Comparison of Risk Factors for Candidemia Versus Bacteremia in Hospitalized Patients

Abstract Background: Classic risk factors for candidemia include use of total parenteral nutrition (TPN), hospital location, use of central venous catheter, and others. Unfortunately, most of these variables are now also risk factors for antibiotic-resistant bacteria. Thus, use of these risk factors to identify patients at high risk for candidemia is difficult. The purpose of this study was to compare these classic risk factors for candidemia in patients with bloodstream infections to determine the relative strength of these predictors in differentiating patients with candidemia and bacteremia. Methods: Clinical data were collected from the medical charts of patients who had been hospitalized between 2002 and 2004. Patients with their first episode of candidemia or bacteremia during their hospital stays were included. Risk factors were assessed using a multivariate logistic regression model and internally validated using a bootstrap analysis. A p-value < 0.05 was considered significant. Results: A total of 164 patients (82 with candidemia) were evaluated. According to the logistic analysis, patients who had stayed in the intensive care unit (ICU) (OR = 6.24; 95% CI: 2.58–15.09) or had been using TPN (OR = 4.69; 95% CI: 1.76–12.48) were more likely to have candidemia than bacteremia. While patients with pulmonary (OR = 0.15; 95% CI: 0.055–0.39) or cardiac disease (OR = 0.21; 95% CI: 0.086–0.51) had a greater chance to have bacteremia than candidemia (p < 0.01 for all variables). These results were further validated using bootstrap analysis. Conclusion: Among classic risk factors for candidemia, the ICU location at the time of culture and TPN use were most predictive of candidemia while certain medical disorders predicted patients at the highest risk for bacteremia. These results can be used to help identify patients most likely to benefit from empiric antifungal therapy. This paper was presented in part at the 10th annual meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), Washington, DC, USA, on May 17th, 2005.     

DNA and RNA Oxidative Damage and Mortality of Patients With COVID-19

BackgroundDeoxyribonucleic acid (DNA) and ribonucleic acid (RNA) oxidative damage is associated with mortality of patients with different diseases. However, there are no data about DNA and RNA oxidative damage from coronavirus disease 2019 (COVID-19) patients. Thus, the objective of this study was to explore DNA and RNA oxidative damage in surviving and non-surviving COVID-19 patients.Materials and MethodsEight Intensive Care Units from 6 hospitals in the Canary Islands (Spain) participated in this prospective and observational study. We recorded the serum levels at ICU admission of the three guanine oxidized species (OGS) because guanine is the nucleobase that forms the DNA and RNA most prone to oxidation. Survival at 30 days was our end-point study.ResultsNon-surviving (n = 11) compared to surviving patients (n = 42) had higher APACHE-II (p < 0.001), SOFA (p = 0.004) and serum OGS levels (p = 0.001). In logistic regression analyses an association between serum OGS levels and 30-day mortality after controlling for SOFA (OR=2.601; 95% CI=1.305–5.182; p = 0.007) or APACHE-II (OR=2.493; 95% CI=1.274–4.879; p = 0.008) was found. The area under curve (AUC) for mortality prediction by serum OGS levels was 83% (95% CI=70–92%; p < 0.001), by APACHE II was 85% (95% CI=75–96%; p < 0.001), and by SOFA was 80% (95% CI=66–94%; p < 0.001). No significant differences were found in the AUC between serum OGS levels and SOFA (p = 0.91), and serum OGS levels and APACHE-II (p = 0.64).ConclusionsTo our knowledge, this is the first study reporting on oxidative DNA and RNA damage in COVID-19 patients, and the main new finding was that serum OGS concentration was associated with mortality.     

Risk factors for infection and treatment outcome of extended-spectrum β-lactamase-producing <Emphasis Type="Italic">Escherichia coli</Emphasis> and <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis> bacteremia in patients with hematologic malignancy

This study was performed to evaluate the impact of extended-spectrum β-lactamase (ESBL)-producing bacteremia on outcome in patients with hematologic malignancy. We collected and analyzed data on 156 hematologic malignancy patients with Escherichia coli or Klebsiella pneumoniae bacteremia from the database of nationwide surveillance studies for bacteremia. Thirty-seven of the 156 patients (23.7%) harbored ESBL-producing bacteremia. No significant differences in underlying diseases were found in either group. The multivariate analysis showed that significant factors associated with ESBL-producing bacteremia were ICU care (OR = 7.03, 95% CI = 1.79–27.6) and nosocomial acquisition (OR = 5.66, 95% CI = 1.60–20.23). There was an association between prior receipt of cephalosporins and ESBL-producing bacteremia, although this association was not statistically significant (OR = 2.27, 95% CI = 0.99–5.23). The overall 30-day mortality rate of the study population was 20.4% (29/142), and the 30-day mortality rate for the ESBL group was significantly higher than that for the non-ESBL group (44.8% vs. 14.2%, P < 0.001). Multivariate analysis showed that ESBL-producing bacteremia was the most important risk factor associated with 30-day mortality (OR, 5.64; 95% CI, 1.91–16.67), along with ICU care (OR = 4.35, 95% CI = 1.16–16.26) and higher Pitt bacteremia score (per 1-point increment) (OR = 1.50, 95% CI = 1.18–1.92). In conclusion, ESBL-producing bacteremia was the most important risk factor associated with 30-day mortality in patients with hematologic malignancy, along with ICU care and higher Pitt bacteremia score. Our data suggest that determining the optimal empiric antimicrobial therapy in patients with hematologic malignancy is now becoming a challenge for clinicians in the era of multidrug-resistant Gram-negative bacilli.     

