Factors associated with mortality in severe community-acquired pneumonia: A multicenter cohort study

Time to recovery and its predictors among under-five children admitted with severe pneumonia in East Wallaga Zone public hospitals, western Ethiopia, 2023; a retrospective cohort study

BACKGROUND

Globally, pneumonia is one of the leading causes of morbidity and mortality as well as hospitalization burden for under-five children. Despite significant initiatives implemented to reduce morbidity and mortality from pneumonia in under-five children, little is known regarding the time to recovery and its predictors among under-five children admitted with severe pneumonia in Ethiopia. Hence, this study intended to estimate the median time to recovery and its predictors among under-five children admitted with severe pneumonia in East Wallaga zone public hospitals, western Ethiopia; 2023.

METHODS

An institution-based retrospective cohort study was conducted among 383 under-five children who were admitted with severe pneumonia in East Wallaga zone public hospitals from January 2017 to December 2022. A systematic sampling method was used to select eligible medical records. EpiData Version 4.6 was used to enter the data and analyzed using STATA Version 17.0. Cox-proportional hazard assumption test and model fitness were checked. Variables with P-value ˂ 0.25 at bivariable Cox regression analysis were selected for the multivariable Cox proportional model. A multivariable Cox regression model with 95% CI and Adjusted Hazard Ratio (AHR) was used to identify a significant predictor of time to recovery from severe pneumonia at a P-value < 0.05.

RESULTS

At the end of the follow-up, 356 observations were developed an event (recovered) with the median time to recovery of 4 days with IQR of 3-5 days. The overall incidence rate of recovery was 22.26 per 100 (95% CI: 20.07-24.70) person-days observations. Being rural residency (AHR: 0.75, 95% CI: 0.60-0.93), late presenters for seeking care (AHR = 0.70, 95% CI: 0.53-0.93), presence of danger sign at admission (AHR = 1.46, 95% CI: 1.15-1.83), and presence of comorbidity (AHR = 1.63, 95% CI, 1.31-2.04) were found to have a statistically significant association with prolonged recovery time.

CONCLUSION

The median time to recovery from severe pneumonia was long, and factors such as Residence, co-morbidity, presence of danger signs, and duration prior to seeking care were statistically significant predictors of recovery time from severe pneumonia. Hence, due attention has to be given to increasing the community's health-seeking behavior to visit health facility early and especial attention should be given for children with danger signs and comorbidity.

Dietary patterns and micronutrients in respiratory infections including COVID-19: a narrative review

BACKGROUND

COVID-19 is a pandemic caused by nCoV-2019, a new beta-coronavirus from Wuhan, China, that mainly affects the respiratory system and can be modulated by nutrition.

METHODS

This review aims to summarize the current literature on the association between dietary intake and serum levels of micronutrients, malnutrition, and dietary patterns and respiratory infections, including flu, pneumonia, and acute respiratory syndrome, with a focus on COVID-19. We searched for relevant articles in various databases and selected those that met our inclusion criteria.

RESULTS

Some studies suggest that dietary patterns, malnutrition, and certain nutrients such as vitamins D, E, A, iron, zinc, selenium, magnesium, omega-3 fatty acids, and fiber may have a significant role in preventing respiratory diseases, alleviating symptoms, and lowering mortality rates. However, the evidence is not consistent and conclusive, and more research is needed to clarify the mechanisms and the optimal doses of these dietary components. The impact of omega-3 and fiber on respiratory diseases has been mainly studied in children and adults, respectively, and few studies have examined the effect of dietary components on COVID-19 prevention, with a greater focus on vitamin D.

CONCLUSION

This review highlights the potential of nutrition as a modifiable factor in the prevention and management of respiratory infections and suggests some directions for future research. However, it also acknowledges the limitations of the existing literature, such as the heterogeneity of the study designs, populations, interventions, and outcomes, and the difficulty of isolating the effects of single nutrients from the complex interactions of the whole diet.

An explainable machine learning-based model to predict intensive care unit admission among patients with community-acquired pneumonia and connective tissue disease

BACKGROUND

There is no individualized prediction model for intensive care unit (ICU) admission on patients with community-acquired pneumonia (CAP) and connective tissue disease (CTD) so far. In this study, we aimed to establish a machine learning-based model for predicting the need for ICU admission among those patients.

