Antibiotic stewardship and nosocomial infection prevention in critically ill patients: a quality improvement program

SUMMARY OBJECTIVE: The objective of this study was to evaluate the impact of the implementation of a bundle of interventions through a "Program for Antibiotic Management and Nosocomial Infection Prevention" in the intensive care unit on antibiotic and devices use and healthcare-associated infections. METHODS: This was a quasi-experimental study of consecutive series of cases in periods before and after the establishment of protocols and checklists for the use of antibiotics as well as other measures to prevent healthcare-associated infection as part of a quality improvement program. Antimicrobial consumption was assessed by the defined daily dose. RESULTS: A total of 1,056 and 1,323 admissions in the pre-intervention and post-intervention phases, respectively, were evaluated. The defined daily dose per 100 patient-day decreased from 89±8 to 77±11 (p=0.100), with a decrease in carbapenems, glycopeptides, polymyxins, penicillins, and cephalosporins. The rates of ventilator and central venous catheter use decreased from 52.8 to 44.1% and from 76 to 70%, respectively. The rates of healthcare-associated infection decreased from 19.2 to 15.5%. CONCLUSION: Quality improvement actions focused primarily on antimicrobial management and prevention of healthcare-associated infection are feasible and have the potential to decrease antibiotic use and healthcare-associated infection rates.

[Procalcitonin as sepsis predictor in cardiovascular surgery with cardiopulmonary bypass]. / Procalcitonina como predictor de sepsis en cirugía cardiovascular con circulación extracorpórea.

Background: Cardiopulmonary bypass generates an exacerbated response that may lead to sepsis. Objective: To describe the association between procalcitonin levels and sepsis diagnosis in cardiovascular surgery subjects with cardiopulmonary bypass. Methods: A case-series study was conducted in 142 patients. Serum procalcitonin levels were measured at 24 hours and at 72 hours after surgery using a point of care testing based on quantitative immunochromatographic method. To assess association between procalcitonin levels and sepsis status, we calculated area under the curve (AUC) and sensitivity, specificity, and predictive values for the best cut-off point. Results: From 142 patients studied, 7 developed sepsis after surgery (4.9%). For 24-hours procalcitonin levels AUC was 0.921 and best cut-off point was 3.8 ng/mL (sensitivity 0.857 and specificity 0.904). In the case of 72-hours procalcitonin levels, we observed a value of 0.868 for AUC and best cut-off point was 8.4 ng/mL (sensitivity 0.86 and specificity 0.97). Conclusions: Procalcitonin levels at 24 and 72 hours after cardiovascular surgery with cardiopulmonary bypass are associated with sepsis presence at cut-off points of 3.8 and 8.4 ng/mL respectively.

Introducción: la circulación extracorpórea durante la cirugía cardiovascular genera una respuesta exacerbada que puede asociarse con sepsis. Objetivo: describir la asociación entre los niveles de procalcitonina y el diagnóstico de sepsis en sujetos de cirugía cardiovascular con circulación extracorpórea. Material y métodos: se realizó un estudio de serie de casos en 142 pacientes. Los niveles de procalcitonina fueron medidos a las 24 horas y a las 72 horas después de la cirugía. Para evaluar la asociación entre los niveles de procalcitonina y la identificación de sepsis, se calculó el área bajo la curva (AUC) y la sensibilidad y especificidad identificando el mejor punto de corte. Resultados: de un total de 142 pacientes estudiados, 7 desarrollaron sepsis (4.9%). En los niveles de procalcitonina en las 24 horas, el AUC fue de 0.921 y el mejor punto de corte fue 3.8 ng/mL (sensibilidad de 0.857 y especificidad de 0.904). En el caso de los niveles de procalcitonina a las 72 horas, observamos un AUC de 0.868 y el mejor punto de corte fue 8.4 ng/mL (sensibilidad de 0.86 y especificidad de 0.97). Conclusiones: los niveles de procalcitonina a las 24 y 72 horas de la cirugía cardiovascular con circulación extracorpórea se asociaron con la presencia de sepsis con los puntos de corte de 3.8 ng/mL y 8.4 ng/mL respectivamente.

Respuesta de procalcitonina ante co-infección e infección secundaria por bacterias multirresistentes en pacientes COVID -19 / Procalcitonin response in co-infection and secondary infection by multidrug resistant bacteria in COVID -19 patients

INTRODUCCIÓN. La procalcitonina, es un biomarcador que puede usarse como apoyo diagnóstico en infecciones bacterianas y la monitorización del tratamiento antibiótico, sobre todo en pacientes con sepsis. De ahí que, fue utilizado durante la pandemia COVID-19 OBJETIVO. Determinar los valores de procalcitonina en pacientes con COVID-19 y definir una p osible correlación entre su incremento y vinculación en coinfección o infección secundaria por Klebsiella pneumoniae y Pseudomonas aeruginosa con multidrogo resistencia y resistencia extendida a los antibióticos. MATERIALES Y MÉTODOS. Estudio retrospectivo observacional, descriptivo transversal, realizado del 1 de mayo al 31 de octubre del 2020 en el Hospital de Especialidades Carlos Andrade Marín sobre 7028 pacientes adultos, hospitalizados, con diagnóstico de COVID-19, y resultados de procalcitonina, cuyas muestras de secreción traqueal y/o hemocultivo presentaron desarrollo de Klebsiella pneumoniae y Pseudomonas aeruginosa. Su análisis estadístico fue desarrollado mediante la prueba Chi Cuadrado de Pearson. RESULTADOS. Se recibieron 861 muestras de hemocultivo y 391 de secreción traqueal, obteniéndose: 32% aislamientos de Klebsiella pneumoniae y Pseudomonas aeruginosa multidrogo y extremadamente resistente. Entre los pacientes COVID-19 que fallecieron, 34,4% mostraron incrementos de procalcitonina. Al contrario, entre los pacientes que sobrevivieron sólo en 8,8% se observó incrementos de procalcitonina evidenciándose un vínculo entre el incremento de procalcitonina y mortalidad. CONCLUSIONES. No existe diferencia en relación al incremento en los valores de procalcitonina en pacientes COVID-19 con co-infección o infección secundaria por Klebsiella pneumoniae y Pseudomonas aeruginosa multidrogo y extremadamente resistente y los valores de procalcitonina en pacientes con coinfección e infección secundaria con otro tipo de aislamientos bacterianos.

