C-reactive protein and albumin kinetics before community-acquired bloodstream infections - a Danish population-based cohort study.

Early changes in biomarker levels probably occur before bloodstream infection (BSI) is diagnosed. However, this issue has not been fully addressed. We aimed at evaluating the kinetics of C-reactive protein (CRP) and plasma albumin (PA) in the 30 days before community-acquired (CA) BSI diagnosis. From a population-based BSI database we identified 658 patients with at least one measurement of CRP or PA from day -30 (D-30) through day -1 (D-1) before the day of CA-BSI (D0) and a measurement of the same biomarker at D0 or D1. Amongst these, 502 had both CRP and PA measurements which fitted these criteria. CRP and PA concentrations began to change inversely some days before CA-BSI diagnosis, CRP increasing by day -3.1 and PA decreasing by day -1.3. From D-30 to D-4, CRP kinetics (expressed as slopes - rate of concentration change per day) was -1.5 mg/l/day. From D-3 to D1, the CRP slope increased to 36.3 mg/l/day. For albumin, the slope between D-30 to D-2 was 0.1 g/l/day and changed to -1.8 g/l/day between D-1 and D1. We showed that biomarker levels begin to change some days before the CA-BSI diagnosis, CRP 3.1 days and PA 1.3 days before.

Participatory implementation of an antibiotic stewardship programme supported by an innovative surveillance and clinical decision-support system.

BACKGROUND: Antibiotic resistance will cause about 10 million deaths per year by 2050. Fighting antimicrobial resistance is a health priority. Interventions aimed to reduce antimicrobial resistance, such as antibiotic stewardship programmes (ASPs), must be implemented. To be effective, those interventions, and the implementation process, should be matched with social-cultural context. The complexity of ASPs can no longer be developed without considering both organizational and information systems. AIM: To support ASPs through the co-design and implementation, in collaboration with healthcare workers, of a surveillance and clinical decision-support system to monitor antibiotic resistance and improve antibiotic prescription. METHODS: The surveillance and clinical decision-support system was designed and implemented in three Portuguese hospitals, using a participatory approach between researchers and healthcare workers following the Design Science Research Methodology. FINDINGS: Based on healthcare workers' requirements, we developed HAITooL, a real-time surveillance and clinical decision-support system that integrates visualizations of patient, microbiology, and pharmacy data, facilitating clinical decision. HAITooL monitors antibiotic usage and rates of antibiotic-resistant bacteria, allowing early identification of outbreaks. It is a clinical decision-support tool that integrates evidence-based algorithms to support proper antibiotic prescription. HAITooL was considered valuable to support monitoring of antibiotic resistant infections and an important tool for ASP sustainability. CONCLUSION: ASP implementation can be leveraged through a surveillance and clinical decision-support system such as HAITooL that allows antibiotic resistance monitoring and supports antibiotic prescription, once it has been adapted to the context and specific needs of healthcare workers and hospitals.

Modelling energy costs for different operational strategies of a large water resource recovery facility.

The main objective of this paper is to demonstrate the importance of applying dynamic modelling and real energy prices on a full scale water resource recovery facility (WRRF) for the evaluation of control strategies in terms of energy costs with aeration. The Activated Sludge Model No. 1 (ASM1) was coupled with real energy pricing and a power consumption model and applied as a dynamic simulation case study. The model calibration is based on the STOWA protocol. The case study investigates the importance of providing real energy pricing comparing (i) real energy pricing, (ii) weighted arithmetic mean energy pricing and (iii) arithmetic mean energy pricing. The operational strategies evaluated were (i) old versus new air diffusers, (ii) different DO set-points and (iii) implementation of a carbon removal controller based on nitrate sensor readings. The application in a full scale WRRF of the ASM1 model coupled with real energy costs was successful. Dynamic modelling with real energy pricing instead of constant energy pricing enables the wastewater utility to optimize energy consumption according to the real energy price structure. Specific energy cost allows the identification of time periods with potential for linking WRRF with the electric grid to optimize the treatment costs, satisfying operational goals.

Operational decision support system for large combined sewage systems: Lisbon/Tagus estuary case study.