METHODS

This was a retrospective study on patients admitted into a University Hospital in China between November 2008 and November 2021. Patients were included if they were diagnosed with CAP and CTD during admission and hospitalization. Data related to demographics, CTD types, comorbidities, vital signs and laboratory results during the first 24 h of hospitalization were collected. The baseline variables were screened to identify potential predictors via three methods, including univariate analysis, least absolute shrinkage and selection operator (Lasso) regression and Boruta algorithm. Nine supervised machine learning algorithms were used to build prediction models. We evaluated the performances of differentiation, calibration, and clinical utility of all models to determine the optimal model. The Shapley Additive Explanations (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) techniques were performed to interpret the optimal model.

RESULTS

The included patients were randomly divided into the training set (1070 patients) and the testing set (459 patients) at a ratio of 70:30. The intersection results of three feature selection approaches yielded 16 predictors. The eXtreme gradient boosting (XGBoost) model achieved the highest area under the receiver operating characteristic curve (AUC) (0.941) and accuracy (0.913) among various models. The calibration curve and decision curve analysis (DCA) both suggested that the XGBoost model outperformed other models. The SHAP summary plots illustrated the top 6 features with the greatest importance, including higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) and C-reactive protein (CRP), lower level of CD4 + T cell, lymphocyte and serum sodium, and positive serum (1,3)-β-D-glucan test (G test).

CONCLUSION

We successfully developed, evaluated and explained a machine learning-based model for predicting ICU admission in patients with CAP and CTD. The XGBoost model could be clinical referenced after external validation and improvement.

Recovery Time From Severe Community Acquired Pneumonia and Risk Factors Among Pediatrics, Ethiopia: A Retrospective Follow-Up Study

Introduction. Severe community acquired pneumonia (CAP) is a life-threatening condition, with high rates of morbidity and mortality. This study aimed to determine the recovery time from severe CAP and risk factors among pediatric patients. Methods. A retrospective follow-up study was conducted among 412 pediatric medical charts with severe CAP enrolled at Asella Referral and Teaching Hospital between January 01, 2021 and December 31, 2022. EpiData version 4.6.0.6 and STATA version 14.2 were used for data entry and statistical analysis, respectively. Bivariable and multivariable Cox proportional hazards regression analyzes were performed. Result. The median recovery time from severe CAP among pediatric patients was 5 days (IQR = 3-8 days). IDR of recovery from severe CAP was 13.089 per 100 [95%CI: 11.82, 14.49] pediatric days observations. The cumulative incidence of recovery from severe CAP was 89.56% [n = 369, 95%CI: 86.20, 92.18]. Age [AHR = 1.55, 95%CI: 1.12, 2.13, P = .007], vaccination status [AHR = 1.29, 95%CI: 1.03, 1.63, P = .027], presence of danger signs [AHR = 1.61, 95%CI: 1.26, 2.05, P = .000], presence of comorbidity [AHR = 1.67, 95%CI: 1.33, 2.10, P = .000], duration of seeking care [AHR = 1.71, 95%CI: 1.18, 2.47, P = .004], and oxygen therapy [AHR = 1.45, 95%CI:1.12, 1.87, P = .004] were statistically significant risk factors for recovery time from severe CAP. Conclusions. The median recovery time of patients with severe CAP is relatively high. Age, vaccination status, presence of danger signs, presence of comorbidities, duration of seeking care, and oxygen therapy were statistically significant risk factors of recovery time from severe CAP.

Efficacy of Random Forest Models in Predicting Multidrug-Resistant Gram-Negative Bacterial Nosocomial Infections Compared to Traditional Logistic Regression Models

This study evaluates whether random forest (RF) models are as effective as traditional Logistic Regression (LR) models in predicting multidrug-resistant Gram-negative bacterial nosocomial infections. Data were collected from 541 patients with hospital-acquired Gram-negative bacterial infections at two tertiary-level hospitals in Urumqi, Xinjiang, China, from August 2022 to November 2023. Relevant literature informed the selection of significant predictors based on patients' pre-infection clinical information and medication history. The data were split into a training set of 379 cases and a validation set of 162 cases, adhering to a 7:3 ratio. Both RF and LR models were developed using the training set and subsequently evaluated on the validation set. The LR model achieved an accuracy of 84.57%, sensitivity of 82.89%, specificity of 80.10%, positive predictive value of 84%, negative predictive value of 85.06%, and a Yoden index of 0.69. In contrast, the RF model demonstrated superior performance with an accuracy of 89.51%, sensitivity of 90.79%, specificity of 88.37%, positive predictive value of 87.34%, negative predictive value of 91.57%, and a Yoden index of 0.79. Receiver operating characteristic curve analysis revealed an area under the curve of 0.91 for the LR model and 0.94 for the RF model. These findings indicate that the RF model surpasses the LR model in specificity, sensitivity, and accuracy in predicting hospital-acquired multidrug-resistant Gram-negative infections, showcasing its greater potential for clinical application.

