RESUMEN
BACKGROUND: Early antiviral therapy was effective in the treatment of coronavirus disease 2019 (COVID-19). We assessed the efficacy and safety of combined interferon beta-1b and remdesivir treatment in hospitalized COVID-19 patients. METHODS: We conducted a multicentre, prospective open-label, randomized-controlled trial involving high-risk adults hospitalized for COVID-19. Patients were randomly assigned to a 5-day interferon beta-1b 16 million units daily and remdesivir 200 mg loading on day 1 followed by 100 mg daily on day 2 to 5 (combination group), or to remdesivir only of similar regimen (control group) (1:1). The primary endpoint was the time to complete alleviation of symptoms (NEWS2 = 0). RESULTS: Two-hundred and twelve patients were enrolled. The median days of starting treatment from symptom onset was 3 days. The median age was 65 years, and 159 patients (75%) had chronic disease. The baseline demographics were similar. There was no mortality. For the primary endpoint, the combination group was significantly quicker to NEWS2 = 0 (4 vs 6.5 days; hazard ratio [HR], 6.59; 95% confidence interval [CI], 6.1-7.09; P < .0001) when compared to the control group. For the secondary endpoints, the combination group was quicker to negative nasopharyngeal swab (NPS) viral load (VL) (6 vs 8 days; HR, 8.16; 95% CI, 7.79-8.52; P < .0001) and to develop seropositive immunoglobulin G (IgG) (8 vs 10 days; HR, 10.78; 95% CI, 9.98-11.58; P < .0001). All adverse events resolved upon follow-up. Combination group (HR, 4.1 95% CI, 1.9-8.6, P < .0001) was the most significant independent factor associated with NEWS2 = 0 on day 4. CONCLUSIONS: Early treatment with interferon beta-1b and remdesivir was safe and better than remdesivir only in alleviating symptoms, and in shortening viral shedding and hospitalization with earlier seropositivity in high-risk COVID-19 patients. CLINICAL TRIALS REGISTRATION: NCT04647695.
Asunto(s)
Antivirales , Tratamiento Farmacológico de COVID-19 , COVID-19 , Interferon beta-1b , Anciano , Humanos , Antivirales/efectos adversos , Antivirales/uso terapéutico , COVID-19/terapia , Interferon beta-1b/administración & dosificación , Interferon beta-1b/uso terapéutico , Estudios Prospectivos , SARS-CoV-2 , Resultado del TratamientoRESUMEN
BACKGROUND: Tuberculosis (TB) is a preventable and curable disease, but mortality remains high among those who develop sepsis and critical illness from TB. METHODS: This was a population-based, multicentre retrospective cohort study of patients admitted to all 15 publicly funded Hong Kong adult intensive care units (ICUs) between 1 April 2008 and 31 March 2019. 940 adult critically ill patients with at least one positive Mycobacterium tuberculosis (MTB) culture were identified out of 133 858 ICU admissions. Generalised linear modelling was used to determine the impact of delay in TB treatment on hospital mortality. Trend of annual Acute Physiology and Chronic Health Evaluation (APACHE) IV-adjusted standardised mortality ratio (SMR) over the 11-year period was analysed by Mann-Kendall's trend test. RESULTS: ICU and hospital mortality were 24.7% (232/940) and 41.1% (386/940), respectively. Of those who died in the ICU, 22.8% (53/232) never received antituberculosis drugs. SMR for ICU patients with TB remained unchanged over the study period (Kendall's τb=0.37, p=0.876). After adjustment for age, Charlson comorbidity index, APACHE IV, albumin, vasopressors, mechanical ventilation and renal replacement therapy, delayed TB treatment was directly associated with hospital mortality. In 302/940 (32.1%) of patients, TB could only be established from MTB cultures alone as Ziehl-Neelsen staining or PCR was either not performed or negative. Among this group, only 31.1% (94/302) had concurrent MTB PCR performed. CONCLUSIONS: Survival of ICU patients with TB has not improved over the last decade and mortality remains high. Delay in TB treatment was associated with higher hospital mortality. Use of MTB PCR may improve diagnostic yield and facilitate early treatment.
