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Peng Y, Minichmayr IK, Liu H, Xie F, Friberg LE. Multistate modeling for survival analysis in critically ill patients treated with meropenem. CPT Pharmacometrics Syst Pharmacol 2024; 13:222-233. [PMID: 37881115 PMCID: PMC10864930 DOI: 10.1002/psp4.13072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/19/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
Appropriate antibiotic dosing to ensure early and sufficient target attainment is crucial for improving clinical outcome in critically ill patients. Parametric survival analysis is a preferred modeling method to quantify time-varying antibiotic exposure - response effects, whereas bias may be introduced in hazard functions and survival functions when competing events occur. This study investigated predictors of in-hospital mortality in critically ill patients treated with meropenem by pharmacometric multistate modeling. A multistate model comprising five states (ongoing meropenem treatment, other antibiotic treatment, antibiotic treatment termination, discharge, and death) was developed to capture the transitions in a cohort of 577 critically ill patients treated with meropenem. Various factors were investigated as potential predictors of the transitions, including patient demographics, creatinine clearance calculated by Cockcroft-Gault equation (CLCRCG ), time that unbound concentrations exceed the minimum inhibitory concentration (fT>MIC ), and microbiology-related measures. The probabilities to transit to other states from ongoing meropenem treatment increased over time. A 10 mL/min decrease in CLCRCG was found to elevate the hazard of transitioning from states of ongoing meropenem treatment and antibiotic treatment termination to the death state by 18%. The attainment of 100% fT>MIC significantly increased the transition rate from ongoing meropenem treatment to antibiotic treatment termination (by 9.7%), and was associated with improved survival outcome. The multistate model prospectively assessed predictors of death and can serve as a useful tool for survival analysis in different infection scenarios, particularly when competing risks are present.
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Affiliation(s)
- Yaru Peng
- Department of PharmacyUppsala UniversityUppsalaSweden
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical SciencesCentral South UniversityChangshaChina
| | - Iris K. Minichmayr
- Department of PharmacyUppsala UniversityUppsalaSweden
- Department of Clinical PharmacologyMedical University ViennaViennaAustria
| | - Han Liu
- Department of PharmacyUppsala UniversityUppsalaSweden
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical SciencesCentral South UniversityChangshaChina
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Guo X, Guo D. A Nomogram Based on Comorbidities and Infection Location to Predict 30 Days Mortality of Immunocompromised Patients in ICU: A Retrospective Cohort Study. Int J Gen Med 2022; 14:10281-10292. [PMID: 34992443 PMCID: PMC8713880 DOI: 10.2147/ijgm.s345632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background The existing comorbidity indexes, like Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI), do not take infection factors into account for critically ill patients with immunocompromise, bringing about a decrease of prediction accuracy. Therefore, we attempted to incorporate infection location into the analysis to construct a rapid comorbidity scoring system independent of laboratory tests. Methods Data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database. A total of 3904 critically ill patients with immunocompromise admitted to ICU were enrolled and assigned into training or validation sets according to the date of ICU admission. The predictive nomogram was constructed in the training set based on logistic regression analysis and then undergone validation in the validation set in comparison with SOFA, CCI and ECI. Results Factors eligible for the nomogram included patient’s age, gender, ethnicity, underlying disease of immunocompromise like metastatic cancer and leukemia, possible infection on admission including pulmonary infection, urinary tract infection and blood infection, and one comorbidity, coagulopathy. The nomogram we developed exhibited better discrimination than SOFA, CCI and ECI with an area under the receiver operating characteristic curve (AUC) of 0.739 (95% CI 0.707–0.771) and 0.746 (95% CI 0.713–0.779) in the training and validation sets, respectively. Combining the nomogram and SOFA could bring a new prediction model with a superior predictive effect in both sets (training set AUC = 0.803 95% CI 0.777–0.828, validation set AUC = 0.818 95% CI 0.783–0.854). The calibration curve exhibited coherence between the nomogram and ideal observation for two cohorts (p>0.05). Decision curve analysis revealed the clinical usefulness of the nomogram in both sets. Conclusion We established a nomogram that could provide an accurate assessment of 30 days ICU mortality in critically ill patients with immunocompromise, which can be employed to evaluate the short-term prognosis of those patients and bring more clinical benefits without dependence on laboratory tests.
