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Drowning associated pneumonia: A descriptive cohort Article in Resuscitation · September 2011 DOI: 10.1016/j.resuscitation.2011.08.023 · Source: PubMed
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Resuscitation 83 (2012) 399–401
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Short communication
Drowning associated pneumonia: A descriptive cohort夽 J.M. Tadié a,∗,e , N. Heming a,e , E. Serve b , N. Weiss a , N. Day c , A. Imbert a , G. Ducharne d , C. Faisy a , J.L. Diehl a , D. Safran b , J.Y. Fagon a , E. Guérot a a
Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Réanimation Médicale, France Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Département d’Anesthésie – Réanimation, France Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Microbiologie, France d Université Paris Descartes, Assistance Publique – Hôpitaux de Paris, Hôpital Européen Georges Pompidou; Service de chirurgie Orthopédique et Traumatologique, France b c
a r t i c l e
i n f o
Article history: Received 15 June 2011 Received in revised form 15 August 2011 Accepted 24 August 2011
Keywords: Submersion Cardiac arrest Early onset pneumonia Multi-drug resistant bacteria
a b s t r a c t Purpose: Pneumonia is the most common infectious complication of drowning. Pneumonia is potentially life threatening and should be treated by effective antibiotic therapy. However the risk factors, microbiological causes, diagnostic approach and appropriate therapy for pneumonia associated with drowning are not well described. The microbiological ecology of the body of water where immersion occurred could be of import. The aim of this study was to report on microorganisms involved in pneumonia associated with drowning and out of hospital cardiac arrest after successful cardiopulmonary resuscitation. Additionally, we retrieved and undertook microbiological analysis on samples of water from our local river. Methods: This retrospective study included all patients having suffered an out of hospital cardiac arrest due to drowning and admitted to our tertiary care academic hospital between 2002 and 2010. Data concerning bacteriological lung samples (tracheal aspirate or bronchoalveolar lavage) at admission were reported and compared to bacteriological samples obtained from our local river (the river Seine). Results: A total of thirty-seven patients were included in the study. Lung samples were obtained for twenty-one of these patients. Lung samples were positive in nineteen cases, with a high frequency of multi-drug resistant bacteria. Samples from the Seine River found microorganisms similar to those found in drowning associated pneumonia. Conclusions: Drowning associated pneumonia can be due to multi drug resistant bacteria. When treating drowning associated pneumonia, antibiotics should be effective against bacteria similar to those found in the body of water where immersion occurred. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Drowning can lead to cardiac arrest caused by hypoxia, hypothermia or traumatic injury.1,2 One of the major issues following successful resuscitation is to identify and treat the cause of hypoxia. Pneumonia is one of the most serious infectious complications associated with drowning as well as being a cause of increased morbidity and mortality.3,4 Aspiration of water or of the gastric content occurs in 90% of cases of drowning.5 Most of the organisms causing pneumonia associated with drowning are only described in case reports or very small case series.3,6 Drowning associated pneumonia is a difficult condition to diagnose, as many victims develop pulmonary abnormalities on chest radiographies
夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.08.023. ∗ Corresponding author at: Service de Réanimation Médicale, Hôpital Européen Georges Pompidou, 20-40 rue Leblanc, 75908 Paris cedex 15, France. E-mail address:
[email protected] (J.M. Tadié). e These authors contributed equally to this work. 0300-9572/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.resuscitation.2011.08.023
or fever without any clear focus of infection.3 However, the use of prophylactic antibiotics is not recommended.3,7,8 Waterborne and oropharyngal organisms have a higher likelihood of being involved in drowning associated pneumonia. Other organisms, including fungi can also be responsible of drowning associated pneumonia. Since ineffective initial antimicrobial therapy has been shown to be an independent predictor of mortality, the microbiological ecology of the body of water where immersion occurred should be taken into consideration before starting empiric antibiotic therapy when drowning associated pneumonia is diagnosed.9 The objective of this study was to report on microorganisms involved in pneumonia associated with drowning and to compare these with microbiological samples retrieved from the Seine River. 2. Methods 2.1. Study setting and population In Paris, management of out-of-hospital cardiac arrest (OHCA) involves mobile emergency units and fire departments. In