Hospital Outcomes in Patients Who Developed Acute Respiratory Distress Syndrome After Community-Acquired Pneumonia

Purpose: To identify risk factors for and outcomes in acute respiratory distress syndrome (ARDS) in patients hospitalized with community-acquired pneumonia (CAP). Methods: This is a retrospective study using the Premier Healthcare Database between 2016 and 2020. Patients diagnosed with pneumonia, requiring mechanical ventilation (MV), antimicrobial therapy, and hospital admission ≥2 days were included. Multivariable regression models were used for outcomes including in-hospital mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and days on MV. Results: 1924 (2.7%) of 72 107 patients with CAP developed ARDS. ARDS was associated with higher mortality (33.7% vs 18.9%; adjusted odds ratio 2.4; 95% confidence interval [CI] 2.16-2.66), longer hospital LOS (13 vs 9 days; adjusted incidence risk ratio (aIRR) 1.24; 95% CI 1.20-1.27), ICU LOS (9 vs 5 days; aIRR 1.51; 95% CI 1.46-1.56), more MV days (8 vs 5; aIRR 1.54; 95% CI 1.48-1.59), and increased hospitalization cost ($46 459 vs $29 441; aIRR 1.50; 95% CI 1.45-1.55). Conclusion: In CAP, ARDS was associated with worse in-patient outcomes in terms of mortality, LOS, and hospitalization cost. Future studies are needed to explore outcomes in patients with CAP with ARDS and explore risk factors for development of ARDS after CAP.

Clinical features, etiologies, and outcomes of central nervous system infections in intensive care: A multicentric retrospective study in a large Brazilian metropolitan area

PURPOSE

The goal of this study was to investigate severe central nervous system infections (CNSI) in adults admitted to the intensive care unit (ICU). We analyzed the clinical presentation, causes, and outcomes of these infections, while also identifying factors linked to higher in-hospital mortality rates.

MATERIALS AND METHODS

We conducted a retrospective multicenter study in Rio de Janeiro, Brazil, from 2012 to 2019. Using a prediction tool, we selected ICU patients suspected of having CNSI and reviewed their medical records. Multivariate analyses identified variables associated with in-hospital mortality.

RESULTS

In a cohort of 451 CNSI patients, 69 (15.3%) died after a median 11-day hospitalization (5-25 IQR). The distribution of cases was as follows: 29 (6.4%) had brain abscess, 161 (35.7%) had encephalitis, and 261 (57.8%) had meningitis. Characteristics: median age 41 years (27-53 IQR), 260 (58%) male, and 77 (17%) HIV positive. The independent mortality predictors for encephalitis were AIDS (OR = 4.3, p = 0.01), ECOG functional capacity limitation (OR = 4.0, p < 0.01), ICU admission from ward (OR = 4.0, p < 0.01), mechanical ventilation ≥10 days (OR = 6.1, p = 0.04), SAPS 3 ≥ 55 points (OR = 3.2, p = 0.02). Meningitis: Age > 60 years (OR = 234.2, p = 0.04), delay >3 days for treatment (OR = 2.9, p = 0.04), mechanical ventilation ≥10 days (OR = 254.3, p = 0.04), SOFA >3 points (OR = 2.7, p = 0.03). Brain abscess: No associated factors found in multivariate regression.

CONCLUSIONS

Patients' overall health, prompt treatment, infection severity, and prolonged respiratory support in the ICU all significantly affect in-hospital mortality rates. Additionally, the implementation of CNSI surveillance with the used prediction tool could enhance public health policies.

Characteristics, clinical course and outcome of ventilated patients at a non-surgical intensive care unit in Germany: a single-centre, retrospective observational cohort analysis

OBJECTIVES

The objective of this study was to evaluate epidemiological characteristics, clinical course and outcome of mechanically ventilated non-surgical intensive care unit (ICU) patients, with the aim of improving the strategic planning of ICU capacities.

