ABSTRACT
BACKGROUND: There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country. METHODS: We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training. RESULTS: We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs. CONCLUSION: Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.
ABSTRACT
Takotsubo syndrome, was described in Japan in 1990, it is a stress cardiomyopathy, predominantly in women, usually postmenopausal. Cardiac hypokinesia occurs, with involvement of multiple coronary territories. In intensive care unit (ICU), it is considered underdiagnosed. Manifestations of severe dengue fever include cardiovascular involvement, mainly arrhythmias and systolic dysfunction. A case of a 72-year-old man is presented, who was hospitalized in ICU for dengue fever, with plateletopenia (15000 cells/mm3) and dehydration. After fluid management the patient reported respiratory discomfort, auscultating crackling rales. A pulmonary ultrasound was made where bilateral B lines were found with B7 pattern compatible with interstitial syndrome and pulmonary edema. Basal hyperkinesia, medial and apical hypokinesia with an image consistent with apical ballooning were observed in the transthoracic echocardiogram. The electrocardiogram showed complete right bundle branch block. Chagas serology was negative and quantitative troponin I was increased. In the context of severe dengue, a Takotsubo syndrome was diagnosed. The patient evolved favorably. After discharge, a normalization of the cardiac function was stated in ultrasound images. The case is of clinical importance due to the low association of these two diseases and the need to screen for cardiac involvement in severe dengue.
El síndrome de Takotsubo, fue descripto en Japón en 1990, se trata de una miocardiopatía por estrés, predominante en mujeres, generalmente postmenopáusicas. Se produce una hipoquinesia cardiaca, con compromiso de múltiples territorios coronarios. En las unidades de terapia intensiva (UTI), se considera subdiagnosticada. En las manifestaciones del dengue grave, se encuentra el compromiso cardiovascular, principalmente arritmias y disfunción sistólica. Se presenta el caso de un hombre de 72 años, internado en UTI por dengue, con plaquetopenia (15000 células/mm3) y deshidratación. Luego de la administración de fluidos refirió disconfort respiratorio, auscultándose estertores pulmonares. Se realizó ecografía pulmonar donde se apreció líneas B bilaterales con patrón B7 compatible con síndrome intersticial y edema pulmonar. En el ecocardiograma transtorácico se objetivó hiperquinesia basal, hipoquinesia medial y apical con imagen compatible con balonamiento apical. En el electrocardiograma se evidenció bloqueo completo de rama derecha. La serología para Chagas fue negativa y la troponina I cuantitativa se detectó aumentada. Se diagnosticó síndrome de Takotsubo en el contexto de dengue grave. El paciente evolucionó favorablemente. Posterior al alta, se constató normalización de la motilidad cardíaca, en las imágenes ecográficas. El caso es de importancia clínica por la baja asociación de las dos enfermedades y la necesidad de pesquisar el compromiso cardíaco en el dengue grave.
Subject(s)
Takotsubo Cardiomyopathy , Humans , Takotsubo Cardiomyopathy/etiology , Takotsubo Cardiomyopathy/diagnostic imaging , Takotsubo Cardiomyopathy/diagnosis , Aged , Male , Dengue/complications , Dengue/diagnosis , Electrocardiography , Severe Dengue/complications , Severe Dengue/diagnosis , EchocardiographyABSTRACT
BACKGROUND: The demand for healthcare services during the COVID-19 pandemic was excessive for less-resourced settings, with intensive care units (ICUs) taking the heaviest toll. OBJECTIVE: The aim was to achieve adequate personal protective equipment (PPE) use in 90% of patient encounters, to reach 90% compliance with objectives of patient flow (OPF) and to provide emotional support tools to 90% of healthcare workers (HCWs). METHODS: We conducted a quasi-experimental study with an interrupted time-series design in 14 ICUs in Argentina. We randomly selected adult critically ill patients admitted from July 2020 to July 2021 and active HCWs in the same period. We implemented a quality improvement collaborative (QIC) with a baseline phase (BP) and an intervention phase (IP). The QIC included learning sessions, periods of action and improvement cycles (plan-do-study-act) virtually coached by experts via platform web-based activities. The main study outcomes encompassed the following elements: proper utilisation of PPE, compliance with nine specific OPF using daily goal sheets through direct observations and utilisation of a web-based tool for tracking emotional well-being among HCWs. RESULTS: We collected 7341 observations of PPE use (977 in BP and 6364 in IP) with an improvement in adequate use from 58.4% to 71.9% (RR 1.2, 95% CI 1.17 to 1.29, p<0.001). We observed 7428 patient encounters to evaluate compliance with 9 OPF (879 in BP and 6549 in IP) with an improvement in compliance from 53.9% to 67% (RR 1.24, 95% CI 1.17 to 1.32, p<0.001). The results showed that HCWs did not use the support tool for self-mental health evaluation as much as expected. CONCLUSION: A QIC was effective in improving healthcare processes and adequate PPE use, even in the context of a pandemic, indicating the possibility of expanding QIC networks nationwide to improve overall healthcare delivery. The limited reception of emotional support tools requires further analyses.
