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Introduction: Cytomegalovirus (CMV) infection is a well-known factor associated with invasive aspergillosis in immunocompromised hosts. However, its association with COVID-19-associated pulmonary aspergillosis (CAPA) has not been described. We aimed to examine the possible link between CMV replication and CAPA occurrence. Methods: A single-center, retrospective case-control study was conducted. A case was defined as a patient diagnosed with CAPA according to 2020 ECMM/ISHAM consensus criteria. Two controls were selected for each case among critically ill COVID-19 patients. Results: In total, 24 CAPA cases were included, comprising 14 possible CAPA and 10 probable CAPA. Additionally, 48 matched controls were selected. CMV replication was detected more frequently in CAPA than in controls (75.0% vs. 35.4%, p = 0.002). Probable CMV end-organ disease was more prevalent in CAPA (20.8% vs. 4.2%, p = 0.037). After adjusting for possible confounding factors, CMV replication persisted strongly associated with CAPA (OR 8.28 95% CI 1.90-36.13, p = 0.005). Among 11 CAPA cases with CMV PCR available prior to CAPA, in 9 (81.8%) cases, CMV replication was observed prior to CAPA diagnosis. Conclusions: Among critically ill COVID-19 patients, CMV replication was associated with CAPA and could potentially be considered a harbinger of CAPA. Further studies are needed to confirm this association.
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BACKGROUND: COVID-19-associated pulmonary aspergillosis (CAPA) is a major complication of critically ill COVID-19 patients, with a high mortality rate and potentially preventable. Thus, identifying patients at high risk of CAPA would be of great interest. We intended to develop a clinical prediction score capable of stratifying patients according to the risk for CAPA at ICU admission. METHODS: Single centre retrospective case-control study. A case was defined as a patient diagnosed with CAPA according to 2020 ECMM/ISHAM consensus criteria. 2 controls were selected for each case among critically ill COVID-19 patients. RESULTS: 28 CAPA patients and 56-matched controls were included. Factors associated with CAPA included old age (68 years vs. 62, p = .033), active smoking (17.9% vs. 1.8%, p = .014), chronic respiratory diseases (48.1% vs. 26.3%, p = .043), chronic renal failure (25.0% vs. 3.6%, p = .005), chronic corticosteroid treatment (28.6% vs. 1.8%, p < .001), tocilizumab therapy (92.9% vs. 66.1%, p = .008) and high APACHE II at ICU admission (median 13 vs. 10 points, p = .026). A score was created including these variables, which showed an area under the receiver operator curve of 0.854 (95% CI 0.77-0.92). A punctuation below 6 had a negative predictive value of 99.6%. A punctuation of 10 or higher had a positive predictive value of 27.9%. CONCLUSION: We present a clinical prediction score that allowed to stratify critically ill COVID-19 patients according to the risk for developing CAPA. This CAPA score would allow to target preventive measures. Further evaluation of the score, as well as the utility of these targeted preventive measures, is needed.
