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BACKGROUND: Acute kidney injury (AKI) is a disease that negatively affects patient prognosis and requires early diagnosis and treatment. Biomarkers that predict AKI are needed for early diagnosis of this disease. METHODS: We compared the AKI group and the non-AKI group in patients who were admitted to our critical care intensive care unit (ICU) and conducted a comparative study focusing on urinary neutrophil gelatinase-associated lipocalin (U-NGAL) and serum procalcitonin (PCT). RESULTS: Seventy-one out of 106 ICU inpatients were diagnosed with AKI in accordance with the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Among the patients who were diagnosed with AKI stages 1 to 3, 94.4% of all patients reached the maximum stage by day 5 after admission. Comparing the non-AKI group and AKI stage 1 to 3 on days 1 to 3 after admission, U-NGAL and PCT levels in the stage 3 group were significantly higher than those in the non-AKI group. Additionally, in receiver operating characteristic curve (ROC) analysis on days 1-3 after admission, U-NGAL and PCT levels can be used as biomarkers for the diagnosis of AKI, and in particular, AKI stage 3 can be predicted and diagnosed with high accuracy. U-NGAL and PCT levels were also significantly higher in AKI due to sepsis and acute pancreatitis and due to sepsis, respectively. CONCLUSIONS: Measuring U-NGAL and PCT levels as biomarkers for AKI may further improve the accuracy of AKI diagnosis in critical care ICU.
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Lesión Renal Aguda/sangre , Lesión Renal Aguda/orina , Cuidados Críticos , Hospitalización , Unidades de Cuidados Intensivos , Lipocalina 2/orina , Polipéptido alfa Relacionado con Calcitonina/sangre , Lesión Renal Aguda/diagnóstico , Anciano , Anciano de 80 o más Años , Biomarcadores/metabolismo , Creatinina/sangre , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Pronóstico , Curva ROC , Factores de TiempoRESUMEN
A circuit clot is one of the most frequent complications during extracorporeal membrane oxygenation (ECMO) support. We identify coagulation/fibrinolysis markers for predicting ECMO circuit exchange because of circuit clots during ECMO support. Ten patients with acute pulmonary failure who underwent veno-venous ECMO were enrolled between January 2014 and December 2016. ECMO support lasted 106 days. The 6 days on which the ECMO circuits were exchanged were considered as circuit clot (+) group, while the remaining 100 days were considered as circuit clot (-) group. The predictors of ECMO circuit exchange because of circuit clots were identified. The mean duration of ECMO support was 10 ± 13 days, and the mean number of ECMO circuit exchange was 0.6 ± 1.1 times per patient. Thrombin-antithrombin complex (TAT) and soluble fibrin (SF) were higher in the circuit clot (+) group than in the circuit clot (-) group (both P < 0.01). According to a multivariate analysis, SF was the only independent predictor of ECMO circuit exchange (P < 0.01). The odds ratio (confidence intervals) for SF (10 µg/ml) was 1.20 (1.06-1.36). The area under the curve and optimal cut-off value were 0.95 and 101 ng/ml for SF (sensitivity, 100%; specificity, 89%). SF may be useful in predicting ECMO circuit exchange because of circuit clots.
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Oxigenación por Membrana Extracorpórea/efectos adversos , Fibrina/metabolismo , Insuficiencia Respiratoria/terapia , Trombosis/sangre , Trombosis/etiología , Anciano , Antitrombina III , Biomarcadores/sangre , Coagulación Sanguínea , Femenino , Humanos , Pulmón , Masculino , Persona de Mediana Edad , Péptido Hidrolasas/sangre , Estudios RetrospectivosRESUMEN
BACKGROUND: The purpose of this study was to investigate whether polymyxin B hemoperfusion (PMX-HP) improves the survival of patients with septic shock. METHODS: This was a retrospective, multicenter study conducted on patients treated during a 3-year period. We performed propensity-score analyses of the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study database. The study included data on 1723 patients with septic shock aged 16 years or older. Furthermore, we divided patients into to PMX-HP- and non-PMX-HP-treated groups. The primary endpoint was all-cause hospital mortality; secondary endpoints included intensive care unit (ICU) mortality and number of ICU-free days (ICUFDs) in the first 28 days. RESULTS: Of 1,723 eligible patients, 522 had received PMX-HP. Propensity score matching created 262 matched pairs (i.e., 262 patients in each of the non-PMX-HP and PMX-HP groups). The proportion of all-cause hospital mortality was significantly lower in the PMX-HP group than in the non-PMX-HP group (32.8% vs. 41.2%; odds ratio (OR): 0.681; 95% confidence interval (CI): 0.470-0.987; P = 0.042). The number of ICUFD in the first 28 days was significantly higher in the PMX-HP group than in the non-PMX-HP group (18 (0-22) vs. 14 (0-22) days, respectively; P = 0.045). On the other hand, there was no significant difference in ICU mortality between the two groups (21.8% vs. 24.4%; OR: 0.844; CI: 0.548-1.300; P = 0.443). CONCLUSIONS: Our results strongly suggest that PMX-HP reduces all-cause hospital mortality and length of ICU stay in patients with septic shock.