Subject(s)
COVID-19 , Intensive Care Units , Quality Improvement , SARS-CoV-2 , Humans , COVID-19/prevention & control , COVID-19/epidemiology , Argentina , Intensive Care Units/organization & administration , Intensive Care Units/statistics & numerical data , Male , Female , Personal Protective Equipment/statistics & numerical data , Middle Aged , Pandemics/prevention & control , Delivery of Health Care/standards , Adult , Public Health/methods , Health Personnel/statistics & numerical data , Health Personnel/psychology , Interrupted Time Series Analysis/methodsABSTRACT
Resumen Introducción : La criptococosis meníngea (CM) es una causa frecuente de meningoencefalitis en personas que viven con HIV (PVHIV) y produce una importante morbi-mortalidad (20-55%). Se describen las características clínicas, la letalidad y las variables de mal pronóstico en PVHIV con CM, en unidades de cuidados intensivos (UCI). Métodos : Estudio observacional y retrospectivo. Pe ríodo 21/11/2006 a 24/05/2023. Población evaluada: 154 PVHIV adultos, admitidos en UCI con diagnóstico de CM. Los porcentajes y valores absolutos, fueron comparados mediante Chi-Cuadrado o test de Fisher y las medianas mediante test de Mann-Whitney. La asociación con mortalidad se evaluó por regresión logística. Se utilizó el programa SPSS 23.0. Un valor p<0.05 fue considerado significativo. Resultados : Los pacientes que fallecieron y los que so brevivieron fueron comparables en edad y sexo (p>0.05). El análisis univariado, observó que un estado funcional y nutricional alterado, falta de tratamiento antirretroviral previo (TARV), CD4 <100 células/μl, APACHE II ≥13 y un score pronóstico de PVHIV ≥8 puntos, requerir ventilación mecánica (VM), sufrir insuficiencia respiratoria, renal, disfunción neurológica o sepsis, podrían estar asociados (p<0.05) con mortalidad. La regresión logística estableció que un estado funcional y nutricional alterado, un score pronóstico PVHIV ≥8, necesitar VM y sufrir sepsis serían variables independientes asociadas a mortalidad. Conclusión : Los resultados indican que el estado funcional y nutricional alterado, un score pronóstico PVHIV ≥8 puntos, requerir VM y sufrir sepsis al ingreso a UCI podrían servir como variables independientes para predecir un mayor riesgo de mortalidad.
Abstract Introduction : Meningeal cryptococcosis (MC) is a frequent cause of meningoencephalitis in people living with HIV (PLHIV), leading to substantial morbidity (20- 55%). Clinical characteristics, lethality and adverse prog nostic factors in PLHIV with MC admitted to intensive care units (ICUs) are described. Methods : A retrospective observational study. Period from 11/21/2006 to 05/24/2023. It involved 154 adult PLHIV diagnosed with MC and admitted to ICUs. Percen tages and absolute values were compared by Chi-Square or Fisher's test and medians by Mann-Whitney test. The association with mortality was assessed by logistic re gression. SPSS 23.0 software was used. A p-value <0.05 was considered significant. Results : Patients who died and those who survived were comparable in age and sex (p>0.05). Univariate analysis showed that impaired functional and nutritio nal status, lack of previous highly active antiretroviral therapy, CD4 <100 cells, APACHE II ≥13 and a PLHIV prognostic score ≥8 points, requiring mechanical venti lation (MV), respiratory failure, renal failure, neurological dysfunction or sepsis could be associated (p<0.05) with mortality. Logistic regression established that impaired functional and nutritional status, a PLHIV prognostic score ≥8, need for MV and presence of sepsis would be independent variables associated with mortality. Conclusion : The results indicate that altered functio nal and nutritional status, a PLHIV prognostic score ≥ 8 points, requiring MV and suffering sepsis on admission to the ICU are more frequent in deceased patients, and they could therefore serve as independent variables to predict a higher risk of mortality.
ABSTRACT
INTRODUCTION: Meningeal cryptococcosis (MC) is a frequent cause of meningoencephalitis in people living with HIV (PLHIV), leading to substantial morbidity (20-55%). Clinical characteristics, lethality and adverse prognostic factors in PLHIV with MC admitted to intensive care units (ICUs) are described. METHODS: A retrospective observational study. Period from 11/21/2006 to 05/24/2023. It involved 154 adult PLHIV diagnosed with MC and admitted to ICUs. Percentages and absolute values were compared by Chi-Square or Fisher's test and medians by Mann-Whitney test. The association with mortality was assessed by logistic regression. SPSS 23.0 software was used. A p-value <0.05 was considered significant. RESULTS: Patients who died and those who survived were comparable in age and sex (p>0.05). Univariate analysis showed that impaired functional and nutritional status, lack of previous highly active antiretroviral therapy, CD4 <100 cells, APACHE II ≥ 13 and a PLHIV prognostic score ≥ 8 points, requiring mechanical ventilation (MV), respiratory failure, renal failure, neurological dysfunction or sepsis could be associated (p<0.05) with mortality. Logistic regression established that impaired functional and nutritional status, a PLHIV prognostic score ≥ 8, need for MV and presence of sepsis would be independent variables associated with mortality. CONCLUSION: The results indicate that altered functional and nutritional status, a PLHIV prognostic score ≥ 8 points, requiring MV and suffering sepsis on admission to the ICU are more frequent in deceased patients, and they could therefore serve as independent variables to predict a higher risk of mortality.