INTRODUCTION. Procalcitonin is a biomarker that can be used as a diagnostic support in bacterial infections and the monitoring of antibiotic treatment, especially in patients with sepsis. Hence, it was used during the COVID-19 pandemic OBJECTIVE. To determine the values of procalcitonin in patients with COVID-19 and to define a possible correlation between its increase and linkage in co-infection or secondary infection by Klebsiella pneumoniae and Pseudomonas aeruginosa with multidrug resistance and extended resistance to antibiotics. MATERIALS AND METHODS. Retrospective observational, descriptive cross-sectional study, conducted from May 1 to October 31, 2020 at the Hospital de Especialidades Carlos Andrade Marín on 7028 adult patients, hospitalized, with diagnosis of COVID-19, and procalcitonin results, whose tracheal secretion and/or blood culture samples presented development of Klebsiella pneumoniae and Pseudomonas aeruginosa. Their statistical analysis was developed using Pearson's Chi-squared test. RESULTS. We received 861 blood culture and 391 tracheal secretion samples, obtaining: 32% isolates of Klebsiella pneumoniae and multidrug-resistant and extremely resistant Pseudomonas aeruginosa. Among the COVID-19 patients who died, 34.4% showed increased procalcitonin levels. On the contrary, among patients who survived, only 8.8% showed increased procalcitonin levels, showing a link between increased procalcitonin levels and mortality. CONCLUSIONS. There is no difference in relation to the increase in procalcitonin values in COVID-19 patients with co-infection or secondary infection by Klebsiella pneumoniae and multidrug-resistant and extremely resistant Pseudomonas aeruginosa and procalcitonin values in patients with co-infection and secondary infection with other types of bacterial isolates.

Procalcitonin and C-reactive protein: markers in the early diagnosis of anastomotic leak.

OBJECTIVE: To determine the efficacy of serum procalcitonin (PCT) and C-reactive protein (CRP) in the early diagnosis of anastomotic leak (AL) in patients undergoing colorectal surgery. METHOD: Diagnostic test in a tertiary care hospital. Patients who did not have preoperative measurements of PCT and CRP were excluded. Those with postoperative infection not related to AL were eliminated. The diagnostic efficacy measures were sensitivity (Sn), specificity (Sp), positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative (LR-) likelihood ratios, and area under the receiver operating characteristic curve (AUROC). RESULTS: Thirty-nine patients were analyzed; six had AL (15.4%). PCT and CRP increased on the second postoperative day, only in patients with AL. The cut-off points at the second postoperative day were 1.55 ng/mL for PCT and 11.25 mg/L for CRP. The most efficacious test was PCR at second postoperative day (AUROC: 1.00; Sn: 100%; Sp: 96.7%; PPV: 85.7%; NPV: 100%; LR+: 33.0). CONCLUSIONS: CRP at second postoperative day was the most effective test in the early diagnosis of AL in patients undergoing colorectal surgery, with a cut-off point lower than that reported in the international literature.

OBJETIVO: Determinar la eficacia de la procalcitonina (PCT) y la proteína C reactiva (PCR) séricas en el diagnóstico de fuga anastomótica (FA) en los pacientes sometidos a cirugía colorrectal. MÉTODO: Prueba diagnóstica en un hospital de tercer nivel. Se excluyeron los pacientes que no tuvieron mediciones preoperatorias de PCT y PCR. Se eliminaron los que cursaron con infección posoperatoria no relacionada con FA. Las medidas de eficacia diagnóstica fueron sensibilidad (S), especificidad (E), valores predictivos positivo (VPP) y negativo (VPN), razones de verosimilitud positiva (RV+) y negativa (RV−), y área bajo la curva característica operativa del receptor (AUROC). RESULTADOS: Se analizaron 39 pacientes, de los cuales 6 (15.4%) tuvieron FA. La PCT y la PCR aumentaron al segundo día posoperatorio solo en los pacientes con FA. Los puntos de corte al día 2 fueron 1.55 ng/ml para PCT y 11.25 mg/l para PCR. La prueba más eficaz fue la PCR al día 2 (AUROC: 1.00; S: 100%; E: 96.7%; VPP: 85.7%; VPN: 100%; RV+: 33.0). CONCLUSIONES: La PCR en el segundo día posoperatorio fue la prueba más eficaz en el diagnóstico temprano de FA en los pacientes sometidos a cirugía colorrectal, con un punto de corte inferior a lo reportado en la literatura internacional.

Low-cost, facile droplet modification of screen-printed arrays for internally validated electrochemical detection of serum procalcitonin.

This manuscript presents the design and facile production of screen-printed arrays (SPAs) for the internally validated determination of raised levels of serum procalcitonin (PCT). The screen-printing methodology produced SPAs with six individual working electrodes that exhibit an inter-array reproducibility of 3.64% and 5.51% for the electrochemically active surface area and heterogenous electrochemical rate constant respectively. The SPAs were modified with antibodies specific for the detection of PCT through a facile methodology, where each stage simply uses droplets incubated on the surface, allowing for their mass-production. This platform was used for the detection of PCT, achieving a linear dynamic range between 1 and 10 ng mL-1 with a sensor sensitivity of 1.35 × 10-10 NIC%/ng mL-1. The SPA produced an intra- and inter-day %RSD of 4.00 and 5.05%, with a material cost of £1.14. Internally validated human serum results (3 sample measurements, 3 control) for raised levels of PCT (>2 ng mL-1) were obtained, with no interference effects seen from CRP and IL-6. This SPA platform has the potential to offer clinicians vital information to rapidly begin treatment for "query sepsis" patients while awaiting results from more lengthy remote laboratory testing methods. Analytical ranges tested make this an ideal approach for rapid testing in specific patient populations (such as neonates or critically ill patients) in which PCT ranges are inherently wider. Due to the facile modification methods, we predict this could be used for various analytes on a single array, or the array increased further to maintain the internal validation of the system.

Avaliação da procalcitonina como tecnologia de saúde a ser incorporada em um hospital universitário para redução de tempo de tratamento com antimicrobianos / Evaluation of procalcitonin as a health technology to be incorporated in a university hospital to reduce treatment time with antimicrobials

Introdução: O uso do biomarcador procalcitonina (PCT) de forma racionalizada pode contribuir para reduzir o uso excessivo de antimicrobianos, poupar recursos e qualificar o cuidado com o paciente. Objetivo: Avaliar a eficácia da PCT na redução do tempo de tratamento com antimicrobianos e o impacto financeiro e factibilidade da incorporação desta tecnologia a partir de cenários simulados em um hospital de pequeno porte e média complexidade. Material e Métodos: Revisão da literatura, a partir da base de dados Pubmed seguida de análise de custo em quatro cenários simulados, comparando o PCR com a PCT. Foram incluídos ensaios clínicos randomizados e revisões sistemáticas cuja intervenção consistia no uso de PCT para guiar o tempo de tratamento com antimicrobianos. A seleção e extração dos dados foi realizada por quatro revisores independentes. A análise de custo foi realizada por meio de cenários simulados com os antimicrobianos de maior impacto na instituição totalizando doze terapias analisadas, a partir de dados de custos efetivamente desembolsados. Resultados: Foram selecionados 8 artigos para a análise final. A PCT possibilitou redução significativa de tempo de tratamento, redução de mortalidade, tempo de internação, eventos adversos e custos. A simulação de custo demonstrou que o cenário com PCT foi mais econômico para 67% das terapias analisadas, chegando à uma economia de até R$567,86 por tratamento, no caso da terapia combinada com meropenem, vancomicina e polimixina. Conclusão: A terapia guiada pela PCT reduz tempo de tratamento, internação e mortalidade apresentando impacto considerável na redução dos custos diretos, sendo factível a sua incorporação no cenário analisado

