Warning signs and severe dengue in end stage renal disease dialysis patients

Background/PurposeThe 2009 WHO guideline established warning signs (WS) to predict severe dengue (SD). However, their positive predictive value has been found to be low in the general adult population, but they might be higher in a different population. This study investigated the association between WS and SD in end stage renal disease (ESRD) patients on maintenance dialysis in Taiwan where both diseases are prevalent.MethodsThis study enrolled ESRD dialysis patients with dengue in 2015. Demographic, laboratory data, symptoms/signs and complication of dengue were retrospectively collected from medical records at our hospital.ResultsOf 49 ESRD patients with dengue, 44 patients were receiving hemodialysis and 5 peritoneal dialysis. Older patients (>65 years old) tended to have the WS(56% vs 16.7%, P = 0.007). The rate of hospitalization, intensive care unit admission and in-hospital mortality was 79.6%, 22.5%, and 8.2%, respectively. Eighteen patients (36.7%) presented WS and eighteen patients (36.7%) developed to SD, including ten with plasma leakage, twelve with hemorrhage, and six with organ failure. Patients with WS were seven times more likely to develop SD than those without (OR: 7.06; 95%CI: 1.34–37.21). WS was associated with plasma leakage (OR: 12.36; 95% CI: 1.56–97.74) and severe hemorrhage (OR: 5.1; 95% CI: 1.03–25.18), but not organ failure.ConclusionsPrevalence of SD is high in ESRD dialysis patients. The presence of WSs in this group was highly correlated with SD. Thus, more attention should be paid to treating ESRD patients with dengue fever if they present WSs.     

Predictors for treatment outcomes among patients with drug-susceptible tuberculosis in the Netherlands: a retrospective cohort study

ObjectivesWe evaluated treatment outcomes and predictors for poor treatment outcomes for tuberculosis (TB) among native- and foreign-born patients with drug-susceptible TB (DSTB) in the Netherlands.MethodsThis retrospective cohort study included adult patients with DSTB treated from 2005 to 2015 from a nationwide exhaustive registry. Predictors for unsuccessful treatment outcomes (default and failure) and TB-associated mortality were analysed using multivariate logistic regression.ResultsAmong 5674 identified cases, the cumulative incidence of unsuccessful treatment and mortality were 2.6% (n/N = 146/5674) and 2.0% (112/5674), respectively. Although most patients were foreign-born (71%; 4042/5674), no significant differences in these outcomes were observed between native- and foreign-born patients (p > 0.05). Significant predictors for unsuccessful treatment were aged 18–24 years (odds ratio (OR), 2.04; 95% CI 1.34–3.10), homelessness (OR, 2.56; 95% CI 1.16–5.63), prisoner status (OR, 5.39; 95% CI 2.90–10.05) and diabetes (OR, 2.02; 95% CI 1.03–3.97). Furthermore, predictors for mortality were aged 74–84 years (OR, 5.58; 95% CI 3.10–10.03) or ≥85 years (OR, 9.35, 95% CI 4.31–20.30), combined pulmonary and extra-pulmonary TB (OR, 4.97; 95% CI 1.42–17.41), central nervous system (OR, 120, 95% CI 34.43–418.54) or miliary TB (OR, 10.73, 95% CI 2.50–46.02), drug addiction (OR, 3.56; 95% CI 1.34–9.47) and renal insufficiency/dialysis (OR, 3.23; 95% CI 1.17–8.96).ConclusionsNative- and foreign-born patients exhibited similar TB treatment outcomes. To further reduce disease transmission and inhibit drug resistance, special attention should be given to high-risk patients.     

Bronchoalveolar lavage fluid analysis and mortality risk in systemic lupus erythematosus patients with pneumonia and respiratory failure