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COVID-19 , Aspergilosis Pulmonar Invasiva , Aspergilosis Pulmonar , Anciano , COVID-19/complicaciones , Estudios de Casos y Controles , Enfermedad Crítica , Humanos , Unidades de Cuidados Intensivos , Aspergilosis Pulmonar Invasiva/complicaciones , Aspergilosis Pulmonar Invasiva/diagnóstico , Aspergilosis Pulmonar Invasiva/tratamiento farmacológico , Aspergilosis Pulmonar/complicaciones , Estudios Retrospectivos , Factores de Riesgo , SARS-CoV-2RESUMEN
Background and objective: To describe the characteristics and the evolution of patients with solid tumours admitted to the ICU and to identify factors associated with hospital mortality and to evaluate three illness severity scores. Material and methods: Descriptive study including 132 patients with solid tumour admitted to the ICU (2010-2016). Demographics and cancer-related data, organ failures, life-supporting therapies and severity scores: APACHE II, SOFA and ICU Cancer Mortality Model (ICMM) were collected. Results: There were 58 patients admitted for medical reasons and 74 for scheduled surgery. The ICU and hospital mortality rate were 12.9% and 19.7%, respectively. The medical reason for admission, the number of organ failures, and the need of life-supporting therapies were significantly associated with a higher mortality (p<0.05). In the logistic regression analysis, the three severity scores: SOFA (OR 1.18, 95% IC 1.14-1.48), APACHE II (OR 1.11, 95% CI 1.09-1.27), and ICMM (OR 1.03, 95% CI 1.02-1.07) were independently associated with a higher mortality (p<0.05). To evaluate the discrimination, the area under the receiver operating characteristics curves (AUROC) were calculated: APACHE II (0.795, 95% CI 0.69-0.9), SOFA (0.77, 95% CI 0.69-0.864) and ICMM (0.794, 95% CI 0.697-0.891). The comparison of AUC ROC after DeLong's test showed no difference between them. Conclusion: Hospital mortality was associated with the type and severity of acute illness. The three severity scores were useful to assess outcome and accurate in the discrimination, but we did not find a significant difference between them
Introducción y objetivo: Describir las características generales y la evolución de los pacientes con tumores sólidos ingresados en una unidad de cuidados intensivos (UCI), identificar los factores asociados a la mortalidad y evaluar el valor pronóstico de 3 escalas de gravedad. Material y métodos: Estudio descriptivo de 132 pacientes con diagnóstico de tumour sólido admitidos en la UCI (2010-2016). Se analizaron los datos demográficos relacionados con el tumour, la disfunción orgánica y las terapias de soporte vital, así como las escalas de gravedad APACHE II, SOFA e ICMM. Resultados: Ingresaron 58 pacientes por causa médica y 74 tras cirugía programada. La tasa de mortalidad en la UCI y hospitalaria fue del 12,9% y 19,7%, respectivamente. La causa médica de ingreso, el número de fallos orgánicos y la necesidad de terapias de soporte vital se asociaron significativamente con mayor mortalidad (p<0,05). En el análisis por regresión logística las 3 escalas evaluadas: SOFA (OR: 1,18; IC 95%: 1,14-1,48), APACHE II (OR: 1,11; IC 95%: 1,09-1,27) e ICMM (OR: 1,03; IC 95%: 1,02-1,07) se asociaron de forma independiente con una mayor mortalidad (p<0,05). Para evaluar la discriminación, se calcularon las AUROC: APACHE II (0,795; CI 95%: 0,69-0,9), SOFA (0,77; CI 95%: 0,69-0,864) e ICMM (0,794; CI 95%: 0,697-0,891). La comparación de las mismas por el test DeLong no mostró diferencias entre los sistemas de puntuación. Conclusiones: La mortalidad hospitalaria se asoció con el tipo y la gravedad de la enfermedad aguda. Las e escalas de gravedad evaluadas fueron igualmente útiles para evaluar el pronóstico, sin mostrar diferencias entre ellas
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Humanos , Masculino , Persona de Mediana Edad , Anciano , Índice de Severidad de la Enfermedad , Neoplasias/diagnóstico , Unidades de Cuidados Intensivos , Pronóstico , Gravedad del Paciente , Mortalidad Hospitalaria , Estudios Retrospectivos , APACHE , Puntuaciones en la Disfunción de ÓrganosRESUMEN
BACKGROUND AND OBJECTIVE: To describe the characteristics and the evolution of patients with solid tumours admitted to the ICU and to identify factors associated with hospital mortality and to evaluate three illness severity scores. MATERIAL AND METHODS: Descriptive study including 132 patients with solid tumour admitted to the ICU (2010-2016). Demographics and cancer-related data, organ failures, life-supporting therapies and severity scores: APACHE II, SOFA and ICU Cancer Mortality Model (ICMM) were collected. RESULTS: There were 58 patients admitted for medical reasons and 74 for scheduled surgery. The ICU and hospital mortality rate were 12.9% and 19.7%, respectively. The medical reason for admission, the number of organ failures, and the need of life-supporting therapies were significantly associated with a higher mortality (p<0.05). In the logistic regression analysis, the three severity scores: SOFA (OR 1.18, 95% IC 1.14-1.48), APACHE II (OR 1.11, 95% CI 1.09-1.27), and ICMM (OR 1.03, 95% CI 1.02-1.07) were independently associated with a higher mortality (p<0.05). To evaluate the discrimination, the area under the receiver operating characteristics curves (AUROC) were calculated: APACHE II (0.795, 95% CI 0.69-0.9), SOFA (0.77, 95% CI 0.69-0.864) and ICMM (0.794, 95% CI 0.697-0.891). The comparison of AUC ROC after DeLong's test showed no difference between them. CONCLUSION: Hospital mortality was associated with the type and severity of acute illness. The three severity scores were useful to assess outcome and accurate in the discrimination, but we did not find a significant difference between them.