DESIGN

We conducted a retrospective observational cohort analysis. Data from mechanically ventilated intensive care patients were obtained by investigating electronic health records. The association between clinical parameters and ordinal scale data of clinical course was evaluated using Spearman correlation and Mann-Whitney U test. Relations between clinical parameters and in-hospital mortality rates were examined using binary logistic regression analysis.

SETTING

A single-centre study at the non-surgical ICU of the University Hospital of Frankfurt, Germany (tertiary care-level centre).

PARTICIPANTS

All cases of critically ill adult patients in need of mechanical ventilation during the years 2013-2015 were included. In total, 932 cases were analysed.

RESULTS

From a total of 932 cases, 260 patients (27.9%) were transferred from peripheral ward, 224 patients (24.1%) were hospitalised via emergency rescue services, 211 patients (22.7%) were admitted via emergency room and 236 patients (25.3%) via various transfers. In 266 cases (28.5%), respiratory failure was the reason for ICU admission. The length of stay was higher in non-geriatric patients, patients with immunosuppression and haemato-oncological disease or those in need of renal replacement therapy. 431 patients died, which corresponds to an all-cause in-hospital mortality rate of 46.2%. 92 of 172 patients with presence of immunosuppression (53.5%), 111 of 186 patients (59.7%) with pre-existing haemato-oncological disease, 27 of 36 patients (75.0%) under extracorporeal membrane oxygenation (ECMO) therapy, and 182 of 246 patients (74.0%) undergoing renal replacement therapy died. In logistic regression analysis, these subgroups and older age were significantly associated with higher mortality rates.

CONCLUSIONS

Respiratory failure was the main reason for ventilatory support at this non-surgical ICU. Immunosuppression, haemato-oncological diseases, the need for ECMO or renal replacement therapy and older age were associated with higher mortality.

Analysis of the association between atrial fibrillation with in-hospital mortality in people admitted for community-acquired pneumonia through an observational, nation-wide, sex-stratified study

We aimed to analyze the influence of atrial fibrillation (AF) prior to hospital admission (“prevalent”) and AF diagnosed during hospital admission (“incident”) on in-hospital mortality (IHM) in women and men admitted for community-acquired pneumonia (CAP) in Spain (2016–2019). We used the Spanish Register of Specialized Care‐Basic Minimum Database. We analyzed 519,750 cases of CAP in people ≥ 18 years (213,631 women (41.1%)), out of which people with prevalent AF represented 23.75% (N = 123,440), whereas people with incident AF constituted 0.60% (N = 3154). Versus no AF, crude IHM was significantly higher for prevalent AF (15.24% vs. 11.40%, p < 0.001) and for incident AF (23.84% vs. 12.24%, p < 0.001). After propensity score marching, IHM in women and men with prevalent AF neared IHM in women and men with no AF (15.72% vs. 15.52%, p = 0.425; and 14.90% vs. 14.99%, p = 0.631, respectively), but IHM in women and men with incident AF was higher than IHM in women and men with no AF (24.37% vs. 13.36%, p < 0.001; and 23.94% vs. 14.04%, p < 0.001, respectively). Male sex was associated with a higher IHM in people with prevalent AF (OR 1.06; 95% CI 1.02–1–10), but not in people with incident AF (OR 0.93; 95% CI 0.77–1–13). AF diagnosed during hospital admission was associated with a higher IHM, irrespectively of sex.

Effect of Undernutrition and Obesity on Clinical Outcomes in Adults with Community-Acquired Pneumonia

Malnutrition comprises two groups of conditions: undernutrition and overweight or obesity. It has been associated with a high risk of contracting infectious diseases and with elevated mortality rates. Community-acquired pneumonia (CAP) is one of the most common infectious diseases worldwide and its prognosis is affected by a large number of recognizable risk factors. This narrative review updates the information on the impact of malnutrition, including both undernutrition and obesity, on the risk and prognosis of adults with CAP. Studies of CAP that have evaluated undernutrition have applied a variety of definitions when assessing the nutritional status of patients. Undernutrition has been associated with unfavorable clinical outcomes, such as prolonged hospital stay, need for intensive care unit admission, and mortality; in contrast, most published studies have found that increased body mass index is significantly associated with higher survival in patients with CAP. However, some authors have presented divergent results, mainly in relation to the etiology of CAP (bacterial versus viral). Influenza infection, caused by influenza A (H1N1) pdm09, has been associated with worse prognosis in obese patients. The current data underscore the need for larger studies to examine the physiological mechanisms that explain the differential impact of malnutrition on outcomes. Achieving a better understanding may help to guide the design of new interventions to improve prognosis.