BackgroundOur aim was to characterize etiologic diagnoses obtained from bronchoalveolar lavage fluid (BALF) and blood specimens, and to identify risk factors for mortality in systemic lupus erythematosus (SLE) patients with pneumonia and respiratory failure.MethodsWe conducted a retrospective analysis of SLE patients with pneumonia and respiratory failure. Clinical characteristics, laboratory profiles, and microbiology in BALF and blood samples were evaluated. We performed univariable analyses to identify mortality risk factors.ResultsAll 24 patients (F:M = 21:3, median age 46.5 years; disease duration 11 years) received mechanical ventilation (median duration: 11 days). Pathogens identified in BALF included Pneumocystis jiroveci (12 patients [50%]), cytomegalovirus (CMV, 7 patients [29.2%]), and bacteria (11 patients [45.8%]). Thirteen patients (54.2%) yielded pathogens in blood (CMV in 8 patients [33.3%] and Escherichia coli in 5 patients [20.8%]). Eight developed septic shock, and 9 died within 30 days. Univariable analysis identified thrombocytopenia (odds ratio [OR]: 8.0, 95% confidence interval [CI]: 1.23–52.25), bacteremia within 30 days before or after endotracheal intubation (OR: 8.0, 95% CI: 1.23–52.5), and P. jiroveci pneumonia (PJP, OR: 7.0, 95% CI: 1.04–46.95) as risk factors for 30-day mortality. Kaplan–Meier analysis confirmed an increased risk of 30-day mortality with thrombocytopenia and bacteremia.ConclusionThere are high prevalence rates of PJP and CMV infections as evidenced by BALF analyses in SLE patients with pneumonia and respiratory failure. BALF analysis can facilitate rescue therapy per pathogen. Thrombocytopenia, bacteremia, and PJP in SLE patients can increase their 30-day mortality, so warrant early and aggressive treatments.     

Impact of Staphylococcus aureus phenotype and genotype on the clinical characteristics and outcome of infective endocarditis. A multicentre,longitudinal, prospective,observational study

ObjectiveWe aimed to evaluate the impact of Staphylococcus aureus phenotype (vancomycin MIC) and genotype (agr group, clonal complex CC) on the prognosis and clinical characteristics of infective endocarditis (IE).MethodsWe performed a multicentre, longitudinal, prospective, observational study (June 2013 to March 2016) in 15 Spanish hospitals. Two hundred and thirteen consecutive adults (≥18 years) with a definite diagnosis of S. aureus IE were included. Primary outcome was death during hospital stay. Main secondary end points were persistent bacteraemia, sepsis/septic shock, peripheral embolism and osteoarticular involvement.ResultsOverall in-hospital mortality was 37% (n = 72). Independent risk factors for death were age-adjusted Charlson co-morbidity index (OR 1.20; 95% CI 1.08–1.34), congestive heart failure (OR 3.60; 95% CI 1.72–7.50), symptomatic central nervous system complication (OR 3.17; 95% CI 1.41–7.11) and severe sepsis/septic shock (OR 4.41; 95% CI 2.18–8.96). In the subgroup of methicillin-susceptible S. aureus IE (n = 173), independent risk factors for death were the age-adjusted Charlson co-morbidity index (OR 1.17; 95% CI 1.03–1.31), congestive heart failure (OR 3.39; 95% CI 1.51–7.64), new conduction abnormality (OR 4.42; 95% CI 1.27–15.34), severe sepsis/septic shock (OR 5.76; 95% CI 2.57–12.89) and agr group III (OR 0.27; 0.10–0.75). Vancomycin MIC ≥1.5 mg/L was not independently associated with death during hospital nor was it related to secondary end points. No other genotype variables were independently associated with in-hospital death.ConclusionsThis is the first prospective study to assess the impact of S. aureus phenotype and genotype. Phenotype and genotype provided no additional predictive value beyond conventional clinical characteristics. No evidence was found to justify therapeutic decisions based on vancomycin MIC for either methicillin-resistant or methicillin-susceptible S. aureus.     

Clinical outcome and predictors of mortality in children with sepsis,severe sepsis,and septic shock from Rohtak,Haryana: A prospective observational study

Background:

Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.

Methods:

A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.

Results:

A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).

Conclusion:

Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.     

Usefulness of EQUAL Candida Score for predicting outcomes in patients with candidaemia: a retrospective cohort study

BackgroundThe European Confederation of Medical Mycology (ECMM) Quality of Clinical Candidaemia Management (EQUAL) score is a tool designed by the ECMM to measure guideline adherence. The current study investigated the association between EQUAL scores and clinical outcomes.MethodsThis retrospective study was conducted in three hospitals in Taiwan. Patients with candidaemia between January 2014 and July 2018 were enrolled. Guideline adherence was evaluated using EQUAL score indicators. Clinical outcomes and predictors of 30-day mortality were investigated.ResultsA total of 384 patients were enrolled. The overall mean EQUAL score was 8.91 ± 3.42 (9.42 ± 3.60 in survivors vs. 8.10 ± 2.94 in non-survivors, p < 0.001). Higher scores were positively correlated with survival (p < 0.001). Scores of 16–22 indicated the highest survival rates (p for trend <0.001). The Kaplan–Meier plot revealed that patients with EQUAL scores ≥10 exhibited significantly higher survival rates (p < 0.001) than those with scores <10. Multivariable analysis revealed that EQUAL scores ≥10 (odds ratio (OR) 0.37, 95% confidence interval (CI) 0.19–0.74), advanced age (OR 1.02, 95% CI 1.00–1.04), septic shock (OR 4.42, 95% CI 2.09–9.36), high sequential organ failure assessment scores (OR 4.28, 95% CI 2.15–8.52), intravascular catheter-related source (OR 0.42, 95% CI 0.19–0.94) and central venous catheter retention (OR 5.41, 95% CI 2.06–14.24) were independent predictors of 30-day mortality.DiscussionGreater guideline adherence with a higher EQUAL score was significantly associated with survival. An EQUAL score cutoff point <10 predicted 30-day mortality.     