Asunto(s)
Enfermedad Crítica , Tuberculosis , Adulto , Humanos , Enfermedad Crítica/terapia , Estudios Retrospectivos , Unidades de Cuidados Intensivos , Mortalidad Hospitalaria , Resultado del TratamientoRESUMEN
BACKGROUND: To compare the outcomes of patients requiring extracorporeal membrane oxygenation (ECMO) support who had a restrictive transfusion strategy with those who had a liberal strategy. STUDY DESIGN AND METHODS: We retrospectively reviewed all adult patients from 2010 to 2019 who received a minimum of one packed red blood cell (pRBC) during ECMO. Hemoglobin values before each transfusion were retrieved. Restrictive transfusion strategy was defined as a transfusion threshold ≤8.5 g/dl in all transfusion episodes for a single patient, while liberal transfusion strategy was defined as a transfusion threshold >8.5 g/dl in any transfusion episode. RESULTS: The analysis included 763 patients, with 138 (18.1%) patients in the restrictive and 625 (81.9%) in the liberal transfusion strategy group. The median hemoglobin level, taking into account all measured hemoglobin values, during ECMO support was 8.3 and 9.9 g/dl, and the average units of pRBC received per day were 0.7 (0.3-1.8) and 1.2 (0.6-2.3), respectively. There were no significant differences in intensive care unit (ICU) mortality (adjusted odds ratio (OR), 0.86; 95% CI 0.56-1.30; p = .47), hospital mortality (adjusted OR, 0.79; 95% CI 0.52-1.21; p = .28), and 90-day mortality (adjusted OR, 0.84; 95% CI 0.55-1.28; p = .42) between the two groups. Among subgroup analyses, a restrictive transfusion strategy was associated with decreased risk of ICU mortality in patients on veno-venous ECMO (adjusted OR, 0.36; 95% CI 0.17-0.73; p = .005). There was no heterogeneity on outcomes across patients stratified by age, APACHE IV score, or need for large volume transfusion. DISCUSSION: Our data suggested it may be safe to adopt a restrictive red cell transfusion threshold of 8.5 g/dl in patients on ECMO, and highlighted the need for prospective trials in this heavily-transfused population.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Adulto , Humanos , Estudios Retrospectivos , Estudios Prospectivos , Transfusión Sanguínea , Hemoglobinas/análisisRESUMEN
BACKGROUND: Effective antiviral therapy is important for tackling the coronavirus disease 2019 (COVID-19) pandemic. We assessed the efficacy and safety of combined interferon beta-1b, lopinavir-ritonavir, and ribavirin for treating patients with COVID-19. METHODS: This was a multicentre, prospective, open-label, randomised, phase 2 trial in adults with COVID-19 who were admitted to six hospitals in Hong Kong. Patients were randomly assigned (2:1) to a 14-day combination of lopinavir 400 mg and ritonavir 100 mg every 12 h, ribavirin 400 mg every 12 h, and three doses of 8 million international units of interferon beta-1b on alternate days (combination group) or to 14 days of lopinavir 400 mg and ritonavir 100 mg every 12 h (control group). The primary endpoint was the time to providing a nasopharyngeal swab negative for severe acute respiratory syndrome coronavirus 2 RT-PCR, and was done in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT04276688. FINDINGS: Between Feb 10 and March 20, 2020, 127 patients were recruited; 86 were randomly assigned to the combination group and 41 were assigned to the control group. The median number of days from symptom onset to start of study treatment was 5 days (IQR 3-7). The combination group had a significantly shorter median time from start of study treatment to negative nasopharyngeal swab (7 days [IQR 5-11]) than the control group (12 days [8-15]; hazard ratio 4·37 [95% CI 1·86-10·24], p=0·0010). Adverse events included self-limited nausea and diarrhoea with no difference between the two groups. One patient in the control group discontinued lopinavir-ritonavir because of biochemical hepatitis. No patients died during the study. INTERPRETATION: Early triple antiviral therapy was safe and superior to lopinavir-ritonavir alone in alleviating symptoms and shortening the duration of viral shedding and hospital stay in patients with mild to moderate COVID-19. Future clinical study of a double antiviral therapy with interferon beta-1b as a backbone is warranted. FUNDING: The Shaw-Foundation, Richard and Carol Yu, May Tam Mak Mei Yin, and Sanming Project of Medicine.