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Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Neoplasias/mortalidad , Admisión del Paciente , Índice de Severidad de la Enfermedad , APACHE , Anciano , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación , Cuidados para Prolongación de la Vida/métodos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Neoplasias/tratamiento farmacológico , Neoplasias/cirugía , Puntuaciones en la Disfunción de Órganos , Curva ROC , Estudios RetrospectivosRESUMEN
INTRODUCTION: Our objectives were to describe the incidence, clinical characteristics, and risk factors for Clostridium difficile infection (CDI) in critically ill patients and to determine C. difficile PCR-ribotypes. METHODS: Prospective, observational study in 26 Spanish ICUs. Patients with diarrhea meeting ESCMID criteria for CDI were included. Molecular characterization of isolates was performed using PCR ribotyping. RESULTS: Of 4258 patients admitted to the ICUs, 190 (4.5%) developed diarrhea. Only 16 patients (8.4%) were diagnosed with CDI. Ribotype 078/126 (25.0%) was the most frequently identified. The mortality rate was similar in patients with ICD compared to patients with diarrhea not caused by C. difficile (p = 0.115). Chronic renal insufficiency was identified as the only factor independently associated with the development of CDI (OR 5.87, 95% CI 1.24-27.83; p = 0.026). CONCLUSIONS: The incidence of CDI in Spanish ICUs is low. Only chronic renal insufficiency was observed to be a risk factor for CDI development
INTRODUCCIÓN: Pretendemos describir la incidencia, las características clínicas y los factores de riesgo de la infección por Clostridium difficile (ICD) en pacientes ingresados en unidades de cuidados intensivos, así como los ribotipos identificados. MÉTODOS: Estudio observacional, prospectivo, realizado en 26 unidades de cuidados intensivos de España. Se incluyeron pacientes con diarrea y criterios clínicos de la ESCMID por sospecha de ICD. La caracterización molecular se realizó mediante PCR. RESULTADOS: De 4.258 pacientes ingresados, 190 (4,5%) presentaron diarrea; en 16 causada por ICD. El ribotipo más frecuentemente aislado fue 078/126 (25%). La tasa de mortalidad cruda fue similar en pacientes con ICD y en pacientes con diarrea no causada por Clostridium difficile (p = 0,115). La insuficiencia renal crónica fue identificada como factor independientemente asociado a desarrollo de ICD (OR: 5,87; IC 95%: 1,24-27,83; p = 0,026). CONCLUSIONES: La incidencia de ICD en las unidades de cuidados intensivos españolas es baja. La insuficiencia renal crónica es el único factor identificado para desarrollo de ICD
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Infección Hospitalaria/microbiología , Clostridioides difficile/aislamiento & purificación , Infecciones por Clostridium/microbiología , Estudio Observacional , Estudios Prospectivos , Factores de Riesgo , Clostridioides difficile/genética , EspañaRESUMEN
INTRODUCTION: Our objectives were to describe the incidence, clinical characteristics, and risk factors for Clostridium difficile infection (CDI) in critically ill patients and to determine C. difficile PCR-ribotypes. METHODS: Prospective, observational study in 26 Spanish ICUs. Patients with diarrhea meeting ESCMID criteria for CDI were included. Molecular characterization of isolates was performed using PCR ribotyping. RESULTS: Of 4258 patients admitted to the ICUs, 190 (4.5%) developed diarrhea. Only 16 patients (8.4%) were diagnosed with CDI. Ribotype 078/126 (25.0%) was the most frequently identified. The mortality rate was similar in patients with ICD compared to patients with diarrhea not caused by C. difficile (p=0.115). Chronic renal insufficiency was identified as the only factor independently associated with the development of CDI (OR 5.87, 95% CI 1.24-27.83; p=0.026). CONCLUSIONS: The incidence of CDI in Spanish ICUs is low. Only chronic renal insufficiency was observed to be a risk factor for CDI development.