Clinical characteristics and risk factors for 28-day mortality in critically ill patients with COVID-19: a retrospective cohort study

BackgroundTo date, the coronavirus disease 2019 (COVID-19) caused more than 2.6 million deaths all around the world. Risk factors for mortality remain unclear. The primary aim was to determine the independent risk factors for 28-day mortality.Materials and MethodsIn this retrospective cohort study, critically ill patients (≥ 18 years) who were admitted to the intensive care unit due to COVID-19 were included. Patient characteristics, laboratory data, radiologic findings, treatments, and complications were analyzed in the study.ResultsA total of 249 patients (median age 71, 69.1% male) were included in the study. 28-day mortality was 67.9% (n = 169). The median age of deceased patients was 75 (66–81). Of them, 68.6% were male. Cerebrovascular disease, dementia, chronic kidney disease, and malignancy were significantly higher in the deceased group. In the multivariate analysis, sepsis/septic shock (OR, 15.16, 95% CI, 3.96–58.11, p < 0.001), acute kidney injury (OR, 4.73, 95% CI, 1.55–14.46,p = 0.006), acute cardiac injury (OR, 9.76, 95% CI, 1.84–51.83, p = 0.007), and chest CT score higher than 15 (OR, 4.49, 95% CI, 1.51-13.38, p = 0.007) were independent risk factors for 28-day mortality.ConclusionEarly detection of the risk factors and the use of chest CT score might improve the outcomes in patients with COVID-19.     

Effect of Dementia on Postoperative Mortality in Elderly Patients with Hip Fracture

BackgroundThe aim of this study was to assess the prevalence of dementia as an underlying disease in elderly patients with hip fracture, to investigate the effect of dementia on postoperative mortality after surgery of hip fracture, and to analyze the differences in postoperative mortalities according to the severity of dementia through subgroup analysis.MethodsThis study selected 2,346 elderly patients who were diagnosed with unilateral intertrochanteric or femoral neck fractures who underwent surgery between January 2004 and December 2018. The patients were classified into the non-dementia group (2,196 patients) and dementia group (150 patients; no-medication [66 patients] and medication [84 patients] subgroups). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the groups. A univariate regression test was performed using age, sex, diagnosis, surgery type, and Charlson''s comorbidity index (CCI), as these variables had P values of < 0.10. Multivariate regression analysis was performed to identify independent risk factors associated with mortality.ResultsThe 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.8%, 3.8%, 5.6%, 8.9%, and 13.6%, respectively, in the non-dementia group, and 2%, 7.3%, 14%, 19.3%, and 24%, respectively, in the dementia group (P = 0.748, P = 0.048, P < 0.001, P < 0.001, and P = 0.001). The factors that affected the 1-year mortality were age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02–1.08; P < 0.001), sex (OR, 2.68; 95% CI, 2.07–3.47; P < 0.001), CCI (OR, 1.34; 95% CI, 1.23–1.47; P < 0.001), and dementia (OR, 1.70; 95% CI, 1.46–1.08; P = 0.016). In subgroup analysis, severity of dementia influenced the 6-month mortality (OR, 1.41; 95% CI, 1.70–2.01; P = 0.018), and 1-year mortality (OR, 1.30; 95% CI, 1.17–1.90; P = 0.027).ConclusionIn elderly hip fracture patients, the comparison between patients with and without dementia revealed that dementia was an independent risk factor for mortality at a minimum of 1 year of follow-up, and the severity of dementia in hip fracture patients was a risk factor for mortality within 6 months and 1 year, postoperatively.     

