Steatotic Liver Disease and Sepsis Outcomes-A Prospective Cohort Study (SepsisFAT).

Background: While it has been shown that steatotic liver disease (SLD) is associated with systemic changes in immune response, the impact of SLD on sepsis outcomes has not yet been established. The aim of this study was to investigate the association between SLD and sepsis severity and outcomes. Methods: A prospective observational study included consecutively hospitalized adult patients with community-acquired sepsis during a 16-month period. Results: Of the 378 included patients (49.5% male, median age of 69, IQR 57-78 years), 174 (46%) were diagnosed with SLD. Patients with SLD were older and more frequently fulfilled the criteria for metabolic syndrome. There were no differences in the source and etiology of sepsis between the groups. Patients with SLD exhibited a higher incidence of acute kidney injury (29.3% vs. 17.6%), the need for renal replacement therapy (16.1% vs. 8.8%), and more frequent use of invasive mechanical ventilation (29.3% vs. 18.1%). In-hospital mortality was significantly higher in the SLD group (18.39% vs. 9.8%). The multivariable analysis indicated that SLD was associated with mortality (HR 2.82, 95% CI 1.40-5.71) irrespective of the other elements within metabolic syndrome. Conclusions: SLD might be associated with higher sepsis in-hospital mortality, and more frequent development of acute kidney and respiratory insufficiency requiring more critical care support.

Hantavirus Pulmonary Syndrome Caused by Puumala Orthohantavirus-A Case Report and Literature Review.

In this article, we report on a rare case of acute respiratory distress syndrome (ARDS) caused by the Puumala orthohantavirus (PUUV), which is typically associated with hemorrhagic fever with renal syndrome (HFRS). This is the first documented case of PUUV-associated ARDS in Southeast Europe. The diagnosis was confirmed by serum RT-PCR and serology and corroborated by phylogenetic analysis and chemokine profiling. The patient was a 23-year-old male from Zagreb, Croatia, who had recently traveled throughout Europe. He presented with fever, headache, abdominal pain, and sudden onset of ARDS. Treatment involved high-flow nasal cannula oxygen therapy and glucocorticoids, which resulted in a full recovery. A systematic literature review identified 10 cases of hantavirus pulmonary syndrome (HPS) caused by PUUV in various European countries and Turkey between 2002 and 2023. The median age of patients was 53 years (range 24-73), and six of the patients were male. Most patients were treated in intensive care units, but none received antiviral therapy targeting PUUV. Eight patients survived hospitalization. The presented case highlights the importance of considering HPS in the differential diagnosis of ARDS, even in areas where HFRS is the dominant form of hantavirus infection.

Extracorporeal membrane oxygenation in COVID-19: Results of the Croatian Extracorporeal Membrane Oxygenation Referral Center.

At the beginning of the COVID-19 pandemic, the role of extracorporeal membrane oxygenation (ECMO) was uncertain and the outcomes of ECMO-treated patients were unfavorable. During the pandemic, medical community realized that carefully selected patients may benefit from ECMO support. The goal of the study was to present the outcomes of ECMO-treated patients with severe COVID-19 ARDS referred to the respiratory ECMO hub in Croatia and to determine variables that influenced the outcome. Our study included all adult patients with confirmed COVID-19 ARDS that required ECMO treatment, in the period between February 2020 and April 2022. All ECMO circuits were veno-venous with femoro-jugular configuration, with drainage at the femoral site. A total of 112 adult patients with COVID-19 induced ARDS were included in the study. All patients had veno-venous ECMO treatment and 34 survived. Surviving patients were discharged home either from the hospital or from a designated rehabilitation facility. The mortality was associated with the incidence of nosocomial bacteremia, occurrence of heparin induced thrombocytopenia and acute renal failure. In order to reduce the mortality in COVID-19 ECMO patients, the treatment should be started as soon as criteria for ECMO are met. Furthermore, complications of the procedure should be detected as soon as possible. However, despite even the optimal approach, the mortality in COVID-19 ECMO patients will surpass that of non-COVID-19 ARDS ECMO patients, mostly due to poor resolving and long lasting ARDS with longer ECMO runs and ensuing infectious complications.

Etiology and Outcomes of Healthcare-Associated Meningitis and Ventriculitis-A Single Center Cohort Study.

