Cutaneous Mucormycosis in a Young Immunocompetent Trauma Patient: A Case Report.

Introduction: Mucormycosis, a rare and life-threatening infection, is caused by microorganisms of the Mucorales order. It affects almost exclusively immunocompromised and diabetic patients, requiring extensive surgical debridement and prolonged antifungal therapy. Discussion/Results: We report the case of a 26-year-old immunocompetent woman, presenting with cutaneous mucormycosis after suffering blunt force trauma. This rare occurrence of mucormycosis in an immunocompetent patient reinforces the importance of elevated clinical suspicion and early initiation of adequate surgical and antifungal treatment. Conclusion: Mucormycosis is a challenging condition with potentially devastating consequences. Timely diagnosis and appropriate management are vital to mitigate the morbidity and mortality associated with this condition. LEARNING POINTS: Cutaneous mucormycosis is a rare life-threatening infection that affects mainly immunocompromised patients.Certain circumstances warrant a high index of clinical suspicion in immunocompetent patients, and indicate histopathological examination.Treatment involves a multidisciplinary approach with aggressive surgical debridement, antifungal therapy, and elimination of risk factors.

A protocol for an international, multicentre pharmacokinetic study for Screening Antifungal Exposure in Intensive Care Units: The SAFE-ICU study.

Objective: To describe whether contemporary dosing of antifungal drugs achieves therapeutic exposures in critically ill patients that are associated with optimal outcomes. Adequate antifungal therapy is a key determinant of survival of critically ill patients with fungal infections. Critical illness can alter an antifungal agents' pharmacokinetics, increasing the risk of inappropriate antifungal exposure that may lead to treatment failure and/or toxicity. Design setting and participants: This international, multicentre, observational pharmacokinetic study will comprise adult critically ill patients prescribed antifungal agents including fluconazole, voriconazole, posaconazole, isavuconazole, caspofungin, micafungin, anidulafungin, and amphotericin B for the treatment or prophylaxis of invasive fungal disease. A minimum of 12 patients are targeted for enrolment for each antifungal agent, across 12 countries and 30 intensive care units to perform descriptive pharmacokinetics. Pharmacokinetic sampling will occur during two dosing intervals (occasions): firstly, between days 1 and 3, and secondly, between days 4 and 7 of the antifungal course, collecting three samples per occasion. Patients' demographic and clinical data will be collected. Main outcome measures: The primary endpoint of the study is attainment of pharmacokinetic/pharmacodynamic target exposures that are associated with optimal efficacy. Thirty-day mortality will also be measured. Results and conclusions: This study will describe whether contemporary antifungal drug dosing achieves drug exposures associated with optimal outcomes. Data will also be used for the development of antifungal dosing algorithms for critically ill patients. Optimised drug dosing should be considered a priority for improving clinical outcomes for critically ill patients with fungal infections.

Prevalence and factors associated with Frailty Syndrome in elderly people in Joinville / Prevalencia y factores asociados al Síndrome de Fragilidad en adultos mayores de Joinville / Prevalência e fatores associados à Síndrome da Fragilidade em idosos de Joinville

INTRODUCTION: With the aging of the Brazilian population, to scale and evaluate the profile of the vulnerable population for having the Frailty Syndrome in Elderly (FSE) and understanding its associated factors is of great importance. OBJECTIVE: To analyze the profile of elders corresponding to the information referred in the frailty indicators on the Edmonton Frail Scale on a geriatric specialized facility. METHODOLOGY: The present study is a cross-sectional, analytical study, with the elders from a geriatrics specialized facility in Joinville, Brazil. It was analyzed the social-economic profiles (gender, ethnicity, income and schooling) and the evaluation for the FSE, as well as comorbidities present. The project has been approved by the Ethics in Research Committee of UNIVILLE under the protocol number 40940020.6.0000.5366. RESULTS: the results were obtained from the 141 elderly interviewed, with 74 years old as the average age. Majority (60%) female, white (90,2%), of low scholar education (56%) and married or in a stable relationship (53,2%). The prevalence of some sort of fragility was of 17,7% (IC95%). DISCUSSION: Although the discussion over the criteria to establish FSE, the present study was based on the Edmonton Frail Scale. The local sample analyzed demonstrated how the discussion over schooling, smoking, income and the high rates of comorbidities predisposes to FSE and, in that way, also in a higher prevalence of elderly falls. This aligns with previous literature studies which showcase higher prevalence of falls in patients with these epidemiological characteristics. CONCLUSION: Despite some limitations of this present study, such as it being done in a well respected specialized geriatric facility, it does demonstrate the local profile of the elderly stricken with FSE.