Community-acquired pneumonia in patients with bacterial meningitis: a prospective nationwide cohort study

ObjectivePneumonia is considered a focus of infection in patients presenting with community-acquired bacterial meningitis but the impact on disease course is unclear. The aim was to study presenting characteristics, clinical course and outcome of meningitis patients with co-existing pneumonia on admission.MethodsWe evaluated adult patients with community-acquired bacterial meningitis with pneumonia on admission in a nationwide, prospective cohort performed from March 2006 to June 2017. We performed logistic regression analysis to identify clinical characteristics predictive of pneumonia on admission, and to quantify the effect of pneumonia on outcome.ResultsPneumonia was diagnosed on admission in 315 of 1852 (17%) bacterial meningitis episodes and confirmed by chest X-ray in 256 of 308 (83%) episodes. Streptococcus pneumoniae was the causative organism in 256 of 315 episodes (81%). Pneumonia on admission was associated with advanced age (OR 1.03 per year increase, 95% CI 1.02–1.04, p < 0.001), alcoholism (OR 1.96, 95% CI 1.23–3.14, p 0.004), cancer (OR 1.54, 95% CI 1.12–2.13, p 0.008), absence of otitis or sinusitis (OR 0.44, 95% CI 0.32–0.59, p < 0.001) and S. pneumoniae (OR 2.14, 95% CI 1.55–2.95, p < 0.001) in the multivariate analysis. An unfavourable outcome defined as a score of 1–4 on the Glasgow Outcome Scale was observed in 172 (55%) episodes and 87 patients (28%) died. Pneumonia on admission was independently associated with unfavourable outcome and mortality in the multivariate analysis (OR 1.48, 95% CI 1.12–1.96; p 0.005).ConclusionPneumonia on admission in bacterial meningitis is a frequent coexisting infection and is independently associated with unfavourable outcome and mortality.     

Epidemiology and outcomes of bloodstream infections in 177 severe burn patients from an industrial disaster: a multicentre retrospective study

ObjectivesTo determine the characteristics of bloodstream infections (BSIs) and to evaluate the impact of BSIs on mortality in severe burn patients.MethodsA retrospective observational study was conducted in 20 tertiary hospitals. A total of 185 patients who experienced a massive dust explosion in eastern China were included.ResultsAfter exclusion, 177 patients were analysed. The median total body surface area (TBSA) burned was 95% (interquartile range 85%–98%). Inhalation injuries occurred in 97.2%. The overall 90-day mortality was 35% (62/177). During the study period, 120 (67.8%) patients developed 253 episodes of BSI with 323 unique causative pathogens. Sixty-six episodes were polymicrobial infections. Catheter-related BSIs (CRBSIs) accounted for 41.5% of the episodes. Acinetobacter baumannii (19.5%), Klebsiella pneumoniae (13.9%) and Candida (12.7%) were the most common organisms. Antimicrobial resistance was found in 63.5% of the isolates, particularly in Gram-negative bacteria. Patients who developed BSIs had a greater illness severity at admission to the intensive care unit, and worse outcomes. After adjusting for demographics, severity of illness and treatment characteristics in a multivariate logistic model, there was a trend toward BSI increasing the risk of 90-day mortality (adjusted OR 3.4; 95% CI 0.9–12.9; p=0.069). In subgroup analyses, CRBSIs (adjusted OR 5.7; 95% CI 1.3–24.9; p=0.021 versus no BSI) and polymicrobial BSIs (adjusted OR 6.1; 95% CI 1.3–28.1; p=0.020 versus no BSI) had greater risk of 90-day mortality.ConclusionsA strikingly high rate of BSIs was observed in severe burn patients. Gram-negative organisms and fungi were the leading causes. CRBSIs and polymicrobial BSIs were associated with high mortality.     

