Association between early manifestations of infection or sepsis and prognosis in a high complexity hospital in the city of Medellín.

OBJECTIVE: To identify the first symptoms and signs of patients with suspected infection or sepsis and their association with the composite outcome of admission to the Intensive Care Unit (ICU) or mortality. DESIGN: Prospective cohort study between June 2019 and March 2020. SETTING: Hospital Universitario San Vicente Fundación, Colombia. PATIENTS: Over 18 years of age with suspicion or confirmation of sepsis, which required hospitalization. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Symptoms and signs associated with infection, with their time of evolution, specified in the study. RESULTS: From 1005 eligible patients, 261 were included. After multivariable adjustment with a logistic regression model, the main factors for ICU admission or mortality were heart rate (OR 1.04 with 95% CI 1.04-3.7), respiratory rate (OR 1.19 with 95% CI 1.0-1.4) and capillary refill time (OR 3.4 with 95% CI 1.9-6.1). CONCLUSIONS: Heart rate, respiratory rate, and capillary refill may behave as early predictors of ICU admission and mortality in cases of sepsis.

Systematic review of the literature on reproducibility of the interpretation of renal biopsy in lupus nephritis.

Objective Before using a test, it should be determined whether the results are reliable. The reliability of the interpretation of renal biopsy in patients with lupus nephritis has not been clearly elucidated. Our objective was to estimate inter and intra-observer reliability of the histological classification, as well as activity and chronicity indices in renal biopsy of patients with lupus nephritis. Methods We conducted a systematic search of the literature, which included articles in any language, using PubMed, Embase, Cochrane and Lilacs databases. Search terms included were: reproducibility, reliability, agreement, systemic lupus erythematosus and lupus nephritis. Comparative studies with any design were included, regardless of the year or the language of publication. Two investigators, independently, screened the literature published in accordance with pre-established inclusion and exclusion criteria. Results We found 13 relevant studies. Inter-observer reproducibility of most measurements was moderate or low, despite the fact that, in most cases, the readings were made by expert nephropathologists. There was great diversity among designs, participants, including samples and outcomes evaluated in different studies. Although there are too many reports on the clinical use, studies evaluating the reliability of classifications on renal biopsy in lupus nephritis are rare. The quality of the methodological design and reporting was fair. Conclusion The interpretation of renal biopsy in lupus nephritis is poorly reproducible, causing serious doubts about its validity and its clinical application. As it can lead to serious diagnosis, treatment and prognosis errors, it is necessary to intensify research in this field.

Actualización en bacteriemia por Staphylococcus Aureus / Update on Staphylococcus aureus bacteremia / Atualização em bacteriémia por Staphylococcus aureus

El Staphylococcus aureus es un patógeno bacteriano de distribución mundial y es el principal responsable de las bacteriemias en numerosas áreas geográficas. Las tasas de resistencia a antibióticos han aumentado exponencialmente y diversos estudios han demostrado que las cepas resistentes ya no se limitan al ámbito hospitalario, con un aumento significativo de las infecciones adquiridas en la comunidad por bacterias meticilino-resistentes. La epidemiología de la infección es cambiante, lo que ha dificultado el enfoque inicial de los pacientes con bacteriemia por S. aureus, sumado a la cantidad de antibióticos relativamente limitada para su tratamiento. A pesar de los avances médicos y científicos, la mortalidad atribuible a esta infección ha permanecido estable durante los últimos años, por lo que se ha convertido en un problema para los sistemas de salud con un aumento considerable en los costos de atención. Es necesario realizar una actualización en este tópico para facilitar un tratamiento clínico adecuado de las bacteriemias por S. aureus.

Staphylococcus aureus is a bacterial pathogen that is distributed worldwide and is the main cause of bacteremia in numerous geographical regions. The rates of resistance to antibiotics have increased exponentially and various studies have demonstrated that the resistant strains are no longer limited to the hospital environment, as there has been a significant increase in community-acquired methicillin-resistant bacteria. The epidemiology of this infection is changing, which has made the initial management of patients with S. aureus bacteremia more complicated, as well as the relatively limited amount of antibiotics for treatment. Despite medical and scientific progress, mortality attributed to this infection has remained the same over the past years. Thus, it is becoming a problem for health systems that implies increased healthcare costs. It is necessary to update this topic in order to offer adequate clinical treatment for S. aureus bacteremia.