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Infecciones por Clostridium/epidemiología , Anciano , Clostridioides difficile/clasificación , Clostridioides difficile/genética , Infecciones por Clostridium/diagnóstico , Enfermedad Crítica , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ribotipificación , Factores de Riesgo , España/epidemiologíaRESUMEN
AIMS: The aim of this study was to evaluate the effectiveness of local low-dose urokinase thrombolysis (LLDUT) in haemodynamically stable pulmonary embolism with right ventricular dysfunction (RVD). METHODS AND RESULTS: This was a prospective study. LLDUT with a 200,000 IU bolus followed by a 100,000 IU/hr infusion was given. Treatment duration was determined through radiological control performed 48-72 hrs into treatment. A follow-up echocardiogram was performed within seven days after LLDUT completion. Evolution of thrombus burden, pulmonary artery pressures (PAP) and RVD were studied, and haemorrhagic complications and mortality were recorded. Eighty-seven patients were included (62.5±16.5 years). In 67 patients (77%), the baseline echocardiogram showed mild-to-severe RVD, a dilated right ventricle (diameter: 44.4±6.2 mm) and a decreased tricuspid annular plane systolic excursion (14 mm [12-17]). Seventy-six patients (87.4%) experienced radiological improvement. Initially high PAP (mmHg) decreased after LLDUT: systolic 52.4 vs. 35.2 (17.2 [95% CI: 14.5-19.9]; p<0.0001), mean 34.2 vs. 23.5 (10.7 [95% CI: 9.0-12.5]; p<0.0001) and diastolic 23.9 vs. 16.0 (7.9 [95% CI: 6.1-9.7]; p<0.0001). Follow-up echocardiography showed overall improvement of RVD. No life-threatening haemorrhagic complications were reported. Six-month survival was 96.5%. CONCLUSIONS: LLDUT rapidly decreased thrombus burden and PAP, improving right ventricular function, and was not associated with any life-threatening complications or pulmonary embolism (PE)- or treatment-related mortality.
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Embolia Pulmonar , Disfunción Ventricular Derecha , Humanos , Estudios Prospectivos , Terapia Trombolítica , Activador de Plasminógeno de Tipo UroquinasaRESUMEN
We study the epidemiology, molecular basis, clinical risk factors, and outcome involved in the clonal dissemination of VIM-1-producing Klebsiella pneumoniae isolates in the hospital setting. All patients infected/colonized by carbapenem-nonsusceptible K. pneumoniae (CNSKP) in 2009 were included. Molecular epidemiology was studied by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Antibiotic resistance genes were analyzed by PCR and sequencing. Plasmids were studied by PFGE with S1 nuclease digestion and for incompatibility group by a PCR-based replicon typing scheme. Risk factors associated with CNSKP colonization/infection were assessed by an observational case-control study. All 55 patients studied were infected (n = 28) or colonized (n = 27) by VIM-1-producing K. pneumoniae. All but one acquired isolates of a single clone (PFGE cluster 1 [C1], sequence type 15 [ST15]), while another clone (PFGE C2, ST340) was detected in four patients. C1 isolates also produced the new extended-spectrum ß-lactamase SHV-134. bla(VIM-1) was carried in a class 1 integron and an untypeable plasmid of â¼50 bp. The number of days that the patient received mechanical ventilation, the use of parenteral nutrition, previous treatment with linezolid, and treatment with extended-spectrum cephalosporins for more than 7 days were detected to be independent risk factors for CNSKP acquisition. The VIM-1-producing K. pneumoniae ST15 clone has a high capacity to spread among intensive care unit patients with severe underlying conditions. A high rate of associated mortality and great difficulty in controlling the spread of this clone, without permanent behavioral changes in the personnel, were observed.
