials (RCTs) assessed mainly non-infectious complications. This study assessed infectious risk associated with catheters inserted with US guidance versus use of anatomical 'landmarks' (AL).

Methods: We used individual data from three large RCTs for which a prospective, high-quality data collection was performed. Adult patients were recruited in various intensive care units (ICU) in France as soon as they required short-term CVC insertion. We applied marginal Cox models with inverse probability weighting to estimate the effect of US-guided insertion on catheter-related bloodstream infections (CRBSI, primary outcome) and major catheter-related infections (MCRI, secondary outcome).We also evaluated insertion site colonization at catheter removal.

Results: Our post hoc analysis included 4636 patients and 5502 catheters inserted in 2088 jugular, 1733 femoral and 1681 subclavian veins, respectively, in 19 ICUs. US was used for 2147 catheter insertions. Among jugular and femoral CVCs and after weighting, we found an association between US and CRBSI (HR 2.21, 95% CI 1.17-4.16, p=0.014) and between US and MCRI (HR 1.55, 95% CI 1.01-2.38, p=0.045). Catheter insertion site colonization at removal was more common in the US-guided group (p=0.0045) among jugular and femoral CVCs in situ for ≤7 days (n=606).

Conclusions: In prospectively collected data in which catheters were not randomized to insertion by US or AL, US guidance was associated with increased risk of infection.
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http://dx.doi.org/10.1093/cid/ciaa1817DOI Listing
December 2020

Concurrent systemic antibiotics at catheter insertion and intravascular catheter-related infection in the ICU: a post hoc analysis using individual data from five large RCTs.

Clin Microbiol Infect 2020 Nov 2. Epub 2020 Nov 2.

University of Paris, INSERM, IAME, F-75006, Paris, France; Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.

Objectives: Data on the impact of systemic antibiotics at the time of catheter insertion are scarce. Therefore, we assessed the association between concurrent antibiotic administration at insertion and short-term catheter-related infections.

Methods: We used individual data gathered from five large, randomized, controlled ICU trials. We analysed adult patients who required arterial, short-term central venous or dialysis catheter insertion in the ICU. The effect of antibiotics at insertion on major catheter-related infection (MCRI), catheter-related bloodstream infection (CRBSI) and colonization was estimated using multivariate marginal Cox and propensity score models.

Results: We included 10 269 patients and 18 743 catheters from 36 ICUs. Antibiotic use was ongoing at the time of 11 361 catheter insertions (60.6%). After adjusting for well-known risk factors for intravascular catheter infection, we observed a similar risk for MCRI (HR 0.83, 95%CI 0.62-1.10, p 0.19) and CRBSI (HR 0.85, 95%CI 0.60-1.22, p 0.38) between the antibiotic and no-antibiotic groups. A confirmatory analysis using propensity score showed consistent results. No specific antibiotic subclasses reduced the risk of MCRI. Non-fermenting Gram-negative bacilli were more frequently observed in the antibiotic group.

Conclusions: Ongoing antibiotic administration at the time of catheter insertion was not associated with a decrease risk of catheter-related infections and should not be carried out for preventing such infections. Our results bring new insights to antimicrobial stewardship in critically ill patients and may direct empirical antimicrobial therapy if an intravascular catheter infection is suspected.
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http://dx.doi.org/10.1016/j.cmi.2020.10.026DOI Listing
November 2020

International recommendations for a vascular access minimum dataset: a Delphi consensus-building study.

BMJ Qual Saf 2020 Sep 22. Epub 2020 Sep 22.

Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia.

Background: Data regarding vascular access device use and outcomes are limited. In part, this gap reflects the absence of guidance on what variables should be collected to assess patient outcomes. We sought to derive international consensus on a vascular access minimum dataset.

Methods: A modified Delphi study with three rounds (two electronic surveys and a face-to-face consensus panel) was conducted involving international vascular access specialists. In Rounds 1 and 2, electronic surveys were distributed to healthcare professionals specialising in vascular access. Survey respondents were asked to rate the importance of variables, feasibility of data collection and acceptability of items, definitions and response options. In Round 3, a purposive expert panel met to review Round 1 and 2 ratings and reach consensus (defined as ≥70% agreement) on the final items to be included in a minimum dataset for vascular access devices.