Managing combined sewage systems in large cities discharging to coastal waters, often bearing recreational activities, remains a challenge. Studying the impacts of such discharges requires the development of specific models. Hydrodynamic and water quality modelling of coastal waters employs numerical methods and algorithms, leading to the design of complex models which require expert use. The use of such models as decision support tools to simulate discharge impacts and define adequate corrective measures could represent a key part in meeting this challenge. In this paper, the authors describe the work undertaken to develop an operational decision support system (ODSS) methodology aiming to enable wastewater utilities' non-expert staff to carry out user-friendly scenario analysis based on computational fluid dynamics simulations. This article depicts the application and validation of the ODSS to the combined sewage system and the Tagus estuary of the city of Lisbon in Portugal. The ODSS was used for simulating the effects in the receiving coastal waters of a discharge caused by a scheduled maintenance operation in the sewage infrastructure. Results show that the use of such ODSS by non-expert staff increases their decision capabilities and knowledge of the wastewater utility's contribution to reducing negative impacts of sewage discharges on the receiving water bodies.

Acute bacterial meningitis in the intensive care unit and risk factors for adverse clinical outcomes: retrospective study.

BACKGROUND: Bacterial meningitis constitutes a medical emergency. Its burden has driven from childhood to the elderly and the immunocompromised population. However, the admission of patients with bacterial meningitis to the intensive care unit (ICU) has been sparsely approached, as have the prognostic factors associated with an adverse clinical outcome. METHODS: We performed a retrospective analysis during a 7-year period of patients older than 18 years admitted to 2 polyvalent ICUs. Clinical, demographic, and outcome data were collected to evaluate its clinical impact on the outcome of patients with acute bacterial meningitis. RESULTS: We identified 65 patients with the diagnosis of acute bacterial meningitis (mean Acute Physiology and Chronic Health Evaluation II, 23; hospital mortality, 40%). Upon clinical presentation, their most frequent signs were fever (84%), seizures (21.5%), and a low Glasgow Coma Scale (GCS) score (GCS<8; 58.4%). Fifty-five patients (85%) required organ support. A definite microbiological diagnosis was achieved in 45 patients. An adverse clinical outcome was noted in 46 patients (71%). These patients were older (P=.005), had higher Physiology and Chronic Health Evaluation II score (P=.022), and had lower GCS (P=.022). In the multivariate analysis, older age (per year; adjusted odds ratio [aOR], 1.059) was associated with an adverse outcome, whereas a higher GCS (per point; aOR, 0.826) and presence of fever upon admission (aOR, 0.142) increase the chance of a good recovery. CONCLUSIONS: Patients with acute bacterial meningitis admitted to ICU had substantial morbidity and mortality. Those with low GCS or absence of fever have a particularly high risk of an adverse outcome.

Bloodstream infections as a marker of community-acquired sepsis severity. Results from the Portuguese community-acquired sepsis study (SACiUCI study).

The impact of bloodstream infection (BSI) on admission to hospital on the outcome of patients with community-acquired sepsis (CAS) admitted to intensive-care units (ICU) is largely unknown. We selected 803 adult patients consecutively admitted with CAS to one of 17 Portuguese ICU, in whom blood cultures were collected before initiation of antibiotic therapy during a 12-month period. A BSI was identified on hospital admission in 160 (19.9%) patients. Those with and without BSI had similar mean Simplified Acute Physiology Score (SAPS) II and age. The presence of BSI was independently associated with mortality in ICU (adjusted odds ratio 1.86; 95% confidence interval 1.20-2.89; p 0.005). On the 4th day in ICU, patients with BSI were found to be significantly more dependent on vasopressor support (p 0.002) but not on ventilatory support. Cumulative ICU mortality was significantly higher in BSI patients from the 9th day onwards. A seasonal variation of BSI isolates was noted: gram-negative BSI were more common in the summer, whereas in the winter, gram-positive infections were more frequent (p 0.024), without mortality differences.

Community-associated methicillin-resistant Staphylococcus aureus infection in Portugal.

Methicillin-resistant Staphylococcus aureus (MRSA) has recently emerged as a cause of community-acquired infections among individuals without risk factors. Community-associated MRSA (CA-MRSA) appears to be more virulent, causing superficial mild skin and soft tissue infections to severe necrotizing fasciitis, and in rare cases, pneumonia. Community-associated MRSA was first reported in Australia in the early 80s, after almost two decades in the USA, and then in several countries in Europe, Asia and South America. No data exists in Portugal. We report the first case of CA-MRSA infection in Portugal, in a young adult with severe necrotizing pneumonia, complicated with bilateral empyema and respiratory failure.

Pharmacokinetics of gentamicin in critically ill patients: pilot study evaluating the first dose.