Application of the sequential organ failure assessment score to cardiac surgical patients

OBJECTIVE: To assess the applicability of the sequential organ failure assessment (SOFA) score to cardiac surgical patients. DESIGN: Observational cohort study. SETTING: Adult cardiac surgical ICU. PATIENTS: Two hundred eighteen patients requiring ICU stay > 96 h. MEASUREMENTS AND RESULTS: The SOFA score was calculated daily until ICU discharge. Derived SOFA variables-total maximum SOFA (TMS), DeltaSOFA, maximum SOFA (maxSOFA), and DeltamaxSOFA-were considered. Length of ICU stay was 8.9 +/- 6.7 days (mean +/- SD). The mortality rate was 11.0% in the ICU and 15.6% in the hospital. Nonsurvivors had higher TMS, DeltaSOFA, single-organ system, and mean total scores on day 1 (9.8 +/- 2.5 vs 7.8 +/- 2.3, p < 0.05) and thereafter until day 10. The total SOFA score on the first 10 days of ICU stay, time, survival status, and their interaction were all significant (p < 0.001), with higher SOFA scores for nonsurvivors, and lower scores for survivors that decreased as the number of days from operation increased. Cardiovascular score on day 1 carried the highest relative risk of mortality among other systems (risk ratio [RR], 2.12; 95% confidence interval [CI], 1.31 to 3.45; p < 0.01), as did maximum cardiovascular score (RR, 2.81; 95% CI, 1.62 to 4.85; p < 0.001). A growing number of failing organs was associated with mortality, from the first to the sixth postoperative day (p < 0.05). Total score on day 1, TMS, DeltaSOFA, maxSOFA, and DeltamaxSOFA were reliable predictors of mortality with area under receiver operating characteristic curve of 0.71 (SE, 0.08), 0.89 (SE, 0.05), 0.86 (SE, 0.06), 0.88 (SE, 0.05), and 0.88 (SE, 0.06), respectively. Length of hospital stay was significantly associated (p = 0.05) to TMS and DeltaSOFA and not to other SOFA scores, age, or sex. CONCLUSIONS: The SOFA score may be used to grade the severity of postoperative morbidity in cardiac surgical patients without specific adaptations. The model identifies patients at increased risk for postoperative mortality.     

Community-Acquired Bacterial Meningitis in Adults: Antibiotic Timing in Disease Course and Outcome

Abstract Objectives: Despite improvements in diagnostic and therapeutic approach to adult patients with bacterial meningitis, the overall mortality rate is still high. The aim of this study was to evaluate antibiotic timing in the course and outcome of bacterial meningitis. Methods: Two hundred and eighty six patients with community-acquired bacterial meningitis aged 14 years and more were included in this retrospective cohort study. Observational period was between 1 January 1990 and 31 December 2004. To assess the association of antibiotic timing and disease outcome we analyzed three timing periods (according to the onset of disease, onset of consciousness disturbance and the time of admission to hospital). Analysis was also performed in a subgroup of culture positive meningitis in 176 patients with altered mental status. Results: Unfavorable outcome was found in 125 (43,7%) patients. In this group, the start of appropriate antibiotic treatment in relation to the onset of first symptoms and particularly to the onset of consciousness disturbance was significantly delayed (p = 0.018 and p < 0.001, respectively) compared to the favorable group. Logistic regression analysis in a subgroup of culture positive meningitis in patients with altered mental status revealed that early adequate antibiotic treatment related to the onset of overt signs of meningitis was independently associated with favorable outcome (OR = 11.19; 95% CI 4.37–32.57; p < 0.001). Advanced age, lower GCS and seizures (OR = 1.05, OR = 1.45 and OR = 3.65, respectively) were other risk factors of poor outcome. The presence of chronic diseases, pneumococcal etiology and clinical and laboratory variables which are indicators of disease severity (renal and/or liver dysfunction, hypotension and low cerebrospinal fluid glucose) were not confirmed as independent risk factors of poor outcome. Conclusions: Our study emphasizes the importance of early and adequate antibiotic treatment in the management of bacterial meningitis which significantly enhances the chances for favorable outcome.     

