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Zheng J, Yang QJ, Qi F, Shen HZ, Zhang L, Xia JW. Continuous Renal Replacement Therapy Improves Indicators and Short-Term Survival in People with AIDS Manifesting Sepsis and Acute Kidney Injury. Jpn J Infect Dis 2024; 77:240-243. [PMID: 38417866 DOI: 10.7883/yoken.jjid.2023.280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
Patients with acquired immune deficiency syndrome (AIDS) are susceptible to numerous complications, such as sepsis and acute kidney injury (AKI), leading to adverse outcomes. Continuous renal replacement therapy (CRRT) is becoming increasingly popular for treating sepsis and AKI. This study aimed to verify the effectiveness of CRRT in the treatment of patients with AIDS with sepsis and AKI to provide new directions for the treatment of severe AIDS. Data of 74 people with AIDS, sepsis, and AKI were collected. The patients were divided into CRRT and non-CRRT groups. There was no difference in the indicators between the two groups at admission. Vital signs, pH, serum potassium level, renal function, blood lactate level, acute physiology and chronic health evaluation II score, and sequential organ failure assessment score in the CRRT group demonstrated significant improvements over those in the non-CRRT group at both 24 and 72 h after admission (P < 0.05). The levels of interleukin 6 and procalcitonin declined more significantly in the CRRT group at 72 h after admission (P < 0.05). The CRRT group had a higher 28-day survival rate than the non-CRRT group (P < 0.05). CRRT improves the clinical indicators and increases the short-term survival rate of patients with AIDS, sepsis, and AKI.
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Affiliation(s)
- Jie Zheng
- Department of Intensive Care Units, The Third People's Hospital of Kunming City, Clinical Medical Center for Infectious Diseases of Yunnan Province, China
| | - Qiu-Jin Yang
- Department of Hepatology and Gastroenterology, The Third People's Hospital of Kunming City, Clinical Medical Center for Infectious Diseases of Yunnan Province, China
| | - Fei Qi
- Department of Intensive Care Units, The Third People's Hospital of Kunming City, Clinical Medical Center for Infectious Diseases of Yunnan Province, China
| | - Han-Zhang Shen
- Department of Intensive Care Units, The Third People's Hospital of Kunming City, Clinical Medical Center for Infectious Diseases of Yunnan Province, China
| | - Le Zhang
- Department of Intensive Care Units, The Third People's Hospital of Kunming City, Clinical Medical Center for Infectious Diseases of Yunnan Province, China
| | - Jia-Wei Xia
- Department of Intensive Care Units, The Third People's Hospital of Kunming City, Clinical Medical Center for Infectious Diseases of Yunnan Province, China
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Andrade HB, Rocha Ferreira da Silva I, Espinoza R, da Silva MST, Theodoro PHN, Ferreira MT, Soares J, Belay ED, Sejvar JJ, Bozza FA, Cerbino-Neto J, Japiassú AM. Profiling and Benchmarking Central Nervous System Infections in an Infectious Diseases Intensive Care Unit. J Intensive Care Med 2024; 39:59-68. [PMID: 37455413 DOI: 10.1177/08850666231188665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND There is little information comparing the performance of community acquired central nervous system infections (CNSI) treatment by intensive care units (ICUs) specialized in infectious diseases with treatment at other ICUs. Our objective was to reduce these gaps, creating bases for benchmarking and future case-mix classification. METHODS This is a retrospective observational cohort of 785 admissions with 82 cases of CNSI admitted to the ICU of an important Brazilian referral center for infectious diseases (INI) between January 2012 and January 2019. Comparisons were made to data retrospectively collected from the 303,500 intensive care admissions from the Brazilian state health care system included in the Epimed Monitor database. Clinical, epidemiologic, and performance indicators: the standardized mortality rate (SMR) and the standardized resource use rate per ICU surviving patient (SRU) were collected. RESULTS Case-mix infections profile and SMR/SRU data. SUS Mixed medical/surgical ICUs: SMR = 1.26, SRU = 1.59; SUS Neurological ICUs: SMR = 1.17, SRU = 2.23; INI ICU: SMR = 1.1, SRU = 1.1; INI ICU CNSI patients: SMR = 0.95, SRU = 1.01. CONCLUSIONS Severe patients with CNSI can be efficiently and effectively treated in an ICU specialized in infectious diseases when compared to mixed medical/surgical and neurological ICUs from the public health system. At the same time, we provided profiling and a case-mix that can help and encourage benchmarking by other institutions and other countries.
