Influence of radiologic pattern and the presence of diffuse parenchymal lung disease on outcome in ventilated patients with COVID-19 pneumonia: impact on prognosis.

BACKGROUND: Suspected organising pneumonia (OP) is a common finding in patients with severe coronavirus disease 2019 (COVID-19), but the impact on outcomes of the radiological patterns of diffuse parenchymal lung disease on outcome of these patients is still uncertain. AIMS: Investigate the presence of radiological images compatible with OP and its association with clinical outcomes in patients with COVID-19 submitted to invasive mechanical ventilation (IMV). METHODS: Retrospective, unicentric cohort study composed of patients who required IMV and underwent chest computerized tomography to investigate secondary complications of COVID-19. We compared patients with radiological findings characteristic of suspected OP with those without this condition. The main outcome was hospital mortality. RESULTS: Two hundred and ten patients were included, and 65 had signals compatible with OP. All patients with suspected OP were treated with corticosteroids. There was no difference in IVM-free days until day 28 between the groups (median, 0 days; interquartile range [IQR], 0-14.8) in the group with suspected OP vs 0 days (IQR, 0-11) in the group without suspected OP (P = 0.14). In univariate analysis, the presence of suspected OP was associated with lower hospital mortality; however, after correction for potential confounding variables, it was not associated with the outcome, even after matching by propensity score in patients without this condition. CONCLUSION: OP radiologic pattern in patients with severe COVID-19 is not associated with worse outcomes.

HIV treatment non-adherence is associated with ICU mortality in HIV-positive critically ill patients.

INTRODUCTION: Combined antiretroviral therapy has led to significant decreases in morbidity and mortality in acquired immunodeficiency syndrome patients. Survival among these patients admitted to intensive care units has also improved in the last years. However, the prognostic predictors of human immunodeficiency vírus patients in intensive care units have not been adequately studied. The main objective of this study was to evaluate if non-adherence to antiretroviral therapy is a predictor of hospital mortality. METHODS: A unicentric, retrospective, cohort study composed of patients admitted to a 59-bed mixed intensive care unit including all patients with human immunodeficiency vírus infection. Patients were excluded if exclusive palliative care was established before completing 48 h of intensive care unit admission. Clinical and treatment data were obtained, including demographic records, underlying diseases, Simplified Acute Physiology III score at the time of intensive care unit admission, CD4 lymphocyte count, antiretroviral therapy adherence, admission diagnosis, human immunodeficiency vírus-related diseases, sepsis and use of mechanical ventilation and hemodialysis. The outcome analyzed was hospital mortality. RESULTS: Overall, 167 patients were included in the study, and intensive care unit mortality was 34.7%. Multivariate analysis indicated that antiretroviral therapy adherence and the Simplified Acute Physiology 3 score were independently related to hospital mortality. antiretroviral therapy adherence was a protective factor (OR 0.2; 95% CI 0.05-0.71; P = 0.01), and Simplified Acute Physiology 3 (OR 1.04; 95% CI 1.01-1.08; P < 0.01) was associated with increased hospital mortality. CONCLUSION: Non-adherence to antiretroviral therapy is associated with hospital mortality in this population. Highly active antiretroviral therapy non-adherence may be associated with other comorbidities that may be associated with a worst prognosis in this scenario.

Early antiretroviral therapy for HIV-infected patients admitted to an intensive care unit (EARTH-ICU): A randomized clinical trial.

BACKGROUND: Highly active antiretroviral therapy (HAART) has reduced HIV-related morbidity and mortality at all stages of infection and reduced transmission of HIV. Currently, the immediate start of HAART is recommended for all HIV patients, regardless of the CD4 count. There are several concerns, however, about starting treatment in critically ill patients. Unpredictable absorption of medication by the gastrointestinal tract, drug toxicity, drug interactions, limited reserve to tolerate the dysfunction of other organs resulting from hypersensitivity to drugs or immune reconstitution syndrome, and the possibility that subtherapeutic levels of drug may lead to viral resistance are the main concerns. The objective of our study was to compare the early onset (up to 5 days) with late onset (after discharge from the ICU) of HAART in HIV-infected patients admitted to the ICU. METHODS: This was a randomized, open-label clinical trial enrolling HIV-infected patients admitted to the ICU of a public hospital in southern Brazil. Patients randomized to the intervention group had to start treatment with HAART within 5 days of ICU admission. For patients in the control group, treatment should begin after discharge from the ICU. The patients were followed up to determine mortality in the ICU, in the hospital and at 6 months. The primary outcome was hospital mortality. The secondary outcome was mortality at 6 months. RESULTS: The calculated sample size was 344 patients. Unfortunately, we decided to discontinue the study due to a progressively slower recruitment rate. A total of 115 patients were randomized. The majority of admissions were for AIDS-defining illnesses and low CD4. The main cause of admission was respiratory failure. Regarding the early and late study groups, there was no difference in hospital (66.7% and 63.8%, p = 0.75) or 6-month (68.4% and 79.2%, p = 0.20) mortality. After multivariate analysis, the only independent predictors of in-hospital mortality were shock and dialysis during the ICU stay. For the mortality outcome at 6 months, the independent variables were shock and dialysis during the ICU stay and tuberculosis at ICU admission. CONCLUSIONS: Although the early termination of the study precludes definitive conclusions being made, early HAART administration for HIV-infected patients admitted to the ICU compared to late administration did not show benefit in hospital mortality or 6-month mortality. ClinicalTrials.gov, NCT01455688. Registered 20 October 2011, https://clinicaltrials.gov/show/NCT01455688.