Results: A total of 64 of 225 interdisciplinary healthcare professionals from 11 countries responded to Round 1 and 2 surveys (response rate of 34% and 29%, respectively). From the original 52 items, 50 items across five domains emerged from the Delphi procedure.Items related to demographic and clinical characteristics (n=5; eg, age), device characteristics (n=5; eg, device type), insertion (n=16; eg, indication), management (n=9; eg, dressing and securement), and complication and removal (n=15, eg, occlusion) were identified as requirements for a minimum dataset to track and evaluate vascular access device use and outcomes.

Conclusion: We developed and internally validated a minimum dataset for vascular access device research. This study generated new knowledge to enable healthcare systems to collect relevant, useful and meaningful vascular access data. Use of this standardised approach can help benchmark clinical practice and target improvements worldwide.
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http://dx.doi.org/10.1136/bmjqs-2020-011274DOI Listing
September 2020

Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit.

Ann Intensive Care 2020 Sep 7;10(1):118. Epub 2020 Sep 7.

Surgical and Medical Intensive Care Unit Hôpital, Raymond Poincaré, 9230, Garches, France.

The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF), worked out guidelines for the management of central venous catheters (CVC), arterial catheters and dialysis catheters in intensive care unit. For adult patients: Using GRADE methodology, 36 recommendations for an improved catheter management were produced by the 22 experts. Recommendations regarding catheter-related infections' prevention included the preferential use of subclavian central vein (GRADE 1), a one-step skin disinfection(GRADE 1) using 2% chlorhexidine (CHG)-alcohol (GRADE 1), and the implementation of a quality of care improvement program. Antiseptic- or antibiotic-impregnated CVC should likely not be used (GRADE 2, for children and adults). Catheter dressings should likely not be changed before the 7th day, except when the dressing gets detached, soiled or impregnated with blood (GRADE 2- adults). CHG dressings should likely be used (GRADE 2+). For adults and children, ultrasound guidance should be used to reduce mechanical complications in case of internal jugular access (GRADE 1), subclavian access (Grade 2) and femoral venous, arterial radial and femoral access (Expert opinion). For children, an ultrasound-guided supraclavicular approach of the brachiocephalic vein was recommended to reduce the number of attempts for cannulation and mechanical complications. Based on scarce publications on diagnostic and therapeutic strategies and on their experience (expert opinion), the panel proposed definitions, and therapeutic strategies.
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http://dx.doi.org/10.1186/s13613-020-00713-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477021PMC
September 2020

Chlorhexidine-impregnated sponge versus chlorhexidine gel dressing for short-term intravascular catheters: which one is better?

Crit Care 2020 07 23;24(1):458. Epub 2020 Jul 23.

University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France.

Background: Chlorhexidine-gluconate (CHG) impregnated dressings may prevent catheter-related bloodstream infections (CRBSI). Chlorhexidine-impregnated sponge dressings (sponge-dress) and gel dressings (gel-dress) have never been directly compared. We used the data collected for two randomized-controlled trials to perform a comparison between sponge-dress and gel-dress.

Methods: Adult critically ill patients who required short-term central venous or arterial catheter insertion were recruited. Our main analysis included only patients with CHG-impregnated dressings. The effect of gel-dress (versus sponge-dress) on major catheter-related infections (MCRI) and CRBSI was estimated using multivariate marginal Cox models. The comparative risks of dressing disruption and contact dermatitis were evaluated using logistic mix models for clustered data. An explanatory analysis compared gel-dress with standard dressings using either CHG skin disinfection or povidone iodine skin disinfection.

Results: A total of 3483 patients and 7941 catheters were observed in 16 intensive care units. Sponge-dress and gel-dress were utilized for 1953 and 2108 catheters, respectively. After adjustment for confounders, gel-dress showed similar risk for MCRI compared to sponge-dress (HR 0.80, 95% CI 0.28-2.31, p = 0.68) and CRBSI (HR 1.13, 95% CI 0.34-3.70, p = 0.85), less dressing disruptions (OR 0.72, 95% CI 0.60-0.86, p < 0.001), and more contact dermatitis (OR 3.60, 95% CI 2.51-5.15, p < 0.01). However, gel-dress increased the risk of contact dermatitis only if CHG was used for skin antisepsis (OR 1.94, 95% CI 1.38-2.71, p < 0.01).