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suspected cases of OHCA, the closest emergency unit is dispatched to the scene. Out-of-hospital advanced resuscitation is delivered by an emergency team, which includes at least one trained physician. Patients in whom return of a spontaneous cardiac activity is obtained are then transferred to the intensive care unit (ICU) of a tertiary care hospital. When no spontaneous cardiac activity is recovered, the patient can be transferred for initiation of extra corporeal life support (ECLS). 2.2. Demographic data All patients admitted to our hospital for drowning in the River Seine and OHCA between 2002 and 2010 were included. In accordance with French law, no local institutional review board authorization was needed, owing to the study’s observational design, and the Commission Nationale de l’Informatique et des Libertés approved the use of computerized medical data with protection of patient confidentiality. The recorded data were: age, sex, temperature and cardiac activity at admission, ECLS use and outcome at ICU discharge. 2.3. Diagnosis of pneumonia Specimens were not systematically retrieved. Pneumonia associated with drowning was suspected when patients had new or persistent radiographic features of pneumonia, a leukocyte count exceeding 12,000/mm3 or below 5000/mm3 and purulent endotracheal secretions. Only specimens obtained during the first 48 h in the ICU were recorded, in order to exclude cases of hospital associated pneumonia.10 Diagnosis was confirmed when a potentially pathogenic bacteria was isolated after culture of the tracheal aspirate or of the bronchoalveolar lavage (BAL) fluid. BAL was undertaken during the day time, in patients devoid of severe hypoxemia. In all other cases, tracheal aspirates were realized. Antibiotic therapy was initiated when bacteria were identified after direct specimen examination. Only good-quality samples of tracheal aspirates (more than 25 neutrophils and less than 10 epithelial cells per microscopic field) were selected for Gram staining and culture (quantitative cultures were not performed). Quantitative cultures were considered positive when more than 10,000 CFU/mL were recovered from the BAL fluid. Antibiotic therapy was interrupted when specimen culture came back negative. The type of initial empiric antimicrobial therapy was recorded and classified as adequate or inadequate depending on whether the isolated organisms were susceptible to initial antibiotic therapy or not. 2.4. River Seine samples Water samples were collected from the River Seine in the 7th and 10th district of Paris during the springtime of 2010. One hundred milliliters of water from each location was filtered through a nitrocellulose membrane (Millipore), plated on a Trypticase Soy medium (Millipore) and incubated at 37 and 22 ◦ C, respectively for 24 and 48 h. Growing bacteria were plated on blood agar (Biomérieux) and selective medium: Uri 4 agar (Biorad), Drigalski agar (Biorad), Columbia blood agar (Biomérieux) and Chromagar candida medium (Becton Dickinson). All bacteria were identified by Gram staining, catalase test, oxidase test (Biorad) and biochemical characteristics (Api20 E, Api20 NE and Api 50CHB (Biomérieux)). In vitro susceptibility to antibiotics was performed by the agar disk diffusion method on MH plates (Biorad) and interpretation of inhibition zones was made according to the guidelines of the French Society of Microbiology.
Table 1 Demographic data. At admission Age (years) Male gender T (◦ C) Asystole In the ICU ECLS initiation Lung samples Outcome (at discharge) Survival
37 [30–48] 20 (54%) 29 [27–31] 18 (49%) 13 (35%) 21 (57%) 7 (19%)
Continuous variables are expressed as median values with interquartile range, categorical variables as percentage of the group from which they are derived. T: temperature; ECLS: extracorporeal life support.
Table 2 Type of organisms causing drowning associated pneumonia. Organism
n
Aeromonas spp. Pseudomonas aeruginosa Escherichia coli Citrobacter koseri Enterobacter cloacae Haemophilius spp. Streptococcus pneumoniae Staphylococcus aureus No germ Oral flora Multiple germs
5a 3 2 1 1 5 3 1 2 3 5
a Two patients died of ARDS due to drowning associated pneumonia treated with the amoxicillin-clavulanate association.
2.5. Statistical analysis Continuous variables are expressed as median values and interquartile ranges, categorical variables as numbers and percentages. 3. Results Thirty-seven patients were included (Table 1). Fourteen patients died within 24 h of admission. No bacteriological lung samples were obtained for these patients. Lung specimens were obtained from 21 patients (two patients were not suspected of pneumonia): 18 patients underwent tracheal aspiration and 3 patients underwent bronchoalveolar lavage. Findings on culture of specimens were: Aeromonas spp. (in five cases), Haemophilus spp. (in five cases, of which Streptococcus pneumoniae was associated in three cases), Pseudomonas aeruginosa resistant to ticarcillin (in two cases, associated with methicillinsusceptible Staphylococus aureus and Escherichia coli resistant to the association amoxicillin-clavulanate in one of these cases), wild type Pseudomonas aeruginosa (in one case), Citrobacter koseri (in one case), Enterobacter cloacae (in one case), wild type Escherichia coli (in one case) and oral flora (in three cases showing several species of Streptococcus and Neisseria). No fungal infection was diagnosed (Table 2). Pneumonia involved only one pathogen in fifteen cases, two pathogens in three cases and three pathogens in one case. Cultures of tracheal aspirates were negative in two cases. The association amoxicillin-clavulanate was used as initial empiric antimicrobial therapy in seventeen cases. The association piperacillin-tazobactam was used in the four other cases. In six cases the association amoxicillin-clavulanate was inadequate (4 Aeromonas spp. and 2 Pseudomonas aeruginosa). Two of these patients died within 48 h of admission of septic shock associated with acute respiratory distress syndrome. Lung specimens