Asunto(s)
Infecciones por Coronavirus/tratamiento farmacológico , Interferon beta-1b/uso terapéutico , Lopinavir/uso terapéutico , Neumonía Viral/tratamiento farmacológico , Ribavirina/uso terapéutico , Ritonavir/uso terapéutico , Adulto , Betacoronavirus , COVID-19 , Combinación de Medicamentos , Quimioterapia Combinada , Femenino , Hong Kong , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Pandemias , SARS-CoV-2 , Tratamiento Farmacológico de COVID-19RESUMEN
AIM: To investigate the impact of renal replacement therapy (RRT) on 90-day mortality in critically ill patients suffering from KDIGO stage 3 acute kidney injury (AKI) with or without life-threatening complications using propensity score matching analysis. METHODS: We conducted a retrospective analysis of critically ill adult patients with KDIGO Stage 3 AKI with or without RRT during ICU stay between 1/1/2011-31/12/2013. Cox regression analysis and propensity score matching methods were used to determine predictors for 90-day mortality. RESULTS: Among 661 patients, 50.5% received RRT. The unadjusted 90-day mortality rate was 42.5% and 54.1% in patients who had or had not received RRT, respectively. After adjustment with propensity score based on the probability of receiving RRT, the cox regression analysis showed that RRT was associated with a lower 90-day mortality (p<0.001). Among 322 propensity-matched pairs, RRT was associated with lower ICU (23.6% vs. 39.8%, p=0.002), hospital (33.5% vs. 55.9%, p<0.001) and 90-day mortality (34.2% vs. 58.4%, p<0.001), and a higher 90-day renal recovery rate (57.8% vs. 45.3% full recovery, p=0.026) compared with no RRT. When an alternate propensity model was used, the benefits associated with RRT were very similar, except 90-day renal recovery became insignificant. CONCLUSION: Our observational study found that in critically ill patients with KDIGO Stage 3 AKI, RRT may be associated with lower 90-day mortality. The benefit of RRT on renal recovery was less prominent. Medical futility and practice variations may complicate study interpretation. To avoid these limitations, large-scale multicenter, non-observational study is recommended.
Asunto(s)
Lesión Renal Aguda/terapia , Terapia de Reemplazo Renal , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/fisiopatología , Anciano , Anciano de 80 o más Años , Enfermedad Crítica , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Recuperación de la Función , Terapia de Reemplazo Renal/efectos adversos , Terapia de Reemplazo Renal/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
We presented a case with massive hepatic portovenous gas (HPVG) and gastric emphysema, probably due to increased intraluminal pressure in the stomach after bagging and noninvasive ventilation. There are multiple microbubbles in the inferior vena cava, right atrium and right ventricle. There has been only one case report ever published showing the similar features of the "aquarium sign" in the right heart in a patient with intussusception. We believe our case is a good illustration of this extremely rare entity in echocardiography.
Asunto(s)
Ecocardiografía/métodos , Enfisema/complicaciones , Cardiopatías/complicaciones , Cardiopatías/diagnóstico por imagen , Intususcepción/complicaciones , Gastropatías/complicaciones , Corticoesteroides/uso terapéutico , Anciano , Antibacterianos/uso terapéutico , Diagnóstico Diferencial , Enfisema/diagnóstico por imagen , Enfisema/tratamiento farmacológico , Atrios Cardíacos/diagnóstico por imagen , Cardiopatías/tratamiento farmacológico , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Intususcepción/diagnóstico por imagen , Intususcepción/tratamiento farmacológico , Masculino , Microburbujas , Estómago/diagnóstico por imagen , Gastropatías/diagnóstico por imagen , Gastropatías/tratamiento farmacológico , Tomografía Computarizada por Rayos X , Vena Cava Inferior/diagnóstico por imagenRESUMEN
We report a 21-year-old young male with Lemierre's syndrome presented as tonsillitis and Fusobacterium septicemia with respiratory failure and required intensive care. Lemierre's syndrome is the septic embolic complication of recent pharyngeal illness. Fusobacterium spp. accounts for the majority of cases. High index of suspicion is needed and prolonged antibiotic is advised. It is seldom seen in intensive care but should never be forgotten.