Effects of different doses of methylprednisolone on clinical outcomes in patients with severe community-acquired pneumonia: a study protocol for a randomized controlled trial

Background

The specific use of methylprednisolone in severe community-acquired pneumonia (SCAP) has not yet formed a consensus. It is not clear whether the clinical efficacy of methylprednisolone in SCAP is dose-dependent, and how to balance the best efficacy with the least complications. The aim of this study is to evaluate the efficacy and safety of different doses of methylprednisolone in the adjuvant treatment for patients with SCAP.

Methods/design

This is a prospective, randomized, double-blind, parallel group, placebo-controlled trial to evaluate the efficacy and safety of different doses of methylprednisolone in the adjuvant treatment for patients with SCAP. Patients with diagnosed SCAP are randomized to the following four groups at a 1:1:1:1 ratio: group 1 (control group)—standard ICU patient care+100ml of normal saline once a day for 5 days; group 2—standard ICU patient care+40mg of methylprednisolone (dissolved in normal saline with a final volume of 100ml) once a day for 5 days; group 3—standard ICU patient care+80mg of methylprednisolone (dissolved in normal saline with a final volume of 100ml) once a day for 5 days; and group 4—standard ICU patient care+120mg of methylprednisolone (dissolved in normal saline with a final volume of 100ml) once a day for 5 days. The primary outcome is PaO₂/FiO₂ ratio at day 5 following randomization. The secondary outcomes are 28-day mortality, ventilator-free days at 28 days, mechanical ventilation duration at 28 days, endotracheal intubation rate, time for temperature recovery, duration of vasopressors use, serum CRP and interleukin-6 level at day 5 following randomization, hospital stay, frequency of nosocomial infections, gastrointestinal hemorrhage, and hyperglycemia.

Discussion

The results of our study may find the optimal dose of glucocorticoid in the adjuvant treatment of SCAP and provide evidence-based proof for clinicians to treat patients with SCAP. Since coronavirus disease 2019 (COVID-19) also belongs to community-acquired pneumonia, perhaps the results of our study will help to determine the appropriate dose of methylprednisolone in COVID-19 treatment.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100045056. Registered on 4 April 2021.

Severe pneumonia: Treatment outcome and its determinant factors among under-five patients, Jimma, Ethiopia

Introduction:

Over 2 million children die from pneumonia each year accounting for almost one in five children’s deaths worldwide which is estimated to be 18% of mortality cases. Therefore, this study is aimed to assess treatment outcome and its determinant factors among under-five patients, Jimma, Ethiopia.

Methods:

Study design was conducted on 522 under-five children with severe pneumonia from 1 January 2017 to 30 December 2020. Pretested chart review format was used to collect data. Data were entered into EpiData, version 3.1, and exported to Statistical Package for the Social Sciences, version 23, for analysis. Logistic regression analysis with 95% confidence interval was used to declare statistical significance at p value <0.05.

Results:

Among 522 under-five children with severe pneumonia, majority (83.91%) of them were improved, whereas 1 over 6 (16.09%) of them were died. This finding showed that children who have malnutrition (adjusted odds ratio = 7.23 (3.17–14.51), p = 0.000), positive serostatus for HIV (adjusted odds ratio = 5.01 (1.91–12.13), p = 0.001), history of upper respiratory tract infections (adjusted odds ratio = 3.27 (1.55–6.91), p = 0.002), unvaccinated (adjusted odds ratio = 4.35 (1.60–11.79), p = 0.004), having complicated types of pneumonia (adjusted odds ratio = 8.48 (4.22–16.65), p < 0.001), and comorbidity disease (adjusted odds ratio = 5.21 (2.03–13.3), p < 0.001) were statistically significant with mortality.

Conclusion:

This study showed that mortality secondary to severe pneumonia was high. Being malnourished, positive serostatus for HIV infection, history of upper respiratory tract infections, unvaccinated, having complicated type of pneumonia, and other comorbidity disease were identified as determinant factors of mortality. Committed, harmonized, and integrated intervention needs to be taken to reduce mortality from severe pneumonia by enhancing child’s nutrition status, early detection and treatment, effectively vaccinating children, and preventing other comorbidity diseases.