INTRODUCCIÓN: Con el envejecimiento de la población brasileña, escalar y evaluar el perfil de la población vulnerable por tener el Síndrome de Fragilidad del Anciano (FSE) y comprender sus factores asociados es de gran importancia. OBJETIVO: Analizar el perfil de los ancianos correspondientes a las informaciones referidas en los indicadores de fragilidad de la Escala de Fragilidad de Edmonton en un establecimiento especializado en geriatría. METODOLOGÍA: El presente estudio es un estudio transversal, analítico, con ancianos de una unidad especializada en geriatría de Joinville, Brasil. Se analizaron los perfiles socioeconómicos (género, etnia, renta y escolaridad) y la evaluación para el FSE, así como las comorbilidades presentes. El proyecto ha sido aprobado por el Comité de Ética en Investigación de UNIVILLE bajo el protocolo número 40940020.6.0000.5366. RESULTADOS: los resultados fueron obtenidos de los 141 ancianos entrevistados, con 74 años como promedio de edad. Mayoritariamente (60%) mujeres, blancas (90,2%), de baja escolaridad (56%) y casadas o en pareja estable (53,2%). La prevalencia de algún tipo de fragilidad fue del 17,7% (IC95%). DISCUSIÓN: A pesar de la discusión sobre los criterios para establecer FSE, el presente estudio se basó en la Escala de Frágil de Edmonton. La muestra local analizada demostró cómo la discusión sobre la escolaridad, el tabaquismo, la renta y los altos índices de comorbilidades predisponen a la EEF y, de ese modo, también a una mayor prevalencia de caídas en ancianos. Esto se alinea con estudios previos de la literatura que muestran una mayor prevalencia de caídas en pacientes con estas características epidemiológicas. CONCLUSIÓN: A pesar de algunas limitaciones de este presente estudio, como que se realizó en un centro geriátrico especializado muy respetado, demuestra el perfil local de los ancianos afectados por FSE.

INTRODUÇÃO: Com o envelhecimento da população Brasileira, dimensionar e avaliar o perfil da população vulnerável a ter a Síndrome da Fragilidade no Idoso (SFI) e entender seus fatores associados é de grande importância. OBJETIVO: Analisar o perfil de idosos que correspondem às informações referentes aos indicadores de fragilidade do questionário de fragilidade de Edmonton, em uma clínica especializada em geriatria. MÉTODO: O presente estudo é do tipo transversal, analítico, com idosos da Unidade especializada de atenção geriátrica em Joinville, Brasil. Foram analisados perfil social econômico (escolaridade, renda, raça, sexo) e a avaliação para a SFI e as comorbidades no idoso. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da UNIVILLE sob parecer de n° 40940020.6.0000.5366. RESULTADO: Os resultados do estudo foram a partir dos 141 idosos entrevistados, com uma média de 74 anos de idade. A maioria (60%) do sexo feminino, de cor branca (90,1%), de baixa escolaridade (56%) e casados ou em união estável (53,2%). A prevalência de algum nível de fragilidade foi de 17,7% (IC95%). DISCUSSÃO: Apesar da discussão sobre os critérios para definição da SFI, o presente estudo baseou-se no questionário de fragilidade de Edmonton - Edmonton Frail Scale. A amostra local da população representa como discussão sobre a escolaridade, tabagismo, renda e o grande número de comorbidades predispõe a SFI e, dessa forma, também uma prevalência maior de queda do idoso. Isso converge com estudos prévios na literatura que ilustram maior prevalência de queda em pacientes com esse perfil epidemiológico. Conclusão: Apesar de algumas limitações do estudo como de ter sido realizado em um serviço de referência em geriatria, o estudo molda o perfil local da população idosa acometida pela SFI.

Phlegmasia cerulea dolens: a swelling, cyanosis and discolouration of the extremity in the ICU.

Phlegmasia cerulea dolens is a rare entity that causes critical limb ischaemia, which may lead to amputation of the limb and may be life-threatening. Here, we describe a case of a healthy man in his 50s with multiple trauma who was transferred to the intensive care unit (ICU) of a central hospital for neuromonitoring following splenectomy for the stabilisation of a hypovolaemic shock. On admission to the ICU, the patient developed a swollen and white leg. The condition was caused by early compromised arterial flow secondary to extensive deep vein thrombosis.