RESUMEN
INTRODUCTION: Extracorporeal blood purification therapies have been proposed to improve outcomes of patients with severe sepsis, with or without accompanying acute kidney injury (AKI), by removal of excessive inflammatory mediators. MATERIALS AND METHODS: We report our experience with EMiC2 high-cutoff continuous venovenous hemofiltration/hemodialysis (HCO-CVVH/HD) in seven patients with AKI complicating septic shock. RESULTS: The median treatment duration was 71 h, and the procedure was well tolerated. Trough serum albumin level of 20 g/L was observed after 2 h of treatment and none of the patients required albumin supplement. The hospital mortality rate was 29%, which appeared more favorable than the predicted mortality of 60%-78% based on disease severity scores. Circulating levels of interleukin-6 (IL-6), IL-10, and tumor necrosis factor-alpha improved over time. CONCLUSION: This case series shows that HCO-CVVH/CVVHD using EMiC2 hemofilter may provide good cytokine modulation, when used along with good quality standard sepsis therapy. A further large-scale prospective randomized controlled trial is recommended.
RESUMEN
Purpose The objective of this study is to examine the incidence, clinical characteristics, and outcome (90-day mortality) of critically ill Chinese patients with septic AKI. Methods Patients admitted to the ICU of a regional hospital from 1 January 2011 to 31 December 2013 were included, excluding those on chronic renal replacement therapy. AKI was defined using KDIGO criteria. Patients were followed till 90 days from ICU admission or death, whichever occurred earlier. Demographics, diagnosis, clinical characteristics, and outcome were analyzed. Results In total, 3687 patients were included and 54.7% patients developed AKI. Sepsis was the most common cause of AKI (49.2%). Compared to those without AKI, AKI patients had higher disease severity, more physiological and biochemical disturbance, and carried significant co-morbidities. Ninety-day mortality increased with severity of AKI (16.7, 27.5, and 48.3% for KDIGO stage 1, 2, and 3 AKI, p < 0.001). Full renal recovery was achieved in 71.6% of AKI patients. Compared with non-septic AKI, septic AKI was associated with higher disease severity and required more aggressive support. Non-recovery of renal function occurred in 2.5% of patients with septic AKI, compared with 6.4% in non-septic AKI (p < 0.001). Cox regression analysis showed that age, emergency ICU admission, post-operative cases, admission diagnosis, etiology of AKI, disease severity score, mechanical ventilation, vasopressor support, and blood parameters (like albumin, potassium and pH) independently predicted 90-day mortality. Conclusions AKI, especially septic AKI is common in critically ill Chinese patients and is associated with poor patient outcome. Etiology of AKI has a significant impact on 90-day mortality and may affect renal outcome.
Asunto(s)
Lesión Renal Aguda , Enfermedad Crítica/mortalidad , Sepsis/complicaciones , APACHE , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/etiología , Anciano , Anciano de 80 o más Años , Femenino , Hong Kong/epidemiología , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sepsis/epidemiologíaRESUMEN
BACKGROUND: Red cell distribution width (RDW) has been shown to be associated with mortality in cardiac surgical patients. This study investigates the association of RDW with the 30-day mortality for those patients who undergo major- or ultra-major noncardiac surgery. METHODS: Patients who received major- or ultra-major noncardiac surgery between July 2012 and May 2013 were included in the study and patients those with preoperative hemoglobin <10 g/day were excluded from the study. Patients were followed till day 30 from the date of surgery or death, whichever occurred earlier. RESULTS: The overall 30-day mortality for major- and ultra-major surgery was 11.4%. The mean RDW of the 30-day survivors was 13.6 ± 1.6 and that of nonsurvivors was 14.2 ± 2.1 (P < 0.001). Other factors that were significantly different (P < 0.05) between survivors and nonsurvivors included age, sex, preoperative pulse rate, current or ex-alcoholic, the American Society of Anesthesiologists score, diabetes mellitus, use of antihypertensives, sepsis with 48 h before surgery, preoperative hemoglobin, white cell count, sodium, urea, creatinine, albumin, international normalized ratio (INR), pH, base excess, estimated blood loss, and emergency surgery. Logistic regression revealed that preoperative RDW > 13.35% (P = 0.025, odds ratio [OR]: 1.52), INR (P = 0.008, OR: 4.49), albumin level (P < 0.001, OR: 1.10), use of antihypertensives (P = 0.001, OR: 1.82), and preoperative pulse rate (P = 0.006, OR: 1.02) independently predicted the 30-day mortality. However, the area under receiver operating characteristic curve for the prediction of 30-day mortality using RDW was only 0.614. CONCLUSIONS: Although preoperative RDW independently predicted 30-day mortality in patients who underwent major- or ultra-major noncardiac surgery, it may not serve as an influential prognostic indicator in view of its low sensitivity and specificity.