O Staphylococcus aureus é um patógeno bacteriano de distribuição mundial e é o principal responsável das bacteriémias em numerosas áreas geográficas. As taxas de resistência a antibióticos aumentaram exponencialmente e diversos estudos demostraram que as cepas resistentes já não se limitam ao âmbito hospitalário, com um aumento significativo das infecções adquiridas na comunidade por bactérias meticilino-resistentes. A epidemiologia da infecção é cambiante, o que há dificultado o enfoque inicial dos pacientes com bacteriémia por S. aureus, somado à quantidade de antibióticos relativamente limitada para seu tratamento. A pesar dos avanços médicos e científicos, a mortalidade atribuível a esta infecção há permanecido estável durante os últimos anos, pelo que se há convertido num problema para os sistemas de saúde com um aumento considerável nos custos de atenção. É necessário realizar uma atualização neste tópico para facilitar um tratamento clínico adequado das bacteriémias por S. aureus.

Validación de las escalas de APACHE II y SOFA en 2 cohortes de pacientes con sospecha de infección y sepsis, no ingresados en unidades de cuidados críticos / Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units

Objetivo: Validar los modelos pronósticos de las escalas APACHE II y SOFA en pacientes con sospecha de infección en escenarios diferentes de las unidades de cuidados intensivos. Materiales y métodos: Se realizó un análisis secundario de 2 estudios de cohortes que incluyó 2.530 pacientes adultos con sepsis o sospecha de la misma, atendidos en las primeras 24 h de su ingreso en salas de hospitalización o servicios de urgencias. Se evaluó el desempeño de ambos sistemas de puntuación para establecer calibración y discriminación, respectivamente, en los desenlaces primarios como la mortalidad intrahospitalaria y a los 28 días, y secundarios como la necesidad de ingreso en Unidad de Cuidados Intensivos, desarrollo de shock séptico y disfunción orgánica múltiple. Resultados: Los valores de AUC-ROC para mortalidad al alta hospitalaria y el día 28 en la primera cohorte estuvieron alrededor de 0,50 para SOFA y APACHE II, mientras que para la segunda cohorte el valor de discriminación fue de alrededor de 0,70. La calibración de ambos sistemas de puntuación para desenlaces primarios, según la prueba de Hosmer-Lemeshow, mostró un valor p > 0,05 en la primera cohorte, mientras que en la segunda cohorte la calibración solo tuvo un valor p > 0,05 en el caso del SOFA para mortalidad al alta hospitalaria. Conclusión: El estudio de validación de los sistemas de puntuación SOFA y APACHE II en los pacientes con sospecha de sepsis en el contexto hospitalario fuera de la Unidad de Cuidados Intensivos evidenció un rendimiento inadecuado para calibración y discriminación; su aplicación en salas de urgencias y hospitalización es limitada (AU)

Objetive: To validate the APACHE II and SOFA scores in patients with suspected infection in clinical settings otrher than intensive care units. Materials and Methods: a secundary analisis was performed on 2,530 adult patiens participating in 2 cohort studies, with suspected infection as admission diagnosis within the first 24h of hospitalitation. The perfomance of both scoring systems was studied in order to set calibration and discrimination, respectively, on the outcomes such as mortality, admission to intensive Care Unit, development of septic shoch, or multiple organ dysfunctions. Results: The AUC-ROC values for mortality at discharge and day 28 in the first cohort were around 0.50 for APACHE II and SOFA scores, whereas for the second cohort the discrimination value was around 0.70.Calibration of both scoring systems for primary outcomes, according to the Hosmer-Lemeshow test showed a p-value> 0.05 in the first cohort, while in the second cohort calibration it only showed a p-value> 0.05 in the case of SOFA for mortality at hospital discharge. Conclusion: The validation study systems SOFA and APACHE II score in patients with suspected sepsis in the hospital setting outside the ICU showed poor performance calibration and discrimination, their application in emergency rooms and hospitalization is limited (AU)

Incidence and risk factors for cytomegalovirus disease in a Colombian cohort of kidney transplant recipients.

Incidence and risk factors for cytomegalovirus (CMV) disease in a Colombian cohort of kidney transplant recipients. CMV infection and disease are important causes of morbidity and mortality in kidney transplant recipients, and its prevalence varies with economic, geographic, and ethnic factors. Among 1620 records from a Colombian reference center, CMV immunoglobulin (Ig)G seroprevalence was found to be 90.9% among recipients and 90.2% among donors. In 86% (n = 264) of the cases, CMV disease occurred during the first 6 months after the transplantation, and the most frequent clinical presentation was CMV syndrome, followed by gastrointestinal disease. The following parameters were independent predictors of CMV disease: serological status of D+/R+ (hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.03-2.63) and D+/R- (HR, 2.72; 95% CI, 1.49-4.93), age of the recipient (HR, 1.02; 95% CI, 1.01-1.03), and receiving more than 30 mg of prednisolone by the end of the first month after transplantation (HR, 1.59; 95% CI, 1.22-2.07). Acyclovir prophylaxis or other antiviral agents significantly decreased the risk of disease (HR, 0.41; 95% CI, 0.29-0.58 and HR, 0.34; 95% CI, 0.20-0.58, respectively). In conclusion, we found a high prevalence of CMV infection in a cohort of Latin American transplant recipients. In accord with findings from other regions, serological status is the main risk factor, prophylaxis with acyclovir is effective, and induction with alemtuzumab does not increase the risk of CMV disease.

[Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units]. / Validación de las escalas de APACHE II y SOFA en 2 cohortes de pacientes con sospecha de infección y sepsis, no ingresados en unidades de cuidados críticos.

OBJECTIVE: To validate the APACHE II and SOFA scores in patients with suspected infection in clinical settings other than intensive care units. MATERIALS AND METHODS: A secondary analysis was performed on 2,530 adult patients participating in 2 cohort studies, with suspected infection as admission diagnosis within the first 24 h of hospitalization. The performance of both scoring systems was studied in order to set calibration and discrimination, respectively, on the outcomes such as mortality, admission to Intensive Care Unit, development of septic shock, or multiple organ dysfunctions. RESULTS: The AUC-ROC values for mortality at discharge and on day 28 in the first cohort were around 0.50 for the SOFA and APACHE II scores; whereas for the second cohort the discrimination value was around 0.70. Calibration of both scoring systems for primary outcomes, according to Hosmer-Lemeshow test, showed p>.05 in the first cohort; while in the second cohort calibration it only showed a p>.05 in the case of the SOFA for mortality at hospital discharge. CONCLUSION: This validation study of SOFA and APACHE II scores in patients with suspected infection in-hospital units other than the Intensive Care Unit, showed no consistent performance for calibration and discrimination. Its application in emergency and in-hospital patients is limited.

Perfil microbiológico de la Infecciones en Unidades de Cuidados Intensivos de Colombia (EPISEPSIS Colombia) / Microbiological profile of infections in the Intensive Care Units of Colombia (EPISEPSIS Colombia)

Introducción y objetivoEn Colombia faltan datos fiables sobre el comportamiento de la sepsis. Se pretende determinar la prevalencia de los microorganismos en las principales infecciones tratadas en las unidades de cuidados intensivos (UCI) de nuestro país.MétodosEste es un subestudio de una cohorte prospectiva recolectada en 10 hospitales durante 6 meses. Los criterios de inclusión eran hospitalización en UCI y confirmación de una infección según las definiciones del CDC, considerando tres grupos (comunidad, hospital, UCI) según el sitio de adquisición de la infección.ResultadosSe incluyó en el análisis a 826 pacientes; el 51% contrajeron procesos infecciosos extrahospitalarios; el 5,33%, en el hospital y el 43,7%, en UCI. Los diagnósticos más frecuentes fueron neumonía (29,54%), infección intraabdominal (18,16%) e infección del tracto urinario (11,62%). El microorganismo más frecuente en las infecciones extrahospitalarias fue Escherichia coli —pulmón (16,4%), peritoneo (57,7%), orina (55,5%) y sangre (22,4%)—. En las adquiridas en UCI predomina también E. coli —peritoneo (29,3%) y orina (52,9%)—, excepto en pulmón y sangre, en los que fueron Staphylococcus aureus (32,4%) y Klebsiella pneumoniae (15,7%) los más prevalentes. Se tomaron cultivos a 655 pacientes, de los que el 40% recibió antibióticos antes de la toma, sin que esto afectara al porcentaje de positividad (p=0,583).ConclusionesLa neumonía fue la infección más frecuente independientemente del sitio de adquisición. E. coli fue el patógeno más prevalente, excepto en las infecciones pulmonares adquiridas en UCI, donde lo fue S. aureus (AU)

AbstractBackground and objective: Valid and reliable data regarding sepsis is lacking in Colombia. Ouraim was to determine the prevalence of the microorganisms in the main infections treated inIntensive Care Units (ICUs) in our country.Methods: This is a sub-study of a prospective cohort with 10 general hospitals in Colombiaduring a 6-month period. The inclusion criteria were hospitalization in ICU and confirmation ofinfection according to the CDC definitions. Patients were classified into three groups, that is,community, hospital and intensive care, according to the site where the infection was acquired.Results: A total of 826 patients were included in this analysis. Of these, 51% developed infectionsin the community, 5.33% in the hospital and 43.7% in intensive care unit. Overall, themost common diagnoses were pneumonia (29.54%), intra-abdominal infection (18.16%) and urinarytract infection (11.62%). The most frequent germ in community-acquired infections wasE. coli —–lung (16. 4%), peritoneum (57.7%), urine (55.5%), blood (22.4%)—–. E. coli —–peritoneum(29.3%), urine (52.9%)—– also predominated in the ICU-acquired infections, except for lung andblood in which Staphylococcus aureus (32.4%) and Klebsiella pneumoniae (15.7%) were the mostprevalent. Cultures were requested from 655 patients, 40% of them having received antibioticsbefore cultures were taken, although this did not affected the percentages of positive cultures(P = 0.583).Conclusions: Pneumonia was the main cause of infection regardless of the site of acquisition.E. coli was the most prevalent germ, except in the pulmonary infections acquired in UCI inwhich S. aureus was the most prevalent (AU)

[Microbiological profile of infections in the Intensive Care Units of Colombia (EPISEPSIS Colombia]. / Perfil microbiológico de la Infecciones en Unidades de Cuidados Intensivos de Colombia (EPISEPSIS Colombia).