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Affiliation(s)
- Hugo Boechat Andrade
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
- Sexually Transmitted Diseases Sector, Instituto Biomédico, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | | | - Rodolfo Espinoza
- Surgical Intensive Care Unit, Hospital Copa Star, Rio de Janeiro, RJ, Brazil
- Intensive Care Unit II, Instituto Nacional do Câncer, Rio de Janeiro, RJ, Brazil
| | - Mayara Secco Torres da Silva
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Marcel Treptow Ferreira
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Jesus Soares
- Division of High-Consequence Pathology and Pathogens, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ermias D Belay
- Division of High-Consequence Pathology and Pathogens, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James J Sejvar
- Division of High-Consequence Pathology and Pathogens, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Fernando Augusto Bozza
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
- Department of Critical Care, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brazil
| | - José Cerbino-Neto
- Immunization and Health Surveillance Research Laboratory, Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - André Miguel Japiassú
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
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Schlabe S, Boesecke C, van Bremen K, Schwarze-Zander C, Bischoff J, Yürüktümen A, Heine M, Spengler U, Nattermann J, Rockstroh JK, Wasmuth JC. People living with HIV, HCV and HIV/HCV coinfection in intensive care in a German tertiary referral center 2014-2019. Infection 2023; 51:1645-1656. [PMID: 37055704 DOI: 10.1007/s15010-023-02032-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/31/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE The epidemiology of HIV-infected individuals on the Medical Intensive Care Units (MICU) has changed after profound progress in treatment of AIDS-defining illnesses and anti-retroviral therapy (ART). Changes of MICU utilization of Hepatitis C (HCV) patients following roll-out of direct-acting antivirals (DAA) are yet to evaluate. METHODS We performed a retrospective study on all patients with HIV, HIV/HCV and HCV admitted to the MICU of University Hospital Bonn 2014-2019. We assessed sociodemographic data, available clinical data from HIV patients (CDC stage, CD4 + lymphocyte cell count, HIV-1-RNA, ART) and HCV patients (HCV-RNA, stage of liver cirrhosis, treatment history) and outcome. RESULTS 237 patients (46 HIV, 22 HIV/HCV, 169 HCV; 168 male, median age 51.3 years) with 325 MICU admissions were included. Admission criteria for HIV patients were infections (39.7% AIDS-associated, 23.8% with controlled HIV-infection) and cardiopulmonary diseases (14.3%). HIV/HCV coinfected patients had infections in controlled/uncontrolled HIV-infection (46.4%), cardiopulmonary diseases and intoxication/drug abuse (17.9% each). Reasons for HCV-mono-infected patients were infections (24.4%), sequelae of liver disease (20.9%), intoxication/drug abuse (18.4%) and cardiopulmonary diseases (15%). 60 patients deceased; most important risk factor was need for mechanical ventilation. The number of HCV-patients admitted to MICU with chronic active disease and sequelae of liver disease decreased while the proportion of patients with completed DAA-treatment increased. CONCLUSION Infections remain the most important reason for MICU admission in patients with HIV and/or HCV infection while non-AIDS related conditions increased. DAA roll-out has a beneficial effect on liver-associated morbidity in HCV patients admitted to MICU.
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Affiliation(s)
- Stefan Schlabe
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany.