RESUMEN
AIM: The performance of plasma neutrophil gelatinase-associated lipocalin (pNGAL) for prediction of acute kidney injury (AKI) in non-cardiac surgical patients has not been well described. This study investigates the use of pNGAL for early detection of AKI in patients admitted to an intensive care unit (ICU) after major or ultra-major non-cardiac surgery. METHODS: A total of 151 patients were recruited. Blood samples at 0 h and 6 h post-ICU admission were collected. Primary outcome was occurrence of AKI within 48 h of ICU admission defined using Acute Kidney Injury Network (AKIN) classification. RESULTS: Forty-five (29.8%) patients developed AKI within 48 h of ICU admission. Among them, 22, 14, and nine were classified as AKIN Stage 1, 2, and 3 respectively. pNGAL levels at 0 h and 6 h were significantly related to AKI severity. The AUROC for pNGAL at 0 h and 6 h increased with AKI severity (AKIN stage ≥1 0.671 ± 0.048 and 0.691 ± 0.047; stage ≥2 0.737 ± 0.055 and 0.796 ± 0.048; stage 3 0.829 ± 0.072 and 0.860 ± 0.065, respectively) and requirement of renal replacement therapy (0.880 ± 0.059 & 0.837 ± 0.088). Change of pNGAL from 0 h to 6 h showed no advantage in predictive power compared with pNGAL level at 0 h or 6 h alone. The addition of pNGAL into clinical AKI prediction model could only provide marginal benefit. CONCLUSION: pNGAL correlated with severity of AKI and requirement of renal replacement therapy in ICU patients who received major or ultra-major non-cardiac surgery. However, the benefit of adding pNGAL into clinical AKI prediction model is marginal.
Asunto(s)
Lesión Renal Aguda/sangre , Lesión Renal Aguda/diagnóstico , Cuidados Críticos , Lipocalinas/sangre , Proteínas Proto-Oncogénicas/sangre , Lesión Renal Aguda/terapia , Proteínas de Fase Aguda , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Lipocalina 2 , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Terapia de Reemplazo Renal , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
BACKGROUND AND AIMS: Severe sepsis and septic shock are common causes of mortality and morbidity in an intensive care unit setting. Endotoxin, derived from the outer membranes of Gram-negative bacteria, is considered a major factor in the pathogenesis of sepsis. This study investigated the effect of Alteco endotoxin hemoadsorption device on Gram-negative septic shock patients. MATERIALS AND METHODS: An open, controlled, prospective, randomized, single-center trial was conducted between February 2010 and June 2012. Patients with septic shock due to intra-abdominal sepsis were randomized to either conventional therapy (n = 8) or conventional therapy plus two 2-hourly sessions of Alteco endotoxin hemoadsorption (n = 7). Primary endpoint was the Sequential Organ Failure Assessment (SOFA) score changes from 0 to 72 h. Secondary end points included vasopressor requirement, PaO2/FiO2 ratio (PFR), length of stay (LOS), and 28-day mortality. RESULTS: This study was terminated early as interim analysis showed a low probability of significant findings. No significant difference was noted between the two groups with respect to change in SOFA score, vasopressor score, PFR, LOS, and 28-day mortality. Side-effect was minimal. CONCLUSIONS: We could not identify any clinical benefit on the addition of Alteco endotoxin hemoadsorption to conventional therapy in patients who suffered from intra-abdominal sepsis with shock. The side effect profile of this novel device was acceptable.