Introduction: The use of the procalcitonin (PCT) biomarker in a rationalized manner can contribute to reducing the excessive usage of antimicrobial, saving resources and improving patient care. Objective: To evaluate the effectiveness of PCT in reducing antimicrobial treatment time and the financial impact and feasibility of incorporating this technology based on simulated scenarios in a small and medium-complexity hospital. Material and Methods: Literature review, based on the Pubmed database followed by cost analysis in four simulated scenarios, comparing PCR with PCT test. Randomized clinical trials and systematic reviews whose intervention consisted of the use of PCT to guide the duration of antimicrobial treatment were included. Data selection and extraction was carried out by four independent reviewers. The cost analysis was carried out through simulated scenarios with the twelve therapies with the greatest impact on the institution, based on data of costs actually disbursed. Results: The final analysis included 8 articles. PCT resulted in significant reduction of duration of antibiotic treatment, reduction in mortality, length of stay, adverse events and costs. The cost simulation demonstrated that the PCT scenario was more economical for 67% of therapies analyzed, reaching savings up to R$567.86 per treatment, in the case of combined therapy with meropenem, vancomycin and polymyxin.Conclusion: PCT-guided therapy reduces treatment duration, hospitalization and mortality, presenting a considerable impact on reducing direct costs, making it feasible to incorporate it into the analyzed scenario.

The Inflammatory Biomarkers Behavior Profile of Patients Following Elective Degenerative Spine Surgery and Differences Compared to Those Coursing With a Postoperative Spinal Infection: Protocol for a Systematic Review.

BACKGROUND: The incidence of postoperative spinal infection (PSI) ranges from 0% to 10%, with devastating effects on the patient prognosis because of higher morbidity while increasing costs to the health care system. PSIs are elusive and difficult to diagnose, especially in the early postoperative state, because of confusing clinical symptoms, rise in serum biomarkers, or imaging studies. Current research on diagnosis has focused on serum biomarkers; nevertheless, most series rely on retrospective cohorts where biomarkers are studied individually and at different time points. OBJECTIVE: This paper presents the protocol for a systematic review that aims to determine the inflammatory biomarker behavior profile of patients following elective degenerative spine surgery and their differences compared to those coursing with PSIs. METHODS: The proposed systematic review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. This protocol was registered at PROSPERO on January 19, 2022. We will include studies related to biomarkers in adult patients operated on for degenerative spinal diseases and those developing PSIs. The following information will be extracted from the papers: (1) study title; (2) study author; (3) year; (4) evidence level; (5) research type; (6) diagnosis group (elective postoperative degenerative disease or PSI); (7a) region (cervical, thoracic, lumbosacral, and coccygeal); (7b) type of infection by anatomical or radiological site; (8) surgery type (including instrumentation or not); (9) number of cases; (10) mean age or individual age; (11) individual serum biomarker values from the preoperative state up to 90 days postoperative for both groups, including (10a) interleukin-6, (10b) presepsin, (10c) erythrocyte sedimentation rate, (10d) leukocyte count, (10e) neutrophil count, (10f) C-reactive protein, (10g) serum amyloid, (10h) white cell count, (10i) albumin, (10j) prealbumin, (10k) procalcitonin, (10l) retinol-associated protein, and (10m) Dickkopf-1; (11) postoperative days at symptoms or diagnosis; (12) type of organism; (13) day of starting antibiotics; (14) duration of treatment; and (15) any biases (including comorbidities, especially those affecting immunological status). All data on biomarkers will be presented graphically over time. RESULTS: No ethical approval will be required, as this review is based on published data and does not involve interaction with human participants. The search for this systematic review commenced in February 2021, and we expect to publish the findings in mid-2023. CONCLUSIONS: This study will provide the behavior profile of biomarkers for PSI and patients following elective surgery for degenerative spinal diseases from the preoperative period up to 90 days postoperative, providing cutoff values on the day of diagnosis. This research will provide clinicians with highly trustable cutoff reference values for PSI diagnosis. Finally, we expect to provide a basis for future research on biomarkers that help diagnose more accurately and in a timely manner in the early stages of illness, ultimately impacting the patient's physical and mental health, and reducing the disease burden. TRIAL REGISTRATION: PROSPERO CRD42022304645; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=304645. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/41555.

Determining the relationship between serum acute phase reactants and cervical premalignant lesions: a cohort study

Abstract BACKGROUND: Acute phase reactants play a role in the progression and prognosis of many malignant and premalignant tumors. This study investigated the diagnostic value of certain reactants as markers for cervical premalignant lesions. OBJECTIVES: Despite advanced screening and vaccination programs, cervical cancer remains a serious health problem worldwide. We aimed to determine the possible relationship between premalignant cervical disease and serum acute phase reactant levels. DESIGN AND SETTING: This study included 124 volunteers who underwent cervical cancer screening. We divided the patients into three groups according to cervical cytology and histopathological findings as follows: no cervical lesion, low-grade neoplasia, or high-grade neoplasia. METHODS: We included women aged 25-65 years with benign smear or colposcopy results, low- and high-grade squamous intraepithelial lesions. The benign group was based only on cytology findings, whereas the other groups were based on histopathology findings. Demographic data and serum albumin, fibrinogen, ferritin, and procalcitonin levels were evaluated in the three groups. RESULTS: We found significant differences among the three groups in terms of age, albumin level, albumin/fibrinogen ratio, and procalcitonin level. The regression analysis revealed lower serum albumin levels in the low- and high-grade squamous intraepithelial lesion groups compared with the benign group. CONCLUSION: This is the first study to evaluate the importance of serum inflammatory markers in cervical intraepithelial lesions. Our results indicate that serum albumin level, albumin/fibrinogen ratio, procalcitonin level, and neutrophil values differ among cervical intraepithelial lesions.

The Impact of Antimicrobial Stewardship in Treating Patients with Escherichia coli Bacteremia in a Small Single Center Community Hospital.