Introducción: La criptococosis meníngea (CM) es una causa frecuente de meningoencefalitis en personas que viven con HIV (PVHIV) y produce una importante morbimortalidad (20-55%). Se describen las características clínicas, la letalidad y las variables de mal pronóstico en PVHIV con CM, en unidades de cuidados intensivos (UCI). Métodos: Estudio observacional y retrospectivo. Período 21/11/2006 a 24/05/2023. Población evaluada: 154 PVHIV adultos, admitidos en UCI con diagnóstico de CM. Los porcentajes y valores absolutos, fueron comparados mediante Chi-Cuadrado o test de Fisher y las medianas mediante test de Mann-Whitney. La asociación con mortalidad se evaluó por regresión logística. Se utilizó el programa SPSS 23.0. Un valor p<0.05 fue considerado significativo. Resultados: Los pacientes que fallecieron y los que sobrevivieron fueron comparables en edad y sexo (p>0.05). El análisis univariado, observó que un estado funcional y nutricional alterado, falta de tratamiento antirretroviral previo (TARV), CD4 <100 células/µl, APACHE II ≥ 13 y un score pronóstico de PVHIV ≥ 8 puntos, requerir ventilación mecánica (VM), sufrir insuficiencia respiratoria, renal, disfunción neurológica o sepsis, podrían estar asociados (p<0.05) con mortalidad. La regresión logística estableció que un estado funcional y nutricional alterado, un score pronóstico PVHIV ≥ 8, necesitar VM y sufrir sepsis serían variables independientes asociadas a mortalidad. Conclusión: Los resultados indican que el estado funcional y nutricional alterado, un score pronóstico PVHIV ≥ 8 puntos, requerir VM y sufrir sepsis al ingreso a UCI podrían servir como variables independientes para predecir un mayor riesgo de mortalidad.
Subject(s)
AIDS-Related Opportunistic Infections , Intensive Care Units , Meningitis, Cryptococcal , Humans , Male , Female , Retrospective Studies , Adult , Meningitis, Cryptococcal/mortality , Meningitis, Cryptococcal/complications , Middle Aged , AIDS-Related Opportunistic Infections/mortality , AIDS-Related Opportunistic Infections/complications , Intensive Care Units/statistics & numerical data , Prognosis , Risk Factors , HIV Infections/complications , HIV Infections/mortalityABSTRACT
Chikungunya virus is an Alphavirus, it belongs to the family Togaviridae and is transmitted by mosquitoes. It was first described during an outbreak in Southern Tanzania in 1952. It generally causes a febrile syndrome, accompanied by joint pain and arthritis, which is often debilitating and may persist for months or years. Its overall fatality rate is not high, around 0.1%. Atypical and severe cases have been reported. This virus has been detected in more than 110 countries globally. In Northeastern Brazil autochthonous cases have been diagnosed since September 2014. In Argentina, as well as in neighboring countries, cases were increasing during 2023, compared to the same periods in previous years. Until epidemiological week 26 of 2023, 1460 cases of chikungunya fever were reported in Argentina, 72% of them were considered of autochthonous transmission. The case of a 76-year-old female patient is here presented, her comorbidities were hypertension and aortic stenosis, who was admitted to intensive care unit due to septic shock with respiratory focus, interstitial pneumonia in X-ray pattern, and torpid evolution. She died within 24 hours of admission. A report of detectable Chikungunya virus by real-time polymerase chain reaction in real time was received post-mortem. This case results of clinical relevance due to its atypical presentation and the country low prevalence of severe infections by this virus. It warns of the need to include the differential diagnosis in cases with suspected diagnosis.
El virus Chikungunya es un Alfavirus de la familia Togaviridae trasmitido por mosquitos. Fue descrito por primera en un brote en el sur de Tanzania en 1952. Genera clásicamente un síndrome febril con poliartralgias y artritis, que pueden ser incapacitantes y tener una duración prolongada. La mortalidad global ronda en 0.1%. Existen reportes en la literatura de presentaciones atípicas y graves con compromiso de múltiples órganos. Se ha detectado la presencia del virus en más de 110 países. En Brasil, en la región noreste, se han hallado casos autóctonos desde septiembre de 2014. En Argentina y países limítrofes, se presentan casos en aumento durante 2023, con respecto a iguales periodos en años previos. Hasta la semana epidemiológica N° 26 del año 2023 se registraron en Argentina 1460 casos de fiebre chikungunya, considerándose autóctonos 72% de ellos. Se presenta el caso de una mujer de 76 años, con antecedentes de hipertensión arterial y estenosis aortica, admitida en terapia intensiva por shock séptico con foco respiratorio, con patrón de neumonía intersticial, evolución tórpida y óbito dentro de las 24 horas del ingreso. Se recibe postmorten el resultado detectable de virus Chikungunya por reacción en cadena de la polimerasa en tiempo real. Este caso, resulta de importancia clínica dada la presentación atípica del mismo y por la baja prevalencia nacional de infecciones graves por dicho virus, alerta sobre la necesidad de incluir el diagnóstico diferencial en los pacientes con sospecha diagnóstica.