Healthcare associated meningitis and ventriculitis (HCAMV) are serious complications of neurosurgical procedures. We conducted a retrospective cohort study of patients with HCAMV treated at the University Hospital for Infectious Diseases Zagreb during the 2013-2019 period. A total of 144 patients with 151 episodes of HCAMV were included. The most common indications for neurosurgical procedures were brain tumor, hemorrhage and hydrocephalus. Etiology was identified in 90 (59.6%) episodes (either positive CSF culture or positive PCR), and in other 61 (40.39%) the diagnosis of HCAMV was made based on clinical and CSF parameters, without microbiologic confirmation. Carbapenem-resistant Acinetobacter baumannii was the most common pathogen (15.89%), followed by Staphylococcus aureus (13.91%), Pseudomonas aeruginosa (13.25%) and Coagulase negative staphylococci (7.95%). Overall, 24 (16.3%) patients died, and the majority had adverse outcomes, persistent vegetative state (8, 5.56%) and severe disability (31, 21.53%). The worst clinical outcomes were observed in A. baumannii infections. High rate of complications, the need for external ventricular drainage (re)placement often complicated with nosocomial infections and prolonged stay in intensive care units were observed. Clinicians should be aware of local microbial epidemiology on guiding proper empirical antimicrobial treatment in patients with HCAMV.

Extracorporeal membrane oxygenation for the treatment of ARDS in Covid-19 and influenza patients: Does etiology matter?

At the beginning of the COVID 19 pandemic, the outcome of patients treated with ECMO was discouraging. Subsequently, it became clear that a certain group of patients may benefit from ECMO treatment. The primary objective of this study was to compare the outcome of ECMO treatment in COVID-19 and influenza patients referred to a tertiary care center. A total of 119 adult patients required ECMO treatment following ARDS secondary to H1N1 (49) and SARS-CoV-2 (70) in the referral ECMO Center based in Zagreb between October 2009 and October 2021. Our study revealed a significantly higher mortality in COVID-19 patients compared to H1N1 influenza when the onset of ARDS was severe enough to require ECMO support. Based on these results and current knowledge, we argue that ECMO treatment for ARDS in COVID-19 patients is more challenging compared to H1N1 influenza patients. Therefore, referral to the most experienced ECMO centers should be considered. Additionally, patient selection and timing for ECMO treatment play a key role in relation to outcome. Mortality rate in COVID-19 patients requiring ECMO treatment may be used as a reference frame for ECMO centers to ensure best possible care and outcome.

Severe West Nile Virus Neuroinvasive Disease: Clinical Characteristics, Short- and Long-Term Outcomes.

West Nile Virus Neuroinvasive Disease (WNV NID) requires prolonged intensive care treatment, resulting in high mortality and early disability. Long-term results are lacking. We have conducted an observational retrospective study with a prospective follow-up of WNV NID patients treated at the Intensive Care Unit (ICU), University Hospital for Infectious Diseases, Zagreb, Croatia, 2013-2018. Short-term outcomes were vital status, length of stay (LOS), modified Rankin Scale (mRS), and disposition at discharge. Long-term outcomes were vital status and mRS at follow-up. Twenty-three patients were identified, 78.3% males, median age 72 (range 33-84) years. Two patients (8.7%) died in the ICU, with no lethal outcomes after ICU discharge. The median ICU LOS was 19 days (range 5-73), and the median hospital LOS was 34 days (range 7-97). At discharge, 15 (65.2%) patients had moderate to severe/mRS 3-5, 6 (26.0%) had slight disability/mRS 2-1, no patients were symptom-free/mRS 0. Ten (47.6%) survivors were discharged to rehabilitation facilities. The median time to follow-up was nine months (range 6-69). At follow-up, seven patients died (30.5%), five (21.7%) had moderate to severe/mRS 3-5, one (4.3%) had slight disability/mRS 2-1, six (26.1%) had no symptoms/mRS 0, and four (17.4%) were lost to follow-up. Briefly, ten (43.5%) survivors improved their functional status, one (4.3%) was unaltered, and one (4.3%) aggravated. In patients with severe WNV NID, intensive treatment in the acute phase followed by inpatient rehabilitation resulted in significant recovery of functional status after several months.

The Impact of Nonalcoholic Fatty Liver Disease on Severe Community-Acquired Pneumonia Outcomes.

Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality, while nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. NAFLD is associated with systemic changes in immune response, possibly linked to CAP severity. However, the impact of NAFLD on CAP outcomes has not been determined. The aim of this study was to evaluate clinical course, complications and outcomes of severe CAP requiring ICU treatment in patients with NAFLD in the pre-COVID-19 era. A retrospective cohort study included 138 consecutively hospitalized adult patients with severe CAP admitted to the ICU during a 4-year period: 80 patients with NAFLD and 58 controls. Patients with NAFLD more frequently presented with ARDS (68.7% vs. 43.1%), and required invasive mechanical ventilation (86.2% vs. 63.8%), respiratory ECMO (50% vs. 24.1%), and continuous renal replacement therapy (62.5% vs. 29.3%). Mortality was significantly higher in the NAFLD group (50% vs. 20.7%), and the time from hospital admission to death was significantly shorter. In survival analysis, NAFLD (HR 2.21, 95%CI 1.03-5.06) was associated with mortality independently of other components of metabolic syndrome. In conclusion, our study identified NAFLD as an independent predictor of mortality in patients with severe CAP.

Trying to Survive A Serious Heart Condition in Time of COVID-19.

The world has suffered over the past year under COVID-19. Unfortunately, people still are getting sick from other, also severe, diseases. Although the COVID-19 infection is present, patients need treatment for other life-threatening conditions. We present the case of a 36-year-old patient with severe infective endocarditis with a large abscess of the aortic root, who also is COVID-19 positive. Definitive diagnostics and treatment were avoided due to COVID-19 infection. In the end, emergent surgery was indicated due to acute cardiac decompensation and the development of heart failure symptoms, and the patient recovered uneventfully after surgery.

A retrospective comparison between influenza and COVID-19-associated ARDS in a Croatian tertiary care center.

BACKGROUND: Since the beginning of the Corona virus disease 2019 (COVID-19) pandemic the new Severe acute respiratory syndrome coronoavirus 2 (SARS-CoV­2) virus has been repeatedly compared to the influenza virus; however, the comparison of invasively mechanically ventilated patients with acute respiratory distress syndrome (ARDS) caused by these viruses is very scarce. The purpose of this study was to compare clinical course and laboratory parameters between the most severely ill flu and COVID 19 patients treated with invasive mechanical ventilation (IMV). METHODS: The study was conducted at the intensive care unit (ICU) of the tertiary care hospital in Zagreb, Croatia in the period between November 2018 and July 2020. Investigation included 72 adult patients requiring IMV due to influenza or SARS-CoV­2 virus infection and 42 patients had influenza and 30 had SARS-CoV­2 virus infection and the comparison between two etiological groups was conducted. RESULTS: Invasively mechanically ventilated patients with COVID 19 and influenza differ in certain aspects. COVID 19 patients are older, male, have lower C-reactive protein (CRP) levels and have less need for extracorporeal membrane oxygenation (ECMO) support. In other measured variables, including mortality, the difference between influenza or SARS-CoV­2 etiology was not significant. CONCLUSION: High mortality of IMV patients with influenza and COVID 19 with 55% and 63%, respectively, challenges and urges medical and especially ICU community to expand our quest for further treatments, especially since ECMO use that is scarcely required in COVID 19 patients probably has limited impact in reducing mortality in COVID 19 patients.

Cauda equina arachnoiditis - a rare manifestation of West Nile virus neuroinvasive disease: A case report.

BACKGROUND: Data regarding the neuroradiology features of the West Nile virus neuroinvasive disease (WNV NID) is rather scarce. To contribute to the knowledge of the WNV NID, we present a patient with a combination of encephalitis and acute flaccid paresis, with cauda equina arachnoiditis as the main magnetic resonance (MR) finding. CASE SUMMARY: A 72-year-old female patient was admitted due to fever, headache and gait instability. During the first several days she developed somnolence, aphasia, urinary incontinence, constipation, and asymmetric lower extremities weakness. Cerebrospinal fluid analysis indicated encephalitis. Native brain computed tomography and MR were unremarkable, while spinal MR demonstrated cauda equina enhancement without cord lesions. Virology testing revealed WNV IgM and IgG antibodies in serum and cerebrospinal fluid, which confirmed acute WNV NID. The treatment was supportive. After two months only a slight improvement was noticed but cognitive impairment, loss of sphincter control and asymmetric inferior extremities weakness remained. The patient died after a month on chronic rehabilitation. CONCLUSION: Cauda equina arachnoiditis is a rare, but possible neuroradiological feature in acute flaccid paresis form of WNV NID.

Chronic meningoencephalitis caused by Echo virus 6 in a patient with common variable immunodeficiency : Successful treatment with pleconaril.