RESUMEN
BACKGROUND: The epidemiological features of the Klebsiella pneumoniae causing bloodstream infections in Hong Kong and their potential threats to human health remained unknown. METHODS: K. pneumoniae strains collected from four hospitals in Hong Kong during the period of 2009-2018 were subjected to molecular typing, string test, antimicrobial susceptibility testing, whole genome sequencing and analysis. Clinical data of patients from whom these strains were isolated were analyzed retrospectively using univariate and multivariate logistic regression approaches. FINDINGS: The 240 Klebsiella spp. strains belonged to 123 different STs and 63 different capsule loci (KLs), with KL1 and KL2 being the major type. 86 out of 212 BSI-KP (40.6%) carried at least one of the virulence genes iuc, iro, rmpA or rmpA2. Virulence plasmid correlated well with the string test positive result, yet 8 strains without rmp genes were also hypermucoviscous, which was due to wzc mutation. The mortality rate of bloodstream infection patients was 43.0%. Univariant analysis showed that factors including renal replacement therapy (FDR adjusted p = 0.0007), mechanical ventilation (FDR adjusted p < 0.0001) and respiratory sepsis (FDR adjusted p < 0.0001) were found to pose the highest risk of death upon infection by Klebsiella spp. INTERPRETATION: This study revealed the high mortality rate and risk factors associated with bloodstream infections caused by K. pneumoniae in Hong Kong, which warrants immediate action to develop effective solution to tackle this problem. FUNDING: Theme Based Research Scheme (T11-104/22-R), Research Impact Fund (R5011-18 F) and Postdoctoral Fellowship (PDFS2223-1S09).
Asunto(s)
Infecciones por Klebsiella , Sepsis , Humanos , Hong Kong/epidemiología , Klebsiella/genética , Epidemiología Molecular , Estudios Retrospectivos , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/genética , AntibacterianosRESUMEN
BACKGROUND AND OBJECTIVE: High-flow nasal cannula (HFNC), a relatively new technique in acute hypoxemic respiratory failure (AHRF), is gaining popularity in intensive care units (ICUs). Our study aims to identify the predictive factors for failure of HFNC. MATERIALS AND METHODS: This is a 5-year retrospective cohort study in patients with AHRF using HFNC in an ICU of a regional hospital in Hong Kong. The primary outcome is to identify the predictive factors for failure of HFNC which is defined as escalation of treatment to noninvasive ventilation, mechanical ventilation, extracorporeal membrane oxygenation, or death. RESULTS: Of the 124 ICU patients with AHRF, 69 (55.65%) failed in the use of HFNC. The patients failing HFNC had higher Acute physiology and Chronic Health Evaluation IV scores, lower Glasgow Coma Scale scores, lower platelet counts and serum sodium levels upon ICU admission, and higher pH on day of HFNC commencement. They had higher respiratory rates before HFNC and higher heart rates before and 1 h after HFNC. The respiratory rate-oxygenation (ROX) index which is defined as a ratio of SpO2/FiO2 to respiratory rate was significantly lower in the failure group 1 h and 12 h after HFNC. By multivariate binary logistic regression, failure of HFNC is associated with lower ROX index at 12 h after HFNC. CONCLUSION: ROX index at 12 h serves as a valuable tool to monitor the responsiveness to HFNC treatment. Close monitoring is required to identify patient failing using HFNC.
RESUMEN
Background: Shewanella species are emerging pathogens that can cause severe hepatobiliary, skin and soft tissue, gastrointestinal, respiratory infections, and bacteremia. Here we reported the largest case series of infections caused by Shewanella species. Aim: To identify the clinical features and risk factors predisposing to Shewanella infections. To evaluate resistance pattern of Shewanella species and appropriateness of antibiotic use in the study cohort. Methods: Patients admitted to a regional hospital in Hong Kong with Shewanella species infection from April 1, 2010 to December 31, 2020 were included. Demographics, antibiotics, microbiology, and outcomes were retrospectively analyzed. Findings: Over the 10 years, we identified 128 patients with Shewanella species infection. 61.7% were male with a median age of 78 (IQR 65-87). Important underlying diseases included hepatobiliary diseases (63.3%), malignancy (26.6%), chronic kidney disease or end-stage renal failure (25.8%), and diabetes mellitus (22.7%). Hepatobiliary infections (60.4%) were the most common clinical manifestation. Majority (92.2%) were infected with Shewanella algae, while 7.8% were infected with Shewanella putrefaciens. The identified organisms were usually susceptible to ceftazidime (98.7%), gentamicin (97.4%), cefoperazone-sulbactam (93.5%) and ciprofloxacin (90.3%). Imipenem-susceptible strains were only present in 76.6% of isolates. Conclusion: This largest case series suggested that Shewanella infections are commonly associated with underlying comorbidities, especially with hepatobiliary diseases and malignancy. Although Shewanella species remained largely susceptible to third and fourth generation cephalosporins and aminoglycosides, carbapenem resistance has been on a significant rise.