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany.
| | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Kathrin van Bremen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Carolynne Schwarze-Zander
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Jenny Bischoff
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Aylin Yürüktümen
- Department of Internal Medicine II, University Hospital Bonn, Bonn, Germany
| | - Mario Heine
- Department of Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - Ulrich Spengler
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Jürgen K Rockstroh
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
| | - Jan-Christian Wasmuth
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- German Centre of Infection Research, Partner-Site Cologne-Bonn, Bonn, Germany
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Szychowiak P, Boulain T, Timsit JF, Elabbadi A, Argaud L, Ehrmann S, Issa N, Canet E, Martino F, Bruneel F, Quenot JP, Wallet F, Azoulay É, Barbier F. Clinical spectrum and prognostic impact of cancer in critically ill patients with HIV: a multicentre cohort study. Ann Intensive Care 2023; 13:74. [PMID: 37608140 PMCID: PMC10444715 DOI: 10.1186/s13613-023-01171-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Both AIDS-defining and non-AIDS-defining cancers (ADC/NADC) predispose people living with HIV (PLHIV) to critical illnesses. The objective of this multicentre study was to investigate the prognostic impact of ADC and NADC in PLHIV admitted to the intensive care unit (ICU). METHODS All PLHIV admitted over the 2015-2020 period in 12 university-affiliated ICUs in France were included in the study cohort. The effect of ADC and NADC on in-hospital mortality (primary study endpoint) was measured through logistic regression with augmented backward elimination of potential independent variables. The association between ADC/NADC and treatment limitation decision (TLD) during the ICU stay (secondary study endpoint) was analysed. One-year mortality in patients discharged alive from the index hospital admission (exploratory study endpoint) was compared between those with ADC, NADC or no cancer. RESULTS Amongst the 939 included PLHIV (median age, 52 [43-59] years; combination antiretroviral therapy, 74.4%), 97 (10.3%) and 106 (11.3%) presented with an active NADC (mostly lung and intestinal neoplasms) and an active ADC (predominantly AIDS-defining non-Hodgkin lymphoma), respectively. Inaugural admissions were common. Bacterial sepsis and non-infectious neoplasm-related complications accounted for most of admissions in these subgroups. Hospital mortality was 12.4% in patients without cancer, 30.2% in ADC patients and 45.4% in NADC patients (P < 0.0001). NADC (adjusted odds ratio [aOR], 7.00; 95% confidence interval [CI], 4.07-12.05) and ADC (aOR, 3.11; 95% CI 1.76-5.51) were independently associated with in-hospital death after adjustment on severity and frailty markers. The prevalence of TLD was 8.0% in patients without cancer, 17.9% in ADC patients and 33.0% in NADC patients (P < 0.0001)-organ failures and non-neoplastic comorbidities were less often considered in patients with cancer. One-year mortality in survivors of the index hospital admission was 7.8% in patients without cancer, 17.0% in ADC patients and 33.3% in NADC patients (P < 0.0001). CONCLUSIONS NADC and ADC are equally prevalent, stand as a leading argument for TLD, and strongly predict in-hospital death in the current population of PLHIV requiring ICU admission.
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Affiliation(s)
- Piotr Szychowiak
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France
| | - Jean-François Timsit
- Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Elabbadi
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Argaud
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Nahema Issa
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Emmanuel Canet
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Frédéric Martino
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de La Guadeloupe, Pointe-À-Pitre, France
| | - Fabrice Bruneel
- Réanimation et Unité de Surveillance Continue, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Jean-Pierre Quenot
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Dijon-Bourgogne, Dijon, France
| | - Florent Wallet
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Élie Azoulay
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Barbier
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France.