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Affiliation(s)
- Xuequn Guo
- Department of Respiratory Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian, People's Republic of China
| | - Donghao Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
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Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature. World J Emerg Surg 2021; 16:33. [PMID: 34112231 PMCID: PMC8194010 DOI: 10.1186/s13017-021-00375-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/26/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. METHODS A systematic review of the literature was conducted. RESULTS Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. CONCLUSION Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population.
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Lu X, Wang X, Gao Y, Yu S, Zhao L, Zhang Z, Zhu H, Li Y. Efficacy and safety of corticosteroids for septic shock in immunocompromised patients: A cohort study from MIMIC. Am J Emerg Med 2021; 42:121-126. [PMID: 32037125 DOI: 10.1016/j.ajem.2020.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/22/2020] [Accepted: 02/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Corticosteroids have been widely used as adjunct therapy for septic shock for many decades, but both the efficacy and safety remain unclear. The study was designed to investigate overall benefits and potential risks of corticosteroids in immunocompromised patients with septic shock. METHODS The Medical Information Mart for Intensive Care III (MIMIC-III) database was employed to conduct a cohort study. Immunocompromised patients with septic shock were enrolled and categorized by whether exposure to intravenous corticosteroids. Cox Proportional-Hazards models were used to control for confounders and assess the relationship between corticosteroids use and mortality. RESULTS A total of 866 patients were enrolled in this study, including 395 in the corticosteroids group and 471 in the non-corticosteroids group. Corticosteroids infusion was not associated with improved 30-day mortality in overall immunocompromised population [34.7% vs 32.1%; adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.87-1.43, p = 0.37]. The mortality effects were similar in 90-day, 180-day, 1-year and hospital mortality. For the subgroup of patients with metastatic cancer, corticosteroids infusion was associated with a statistically significant increase in the 30-day mortality risk (HR 1.58, 95% CI 1.06-2.37; p = 0.02). Corticosteroids had adverse effects on hemodynamic stability, prolonged ICU and hospital duration, and increased risk of hyperglycemia. CONCLUSIONS Corticosteroids therapy for the maintenance of blood pressure was not associated with improved mortality or hemodynamic stability in overall immunocompromised population with septic shock. Future randomized clinical trials are required to validate the effects of corticosteroids for septic shock in the special immunocompromised population.
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Affiliation(s)
- Xin Lu
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xue Wang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Yanxia Gao
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Shiyuan Yu
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Lina Zhao
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310020, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yi Li
- Emergency Department, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China.
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Cortegiani A, Crimi C, Sanfilippo F, Noto A, Di Falco D, Grasselli G, Gregoretti C, Giarratano A. High flow nasal therapy in immunocompromised patients with acute respiratory failure: A systematic review and meta-analysis. J Crit Care 2018; 50:250-256. [PMID: 30622042 DOI: 10.1016/j.jcrc.2018.12.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/27/2018] [Accepted: 12/27/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE The role of high-flow nasal therapy (HFNT) as compared to conventional oxygen therapy (COT) in immunocompromised patients admitted to intensive care unit (ICU) with acute respiratory failure (ARF) remains unclear. We conducted a systematic review and meta-analysis in order to address this issue. METHODS We searched PubMed, Medline and Embase until November 7th, 2018. Randomized controlled trials (RCTs), non-randomized prospective and retrospective evidence were selected. Observational studies were considered for sensitivity analysis. Primary outcome was mortality rate; intubation rate was a secondary outcome. RESULTS We included four studies in the primary analysis: one RCT, two RCT's post-hoc analyses and one retrospective study. We found no significant difference in short-term mortality comparing HFNT vs. COT: 1) ICU: n = 872 patients, odds ratio (OR) = 0.80 [0.44,1.45], p = 0.46, I2 = 30%, p = 0.24; 2) 28-day: n = 996 patients, OR = 0.79 [0.45,1.38], p = 0.40, I2 = 52%, p = 0.12). Conversely, we found a reduction of intubation rate in the HFNT group (n = 1052 patients, OR = 0.74 [0.55,0.98], p = 0.03, I2 = 7%, p = 0.36). The inclusion of one observational study for sensitivity analysis did not grossly change results. CONCLUSIONS We found no benefit of HFNT over COT on mortality in immunocompromised patients with ARF. However, HFNT was associated with a lower intubation rate warranting further research.