Prognostic value of hyperlactatemia in infected patients admitted to intensive care units: a multicenter study. / Valor prognóstico da hiperlactatemia em pacientes admitidos com infecção em unidades de terapia intensiva: estudo multicêntrico.

OBJECTIVE: To evaluate the influence of patient characteristics on hyperlactatemia in an infected population admitted to intensive care units and the influence of hyperlactatemia severity on hospital mortality. METHODS: A post hoc analysis of hyperlactatemia in the INFAUCI study, a national prospective, observational, multicenter study, was conducted in 14 Portuguese intensive care units. Infected patients admitted to intensive care units with a lactate measurement in the first 12 hours of admission were selected. Sepsis was identified according to the Sepsis-2 definition accepted at the time of data collection. The severity of hyperlactatemia was classified as mild (2 - 3.9mmol/L), moderate (4.0 - 9.9mmol/L) or severe (> 10mmol/L). RESULTS: In a total of 1,640 patients infected on admission, hyperlactatemia occurred in 934 patients (57%), classified as mild, moderate and severe in 57.0%, 34.4% and 8.7% of patients, respectively. The presence of hyperlactatemia and a higher degree of hyperlactatemia were both associated with a higher Simplified Acute Physiology Score II, a higher Charlson Comorbidity Index and the presence of septic shock. The lactate Receiver Operating Characteristic curve for hospital mortality had an area under the curve of 0.64 (95%CI 0.61 - 0.72), which increased to 0.71 (95%CI 0.68 - 0.74) when combined with Sequential Organ Failure Assessment score. In-hospital mortality with other covariates adjusted by Simplified Acute Physiology Score II was associated with moderate and severe hyperlactatemia, with odds ratio of 1.95 (95%CI 1.4 - 2.7; p < 0.001) and 4.54 (95%CI 2.4 - 8.5; p < 0.001), respectively. CONCLUSION: Blood lactate levels correlate independently with in-hospital mortality for moderate and severe degrees of hyperlactatemia.

OBJETIVO: Avaliar a influência das características dos pacientes na hiperlactatemia em uma população admitida com infecção em unidades de terapia intensiva, bem como a influência da gravidade da hiperlactatemia na mortalidade hospitalar. METÓDOS: Foi realizada uma análise post hoc da hiperlactatemia no INFAUCI, um estudo nacional prospectivo, observacional e multicêntrico, que incluiu 14 unidades de terapia intensiva portuguesas. Foram selecionados pacientes admitidos com infecção em unidades de terapia intensiva com dosagem de lactato nas primeiras 12 horas de admissão. A sepse foi identificada de acordo com a definição Sepsis-2 aceita no momento da coleta de dados. A gravidade da hiperlactatemia foi classificada como leve (2 - 3,9mmol/L), moderada (4,0 - 9,9mmol/L) ou grave (> 10mmol/L). RESULTADOS: De 1.640 pacientes admitidos com infecção, a hiperlactatemia ocorreu em 934 (57%) e foi classificada como leve, moderada e grave em 57,0%, 34,4% e 8,7% dos pacientes, respectivamente. A presença de hiperlactatemia e um maior grau de hiperlactatemia se associaram a um maior Simplified Acute Physiology Score II, a maior Índice de Comorbidade de Charlson e à presença de choque séptico. Em relação à curva Receiver Operating Characteristic do lactato para mortalidade hospitalar, foi encontrada área sob a curva de 0,64 (IC95% 0,61 - 0,72), que aumentou para 0,71 (IC95% 0,68 - 0,74) quando se combinou o Sequential Organ Failure Assessment. A mortalidade intra-hospitalar com outras covariáveis ajustadas pelo Simplified Acute Physiology Score II se associou à hiperlactatemia moderada e grave, com razão de chances de 1,95 (IC95% 1,4 - 2,7; p < 0,001) e 4,54 (IC95% 2,4 - 8,5; p < 0,001), respectivamente. CONCLUSÃO: Os níveis de lactato sanguíneo correlacionam-se independentemente com a mortalidade intra-hospitalar para graus moderados e graves de hiperlactatemia.