Subject(s)
Chikungunya Fever , Chikungunya virus , Humans , Female , Animals , Aged , Chikungunya Fever/diagnosis , Chikungunya Fever/epidemiology , Disease Outbreaks , Diagnosis, Differential , Critical CareABSTRACT
Resumen El virus Chikungunya es un Alfavirus de la familia Togaviridae trasmitido por mosquitos. Fue descrito por primera en un brote en el sur de Tanzania en 1952. Genera clásicamente un síndrome febril con poliartral gias y artritis, que pueden ser incapacitantes y tener una duración prolongada. La mortalidad global ronda en 0.1%. Existen reportes en la literatura de presenta ciones atípicas y graves con compromiso de múltiples órganos. Se ha detectado la presencia del virus en más de 110 países. En Brasil, en la región noreste, se han hallado casos autóctonos desde septiembre de 2014. En Argentina y países limítrofes, se presentan casos en aumento duran te 2023, con respecto a iguales periodos en años previos. Hasta la semana epidemiológica N° 26 del año 2023 se registraron en Argentina 1460 casos de fiebre chikun gunya, considerándose autóctonos 72% de ellos. Se presenta el caso de una mujer de 76 años, con an tecedentes de hipertensión arterial y estenosis aortica, admitida en terapia intensiva por shock séptico con foco respiratorio, con patrón de neumonía intersticial, evolu ción tórpida y óbito dentro de las 24 horas del ingreso. Se recibe postmorten el resultado detectable de virus Chikungunya por reacción en cadena de la polimerasa en tiempo real. Este caso, resulta de importancia clínica dada la pre sentación atípica del mismo y por la baja prevalencia nacional de infecciones graves por dicho virus, alerta sobre la necesidad de incluir el diagnóstico diferencial en los pacientes con sospecha diagnóstica.
Abstract Chikungunya virus is an Alphavirus, it belongs to the family Togaviridae and is transmitted by mos quitoes. It was first described during an outbreak in Southern Tanzania in 1952. It generally causes a febrile syndrome, accompanied by joint pain and arthritis, which is often debilitating and may persist for months or years. Its overall fatality rate is not high, around 0.1%. Atypical and severe cases have been reported. This virus has been detected in more than 110 countries globally. In Northeastern Brazil autoch thonous cases have been diagnosed since September 2014. In Argentina, as well as in neighboring countries, cases were increasing during 2023, compared to the same periods in previous years. Until epidemiological week 26 of 2023, 1460 cases of chikungunya fever were reported in Argentina, 72% of them were considered of autochthonous transmission. The case of a 76-year-old female patient is here presented, her comorbidities were hypertension and aortic stenosis, who was admitted to intensive care unit due to septic shock with respiratory focus, intersti tial pneumonia in X-ray pattern, and torpid evolution. She died within 24 hours of admission. A report of detectable Chikungunya virus by real-time polymerase chain reaction in real time was received post-mortem. This case results of clinical relevance due to its atypi cal presentation and the country low prevalence of severe infections by this virus. It warns of the need to include the differential diagnosis in cases with sus pected diagnosis.
ABSTRACT
Resumen La malaria es una enfermedad con amplia distribu ción en áreas tropicales. En su forma grave se caracteriza por afección orgánica y/o hiperparasitemia. Se definen los criterios para el monitoreo temprano en las salas de terapia intensiva, debido a que sin tratamiento oportu no y precoz la malaria grave tiene una mortalidad de 100%. Si bien no es amplia la literatura en este aspecto la terapia extracorpórea en forma secuencial para de toxificación hepática y renal es una herramienta útil y segura que puede ser utilizada en terapia intensiva. Se describe un caso de un varón de 36 años con diagnóstico de malaria grave según criterio de la Organización Mun dial de la Salud (OMS) que comenzó con tratamiento con artesunato endovenoso y por evolución tórpida, ascenso brusco de bilirrubinemia con encefalopatía, parámetros de lesión renal aguda y edema agudo de pulmón, realiza tratamiento extracorpóreo secuencial, plasma filtración acoplada a adsorción, plasmaféresis de alto intercambio y hemodiafiltración continua con evolución favorable. En conclusión, el caso presentado nos demuestra que el rol del sostén extracorpóreo en manos entrenadas y en forma oportuna es crucial cuando el fallo de órganos evoluciona rápidamente para lograr dar estabilidad y otorgar el tiempo necesario para la acción del tratamien to definitivo en este caso, los antimaláricos de acción rápida hasta negativización de la parasitemia.
Abstract Malaria is a wide-spread disease in tropical areas. The severe form is characterized by organic involve ment and/or hyperparasitaemia. Criteria for early monitoring in intensive care rooms are defined; with out a timely and early treatment, severe malaria has a 100% mortality. Although the literature in these cases is not extensive, extracorporeal therapy used sequentially for hepatic and renal detoxification is a useful and safe tool that can be used in intensive care. We describe the case of a 36-year-old man with a diag nosis of severe malaria according to WHO criteria. He began treatment with intravenous artesunate and due to a torpid evolution, a sudden increase in bilirubine mia with encephalopathy, parameters of acute kidney injury and acute pulmonary edema, undergoes extra corporeal sequential treatment, coupled with plasma filtration adsorption, high-exchange plasmapheresis, and continuous hemodiafiltration with favorable evo lution. This case shows that extracorporeal support in trained hands and in a timely manner is effective when organ failure evolves rapidly to achieve stability and provide necessary time for definitive treatment, in this case rapid action antimalarials until parasitemia becomes negative.