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Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Claudia Crimi
- Respiratory Medicine Unit, AOU "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele, Catania, Italy
| | - Alberto Noto
- Anesthesia and Intensive Care Unit, AOU Policinico "G. Martino", Messina, Italy
| | - Davide Di Falco
- Department of Anesthesia and Intensive Care, School of Anesthesia and Intensive Care, University of Catania, 95100 Catania, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122, Milan, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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Rello J, van Engelen TSR, Alp E, Calandra T, Cattoir V, Kern WV, Netea MG, Nseir S, Opal SM, van de Veerdonk FL, Wilcox MH, Wiersinga WJ. Towards precision medicine in sepsis: a position paper from the European Society of Clinical Microbiology and Infectious Diseases. Clin Microbiol Infect 2018; 24:1264-1272. [PMID: 29581049 DOI: 10.1016/j.cmi.2018.03.011] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/06/2018] [Accepted: 03/10/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Our current understanding of the pathophysiology and management of sepsis is associated with a lack of progress in clinical trials, which partly reflects insufficient appreciation of the heterogeneity of this syndrome. Consequently, more patient-specific approaches to treatment should be explored. AIMS To summarize the current evidence on precision medicine in sepsis, with an emphasis on translation from theory to clinical practice. A secondary objective is to develop a framework enclosing recommendations on management and priorities for further research. SOURCES A global search strategy was performed in the MEDLINE database through the PubMed search engine (last search December 2017). No restrictions of study design, time, or language were imposed. CONTENT The focus of this Position Paper is on the interplay between therapies, pathogens, and the host. Regarding the pathogen, microbiologic diagnostic approaches (such as blood cultures (BCs) and rapid diagnostic tests (RDTs)) are discussed, as well as targeted antibiotic treatment. Other topics include the disruption of host immune system and the use of biomarkers in sepsis management, patient stratification, and future clinical trial design. Lastly, personalized antibiotic treatment and stewardship are addressed (Fig. 1). IMPLICATIONS A road map provides recommendations and future perspectives. RDTs and identifying drug-response phenotypes are clear challenges. The next step will be the implementation of precision medicine to sepsis management, based on theranostic methodology. This highly individualized approach will be essential for the design of novel clinical trials and improvement of care pathways.
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Affiliation(s)
- J Rello
- CIBERES, Vall d'Hebron Barcelona Campus Hospital, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain.