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Antibacterianos/administración & dosificación , Carbapenémicos/administración & dosificación , Infección Hospitalaria/tratamiento farmacológico , Brotes de Enfermedades , Infecciones por Klebsiella/tratamiento farmacológico , Klebsiella pneumoniae/genética , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Infección Hospitalaria/transmisión , Dermatoglifia del ADN , ADN Bacteriano/análisis , ADN Bacteriano/biosíntesis , Farmacorresistencia Bacteriana Múltiple , Electroforesis en Gel de Campo Pulsado , Femenino , Hospitales , Humanos , Infecciones por Klebsiella/microbiología , Infecciones por Klebsiella/mortalidad , Infecciones por Klebsiella/transmisión , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Tipificación de Secuencias Multilocus , Factores de Riesgo , España/epidemiología , Tasa de Supervivencia , Resultado del Tratamiento , beta-Lactamasas/biosíntesisRESUMEN
La afectación del intestino delgado por Clostridium difficile constituye una entidad clínica infrecuente.MétodoSe presenta el primer caso de enteritis por C. difficile diagnosticado en España y se realiza una revisión de la literatura médica.ResultadosVarón de 30 años de edad intervenido por recidiva de un tumor germinal retroperitoneal. Siete días después presentó vómitos, diarrea y, finalmente, obstrucción intestinal por seudomembranas originadas por enteritis por C. difficile. En la literatura médica han sido descritos otros 57 casos de enteritis por C. difficile. La edad media era de 52±17 años con un rango desde 18 a 86 años. Veintinueve pacientes (50%) presentaban enfermedad inflamatoria intestinal. Cuarenta y siete (81%) tenían antecedentes de cirugía de colon o intestino delgado. La mortalidad fue más acusada en pacientes de mayor edad y en los que no presentaban enfermedad inflamatoria intestinal.ConclusiónLa enteritis por C. difficile se caracteriza por su elevada gravedad y morta(AU)
A 30-year-old man underwent surgery for recurrence of a retroperitoneal germ cell tumor. Seven days later the patient developed vomiting, diarrhea and, finally, intestinal obstruction due to pseudomembranes caused by CDE. Only 57 cases of CDE have been reported in the literature. The mean age was 52±17 years with a range of 18 to 86 years. Twenty-nine patients (50%) had inflammatory bowel disease. Forty-seven (81%) had a history of colon or small intestine surgery. Mortality was higher in older patients and in those without inflammatory bowel disease (AU)
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Humanos , Masculino , Adulto , Clostridioides difficile/patogenicidad , Enterocolitis Seudomembranosa/diagnóstico , Enfermedades Inflamatorias del Intestino/complicaciones , Insuficiencia Multiorgánica/fisiopatologíaRESUMEN
INTRODUCTION: Clostridium difficile infection of the small intestine is infrequent. METHOD: We present the first case of C. difficile enteritis (CDE) diagnosed in Spain and provide a review of the literature. RESULTS: A 30-year-old man underwent surgery for recurrence of a retroperitoneal germ cell tumor. Seven days later the patient developed vomiting, diarrhea and, finally, intestinal obstruction due to pseudomembranes caused by CDE. Only 57 cases of CDE have been reported in the literature. The mean age was 52±17 years with a range of 18 to 86 years. Twenty-nine patients (50%) had inflammatory bowel disease. Forty-seven (81%) had a history of colon or small intestine surgery. Mortality was higher in older patients and in those without inflammatory bowel disease. CONCLUSION: CDE is characterized by high severity and mortality.