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Coagulación Intravascular Diseminada/mortalidad , Hemoperfusión/métodos , Polimixina B/farmacología , Choque Séptico/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Coagulación Intravascular Diseminada/tratamiento farmacológico , Coagulación Intravascular Diseminada/prevención & control , Femenino , Hemoperfusión/normas , Humanos , Unidades de Cuidados Intensivos/organización & administración , Japón , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Polimixina B/uso terapéutico , Puntaje de Propensión , Estudios Retrospectivos , Choque Séptico/mortalidad , Análisis de SupervivenciaRESUMEN
INTRODUCTION: There are few investigations regarding the relationships between procalcitonin (PCT) and the acute kidney injury (AKI) in the diagnosis of sepsis. The purpose of this study was to clarify the diagnostic accuracy of the use of PCT levels in patients with or without AKI. METHODS: This study was conducted as a single-center retrospective study. We enrolled 393 patients in whom PCT were measured on admission. We grouped the patients into non-AKI and AKI, and those with AKI were classified according to the RIFLE criteria (Risk, Injury, Failure). The patients in each group were further classified into the sepsis and the non-sepsis group. We subsequently investigated the diagnostic accuracy of the PCT for detecting sepsis in these groups. RESULTS: The levels of PCT were significantly higher in the sepsis group than in the non-sepsis group among the non-AKI and each AKI patients (p < 0.0001). The diagnostic accuracy of the PCT for detecting sepsis was determined according to a ROC analysis; AUC value was 0.958 in the non-AKI group, in the Risk, Injury and Failure groups were 0.888 and 0.917, 0.857, respectively. AUC value for non-AKI group was significantly different from that of Failure group (p < 0.05). CONCLUSIONS: In Failure AKI patients, the diagnostic accuracy of the PCT level is significantly lower than non-AKI patients. It is therefore suggested that we should be careful in using PCT value to diagnose sepsis in patients with Failure under RIFLE criteria.
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Lesión Renal Aguda/sangre , Lesión Renal Aguda/complicaciones , Biomarcadores/sangre , Calcitonina/sangre , Precursores de Proteínas/sangre , Sepsis/sangre , Sepsis/complicaciones , Lesión Renal Aguda/epidemiología , Anciano , Péptido Relacionado con Gen de Calcitonina , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sepsis/diagnóstico , Sepsis/epidemiologíaRESUMEN
BACKGROUND: Presepsin is useful for differentiating sepsis from non-infection related systemic inflammatory response syndrome. However, there are no studies investigating the usefulness of presepsin in diagnosing sepsis involving patients with acute kidney injury (AKI). The purpose of this study is to determine levels of blood presepsin in patients with or without sepsis and among non-AKI patients or patients with different degrees of AKI severity. METHODS: This is a single center retrospective study. 247 patients admitted to the ICU between June 2010 and October 2012 were analyzed for their presepsin levels. We classified the patients into non-AKI and AKI according to the RIFLE (Risk, Injury, Failure, and Loss of kidney function and End-stage kidney disease or simply Loss and ESKD) criteria. We then sub-classified the patients in each group into either non-sepsis or sepsis sub-group and analyzed the accuracy of diagnosing sepsis based on their levels of presepsin. RESULTS: The number of patients for each group was: non-AKI, 112; under AKI: Risk, 50; Injury, 36; Failure, 42; Loss and ESKD, 7. The levels of presepsin in sepsis groups were significantly higher than that in the non-sepsis group among the non-AKI, Risk and Injury patients (p < 0.0001, p < 0.01, p < 0.01, respectively). However, no significant difference in the level of presepsin between non-sepsis and sepsis groups among patients with Failure. In the receiver operating characteristic (ROC) analysis, the area under the curve (AUC) was 0.784 in the non-AKI group and 0.698 in the AKI comprising Risk, Injury and Failure groups. AUC value for non-AKI was not significantly different from that of AKI (p = 0.200). When 670 pg/mL was used as the cutoff value for presepsin, sensitivity and specificity were 70.3% and 81.3%, respectively. When 864 pg/mL was used as the cutoff value for presepsin, sensitivity and specificity were 71.4% and 63.8%, respectively. CONCLUSIONS: Presepsin level can be a reliable indicator of sepsis not only among non-AKI patients but also patients with less severe forms of AKI. However, it may not be a reliable indicator of sepsis in patients with a more advanced form of AKI.
