Functional outcomes in adults with tuberculous meningitis admitted to the ICU: a multicenter cohort study

被引:19
作者
Cantier, Marie [1 ,16 ]
Morisot, Adeline [2 ]
Guerot, Emmanuel [3 ]
Megarbane, Bruno [4 ]
Razazi, Keyvan [5 ]
Contou, Damien [5 ]
Mariotte, Eric [6 ]
Canet, Emmanuel [6 ]
De Montmollin, Etienne [7 ]
Dubee, Vincent [8 ]
Boulet, Eric [9 ]
Gaudry, Stephane [10 ]
Voiriot, Guillaume [11 ]
Mayaux, Julien [12 ]
Pene, Frederic [13 ]
Neuville, Mathilde [1 ]
Mourvillier, Bruno [1 ,14 ]
Ruckly, Stephane [14 ]
Bouadma, Lila [1 ,14 ]
Wolff, Michel [1 ]
Timsit, Jean-Francois [1 ,14 ]
Sonneville, Romain [1 ,15 ]
机构
[1] Bichat Claude Bernard Univ Hosp, AP HP, Dept Intens Care Med & Infect Dis, 46 Rue Henri Huchard, F-75018 Paris, France
[2] Nice Univ Hosp, LArchet Hosp, Dept Publ Hlth, Nice, France
[3] Georges Pompidou European Hosp, AP HP, Dept Intens Care Med, Paris, France
[4] Lariboisiere Univ Hosp, AP HP, Dept Intens Care Med & Toxicol, Paris, France
[5] Henri Mondor Univ Hosp, AP HP, Dept Intens Care Med, Paris, France
[6] St Louis Univ Hosp, AP HP, Dept Intens Care Med, Paris, France
[7] St Denis Delafontaine Hosp, Dept Intens Care Med, St Denis, France
[8] St Antoine Univ Hosp, AP HP, Dept Intens Care Med, Paris, France
[9] Rene Dubos Hosp, Dept Intens Care Med, Pontoise, France
[10] Louis Mourier Univ Hosp, AP HP, Med Surg Intens Care Unit, Colombes, France
[11] Tenon Univ Hosp, AP HP, Dept Intens Care Med, Paris, France
[12] La Pitie Salpetriere Univ Hosp, AP HP, Dept Pneumol & Intens Care Med, Paris, France
[13] Cochin Univ Hosp, AP HP, Dept Intens Care Med, Paris, France
[14] Univ Paris Diderot, Sorbonne Paris Cite, INSERM, UMR 1137,IAME Team 5,DeSCID Decis SCi Infect Dis, Paris, France
[15] Univ Paris Diderot, Sorbonne Paris Cite, INSERM, UMR 1148,Lab Vasc & Translat Sci, Paris, France
[16] St Antoine Univ Hosp, AP HP, Dept Neurol, 184 Rue Faubourg St Antoine, F-75011 Paris, France
来源
CRITICAL CARE | 2018年 / 22卷
关键词
Tuberculous meningitis; Steroids; Intensive care; Functional outcomes; ENCEPHALITIS; PREDICTORS; DEXAMETHASONE; MORTALITY; APACHE;
D O I
10.1186/s13054-018-2140-8
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Background: Tuberculous meningitis (TBM) is a devastating infection in tuberculosis endemic areas with limited access to intensive care. Functional outcomes of severe adult TBM patients admitted to the ICU in nonendemic areas are not known. Methods: We conducted a retrospective multicenter cohort study (2004-2016) of consecutive TBM patients admitted to 12 ICUs in the Paris area, France. Clinical, biological, and brain magnetic resonance imaging (MRI) findings at admission associated with a poor functional outcome (i.e., a score of 3-6 on the modified Rankin scale (mRS) at 90 days) were identified by logistic regression. Factors associated with 1-year mortality were investigated by Cox proportional hazards modeling. Results: We studied 90 patients, of whom 61 (68%) had a score on the Glasgow Coma Scale <= 10 at presentation and 63 (70%) required invasive mechanical ventilation. Brain MRI revealed infarction and hydrocephalus in 38/75 (51%) and 25/75 (33%) cases, respectively. A poor functional outcome was observed in 55 (61%) patients and was independently associated with older age (adjusted odds ratio (aOR) 1.03, 95% CI 1.0-1.07), cerebrospinal fluid protein level >= 2 g/L (aOR 5.31, 95% CI 1.67-16.85), and hydrocephalus on brain MRI (aOR 17.2, 95% CI 2.57-115.14). By contrast, adjunctive steroids were protective (aOR 0.13, 95% CI 0.03-0.56). The multivariable adjusted hazard ratio of adjunctive steroids for 1-year mortality (47%, 95% CI 37%-59%) was 0.23 (95% CI 0.11-0.44). Among survivors at 1 year, functional independence (mRS of 0-2) was observed in 27/37 (73%, 95% CI 59%-87%) cases. Conclusions: A poor functional outcome in adult TBM patients admitted to the ICU in a nonendemic area is observed in 60% of cases and is independently associated with elevated cerebrospinal fluid protein level and hydrocephalus. Our data also suggest a protective effect of adjunctive steroids, with reduced disability and mortality, irrespective of immune status and severity of disease at presentation. One-year follow-up revealed functional independence in most survivors.
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页数:8
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