Gentamicin is extensively used in the treatment of severe Gram-negative bacterial infections. A loading dose of 7 mg/kg is recommended to achieve a maximum concentration (C(max)) above 16 mg/L. We studied gentamicin pharmacokinetic data from patients treated between January 2006 and June 2008 in two intensive-care units. The Sawchuk and Zaske one-compartment pharmacokinetic model was used to estimate the gentamicin volume of distribution (the 32 patients had a median age of 68 years (23 men)). The median volume of distibution (V(d)) per kilogram of body weight (V(d)/kg) was 0.41 L/kg (interquartile range of 0.36-0.46 L/kg), with no correlations with age, Charlson comorbidity score, sequential organ failure assessment (SOFA) score and creatinine serum level (r(2) = 0.016, 0.058, 0.037, and 0.067, respectively). Women had a significantly higher median V(d)/kg (0.50 vs. 0.40 L/kg, p 0.002) and lower C(max) (15.2 vs. 18.5 mg/L, p 0.016), despite similar dose/kg. In a logistic regression model, only sex (female: OR 0.032; 95% CI 0.03-0.387) and dose/kg (per mg/kg: OR 3.21; 95% CI 1.17-8.79) were significantly associated with the achievement of C(max) above 16 mg/L. Gentamicin clearance was 57 mL/min (interquartile range of 44.7-78 mL/min) and decreased with age (r(2) = 0.178, p 0.016), SOFA score (r(2) = 0.199, p 0.011) and creatinine clearance (r(2) = 0.258, p 0.003). Gentamicin V(d) was increased in critically ill patients, particularly in women. Therefore, high gentamicin loading doses should be given to all patients, especially women, independently of organ failure. Gentamicin clearance decreases with age, SOFA score, and renal failure.

Is C-reactive protein a good prognostic marker in septic patients?

RATIONALE: Several studies have shown that C-reactive protein (CRP) is a marker of infection. The aim of this study was to evaluate CRP as marker of prognosis outcome in septic patients and to assess the correlation of CRP with severity of sepsis. METHODS: During a 14-month period, we prospectively included all patients with sepsis admitted to an intensive care unit (ICU). Patients were categorized into sepsis, severe sepsis and septic shock. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, CRP, body temperature and white cell count (WCC) of the day of sepsis diagnosis were collected. RESULTS: One hundred and fifty-eight consecutive septic patients (mean age 59 years, 98 men, ICU mortality 34%) were studied. The area under the receiver operating characteristics curves of APACHE II, SAPS II, SOFA, CRP, body temperature and WCC as prognostic markers of sepsis were 0.75 [95% confidence interval (CI) 0.67-0.83], 0.82 (95% CI 0.75-0.89), 0.8 (95% CI 0.72-0.88), 0.55 (95% CI 0.45-0.65), 0.48 (95% CI 0.38-0.58) and 0.46 (95% CI 0.35-0.56), respectively. In the subgroup of patients with documented sepsis we obtained similar results. The ICU mortality rate of septic patients with CRP < 10, 10-20, 20-30, 30-40 and >40 mg/dL was 20, 34, 30.8, 42.3 and 39.1%, respectively (P = 0.7). No correlation was found between CRP concentrations and severity of sepsis. CONCLUSIONS: In septic patients, CRP of the day of sepsis diagnosis is not a good marker of prognosis.

C-reactive protein as a marker of ventilator-associated pneumonia resolution: a pilot study.

The aim of this study was to evaluate C-reactive protein (CRP) levels, body temperature and white cell count (WCC) after prescription of antibiotics in order to describe the clinical resolution of ventilator-associated pneumonia (VAP). A cohort of 47 VAP patients with microbiological confirmation of disease was assessed. CRP levels, body temperature and WCC were monitored daily. On day 4 of the antibiotic therapy, the CRP level of survivors was 0.62 times the initial value, whereas, in nonsurvivors, it was 0.98. Body temperature and WCC remained almost unchanged. By day 4, a CRP of >0.6 times the initial level was a marker of poor outcome (sensitivity 0.92; specificity 0.59). Patients were divided according to their CRP patterns of response to antibiotics: fast response, slow response, nonresponse, and biphasic response. All patients with fast and slow response patterns survived, whereas those showing nonresponse and a biphasic response pattern exhibited a mortality of 78 and 75%, respectively. The adequacy of the initial antibiotic therapy had a marked influence on the rate of CRP decrease, as well as on mortality. In conclusion, daily C-reactive protein measurements after antibiotic prescription were useful in the identification, as early as day 4, of ventilator-associated pneumonia patients with poor outcome. The identification of the pattern of C-reactive protein response to antibiotics was useful in the recognition of individual clinical course, improving or worsening, as well as of the rate of improvement.

C-reactive protein as a marker of infection in critically ill patients.