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Lesión Renal Aguda/diagnóstico , Biomarcadores/sangre , Receptores de Lipopolisacáridos/sangre , Fragmentos de Péptidos/sangre , Sepsis/diagnóstico , Lesión Renal Aguda/sangre , Lesión Renal Aguda/complicaciones , Adolescente , Adulto , Anciano , Femenino , Tasa de Filtración Glomerular , Humanos , Fallo Renal Crónico/sangre , Fallo Renal Crónico/complicaciones , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sepsis/sangre , Sepsis/complicaciones , Adulto JovenRESUMEN
Whether empirical therapy with carbapenems positively affects the outcomes of critically ill patients with bacterial infections remains unclear. This study aimed to investigate whether the use of carbapenems as the initial antimicrobial administration reduces mortality and whether the duration of carbapenem use affects the detection of multidrug-resistant (MDR) pathogens. This was a post hoc analysis of data acquired from Japanese participating sites from a multicenter, prospective observational study [Determinants of Antimicrobial Use and De-escalation in Critical Care (DIANA study)]. A total of 268 adult patients with clinically suspected or confirmed bacterial infections from 31 Japanese intensive care units (ICUs) were analyzed. The patients were divided into two groups: patients who were administered carbapenems as initial antimicrobials (initial carbapenem group, n = 99) and those who were not administered carbapenems (initial non-carbapenem group, n = 169). The primary outcomes were mortality at day 28 and detection of MDR pathogens. Multivariate logistic regression analysis revealed that mortality at day 28 did not differ between the two groups [18 (18%) vs 27 (16%), respectively; odds ratio: 1.25 (95% confidence interval (CI): 0.59-2.65), P = 0.564]. The subdistribution hazard ratio for detecting MDR pathogens on day 28 per additional day of carbapenem use is 1.08 (95% CI: 1.05-1.13, P < 0.001 using the Fine-Gray model with death regarded as a competing event). In conclusion, in-hospital mortality was similar between the groups, and a longer duration of carbapenem use as the initial antimicrobial therapy resulted in a higher risk of detection of new MDR pathogens.IMPORTANCEWe found no statistical difference in mortality with the empirical use of carbapenems as initial antimicrobial therapy among critically ill patients with bacterial infections. Our study revealed a lower proportion of inappropriate initial antimicrobial administrations than those reported in previous studies. This result suggests the importance of appropriate risk assessment for the involvement of multidrug-resistant (MDR) pathogens and the selection of suitable antibiotics based on risk. To the best of our knowledge, this study is the first to demonstrate that a longer duration of carbapenem use as initial therapy is associated with a higher risk of subsequent detection of MDR pathogens. This finding underscores the importance of efforts to minimize the duration of carbapenem use as initial antimicrobial therapy when it is necessary.