Purpose: There are many challenges that pharmacist led antimicrobial stewardship programs can encounter including lack of resources, costs, and inaccurate antimicrobial susceptibility testing (AST) results. The COVID-19 pandemic has led to increased resistance especially with gram negative infections. At a small single center community hospital, gram negative infections, particularly Escherichia coli infections, predominately occur. Therefore, this study aims to address gram negative bacteremia burden and its impact on antimicrobial stewardship efforts for combatting Escherichia coli and ESBL organisms with such barriers during the pandemic. Methods: In a retrospective cohort study, patients ≥ 18 years of age from a small community hospital were reviewed. Patients were excluded if their blood cultures were not positive for Escherichia coli and if antibiotics were not initiated during hospital stay. The primary endpoint was to determine the length of hospital stay. Critical secondary endpoints include antibiotic de-escalations, duration of antibiotics, time to definitive antibiotic therapy, serum procalcitonin levels, blood culture availabilities, MIC breakpoints, co-infection of COVID-19, and Clostridioides difficile occurrences. Results: Out of 74 patients with gram negative bacteremia, 41 patients specifically had Escherichia coli bacteremia. The primary endpoint results showed that patients with Escherichia coli bacteremia that stayed in the ICU had a length of stay of 13.6 days. Patients with Escherichia coli bacteremia in the Non-ICU setting has a length of stay of 7.3 days, and patients with ESBL bacteremia in the Non-ICU setting had a length of stay of 6.8 days. Conclusions: Despite the various challenges that antimicrobial stewardship programs (ASP) face in a single center small community hospital, the ASP at this small community hospital utilizes various policies and tools to increase appropriate antibiotic use and decrease hospital length of stay in patients with Escherichia coli bacteremia.

Asociación de marcadores inflamatorios en COVID-19 severo al ingreso con mortalidad y disfunción orgánica / Association of severe COVID-19 inflammatory markers at hospitalization with mortality and organic dysfunction / Associação de marcadores inflamatórios em COVID-19 grave na admissão com mortalidade e disfunção orgânica

Resumen: Introducción: se ha demostrado que los niveles iniciales de marcadores inflamatorios involucrados en COVID-19 (ej. ferritina, proteína C reactiva, procalcitonina, dímero D e interleucina-6) se relacionan con la mortalidad, sin encontrar resultados similares en pacientes con COVID-19 severo o quienes se encuentran bajo ventilación mecánica invasiva. Objetivo: determinar el nivel sérico con mayor sensibilidad y especificidad en los marcadores inflamatorios con relación a la mortalidad y gravedad de la disfunción orgánica en pacientes con COVID-19 severo usuarios de ventilación mecánica invasiva en las primeras 48 horas tras el ingreso hospitalario. Material y métodos: se realizó un estudio descriptivo de tipo cohorte retrospectiva y longitudinal en pacientes con diagnóstico de COVID-19 severo que fueran intubados antes de 48 horas tras el ingreso hospitalario por falla respiratoria aguda de enero de 2021 a agosto de 2021. Se determinó la relación entre los niveles de estos marcadores con las escalas pronósticas (SOFA, APACHE-II y SAPS-II), días de estancia hospitalaria, días en la Unidad de Terapia Intensiva Respiratoria, días de ventilación mecánica invasiva y las características de la mecánica ventilatoria inicial. Se agruparon los marcadores en niveles elevados y bajos para determinar su papel individual y en conjunto con los desenlaces. Resultados: se estudió una N = 218, con predominio de género masculino (77.5%) con media de edad de 60.3 ± 12.8 años. La hipertensión arterial sistémica y la diabetes mellitus tipo 2 fueron las comorbilidades más prevalentes (50.5% y 26.1%, respectivamente). La mediana de la relación PaO2/FiO2 fue de 128 mmHg (83.3-204.2), con una mortalidad total de 24.8%. Los niveles de biomarcadores con mayor sensibilidad para mortalidad y disfunción orgánica fueron: proteína C reactiva: ≥ 16 mg/dL, procalcitonina: ≥ 0.83 ng/mL, dímero D: ≥ 1,290 ng/mL, ferritina: ≥ 1,450 ng/mL e interleucina-6: ≥ 195 pg/mL. La procalcitonina y la interleucina-6 de manera aislada demostraron mayor riesgo de mortalidad y peor disfunción orgánica. Los marcadores inflamatorios se relacionaron a peor desenlace con respecto a las características del sistema respiratorio y el grado de alteración en gases arteriales. De forma conjunta (≥ 3 altos), los marcadores inflamatorios se relacionaron a mayor número de días de estancia hospitalaria, días en la Unidad de Terapia Intensiva Respiratoria y de días de ventilación mecánica invasiva. La proteína C reactiva, procalcitonina e interleucina-6 se asociaron a mayor riesgo de peor grado de disfunción orgánica por SOFA y peor pronóstico por APACHE-II y SAPS-II. Conclusión: la medición individual y conjunta de marcadores inflamatorios al ingreso hospitalario puede identificar a pacientes con mayor riesgo de estancia hospitalaria prolongada, así como ventilación mecánica invasiva, con mayor riesgo de mortalidad en el caso de procalcitonina e interleucina-6.

Abstract: Introduction: it has being demonstrated that the initial levels of inflammatory markers involved in COVID-19 (eg. C-reactive protein, procalcitonin, D-dimer, ferritin and interleukine-6) have an association with mortality, in different degree on severe COVID-19 patients or in those on invasive mechanical ventilation secondary to COVID-19 related acute respiratory distress syndrome. Objective: to determine the serum levels of these markers with the greatest sensibility and specificity for mortality and worst organ dysfunction in patients under invasive mechanical ventilation within the first 48 hours of hospitalization. Material and methods: in a retrospective and longitudinal cohort of severe COVID-19 patients on invasive mechanical ventilation within first 48 hours of hospitalization due to respiratory failure through January 2021 to August 2021, we determined the relation of inflammatory markers with prognostic scores (SOFA, APACHE-II and SAPS-II), hospital length-of-stay (LOS), intensive care LOS, invasive ventilation's days and initial ventilatory mechanics. We divided markers in high and low levels to identify the relation between each one and by groups with the outcomes. Results: we studied a N = 218, with male predominance (77.5%) and mean age of 60.3 ± 12.8 years. Arterial hypertension and diabetes mellitus type 2 were the most prevalent co-comorbidities (50.5% y 26.1%, respectively). The median initial PaO2/FiO2 was 128 mmHg (83.3-204.2), with a total mortality rate of 24.8%. Inflammatory markers levels with the highest sensibility for mortality were: C-reactive protein: ≥ 16 mg/dL, procalcitonin: ≥ 0.83 ng/mL, D-dimer: ≥ 1,290 ng/mL, ferritin: ≥ 1,450 ng/mL and interleukin-6: ≥ 195 pg/mL. Procalcitonin and interleukin-6 were associated to higher risk of mortality and worst organ dysfunction. The inflammatory markers were related with worst outcome in relation to respiratory mechanics and the amount of arterial-blood gases' alteration. Having ≥ 3 inflammatory markers within high levels was associated with prolonged LOS, more intensive care LOS and more days under invasive mechanical ventilation. The c-reactive protein, procalcitonin and interleukin-6 had higher organic dysfunction defined by SOFA and worst outcome defined by APACHE-II and SAPS-II. Conclusion: individual and joint measurement of inflammatory markers at hospitalization can identify patients with greater risk of longer hospital LOS, intensive care LOS and longer mechanical ventilation's days, with greater risk of mortality with higher procalcitonin and interleukine-6 serum levels.