ABSTRACT
Resumen El tétanos es causado por el Clostridium tetani, una bacteria ubicua que frente a condiciones de anaerobio sis puede sintetizar y liberar sus toxinas, responsables del cuadro clínico. Dado que es una bacteria que se encuentra en el suelo y en el tracto gastrointestinal de muchas especies, se trata de una enfermedad no erra dicable pero si controlable a través de la inmunización para la prevención. Las tasas de inmunización han disminuido en los últimos años, evento que se ha acentuado durante la COVID-19. Se presentan a continuación dos casos clínicos in gresados durante el año 2022. El primero es un hombre de 39 años cuya puerta de entrada fue una herida de arma de fuego conevolución favorable y el segundo caso se trata de una mujer de 83 años sin puerta de entrada clara quien falleció durante su internación en terapia intensiva. La importancia de esta presentación es mos trar la gravedad de la enfermedad, cuyavaloración es principalmente clínica y no debe escapar al algoritmo de diagnósticos diferenciales, acentuando que se debe instaurar el tratamiento de forma precoz o frente a la duda consultar con un centro especializado. Asímismo, es importante revisar las tasas de inmuni zación en nuestro país y los cambios que se presentaron durante la pandemia, teniendo en cuenta, como se ha expuesto previamente, se trata de una enfermedad in munoprevenible.
Abstract Tetanus is an infectious disease caused by a ubiqui tous bacterium Clostridium tetani, that synthesizes and releasesa potent neurotoxin under anaerobic conditions, which is responsible for the clinical manifestations. As it is found in soil contaminated with animal and human excreta, it is difficult to eradicate but it may be prevented by immunization. Immunization rate has decreased in the last years, especially during the COVID-19 pandemic. We report two cases of tetanus, attended during 2022. A 39-year-old man whose entry route was a gunshot wound and he was discharged from the intensive care unit (ICU) and a second case of an 83-year-old woman with unknown entry point, who died during her ICU stay. The cases reported highlight that it is a life-threatening disease, its diagnosis is mainly clinical and it should be in the algorithm of differential diagnoses. We emphasize about the prompt treatment administration or consulta tion to a specialized healthcare center. The importance of this presentation is to show the severity of the dis ease, whose assessment is mainly clinical and should not escape the algorithm of differential diagnoses, em phasizing that treatment should be instituted early or when in doubt consult a specialized center. In addition to this, it is important to check theimmunization rate in our country, especially during thepandemic, becauseit is a vaccine-pre ventable disease.
ABSTRACT
Malaria is a wide-spread disease in tropical areas. The severe form is characterized by organic involvement and/or hyperparasitaemia. Criteria for early monitoring in intensive care rooms are defined; without a timely and early treatment, severe malaria has a 100% mortality. Although the literature in these cases is not extensive, extracorporeal therapy used sequentially for hepatic and renal detoxification is a useful and safe tool that can be used in intensive care. We describe the case of a 36-year-old man with a diagnosis of severe malaria according to WHO criteria. He began treatment with intravenous artesunate and due to a torpid evolution, a sudden increase in bilirubinemia with encephalopathy, parameters of acute kidney injury and acute pulmonary edema, undergoes extracorporeal sequential treatment, coupled with plasma filtration adsorption, high-exchange plasmapheresis, and continuous hemodiafiltration with favorable evolution. This case shows that extracorporeal support in trained hands and in a timely manner is effective when organ failure evolves rapidly to achieve stability and provide necessary time for definitive treatment, in this case rapid action antimalarials until parasitemia becomes negative.
La malaria es una enfermedad con amplia distribución en áreas tropicales. En su forma grave se caracteriza por afección orgánica y/o hiperparasitemia. Se definen los criterios para el monitoreo temprano en las salas de terapia intensiva, debido a que sin tratamiento oportuno y precoz la malaria grave tiene una mortalidad de 100%. Si bien no es amplia la literatura en este aspecto la terapia extracorpórea en forma secuencial para detoxificación hepática y renal es una herramienta útil y segura que puede ser utilizada en terapia intensiva. Se describe un caso de un varón de 36 años con diagnóstico de malaria grave según criterio de la Organización Mundial de la Salud (OMS) que comenzó con tratamiento con artesunato endovenoso y por evolución tórpida, ascenso brusco de bilirrubinemia con encefalopatía, parámetros de lesión renal aguda y edema agudo de pulmón, realiza tratamiento extracorpóreo secuencial, plasma filtración acoplada a adsorción, plasmaféresis de alto intercambio y hemodiafiltración continua con evolución favorable. En conclusión, el caso presentado nos demuestra que el rol del sostén extracorpóreo en manos entrenadas y en forma oportuna es crucial cuando el fallo de órganos evoluciona rápidamente para lograr dar estabilidad y otorgar el tiempo necesario para la acción del tratamiento definitivo en este caso, los antimaláricos de acción rápida hasta negativización de la parasitemia.
Subject(s)
Antimalarials , Brain Diseases , Malaria, Falciparum , Malaria , Male , Humans , Adult , Malaria, Falciparum/diagnosis , Malaria, Falciparum/drug therapy , Malaria/drug therapy , Antimalarials/therapeutic use , Artesunate/therapeutic use , Brain Diseases/drug therapyABSTRACT
Tetanus is an infectious disease caused by a ubiquitous bacterium Clostridium tetani, that synthesizes and releasesa potent neurotoxin under anaerobic conditions, which is responsible for the clinical manifestations. As it is found in soil contaminated with animal and human excreta, it is difficult to eradicate but it may be prevented by immunization. Immunization rate has decreased in the last years, especially during the COVID-19 pandemic. We report two cases of tetanus, attended during 2022. A 39-year-old man whose entry route was a gunshot wound and he was discharged from the intensive care unit (ICU) and a second case of an 83-year-old woman with unknown entry point, who died during her ICU stay. The cases reported highlight that it is a life-threatening disease, its diagnosis is mainly clinical and it should be in the algorithm of differential diagnoses. We emphasize about the prompt treatment administration or consultation to a specialized healthcare center. The importance of this presentation is to show the severity of the disease, whose assessment is mainly clinical and should not escape the algorithm of differential diagnoses, emphasizing that treatment should be instituted early or when in doubt consult a specialized center. In addition to this, it is important to check theimmunization rate in our country, especially during thepandemic, becauseit is a vaccine-preventable disease.