Antimicrobial prescription in severe COVID-19 and CAP: a matched case-control study

BACKGROUND

In severe coronavirus diseases 2019 (COVID-19), a high and potentially excessive use of antimicrobials for suspected bacterial co-infection and intensive care unit (ICU)-acquired infections has been repeatedly reported.

OBJECTIVES

To compare an ICU cohort of community-acquired pneumonia (CAP) with a cohort of severe COVID-19 pertaining to co-infections, ICU-acquired infections and associated antimicrobial consumption.

METHODS

We retrospectively compared a cohort of CAP patients with a cohort of COVID-19 patients matched according to organ failure, ICU length of stay (LOS) and ventilation days. Patient data such as demographics, infection focus, probability and severity, ICU severity scores and ICU and in-hospital mortality, days of antimicrobial therapy (DOT) and number of antimicrobial prescriptions, using an incremental scale, were registered and analysed. The total number of cultures (sputum, urinary, blood cultures) was collected and corrected for ICU LOS.

FINDINGS

CAP patients (n = 148) were matched to COVID-19 patients (n = 74). Significantly less sputum cultures (68.2% versus 18.9%, P < 0.05) and bronchoalveolar lavages (BAL) (73.7% versus 36.5%, P < 0.05) were performed in COVID-19 patients. Six (8.1%) COVID-19 patients were diagnosed with a co-infection. Respectively, 58 of 148 (39.2%) CAP and 38 of 74 (51.4%) COVID-19 patients (P = 0.09) developed ICU-acquired infections. Antimicrobial distribution, both in the number of prescriptions and DOT, was similar in both cohorts.

CONCLUSIONS

We found a low rate of microbiologically confirmed bacterial co-infection and a high rate of ICU-acquired infections in COVID-19 patients. Infection probabilities, antimicrobial prescriptions and DOT were comparable with a matched CAP cohort.

Clinical factors associated with composition of lung microbiota and important taxa predicting clinical prognosis in patients with severe community-acquired pneumonia

Few studies have described the key features and prognostic roles of lung microbiota in patients with severe community-acquired pneumonia (SCAP). We prospectively enrolled consecutive SCAP patients admitted to ICU. Bronchoscopy was performed at bedside within 48 h of ICU admission, and 16S rRNA gene sequencing was applied to the collected bronchoalveolar lavage fluid. The primary outcome was clinical improvements defined as a decrease of 2 categories and above on a 7-category ordinal scale within 14 days following bronchoscopy. Sixty-seven patients were included. Multivariable permutational multivariate analysis of variance found that positive bacteria lab test results had the strongest independent association with lung microbiota (R² = 0.033; P = 0.018), followed by acute kidney injury (AKI; R² = 0.032; P = 0.011) and plasma MIP-1β level (R² = 0.027; P = 0.044). Random forest identified that the families Prevotellaceae, Moraxellaceae, and Staphylococcaceae were the biomarkers related to the positive bacteria lab test results. Multivariable Cox regression showed that the increase in α-diversity and the abundance of the families Prevotellaceae and Actinomycetaceae were associated with clinical improvements. The positive bacteria lab test results, AKI, and plasma MIP-1β level were associated with patients’ lung microbiota composition on ICU admission. The families Prevotellaceae and Actinomycetaceae on admission predicted clinical improvements.

Characterisation of the first 250,000 hospital admissions for COVID-19 in Brazil: a retrospective analysis of nationwide data

Background

Most low-income and middle-income countries (LMICs) have little or no data integrated into a national surveillance system to identify characteristics or outcomes of COVID-19 hospital admissions and the impact of the COVID-19 pandemic on their national health systems. We aimed to analyse characteristics of patients admitted to hospital with COVID-19 in Brazil, and to examine the impact of COVID-19 on health-care resources and in-hospital mortality.

Methods

We did a retrospective analysis of all patients aged 20 years or older with quantitative RT-PCR (RT-qPCR)-confirmed COVID-19 who were admitted to hospital and registered in SIVEP-Gripe, a nationwide surveillance database in Brazil, between Feb 16 and Aug 15, 2020 (epidemiological weeks 8–33). We also examined the progression of the COVID-19 pandemic across three 4-week periods within this timeframe (epidemiological weeks 8–12, 19–22, and 27–30). The primary outcome was in-hospital mortality. We compared the regional burden of hospital admissions stratified by age, intensive care unit (ICU) admission, and respiratory support. We analysed data from the whole country and its five regions: North, Northeast, Central-West, Southeast, and South.