Resumo: Introdução: demonstrou-se que os níveis iniciais de marcadores inflamatórios envolvidos no COVID-19 (por exemplo, ferritina, proteína C reativa, procalcitonina, D-dímero e interleucina-6) estão relacionados à mortalidade, sem encontrar resultados semelhantes em pacientes com COVID-19 grave ou que estejam sob ventilação mecânica invasiva. Objetivos: nosso objetivo foi determinar o nível sérico com maior sensibilidade e especificidade em marcadores inflamatórios em relação à mortalidade e gravidade da disfunção orgânica em pacientes com COVID-19 grave que usaram ventilação mecânica invasiva nas primeiras 48 horas após a admissão hospitalar. Material e métodos: realizou-se um estudo descritivo do tipo coorte retrospectivo e longitudinal em pacientes diagnosticados com COVID-19 grave que foram intubados nas primeiras 48 horas após a internação hospitalar por insuficiência respiratória aguda no período de janeiro de 2021 a agosto de 2021. A relação entre os níveis desses marcadores com as escalas de prognóstico (SOFA, APACHE-II e SAPS-II), dias de internação, dias na unidade de terapia intensiva respiratória, dias de ventilação mecânica invasiva e as características da ventilação mecânica inicial. Agrupou-se marcadores em níveis altos e baixos para determinar seu papel individualmente e em conjunto com os resultados. Resultados: estudou-se uma N = 218, com predominância do sexo masculino (77.5%) com idade média de 60.3 ± 12.8 anos. A hipertensão arterial sistêmica e a diabetes mellitus tipo 2 foram as comorbidades mais prevalentes (50.5% e 26.1%, respectivamente). A mediana da relação PaO2/FiO2 foi de 128 mmHg (83.3-204.2), com mortalidade total de 24.8%. Os níveis de biomarcadores com maior sensibilidade para mortalidade e disfunção orgânica foram: proteína C reativa: ≥ 16 mg/dL, procalcitonina: ≥ 0.83 ng/mL, dímero: ≥ 1.290 ng/mL, ferritina: ≥ 1.450 ng/mL, e interleucina-6: ≥ 195 pg/mL. A procalcitonina e a interleucina-6 sozinhas demonstraram maior risco de mortalidade e pior disfunção orgânica. Os marcadores inflamatórios foram relacionados a pior evolução quanto às características do sistema respiratório e ao grau de alteração dos gases arteriais. Juntos (≥ 3 altos), os marcadores inflamatórios foram relacionados a um maior número de dias de internação, dias na unidade de terapia intensiva respiratória e dias de ventilação mecânica invasiva. A proteína C-reativa, procalcitonina e interleucina-6 foram associadas a maior risco de pior grau de disfunção orgânica pelo SOFA e pior prognóstico pelo APACHE-II e SAPS-II. Conclusão: a medida individual e conjunta de marcadores inflamatórios na admissão hospitalar pode identificar pacientes com maior risco de internação prolongada e ventilação mecânica invasiva, com maior risco de mortalidade no caso da procalcitonina e interleucina-6.

Procalcitonina y proteína C reactiva séricas como biomarcadores predictivos de dehiscencia de anastomosis intestinal en cirugía colorrectal.

BACKGROUND: There has been recent interest in the seric levels of procalcitonin (PCT) and C reactive protein (PCR) as a marker of intraabdominal infection after a colorrectal surgery, however, the actual literature remains inconclusive. OBJECTIVE: To test if C-Reactive Protein (PCR) and procalcitonin (PCT) as predictive factors of anastomotic leak after colorectal surgery. METHOD: Retrospective cohort, of patients with ileostomy or colostomy who had intestinal transit restitution by general surgeons in our center, from march 2018 to march 2020. RESULTS: We registered 4 (36.4%) anastomotic leaks. We compared median PCR and PCT between group 1 (without anastomotic leak) and group 2 (with anastomotic leak). Median PCT3PO was 4.86 ng/ml in group 1 vs 13.7 ng/ml in group 2, and PCT5PO was 1.3071 ng/ml vs 6.74 ng/ml (DS: 5.04 vs. 11.53 and 0.779 vs. 10.44). Median PCR3PO and PCR5PO was 194.7 mg/l in group 1 vs 100.97 mg/l in group 2, and 159.8 mg/l vs 65.67 mg/l, (DS: 88.78 vs. 82.01 and 94.77 vs. 58.009). CONCLUSIONS: Persistent higher levels of seric PCR and PCT at 3rd and 5th postoperative day could be an anastomotic leackage. This biomarkers might be added as additional criteria of discharge.

ANTECEDENTES: La medición sérica de procalcitonina (PCT) y proteína C reactiva (PCR) como marcadores de infección intraabdominal posterior a la cirugía colorrectal ha tomado interés en los recientes años, sin embargo, la literatura que existe en la actualidad no es concluyente. OBJETIVO: Evaluar los biomarcadores séricos de inflamación procalcitonina (PCT) y proteína C reactiva (PCR) como factores predictores para dehiscencia de anastomosis (DA) en cirugía colorrectal. MÉTODO: Cohorte retrospectiva de pacientes con cirugía abdominal, con ileostomía o colostomía, que fueron protocolizados para restitución del tránsito intestinal por el departamento de cirugía general en un hospital de tercer nivel, de marzo de 2018 a marzo de 2020. RESULTADOS: La DA ocurrió en 4 (36.4%) de 11 pacientes. Se comparó la media de dos grupos: el grupo 1 sin DA frente al grupo 2 que presentaron DA. Las concentraciones séricas de PCT3PO fueron de 4.86 ng/ml en el grupo 1 y 13.7 ng/ml en el grupo 2, y las de PCT5PO fueron de 1.3071 ng/ml y 6.74 ng/ml, respectivamente (desviación estándar [DE]: 5.04 vs. 11.53 y 0.779 vs. 10.44). Las concentraciones séricas de PCR3PO fueron de 194.7 mg/l en el grupo 1 y 100.97 mg/l en el grupo 2, y las de PCR5PO fueron de 159.8 mg/l y 65.67 mg/l, respectivamente (DE: 88.78 vs. 82.01 y 94.77 vs. 58.009). CONCLUSIONES: La persistencia de valores elevados den PCR y PCT séricas al tercer y quinto día posoperatorios pudieran demostrar DA. Estos marcadores podrían agregarse como criterio de egreso.