| | - T S R van Engelen
- Centre for Experimental Molecular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - E Alp
- Department of Infectious Diseases, Infection Control Committee, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - T Calandra
- Infectious Diseases Service, Department of Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - V Cattoir
- University Hospital of Rennes, Department of Clinical Microbiology, Rennes, France and National Reference Center for Antimicrobial Resistance (lab Enterococci), Rennes, France
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, University Hospital and Medical Centre, Albert-Ludwigs-University Faculty of Medicine, Freiburg, Germany; Executive Committee of ESCMID Study Group for Bloodstream Infections and Sepsis (ESGBIS), The Netherlands
| | - M G Netea
- Department of Internal Medicine and Radboud Centre for Infectious Diseases (RCI), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; Human Genomics Laboratory, Craiova University of Medicine and Pharmacy, Craiova, Romania
| | - S Nseir
- Faculté de Médecine, University of Lille and Centre de Réanimation, CHU Lille, Lille, France
| | - S M Opal
- Brown University, Infectious Diseases, Providence, RI, USA
| | - F L van de Veerdonk
- Department of Internal Medicine and Radboud Centre for Infectious Diseases (RCI), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - M H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds, UK
| | - W J Wiersinga
- Centre for Experimental Molecular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Department of Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Executive Committee of ESCMID Study Group for Bloodstream Infections and Sepsis (ESGBIS), The Netherlands.
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Moreau AS, Martin-Loeches I, Povoa P, Salluh J, Rodriguez A, Thille AW, Diaz Santos E, Vedes E, Lobo SM, Mégarbane B, Molero Silvero E, Coelho L, Argaud L, Sanchez Iniesta R, Labreuche J, Rouzé A, Nseir S. Impact of immunosuppression on incidence, aetiology and outcome of ventilator-associated lower respiratory tract infections. Eur Respir J 2018; 51:13993003.01656-2017. [PMID: 29439020 DOI: 10.1183/13993003.01656-2017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022]
Abstract
The aim of this planned analysis of the prospective multinational TAVeM database was to determine the incidence, aetiology and impact on outcome of ventilator-associated lower respiratory tract infections (VA-LRTI) in immunocompromised patients.All patients receiving mechanical ventilation for >48 h were included. Immunocompromised patients (n=663) were compared with non-immunocompromised patients (n=2297).The incidence of VA-LRTI was significantly lower among immunocompromised than among non-immunocompromised patients (16.6% versus 24.2%; sub-hazard ratio 0.65, 95% CI 0.53-0.80; p<0.0001). Similar results were found regarding ventilator-associated tracheobronchitis (7.3% versus 11.6%; sub-hazard ratio 0.61, 95% CI 0.45-0.84; p=0.002) and ventilator-associated pneumonia (9.3% versus 12.7%; sub-hazard ratio 0.72, 95% CI 0.54-0.95; p=0.019). Among patients with VA-LRTI, the rates of multidrug-resistant bacteria (72% versus 59%; p=0.011) and intensive care unit mortality were significantly higher among immunocompromised than among non-immunocompromised patients (54% versus 30%; OR 2.68, 95% CI 1.78-4.02; p<0.0001). In patients with ventilator-associated pneumonia, mortality rates were higher among immunocompromised than among non-immunocompromised patients (64% versus 34%; p<0.001).Incidence of VA-LRTI was significantly lower among immunocompromised patients, but it was associated with a significantly higher mortality rate. Multidrug-resistant pathogens were more frequently found in immunocompromised patients with VA-LRTI.
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Affiliation(s)
| | - Ignacio Martin-Loeches
- Dept of Clinical Medicine, Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland
| | - Pedro Povoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge Salluh
- Dept of Critical Care, D'Or Institute for Research and Education, Rio De Janeiro, Brazil
| | | | - Arnaud W Thille
- CHU de Poitiers, Réanimation Médicale, Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France
| | - Emilio Diaz Santos
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, CIBER de Enfermedades Respiratorias (CIBERES), Sabadell, Spain
| | - Elisa Vedes
- Unidade de Cuidados Intensivos do Hospital da Luz, Lisbon, Portugal
| | | | - Bruno Mégarbane
- Dept of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMRS-1144, Paris, France
| | | | - Luis Coelho
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Laurent Argaud
- Service de Réanimation Médicale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Julien Labreuche
- CHU Lille, Clinique de Santé Publique, Plateforme d'Aide Méthodologique, Lille, France
| | | | - Saad Nseir
- Centre de Réanimation, CHU Lille, Lille, France.,Medical School, Lille University, Lille, France
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