Recommended Antibiotic Dosage Regimens in Critically Ill Patients with Augmented Renal Clearance: A Systematic Review.

PURPOSE: Augmented renal clearance (ARC) is common in critically ill patients and may lead to subtherapeutic levels of antibiotics, thus influencing clinical outcomes and emergence of multidrug-resistant bacteria. The aim of this systematic review was to search the literature for recommendations concerning dosage adjustment for antibiotics administered to critically ill patients with ARC. METHODS: A search of three electronic databases (Pubmed, Embase and Cochrane) was conducted from inception until the end of March 2021, using terms related to: 1) pharmacokinetics/pharmacodynamics (PK/PD), 2) antibiotic, 3) ARC and 4) critically ill. Two reviewers searched for relevant data and included studies suggesting specific doses for critically ill patients with ARC. RESULTS: Forty-seven studies met the inclusion criteria. Dosage recommendations were found for 18 antibiotics. Differences were found in population characteristics, ARC definition, creatinine clearance (CLCR) determination method, PK methodology and definition of PK/PD targets. Cut-off values for CLCR ranged 120-240 mL/min; the most frequently employed method to define CLCR was Cockcroft-Gault estimation; and 83% of studies used population PK models to predict dosing regimens. All antibiotics, except three, needed upward dosing and/or infusion modality adjustments to reach PK/PD targets. CONCLUSION: Despite the lack of high-quality studies and high heterogeneity, incremental dosing adjustment of antibiotics was frequently needed for critically ill patients with ARC to achieve the desired PK/PD targets. More research is needed to enlarge the number of antibiotics with recommendations for ARC and to validate current suggestions based on mathematical models in a clinical scenario.

Valor prognóstico da hiperlactatemia em pacientes admitidos com infecção em unidades de terapia intensiva: estudo multicêntrico / Prognostic value of hyperlactatemia in infected patients admitted to intensive care units: a multicenter study

RESUMO Objetivo: Avaliar a influência das características dos pacientes na hiperlactatemia em uma população admitida com infecção em unidades de terapia intensiva, bem como a influência da gravidade da hiperlactatemia na mortalidade hospitalar. Metódos: Foi realizada uma análise post hoc da hiperlactatemia no INFAUCI, um estudo nacional prospectivo, observacional e multicêntrico, que incluiu 14 unidades de terapia intensiva portuguesas. Foram selecionados pacientes admitidos com infecção em unidades de terapia intensiva com dosagem de lactato nas primeiras 12 horas de admissão. A sepse foi identificada de acordo com a definição Sepsis-2 aceita no momento da coleta de dados. A gravidade da hiperlactatemia foi classificada como leve (2 - 3,9mmol/L), moderada (4,0 - 9,9mmol/L) ou grave (> 10mmol/L). Resultados: De 1.640 pacientes admitidos com infecção, a hiperlactatemia ocorreu em 934 (57%) e foi classificada como leve, moderada e grave em 57,0%, 34,4% e 8,7% dos pacientes, respectivamente. A presença de hiperlactatemia e um maior grau de hiperlactatemia se associaram a um maior Simplified Acute Physiology Score II, a maior Índice de Comorbidade de Charlson e à presença de choque séptico. Em relação à curva Receiver Operating Characteristic do lactato para mortalidade hospitalar, foi encontrada área sob a curva de 0,64 (IC95% 0,61 - 0,72), que aumentou para 0,71 (IC95% 0,68 - 0,74) quando se combinou o Sequential Organ Failure Assessment. A mortalidade intra-hospitalar com outras covariáveis ajustadas pelo Simplified Acute Physiology Score II se associou à hiperlactatemia moderada e grave, com razão de chances de 1,95 (IC95% 1,4 - 2,7; p < 0,001) e 4,54 (IC95% 2,4 - 8,5; p < 0,001), respectivamente. Conclusão: Os níveis de lactato sanguíneo correlacionam-se independentemente com a mortalidade intra-hospitalar para graus moderados e graves de hiperlactatemia.

