Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.

Multidrug-resistant Gram-negative bacteria-related infections have become a real public health problem and have exposed the risk of a therapeutic impasse. In recent years, many new antibiotics have been introduced to enrich the therapeutic armamentarium. Among these new molecules, some are mainly of interest for the treatment of the multidrug-resistant infections associated with Pseudomonas aeruginosa (ceftolozane/tazobactam and imipenem/relebactam); others are for carbapenem-resistant infections associated with Enterobacterales (ceftazidime/avibactam, meropenem/vaborbactam); and finally, there are others that are effective on the majority of multidrug-resistant Gram-negative bacilli (cefiderocol). Most international guidelines recommend these new antibiotics in the treatment of microbiologically documented infections. However, given the significant morbidity and mortality of these infections, particularly in the case of inadequate therapy, it is important to consider the place of these antibiotics in probabilistic treatment. Knowledge of the risk factors for multidrug-resistant Gram-negative bacilli (local ecology, prior colonization, failure of prior antibiotic therapy, and source of infection) seems necessary in order to optimize antibiotic prescriptions. In this review, we will assess these different antibiotics according to the epidemiological data.

Introduction Renal replacement therapy (RRT) is a life-saving intervention in severe acute kidney injury (AKI). After a clinician-initiated discontinuation, the likelihood of sustained liberation remains uncertain. We aimed to identify predictors of successful RRT weaning and to develop a pragmatic bedside tool (the UNDERSCORE) to support post-discontinuation management. Methods This post-hoc analysis of two multicenter randomized trials (AKIKI and AKIKI2) included ICU patients with KDIGO stage 3 AKI managed with a conservative initiation approach. Patients were eligible if they underwent an RRT weaning attempt, defined as discontinuation for ≥ 3 consecutive days. The primary outcome was successful weaning, i.e., no RRT resumption within seven days. Independent predictors were identified using multivariable logistic regression, and the resulting model (UNDERSCORE) was externally validated in an independent Swiss ICU cohort. Results Among 554 patients who received RRT, 180 underwent a weaning attempt and 101 (56%) were successfully weaned. Six predictors were retained to construct the UNDERSCORE: RRT duration before the attempt, septic shock on admission, baseline serum creatinine, and three clinical variables assessed after the weaning attempt (use of vasopressors, invasive mechanical ventilation, and urine output). The score showed strong discrimination in the derivation cohort (AUC 0.86, 95% CI 0.80–0.91). In the external Swiss cohort (n = 415), 338 patients (81%) were successfully weaned, with fair performance across a broader case mix (AUC 0.73, 95% CI 0.66–0.80). Conclusion The UNDERSCORE, derived from a homogeneous conservative RRT initiation cohort and validated in a diverse ICU population, provides a bedside tool to estimate the probability of sustained RRT discontinuation after an initial clinician-initiated stop. Graphic abstract

Autoimmune hemolytic anemia (AIHA) is a rare but potentially life-threatening condition requiring intensive care unit (ICU) admission in severe cases. While corticosteroids and immunosuppressants are standard treatments, their delayed efficacy limits their utility in critical settings requiring rapid hemolysis control. Plasma exchange (PlEx) may offer a rapid intervention, but its effectiveness in severe AIHA remains uncertain. This study aims to assess the clinical characteristics, outcomes, and the potential benefit of PlEx in ICU cases with severe AIHA. We conducted a multicenter retrospective cohort study including patients with severe AIHA admitted to 15 ICUs within the Assistance Publique–Hôpitaux de Paris (AP-HP) network between 2017 and 2024. Clinical, biological, and therapeutic data were collected. A multivariate logistic regression model, an analysis adjusted on a propensity score (PS) and on inverse probability of treatment weighting (IPTW) were used to identify predictors of in-ICU mortality and evaluate the association between PlEx and in-ICU mortality. One hundred forty-eight ICU stays involving severe AIHA hemolytic crises were analyzed. The median age at ICU admission was 61 {48–71} years, with a balanced sex ratio (51% male). Admission median hemoglobin was 5.2 g/dL {4.2–7.2} and in-ICU mortality was 17.6%. Risk factors for in-ICU mortality included age > 60 years, renal replacement therapy, mechanical ventilation, and high-dose intravenous methylprednisolone (HDIM). Therefore, ICU mortality was mainly driven by organ dysfunction rather than anemia severity. Standard corticosteroid therapy (1–2 mg/kg) (OR:0.19 [0.03–0.94], P = 0.05) and PlEx (OR:0.04 [0.004–0.4], P = 0.008) were associated with improved survival. The association between PlEx and outcome persisted after PS (OR: 0.04 [0.001–0.39]; P = 0.012) and IPTW (OR: 0.13 [0.02–0.55]; P = 0.011) adjustment. In this large ICU cohort, severe AIHA was associated with high mortality, driven by organ failure rather than anemia severity. PlEx are associated with survival, suggesting its potential role as a bridge to immunosuppressive therapy in selected cases. Prospective studies are needed to confirm these findings.

Acute kidney injury (AKI) is a frequent and severe complication among critically ill patients. Circulating dipeptidyl peptidase 3 (cDPP3), an enzyme releas