Chronic enteroviral meningoencephalitis, most commonly caused by echoviruses, can particularly be seen in agammaglobulinemic patients. In spite of the fact that no specific treatment for enteroviral infections exists, pleconaril is an antiviral drug reported to be efficient against enteroviral infections in infants and adults. We present a case of a 42-year-old male, previously diagnosed with common variable immunodeficiency, who presented with severe chronic meningoencephalitis caused by Echo virus 6 and was successfully treated with pleconaril. Enteroviruses usually cause mild symptoms, but some strains can cause life-threatening conditions especially in immunocompromised patients. Although pleconaril production is unprofitable due to the rarity of severe disease, our effective treatment should encourage further availability of pleconaril.

Intensive care unit patients with lower respiratory tract nosocomial infections: the ENIRRIs project.

The clinical course of intensive care unit (ICU) patients may be complicated by a large spectrum of lower respiratory tract infections (LRTI), defined by specific epidemiological, clinical and microbiological aspects. A European network for ICU-related respiratory infections (ENIRRIs), supported by the European Respiratory Society, has been recently established, with the aim at studying all respiratory tract infective episodes except community-acquired ones. A multicentre, observational study is in progress, enrolling more than 1000 patients fulfilling the clinical, biochemical and radiological findings consistent with a LRTI. This article describes the methodology of this study. A specific interest is the clinical impact of non-ICU-acquired nosocomial pneumonia requiring ICU admission, non-ventilator-associated LRTIs occurring in the ICU, and ventilator-associated tracheobronchitis. The clinical meaning of microbiologically negative infectious episodes and specific details on antibiotic administration modalities, dosages and duration are also highlighted. Recently released guidelines address many unresolved questions which might be answered by such large-scale observational investigations. In light of the paucity of data regarding such topics, new interesting information is expected to be obtained from our network research activities, contributing to optimisation of care for critically ill patients in the ICU.

Quadruple-valve infective endocarditis caused by Abiotrophia defectiva.

Quadruple-valve endocarditis is a challenging condition, for which there is limited treatment experience and poor overall survival. We report the first case caused by Abiotrophia defectiva that has been surgically treated both with the replacement of the aortic and pulmonary valves and the repair of the mitral and tricuspid valves with a good outcome. The patient's clinical course is described and a review of literature on this rare causative agent is given.

Development of the first adult respiratory extracorporeal membrane oxygenation center in Croatia under emergency circumstances.

INTRODUCTION: We report on the challenges of establishing a successful adult respiratory extracorporeal membrane oxygenation (ECMO) center in a developing country like Croatia under emergency conditions. We further introduce measures that would improve the outcome of patients treated with ECMO for respiratory failure at the national level. METHODS: 100 consecutive adult patients treated with venovenous (VV) ECMO for acute respiratory failure were enrolled to the database prospectively from October 2009 until June 2016. A review of methodology in establishing an adult respiratory ECMO center is provided. RESULTS: 7 years after the establishment of the first respiratory ECMO center in Croatia the hospital mortality was 44% and ECMO procedure survival was 71%. With this data, our results are comparable to an average extracorporeal life support organization (ELSO) center. CONCLUSIONS: Our results demonstrate that a successful adult respiratory ECMO center can be established under emergency conditions even in less developed countries like Croatia. Today Croatia's respiratory ECMO network is insufficiently organized and the Ministry of Health should provide a comprehensive, national, ECMO network strategy. Currently, and contrary to the opinion of the world's leading experts, any hospital in Croatia is allowed to perform the ECMO procedure without any control or validation. Only if health-policy makers in Croatia reconsider this issue will we be able to provide the best care possible for respiratory ECMO patients at the national level.

Nosocomial blood stream infections in patients treated with venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome.

BACKGROUND: The incidence of complication rates in patients treated with venovenous extracorporeal membrane oxygenation (VV ECMO) remains substantial and impacts the results of any future trial dealing with ECMO efficacy. Of these complications blood stream infections (BSI) are less well studied. Our objective was to report influence of BSI in ARDS patients treated with VV ECMO. METHODS: One-hundred adult patients with ARDS treated with VV ECMO at the tertiary care hospital in Zagreb, Croatia between the October of 2009 and the June of 2016 were prospectively included in the study. RESULTS: In 35% of patients an episode of the nosocomial BSI during VV ECMO treatment was detected. ECMO duration of more than 250 hours and significant bleeding episode independently increase the possibility of acquiring BSI during an ECMO run (odds ratio 3.189, 95% confidence limits 1.108-9.180 and odds ratio 3.378, 95% confidence limits 1.055-10.869 respectively). BSI occurrence had no effect on mortality. CONCLUSIONS: Our study found that BSI incidence increases with the duration of an ECMO run and bleeding complications with no effect on hospital mortality. Further studies of BSI in this risk group should address the problem of rapid diagnosis and appropriate antimicrobial therapy in an era of growing multiresistance.