Value of APACHE II, SOFA and CPIS scores in predicting prognosis in patients with ventilator-associated pneumonia

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most frequent infection with high mortality rates in intensive care units (ICUs) and the prediction of outcome is important in the decision-making process. OBJECTIVE: To assess the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Clinical Pulmonary Infection Score (CPIS) in the prediction of mortality during VAP episodes in pulmonary patients. METHODS: This study was a prospective observational cohort study. Sixty-three patients who were admitted to the ICU and developed VAP were included in the study consecutively. Clinical and laboratory data conforming to the APACHE II and SOFA scores were recorded on admission and APACHE II, SOFA and CPIS scores on the day of the diagnosis of VAP. The outcome measure was the ICU mortality. Logistic regression and receiver operating characteristic (ROC) curve analyses and the area under the curve (AUC) were used to estimate the predictive ability of the scoring systems. RESULTS: Mortality rate was 54%. The mean APACHE II (21 +/- 6, 14 +/- 5; p = 0.001), SOFA (7 +/- 3, 4 +/- 2; p = 0.002) and CPIS (8 +/- 2, 7 +/- 3; p = 0.025) scores determined at the time of VAP diagnosis were significantly higher in nonsurvivors than in survivors. Discrimination was excellent for APACHE II (ROC AUC: 0.81; p = 0.001) and acceptable for SOFA (ROC AUC: 0.71; p = 0.005) scores. Of the three scores only APACHE II >16 was an independent predictor of the mortality (OR: 5; 95% CI: 1.3-18; p = 0.019) in the logistic regression analysis. CONCLUSION: These results suggest that APACHE II determined at the time of VAP diagnosis may be useful in predicting mortality in the pulmonary ICU patient population who develops VAP.     

Is Lone Hypertension a Risk Factor for More Severe COVID-19 Outcomes?

Background:Based on current evidence, it is not clear whether lone hypertension increases the risk for severe illness from COVID-19, or if increased risk is mainly associated with age, obesity and diabetes. The objective of the study was to evaluate whether lone hypertension is associated with increase mortality or a more severe course of COVID-19, and if treatment and control of hypertension mitigates this risk.Methods:This is a prospective multi-center observational cohort study with 30-day outcomes of 9,531 consecutive SARS-CoV-2 PCR-positive patients ≥ 18 years old (41.9 ± 9.7 years, 49.2% male), Uzbekistan, June 1-September 30, 2020. Patients were subclassified according to JNC8 criteria into six blood pressure stages. Univariable and multiple logistic regression was conducted to examine how variables predict outcomes.Results:The 30-days all-cause mortality was 1.18% (n = 112) in the whole cohort. After adjusting for age, sex, history of myocardial infarction (MI), type-2 diabetes, and obesity, none of six JNC8 groups showed any significant difference in all-cause mortality. However, age was associated with an increased risk of 30-days all-cause mortality (OR = 1.09, 95%CI [1.07–1.12], p < 0.001), obesity (OR = 7.18, 95% CI [4.18–12.44], p < 0.001), diabetes (OR 4.18, 95% CI [2.58–6.76], p < 0.001), and history of MI (OR = 2.68, 95% CI [1.67–4.31], p < 0.001). In the sensitivity test, being ≥ 65 years old increased mortality 10.56-fold (95% CI [5.89–18.92], p < 0.001). Hospital admission was 12.4% (n = 1,183), ICU admission 1.38% (n = 132). The odds of hospitalization increased having stage-2 untreated hypertension (OR = 4.51, 95%CI [3.21–6.32], p < 0.001), stage-1 untreated hypertension (OR = 1.97, 95%CI [1.52–2.56], p < 0.001), and elevated blood pressure (OR = 1.82, 95% CI [1.42–2.34], p < 0.001). Neither stage-1 nor stage-2 treated hypertension patients were at statistically significant increased risk for hospitalization after adjusting for confounders. Presenting with stage-2 untreated hypertension increased the odds of ICU admission (OR = 3.05, 95 %CI [1.57–5.93], p = 0.001).Conclusions:Lone hypertension did not increase COVID-19 mortality or in treated patients risk of hospitalization.     