Procalcitonina sérica como marcador de la función del injerto en el postrasplante renal inmediato

Contexto la procalcitonina (PCT) podría ser útil en la evaluación de la función del injerto renal (IR) en el postrasplante inmediato, ya que sus niveles se incrementan posterior a la elevación de citocinas inflamatorias (IL-6, TNF-ß) durante eventos de disfunción renal. Objetivo determinar la asociación de la PCT sérica con la función del injerto renal en el periodo postrasplante inmediato. Metodología cohorte retrospectiva de septiembre del 2018 a abril del 2019 en la División de Nefrología y Trasplantes, del Centro Médico Nacional de Occidente (CMNO), del Instituto Mexicano del Seguro Social (IMSS). Se incluyeron 62 receptores de trasplante renal de donante vivo (DV) y fallecido (DF) con determinación de PCT antes del séptimo día del TR y el registro de eventos de disfunción temprana del injerto (DTI), comparados con pacientes sin DTI (sDTI). Resultados los receptores con DTI presentaron niveles más altos de PCT (13,90, 3,90, 1,22 ng/mL) comparado con el grupo sin DTI (0,32, 0,31 y 0,22 ng/ml) en los días 1, 3 y 5 respectivamente; p < 0,05. Conclusiones la PCT es un marcador biológico asociado a DTI en el postrasplante renal inmediato.

Background Procalcitonin (PCT) could be useful for evaluation of the renal allograft (RG) in the immediate post-transplant since its levels increase after elevation of the inflammatory cytokines (IL-6, TNF-ß) during events of renal failure. Purpose Our objective was to determine the association of serum PCT with the function of the RG in the immediate post-transplant. Methodology A retrospective cohort from September 2018- April 2019 in the National Western Medical Center of the Mexican Social Security Institute (IMSS), was performed. Sixty-two recipients of living donor (LD) and deceased donor (DD) renal transplant (RT) with PCT evaluation before the seventh days of RT were included; and, events of early renal allograft failure (EAF) were recorded and compared to patients no EAF (nEAF). Results The recipients with EAF presented with higher PCT levels (13.90, 3.90, 1.22 ng/mL) compared to the nEAF group (0.32, 0.31, and 0.22 ng/ml) on days 1, 3, and 5, respectively (p < 0.05). Conclusions The PCT is a biological marker associated with EAF in the immediate post-transplant.

Utilidad del modelo 5MPB-Toledo para predecir bacteriemia en el paciente anciano / Usefulness of the 5MPB-Toledo model to predict bacteremia in the elderly patient

Resumen Objetivo: Analizar la utilidad del modelo predictivo de bacteriemia (5MPB-Toledo) en los mayores de 65 años atendidos por infección en el servicio de urgencias (SU). Material y Método: Estudio observacional prospectivo y multicéntrico de los hemocultivos (HC) obtenidos en pacientes mayores de 65 años atendidos por infección en 66 SU españoles desde el 1 de diciembre de 2019 hasta el 30 de abril de 2020. Se analizó la capacidad predictiva del modelo con el área bajo la curva (ABC) de la característica operativa del receptor (COR) y se calculó el rendimiento diagnóstico de los puntos de corte (PC) del modelo elegido con los cálculos de la sensibilidad, la especificidad, el valor predictivo positivo y el valor predictivo negativo. Resultados: Se incluyeron 2.401 episodios de HC extraídos. De ellos, se consideró como bacteriemia verdadera a 579 (24,11%) y como HC negativo a 1.822 (75,89%). Entre los negativos, 138 (5,74%) se consideraron contaminados. Se categorizó a los pacientes en bajo (0-2 puntos), moderado (3-5 puntos) y alto (6-8 puntos) riesgo, con una probabilidad de bacteriemia de 1,2%, 18,1% y 80,7%, respectivamente. El ABC-COR del modelo tras remuestreo fue de 0,908 (IC 95%: 0,897-0,924). El rendimiento diagnóstico del modelo, considerando un PC ≥ 5 puntos, obtiene una sensibilidad de 94% (IC 95%:92-96), especificidad de 77% (IC 95%:76-79) y un valor predictivo negativo de 97% (IC 95%:96-98). Conclusión: El modelo 5MPB-Toledo es de utilidad para predecir bacteriemia en los mayores de 65 años atendidos en el SU por un episodio de infección.

Abstract Objective: To analyse a risk score to predict bacteremia (MPB5-Toledo) in the patients aged older 65 years seen in the emergency departments (ED) due to infections. Patients and Methods: Prospective and multicenter observational cohort study of the blood cultures (BC) ordered in 66 Spanish ED for patients aged older 65 years seen from December 1, 2019, to April 30, 2020. The predictive ability of the model was analyzed with the area under the Receiver Operating Characteristic curve (AUC-ROC). The prognostic performance for true bacteremia was calculated with the cut-off values chosen for getting the sensitivity, specificity, positive predictive value and negative predictive value. Results: A total of 2.401 blood samples wered cultured. True cases of bacteremia were confirmed in 579 (24.11%). The remaining 1.822 cultures (75.89%) wered negative. And, 138 (5.74%) were judged to be contaminated. Low risk for bacteremia was indicated by a score of 0 to 2 points, intermediate risk by 3 to 5 points, and high risk by 6 to 8 points. Bacteremia in these 3 risk groups was predicted for 1.2%, 18.1%, and 80.7%, respectively. The model´s area under the receiver ope rating characteristic curve was 0.908 (95% CI, 0.897-0.924). The prognostic performance with a model´s cut-off value of ≥ 5 points achieved 94% (95% CI: 92-96) sensitivity, 77% (95% CI: 76-79) specificity, and negative predictive value of 97% (95% CI: 96-98). Conclusion: The 5MPB-Toledo score is useful for predicting bacteremia in the patients aged older 65 years seen in the emergency departments due to infections.

Papel da mudança nos níveis de marcadores inflamatórios pós drenagem na previsão de resultado em colangite aguda / Role of change in the levels of inflammatory markers post drainage in predicting outcome in acute cholangitis

ABSTRACT Background: Acute cholangitis (AC) is a gastro-intestinal emergency associated with significant mortality. Role of change in the levels of inflammatory markers post drainage in predicting outcome in acute cholangitis is uncertain. Objective: To evaluate the predictive value of changes in C-reactive protein (CRP) and procalcitonin levels after biliary drainage in relation to outcomes (survival or mortality) at 1 month. Methods A prospective observational study of consecutive adults presenting with AC was performed. At admission and at 48 hours post biliary drainage, procalcitonin and CRP were sent. Results: Between August 2020 till December 2020 we recruited 72 consecutive patients of AC. The median age of the patients was 55 years (range 43-62 years) and 42 (58.33%) were females. Although the delta change in serum procalcitonin (P value<0.001) and CRP (P value<0.001) was significant, it had no bearing on the outcome. Altered sensorium and INR were independently associated with mortality at 1 month. The 30-day mortality prediction of day 0 procalcitonin was measured by receiver operating characteristic analysis which resulted in an area under the curve of 0.697 with a 95% confidence interval (95%CI) of 0.545-0.849. The optimal cut-off of procalcitonin would be 0.57ng/mL with a sensitivity and specificity of 80% and 60% respectively to predict mortality. Conclusion: Change in serum procalcitonin and CRP levels at 48 hours post drainage although significant, had no impact on the outcome of acute cholangitis.