Conclusions: We described a similar infection risk for gel-dress and sponge-dress. Gel-dress showed fewer dressing disruptions. Concomitant use of CHG for skin disinfection and CHG-impregnated dressing may significantly increase contact dermatitis.

Trials Registration: These studies were registered within ClinicalTrials.gov (numbers NCT01189682 and NCT00417235 ).
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http://dx.doi.org/10.1186/s13054-020-03174-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376730PMC
July 2020

Ultrasound guidance and risk for intravascular catheter-related infections among peripheral arterial catheters: a post-hoc analysis of two large randomized-controlled trials.

Ann Intensive Care 2020 Jul 8;10(1):89. Epub 2020 Jul 8.

University of Paris, INSERM IAME, U1137, Team DeSCID, Paris, France.

Background: The impact on infectious risk of ultrasound guidance at insertion remains controversial in short-term arterial catheters (ACs). The present study investigated the association between ultrasound guidance (US) during AC insertion and major catheter-related infections (MCRI), catheter-related bloodstream infections (CR-BSI) or colonization, using univariate and multivariate marginal Cox model for clustered data. The skin colonization at catheter removal was evaluated to explain our results.

Results: We used individual data from two multicenter randomized-controlled trials (RCTs) that included a total of 3029 patients, 10 ICUs and 3950 ACs. US guidance was used for 386 (9.8%) catheter placements. In the univariate Cox model analysis, AC insertion with US versus without US exhibited similar risks for MCRI (HR 0.86, CI 95% 0.27-2.72, p = 0.79), CR-BSI (HR 0.87, CI 95% 0.20-3.72, p = 0.85) and catheter colonization (HR 1.31, CI 95% 0.92-1.86, p = 0.13). After adjustment on confounders, risks associated with US guidance remained similar versus non-US for MCRI (HR 0.71, CI 95% 0.23-2.24, p = 0.56), CR-BSI (HR 0.71, CI 95% 0.17-3.00, p = 0.63) and catheter colonization (HR 0.92, CI 95% 0.63-1.34, p = 0.67). No differences between US and non-US for MCRI, CR-BSI and colonization were observed according to the insertion site, radial or femoral. At catheter removal, the skin colonization was similar between US and non-US groups (p = 0.69).

Conclusions: Using the largest dataset ever collected from large multi-centric RCTs conducted with relatively consistent insertion and maintenance catheter protocols, we showed that the risk of infectious complications for ACs inserted under US guidance is not superior compared to those inserted without US guidance. Trial registration These studies were registered within ClinicalTrials.gov (numbers NCT01629550 and NCT01189682).
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http://dx.doi.org/10.1186/s13613-020-00705-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343671PMC
July 2020

High-flow nasal cannula oxygen therapy in acute respiratory failure at Emergency Departments: A systematic review.

Am J Emerg Med 2020 07 4;38(7):1508-1514. Epub 2020 May 4.

INSERM, CIC-1402 Team 5 ALIVE, Poitiers, France; Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers, France; CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.

Objectives: The use of high-flow oxygen therapy (HFOT) through nasal cannula for the management of acute respiratory failure at the emergency department (ED) has been only sparsely studied. We conducted a systematic review of randomized-controlled and quasi-experimental studies comparing the early use of HFOT versus conventional oxygen therapy (COT) in patients with acute respiratory failure admitted to EDs.

Methods: A systematic research of literature was carried out for all published control trials comparing HFOT with COT in adult patients admitted in EDs. Eligible data were extracted from Medline, Embase, Pascal, Web of Science and the Cochrane database. The primary outcome was the need for mechanical ventilation, i.e. intubation or non-invasive ventilation as rescue therapy. Secondary outcomes included respiratory rate, dyspnea level, ED length of stay, intubation and mortality.

Results: Out of 1829 studies screened, five studies including 673 patients were retained in the analysis (350 patients treated with HFOT and 323 treated with COT). The need for mechanical ventilation was similar in both treatments (RR = 0.75; 95% CI 0.41 to 1.35; P = 0.31; I = 16%). Respiratory rate was lower with HFOT (Mean difference (MD) = -3.14 breaths/min; 95% CI = -4.9 to -1.4; P < 0.001; I = 39%), whereas sensation of dyspnea did not differ. (MD = -1.04; 95% CI = -2.29 to -0.22; P = 0.08; I = 67%). ED length of stay and mortality were similar between groups.