Risk Factors for Community-Acquired Urinary Tract Infection Due to Quinolone-Resistant <Emphasis Type="Italic">E. coli</Emphasis>

Abstract Background: Resistance to fluoroquinolone drugs is emerging among E. coli causing community acquired urinary tract infections (COMA-UTI). Objectives: To evaluate demographic and clinical risk factors associated with COMA-UTI due to quinolone-resistant E. coli (QREc). Methods: In this case-control study, clinical and demographic data from 300 COMA-UTI due to E. coli (including 150 QREc) were analyzed. Results: By univariate analysis QREc was associated to males, older patients, nursing home residents, functionally dependent, dementia, diabetes, cardiovascular diseases, immunosupression, nephrolithiasis, recurrent UTI, invasive procedures, hospitalization, and antibiotic use within previous 6 months. By multivariate analysis, use of ciprofloxacin (OR 20.6 [CI 2.3–179.2], p = 0.006) or ofloxacin (OR 7.5 [CI 2.9–19.4], p < 0.0001), previous invasive procedure (OR 6.6 [CI 3.0–14.7], p < 0.0001), recurrent UTI (OR 4.7 [CI 2.3–9.3], p < 0.0001), and previous hospitalization (OR 2.9 [CI 1.4–6], p = 0.003) were identified as independent risk factors for COMA-UTI due to QREc. Conclusion: In patients with one or more of the risk factors identified here, the empiric use of quinolones should be reconsidered.     

Bacteremia is a prognostic factor for poor outcome in spontaneous bacterial peritonitis

We performed a retrospective study to determine the influence of bacteremia on the mortality of patients with spontaneous bacterial peritonitis (SBP), a major complication of liver cirrhosis. Patients with SBP with identified pathogens from ascites and/or blood were analyzed by retrospective review of clinical and laboratory records in a university hospital in Korea for 3 y and classified into the bacteremic and non-bacteremic groups. The underlying liver function was determined by model for end-stage liver disease (MELD) score. Microbiological response rate, ascites polymorphonuclear leukocyte (PML) count reduction rate, and SBP-related mortality were compared between the 2 groups. To identify the independent risk factors of mortality, a multiple logistic regression model was used to control for the confounders. A total of 189 patients was enrolled in the study. Among 189 patients, 110 (58.2%) were bacteremic, and 79 (41.8%) non-bacteremic. Escherichia coli was the most common etiologic organism, followed by Klebsiella pneumoniae. MELD scores, microbiological response rate (82.6% vs 88.6%, p=0.295), and ascites PML count reduction rate (33.2% vs 44.8%, p=0.479) were not different between the bacteremic and non-bacteremic group. However, the SBP-related mortality rate of the bacteremic group was significantly higher than that of the non-bacteremic group (37.3% vs 12.7%, p<0.001). Bacteremia (OR=2.86: 95% CI 1.06-7.74, p=0.038), APACHE II score (OR=1.20: 95% CI 1.10-1.31, p<0.001), MELD score (OR=1.07: 95% CI 1.01-1.31, p=0.016) and microbiological no response (OR=5.51: 95% CI 1.82-16.72, p=0.003) were independent risk factors of SBP-related mortality.     

The sepsis-related Organ Failure Assessment (SOFA) score is predictive for survival of patients admitted to the intensive care unit following allogeneic blood stem cell transplantation

Intensive care unit (ICU) support following allogeneic peripheral blood stem cell transplantation (PBSCT) is controversial due to the limited prognosis of these patients in case of secondary critical illness. In this retrospective single centre study, we looked for factors predicting survival in patients who needed ICU support after myeloablative (MAC) or non-myeloablative conditioning (non-MAC) therapy and allogeneic PBSCT. Between 1999 and 2006, 64 out of 319 patients following allogeneic PBSCT were admitted to the ICU (24 female and 40 male patients, median age 47 years, range 17–65 years; MAC 49 patients, non-MAC 15 patients). All 64 patients required mechanical ventilation. We looked for variables defining the Sepsis-related Organ Failure Assessment (SOFA) score as well as for baseline characteristics and transplant-associated parameters on the day of ICU admission possibly predictive for poor or good survival prognosis. Nineteen of 49 patients who had received MAC therapy survived the ICU stay for a median time of 9 months (range 2–29 months) and three of 15 patients who had received non-MAC therapy could be discharged from the ICU with a survival time of 4, 5 and 12 months. After univariate and multivariate analysis the SOFA score discriminated survivors and non-survivors of the ICU stay. We conclude that the SOFA score is predictive for survival when applied on the day of ICU admission.     

Klebsiella bacteremia in children in southern Israel (1988-1997)