Venovenous extracorporeal membrane oxygenation for ARDS: outcome analysis of a Croatian referral center for respiratory ECMO.

BACKGROUND: The use of venovenous extracorporeal membrane oxygenation (VV-ECMO) as a rescue therapy in severe acute respiratory distress syndrome (ARDS) has become well established; however, the affirmation of evidence on VV-ECMO application and the analysis of patient outcomes after VV-ECMO treatment for ARDS continues. The aim of the study is to identify variables that affected the outcome of patients treated with VV-ECMO for severe ARDS outside a major ECMO center. METHODS: The study included adult patients with severe ARDS treated with ECMO at a tertiary care hospital in Zagreb, Croatia between October 2009 and July 2014. Patients were recruited from a prospective database. RESULTS: The study enrolled 40 patients, 20 of whom had H1N1-induced ARDS. The hospital mortality was 38%. The difference in mortality and long-term outcome in H1N1-induced ARDS as compared to non-H1N1-induced ARDS was not significant. Variables associated with mortality included immunosuppression, shock at time of admission, acute renal failure, occurrence of heparin-induced thrombocytopenia antibodies, nosocomial sepsis and duration of ECMO. CONCLUSIONS: The results of our study indicate that ECMO use in severe ARDS is feasible with low mortality and identify or assert the variables associated with adverse outcomes.

Extracorporeal membrane oxygenation treatment for H1N1-induced acute respiratory distress syndrome (ARDS): results of the Croatian Referral Center for Respiratory ECMO.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) has been effective in the treatment of H1N1-induced ARDS across the globe. However, the evidence supporting the use of ECMO in ARDS is still being collected. The intention of this study was to add a piece of puzzle to the growing body of evidence on the use of ECMO in ARDS patients. METHODS: The study included adult patients with H1N1-induced ARDS treated with ECMO at the University Hospital for Infectious Diseases in Zagreb, Croatia between October 2009 and December 2013. RESULTS: 17 patients with H1N1-induced ARDS treated with ECMO were included in the study. The patient cohort of the study was young with a median age of 43 years (range 23-74). The hospital mortality was 35%. Possible variables associated with mortality were analyzed and only hemolysis was found to be significant. CONCLUSIONS: Our results confirm the usefulness of ECMO treatment in patients with H1N1-induced ARDS.

Therapeutic hypothermia for adult community-acquired bacterial meningitis-historical control study.

OBJECTIVE: Despite advances in antibiotic therapy and critical care, community-acquired bacterial meningitis (CABM) continues to have poor outcome in a significant portion of patients. This study was designed to assess the efficacy of therapeutic hypothermia (TH) in the treatment of CABM. MATERIAL AND METHODS: In a period from January 2009 to January 2013, 41 enrolled patients with CABM were treated with TH. Their outcome was compared to 90 patients in the historical control group that were recruited from the existing database and included patients in a period between 1994 and 2008 with Glasgow coma scale score (GCS) ≤9 and respiratory failure. TH was indicated in patients with GCS ≤9, respiratory failure, and breath holding index ≤0.835 (measured with transcranial Doppler). If the acoustic window was absent, GCS ≤9 plus optic nerve sheath diameter of ≥6mm plus respiratory failure were indications for TH. RESULTS: Outcome variables were mortality and neurologic recovery measured with the Glasgow outcome scale (GOS). The incidence of hospital mortality (19.5% vs 48.9%, p=0.002) and adverse neurological outcome (GOS 1-3) (43.9% vs 65.6%, p=0.023) were significantly lower in patients treated with TH. Multivariate analysis confirmed the positive effect of TH on hospital mortality (OR=0.059, 95% CI 0.017-0.211) and risk of adverse neurological outcome (OR=0.209, 95% CI 0.082-0.534) after an adjustment for other risk factors of unfavorable patients' outcome. CONCLUSIONS: The new therapeutic concept based on hypothermia significantly improves the outcome in adult patients with severe CABM.

Acute pneumococcal myelitis in an adult patient.

Pneumococcal meningitis represents the most severe community-acquired bacterial meningitis. The disease is frequently associated with various complications. We present a case of pneumococcal meningitis in an immunocompetent adult patient treated with hypothermia. The disease course was complicated with severe myelitis and consequent paraplegia which is an extremely rare complication of pneumococcal disease.