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Antibacterianos , Infecciones Bacterianas , Carbapenémicos , Enfermedad Crítica , Farmacorresistencia Bacteriana Múltiple , Unidades de Cuidados Intensivos , Humanos , Carbapenémicos/uso terapéutico , Masculino , Estudios Prospectivos , Femenino , Anciano , Antibacterianos/uso terapéutico , Persona de Mediana Edad , Unidades de Cuidados Intensivos/estadística & datos numéricos , Infecciones Bacterianas/tratamiento farmacológico , Infecciones Bacterianas/mortalidad , Infecciones Bacterianas/microbiología , Japón , Anciano de 80 o más Años , Bacterias/efectos de los fármacos , Bacterias/aislamiento & purificación , Bacterias/clasificación , Bacterias/genéticaRESUMEN
BACKGROUND: Sepsis occurs as a result of dysregulated host response to infection. However, cytokine adsorption therapy may restore the balance of proinflammatory and anti-inflammatory mediator responses in patients with sepsis. This study aimed to determine the cytokine adsorption ability of two different types of continuous renal replacement therapy (CRRT) hemofilters for polyethyleneimine-coated polyacrylonitrile (AN69ST) (surface-treated) and polymethylmethacrylate (PMMA) CRRT. METHODS: We performed a randomized controlled trial among sepsis patients undergoing CRRT, who were randomly assigned (1:1) to receive either AN69ST or PMMA-CRRT. The primary outcome was cytokine clearance of hemofilter adsorption (CHA). The secondary endpoints were the intensive care unit (ICU) and 28-day mortalities. RESULTS: We randomly selected 52 patients. Primary outcome data were available for 26 patients each in the AN69ST-CRRT and PMMA-CRRT arms. The CHA of high-mobility group box 1, tumor necrosis factor, interleukin (IL)-8, monokine induced by interferon-γ, and macrophage inflammatory protein were significantly higher in the AN69ST-CRRT group than in the PMMA-CRRT group (P < 0.001, P < 0.01, P < 0.001, P < 0.001 and P < 0.001, respectively). In contrast, the CHA of IL-6 was significantly higher in the PMMA-CRRT group than in the AN69ST-CRRT group (P < 0.001). In addition, the 28-day mortality was not significantly different between the two groups (50% in AN69ST-CRRT vs. 30.8% in PMMA-CRRT, P = 0.26). CONCLUSION: AN69ST and PMMA membranes have different cytokine CHA in patients with sepsis. Therefore, these two hemofilters may have to be used depending on the target cytokine. TRIAL REGISTRATION NUMBER: This study was registered in the University Hospital Medical Information Network on November 1, 2017 (Trial No: UMIN000029450, https://center6.umin.ac.jp ).
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Terapia de Reemplazo Renal Continuo , Humanos , Citocinas , Polimetil Metacrilato , Polietileneimina , AdsorciónRESUMEN
Objective: This study aimed to clarify whether the glial fibrillary acidic protein (GFAP) and soluble protein-100ß (S100ß) can predict severe traumatic brain injury (TBI) in patients with severe multiple trauma. Methods: This is a single-center retrospective observational study of 179 patients with severe multiple trauma. The GFAP and S100ß were measured upon patient arrival at the hospital. We divided the patients into the severe TBI group (with a Traumatic Coma Data Bank classification of ≥III), the non-severe TBI group (non-TBI group [absence of abnormality on the computed tomography scan and extracranial injury], and the mild to moderate TBI group [TCDB classification I and II]). We compared biomarker levels between the two groups and then evaluated the accuracy of predicting severe TBI using a receiver operating characteristic curve. Results: A total of 41 patients had severe TBI, and 138 had non-severe TBI. Mean GFAP levels were significantly higher in the severe TBI group (median, 6000 pg/mL; interquartile range [IQR], 651-15,548 pg/mL) than in the non-severe TBI group (median, 149 pg/mL; IQR, 0-695 pg/mL) (p < 0.0001). In contrast, there was no significant difference in S100ß levels between the severe TBI group (median, 64 pg/mL; IQR, 0-536 pg/mL) and non-severe TBI group (median, 117 pg/mL; IQR, 0-403 pg/mL) (p = 0.637). The area under the receiver operating characteristic curve was 0.810 (p < 0.0001) for GFAP and 0.476 (p = 0.908) for S100ß. For the GFAP, the optimal cutoff value for detecting severe TBI was 947 pg/mL (sensitivity, 75.6%; specificity, 78.3%). Conclusions: In patients with severe multiple trauma, the GFAP level at hospital arrival could predict severe TBI, whereas the S100ß level was not a useful predictor.
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BACKGROUND: We investigated whether a decrease in the serum zinc level (SZL) among patients with sepsis admitted to the intensive care unit (ICU) was related to sepsis-induced coagulopathy. METHODS: All patients (≥20 years) with a diagnosis of sepsis defined by Sepsis-3 criteria, presenting to the ICU between June 2016 and July 2017, were enrolled. Demographic characteristics and the Sequential Organ Failure Assessment (SOFA) and Japanese Association of Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) scores were recorded. Blood samples were collected upon admission and analyzed for SZL. RESULTS: One hundred patients with sepsis (median age, 70 years) were enrolled. Patients with SOFA scores ≥8 had a significantly lower SZL compared to those with SOFA scores <8 (p < 0.001). The SZL in the DIC group (JAAM DIC score ≥4) was significantly lower than that in the non-DIC group (JAAM DIC score <4) (p < 0.001). Analysis of receiver operating characteristic (ROC) curves for prediction of sepsis-induced DIC based on SZL in patients with sepsis showed a cut-off value of 25 µg/dL for zinc level and a sensitivity of 63% and a specificity of 72% with AUC of 0.7 (p = 0.0065). CONCLUSION: We observed that SZL reflects organ failure, particularly coagulopathy, in patients with sepsis.