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Gray K, Engoren M. Outcomes of Sepsis in Patients With and Without HIV Infection: A Retrospective Study. Am J Crit Care 2023; 32:288-293. [PMID: 37391374 DOI: 10.4037/ajcc2023446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND HIV infection is associated with increased infections. OBJECTIVES To (1) compare patients with sepsis with and without HIV, (2) assess whether HIV is associated with mortality in sepsis, and (3) identify factors associated with mortality in patients with HIV and sepsis. METHODS Patients who met Sepsis-3 criteria were studied. HIV infection was defined as administration of highly active antiretroviral therapy, a diagnosis of AIDS encoded by the International Classification of Diseases, or a positive HIV blood test result. Propensity scores were used to match patients with HIV to similar patients without HIV, and mortality was compared with χ2 tests. Logistic regression was used to determine factors independently associated with mortality. RESULTS Sepsis developed in 34 673 patients without HIV and 326 patients with HIV. Of these, 323 (99%) patients with HIV were matched to similar patients without HIV. The 30-60- and 90-day mortality was 11%, 15%, and 17%, respectively, in patients with sepsis and HIV, which was similar to the 11% (P > .99), 15% (P > .99), and 16% (P = .83) in patients without HIV. Logistic regression to adjust for confounders showed that obesity (odds ratio, 0.12; 95% CI, 0.03-0.46; P = .002) and high total protein on admission (odds ratio, 0.71; 95% CI, 0.56-0.91; P = .007) were associated with lower mortality. Mechanical ventilation at sepsis onset, renal replacement therapy, positive blood culture, and platelet transfusion were associated with increased mortality. CONCLUSIONS HIV infection was not associated with increased mortality in patients with sepsis.
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Affiliation(s)
- Kevin Gray
- Kevin Gray is a resident physician, Department of Anesthesiology, The Ohio State University, Columbus, Ohio
| | - Milo Engoren
- Milo Engoren is a clinical professor, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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Mamani RF, López TDA, Jalo WM, Alves MR, Nunes EP, Pereira MS, Silva EADSRD, Lourenço MCDS, Veloso VG, Grinsztejn BJ, Cardoso SW, Lamas CDC. Invasive Pneumococcal Disease in People Living with HIV: A Retrospective Case-Control Study in Brazil. Trop Med Infect Dis 2023; 8:328. [PMID: 37368746 DOI: 10.3390/tropicalmed8060328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
HIV-infected patients are at particular risk for invasive pneumococcal disease (IPD). We describe cases of IPD in people living with HIV/AIDS (PLWHA) and find associated risk factors for infection and death. METHODS A retrospective case-control study, nested in a cohort, including PLWHA with and without IPD, conducted in Brazil, 2005-2020. Controls were of the same gender/age and seen at the same time/place as cases. RESULTS We identified 55 episodes of IPD (cases) in 45 patients and 108 controls. The incidence of IPD was 964/100,000 person-years. A total of 42 of 55 (76.4%) IPD episodes presented with pneumonia and 11 (20%) with bacteremia without a focus and 38/45 (84.4%) were hospitalized. Blood cultures were positive in 54/55 (98.2%). Liver cirrhosis and COPD were the only factors associated with IPD in PLWHA in univariate analysis, although no associated factors were found in multivariate analysis. Penicillin resistance was found in 4/45 (8.9%). Regarding antiretroviral therapy (ART), 40/45 (88.9%) cases vs. 80/102 controls (74.1%) were in use (p = 0.07). Patients with HIV and IPD had a higher CD4 count of 267 cells/mm3 compared with the control group, in which it was 140 cells/mm3 (p = 0.027). Pneumococcal vaccination was documented in 19%. Alcoholism (p = 0.018), hepatic cirrhosis (p = 0.003), and lower nadir CD4 count (p = 0.033) were associated with the risk of death in patients with IPD. In-hospital mortality among PLWHA and IPD was 21.1%, and it was associated with thrombocytopenia and hypoalbuminemia, elevated band forms, creatinine, and aspartate aminotransferase (AST). CONCLUSIONS The incidence of IPD in PLWHA remained high despite ART. The vaccination rate was low. Liver cirrhosis was associated with IPD and death.