El tétanos es causado por el Clostridium tetani, una bacteria ubicua que frente a condiciones de anaerobiosis puede sintetizar y liberar sus toxinas, responsables del cuadro clínico. Dado que es una bacteria que se encuentra en el suelo y en el tracto gastrointestinal de muchas especies, se trata de una enfermedad no erradicable pero si controlable a través de la inmunización para la prevención. Las tasas de inmunización han disminuido en los últimos años, evento que se ha acentuado durante la COVID-19. Se presentan a continuación dos casos clínicos ingresados durante el año 2022. El primero es un hombre de 39 años cuya puerta de entrada fue una herida de arma de fuego conevolución favorable y el segundo caso se trata de una mujer de 83 años sin puerta de entrada clara quien falleció durante su internación en terapia intensiva. La importancia de esta presentación es mostrar la gravedad de la enfermedad, cuyavaloración es principalmente clínica y no debe escapar al algoritmo de diagnósticos diferenciales, acentuando que se debe instaurar el tratamiento de forma precoz o frente a la duda consultar con un centro especializado. Asímismo, es importante revisar las tasas de inmunización en nuestro país y los cambios que se presentaron durante la pandemia, teniendo en cuenta, como se ha expuesto previamente, se trata de una enfermedad inmunoprevenible.
Subject(s)
Tetanus , Wounds, Gunshot , Humans , Male , Female , Animals , Aged, 80 and over , Adult , Tetanus/diagnosis , Tetanus/prevention & control , Pandemics , Wounds, Gunshot/drug therapy , Tetanus Toxoid/therapeutic use , Clostridium tetaniABSTRACT
Clostridium tertium is a bacterium of the Clostridiaceae family which can be found colonizing the gastrointestinal tract. Unlike other members of its family, it does not produce exotoxins. It was described for the first time in 1917 and in 1963 it was established as a pathogen in humans. Since then, cases have been reported mainly in immunosuppressed hosts, predominantly with primary focus at the abdominal level. The case of a 48-year-old man with a history of cirrhosis and hepatitis C virus infection is described. He presented an obstructed umbilical hernia that required intestinal resection and anastomosis, with positive blood and abdominal fluid cultures for Clostridium tertium. This case is of clinical importance due to the low prevalence of this germ, the possibility of resistance to usual antibiotic regimens and its sub diagnostic given the morphological and growth similarities with Bacillus or Lactobacillus.
Clostridium tertium es una bacteria de la familia Clostridiaceae que se puede encontrar colonizando el tracto gastrointestinal. A diferencia de otros miembros de su familia, no produce exotoxinas. Fue descripto por primera vez en 1917 y en el año 1963 se pudo establecer como patógeno en humanos. Desde entonces, se han reportado casos principalmente en huéspedes inmunosuprimidos, prevalentemente con foco primario abdominal. Se describe el caso de un hombre de 48 años de edad con antecedentes de cirrosis e infección por virus de la hepatitis C, presentó una hernia umbilical atascada que requirió resección y anastomosis intestinal, con cultivos de líquido abdominal y hemocultivos positivos para Clostridium tertium. Este caso es de importancia clínica por la baja prevalencia de este germen, la posibilidad de resistencia a los esquemas antibióticos usuales y de subdiagnóstico del microorganismo dada su similitud morfológica y de crecimiento con Bacillus o Lactobacillus.
Subject(s)
Bacteremia , Clostridium Infections , Clostridium tertium , Male , Humans , Middle Aged , Clostridium Infections/complications , Clostridium Infections/diagnosis , Bacteremia/complications , Bacteremia/diagnosis , Bacteremia/drug therapy , Liver Cirrhosis/complications , Anti-Bacterial Agents/therapeutic useABSTRACT
Resumen Clostridium tertium es una bacteria de la familia Clos tridiaceae que se puede encontrar colonizando el tracto gastrointestinal. A diferencia de otros miembros de su familia, no produce exotoxinas. Fue descripto por prime ra vez en 1917 y en el año 1963 se pudo establecer como patógeno en humanos. Desde entonces, se han reportado casos principalmente en huéspedes inmunosuprimi dos, prevalentemente con foco primario abdominal. Se describe el caso de un hombre de 48 años de edad con antecedentes de cirrosis e infección por virus de la hepatitis C, presentó una hernia umbilical atascada que requirió resección y anastomosis intestinal, con cultivos de líquido abdominal y hemocultivos positivos para Clostridium tertium. Este caso es de importancia clínica por la baja prevalencia de este germen, la posibilidad de resistencia a los esquemas antibióticos usuales y de subdiagnóstico del microorganismo dada su similitud morfológica y de crecimiento con Bacillus o Lactobacillus.