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Coagulación Intravascular Diseminada/diagnóstico , Coagulación Intravascular Diseminada/etiología , Sepsis/complicaciones , Sepsis/diagnóstico , Zinc/sangre , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Curva ROC , Sensibilidad y EspecificidadRESUMEN
We observed an emerging resistance to ß-lactams in a P. ananatis bacteremia case. Whole genome sequence analysis detected two ß-lactamase genes as well as related genes that regulate the ß-lactamase genes in the chromosome. The induction experiment resulted in the expression of the class A ß-lactamase gene in the isolate.
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Bacteriemia , Pantoea , Bacteriemia/diagnóstico , Bacteriemia/tratamiento farmacológico , Humanos , Pantoea/genética , beta-Lactamas/farmacologíaRESUMEN
BACKGROUND: Large multicenter studies reporting on the association between the duration of broad-spectrum antimicrobial administration and the detection of multidrug-resistant (MDR) bacteria in the intensive care unit (ICU) are scarce. We evaluated the impact of broad-spectrum antimicrobial therapy for more than 72 h on the detection of MDR bacteria using the data from Japanese patients enrolled in the DIANA study. METHODS: We analyzed the data of ICU patients in the DIANA study (a multicenter international observational cohort study from Japan). Patients who received empirical antimicrobials were divided into a broad-spectrum antimicrobial group and a narrow-spectrum antimicrobial group, based on whether they received broad-spectrum antimicrobials for more or less than 72 h, respectively. Differences in patient characteristics, background of infectious diseases and empirical antimicrobial administration, and outcomes between the two groups were compared using the chi-square tests (Monte Carlo method) for categorical variables and the Mann-Whitney U-test for continuous variables. We also conducted a logistic regression analysis to investigate the factors associated with the detection of new MDR bacteria. RESULTS: A total of 254 patients from 31 Japanese ICUs were included in the analysis, of whom 159 (62.6%) were included in the broad-spectrum antimicrobial group and 95 (37.4%) were included in the narrow-spectrum antimicrobial group. The detection of new MDR bacteria was significantly higher in the broad-spectrum antimicrobial group (11.9% vs. 4.2%, p = 0.042). Logistic regression showed that broad-spectrum antimicrobial continuation for more than 72 h (OR [odds ratio] 3.09, p = 0.047) and cerebrovascular comorbidity on ICU admission (OR 2.91, p = 0.041) were associated with the detection of new MDR bacteria. CONCLUSIONS: Among Japanese ICU patients treated with empirical antimicrobials, broad-spectrum antimicrobial usage for more than 72 h was associated with the increased detection of new MDR bacteria. Antimicrobial stewardship programs in ICUs should discourage the prolonged use of empirical broad-spectrum antimicrobial therapy. Trial registration ClinicalTrials.gov, NCT02920463, Registered 30 September 2016, https://clinicaltrials.gov/ct2/show/NCT02920463.
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Antiinfecciosos , Infección Hospitalaria , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Antiinfecciosos/farmacología , Antiinfecciosos/uso terapéutico , Bacterias , Infección Hospitalaria/microbiología , Humanos , Unidades de Cuidados Intensivos , Japón/epidemiología , Estudios RetrospectivosRESUMEN
AIM: Our previous report indicated that plasminogen activator inhibitor-1 (PAI-1) levels of ≥83 ng/mL in patients with sepsis tended to be associated with disseminated intravascular coagulation (DIC), suppressed fibrinolysis, multiple organ dysfunction, and mortality. Therefore, the present study aimed to validate whether 83 ng/mL was a useful cut-off value for using PAI-1 levels to predict a poor prognosis in sepsis. METHODS: Patients with sepsis were included in this single-center retrospective study. The patients were classified as having high or low PAI-1 values (<83 ng/mL versus ≥83 ng/mL), and were compared in terms of their pre-DIC state, intensive care unit-free days, continuous renal replacement therapy-free days, ventilator-free days, catecholamine-free days, and 28-day survival rate. RESULTS: The high PAI-1 group included 61 patients (54%) and the low PAI-1 group included 52 patients (46%). The high PAI-1 group had significantly higher frequencies of a pre-DIC state within 1 week (P = 0.009). There was no significant difference in ventilator-free days. However, the high PAI-1 group had significantly lower values for intensive care unit-free days (P = 0.01), continuous renal replacement therapy-free days (P = 0.02), and catecholamine-free days (P = 0.02). The high PAI-1 group also had a significantly lower 28-day survival rate based on the Kaplan-Meier analysis (log-rank, P = 0.03). CONCLUSION: Patients with sepsis and PAI-1 levels of ≥83 ng/mL had elevated risks of coagulopathy, organ failure, and mortality. Thus, these results suggest that 83 ng/mL could be a useful cut-off value for prognostication based on PAI-1 levels in this setting.