ABSTRACT Objective: To evaluate the influence of patient characteristics on hyperlactatemia in an infected population admitted to intensive care units and the influence of hyperlactatemia severity on hospital mortality. Methods: A post hoc analysis of hyperlactatemia in the INFAUCI study, a national prospective, observational, multicenter study, was conducted in 14 Portuguese intensive care units. Infected patients admitted to intensive care units with a lactate measurement in the first 12 hours of admission were selected. Sepsis was identified according to the Sepsis-2 definition accepted at the time of data collection. The severity of hyperlactatemia was classified as mild (2 - 3.9mmol/L), moderate (4.0 - 9.9mmol/L) or severe (> 10mmol/L). Results: In a total of 1,640 patients infected on admission, hyperlactatemia occurred in 934 patients (57%), classified as mild, moderate and severe in 57.0%, 34.4% and 8.7% of patients, respectively. The presence of hyperlactatemia and a higher degree of hyperlactatemia were both associated with a higher Simplified Acute Physiology Score II, a higher Charlson Comorbidity Index and the presence of septic shock. The lactate Receiver Operating Characteristic curve for hospital mortality had an area under the curve of 0.64 (95%CI 0.61 - 0.72), which increased to 0.71 (95%CI 0.68 - 0.74) when combined with Sequential Organ Failure Assessment score. In-hospital mortality with other covariates adjusted by Simplified Acute Physiology Score II was associated with moderate and severe hyperlactatemia, with odds ratio of 1.95 (95%CI 1.4 - 2.7; p < 0.001) and 4.54 (95%CI 2.4 - 8.5; p < 0.001), respectively. Conclusion: Blood lactate levels correlate independently with in-hospital mortality for moderate and severe degrees of hyperlactatemia.

Corticosteroid Therapy in Severe Cases of Pneumonia Caused by SARS-CoV-2.

We present a case of severe pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a 63-year-old woman needing venous oxygenation by an extracorporeal membrane. Given the difficult clinical resolution with persistent inflammatory parameters, treatment with corticosteroids (methylprednisolone) was prescribed. The clinical evolution observed, namely the improvement of respiratory and imaging parameters, reiterates the recommendations of corticosteroids for moderate to severe disease.

Life-threatening complications of Ludwig's angina: a series of cases in a developed country.

Ludwig's angina is a deep neck space infection defined as a rapidly progressive bilateral cellulitis of the submandibular space. In spite of being an uncommon entity in developed countries and the reduction of mortality and morbidity due to modern era of antibiotics, improved imaging and airway management, it is still an important and potentially life-threatening condition. The authors present 3 cases of Ludwig's angina that occurred in a developed country, and that required admission in intensive care unit and extensive surgical and medical treatment.

Impact of age in critically Ill infected patients: a post-hoc analysis of the INFAUCI study.

PURPOSE: Older patients are the fastest expanding subgroup of intensive care units (ICU) and are particularly susceptible to bacterial infections and sepsis. The aim of this study was to address the epidemiology and the main determinants of outcome of infection in old and very old patients admitted to ICU. METHODS: We performed a post hoc analysis of all infected patients admitted to ICU enrolled in a 1-year prospective, observational, multipurpose study. Patients aged < 65, 65-74 and ≥ 75 years were compared. RESULTS: Of the 1652 patients included, 50% were older than 65 years. There were no significant differences between young, old and very old patients in either ICU, hospital length of stay, or nosocomial infection. All-cause mortality was significantly higher in participants aged ≥ 75. Increased Gram-negative microorganisms' isolates occurred in > 65 years (25% versus 31%; p = 0.034). Multidrug-resistant (MDR) microorganisms were directly associated to inappropriate empiric antibiotic therapy (OR 4.73; 95% CI 2.99-7.47) and inversely associated with community-acquired infection (OR 0.39; 95% CI 0.19-0.83). Age (65-74 years: OR 1.10; 95% CI 0.64-1.90 and ≥ 75 years: OR 1.52; 95% CI 0.89-2.59) and sepsis severity (sepsis: OR 0.67; 95% CI 0.18-2.46; severe sepsis: OR 1.17; 95% CI 0.40-3.44; septic shock: OR 0.77; 95% CI 0.27-2.24) were not associated to MDR bacteria. CONCLUSION: Patients > 65 years accounted for 50% of infected patients admitted to an ICU. ICU and hospital length of stay, and nosocomial infection did not increase with age. Age did predispose to increased risk for infection by Gram-negatives. These findings may optimize strategies for infection management in older patients.

Disseminated Strongyloides stercoralis Infection Associated with Endogenous Hypercortisolism - A Case Report.