Conclusion: The early use of HFOT in patients admitted to an ED for acute respiratory failure did not reduce the need for mechanical ventilation as compared to COT. However, HFOT decreased respiratory rate.

Registration: PROSPERO ID CRD42019125696.
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http://dx.doi.org/10.1016/j.ajem.2020.04.091DOI Listing
July 2020

Feasibility but unclear benefit of minimising endotracheal cuff under inflation using an elastomeric device.

Anaesth Crit Care Pain Med 2020 06 28;39(3):419-420. Epub 2020 Apr 28.

Service des Urgences Adultes & SAMU 86, CHU de Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, France; Inserm U1070, Pharmacology of Antimicrobial Agents, Poitiers, France. Electronic address:

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http://dx.doi.org/10.1016/j.accpm.2020.04.006DOI Listing
June 2020

The Insertion Site Should Be Considered for the Empirical Therapy of Short-Term Central Venous and Arterial Catheter-Related Infections.

Crit Care Med 2020 May;48(5):739-744

INSERM IAME, U1137, Team DesCID, Paris, France.

Objectives: Little is known on causative pathogens of intravascular catheters infection according to the catheter insertion site. The present study aimed to describe the epidemiology of causative microorganisms of catheter-related infection and colonization according to the insertion site.

Design: Multicenter observational study using data from four large randomized controlled trials investigating different prevention strategies in which extensive prospective high-quality data collection at catheter insertion and catheter removal was performed.

Setting: Twenty-five ICUs in France.

Patients: Patients were recruited from 2006 to 2014 as soon as they required a catheterization with a short-term central venous catheter or peripheral arterial catheter with an expected duration of use of more than 48 hours. We described the distribution of microorganisms in central venous catheter and arterial catheter-related bloodstream infections and colonization according to the insertion type (femoral vs nonfemoral) included in the four studies.

Interventions: None.

Measurements And Main Results: A total of 7,235 patients and 15,259 catheters were included. Among central venous catheter, the distribution of microorganisms associated with catheter-related bloodstream infection and colonization was significantly different between femoral and nonfemoral sites. Among central venous catheter catheter-related bloodstream infection, nonfermenting Gram-negative bacilli were more frequently detected at the femoral site (31% vs 4% for nonfemoral site; p < 0.01). After adjustment for confounding factors, the femoral site was still associated with an increased risk for catheter-related bloodstream infection due to nonfermenting Gram-negative bacilli (odds ratio, 6.33; 95% CI, 1.59-25.28; p < 0.01). Among colonized arterial catheters, the distribution of microorganisms was significantly different between femoral and radial site (p < 0.01). Colonized arterial catheters due to nonfermenting Gram-negative bacilli were more frequently observed at the femoral site (20% vs nonfemoral site 12%; p = 0.01).

Conclusions: The proportion of intravascular catheter infections due to nonfermenting Gram-negative bacilli was high for the femoral insertion site. Empirical antipseudomonal therapy should be considered if a femoral catheter-related bloodstream infection is suspected.
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http://dx.doi.org/10.1097/CCM.0000000000004270DOI Listing
May 2020

The IASIS, INHALE and VAPORISE trials. Reasons for a triple failure: Study design, aminoglycosides dosing and technique of nebulisation.

Anaesth Crit Care Pain Med 2020 Apr 7;39(2):179-183. Epub 2020 Mar 7.

Intensive Care Division, University Hospitals of Geneva, Geneva, Switzerland.

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http://dx.doi.org/10.1016/j.accpm.2020.03.007DOI Listing
April 2020

Short-term dialysis catheter versus central venous catheter infections in ICU patients: a post hoc analysis of individual data of 4 multi-centric randomized trials.

Intensive Care Med 2019 12 17;45(12):1774-1782. Epub 2019 Oct 17.

University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France.

Purpose: Little is known on catheter-related infections associated with short-term dialysis catheters (DC). Recommendations for infection prevention are mostly derived from those related to central venous catheters (CVC). A comparison of infectious risk of DCs and CVCs would be instrumental for improving infection control prevention strategies. This study aimed to describe differences in infectious risk between DC and CVC.

