Damien Contou1,2, Romain Sonneville3, Florence Canoui-Poitrine4,5, Gwenhaël Colin6, Rémi Coudroy7,8, Frédéric Pène9, Jean-Marc Tadié10, Martin Cour11, Gaëtan Béduneau12, Antoine Marchalot13, Laurent Guérin14, Sébastien Jochmans15, Stephan Ehrmann16, Nicolas Terzi17, Sébastien Préau18, François Barbier19, Guillaume Schnell20, Damien Roux21, Olivier Leroy22, Claire Pichereau23, Elodie Gélisse24, Lara Zafrani25, Richard Layese4, Christian Brun-Buisson26, Armand Mekontso Dessap26, Nicolas de Prost26. 1. Service de Réanimation Médicale, Groupe de Recherche CARMAS, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France. damien.contou@ch-argenteuil.fr. 2. Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 Rue du Lieutenant-Colonel Prudhon, 95100, Argenteuil, France. damien.contou@ch-argenteuil.fr. 3. Service de Réanimation Médicale, Hôpital Bichat Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 Rue Henri Huchard, 75018, Paris, France. 4. Service de Santé Publique, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris, 51,Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France. 5. Clinical Epidemiology and Ageing Unit, Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA7376 CEpiA, Créteil, France. 6. Service de Réanimation Médico-chirurgicale, Centre Hospitalier Départemental de Vendée, Boulevard Stéphane Moreau, 85925, La Roche-sur-Yon, France. 7. Service de Réanimation Médicale, Centre Hospitalier Universitaire de Poitiers, 2 Rue de la Milétrie, 86021, Poitiers, France. 8. INSERM CIC1402, ALIVE Group, Université de Poitiers, Poitiers, France. 9. Service de Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France. 10. Service de Réanimation Médicale, Centre Hospitalier Universitaire de Rennes, 2 Rue Henri le Guilloux, 35033, Rennes, France. 11. Réanimation Médicale, Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, 3 Quai des Célestins, 69002, Lyon, France. 12. Service de Réanimation Médicale, Centre Hospitalier Universitaire de Rouen, 1 Rue de Germont, 76000, Rouen, France. 13. Service de Réanimation Polyvalente, Centre Hospitalier de Melun, 98 Rue Freteau de Peny, 77000, Melun, France. 14. CHRU de Tours, Médecin Intensive Réanimation, CIC 1415, CRICS-TriggerSEP, Centre d'étude des Pathologies Respiratoires, INSERM U1100, Université de Tours, Tours, France. 15. Service de Réanimation Polyvalente, Centre Hospitalier de Melun, 98 Avenue du Général Patton, 77000, Melun, France. 16. Service de Réanimation Médicale, Centre Hospitalier Régional Universitaire, 2 Boulevard Tonnellé, 37000, Tours, France. 17. Service de Réanimation Médicale, Centre Hospitalier Universitaire Grenoble Alpes, Avenue Maquis du Grésivaudan, 38700, La Tronche, France. 18. Service de Réanimation Médicale, Centre Hospitalier Régional Universitaire de Lille, 2 Avenue Oscar Lambret, 59000, Lille, France. 19. Service de Réanimation Médicale, Centre Hospitalier Régional d'Orléans, 1 Rue Porte Madeleine, 45000, Orléans, France. 20. Service de Réanimation Médico-Chirurgicale, GH Le Havre, 76600, Le Havre, France. 21. Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, 178 Rue des Renouillers, 92700, Colombes, France. 22. Service de Réanimation Médico-Chirurgicale, Centre Hospitalier de Tourcoing, 55 Rue du Président Coty, 59200, Tourcoing, France. 23. Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, 78300, Poissy, France. 24. Service de Réanimation Médico-Chirurgicale, Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, 51092, Reims, France. 25. Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France. 26. Service de Réanimation Médicale, Groupe de Recherche CARMAS, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.
Abstract
PURPOSE: Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality. METHODS: A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up). RESULTS: Among the 306 included patients, 126 (41.2%; 95% CI 35.6-46.9) died and 180 (58.8%; 95% CI 53.3-64.3) survived during the follow-up period [13 (3-24) days], including 51/180 patients (28.3%, 95% CI 21.9-35.5) who eventually required limb amputations, with a median number of 3 (1-4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02-1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69-0.99); p = 0.034] and platelet counts [HR 0.77 (0.60-0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68-4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28-0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06-3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis. CONCLUSION: Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation. TRIALS REGISTRATION: NCT03216577.
PURPOSE: Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality. METHODS: A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up). RESULTS: Among the 306 included patients, 126 (41.2%; 95% CI 35.6-46.9) died and 180 (58.8%; 95% CI 53.3-64.3) survived during the follow-up period [13 (3-24) days], including 51/180 patients (28.3%, 95% CI 21.9-35.5) who eventually required limb amputations, with a median number of 3 (1-4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02-1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69-0.99); p = 0.034] and platelet counts [HR 0.77 (0.60-0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68-4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28-0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06-3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis. CONCLUSION:Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation. TRIALS REGISTRATION: NCT03216577.
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