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BACKGROUND: Levels of the biomarkers presepsin and procalcitonin are affected by renal function. We evaluated the accuracies of presepsin and procalcitonin levels for diagnosing sepsis in patients with and without acute kidney injury (AKI). METHODS: We evaluated patients with presepsin and procalcitonin data, and classified them into AKI and non-AKI groups based on the Kidney Disease Improving Global Outcomes criteria. Each group was then subdivided according to sepsis status for each stage of AKI. Receiver operating characteristic curve analyses were used to investigate the accuracies of biomarker levels for diagnosing sepsis. RESULTS: In the non-AKI group, the area under the curves (AUCs) for procalcitonin and presepsin levels were 0.897 and 0.880, respectively (pâ¯=â¯.525) and optimal cut-off values were 0.10â¯ng/ml (sensitivity: 85.1%, specificity: 79.1%) and 240â¯pg/ml (sensitivity: 80.9%, specificity: 83.2%), respectively. In the stage 3 subgroup, the AUC for procalcitonin (0.946) was significantly higher than that for presepsin (0.768, pâ¯<â¯.001). The optimal cut-off values for diagnosing sepsis were 4.07â¯ng/ml (sensitivity: 87.2%, specificity: 93.5%) for procalcitonin and 500â¯pg/ml (sensitivity: 89.7%, specificity: 59.7%) for presepsin. CONCLUSIONS: In patients with severe AKI, the accuracy of the diagnosis of sepsis with procalcitonin was significantly higher than with presepsin.
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Lesión Renal Aguda/complicaciones , Límite de Detección , Receptores de Lipopolisacáridos/metabolismo , Fragmentos de Péptidos/metabolismo , Polipéptido alfa Relacionado con Calcitonina/metabolismo , Sepsis/diagnóstico , Sepsis/metabolismo , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sepsis/complicacionesRESUMEN
We herein report a case of systemic phaeohyphomycosis by Exophiala dermatitidis (E. dermatitidis) with chronic graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). The patient had been taking oral corticosteroids for years to control the GVHD. Yeast-like fungi were identified in a blood culture, so treatment with micafungin (150 mg/day) was begun, with no improvement. The patient passed away on hospital Day 12. A sequence analysis of rRNA revealed the isolate to be E. dermatitidis. This report brings attention to an emerging mycosis of community-acquired Exophiala species infection in the very-late phase after allogenic HSCT in patients with chronic GVHD.
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Exophiala/aislamiento & purificación , Fascitis Necrotizante/diagnóstico , Enfermedad Injerto contra Huésped/complicaciones , Trasplante de Células Madre Hematopoyéticas/efectos adversos , Feohifomicosis/diagnóstico , Enfermedad Crónica , Fascitis Necrotizante/etiología , Femenino , Humanos , Feohifomicosis/etiología , Adulto JovenRESUMEN
Recently, augmented renal clearance (ARC), which accelerates glomerular filtration of renally eliminated drugs thereby reducing the systemic exposure to these drugs, has started to receive attention. However, the clinical features associated with ARC are still not well understood, especially in the Japanese population. This study aimed to evaluate the clinical characteristics and outcomes of ARC patients with infections in Japanese intensive care unit (ICU) settings. We conducted a retrospective observational study from April 2013 to May 2017 at two tertiary level ICUs in Japan, which included 280 patients with infections (median age 74 years; interquartile range, 64-83 years). We evaluated the estimated glomerular filtration rate (eGFR) at ICU admission using the Japanese equation, and ARC was defined as eGFR >130 mL/min/1.73 m2. Multivariable logistic regression analysis was performed to identify the independent risk factors for ARC and to determine if it was a predictor of ICU mortality. In addition, a receiver operating curve (ROC) analysis was performed, and the area under the ROC (AUROC) was determined to examine the significant variables that predict ARC. In total, 19 patients (6.8%) manifested ARC. Multivariable logistic regression analysis identified younger age as an independent risk factor for ARC (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.91-0.96). However, ARC was not found to be a predictor of ICU mortality (OR, 0.57; 95% CI, 0.11-2.92). In addition, the AUROC of age was 0.79 (95% CI, 0.68-0.91), and the optimal cut off age for ARC was ≤63 years (sensitivity, 68.4%; specificity, 78.9%). The incidence of ARC was, therefore, low among patients with infections in the Japanese ICUs. Although younger age was associated with the incidence of ARC, it was not an independent predictor of ICU mortality.