A prospective, observational study was conducted in a medico-surgical intensive care unit to assess the value of C-reactive protein (CRP), temperature and white cell count (WCC) measurements for the diagnosis of infection in critically ill patients. CRP, temperature and WCC were monitored daily in 76 infected and 36 non-infected patients. Multiple receiver-operating characteristics (ROC) curves were used to compare each parameter for infection diagnosis. The area under the curve (AUC) of CRP was significantly higher than that of temperature (0.93 and 0.75, respectively; p < 0.001). A CRP concentration of >8.7 mg/dL and a temperature of >38.2 degrees C were associated with infection, with a sensitivity of 93.4% and 54.8%, and a specificity of 86.1% and 88.9%, respectively. The ROC curve of WCC showed a poor diagnostic performance. The combination of CRP and temperature increased the specificity for infection diagnosis to 100%. In the subgroup of patients with ventilator-associated pneumonia (n = 48), CRP measurements were more reliable than temperature (AUC 0.92 and 0.78, respectively; p 0.006). The CRP levels in infected patients with sepsis, severe sepsis and septic shock were 15.2 +/- 8.2, 20.3 +/- 10.9 and 23.3 +/- 8.7 mg/dL, respectively (p 0.044). It was concluded that CRP was a better marker of infection than temperature. However, the combination of CRP and temperature measurements further increased the specificity for infection diagnosis, even in the subgroup of patients with VAP.

Evaluation of a recruitment maneuver with positive inspiratory pressure and high PEEP in patients with severe ARDS.

BACKGROUND: To evaluate the effect of a recruitment maneuver (RM) with constant positive inspiratory pressure and high positive end-expiratory pressure (PEEP) on oxygenation and static compliance (Cs) in patients with severe acute respiratory distress syndrome (ARDS). METHODS: Eight patients with ARDS ventilated with lung-protective strategy and an arterial partial pressure of oxygen to inspired oxygen fraction ratio (PaO2/FIO2) < or =100 mmHg regardless of PEEP were prospectively studied. The RM was performed in pressure-controlled ventilation at FIO2 of 1.0 until PaO2 reached 250 mmHg or a maximal plateau pressure/PEEP of 60/45 cmH2O was achieved. The RM was performed with stepwise increases of 5 cmH2O of PEEP every 2 min and thereafter with stepwise decreases of 2 cmH2O of PEEP every 2 min until a drop in PaO2 >10% below the recruitment PEEP level. Data was collected before (preRM), during and after 30 min (posRM). RESULTS: The PaO2/FIO2 increased from 83 +/- 22 mmHg preRM to 118 +/- 32 mmHg posRM (P = 0.001). The Cs increased from 28 +/- 10 ml cmH2O(-1) preRM to 35 +/- 12 ml cmH2O(-1) posRM (P = 0.025). The PEEP was 12 +/- 3 cmH2O preRM and was set at 15 +/- 4 cmH2O posRM (P = 0.025). The PEEP of recruitment was 36 +/- 9 cmH2O and the collapsing PEEP was 13 +/- 4 cmH2O. The PaO2 of recruitment was 225 +/- 105 mmHg, with five patients reaching a PaO2 > or = 250 mmHg. The FIO2 decreased from 0.76 +/- 0.16 preRM to 0.63 +/- 0.15 posRM (P = 0.001). No major complications were detected. CONCLUSION: Recruitment maneuver was safe and useful to improve oxygenation and Cs in patients with severe ARDS ventilated with lung-protective strategy.

C-reactive protein as an indicator of sepsis.

OBJECTIVE: To determine the use of plasma C-reactive protein (CRP) concentrations, body temperature (BT) and white blood cell count (WBC) in the detection of sepsis in critically ill patients. DESIGN: All patients admitted for more than 24 h in the intensive care unit (ICU) were prospectively included. Patients were followed up to ICU discharge and each patient-day was classified in one of four categories according to the infectious status: 1) Negative, patient-day without systemic inflammatory response syndrome (SIRS); 2) Definite, patient-day with SIRS and a positive culture; 3) SIRS, patient-day with SIRS and negative or no cultures. The last group was subdivided according to the following criteria: a) new, or persistence of, pulmonary infiltrates, b) the presence of pus in a place known to be sterile. Patient-days without these criteria were classified as SIRS with improbable sepsis (Unlikely), and with one criteria or more as SIRS with probable sepsis (Probable). SETTING: Medical/surgical intensive care unit. PATIENTS: Twenty-three patients were followed. MEASUREMENTS AND RESULTS: A total of 306 patient-days were analysed: 20 Negative, 15 Definite, 63 Unlikely and 208 Probable. The median (range) CRP values for Negative, Unlikely, Probable and Definite groups were as follows: 24.5 (7-86), 34 (5-107), 143 (39-544), and 148 (52-320) mg/l. The plasma CRP levels were significantly related to the infectious status (Negative, Unlikely, Probable or Definite) of the patient-day classification (p < 0.05). Concentrations of CRP in the Negative and Unlikely groups were significantly lower than in the Probable and Definite ones (p < 0.05). A plasma CRP of 50 mg/l or more was highly suggestive of sepsis (sensitivity 98.5%, specificity 75%). CONCLUSIONS: Daily measurement of CRP is useful in the detection of sepsis and it is more sensitive than the currently used markers, such as BT and WBC.