BACKGROUND AND OBJECTIVE: Valid and reliable data regarding sepsis is lacking in Colombia. Our aim was to determine the prevalence of the microorganisms in the main infections treated in Intensive Care Units (ICUs) in our country. METHODS: This is a sub-study of a prospective cohort with 10 general hospitals in Colombia during a 6-month period. The inclusion criteria were hospitalization in ICU and confirmation of infection according to the CDC definitions. Patients were classified into three groups, that is, community, hospital and intensive care, according to the site where the infection was acquired. RESULTS: A total of 826 patients were included in this analysis. Of these, 51% developed infections in the community, 5.33% in the hospital and 43.7% in intensive care unit. Overall, the most common diagnoses were pneumonia (29.54%), intra-abdominal infection (18.16%) and urinary tract infection (11.62%). The most frequent germ in community-acquired infections was E. coli -lung (16. 4%), peritoneum (57.7%), urine (55.5%), blood (22.4%)-. E. coli -peritoneum (29.3%), urine (52.9%)- also predominated in the ICU-acquired infections, except for lung and blood in which Staphylococcus aureus (32.4%) and Klebsiella pneumoniae (15.7%) were the most prevalent. Cultures were requested from 655 patients, 40% of them having received antibiotics before cultures were taken, although this did not affected the percentages of positive cultures (P=0.583). CONCLUSIONS: Pneumonia was the main cause of infection regardless of the site of acquisition. E. coli was the most prevalent germ, except in the pulmonary infections acquired in UCI in which S. aureus was the most prevalent.

Oclusion experimental de la arteria mesenterica superior. Accion del oxigeno por via digestiva. / Experimental occlusion to the superior mesenteric artery. Oxygen action by digestive way

La oclusion experimental de la arteria mesenterica superior fue realizada en 9 perros para obtener una isquemia intestinal aguda. Este lote fue dividido en 3 grupos: I. de control, II. con oxigenacion endoluminal gastrica y III. con oxigenacion endoluminal yeyunal. Para evaluar el efecto terapeutico del oxigeno se controlo la presion arterial media, el funcionamiento cardiaco con monitoreo electrocardiografico, y los valores de la glucemia, enzimas y gases sanguineos en condiciones basales y a las 2 y 5 horas de la oclusion vascular. Para el estudio histopatologico se tomaron biopsias de la mucosa intestinal y otros parenquimas. Los resultados obtenidos indicaron una perfecta adaptacion a la difusion del oxigeno a traves de la mucosa gastroenterica y su accion protectora en la evolucion de la isquemia intestinal. Se comprobo una correlacion entre los cambios histologicos de la mucosa intestinal y los parametros hemodinamicos y humorales estudiados. Con el oxigeno endoluminal las alteraciones histologicas celulares fueron de escasa intensidad y, consiguientemente, la homeostasis o equilibrio organico general se mantuvo sin modificaciones durante el tiempo que duro la experimentacion

Oclusion experimental de la arteria mesenterica superior. Accion del oxigeno por via digestiva. / Experimental occlusion to the superior mesenteric artery. Oxygen action by digestive way

La oclusion experimental de la arteria mesenterica superior fue realizada en 9 perros para obtener una isquemia intestinal aguda. Este lote fue dividido en 3 grupos: I. de control, II. con oxigenacion endoluminal gastrica y III. con oxigenacion endoluminal yeyunal. Para evaluar el efecto terapeutico del oxigeno se controlo la presion arterial media, el funcionamiento cardiaco con monitoreo electrocardiografico, y los valores de la glucemia, enzimas y gases sanguineos en condiciones basales y a las 2 y 5 horas de la oclusion vascular. Para el estudio histopatologico se tomaron biopsias de la mucosa intestinal y otros parenquimas. Los resultados obtenidos indicaron una perfecta adaptacion a la difusion del oxigeno a traves de la mucosa gastroenterica y su accion protectora en la evolucion de la isquemia intestinal. Se comprobo una correlacion entre los cambios histologicos de la mucosa intestinal y los parametros hemodinamicos y humorales estudiados. Con el oxigeno endoluminal las alteraciones histologicas celulares fueron de escasa intensidad y, consiguientemente, la homeostasis o equilibrio organico general se mantuvo sin modificaciones durante el tiempo que duro la experimentacion