Clinical associations of renal involvement in ANCA-associated vasculitis

ObjectiveRenal involvement in anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis is associated with significant morbidity and higher mortality rates. This study examined clinical manifestations associated with renal involvement in ANCA-associated vasculitis within a large, international cross-sectional cohort.MethodsUnivariate and multivariate analyses were performed to identify clinical factors associated with renal disease, which was defined as i) a serum-creatinine >30% above normal and a fall in creatinine-clearance >25%; or ii) haematuria attributable to active vasculitis.ResultsThe study cohort include 1230 patients from 31 countries; 723 (58.8%) presented with renal involvement: microscopic polyangiitis (82.2%), granulomatosis with polyangiitis (58.6%), and eosinophilic granulomatosis with polyangiitis (26.4%). The following clinical and laboratory factors were more common among patients with renal disease: age (OR 1.01, 95% CI 1.01–1.02), fever (OR 1.97, 95% CI 1.35–2.88), fatigue (OR 1.55, 95% CI 1.14–2.10), weight loss (OR 1.62, 95% CI 1.23–2.12), polyarthritis (OR 1.39, 95% CI 1.02–1.89), petechiae/purpura (OR 1.47, 95% CI 1.06–2.05), pulmonary haemorrhage (OR 5.23, 95% CI 1.39–19.63), gastrointestinal symptoms (OR 2.19, 95% CI 1.34–3.58), seizures (OR 3.42, 95% CI 1.26–9.30), lower serum albumin (OR 2.42, 95% CI 1.64–3.57), higher CRP (OR 2.06, 95% CI 1.04–4.06), low serum C3 at baseline (OR 3.86, 95% CI 1.30–11.53), myeloperoxidase- (OR 7.97, 95% CI 2.74–23.20) and proteinase 3-ANCA (OR 3.40, 95% CI 1.22–9.50). The following clinical factors were less common among patients with renal disease: mononeuritis multiplex (OR 0.63, 95% CI 0.41–0.98), proptosis/exophthalmos (OR 0.19, 95% CI 0.06–0.59), nasal polyps (OR 0.32, 95% CI 0.19–0.55), septal defect/perforation (OR 0.29, 95% CI 0.14–0.60), respiratory distress/pulmonary fibrosis/asthma (OR 0.08, 95% CI 0.04–0.19), and wheeze/obstructive airway disease (OR 0.29, 95% CI 0.16–0.52).ConclusionIn this large international study, several clinical and laboratory factors were identified as associated with renal involvement in ANCA-associated vasculitis.     

Stenotrophomonas isolates in a tertiary care centre in South India

PurposeStenotrophomonas maltophilia is an emerging multi-drug resistant pathogen increasingly isolated in India. This study aimed to identify patients from whom Stenotrophomonas maltophilia had been isolated and assess predictors of mortality in this population.MethodsThis was a retrospective cohort study of hospitalized patients with a positive culture for S. maltophilia over a 3-year period. Clinical details and laboratory results were assessed from hospital records. Bivariate and multivariate analysis was used to identify risk factors for mortality.ResultsOne hundred and nineteen patients (mean age 48.6 years) were included in the study. Of these, 111 patients were hospitalized for at least 48 ?hours prior to culture and 98 were admitted in the intensive care unit. Bivariate analysis revealed multiple associations with mortality, including a background of renal, cardiac, autoimmune disease, recent carbapenam use and COVID-19 infection and increasing ventilatory requirement, lower PaO₂/FiO₂ (P/F) ratio, vasopressor use, thrombocytopenia, and hypoalbuminemia at the time of positive isolate. Multivariate analysis showed that autoimmune disease [OR 27.38; 95% CI (1.39–540)], a P/F ratio of less than 300 [OR 7.58; 95% CI (1.52–37.9)], vasopressor requirement [OR 39.50; 95% CI (5.49–284)] and thrombocytopenia [OR 11.5; 95% CI (2.04–65.0)] were statistically significantly associated with increased mortality, while recent surgery and receipt of antibiotics [OR 0.16; 95% CI (0.03–0.8)] targeted against S. maltophilia were associated with decreased mortality.ConclusionStenotrophomonas maltophilia is primarily isolated in patients in the intensive care unit. In our study the need for vasopressors, autoimmune disease, lower P/F ratios and thrombocytopenia were associated with higher mortality. The association of targeted antibiotics with reduced mortality suggests that the pathogenic role of S. maltophilia should not be underestimated. This finding needs to be confirmed with larger, prospective studies.     

Predictors of multidrug-resistant Pseudomonas aeruginosa in neutropenic patients with bloodstream infection