RESUMEN
The neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width (RDW) are emerging biomarkers to predict outcomes in general ward patients. However, their role in the prognostication of critically ill patients with pneumonia is unclear. A total of 216 adult patients were enrolled over 2 years. They were classified into viral and bacterial pneumonia groups, as represented by influenza A virus and Streptococcus pneumoniae, respectively. Demographics, outcomes, and laboratory parameters were analysed. The prognostic power of blood parameters was determined by the respective area under the receiver operating characteristic curve (AUROC). Performance was compared using the APACHE IV score. Discriminant ability in differentiating viral and bacterial aetiologies was examined. Viral and bacterial pneumonia were identified in 111 and 105 patients, respectively. In predicting hospital mortality, the APACHE IV score was the best prognostic score compared with all blood parameters studied (AUC 0.769, 95% CI 0.705-0.833). In classification tree analysis, the most significant predictor of hospital mortality was the APACHE IV score (adjusted P = 0.000, χ2 = 35.591). Mechanical ventilation was associated with higher hospital mortality in patients with low APACHE IV scores ≤ 70 (adjusted P = 0.014, χ2 = 5.999). In patients with high APACHE IV scores > 90, age > 78 (adjusted P = 0.007, χ2 = 11.221) and thrombocytopaenia (platelet count ≤ 128, adjusted P = 0.004, χ2 = 12.316) were predictive of higher hospital mortality. The APACHE IV score is superior to all blood parameters studied in predicting hospital mortality. The single inflammatory marker with comparable prognostic performance to the APACHE IV score is platelet count at 48 h. However, there is no ideal biomarker for differentiating between viral and bacterial pneumonia.
Asunto(s)
Neutrófilos , Neumonía Bacteriana , Adulto , Biomarcadores , Índices de Eritrocitos , Humanos , Unidades de Cuidados Intensivos , Linfocitos , Monocitos , Pronóstico , Curva ROC , Estudios RetrospectivosRESUMEN
BACKGROUND: Sepsis is an important cause of mortality and morbidity among critically ill patients with underlying malignancy. METHODS: Patients with sepsis admitted to the intensive care unit (ICU) of the Pamela Youde Nethersole Eastern Hospital from January 1, 2010 to April 30, 2019 were recruited. Demographics, laboratory parameter, and outcome were analyzed. Those with underlying malignancy were matched with those without malignancy based on their severity of organ failure (defined by the sequential organ failure assessment [SOFA] score) and septic source. RESULTS: Two hundred sixty-three patients with underlying active malignancy were matched with 259 patients without malignancy. Those with malignancy had higher APACHE IV score (89 vs. 83), lower albumin (22.1 vs. 24.4), neutrophil count (6.0 vs. 9.3), hemoglobin (8.0 vs. 9.8), platelet count (113 vs. 133), less use of mechanical ventilation (35.7% vs. 45.9%), renal replacement therapy (22.1% vs. 28.2%) and vasopressor (66.2% vs. 74.9%), higher 30-day (34.2% vs. 24.3%) ICU (22.4% vs. 18.9%), and 1-year (62.4% vs. 36.7%) mortality compared with those without malignancy. A higher APACHE IV score and pulmonary sepsis were predictors of 30-day mortality by Cox regression analysis. CONCLUSION: Disease severity and pulmonary sepsis, but not underlying malignancy, predicted short-term mortality among critically ill septic patients.
Asunto(s)
Neoplasias , Sepsis , Enfermedad Crítica , Humanos , Unidades de Cuidados Intensivos , Neoplasias/complicaciones , Neoplasias/terapia , Puntuaciones en la Disfunción de Órganos , Pronóstico , Estudios Retrospectivos , Sepsis/complicacionesRESUMEN
The main mechanism of virulence in Klebsiella pneumoniae is the acquisition of K. pneumoniae virulence plasmids (KpVPs), which include two dominant types, namely, KpVP-1 (carrying iuc1, iro1, rmpA, and rmpA2) and KpVP-2 (carrying iuc2, iro2, and rmpA). Both are non-conjugative and associated with different hypervirulent clones. In contrast to KpVP-1 reported in K1, K2, and other serotypes of K. pneumoniae, KpVP-2 was only reported in K2 strains and rarely characterized. In this study, we identified a conjugative KpVP-2-type virulence plasmid from a clinical hypervirulent K. pneumoniae strain. This plasmid was generated by the integration of conjugative transfer genes into the KpVP-2-type plasmid Kp52.145 II and could be readily conjugated to Escherichia coli strain EC600 and K. pneumoniae strains of various types which are clinically existing, mediating hypervirulence. Furthermore, this kind of conjugative KpVP-2-type virulence plasmid has been disseminated in clinical settings in Hong Kong and other regions of the world. The generation of conjugative virulence plasmid may promote its transmission and explain the evolution of this type of virulence plasmid.