RESUMO Contexto: A colangite aguda (CA) é uma emergência gastro-intestinal associada à significativa mortalidade. O papel da mudança nos níveis de marcadores inflamatórios pós drenagem na previsão do desfecho em CA é incerto. Objetivo: Avaliar o valor preditivo das alterações nos níveis de proteína reativa C (PCR) e procalcitonina após drenagem biliar em relação aos desfechos (sobrevida ou mortalidade) em um mês. Métodos Realizou-se estudo observacional prospectivo de adultos consecutivos que apresentam CA. Na admissão e após 48 horas de drenagem biliar, foram analisadas a procalcitonina e a PCR. Resultados Entre agosto de 2020 e dezembro de 2020, foram recrutados 72 pacientes consecutivos de CA. A idade mediana dos pacientes foi de 55 anos (faixa de 43 a 62 anos) e 42 (58,33%) do sexo feminino. Embora a variação delta no soro procalcitonina (valor P<0,001) e PCR (valor P<0,001) tenha sido significativa, não houve influência sobre o resultado. Sensório alterado e INR foram independentemente associados à mortalidade em 1 mês. A previsão de mortalidade de 30 dias no dia 0 da procalcitonina foi medida pela análise característica operacional receptora que resultou em uma área sob a curva de 0,697 com intervalo de confiança de 95% (IC95%) de 0,545-0,849. O corte ideal de procalcitonina seria de 0,57ng/mL com sensibilidade e especificidade de 80% e 60% respectivamente para prever a mortalidade. Conclusão: A mudança nos níveis de procalcitonina sérica e PCR em 48 horas após a drenagem, embora significativa, não teve impacto no resultado da colangite aguda.

Antimicrobial Stewardship Programs: A Review of Strategies to Avoid Polymyxins and Carbapenems Misuse in Low Middle-Income Countries.

Antibiotics misuse and overuse are concerning issues worldwide, especially in low middle-income countries. These practices contribute to the increasing rates of antimicrobial resistance. One efficient strategy to avoid them is antimicrobial stewardship programs. In this review, we focus on the possible approaches to spare the prescription of polymyxins and carbapenems for the treatment of Acinetobacter baumannii, carbapenem-resistant Enterobacterales, and Pseudomonas aeruginosas infections. Additionally, we highlight how to implement cumulative antibiograms and biomarkers to a sooner de-escalation of antibiotics.

Surgical Management of Infected Pancreatic Necrosis. Case Series in a Quaternary Care Hospital in Bogotá, Colombia, 2014-2021 / Manejo quirúrgico de la necrosis pancreática infectada. Serie de casos en un hospital de cuarto nivel en Bogotá, Colombia, 2014-2021

Abstract Introduction: Pancreatitis is a frequent pathology in our environment, mostly related to benign biliary pathology. It can progress to severe forms in 10-15 % of cases, where the pancreatic tissue becomes necrotic and forms large collections with risk of infection. We do not have epidemiological data about the incidence or management of this complication in Colombia. Aim: This study aims to study the prevalence of infected pancreatic necrosis and describe the cases identified in a quaternary care hospital between 2014 and 2021. Materials and methods: A cross-sectional observational study. We analyzed records of patients diagnosed with stage 2 pancreatitis. Those cases with infected pancreatic necrosis that underwent debridement plus laparoscopic and open surgical drainage at Hospital Universitario Mayor Méderi in Bogotá, Colombia, between January 2014 and January 2021 were studied. A convenience sampling was carried out without calculating the sample size. We collected the patients' demographic and clinical variables, performing a descriptive statistical analysis in Excel. Qualitative variables were described through absolute and relative frequencies, while quantitative ones were expressed through measures of central tendency and dispersion based on their distribution. Results: We analyzed 1020 episodes of pancreatitis, finding pancreatic necrosis in 30 patients, i.e., a period prevalence of 2.9 %. Of the patients, 83 % (n = 25) underwent open drainage, with 48 % (n = 12) mortality. About laparoscopic management, the reduction in postoperative organ failure was 40 % (n = 2), with a 30 % shorter hospital stay than the open drainage approach. Those patients with a level of procalcitonin (PCT) lower than 1.8 ng/mL had less mortality. Conclusions: The laparoscopic approach shows promising results regarding final morbidity and mortality.

Resumen Introducción: la pancreatitis es una patología frecuente en nuestro medio, mayormente relacionada con la patología biliar benigna. Esta puede progresar a formas severas en 10 %-15 % de los casos, en donde el tejido pancreático se necrosa y forma grandes colecciones, con riesgo de infección. En Colombia no conocemos los datos epidemiológicos acerca de la incidencia de este tipo de complicaciones, ni del manejo de las mismas. Objetivo: este estudio tiene como objetivo estudiar la prevalencia de la necrosis pancreática infectada y describir los casos identificados en un hospital de alto nivel de complejidad entre 2014 y 2021. Métodos: estudio observacional de corte transversal. Se analizaron los registros de pacientes diagnosticados con pancreatitis en segunda etapa. Se estudiaron aquellos casos que presentaron necrosis pancreática infectada y se sometieron a desbridamiento más drenaje quirúrgico por vía laparoscópica y abierta en el Hospital Universitario Mayor Méderi de Bogotá, Colombia, entre enero de 2014 y enero de 2021. Se realizó un muestreo por conveniencia, sin cálculo de tamaño de muestra. Se recolectaron variables demográficas y clínicas de los pacientes. Se realizó un análisis estadístico descriptivo de las variables obtenidas en Excel. Las variables cualitativas se describieron a través de frecuencias absolutas y relativas; mientras que las cuantitativas se expresaron mediante medidas de tendencia central y de dispersión en función de su distribución. Resultados: se analizaron 1020 episodios de pancreatitis y se evidenció necrosis pancreática en 30 pacientes, es decir, una prevalencia de período de 2,9 %. De los pacientes, 83 % (n = 25) se llevó a drenajes por vía abierta, con un 48 % (n = 12) de mortalidad. En relación con el manejo por vía laparoscópica, la reducción en la falla orgánica posoperatoria fue de 40 % (n = 2), con un 30 % menos de duración en la estancia hospitalaria, comparado con la vía abierta. Aquellos pacientes que presentaron un nivel de procalcitonina (PCT) menor de 1,8 ng/mL tuvieron menos mortalidad. Conclusiones: el abordaje laparoscópico muestra resultados prometedores en cuanto a la morbilidad y mortalidad final observada.

Do biomarkers have predictive value in the treatment modality of the patients diagnosed with bowel obstruction?