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Affiliation(s)
- Roxana Flores Mamani
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Tiago de Assunção López
- Barra da Tijuca Campus, Department of Medicine, Universidade do Grande Rio/Afya, Avenida Ayrton Senna, 2.200, Barra da Tijuca 22775-003, RJ, Brazil
| | - Waldir Madany Jalo
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Marcelo Ribeiro Alves
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Estevão Portela Nunes
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Mario Sérgio Pereira
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | | | - Maria Cristina da Silva Lourenço
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Valdiléa Gonçalves Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Beatriz Jegerhorn Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
| | - Cristiane da Cruz Lamas
- Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Avenida Brasil 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil
- Instituto Nacional de Cardiologia, Rua das Laranjeiras, 374-Laranjeiras, Rio de Janeiro 22240-006, RJ, Brazil
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Dagenais A, Villalba-Guerrero C, Olivier M. Trained immunity: A “new” weapon in the fight against infectious diseases. Front Immunol 2023; 14:1147476. [PMID: 36993966 PMCID: PMC10040606 DOI: 10.3389/fimmu.2023.1147476] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/23/2023] [Indexed: 03/18/2023] Open
Abstract
Innate immune cells can potentiate the response to reinfection through an innate form of immunological memory known as trained immunity. The potential of this fast-acting, nonspecific memory compared to traditional adaptive immunological memory in prophylaxis and therapy has been a topic of great interest in many fields, including infectious diseases. Amidst the rise of antimicrobial resistance and climate change—two major threats to global health—, harnessing the advantages of trained immunity compared to traditional forms of prophylaxis and therapy could be game-changing. Here, we present recent works bridging trained immunity and infectious disease that raise important discoveries, questions, concerns, and novel avenues for the modulation of trained immunity in practice. By exploring the progress in bacterial, viral, fungal, and parasitic diseases, we equally highlight future directions with a focus on particularly problematic and/or understudied pathogens.
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Affiliation(s)
- Amy Dagenais
- Department of Microbiology and Immunology, Faculty of Medicine, Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Carlos Villalba-Guerrero
- Department of Microbiology and Immunology, Faculty of Medicine, Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Martin Olivier
- Department of Microbiology and Immunology, Faculty of Medicine, Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
- Department of Medicine, Faculty of Medicine, Infectious Diseases and Immunity in Global Health Program, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
- *Correspondence: Martin Olivier,
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Ruiz GO, Herrera CFL, Bohórquez JAM, Betancur JE. Mortality in patients with acquired human immunodeficiency virus infection hospitalized in an intensive care unit during the period 2017-2019. Sci Rep 2022; 12:15644. [PMID: 36123430 PMCID: PMC9483872 DOI: 10.1038/s41598-022-19904-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Identify risk factors associated with mortality in HIV patients admitted to an ICU in the city of Bogotá. Retrospective cohort study of patients treated in an ICU during the years 2017–2019. The analysis included descriptive statistics, association tests, and a logistic regression model. A predictive model of mortality at the time of admission to the ICU was developed. 110 HIV patients were identified. Association was found between a Charlson index ≥ 6 and mortality (OR = 2.3, 95% CI 1.0–5.1) and an increase in mortality in the first 21 days of ICU stay (OR = 2.2, 95% CI 1.0–4.9). In the logistic regression analysis, the absence of highly active antiretroviral therapy (HAART) upon admission to the ICU (OR = 2.5 95% CI 1.0–6.1) and the first 21 days of ICU stay (OR = 2.3 95% CI 1.0–5.4) were associated with an increase in mortality. The predictive mortality model established that mortality was higher in patients admitted to the ICU without having previously received HAART than in those who did receive therapy at the time of admission to the ICU. In patients with HIV admitted to the ICU, the absence of HAART will negatively impact mortality during their hospital stay.