Patients with Strongyloides stercoralis infections are usually asymptomatic but massive hyperinfection may occur in patients with diseases associated with abnormal cell-mediated immunity or receiving immunosuppressive therapy. The authors present the clinical case of a 49-year-old man with a history of diarrhoea and cramping abdominal pain, generalized oedema, petechial rash, melanoderma, cough and dyspnoea. He presented hypokalaemia and arterial hypertension and was admitted with the diagnostic hypothesis of Cushing's syndrome or adrenocorticotropic hormone ectopic production. The patient developed respiratory failure associated with bilateral lung opacities and was admitted to the Intensive Care Unit. The abdominal computed tomography scan revealed liver and duodenal masses. The duodenal biopsy showed the presence of Strongyloides stercoralis and the liver biopsy showed the presence of small cell neuroendocrine carcinoma. The patient died 50 days after hospital admission. The high level of endogenous cortisol observed in this patient may have facilitated the progression to severe fatal infection. LEARNING POINTS: Strongyloides stercoralis hyperinfection and disseminated disease can present as a multiorgan infection in immunocompromised patients with an appropriate clinical and epidemiological context.Strongyloides stercoralis hyperinfection and disseminated disease can present with no eosinophilia and negative parasitological stool tests in more than 70% of cases.

Prevalence and Risk Factors for Augmented Renal Clearance in a Population of Critically Ill Patients.

BACKGROUND: Critically ill patients show a high, albeit variable, prevalence of augmented renal clearance (ARC). This condition has relevant consequences on the elimination of hydrophilic drugs. Knowledge of risk factors for ARC helps in the early identification of ARC. The aims of this study were evaluation of (1) risk factors for ARC and (2) the prevalence of ARC in critically ill patients over a period of 1 year. METHODS: A retrospective cohort study was performed for all consecutive patients admitted to our intensive care unit (ICU). Augmented renal clearance was defined by a creatinine clearance ≥130 mL/min/1.73 m2. "Patient with ARC" was defined as a patient with a median of creatinine clearance ≥130 mL/min/1.73 m2 over the period of admission. Four variables were tested, Simplified Acute Physiology Score II (SAPS II), male gender, age, and trauma as cause for ICU admission. An analysis (patient based and clearance based) was performed with logistic regression. RESULTS: Of 475 patients, 446 were included in this study, contributing to 454 ICU admissions and 5586 8-hour creatinine clearance (8h-CLCR). Overall, the prevalence of patients with ARC was 24.9% (n = 113). In a subset of patients with normal serum creatinine levels, the prevalence was 43.0% (n = 104). Of the set of all 8h-CLCR measurements, 25.4% (1418) showed ARC. In the patient-based analysis, the adjusted odds ratio was: 2.0 (confidence interval [CI]:1.1-3.7; P < .05), 0.93 (CI: 0.91-0.94; P < .01), 2.7 (CI: 1.4-5.3; P < .01), and 0.98 (CI: 0.96 -1.01; P = .15), respectively, for trauma, age, male sex, and SAPS II. In the clearance-based analysis, the adjusted odds ratio were 1.7 (CI: 1.4-1.9; P < .01), 0.94 (CI: 0.932-0.942; P < .01), and 2.9 (CI: 2.4-3.4; P < .01), respectively, for trauma, age, and male sex. CONCLUSIONS: Trauma, young age, and male sex were independent risk factors for ARC. This condition occurs in a considerable proportion of critical care patients, which was particularly prevalent in patients without evidence of renal dysfunction.

Hospital-Acquired Pneumonia in a Multipurpose Intensive Care Unit: One-Year Prospective Study.