Background: Klebsiella spp. have emerged in recent years as a major cause of gram-negative bacteremia in infants and children. We therefore aimed to document the epidemiology, antibiotic susceptibility pattern and outcome of both community-acquired and nosocomial Klebsiella spp. bacteremias in children. Patients and Methods: From 1998–1997, 177 episodes of Klebsiella bacteremia, representing 15% of all gram-negative bacteremias, occurred at the Soroka Medical Center in 166 children aged 0–14 years. Results: The overall incidence of Klebsiella bacteremia in southern Israel during the study period was 0.13/1,000, with an increase from 0.1 to 0.2/1,000 children from 1988–1992 to 1993–1997 (p = 0.02). 113 and 64 episodes were recorded in Bedouin Arabs and Jewish children, respectively. The incidence of Klebsiella bacteremia was significantly higher in Bedouins compared to Jewish children (p < 0.001). The incidence of Klebsiella bacteremia increased significantly among Jewish children from 1993–1997 compared to 1988–1992. The incidence of Klebsiella bacteremia was 2/1,000 admissions, with an increase from 1.8 to 2.2/1,000 from 1993–1997 compared to 1988–1992. The incidence of Klebsiella bacteremia was significantly higher among hospitalized Bedouin children compared to Jewish children (3.1 vs. 1.4/1,000 admissions, p < 0.001). There were 48 (27%), 24 (14%) and 98 (55%) Klebsiella bacteremia episodes at the pediatric departments, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU), respectively. 76% of Klebsiella bacteremia episodes were nosocomial; 66% occurred at NICU. 71% and 90% of Klebsiella bacteremia episodes occurring at NICU and PICU, respectively, were nosocomial. The overall incidence of nosocomial infections was 1.5/1,000 admissions, with an increase from 1.2 to 1.8/1,000 from 1993–1997 compared to 1988–1992 (p = 0.03). The resistance rates of Klebsiella spp. to piperacillin, ceftriaxone, ceftazidime and gentamicin were 34%, 17%, 17% and 14%, respectively. A significant increase in the resistance rates to ceftriaxone and ceftazidime was observed from 1993–1997 compared to 1988–92 (21.9% vs. 7.8%, p = 0.05 and 21.9% vs 5%, p = 0.03). A significant increase in resistance of ceftriaxone was recorded at PICU and NICU (from 12% and 0%, respectively, from 1988–1992, to 61% and 16%, respectively, from 1993–1997, p = 0.02). Overall mortality rate of Klebsiella bacteremia was 13% (21/167 cases, 12 and eight at PICU and NICU, respectively). Conclusion: An increase in Klebsiella bacteremia was recorded in southern Israel during the 10 years of the study. A marked increase in the rate of nosocomial Klebsiella bacteremia occurred at all departments. Resistance to third-generation cephalosporins emerged frequently at PICU and NICU during the last period of the survey. Received: March 26, 2001 · Revision accepted: January 8, 2002     

Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes

Introduction: Acute pancreatitis (AP) incidence in the elderly population has increased in the last years. However, the role of age as influencing factor on the AP clinical course is still debated.

Methods: We reviewed clinical records of consecutive patients admitted with diagnosis of AP. Patients were divided in elderly (≥65 years) and non-elderly (<65 years). Primary endpoint was comparison of overall mortality. Secondary endpoint included ICU admission, in-hospital length of stay (LOS) and surgical procedures.

Results: We enrolled 352 elderly and 532 non-elderly patients. A higher mortality rate (7.4% vs 1.9%; p?<?.001), ICU admission rate (18.9% vs 6.3%; p?<?.001) and prolonged length of hospital stay (9 (6–14) vs 7 (5–11.7) days; p?=?.01) were registered in the ≥65 years group. Multivariate analysis identified age (OR: 3.5; 95% CI:1.645–7.555; p?=?.001), a higher Ranson score at admission (OR: 5.52; 95% CI:1.11–27.41; p<.001) and necrotic pancreatitis (OR: 8.6; 95% CI:2.46–30.27; p?=?.001) as independent predictors of mortality. Conversely age and necrotic pancreatitis were independent risk factors for higher LOS and ICU admission.

Conclusions: Patients with AP and age ≥65 years have a higher mortality, ICU admission and prolonged LOS. Early recognition and prompt treatment are key elements to improve outcomes in this population.     

The predictive value of epicardial fat volume for clinical severity of COVID-19

IntroductionEpicardial adipose tissue serves as a source of inflammatory cytokines and mediators. Cytokine storm is an important cause of morbidity and mortality in coronavirus disease 2019 (COVID-19).ObjectivesTo investigate the association between epicardial fat volume (EFV), inflammatory biomarkers and clinical severity of COVID-19.MethodsThis retrospective study included 101 patients who were infected with COVID-19. Serum inflammatory biomarkers including C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT) and ferritin levels were measured. Computed tomography images were analyzed and semi-automated measurements for EFV were obtained. The primary composite endpoint was admission to the intensive care unit (ICU) or death.ResultsThe primary composite endpoint occurred in 25.1% (n=26) of patients (mean age 64.8±14.8 years, 14 male). A total of 10 patients died. EFV, CRP, PCT, ferritin and IL-6 levels were significantly higher in ICU patients. Moreover, a positive correlation was determined between EFV and CRP (r: 0.494, p<0.001), PCT (r: 0.287, p=0.005), ferritin (r: 0.265, p=0.01) and IL-6 (r: 0.311, p=0.005). On receiver operating characteristic analysis, patients with EFV >102 cm³ were more likely to have severe complications. In multivariate logistic regression analysis, EFV independently predicted admission to the ICU at a significant level (OR: 1.02, 95% CI: 1.01-1.03, p=0.025).ConclusionEFV and serum CRP, IL-6, PCT and ferritin levels can effectively assess disease severity and predict the outcome in patients with COVID-19. EFV is an independent predictor of admission to the ICU in hospitalized COVID-19 patients.     