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Affiliation(s)
- Guillermo Ortiz Ruiz
- Critical Medicine and Intensive Care and Pulmonology, Universidad del Bosque, Bogotá, Colombia.,National Academy of Medicine, Hospital Santa Clara, Bogotá, Colombia
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Zhang S, Fu B, Xiong Y, Zhao Q, Xu S, Lin X, Wu H. Tgm2 alleviates LPS-induced apoptosis by inhibiting JNK/BCL-2 signaling pathway through interacting with Aga in macrophages. Int Immunopharmacol 2021; 101:108178. [PMID: 34607226 DOI: 10.1016/j.intimp.2021.108178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/08/2021] [Accepted: 09/18/2021] [Indexed: 12/19/2022]
Abstract
Sepsis is an unusual systemic infection caused by bacteria, which is a life-threatening organ dysfunction. The innate immune system plays an important role in this process; however, the specific mechanisms remain unclear. Using the LPS + treated mouse model, we found that the survival rate of Tgm2-/- mice was lower than that of the control group, while the inflammation was much higher. We further showed that Tgm2 suppressed apoptosis by inhibiting the JNK/BCL-2 signaling pathway. More importantly, Tgm2 interacted with Aga and regulated mitochondria-mediated apoptosis induced by LPS. Our findings elucidated a protective mechanism of Tgm2 during LPS stimulation and may provide a new reference target for the development of novel anti-infective drugs from the perspective of host immunity.
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Affiliation(s)
- Shanfu Zhang
- School of Life Sciences, Chongqing University, Chongqing 401331, China
| | - Beibei Fu
- School of Life Sciences, Chongqing University, Chongqing 401331, China
| | - Yan Xiong
- School of Life Sciences, Chongqing University, Chongqing 401331, China
| | - Qingting Zhao
- School of Life Sciences, Chongqing University, Chongqing 401331, China
| | - Shiyao Xu
- School of Life Sciences, Chongqing University, Chongqing 401331, China
| | - Xiaoyuan Lin
- School of Life Sciences, Chongqing University, Chongqing 401331, China.
| | - Haibo Wu
- School of Life Sciences, Chongqing University, Chongqing 401331, China.
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Lactic acidosis and hyperlactatemia associated with lamivudine accumulation and sepsis in a kidney transplant recipient-a case report and review of the literature. AIDS Res Ther 2021; 18:56. [PMID: 34481501 PMCID: PMC8418711 DOI: 10.1186/s12981-021-00382-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background We report a case of sudden, lethal metabolic acidosis in a 70-year-old man on long-term nucleoside reverse transcriptase inhibitor (NRTI) -based antiretroviral therapy (ART) who had developed atypical necrotizing fasciitis 1 month after kidney transplantation. Case presentation The HIV infection of the patient was treated for the last four months with an integrase strand inhibitor (dolutegravir 50 mg/d) plus a NRTI backbone including lamivudine (150 mg/d) and abacavir (600 mg/d). In this renal transplant patient we hypothesize that the co-existence of sepsis, renal failure and an accumulation of lamivudine led to the development of fatal metabolic acidosis and hyperlactatemia. Although lamivudine is only rarely associated with hyperlactatemia, there is evidence that overdose may be a risk factor for developing it. In our patient the lamivudine concentration two days after stopping and during hemodiafiltration was more than 50 times higher than therapeutic target trough concentrations. Likely reasons for this were renal impairment and concurrent treatment with trimethoprim, known to inhibit the renal elimination of lamivudine. Conclusions NRTIs could trigger the development of hyperlactatemia in septic patients. The use of NRTI sparing regimens might be considered in the presence of this critical condition.
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Monica Simamora R, Arfijanto MV, Rusli M, Utomo B, Pakpahan C, Adi GP. Clinical Signs and Laboratory Parameters as Predictors of Mortality among Hospitalized Human Immunodeficiency Virus-Infected Adult Patients at Tertiary Hospital in Surabaya. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: The morbidity and mortality rates due to human immunodeficiency virus (HIV) infection are still high despite various and advanced efforts in the management given for HIV/AIDS patients.
AIM: This study proposed that clinical signs and laboratory parameters could be expected to predict the patient’s mortality.