[Ogilvie's syndrome. Therapeutic efficacy of cecostomy]. / Síndrome de Ogilvie. Eficácia terapêutica de cecostomia.

Ogilvie's syndrome is an uncommon clinical situation, which was first described in 1948. It is characterized by an acute colonic massive dilatation without evidence of organic obstruction. Association with extracolonic disease is a nearly constant feature. Clinically, the syndrome manifests itself as an acute abdominal distention the cecum being the site of greatest dilatation. This situation is rapidly progressive and, if untreated, may cause cecal necrosis and perforation. Treatment should be instituted early, beginning with medical measures, followed by surgery if no improvement is seen. We report a case of Ogilvie's syndrome, and discuss the treatment procedures.

Streptococcus bovis spontaneous bacterial peritonitis in patients with alcoholic cirrhosis.

Spontaneous bacterial peritonitis (SBP) is a frequent cause of decompensated alcoholic cirrhosis. The authors describe the first two cases caused by infection with Streptococcus bovis. They suggest that this microorganism may be present in the intestinal flora of these patients more frequently than assumed. Furthermore, the course of SBP due to S. bovis may be particularly severe.

[Assessment of cardiovascular reflexes in patients with mitral valve prolapse syndrome]. / Avaliação de reflexos cardiovasculares em doentes com síndrome do prolapso da válvula mitral.

OBJECTIVE: Functional evaluation of Autonomic Nervous System in patients with Mitral Valve Prolapse Syndrome. DESIGN: Study of cardiovascular reflexes. SETTING: Out patients studied in the Laboratory for Study of Autonomic Nervous System Function of Santa Maria Hospital, Lisbon, Portugal. MATERIAL AND METHODS: We studied 20 patients with clinical and echocardiographic diagnosis of mitral valve prolapse, who presented Mitral Valve Prolapse Syndrome, without significant mitral regurgitation, and with normal left ventricular function. Cardiovascular reflexes were analysed by mean of five tests. RESULTS: In 75% of the cases, patients had results according to vagal hypofunction. Orthostatic hypotension was present in 40%. Among patients with orthostatic hypotension, 75% had postural phenomena. Among patients with postural phenomena, 75% had orthostatic hypotension. CONCLUSIONS: In the present study, patients behaviour hasn't been uniform. Vagal hypofunction was present in 75% and orthostatic hypotension in 40% of the cases. A relation has been found between orthostatic hypotension and postural into.

[Severe poisoning by organophosphate compounds. An analysis of mortality and of the value of serum cholinesterase in monitoring the clinical course]. / Intoxicação grave por compostos organofosforados. Análise da mortalidade e do valor da colinesterase sérica na monitorização do curso clínico.

Ingestion of organophosphate (OP) compounds usually results in severe poisoning. We undertook a retrospective study of 52 consecutive patients admitted with severe OP poisoning to determine the value of serum cholinesterase (SChE) in monitoring clinical course. Considering survivors and non-survivors, we evaluate clinical and laboratory baseline characteristics, severity scores (APACHE II, SAPS II), atropine rate (mg/h), SChE evolution at 24, 72 and 120 h and final SChE (SChE at the day of discharge or death). Mortality in the ICU was 28.9% (n = 15). In both groups SChE showed a trend to increase. In survivors, SChE recovery was statistically significant for SChE 24h-SChE 72 h, SChE 24 h-SChE 120 h and SChE initial-SChE 120 h (p = 0.008, p = 0.00003, p = 0.0002 respectively). In this group a simultaneous decrease in atropine requirements was registered. In non-survivors, the rate of atropine remained unchanged up to 120 h. Three groups could be defined in non-survivors according to their final SChE and day of death. Non-survivors-1 (death in the first 24h; 2 patients) and non-survivors-2 (death after the first 24 h; 5 patients) had a final SChE below 10% of normal SChE activity and statistically different from survivors' final SChE. Non-survivors-3 (8 patients) had a final SChE similar to the survivors and death was due to sepsis and multiple organ failure (MOF). We conclude that SChE is useful in OP poisoning diagnosis and also in monitoring clinical course. SChE recovery above 10% of normal seems to correlate with good prognosis. Sepsis and MOF were important determinants of mortality.