Abstract Clostridium tertium is a bacterium of the Clostridiaceae family which can be found colonizing the gastrointes tinal tract. Unlike other members of its family, it does not produce exotoxins. It was described for the first time in 1917 and in 1963 it was established as a pathogen in humans. Since then, cases have been reported mainly in immunosuppressed hosts, predominantly with primary focus at the abdominal level. The case of a 48-year-old man with a history of cirrhosis and hepatitis C virus infection is described. He presented an obstructed um bilical hernia that required intestinal resection and anastomosis, with positive blood and abdominal fluid cultures for Clostridium tertium. This case is of clinical importance due to the low prevalence of this germ, the possibility of resistance to usual antibiotic regimens and its sub diagnostic given the morphological and growth similarities with Bacillus or Lactobacillus.
ABSTRACT
Resumen La viruela símica es una enfermedad zoonótica poco frecuente. Fue descripta en humanos por primera vez en África en 1970. El 23 de julio del 2022, ante la cantidad ascendente de casos notificados en diversos países y territorios, la Organización Mundial de la Sa lud (OMS) concluyó que el brote mundial constituye una emergencia de salud pública de importancia internacional. En nuestro país el primer caso se noti ficó el 22 de mayo de 2022 hasta el 22 de noviembre se confirmaron 895 casos. Describimos el primer caso registrado en Argentina, según el boletín epidemiológico de la semana epidemiológica 46, del Ministerio de Salud de la Nación con requerimiento de cuidados intensivos. Se trata de un hombre de 44 años con síndrome de in munodeficiencia adquirida y viruela símica grave, que presentó insuficiencia ventilatoria obstructiva, por com promiso de vías aéreas y lesiones generalizadas extensas de tegumento, genitales y fauces. En conclusión, el caso presentado alerta sobre las potenciales complicaciones que pueden requerir cuidados críticos y poner en riesgo la vida del paciente.
Abstract Monkey pox is a rare zoonotic disease. It was first described in humans in Africa in 1970. On July 23, 2022, in view of the increasing number of cases reported in several countries and territories, the World Health Or ganization (WHO) concluded that the global outbreak constitutes a public health emergency of international concern. In our country, the first case was reported on May 22, 2022 and up to November 22 of this year, 895 patients were reported. We describe here the first case registered in Argentina requiring intensive care, accor ding to the Epidemiological Bulletin, 46th epidemio logical week, National Ministry of Health. The patient was a 44-year-old man with acquired immunodeficiency syndrome and severe Monkeypox, who presented obs tructive ventilatory failure due to airway compromise and extensive generalized lesions of the integument, genitalia and fauces. In conclusion, the case presented alerts about potential complications that may require critical care and risk the patient's life.
ABSTRACT
Monkey pox is a rare zoonotic disease. It was first described in humans in Africa in 1970. On July 23, 2022, in view of the increasing number of cases reported in several countries and territories, the World Health Organization (WHO) concluded that the global outbreak constitutes a public health emergency of international concern. In our country, the first case was reported on May 22, 2022 and up to November 22 of this year, 895 patients were reported. We describe here the first case registered in Argentina requiring intensive care, according to the Epidemiological Bulletin, 46th epidemiological week, National Ministry of Health. The patient was a 44-year-old man with acquired immunodeficiency syndrome and severe Monkeypox, who presented obstructive ventilatory failure due to airway compromise and extensive generalized lesions of the integument, genitalia and fauces. In conclusion, the case presented alerts about potential complications that may require critical care and risk the patient's life.
La viruela símica es una enfermedad zoonótica poco frecuente. Fue descripta en humanos por primera vez en África en 1970. El 23 de julio del 2022, ante la cantidad ascendente de casos notificados en diversos países y territorios, la Organización Mundial de la Salud (OMS) concluyó que el brote mundial constituye una emergencia de salud pública de importancia internacional. En nuestro país el primer caso se notificó el 22 de mayo de 2022 hasta el 22 de noviembre se confirmaron 895 casos. Describimos el primer caso registrado en Argentina, según el boletín epidemiológico de la semana epidemiológica 46, del Ministerio de Salud de la Nación con requerimiento de cuidados intensivos. Se trata de un hombre de 44 años con síndrome de inmunodeficiencia adquirida y viruela símica grave, que presentó insuficiencia ventilatoria obstructiva, por compromiso de vías aéreas y lesiones generalizadas extensas de tegumento, genitales y fauces. En conclusión, el caso presentado alerta sobre las potenciales complicaciones que pueden requerir cuidados críticos y poner en riesgo la vida del paciente.