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Infecciones/metabolismo , Infecciones/terapia , Adulto , Anciano , Anciano de 80 o más Años , Cuidados Críticos , Tasa de Filtración Glomerular , Humanos , Incidencia , Infecciones/diagnóstico , Infecciones/mortalidad , Unidades de Cuidados Intensivos , Riñón/metabolismo , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
INTRODUCTION: Candidaemia, recognised as a fairly common disease among intensive care unit (ICU) patients, carries a poor prognosis. However, as studies on the prognostic factors associated with candidaemia in ICU patients are limited, this study aimed to establish the best prognostic factor for ICU patients with candidaemia in a tertiary care hospital in Japan. METHODS: We conducted a retrospective cohort study of patients with candidaemia in the emergency ICU at Fukuoka University Hospital, Fukuoka, Japan, from April 2010 to March 2015. Demographic and clinical data was collected from the patients' medical records and laboratory databases. RESULTS: A total of 25 patients were included in the study. However, 18 patients died during hospitalisation, resulting in an in-hospital mortality rate of 72.0%. The variables of Sequential Organ Failure Assessment (SOFA) score and cumulative number of risk factors for invasive candidiasis showed significant differences between patients in the survivor and non-survivor groups (p < 0.05). The areas under the receiver operating characteristic curves for the SOFA score and cumulative number of risk factors for invasive candidiasis were 0.873 (95% confidence interval [CI] 0.72-1.00) and 0.937 (95% CI 0.84-1.00), respectively. CONCLUSION: Our results suggest that the cumulative number of risk factors for invasive candidiasis was the most useful prognostic indicator for candidaemia in ICU patients.
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Candidemia/epidemiología , Medición de Riesgo/métodos , Adulto , Anciano , Anciano de 80 o más Años , Candida/aislamiento & purificación , Candidemia/diagnóstico , Candidemia/mortalidad , Candidemia/terapia , Femenino , Humanos , Unidades de Cuidados Intensivos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Pronóstico , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Centros de Atención Terciaria , Adulto JovenRESUMEN
BACKGROUND: Sepsis is one of the most significant causes of mortality in intensive care units. It indicates crosstalk between inflammation and coagulation. In this study, we aimed to identify prognostic markers among sepsis biomarkers and coagulation/fibrinolysis markers. METHODS: Patients with sepsis according to the Sepsis-3 criteria were enrolled from January 2013 to September 2015. Univariate and multivariate logistic regression analyses were performed to identify an independent predictive marker of 28-day mortality among sepsis biomarkers and coagulation/fibrinolysis markers on ICU admission. Receiver operating characteristic analysis was performed; the optimal cutoff value of 28-day mortality was calculated using the predictive marker. Patients were classified into two groups according to the cutoff level of the predictive marker. Patient characteristics were compared between the groups. RESULTS: A total of 186 patients were enrolled in this study; the 28-day mortality was 19.4% (36/186). PAI-1 was identified as the only independent predictive marker of 28-day mortality by univariate and multivariate logistic regression. The area under the curve was 0.72; the optimal cutoff level was 83 ng/ml (sensitivity, 75%; specificity, 61%). Patients were classified into a higher group (PAI-1 level ≥83 ng/ml; n = 85) and a lower group (PAI-1 level <83 ng/ml; n = 101). All disseminated intravascular coagulation (DIC) scores and Sequential Organ Failure Assessment score were significantly higher in the higher group than in the lower group. CONCLUSIONS: PAI-1 can predict prognosis in sepsis patients. PAI-1 reflects DIC with suppressed fibrinolysis and organ failure, with microthrombi leading to microcirculatory dysfunction.