Methods: We used individual data from 4 multicenter randomized controlled trials in intensive care units (ICUs) that evaluated various prevention strategies regarding colonization, major catheter-related infections (MCRI) and catheter-related bloodstream infections (CR-BSI). We selected only catheters with non-chlorhexidine gluconate impregnated dressings. A marginal Cox model for clustered data was used for the evaluation of the daily hazard rate for catheter-tip colonization, MCRI and CR-BSI.

Results: We included 3029 patients and 4148 catheters (31,547 catheter-days) which comprised 1872 DCs and 2276 CVCs. After adjustment on confounders, we identified an increased risk in DC compared to CVC for colonization (HR 1.45, 95% CI 1.03-2.04, p = 0.04) and for MCRI (HR 2.97, 95% CI 1.03-8.51, p = 0.04) in the first 7 days of catheter maintenance. The daily hazard rate for colonization and MCRI was generally higher for DC in the first catheter-days, whereas it was similar between DC and CVC for longer catheterizations.

Conclusions: The daily risk of colonization and MCRI was significantly higher in DC compared to CVC within the first 7 days of catheter maintenance. Targeted prevention strategies for DC should mostly focus on the period following the insertion.
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http://dx.doi.org/10.1007/s00134-019-05812-wDOI Listing
December 2019

Rapid or Slow Time to Brain Death? Impact on Kidney Graft Injuries in an Allotransplantation Porcine Model.

Int J Mol Sci 2019 Jul 26;20(15). Epub 2019 Jul 26.

INSERM U1082 (IRTOMIT), F-86000 Poitiers, France.

The use of donors deceased after brain death (DBD) with extended criteria in response to the shortage of grafts leads to the removal of more fragile kidneys. These grafts are at greater risk of not being grafted or delayed function. A better knowledge of the pathophysiology of DBDs would improve this situation. There is a difference between the results from animal models of DBD and the clinical data potentially explained by the kinetics of brain death induction. We compared the effect of the induction rate of brain death on the recovery of post-transplant renal function in a pig model of DBD followed by allografts in nephrectomized pigs. Resumption of early function post-transplant was better in the rapidly generated brain death group (RgBD) and graft fibrosis at three months less important. Two groups had identical oxidative stress intensity but a greater response to this oxidative stress by SIRT1, PGC1-α and NRF2 in the RgBD group. Modulation of mechanistic target of rapamycin (mTOR) stimulation by NRF2 would also regulate the survival/apoptosis balance of renal cells. For the first time we have shown that an allostatic response to oxidative stress can explain the impact of the rapidity of brain death induction on the quality of kidney transplants.
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http://dx.doi.org/10.3390/ijms20153671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696377PMC
July 2019

An easy and accurate respiratory rate monitor is necessary.

J Clin Monit Comput 2020 04 24;34(2):221-222. Epub 2019 Jul 24.

Emergency Department and Prehospital Care, University Hospital of Poitiers, Rue de la Milétrie, 86000, Poitiers, France.

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http://dx.doi.org/10.1007/s10877-019-00357-1DOI Listing
April 2020

Reassessing the dosing of cefoxitin prophylaxis during major abdominal surgery: insights from microdialysis and population pharmacokinetic modelling.

J Antimicrob Chemother 2019 07;74(7):1975-1983

Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France.

Objectives: Cefoxitin is frequently used for surgical antibiotic prophylaxis (SAP). Using microdialysis, we evaluated whether the currently recommended dosing regimen is appropriate to maintain cefoxitin subcutaneous tissue concentrations above the MIC for pathogens involved in abdominal surgical site infection.

Methods: Data from eight patients undergoing major abdominal surgery were analysed using population pharmacokinetic modelling, and Monte Carlo simulations were conducted to determine the PTA for aerobic and anaerobic pathogens. ClinicalTrials.gov: NCT02703857.

Results: Only 2.3% and 47.4% of the simulated patients maintained cefoxitin subcutaneous concentrations above the MIC breakpoint for anaerobic (MIC = 16 mg/L) and aerobic (MIC = 8 mg/L) pathogens, respectively. New simulations with administration of a loading dose followed by a constant infusion of cefoxitin were conducted and demonstrate that, notwithstanding using the same total dose per unit of time, continuous infusion of cefoxitin can cover aerobes in 96.6% of the simulated patients, but remains insufficient for anaerobic bacteria.