INTRODUCTION: Hospital-acquired pneumonia continues to be a frequent complication in the intensive care unit and an important cause of admission in the intensive care unit. The aim of our study was to evaluate the demography, incidence, risk factors, causative bacterial pathogens and outcome of all episodes of Hospital-acquired pneumonia in our unit. MATERIAL AND METHODS: Prospective observational study, at a tertiary university hospital during one year (2014) including all the cases of hospital-acquired pneumonia in the intensive care unit. RESULTS: Sixty patients were identified with pneumonia. Thirty-five (58.3%) had an intensive care unit acquired pneumonia, corresponding to 6.9 cases/1000 intubation-days. Antibiotic treatment in the previous 30 days was present in 75% of the cases. The incidence of Staphylococcus aureus, Pseudomonas aeruginosa and Acinetobacter baumannii was 26.2%, 20.0% and 9.2%, respectively. Patients with late-onset hospital-acquired pneumonia (≥ 7 days) showed higher frequency of non-fermenting Gram-negative bacilli isolates, and methicillin-resistant S. aureus. Combination therapy was performed in 67.0%, and de-escalation in 18.3%. The mortality rate was 18.3%. The adjusted odds ratio for intensive care unit mortality in the group of patients with non-intensive care unit acquired pneumonia was 5.2 (95% CI of 1.02 - 22.10; p = 0.046). DISCUSSION: The knowledge of local bacterial flora and resistance patterns is of crucial importance and strongly recommended. This evidence increases the probability of success of empiric antibiotic therapy. CONCLUSION: S. aureus was the predominant causative agent of nosocomial pneumonia. The most frequent risk factor identified for infection with multidrug-resistant organisms was previous treatment with antibiotics. Multidrug-resistant organisms were present in 45% of documented hospital-acquired pneumonias. In admitted patients with non-intensive care unit acquired pneumonia, the intensive care unit mortality rate was nearly five times higher compared to intensive care unit acquired pneumonia.

Introdução: A pneumonia adquirida no hospital é uma complicação frequente nos doentes críticos e uma importante causa de admissão nos Cuidados Intensivos. O objetivo deste estudo foi avaliar a demografia, incidência, fatores de risco, microbiologia e outcome da pneumonia nosocomial num Serviço de Medicina Intensiva. Material e Métodos: Estudo prospectivo e observacional, num hospital universitário terciário, durante o período de um ano (2014). Resultados: Foram avaliados 60 doentes. Trinta e cinco (58,3%) com pneumonia nosocomial adquirida no Serviço de Medicina Intensiva, correspondendo a 6,9 casos/1000 dias de intubação. A antibioterapia nos últimos 30 dias esteve presente em 75% dos casos. A incidência de Staphylococcus aureus, Pseudomonas aeruginosa e Acinetobacter baumannii foi de 26,2%, 20,0% e 9,2% respetivamente. Os doentes com pneumonia de início tardio (≥ 7 dias) apresentaram maior frequência de bacilos Gram-negativos não-fermentadores e S. aureus resistente à meticilina. A antibioterapia em associação foi aplicada em 67,0% e a descalação em 18,3% dos doentes. A taxa de mortalidade foi 18,3%. O odds ratio ajustado de mortalidade no grupo de doentes críticos com pneumonia nosocomial adquirida fora da UCI foi de 5,2 (95% CI de 1,02 ­ 22,10; p = 0,046). Discussão: O conhecimento da flora local bacteriana e os padrões de resistência bacteriana são de grande importância e amplamente recomendados. Esta evidência aumenta a probabilidade de sucesso da antibioterapia empírica. Conclusão: O S. aureus foi o agente causador predominante da pneumonia. O fator de risco mais frequente para infecção por organismos multirresistentes foi o tratamento prévio com antibióticos. Organismos multirresistentes estavam presentes em 45% das pneumonias adquiridas no hospital de origem bacteriana comprovada. O grupo de doentes críticos com pneumonia nosocomial não adquirida no Serviço de Medicina Intensiva apresentou um risco de mortalidade cerca de cinco vezes maior comparativamente aos doentes com pneumonia nosocomial adquirida no Serviço de Medicina Intensiva.

Pathophysiology of acute fibrinous and organizing pneumonia - Clinical and morphological spectra.

Acute Fibrinous and Organizing Pneumonitis (AFOP) is a disease with histopathological pattern characterized by the presence of intra-alveolar fibrin in the form of fibrin "balls" and organizing pneumonia represented by inflammatory myofibroblastic polyps. Symptoms of this rare interstitial pulmonary disease can be either acute or sub-acute and it can rapidly progress to death. Diagnosis should be considered in the Intensive Care Unit (ICU) if patients' symptomatology and radiology correlates with non-responding or progressive pneumonia and when morphology, on biopsies, encompasses criteria of diffuse alveolar damage (DAD) and organizing pneumonia (OP) balancing in between. Three clinical cases of patients presenting severe lung disease requiring mechanical ventilation and prolonged intensive care fitted on the variable spectra of AFOP histopathology and had poor outcome: a 23 year-old women had AFOP in the context of antiphospholipid syndrome pulmonary compromise; a 35 year-old man developed a letal intensive care pneumonia with AFOP pattern registered in post-mortem biopsy; and a 79 year-old man died 21 days after intensive care unit treatment of a sub-pleural organizing pneumonia with intra-alveolar fibrin, seen in post-mortem biopsy. The predominance of acute fibrin alveolar deposition pattern is helpful in raising AFOP differential diagnosis while organizing pneumonia pattern establishes a wider range of diagnosis that can go till solitary pulmonary nodule, remaining indefinite to suggest diagnosis. The performance time of biopsy in a larger number of clinical cases may be helpful in establishing the evolutionary morphological pattern, taking in mind the poor outcome of the disease, deserving rapid diagnosis to define treatment.