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showed Aeromonas spp. in both cases.The water sample collected from the tenth district contained wild-type Aeromonas hydrophila, Acinetobacter haemolyticus, Bacillus cereus and Micrococcus spp. The sample collected from the seventh district contained wildtype Escherichia coli, Aeromonas hydrophila, Alcaligenes faecalis and carbapenem-resistant Pseudomonas fluorescens. No difference was found between the culture undertaken at 22 and 37 ◦ C, except for the presence of Micrococcus spp. at 22 ◦ C in the sample coming from the tenth district. All bacteria were susceptible to the association of piperacillin and tazobactam. No fungi were isolated. 4. Discussion Pneumonia often occurs after drowning and OHCA, even though aspiration of water or of the gastric content is not the major cause of hypoxia.1,3 Prophylactic antibiotics have never been demonstrated as being beneficial in this setting.7,11 We found eight cases of pneumonia caused by germs known to colonize the upper oropharyngeal sphere, consistent with aspiration due to impaired consciousness.12 Our findings support the initiation of broad spectrum antibiotic therapy when drowning associated pneumonia is diagnosed, when drowning reaches a successful cardiopulmonary resuscitation, taking the ecology of the body of water where immersion occurred into account.3 Indeed, we report on five cases of drowning associated pneumonia due to Aeromonas ssp., two cases due to Pseudomonas aeruginosa and one case due to Escherichia coli, which are all resistant to the amoxicillin-clavulanate association. Aeromonas ssp. associated pneumonia has previously been described as being associated with immersion in fresh water.3,13 Despite its water tropism, Pseudomonas aeruginosa has rarely been described as a cause of drowning associated pneumonia.3,14 These bacteria were also found in water samples from the river Seine. Due to the high frequency of drowning associated pneumonia and the implication of uncommon and potentially multidrug resistant organisms, systematic lung sampling of these patients on admission may be proposed. Tracheal aspiration is indeed an easy technique in the setting of mechanically ventilated patients. Nevertheless, systematic lung sampling would increase patient exposure to antibiotics.10 Plus, inadequate antibiotic treatment is susceptible to induce bacterial resistance and increases global cost.15 4.1. Limitations Firstly the design of the study is retrospective and a small number of patients were included. However, few studies report on more patients. Secondly, differences in the bacterial composition of rivers occur when environmental conditions change.16–18 Indeed, we collected samples of water from two locations of the river in 2010, providing only a snapshot of the situation. Nevertheless the bacterial ecology of the River Seine was not reported to have changed significantly over the last 10 years.19 Thirdly, we did not obtain
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bacterial concentrations for samples collected from the river. Lastly, because pneumonia is a difficult condition to diagnose in patients suffering from ARDS or with a water aspirate radiologic image, the impact of inappropriate antimicrobial therapy in these patients could be overstated. 5. Conclusion When treating drowning associated pneumonia, antibiotic therapy should cover a broad spectrum of microorganisms in accordance with the ecology of the body of water where immersion occurred. Conflict of interest statement The authors declare that they have no competing interests. References 1. Layon AJMJ. Drowning: update 2009. Anesthesiology 2009;110:1390–401. 2. Salomez F, Vincent JL. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. Resuscitation 2004;63:261–8. 3. Ender PTDM. Pneumonia associated with near-drowning. Clin Infect Dis 1997;25:896–907. 4. van Berkel M, Bierens JJ, Lie RL, et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intensive Care Med 1996;22:101–7. 5. Tabeling BB, Modell JH. Fluid administration increases oxygen delivery during continuous positive pressure ventilation after freshwater near-drowning. Crit Care Med 1983;11:693–6. 6. Vieira DF, Van Saene HK, Miranda DR. Invasive pulmonary aspergillosis after near-drowning. Intensive Care Med 1984;10:203–4. 7. Oakes DD, Sherck JP, Maloney JR, et al. Prognosis and management of victims of near-drowning. J Trauma 1982;22:544–9. 8. Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976;70:231–8. 9. Sims JK, Enomoto PI, Frankel RI, et al. Marine bacteria complicating seawater near-drowning and marine wounds: a hypothesis. Ann Emerg Med 1983;12:212–6. 10. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867–903. 11. Modell JH. Drowning. New Engl J Med 1993;328:253–6. 12. Fabregas N, Torres A. Pulmonary infection in the brain injured patient. Minerva Anestesiol 2002;68:285–90. 13. Ender PT, Dolan DM, Farmer D, Melcher JCGP. Near-drowning-associated Aeromonas pneumonia. J Emerg Med 1996;14:737–41. 14. Mena KD, Gerba CP. Risk assessment of Pseudomonas aeruginosa in water. Rev Environ Contam Toxicol 2009;201:71–115. 15. Goldmann DA, Weinstein RA, Wenzel RP, et al. Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals. A challenge to hospital leadership. JAMA 1996;275:234–40. 16. Winter C, Hein T, Kavka G, et al. Longitudinal changes in the bacterial community composition of the Danube River: a whole-river approach. Appl Environ Microbiol 2007;73:421–31. 17. Tryland I, Surman S, Berg JD. Monitoring faecal contamination of the Thames estuary using a semiautomated early warning system. Water Sci Technol 2002;46:25–31. 18. Hazen TC, Fliermans CB. Distribution of Aeromonas hydrophila in natural and man-made thermal effluents. Appl Environ Microbiol 1979;38:166–8. 19. Servais P, Passerat J. Antimicrobial resistance of fecal bacteria in waters of the Seine river watershed (France). Sci Total Environ 2009;408:365–72.