Subject(s)
Mpox (monkeypox) , Male , Humans , Adult , Argentina , Critical Care , Disease Outbreaks , Public Health , Rare DiseasesABSTRACT
Antecedentes: Se ha demostrado que la coinfección tu-berculosis y COVID-19 presenta peor evolución clínica. La inmunidad protectora se debilita frente a esta situación, generando fallo en el control de ambas infecciones, reac-tivación de formas latentes de tuberculosis y progresión exacerbada de los casos activos. Asimismo, la terapia con corticoides utilizada dentro del tratamiento de infecciones graves por COVID-19 puede generar inmunosupresión y precipitar la progresión de la tuberculosis.Objetivos: Describir las características clínicas, presenta-ción y evolución de los pacientes críticos con coinfección COVID-19 y tuberculosis. Evaluar la incidencia y letalidad de la asociación COVID-19 y tuberculosis en cuidados in-tensivos. Materiales y métodos: Se realizó un estudio retrospectivo, descriptivo. Se revisaron 12 historias clínicas de pacientes con coinfección COVID-19-tuberculosis sobre 1014 histo-rias clínicas de pacientes ingresados con diagnóstico de COVID-19, durante el periodo comprendido enero 2020 y junio 2022. Se utilizó estadística descriptiva. Resultados y discusión: Sobre un total de 1014 historias clínicas, se encontraron 12 pacientes con coinfección (in-cidencia de 0,011). La letalidad global en cuidados inten-sivos fue del 75%, a los 45 días fue del 83,3%, duplicando la letalidad general de los pacientes COVID-19 no coinfec-tados ingresados durante el mismo periodo (75% versus 37%). Los pacientes que requirieron ingreso a ventilación RESUMENARTÍCULO ORIGINALmecánica tuvieron una letalidad del 100% y aquellos que tenían infección por virus de inmunodeficiencia adquirida presentaron una letalidad de 100%. Resulta importante describir los hallazgos y alertar sobre la evolución desfavorable de aquellos pacientes que pre-sentan esta asociación a fin de optimizar el manejo y espe-cialmente recomendar la búsqueda de coinfección cuando el criterio clínico lo requiera
Background: Coinfection with tuberculosis and COVID-19 has been shown to have a worse clinical course. Protective immunity is weakened in this situation, leading to failure to control both infections, reactivation of latent forms of TB and exacerbated progression of active cases. Furthermore, corticosteroid therapy used in the treatment of severe COVID-19 infections can lead to immunosuppression and precipitate TB progression.Objectives: To describe the clinical characteristics, presentation and evolution of critically ill patients with COVID-19 and tuberculosis co-infection.To evaluate the incidence and lethality of COVID-19 and tuberculosis association in intensive care.Materials and methods: A retrospective, descriptive study was conducted. Twelve medical records of patients aged 18 years or older admitted to intensive care with a diagnosis of COVID-19 during the period January 2020 to July 2022 were reviewed. Descriptive statistics were used.Results and discussion: Out of a total of 1014 medical records, 12 patients were found with co-infection (incidence 0.011). The global intensive care case fatality was 75%, at 45 days it was 83.3%. This was twice the overall case fatality of non-co-infected COVID-19 patients admitted during the same period (75% versus 37%). Patients requiring admission to mechanical ventilation had a 100% case fatality and those with acquired immunodeficiency virus infection had a 100% case fatality.It is important to describe the findings and to alert to the worse evolution of those patients presenting with this association, in order to improve management and recommend searching for co-infection when clinical criteria require it
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Tuberculosis/therapy , Critical Care , Coinfection/immunology , COVID-19/immunologyABSTRACT
Resumen La aspergilosis invasiva (AI) es una enfermedad grave y con alta mortalidad. Existen factores de riesgo y se describen brotes intrahospitalarios relacionados con construcciones. También se des cribe una entidad relacionada con la infección por COVID-19, conocida como aspergilosis pulmonar asociada a COVID-19 (APAC). Es de vital importancia implementar un tratamiento adecuado y precoz, especialmente en pacientes inmunocomprometidos y críticamente enfermos. El diagnóstico se basa en reconocer los factores predisponentes, la clínica, la obtención de imágenes, exámenes directos, cultivos, histopatología y biomarca dores como el galactomanano. La droga de elección es el voriconazol, pero se deben conocer las alternativas terapéuticas dada la creciente presencia de aislamientos resistentes.
Abstract Invasive aspergillosis (IA) is a serious disease with high mortality. There are several risk factors and in-hospital outbreaks related with construction have been described. An entity related to COVID-19 infection, known as COVID-19 associated pulmonary aspergillosis (CAPA), has recently appeared. Early and appropriate treatment is of paramount importance, especially in immunocompromised and critically ill patients. Diagnosis is based on recognition of predisposing factors, clinical signs, imaging, direct examination, culture, histopathology, and biomarkers such as galactomannan. The drug of choice is voriconazole, but alternative therapies must be taken into account given the increasing presence of resistant isolates.
ABSTRACT
Invasive aspergillosis (IA) is a serious disease with high mortality. There are several risk factors and in-hospital outbreaks related with construction have been described. An entity related to COVID-19 infection, known as COVID-19 associated pulmonary aspergillosis (CAPA), has recently appeared. Early and appropriate treatment is of paramount importance, especially in immunocompromised and critically ill patients. Diagnosis is based on recognition of predisposing factors, clinical signs, imaging, direct examination, culture, histopathology, and biomarkers such as galactomannan. The drug of choice is voriconazole, but alternative therapies must be taken into account given the increasing presence of resistant isolates.
La aspergilosis invasiva (AI) es una enfermedad grave y con alta mortalidad. Existen factores de riesgo y se describen brotes intrahospitalarios relacionados con construcciones. También se describe una entidad relacionada con la infección por COVID-19, conocida como aspergilosis pulmonar asociada a COVID-19 (APAC). Es de vital importancia implementar un tratamiento adecuado y precoz, especialmente en pacientes inmunocomprometidos y críticamente enfermos. El diagnóstico se basa en reconocer los factores predisponentes, la clínica, la obtención de imágenes, exámenes directos, cultivos, histopatología y biomarcadores como el galactomanano. La droga de elección es el voriconazol, pero se deben conocer las alternativas terapéuticas dada la creciente presencia de aislamientos resistentes.