Decreasing the time to achieve therapeutic vancomycin concentrations in critically ill patients: developing and testing of a dosing nomogram.

INTRODUCTION: Achievement of optimal vancomycin exposure is crucial to improve the management of patients with life-threatening infections caused by susceptible Gram-positive bacteria and is of particular concern in patients with augmented renal clearance (ARC). The aim of this study was to develop a dosing nomogram for the administration of vancomycin by continuous infusion for the first 24 hours of therapy based on the measured urinary creatinine clearance (8 h CLCR). METHODS: This single-center study included all critically ill patients treated with vancomycin over a 13-month period (group 1), in which we retrospectively assessed the correlation between vancomycin clearance and 8 h CLCR. This data was used to develop a formula for optimised drug dosing. The efficiency of this formula was prospectively evaluated in a second cohort of 25 consecutive critically ill patients (group 2). Vancomycin serum concentrations between 20 to 30 mg/L were considered adequate. ARC was defined as 8 h CLCR more than 130 ml/min/1.73 m(2). RESULTS: The incidence of ARC was 36% (n = 29/79) and 40% (10/25) in group 1 (n = 79) and 2 (n = 25), respectively. The mean serum vancomycin concentration on day 1 was 21.5 (6.4) and 24.5 (5.2) mg/L, for both groups respectively. On the treatment day, vancomycin plasma clearance was 5.12 (1.9) L/h in group 1 and correlated significantly with the 8 h CLCR (r(2) = 0.66; P < 0.001). The achievement of adequate vancomycin serum concentrations in group 2 was 84% (n = 21/25) versus 51% (n = 40/79) - P < 0.005. CONCLUSIONS: This new vancomycin nomogram enabled the achievement of adequate serum concentrations in 84% of the patients on the first day of treatment.

Accuracy of the estimation of glomerular filtration rate within a population of critically ill patients.

BACKGROUND: Accuracy of glomerular filtration rate (GFR) estimates has been questioned and several authors recommend routine use of measured renal creatinine clearance (CLCR) as a surrogate of GFR in the intensive care unit (ICU). Our purpose was to compare estimates of GFR using Cockroft-Gault (CG), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease Study (MDRD) equations with 8h-CLCR, within a population of critically ill patients with a wide range of measured CLCR. METHODS: Through a prospective, observational study of 54 patients with normal serum creatinine (sCr) admitted to ICU, daily 8h-CLCR (reference method) and GFR estimates (644 paired samples) were matched and compared. Augmented renal clearance (ARC) was defined as 8h-CLCR >130 ml/min/1.73 m(2). RESULTS: No significant difference was found between mean 8h-CLCR (135.5 ml/min/1.73 m(2)) and CG equation (135.7 ml/min/1.73 m(2)), but significant differences (p < 0.01) were found for the MDRD (124.4 ml/min/1.73 m(2)) and CKD-EPI (107.6 ml/min/1.73 m(2)) equations. Correlation between 8h-CLCR and all estimates was weak (R = 0.2, 0.19 and 0.34, respectively). We observed poor agreement in terms of precision (40.9, 39.8 and 33.4%, respectively). Analysing subgroups, we observed that all equations significantly underestimated 8h-CLCR >120 ml/min/1.73 m(2) and overestimated 8h-CLCR <120 ml/min/1.73 m(2) (p < 0.05). The incidence of ARC patients was 55.6%. CONCLUSIONS: Estimates of GFR using CG, CKD-EPI and MDRD formulae are flawed in the critically ill with normal sCr, significantly underestimating renal function in those with ARC and overestimating it in those with normal or decreased 8h-CLCR. Globally, the population exhibited ARC on more than half of the ICU admission days.