Conclusions: The recommended dosing regimen of cefoxitin is insufficient for covering the usual bacteria during abdominal surgery. Administration of a loading dose followed by a constant infusion should be considered for aerobic bacteria and cefoxitin should be avoided as SAP for anaerobic bacteria.
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http://dx.doi.org/10.1093/jac/dkz139DOI Listing
July 2019

Multicentre, open-label, randomised, controlled clinical trial comparing 2% chlorhexidine-70% isopropanol and 5% povidone iodine-69% ethanol for skin antisepsis in reducing surgical-site infection after cardiac surgery: the CLEAN 2 study protocol.

BMJ Open 2019 06 17;9(6):e026929. Epub 2019 Jun 17.

INSERM U1070, Universite de Poitiers UFR Medecine et Pharmacie, Poitiers, France.

Introduction: Surgical-site infection (SSI) is the second most frequent cause of healthcare-associated infection worldwide and is associated with increased morbidity, mortality and healthcare costs. Cardiac surgery is clean surgery with low incidence of SSI, ranging from 2% to 5%, but with potentially severe consequences.Perioperative skin antisepsis with an alcohol-based antiseptic solution is recommended to prevent SSI, but the superiority of chlorhexidine (CHG)-alcohol over povidone iodine (PVI)-alcohol, the two most common alcohol-based antiseptic solutions used worldwide, is controversial. We aim to evaluate whether 2% CHG-70% isopropanol is more effective than 5% PVI-69% ethanol in reducing the incidence of reoperation after cardiac surgery.

Methods And Analysis: The CLEAN 2 study is a multicentre, open-label, randomised, controlled clinical trial of 4100 patients undergoing cardiac surgery. Patients will be randomised in 1:1 ratio to receive either 2% CHG-70% isopropanol or 5% PVI-69% ethanol for perioperative skin preparation. The primary endpoint is the proportion of patients undergoing any re-sternotomy between day 0 and day 90 after initial surgery and/or any reoperation on saphenous vein/radial artery surgical site between day 0 and day 30 after initial surgery. Data will be analysed on the intention-to-treat principle.

Ethics And Dissemination: This protocol has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

Trial Registration Number: EudraCT 2017-005169-33 and NCT03560193.
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http://dx.doi.org/10.1136/bmjopen-2018-026929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6596966PMC
June 2019

A clinical evaluation of two central venous catheter stabilization systems.

Ann Intensive Care 2019 Apr 17;9(1):49. Epub 2019 Apr 17.

Corporate Division, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK.

Background: Central venous catheters (CVCs) are commonly secured with sutures which are associated with microbial colonization and infection. We report a comparison of a suture-free system with standard sutures for securing short-term CVC in an international multicentre, prospective, randomized, non-blinded, observational feasibility study. Consented critical care patients who had a CVC inserted as part of their clinical management were randomized to receive either sutures or the suture-free system to secure their CVC. The main outcome measures were CVC migration (daily measurement of catheter movement) and unplanned catheter removals.

Results: The per cent of unplanned CVC removal in the two study groups was 2% (suture group 2 out of 86 patients) and 6% (suture-free group 5 out of 85 patients). Both securement methods were well tolerated in terms of skin irritation. The time and ease of application and removal of either securement systems were not rated significantly different. There was also no significant difference in CVC migration between the two securement systems in exploratory univariate and multivariate analyses. Overall, 42% (36 out of 86) of the CVC secured with sutures and 56% (48 out of 85) of the CVC secured with the suture-free securement system had CVC migration of ≥ 2 mm.

Conclusions: The two securement systems performed similarly in terms of CVC migration and unplanned removal of CVC; however, the feasibility study was not powered to detect statistically significant differences in these two parameters.

Trial Registration: ISRCTN, ISRCTN13939744. Registered 9 July 2015, http://www.isrctn.com/ISRCTN13939744 .
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http://dx.doi.org/10.1186/s13613-019-0519-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470223PMC
April 2019

Effects of videolaryngoscopes on cognitive workload during tracheal intubation performed by emergency residents.

Am J Emerg Med 2019 10 2;37(10):1973-1975. Epub 2019 Apr 2.

Emergency Department and Prehospital Care, University Hospital of Poitiers, Poitiers, France.