RESUMEN
Veno-venous extracorporeal membrane oxygenation (VV ECMO) offers the last resort in the treatment of acute respiratory distress syndrome (ARDS). Various scoring systems have been established, yet external validation of these scoring systems in the Asian population remains scarce. We aim to identify factors associated with hospital mortality and to validate various scoring systems in the prediction of hospital mortality. A retrospective analysis of adults admitted to Pamela Youde Nethersole Eastern Hospital intensive care unit who received VV ECMO from January 1, 2010 to June 30, 2019 was performed. Demographics, ventilation strategies, rescue therapies, and clinical outcomes were compared. The primary outcome was hospital mortality and secondary outcomes were intensive care unit (ICU) mortality, ICU, and hospital length of stay. There were 122 VV ECMO performed for ARDS, of which 78 survived and 44 died. VV ECMO performed for viral pneumonitis was significantly associated with better survival (55.1% vs. 25%, p = 0.001) compared with other causes. As for prediction scores, the PREdiction of Survival on ECMO Therapy-Score had the highest area under receiver operator curve of 0.733 (95% confidence interval [CI]: 0.643-0.823), whereas that of PRedicting dEath for SEvere ARDS on VV ECMO score was 0.662 (95% CI: 0.561-0.764), Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score was 0.657 (95% CI: 0.553-0.761), Sequential Organ Failure Assessment score was 0.652 (95% CI: 0.547-0.757), and VV ECMO mortality score was 0.637 (95% CI: 0.532-0.742). In our cohort, VV ECMO performed for viral pneumonitis was associated with a higher hospital survival. Prediction scores are helpful in our population and provide a useful reference to hospital mortality.
Asunto(s)
Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria , Adulto , Oxigenación por Membrana Extracorpórea/efectos adversos , Mortalidad Hospitalaria , Humanos , Puntuaciones en la Disfunción de Órganos , Síndrome de Dificultad Respiratoria/terapia , Estudios RetrospectivosRESUMEN
Background: The utilization of extracorporeal membrane oxygenation (ECMO) has increased rapidly around the world. Being an overall low-volume high-cost form of therapy, the effectiveness of having care delivered in segregated units across a geographical locality is debatable. Methods: All adult extracorporeal membrane oxygenation cases admitted to public hospitals in Hong Kong between 2010 and 2019 were included. "High-volume" centers were defined as those with >20 extracorporeal membrane oxygenation cases in the respective calendar year, while "low-volume" centers were those with ≤20. Clinical outcomes of patients who received extracorporeal membrane oxygenation care in high-volume centers were compared with those in low-volume centers. Results: A total of 911 patients received extracorporeal membrane oxygenation-297 (32.6%) veno-arterial extracorporeal membrane oxygenation, 450 (49.4%) veno-venous extracorporeal membrane oxygenation, and 164 (18.0%) extracorporeal membrane oxygenation-cardiopulmonary resuscitation. The overall hospital mortality was 456 (50.1%). The annual number of extracorporeal membrane oxygenation cases in high- and low-volume centers were 29 and 11, respectively. Management in a high-volume center was not significantly associated with hospital mortality (adjusted odds ratio (OR) 0.86, 95% confidence interval (CI): 0.61-1.21, P=0.38), or with intensive care unit mortality (adjusted OR 0.76, 95% CI: 0.54-1.06, P=0.10) compared with a low-volume center. Over the 10-year period, the overall observed mortality was similar to the Acute Physiology And Chronic Health Evaluation IV-predicted mortality, with no significant difference in the standardized mortality ratios between high- and low-volume centers (P=0.46). Conclusions: In a territory-wide observational study, we observed that case volumes in extracorporeal membrane oxygenation centers were not associated with hospital mortality. Maintaining standards of care in low-volume centers is important and improves preparedness for surges in demand.