ObjectivesTo assess risk factors for multidrug-resistant Pseudomonas aeruginosa (MDR-PA) infection in neutropenic patients.MethodsSingle-centre retrospective analysis of consecutive bloodstream infection (BSI) episodes (2004–2017, Barcelona). Two multivariate regression models were used at BSI diagnosis and P. aeruginosa detection. Significant predictors were used to establish rules for stratifying patients according to MDR-PA BSI risk.ResultsOf 661 Gram-negative BSI episodes, 190 (28.7%) were caused by P. aeruginosa (70 MDR-PA). Independent factors associated with MDR-PA among Gram-negative organisms were haematological malignancy (OR 3.30; 95% CI 1.15–9.50), pulmonary source of infection (OR 7.85; 95% CI 3.32–18.56), nosocomial-acquired BSI (OR 3.52; 95% CI 1.74–7.09), previous antipseudomonal cephalosporin (OR 13.66; 95% CI 6.64–28.10) and piperacillin/tazobactam (OR 2.42; 95% CI 1.04–5.63), and BSI occurring during ceftriaxone (OR 4.27; 95% CI 1.15–15.83). Once P. aeruginosa was identified as the BSI aetiological pathogen, nosocomial acquisition (OR 7.13; 95% CI 2.87–17.67), haematological malignancy (OR 3.44; 95% CI 1.07–10.98), previous antipseudomonal cephalosporin (OR 3.82; 95% CI 1.42–10.22) and quinolones (OR 3.97; 95% CI 1.37–11.48), corticosteroids (OR 2.92; 95% CI 1.15–7.40), and BSI occurring during quinolone (OR 4.88; 95% CI 1.58–15.05) and β-lactam other than ertapenem (OR 4.51; 95% CI 1.45–14.04) were independently associated with MDR-PA. Per regression coefficients, 1 point was assigned to each parameter, except for nosocomial-acquired BSI (3 points). In the second analysis, a score >3 points identified 60 (86.3%) out of 70 individuals with MDR-PA BSI and discarded 100 (84.2%) out of 120 with non-MDR-PA BSI.ConclusionsA simple score based on demographic and clinical factors allows stratification of individuals with bacteraemia according to their risk of MDR-PA BSI, and may help facilitate the use of rapid MDR-detection tools and improve early antibiotic appropriateness.     

Clinical characteristics and risk factors of in-hospital mortality in patients coinfected with Pneumocystis jirovecii and Aspergillus

ObjectiveTo analyze clinical characteristics and risk factors for in-hospital mortality in patients coinfected with P. jirovecii and Aspergillus.MethodsThis study included 53 patients with coinfection of P. jirovecii pneumonia (PJP) and invasive pulmonary aspergillosis (IPA) in our center from January 2011 to December 2021. All cases were divided into survivor (n=27) and non-survivor groups (n=26). Medical records, laboratory and radiology data were collected. Risk factors for in-hospital mortality were identified by multivariable analyses.ResultsHIV-positive patients accounted for 3.8%. Fever (77.4%), dyspnea (69.8%) and wet cough (24.5%) were common symptoms. Ground-glass opacity (83.0%), consolidation (71.7%), septal thickening (66.0%), and nodules (54.7%) were the most common radiological signs. CD4+ T cell count and serum albumin (ALB) level were significantly lower in non-survival group than in the survival group. Conversely, serum lactate dehydrogenase (LDH) and procalcitonin (PCT) levels were higher in non-survival group than in survival group. Lactic acidosis [odds ratio (OR): 33.999,95% confidential interval (CI): 3.112-371.409; p=0.004], low CD4+ T cell count (<114 cell/µL) [OR: 19.343, 95% CI: 1.533-259.380; p=0.022] and high level of LDH (> 519 U/L) [OR: 11.422, 95% CI: 1.271-102.669; p=0.030] were independent risk factors for mortality.ConclusionPJP coinfected with IPA incurs high mortality with nonspecific clinical characteristics and is more likely to involve HIV-negative patients. Lactic acidosis, low CD4+ T cell count and high LDH level are independent risk factors for mortality, close monitoring of these parameters is necessary to help distinguish high-risk patients and make appropriate clinical decisions.     

Clinical Outcomes of Patients with Acute Myocardial Infarction Complicated by Severe Refractory Cardiogenic Shock Assisted with Percutaneous Cardiopulmonary Support

Purpose

Limited data are available on the role of percutaneous cardiopulmonary support (PCPS) for the treatment of acute myocardial infarction (AMI) patients with cardiogenic shock. We investigated the clinical outcomes and predictors of in-hospital mortality after PCPS in patients with AMI complicated by severe refractory cardiogenic shock.

Materials and Methods

From January 2004 to December 2011, we analyzed data from 96 consecutive AMI patients with cardiogenic shock assisted by a PCPS system. The primary outcome was in-hospital mortality. The predictors of in-hospital mortality were determined by a Cox proportional-hazards model.

Results

In-hospital mortality occurred in 51 (53.1%) patients and 58 (60.4%) patients were able to be weaned from PCPS. Cardiopulmonary resuscitation (CPR) was performed in 61 (63.5%) patients before PCPS initiation. On multivariate analysis, age ≥67 years [adjusted hazard ratio (HR), 4.74; 95% confidence interval (CI), 2.27-9.93; p<0.001], CPR (adjusted HR, 2.32; 95% CI, 1.11-4.85; p=0.03), lactate clearance for 48 hours <70% (adjusted HR, 2.50; 95% CI, 1.04-6.05; p=0.041), and unsuccessful revascularization (adjusted HR, 3.57; 95% CI, 1.85-6.90; p=0.002) were independent predictors of in-hospital mortality after PCPS in patients with AMI complicated by cardiogenic shock.