METHODS: This retrospective study was done by collecting 408 medical records of adult HIV/AIDS inpatients at a tertiary hospital in Surabaya from January 1, 2017, to December 31, 2019. Bivariate analysis using Chi-square test was carried out on nine variables, which were Glasgow Coma Scale (GCS) <15, hypotension, PaO2/FiO2 <400 mmHg, elevated liver enzymes, hemoglobin levels <10 mg/dl, platelet count <150,000/mm3, eGFR <60 ml/min/1.73 m2, albumin levels <3.5 mg/dl, and body mass index (BMI) <18.5 kg/m2. Variables which met the criteria would be included in the multivariate analysis using logistic regression.
RESULTS: Based on bivariate analysis, mortality was found to be significantly associated with GCS <15, hypotension, PaO2/FiO2, elevated liver enzymes, platelet count <100,000 mm3, eGFR <60 ml/1.73kg/m2, albumin levels <3.5 mgdl, and BMI <18.5 kg/m2. However, based on multivariate analysis, there were five variables which were found to be able to independently predict the patients’ mortality, those were GCS <15 (OR 11.625), hypotension (OR 6.062), PaO2/FiO2< 400 mmHg (OR 7.794), eGFR <60 ml/min/1.73 m2 (OR 2.646), and albumin levels <3.5 mg/dl (OR 4.091).
CONCLUSION: GCS <15, hypotension, PaO2/FiO2 <400 mmHg, eGFR <60 ml/1.73g/m2, and albumin levels <3.5 mg/dl were found as the independent risk factors which could predict the hospitalized HIV/AIDS patients’ mortality.
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Vally F, Selvaraj WMP, Ngalamika O. Admitted AIDS-associated Kaposi sarcoma patients: Indications for admission and predictors of mortality. Medicine (Baltimore) 2020; 99:e22415. [PMID: 32991474 PMCID: PMC7523766 DOI: 10.1097/md.0000000000022415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Kaposi sarcoma (KS) is an AIDS-defining angioproliferative malignancy associated with high morbidity and mortality. Most KS patients in regions with high incidence such as sub-Saharan Africa present late with advanced stage disease. Admitted KS patients have high mortality rates. Factors associated with mortality of admitted KS patients are poorly defined.We conducted a retrospective file review to ascertain reasons for admission and identify factors associated with mortality of admitted HIV-associated (epidemic) KS patients in Zambia. Baseline study variables were collected, and patients were retrospectively followed from admission to time of discharge or death.Mortality rate for admitted epidemic KS patients was high at 20%. The most common reasons for admission included advanced KS disease, severe anemia, respiratory tract infections, and sepsis. The majority (48%) of admitted patients had advanced clinical stage with visceral involvement on admission. Clinical predictors of mortality on univariate analysis included visceral KS [odds ratio (OR) = 13.74; 95% confidence interval (95% CI) = 1.68-113; P = 0.02), fever (OR = 26; 95% CI = 4.85-139; P = .001), and sepsis (OR = 35.56; 95% CI = 6.05-209; P = .001). Baseline hemoglobin levels (5.6 vs 8.2 g/dL; P = .001) and baseline platelet counts (63 x 10^9/L vs 205 x 10^9/L; P = .01) were significantly lower in mortalities vs discharges. Baseline white cell counts were higher in mortalities vs discharges (13.78 x 10^9/L vs 5.58 x 10^9/L; P = .01), and HIV-1 viral loads at the time of admission were higher in mortalities vs discharges (47,607 vs 40 copies/μL; P = .02). However, only sepsis (or signs and symptoms of sepsis) were independently associated with mortality after controlling for confounders.In conclusion, common reasons for admission of epidemic KS patients include advanced disease, severe anemia, respiratory tract infections, and signs and symptoms of sepsis. Signs and symptoms of sepsis are independent predictors of mortality in these patients.