RESUMEN
Case: A 75-year-old woman presented with a 10-day history of intermittent fever, general fatigue, and progressive dyspnea. Although she had a low PaO2/FIO2 ratio, the cause of acute respiratory distress syndrome was not clear until day 9 in hospital. Outcome: We treated the patient with direct hemoperfusion with a polymyxin B-immobilized fiber column incidentally; the PaO2/FIO2 ratio improved following this therapy. Acid-fast bacilli, which were not seen in the sputum on admission, were detected in cultures from sputum, urine, bone marrow, liver biopsy, and blood samples, with a real-time polymerase chain reaction assay confirming tuberculosis. She was immediately transferred to a specialized tuberculosis hospital, and after a 3-month treatment, was discharged. Conclusion: Treatment with polymyxin B-immobilized fiber column may provide good results for pulmonary oxygenation in acute respiratory distress syndrome caused by tuberculosis.
RESUMEN
BACKGROUND: Augmented renal clearance (ARC) of circulating solutes and drugs has been recently often reported in intensive care unit (ICU) patients. However, only few studies on ARC have been reported in Japan. The aims of this pilot study were to determine the prevalence and risk factors for ARC in Japanese ICU patients with normal serum creatinine levels and to evaluate the association between ARC and estimated glomerular filtration rate (eGFR) calculated using the Japanese equation. METHODS: We conducted a prospective observational study from May 2015 to April 2016 at the emergency ICU of a tertiary university hospital; 111 patients were enrolled (mean age, 67 years; interquartile range, 53-77 years). We measured 8-h creatinine clearance (CLCR) within 24 h after admission, and ARC was defined as body surface area-adjusted CLCR ≥ 130 mL/min/1.73 m2. Multiple logistic regression analysis was performed to identify the risk factors for ARC. Moreover, a receiver operating curve (ROC) analysis, including area under the receiver operating curve (AUROC) was performed to examine eGFR accuracy and other significant variables in predicting ARC. RESULTS: In total, 43 patients (38.7 %) manifested ARC. Multiple logistic regression analysis was performed for age, body weight, body height, history of diabetes mellitus, Acute Physiology and Chronic Health Evaluation II scores, admission categories of post-operative patients without sepsis and trauma, and serum albumin, and only age was identified as an independent risk factor for ARC (odds ratio, 0.95; 95 % confidence interval [CI], 0.91-0.98). Moreover, the AUROC of ARC for age and eGFR was 0.81 (95 % CI, 0.72-0.89) and 0.81 (95 % CI, 0.73-0.89), respectively. The optimal cutoff values for detecting ARC were age and eGFR of ≤63 years (sensitivity, 72.1 %; specificity, 82.4 %) and ≥76 mL/min/1.73 m2 (sensitivity, 81.4 %; specificity, 72.1 %), respectively. CONCLUSIONS: ARC is common in Japanese ICU patients, and age was an independent risk factor for ARC. In addition, age and eGFR calculated using the Japanese equation were suggested to be useful screening tools for identifying Japanese patients with ARC.
RESUMEN
INTRODUCTION: Few studies have investigated the effect of increased creatinine clearance (CrCl) on linezolid (LZD) concentration. Herein, we report the pharmacokinetic/pharmacodynamic (PK/PD) profile of LZD used in the management of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia with concomitant bacteremia in a patient with high CrCl caused by diabetes insipidus (DI). CASE REPORT: A 19-year-old man was admitted to the intensive care unit following a traumatic brain injury. After admission, he underwent a craniotomy for the severe brain injury. However, he developed DI after the operation. Despite treatment with vasopressin, his urine output reached 5-6 L/day as a result of the DI, and his CrCl increased to 180-278 mL/min. We were required to administer 6-7 L of fluid a day to compensate for the high urinary fluid output. On day 55, MRSA pneumonia with sepsis was suspected and, consequently, LZD was administrated intravenously (600 mg every 12 h). He was treated with LZD for 14 days. The patient has since successfully recovered from MRSA pneumonia with concomitant bacteremia, and was transferred to the general ward on day 82. Blood LZD levels from days 60-68, which were measured after the patient's transfer to the general ward, showed that the trough levels were lower than the threshold level of detection. The blood 24-h area under the plasma LZD concentration-time curve (AUC)24/minimum inhibitory concentration (MIC) was 69.3. CONCLUSION: In spite of the low level of LZD AUC24/MIC caused by the high CrCl with DI, MRSA pneumonia with concomitant bacteremia was successfully treated with LZD.