Conclusion

In spite of PCPS management, AMI patients complicated by severe refractory cardiogenic shock demonstrated high mortality. Older age, CPR, lower lactate clearance for 48 hours, and unsuccessful revascularization were independent predictors of in-hospital mortality.     

Clinical significance of Staphylococcus aureus bacteremia in patients with liver cirrhosis

Patients with liver cirrhosis (LC) have impaired immunity and thus are predisposed to infections. Few studies have attempted to evaluate Staphylococcus aureus bacteremia (SAB) in LC patients. Therefore, this study prospectively evaluated the clinical characteristics and outcomes of 642 episodes of SAB from August 1, 2008 to September 31, 2010. Of 642 patients with SAB, 109 (17.0?%) were classified as LC patients whereas the remaining 533 (83.0?%) were classified as non-LC patients. The 30-day mortality rate of LC patients was significantly higher than that of patients with other diseases (32?% vs. 22?%, respectively; P?=?0.047). The 30-day mortality rates of patients with MSSA bacteremia and MRSA bacteremia were not significantly different among LC patients (35.1?% with MSSA vs. 26.9?% with MRSA; P?=?0.41). A univariate analysis of the 30-day mortality rate of LC patients with SAB for survivors and non-survivors showed that rapidly fatal or ultimately fatal according to the criteria of McCabe and Jackson (OR 5.0; 95?% CI 1.60–15.65), septic shock at initial presentation (OR 3.5; 95?% CI 1.18–10.39) and Child-Pugh class C (OR 2.8; 95?% CI 1.20–6.59) were associated with increased mortality. In contrast, the removal of the eradicable focus was associated with decreased mortality (OR 0.14; 95?% CI 0.04–0.52). Disease severity and liver dysfunction may be useful for predicting the prognosis of SAB in LC patients.     

Epidemiology and predictive factors for early and late mortality in Candida bloodstream infections: a population-based surveillance in Spain

A prospective, multicentre, population-based surveillance programme for Candida bloodstream infections was implemented in five metropolitan areas of Spain to determine its incidence and the prevalence of antifungal resistance, and to identify predictors of death. Between May 2010 and April 2011, Candida isolates were centralized to a reference laboratory for species identification by DNA sequencing and for susceptibility testing by EUCAST reference procedure. Prognostic factors associated with early (0–7 days) and late (8–30 days) death were analysed using logistic regression modelling. We detected 773 episodes: annual incidence of 8.1 cases/100 000 inhabitants, 0.89/1000 admissions and 1.36/10 000 patient-days. Highest incidence was found in infants younger than 1 year (96.4/100 000 inhabitants). Candida albicans was the predominant species (45.4%), followed by Candida parapsilosis (24.9%), Candida glabrata (13.4%) and Candida tropicalis (7.7%). Overall, 79% of Candida isolates were susceptible to fluconazole. Cumulative mortality at 7 and 30 days after the first episode of candidaemia was 12.8% and 30.6%, respectively. Multivariate analysis showed that therapeutic measures within the first 48 h may improve early mortality: antifungal treatment (OR 0.51, 95% CI 0.27–0.95) and central venous catheter removal (OR 0.43, 95% CI 0.21–0.87). Predictors of late death included host factors (e.g. patients' comorbid status and signs of organ dysfunction), primary source (OR 1.63, 95% CI 1.03–2.61), and severe sepsis or septic shock (OR 1.77, 95% CI 1.05–3.00). In Spain, the proportion of Candida isolates non-susceptible to fluconazole is higher than in previous reports. Early mortality may be improved with strict adherence to guidelines.     

The Risk Factors of Avascular Necrosis in Patients with Systemic Lupus Erythematosus: a Meta-analysis