Predictors of major postoperative cardiac complications in a surgical ICU.

INTRODUCTION: Cardiovascular complications are associated with increased mortality and morbidity during the postoperative period, resulting in longer hospital stay and higher treatment costs. OBJECTIVES: The aim of this study was to identify predictors of major postoperative cardiac complications. METHODS: 187 patients undergoing noncardiac surgery, admitted to a surgical intensive care unit (ICU) between November 2004 and April 2005. Variables recorded were age, gender, American Society of Anesthesiologists (ASA) physical status, type and magnitude of surgery, mortality, ICU and hospital length of stay (LOS), Simplified Acute Physiology Score II (SAPS II), cardiac troponin I (cTnI) at postoperative day 0, 1, 2 and 3, history of hypertension, hyperlipidemia, Revised Cardiac Risk Index (RCRI) score, major cardiac events (MCE): acute myocardial infarction (AMI), pulmonary edema (PE), ventricular fibrillation (VF) or primary cardiac arrest (PCA). Correlations between variables and MCE were made by univariate analysis by simple logistic regression with odds ratio (OR) and 95% confidence interval (95% CI). RESULTS: Total of 14 MCE: 9 AMI, 1 VF, 4 PE. Significant risk factors for MCE were high-risk surgery (OR 8.26, 95% CI 1.76-38.85, p = 0.008), RCRI > or = 2 (OR 4.0, 95% CI 1.22-13.16, p = 0.022), admission cTnI (OR 1.46, 95% CI 1.07-1.99, p = 0.018); day 1 cTnI (OR 1.75, 95% CI 1.27-2.41, p = 0.001); day 2 cTnI (OR 2.23, 95% CI 1.24-3.98, p = 0.007), SAPS II (OR 1.08, 95% CI 1.04-1.12, p < 0.001). Patients with MCE had longer ICU LOS (19.1 +/- 19.3 days against 3.4 +/- 4.9) (OR 1.15, 95% CI 1.08-1.22, p < 0.001) and higher ICU mortality (21.4% versus 4.6%) (OR 5.63, 95% CI 1.31-24.23, p = 0.02) in the ICU. CONCLUSIONS: High-risk surgery, RCRI > or = 2, cTnI levels and SAPS II were predictors of postoperative MCE. Patients with MCE had longer ICU stay and higher mortality rate.     

Pseudomonas aeruginosa Strains from Nosocomial Pneumonia Are More Serum Resistant than P. aeruginosa Strains from Noninfectious Respiratory Colonization Processes

Abstract Background: Serum resistance is regarded as a major virulence factor of bacteria and is thought to be mediated by O side chains of the lipopolysaccharides (LPS). We investigated the serum–resistance properties and O serogroups of Pseudomonas aeruginosa strains isolated from intensive careunit (ICU) patients with pneumonia and from the respiratory tract of ICU patients without respiratory tract infections. Materials and Methods: 171 P. aeruginosa strains were consecutively isolated from bronchoalveolar lavage fluid or transtracheal aspirates of ICU patients with monobacterial nosocomial pneumonia and 49 strains were isolated from the respiratory tract of ICU patients without respiratory tract infections. All strains were O serogrouped using Oantigen– specific sera for 14 O serogroups and tested for their sensitivity to the serum’s bactericidal effect. Results: Using two different analyses, the frequency of serum–sensitive isolates was significantly lower in strains from patients with pneumonia (56.1%; n = 96/171 and 22.8%, n = 39/171, respectively) than in strains from asymptomatically colonized patients (73.46%; 36/49 and 38.8%, n = 19/49, respectively) (p = 0.03; OR = 2.163; 95% CI = 1.072–4.368 and p = 0.0289; OR = 2.144; 95% CI = 1.089–4.368, respectively). O serogrouping revealed higher frequency of the serogroups A (11.9% and 16.3%, respectively), B (14.3% and 21%), E (26.5% and 24.6%), and I (28.6% and 28%) in both strain collections. The frequency of serum–sensitive strains (13/28 and 3/45, respectively) was significantly lower among strains expressing the A and B serogroups, than for all other serogroups (p < 0.05). Conclusion: Strains isolated from patients with pneumonia and strains possessing O–A or O–B serogroups appear to have greater pathogenic potential by virtue of their ability to resist serum–mediated killing. The linkage, however, between the O serogroups, serum resistance, and a strain's virulence remains unclear at this stage. This paper is dedicated to the founders of the Walter Marget Foundation, D. Adam and F. Daschner, in gratitude for their support of the training in infectious diseases.     