SUMMARY OBJECTIVES: This study aimed to investigate the ability of the biomarkers to predict the surgery treatment and mortality in patients above 18 years of age who were hospitalized with the diagnosis of bowel obstruction from the emergency department. METHODS: This is a 2-year retrospective study. The patients' demographic data, laboratory parameters on admission to emergency department, treatment modalities, and the length of hospital stay were recorded. Patients were divided into two groups: conservative and surgical treatment. Statistical analysis was performed to investigate the value of biomarkers in predicting mortality and the need for surgery. Data were analyzed using IBM SPSS version 22. RESULTS: A total of 179 patients were included in this study. Of these, 105 (58.7%) patients were treated conservative and 74 (41.3%) were treated operatively. The elevated procalcitonin (PCT) level, C-reactive protein, blood urea nitrogen-to-albumin ratio, and lactate-to-albumin ratio were significantly correlated with surgical treatment, length of hospital stay, and mortality. procalcitonin threshold value of 0.13 ng/mL was able to predict the need for surgical treatment, with a sensitivity of 79% and a specificity of 70.3%. Procalcitonin threshold value of 0.65 ng/mL was able to predict the mortality rate of the patients, with a sensitivity of 92.9% and a specificity of 78.1%. CONCLUSIONS: Biomarkers, especially procalcitonin, may be useful in bowel obstruction treatment management and may predict mortality.

Quick Sequential Organ Failure Assessment, Sequential Organ Failure Assessment, and Procalcitonin for Early Diagnosis and Prediction of Death in Elderly Patients with Suspicion of Sepsis in the Emergency Department, Based on Sepsis-3 Definition.

BACKGROUND: Sepsis is a disease with a high mortality rate without prompt treatment. However, this entity is difficult to diagnose in the elderly population in the emergency room; for this reason, it is necessary to have diagnostic tools for early detection. OBJECTIVE: The aim of the study was to determine the highest diagnostic yield of procalcitonin (PCT), Quick Sequential Organ Failure Assessment (qSOFA), and Sequential Organ Failure Assessment (SOFA) for sepsis (based on the sepsis-3 consensus), on admission at the emergency department, in those older than 65 years. METHODS: This is a diagnostic test study of a historical cohort of 65-year-old patients with suspected sepsis. RESULTS: In the sample of 179 patients, 53.6% had confirmed sepsis. Significant differences were found (p < 0.0001), with a greater diagnostic and predictive capacity of PCT for the diagnosis of sepsis (receiver operating characteristics curve area [area under the curve (AUC) = 0.883, 95% CI: 0.835-0.931] than qSOFA (AUC = 0.559, 95% CI: 0.485-0.663) and SOFA (AUC = 0.662, 95% CI: 0.584-0.739); these results were similar in the cohort of patients ≥75 years. In positive PCT(≥0.5 ng/mL), the sensitivity was 71.8% (95% CI: 62.36-81.39), specificity of 89.1% (95% CI: 81.87-96.45%), V+ 88.4% (95% CI: 80.73-96.19%), V- of 73.2% (95% CI: 64.14-82.39%), positive likelihood ratio of 6.63 (95% CI: 3.53-12.44), and negative likelihood ratio of 0.32 (95% CI: 0.23-0.44); these results were similar in the cohort of patients ≥75 years. Lactate ≥2 mmol/L (RR = 1.659 [95% CI: 1.002-2.747]) and PCT ≥0.5 ng/mL (RR = 1.942 [95% CI: 1.157-3.261]) showed a significant association with in-hospital mortality. CONCLUSION: In the elderly population with suspicion of infection on admission to the emergency department, qSOFA presents a low diagnostic performance of confirmed sepsis and in-hospital mortality, for which other tools with higher diagnostic and prognostic performance should be added, such as PCT and lactate.

C-reactive protein and procalcitonin after congenital heart surgery utilizing cardiopulmonary bypass: When should we be worried?

INTRODUCTION: To assess the efficacy of C-reactive protein (CRP) and procalcitonin (PCT) at identifying infection in children after congenital heart surgery (CHS) with cardiopulmonary bypass (CPB). MATERIALS AND METHODS: Systematic review of the literature was conducted to identify studies with data regarding CRP and/or PCT after CHS with CPB. The primary variables identified to be characterized were CRP and PCT at different timepoints. The main inclusion criteria were children who underwent CHS with CPB. Subset analyses for those with and without documented infection were conducted in similar fashion. A p value of less than .05 was considered statistically significant. RESULTS: A total of 21 studies were included for CRP with 1655 patients and a total of 9 studies were included for PCT with 882 patients. CRP peaked on postoperative Day 2. A significant difference was noted in those with infection only on postoperative Day 4 with a level of 53.60 mg/L in those with documented infection versus 29.68 mg/L in those without. PCT peaked on postoperative Day 2. A significant difference was noted in those with infection on postoperative Days 1, 2, and 3 with a level of 12.9 ng/ml in those with documented infection versus 5.6 ng/ml in those without. CONCLUSIONS: Both CRP and PCT increase after CHS with CPB and peak on postoperative day 2. PCT has a greater statistically significant difference in those with documented infection when compared to CRP and a PCT of greater than 5.6 ng/ml should raise suspicion for infection.

Methicillin-resistant Staphylococcus aureus of the clonal lineage ST5-SCCmecII-t2460 was associated with high mortality in a Wuhan hospital.

Methicillin-resistant Staphylococcus aureus (MRSA) is an important human pathogen that can cause serious infectious diseases. An emerging MRSA strain, ST5-SCCmecII spa-type-t2460 (SMRSA), has spread rapidly since its recent emergence in China, but little information is available about this lineage. In this study, 91 MRSA isolates were collected from patients treated in the Zhongnan Hospital, Wuhan University, from 2018 to 2019, and investigated for their molecular characteristics, antibiotic resistance profiles, and clinical characteristics. The predominant lineage, SMRSA, accounted for 37.4% (34/91) of the isolates, followed by ST239-SCCmecIII-t030 (19.8%, 18/91) and ST59-SCCmecIV-t437 (8.8%, 8/91). In contrast to the latter two non-SMRSA (nSMRSA) lineages, which are among the main MRSA found in Chinese settings, SMRSA exhibited small colony variant (SCV) phenotype and had extremely high resistance rates to erythromycin (100.0%), clindamycin (100.0%), levofloxacin (100.0%), tetracycline (97.1%), moxifloxacin (97.1%), and ciprofloxacin (100%), but was more susceptible to rifampicin (resistance rate 3%). The levels of white blood cells (WBC) and procalcitonin (PCT) and the 30-day mortality in patients infected with SMRSA were (12.54 ± 6.61) × 109/L, 0.66 ng/mL, and 52.9%, respectively, which were much higher than those in patients infected with nSMRSA. In addition, patients infected with SMRSA were more frequently admitted to the intensive care unit (ICU) and submitted to invasive procedures than those infected with nSMRSA. In conclusion, SMRSA showed SCV phenotype and exhibited multiple antibiotic-resistance profiles. In this study, SMRSA was associated with serious infections and poor prognosis. Compared with ST239, ST59, or other nSMRSA strains, patients infected with SMRSA strains have higher 30-day mortality, increased levels of inflammatory biomarkers, and more frequent ICU hospitalization and invasive procedures.