The aim of this study was to determine the risk factors for avascular necrosis (AVN) in patients with systemic lupus erythematosus (SLE). Four electronic databases (PubMed, EMBASE, Ovid, and Science Direct) were searched for. The search was performed to identify the articles as to SLE with AVN before September 2013. The clinical and laboratory data were extracted, and a meta-analysis was performed to identify the risk factors for AVN in patients with SLE. Publication bias was assessed with funnel plot and Egger’s test. A total of 995 papers were found from the four databases; 16 studies were finally included. Pooled analysis showed the following result. The result showed that arthritis (odds ratio (OR)?=?2.448, 95 % confidence interval (CI)?=?1.617–3.707), cushingoid (OR?=?3.890, 95 % CI?=?1.591–9.510), gastrointestinal involvement (OR?=?2.054, 95 % CI?=?1.283–3.290), hypertension (OR?=?1.482, 95 % CI?=?1.093–2.008), oral ulcers (OR?=?1.877, 95 % CI?=?1.182–2.979), pleuritis (OR?=?2.302, 95 % CI?=?1.325–4.001), renal disease (OR?=?1.475, 95 % CI?=?1.124–1.936), and vasculitis (OR?=?2.591, 95 % CI?=?1.358–4.944) were relevant with AVN in SLE patients. Cytotoxic drug (OR?=?1.834, 95 % CI?=?1.065–3.156, P?=?0.029), the total cumulative dose (Standard Mean Difference (SMD) = 1.104, 95 % CI = 0.118–2.090, P = 0.028), maximum daily dose (SMD = 0.484, 95 % CI = 0.288–0.678, P < 0.001), and mean daily dose (SMD?=?1.305, 95 % CI?=?0.061–2.549, P?=?0.040) were significantly higher in AVN group. There were no significantly laboratory features that appeared in this pooled analysis. We conclude that arthritic, cushingoid, gastrointestinal involvement, hypertension, oral ulcers, pleuritis, renal disease, vasculitis, cytotoxic drug, and steroid treatment may contribute to AVN in SLE patients.     

Outcome of critically ill patients with influenza virus infection

BackgroundInfluenza is a major cause of morbidity and mortality, with its greatest burden on the elderly and patients with chronic co-morbidities in the intensive care unit (ICU). An accurate prognosis is essential for decision-making during pandemic as well as interpandemic periods.MethodsA retrospective cohort study was conducted to determine prognostic factors influencing short term outcome of critically ill patients with confirmed influenza virus infection. Baseline characteristics, laboratory and diagnostic findings, ICU interventions and complications were abstracted from medical records using standard definitions and compared between hospital survivors and non-survivors with univariate and multivariate logistic regression analyses.Results111 patients met the inclusion criteria. Acute respiratory distress syndrome (ARDS) complicated ICU course in 25 (23%) of the patients, with mortality rate of 52%. Multivariate logistic regression analysis identified the following predictors of hospital mortality: Acute Physiology and Chronic Health Evaluation (APACHE) III predicted mortality (Odds ratio [OR] 1.49, 95% confidence interval [CI] 1.1–2.1 for 10% increase), ARDS (OR 7.7, 95% CI 2.3–29) and history of immunosuppression (OR 7.19, 95% CI 1.9–28).ConclusionsAPACHE III predicted mortality, the development of ARDS and the history of immunosuppression are independent risk factors for hospital mortality in critically ill patients with confirmed influenza virus infection.     

Predictors of mortality in nursing-home residents with pneumonia: a multicentre study

ObjectivesTo evaluate predictors of mortality in patients residing in nursing-homes (NHs) or long-term care facilities (LTCFs) with diagnosis of NH-acquired pneumonia (NHAP).MethodsWe conducted an observational, prospective study (December 2013-December 2015) of patients residing in nine NHs/LTCFs of Central and Northern Italy with diagnosis of NHAP. Data on demographics, comorbidities, microbiology, and therapies were entered into an electronic database. To identify risk factors associated with 30-day mortality, we performed univariable and multivariable analyses, and predictors were internally validated using a bootstrap resampling procedure. We derived a prediction rule using the coefficients obtained from the multivariable logistic regression. The model obtained was assessed using the area under the receiver operating characteristic curve (AUROC).ResultsOverall, 446 patients with NHAP were included in the final cohort. The median age was 80 (IQR 75–87) years. A definite aetiology was obtained in 120 (26.9%) patients; of these, 66 (55%) had a culture positive for a multidrug-resistant pathogen. The 30-day mortality was 28.7%. On multivariate analysis, malnutrition (OR 7.8; 95% CI 3–20.2, 2 points), bilateral pneumonia (OR 3.7; 95% CI 1.4–9.8, 1 point), acute mental status deterioration (OR 6.2; 95% CI 2.2–17.6, 2 points), hypotension (OR 7.7; 95% CI 2.3–24.9, 2 points), and PaO₂/FiO₂ ratio ≤250 (OR 7.4; 95% CI 2.2–24.2, 2 points) were independently associated with 30-day mortality. The derived prediction rule showed an AUROC of 0.83 (95% CI 0.78–0.87, p <0.001).ConclusionsNH residents with pneumonia have specific risk factors associated with 30-day mortality. Malnutrition and acute mental change appear as major determinants of death in this population.