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http://dx.doi.org/10.1016/j.ajem.2019.04.002DOI Listing
October 2019

Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, combined or not with use of a bundle of new devices, for prevention of short-term peripheral venous catheter-related infectious complications and catheter failure: an open-label, single-centre, randomised, four-parallel group, two-by-two factorial trial: CLEAN 3 protocol study.

BMJ Open 2019 04 2;9(4):e028549. Epub 2019 Apr 2.

Emergency Department and Prehospital Care, Centre Hospitalier Universitaire de Poitiers, Poitiers, France.

Introduction: Short peripheral intravenous catheters (PVCs) are the most frequently used invasive medical devices in hospitals. Unfortunately, PVCs often fail before the end of treatment due to the occurrence of mechanical, vascular or infectious complications, which prolongs hospitalisation and increases healthcare costs and mortality.Prevention of these complications is mainly based on the respect of hygiene rules and the use of biocompatible catheters. In critically ill patients, 2% chlorhexidine-alcohol is superior to 5% povidone iodine-alcohol for skin preparation before central venous and arterial catheters; whether this finding can be extended to PVC inserted in the wards remains speculative. Similarly, the use of new technologies such as catheters designed to minimise blood exposure, zero-reflux needleless connectors, disinfecting caps and flushing PVCs before and after each medication administration to maintain catheter patency are of theoretical interest to prevent PVC failure, but little scientific data support their routine use.

Methods And Analysis: The CLEAN 3 study is an open-label, single-centre, randomised, two-by-two factorial trial. One thousand patients visiting our emergency department and requiring hospital admission in the wards will be randomised to one of four strategies according to skin preparation and devices used. The two primary endpoints will be (1) the incidence of infectious complications related to the catheters (colonisation, local infection or bloodstream infection) and (2) the time between catheter insertion and catheter failure defined as any premature removal of PVC before end of treatment, other than for routine replacement.

Ethics And Dissemination: This protocol has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

Trial Registration Number: EudraCT 2018-A02535-50; NCT03757143.
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http://dx.doi.org/10.1136/bmjopen-2018-028549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500304PMC
April 2019

Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: A before-after study.

Am J Emerg Med 2019 11 5;37(11):2091-2096. Epub 2019 Mar 5.

INSERM CIC-1402, ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France; CHU de Poitiers, Réanimation Médicale, Poitiers, France.

Objectives: To compare clinical impact after early initiation of high-flow nasal cannula oxygen therapy (HFNC) versus standard oxygen in patients admitted to an emergency department (ED) for acute hypoxemic respiratory failure.

Methods: We performed a prospective before-after study at EDs in two centers including patients with acute hypoxemic respiratory failure defined by a respiratory rate above 25 breaths/min or signs of increased breathing effort under additional oxygen for a pulse oximetry above 92%. Patients with cardiogenic pulmonary edema or exacerbation of chronic lung disease were excluded. All patients were treated with standard oxygen during the first period and with HFNC during the second. The primary outcome was the proportion of patients with improved respiratory failure 1 h after treatment initiation (respiratory rate ≤ 25 breaths/min without signs of increased breathing effort). Dyspnea and blood gases were also assessed.

Results: Among the 102 patients included, 48 were treated with standard oxygen and 54 with HFNC. One hour after treatment initiation, patients with HFNC were much more likely to recover from respiratory failure than those treated with standard oxygen: 61% (33 of 54 patients) versus 15% (7 of 48 patients), P < 0.001. They also showed greater improvement in oxygenation (increase in PaO was 31 mm Hg [0-67] vs. 9 [-9-36], P = 0.02), and in feeling of breathlessness.

Conclusions: As compared to standard oxygen, patients with acute hypoxemic respiratory failure treated with HFNC at the ED had better oxygenation, less breathlessness and were more likely to show improved respiratory failure 1 h after initiation.
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http://dx.doi.org/10.1016/j.ajem.2019.03.004DOI Listing
November 2019

No benefit of chlorhexidine bathing in non-critical care units.

Lancet 2019 03 5;393(10177):1179-1180. Epub 2019 Mar 5.

Services des Urgences Adultes and SAMU 86, Centre Hospitalier Universitaire de Poitiers, Poitiers 86021, France.

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http://dx.doi.org/10.1016/S0140-6736(18)33130-1DOI Listing
March 2019