Comparison of prognosis predictive value of 4 disease severity scoring systems in patients with acute respiratory failure in intensive care unit: A STROBE report

Various disease severity scoring systems were currently used in critically ill patients with acute respiratory failure, while their performances were not well investigated.The study aimed to investigate the difference in prognosis predictive value of 4 different disease severity scoring systems in patients with acute respiratory failure.With a retrospective cohort study design, adult patients admitted to intensive care unit (ICU) with acute respiratory failure were screened and relevant data were extracted from an open-access American intensive care database to calculate the following disease severity scores on ICU admission: acute physiology score (APS) III, Sequential Organ Failure Assessment score (SOFA), quick SOFA (qSOFA), and Oxford Acute Severity of Illness Score (OASIS). Hospital mortality was chosen as the primary outcome. Multivariable logistic regression analyses were performed to analyze the association of each scoring system with the outcome. Receiver operating characteristic curve analyses were conducted to evaluate the prognosis predictive performance of each scoring system.A total of 4828 patients with acute respiratory failure were enrolled with a hospital mortality rate of 16.78%. APS III (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02–1.03), SOFA (OR 1.15, 95% CI 1.12–1.18), qSOFA (OR 1.26, 95% CI 1.11–1.42), and OASIS (OR 1.06, 95% CI 1.05–1.08) were all significantly associated with hospital mortality after adjustment for age and comorbidities. Receiver operating characteristic analyses showed that APS III had the highest area under the curve (AUC) (0.703, 95% CI 0.683–0.722), and SOFA and OASIS shared similar predictive performance (area under the curve 0.653 [95% CI 0.631–0.675] and 0.664 [95% CI 0.644–0.685], respectively), while qSOFA had the worst predictive performance for predicting hospital mortality (0.553, 95% CI 0.535–0.572).These results suggested the prognosis predictive value varied among the 4 different disease severity scores for patients admitted to ICU with acute respiratory failure.     

The chronic ICU patient: Is intensive care worthwhile for patients with very prolonged ICU-stay (≥ 90 days)?

BackgroundDue to medical advances, an increasing number of patients are surviving the acute critical illness. However, some patients require a prolonged critical care treatment. Data on outcome and functional status of patients with an ICU-stay ≥90 days are scarce.MethodsSingle-center retrospective study including all adult patients with ICU stay ≥90 days treated at the department of intensive care medicine at the university medical center Hamburg-Eppendorf, Germany, between January 1st 2008 and December 31st 2016.ResultsOut of 65,249 patients, we identified 96 (0.1%) patients with a very prolonged ICU stay. Median age was 61 (49.8–67) years, 30 (31%) patients were female. Patients were admitted to ICU due to abdominal (28%) reasons, followed by sepsis (23%) and transplantation (15%). Fourteen patients received organ-transplantation: 9 received liver-, 4 lung- and 1 heart-transplantation. All patients needed mechanical ventilation (MV), median duration was 74.1 (55–95.1) days. Sixty-Three (66%) patients survived the ICU-stay and 1-Year survival rate was 28%. Overall eight (8%) patients had a favourable outcome after 1-Year. Severity of illness (SOFA, SAPS II) on admission were comparable. Length of MV, use of renal replacement therapy (both p < .01) and maximum lactate (5.3 vs 11.5 mmol/l; p < .001) were significantly higher in ICU non-survivors. ICU-stay was significantly longer in ICU non-survivors (137 vs 107 days; p < .05). Cox-regression-model revealed age (HR 1.02, 95% CI 1.00–1.04, p < .05) and surgical admission (HR 0.50, 95% CI 0.28–0.90, p < .05) as independent predictors of 1-year mortality.ConclusionsOnly a small number of patients requires a very prolonged ICU stay. Two-third of patients survive the ICU stay and about one-third 1-Year. However, about 10% of patients have a remarkable recovery with a favourable overall outcome after 1-Year.     

Prognostic Value of Delirium in Patients With Acute Heart Failure in the Intensive Care Unit

BackgroundDelirium is a common adverse event observed in patients admitted to the intensive care unit (ICU). However, the prognostic value of delirium and its determinants have not been thoroughly investigated in patients with acute heart failure (AHF).MethodsWe investigated 408 consecutive patients with AHF admitted to the ICU. Delirium was diagnosed by means of the Confusion Assessment Method for ICU tool and evaluated every 8 hours during the patients’ ICU stays.ResultsDelirium occurred in 109 patients (26.7%), and the in-hospital mortality rate was significantly higher in patients with delirium (13.8% vs 2.3%; P < 0.001). Multivariate logistic regression analysis showed that delirium independently predicted in-hospital mortality (odds ratio [OR] 4.33, confidence interval [CI] 1.62-11.52; P = 0.003). Kaplan-Meier analysis showed that the 12-month mortality rate was significantly higher in patients with delirium compared with those without (log-rank test: P < 0.001), and Cox proportional hazards analysis showed that delirium remained an independent predictor of 12-month mortality (hazard ratio 2.19, 95% CI 1.49-3.25; P < 0.001). The incidence of delirium correlated with severity of heart failure as assessed by means of the Get With The Guidelines–Heart Failure risk score (chi-square test: P = 0.003). Age (OR 1.05, 95% CI 1.02-1.09; P = 0.003), nursing home residential status (OR 3.32, 95% CI 1.59-6.94; P = 0.001), and dementia (OR 5.32, 95% CI 2.83-10.00; P < 0.001) were independently associated with the development of delirium.ConclusionsDevelopment of delirium during ICU stay is associated with short- and long-term mortality and is predicted by the severity of heart failure, nursing home residential, and dementia status.     