Findings

Between Feb 16 and Aug 15, 2020, 254 288 patients with RT-qPCR-confirmed COVID-19 were admitted to hospital and registered in SIVEP-Gripe. The mean age of patients was 60 (SD 17) years, 119 657 (47%) of 254 288 were aged younger than 60 years, 143 521 (56%) of 254 243 were male, and 14 979 (16%) of 90 829 had no comorbidities. Case numbers increased across the three 4-week periods studied: by epidemiological weeks 19–22, cases were concentrated in the North, Northeast, and Southeast; by weeks 27–30, cases had spread to the Central-West and South regions. 232 036 (91%) of 254 288 patients had a defined hospital outcome when the data were exported; in-hospital mortality was 38% (87 515 of 232 036 patients) overall, 59% (47 002 of 79 687) among patients admitted to the ICU, and 80% (36 046 of 45 205) among those who were mechanically ventilated. The overall burden of ICU admissions per ICU beds was more pronounced in the North, Southeast, and Northeast, than in the Central-West and South. In the Northeast, 1545 (16%) of 9960 patients received invasive mechanical ventilation outside the ICU compared with 431 (8%) of 5388 in the South. In-hospital mortality among patients younger than 60 years was 31% (4204 of 13 468) in the Northeast versus 15% (1694 of 11 196) in the South.

Interpretation

We observed a widespread distribution of COVID-19 across all regions in Brazil, resulting in a high overall disease burden. In-hospital mortality was high, even in patients younger than 60 years, and worsened by existing regional disparities within the health system. The COVID-19 pandemic highlights the need to improve access to high-quality care for critically ill patients admitted to hospital with COVID-19, particularly in LMICs.

Funding

National Council for Scientific and Technological Development (CNPq), Coordinating Agency for Advanced Training of Graduate Personnel (CAPES), Carlos Chagas Filho Foundation for Research Support of the State of Rio de Janeiro (FAPERJ), and Instituto de Salud Carlos III.

The Performance of CURB-65 and PSI for Predicting In-Hospital Mortality of Community-Acquired Pneumonia in Patients with Type 2 Diabetes Compared with the Non-Diabetic Population

OBJECTIVE

To compare the performance of CURB-65 and Pneumonia Severity Index (PSI) for predicting in-hospital mortality of community-acquired pneumonia (CAP) between patients with and without type 2 diabetes (T2DM).

METHODS

A retrospective study was conducted on 2365 CAP patients in The First Hospital of Qinhuangdao, China. The primary outcome was in-hospital mortality. The area under curves (AUCs) was used to evaluate the abilities of CRB-65, CURB-65, and PSI class for predicting in-hospital mortality in patients with CAP.

RESULTS

Among CAP patients, 127 patients (5.4%) died, 80 patients were without diabetes, and 47 patients had T2DM. In-hospital mortality increased with the risk stratification defined as CURB-65 and PSI class in both non-diabetes and T2DM patients (P<0.05). The AUCs for predicting in-hospital mortality were 0.728～0.798 in patients without T2DM (CRB-65: 0.728, CURB-65: 0.757 and PSI class: 0.798) and 0.641～0.716 in patients with T2DM (CRB-65: 0.641, CURB-65: 0.677 and PSI class: 0.716)(P<0.001). The AUC of the PSI class was lower in patients with T2DM than in patients without T2DM (P<0.05).

CONCLUSION

CURB-65 and PSI class are correlated with in-hospital mortality of CAP in patients with and without T2DM. Compared with non-diabetes patients, the predictive performance of CURB-65 and PSI class decreased in patients with T2DM. A prediction model for evaluating the CAP severity in the T2DM population should be developed by future studies.

Short- and medium-term prognosis of HIV-infected patients receiving intensive care: a Brazilian multicentre prospective cohort study

OBJECTIVES

The characteristics of critically ill HIV-positive patients and the causes of their admission to intensive care units (ICUs) are only known through retrospective and unicentric studies. This study aims to fill this knowledge gap.

METHODS

This is a prospective, multicentre cohort study of short- and medium-term prognostic factors. The setting consisted of ICUs of three tertiary referral hospitals from the three largest metropolitan areas in Brazil in the period January 2014 to November 2015. In all, 161 HIV patients over 18 years old were included.