Outcomes Following Percutaneous Coronary Intervention in Saphenous Vein Grafts With and Without Embolic Protection Devices

ObjectivesThe aim of this study was to describe the early (inpatient and 30-day) and late (1-year) outcomes of percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs), with and without the use of embolic protection devices (EPD), in a large, contemporary, unselected national cohort from the database of the British Cardiovascular Intervention Society.BackgroundThere are limited, and discrepant, data on the clinical benefits of the adjunctive use of EPDs during PCI to SVGs in the contemporary era.MethodsA longitudinal cohort of patients (2007 to 2014, n = 20,642) who underwent PCI to SVGs in the British Cardiovascular Intervention Society database was formed. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 2 groups: no EPD (PCI to SVGs without EPDs, n = 17,730) and EPD (PCI to SVGs with EPDs, n = 2,912).ResultsPatients in the EPD group were older, had more comorbidities, and had a higher prevalence of moderate to severe left ventricular systolic dysfunction. Mortality was lower in the EPD group during hospital admission (0.70% vs. 1.29%; p = 0.008) and at 30 days (1.44% vs. 2.01%; p = 0.04) but similar at 1 year (6.22% vs. 6.01%; p = 0.67). Following multivariate analyses, no significant difference in mortality was observed during index admission (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.42 to 1.19; p = 0.19), at 30 days (OR: 0.87; 95% CI: 0.60 to 1.25; p = 0.45), and at 1 year (OR: 0.92; 95% CI: 0.77 to 1.11; p = 0.41), along with similar rates of in-hospital major adverse cardiovascular events (OR: 1.16; 95% CI: 0.83 to 1.62; p = 0.39) and stroke (OR: 0.68; 95% CI: 0.20 to 2.35; p = 0.54). In propensity score–matched analyses, lower inpatient mortality was observed in the EPD group (OR: 0.46; 95% CI: 0.13 to 0.80; p = 0.002), although the adjusted risk for the periprocedural no-reflow or slow-flow phenomenon was higher in patients in whom EPDs were used (OR: 2.16; 95% CI: 1.71 to 2.73; p < 0.001).ConclusionsIn this contemporary cohort, EPDs were used more commonly in higher risk patients but were associated with similar clinical outcomes in multivariate analyses. Lower inpatient mortality was observed in the EPD group in univariate and propensity score–matched analyses.     

Factors associated with outcome in acute liver failure in an intensive care unit

Aim

To study the factors associated with outcome in acute liver failure (ALF) in an intensive care unit (ICU).

Methods

Consecutive patients with ALF admitted to the ICU from August 2003 to April 2010 were included. Factors associated with the primary outcome, death or survival, were compared.

Results

Of 52 patients of median age 19 years (range 3–65), 35 (67 %) died. The etiology was viral hepatitis in 66 %, drug induced (anti-tubercular therapy) in 15 % and idiopathic in 15 %. Grades III+IV encephalopathy were found in 12 (70.6 %) survivors as against 33 (94.3 %) nonsurvivors (p?=?0.019). The median admission sequential organ failure assessment (SOFA) score was eight in survivors vs. 12 in nonsurvivors (p?<?0.001). Median admission prothrombin time (PT) was 42 s in survivors vs. 51 in nonsurvivors (p?=?0.384); 16/17 (94.1 %) survivors had normal PT on day 4 as compared to 7/35 (20 %) nonsurvivors (p?<?0.001). Median PT on day 4 was 18 s in survivors against 37 in nonsurvivors (p?<?0.001). Serum bilirubin, alanine aminotransferase; and serum creatinine, sodium and phosphorus were similar in survivors and nonsurvivors. Mechanical ventilation, vasopressors and dialysis were used in 65 %, 30 %, and 12 % survivors as against 100 % (p?<?0.001), 51 % and 26 % nonsurvivors. Sixteen patients had upper gastrointestinal (GI) bleed. Blood cultures were positive more often in nonsurvivors (p?=?0.058). On multiple regression analysis, factors independently associated with outcome included admission SOFA score >9.5 and absolute value of PT on day 4.

Conclusions

Grades III and IV encephalopathy, higher SOFA score at admission and a prolonged PT which did not normalize by 4 days were associated with mortality in ALF.