RESULTS

The clinical data of the outcomes (ICU mortality, hospital mortality and 90-day survival) were extracted from medical records using the REDCap^®️ web-based form and analysed with the MedCalc^{® ️} application. Median age was 41.7 [interquartile range (IQR): 34-50] years, the Simplified Acute Physiologic Score 3 (SAPS 3) was 64 (IQR: 56-74), and the Sequential Organ Failure Assessment Score (SOFA) was 6 (IQR: 4-9) points. The main causes of admission were sepsis (54.5%) and acute respiratory failure (13.7%). ICU and hospital mortality rates were 32.3% and 40.4%, respectively. In a multivariate analysis, time until ICU admission ≥ 3 days (P = 0.0013), performance status (Eastern Cooperative Oncology Group score, P = 0.0344), coma (Glasgow Coma Scale ≤ 8 points, P = 0.0213) and sepsis (P = 0.0003) were associated with increased hospital mortality. Coma (P = 0.0002) and sepsis (P = 0.0008) were independently associated with 90-day survival.

CONCLUSIONS

Delayed ICU admission and the severity of critical illness determine the short- and medium-term mortality rates of HIV-infected patients admitted to the ICU, rather than factors associated with HIV infection. These results suggest that prognostic factors of HIV-infected patients in the ICU are similar to those of non-HIV-infected populations.

Current Issues and Perspectives in Patients with Possible Sepsis at Emergency Departments

In the area of Emergency Room (ER), many patients present criteria compatible with a SIRS, but only some of them have an associated infection. The new definition of sepsis by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine (2016), revolutionizes precedent criteria, overcoming the concept of SIRS and clearly distinguishing the infection with the patient's physiological response from the symptoms of sepsis. Another fundamental change concerns the recognition method: The use of SOFA (Sequential-Sepsis Related-Organ Failure Assessment Score) as reference score for organ damage assessment. Also, the use of the qSOFA is based on the use of three objective parameters: Altered level of consciousness (GCS <15 or AVPU), systolic blood pressure ≤ 100 mmHg, and respiratory rate ≥ 22/min. If patients have at least two of these altered parameters in association with an infection, then there is the suspicion of sepsis. In these patients the risk of death is higher, and it is necessary to implement the appropriate management protocols, indeed the hospital mortality rate of these patients exceeds 40%. Patients with septic shock can be identified by the association of the clinical symptoms of sepsis with persistent hypotension, which requires vasopressors to maintain a MAP of 65 mmHg, and serum lactate levels >18 mg/dL in despite of an adequate volume resuscitation. Then, patient first management is mainly based on: (1) Recognition of the potentially septic patient (sepsis protocol-qSOFA); (2) Laboratory investigations; (3) Empirical antibiotic therapy in patients with sepsis and septic shock. With this in mind, the authors discuss the most important aspects of the sepsis in both adults and infants, and also consider the possible treatment according current guidelines. In addition, the possible role of some nutraceuticals as supportive therapy in septic patient is also discussed.

Current Issues and Perspectives in Patients with Possible Sepsis at Emergency Departments

In the area of Emergency Room (ER), many patients present criteria compatible with a SIRS, but only some of them have an associated infection. The new definition of sepsis by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine (2016), revolutionizes precedent criteria, overcoming the concept of SIRS and clearly distinguishing the infection with the patient’s physiological response from the symptoms of sepsis. Another fundamental change concerns the recognition method: The use of SOFA (Sequential-Sepsis Related-Organ Failure Assessment Score) as reference score for organ damage assessment. Also, the use of the qSOFA is based on the use of three objective parameters: Altered level of consciousness (GCS <15 or AVPU), systolic blood pressure ≤ 100 mmHg, and respiratory rate ≥ 22/min. If patients have at least two of these altered parameters in association with an infection, then there is the suspicion of sepsis. In these patients the risk of death is higher, and it is necessary to implement the appropriate management protocols, indeed the hospital mortality rate of these patients exceeds 40%. Patients with septic shock can be identified by the association of the clinical symptoms of sepsis with persistent hypotension, which requires vasopressors to maintain a MAP of 65 mmHg, and serum lactate levels >18 mg/dL in despite of an adequate volume resuscitation. Then, patient first management is mainly based on: (1) Recognition of the potentially septic patient (sepsis protocol-qSOFA); (2) Laboratory investigations; (3) Empirical antibiotic therapy in patients with sepsis and septic shock. With this in mind, the authors discuss the most important aspects of the sepsis in both adults and infants, and also consider the possible treatment according current guidelines. In addition, the possible role of some nutraceuticals as supportive therapy in septic patient is also discussed.