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13
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Boniatti MM, Pellegrini JAS, Marques LS, John JF, Marin LG, Maito LRDM, Lisboa TC, Damiani LP, Falci DR. Early antiretroviral therapy for HIV-infected patients admitted to an intensive care unit (EARTH-ICU): A randomized clinical trial. PLoS One 2020; 15:e0239452. [PMID: 32956419 PMCID: PMC7505451 DOI: 10.1371/journal.pone.0239452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/04/2020] [Indexed: 12/30/2022] Open
Abstract
Background Highly active antiretroviral therapy (HAART) has reduced HIV-related morbidity and mortality at all stages of infection and reduced transmission of HIV. Currently, the immediate start of HAART is recommended for all HIV patients, regardless of the CD4 count. There are several concerns, however, about starting treatment in critically ill patients. Unpredictable absorption of medication by the gastrointestinal tract, drug toxicity, drug interactions, limited reserve to tolerate the dysfunction of other organs resulting from hypersensitivity to drugs or immune reconstitution syndrome, and the possibility that subtherapeutic levels of drug may lead to viral resistance are the main concerns. The objective of our study was to compare the early onset (up to 5 days) with late onset (after discharge from the ICU) of HAART in HIV-infected patients admitted to the ICU. Methods This was a randomized, open-label clinical trial enrolling HIV-infected patients admitted to the ICU of a public hospital in southern Brazil. Patients randomized to the intervention group had to start treatment with HAART within 5 days of ICU admission. For patients in the control group, treatment should begin after discharge from the ICU. The patients were followed up to determine mortality in the ICU, in the hospital and at 6 months. The primary outcome was hospital mortality. The secondary outcome was mortality at 6 months. Results The calculated sample size was 344 patients. Unfortunately, we decided to discontinue the study due to a progressively slower recruitment rate. A total of 115 patients were randomized. The majority of admissions were for AIDS-defining illnesses and low CD4. The main cause of admission was respiratory failure. Regarding the early and late study groups, there was no difference in hospital (66.7% and 63.8%, p = 0.75) or 6-month (68.4% and 79.2%, p = 0.20) mortality. After multivariate analysis, the only independent predictors of in-hospital mortality were shock and dialysis during the ICU stay. For the mortality outcome at 6 months, the independent variables were shock and dialysis during the ICU stay and tuberculosis at ICU admission. Conclusions Although the early termination of the study precludes definitive conclusions being made, early HAART administration for HIV-infected patients admitted to the ICU compared to late administration did not show benefit in hospital mortality or 6-month mortality. ClinicalTrials.gov, NCT01455688. Registered 20 October 2011, https://clinicaltrials.gov/show/NCT01455688
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Affiliation(s)
- Márcio M. Boniatti
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Universidade La Salle, Porto Alegre, Brazil
- * E-mail:
| | - José Augusto S. Pellegrini
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Universidade La Salle, Porto Alegre, Brazil
| | - Leonardo S. Marques
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, Porto Alegre, Brazil
| | - Josiane F. John
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Universidade La Salle, Porto Alegre, Brazil
| | - Luiz G. Marin
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, Porto Alegre, Brazil
| | - Lina R. D. M. Maito
- Critical Care Department, Hospital São Vicente de Paulo, Passo Fundo, Brazil
| | - Thiago C. Lisboa
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Instituto de Pesquisa HCor, Universidade La Salle, Porto Alegre, Brazil
| | | | - Diego R. Falci
- Infectious Disease Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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14
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Andrade HB, da Silva I, Ramos GV, Medeiros DM, Ho YL, de Carvalho FB, Bozza FA, Japiassú AM. Short- and medium-term prognosis of HIV-infected patients receiving intensive care: a Brazilian multicentre prospective cohort study. HIV Med 2020; 21:650-658. [PMID: 32876389 DOI: 10.1111/hiv.12939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/15/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- H B Andrade
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.,Sexually Transmitted Diseases Sector, Biomedical Institute, Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil
| | - Irf da Silva
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - G V Ramos
- Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - D M Medeiros
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Y L Ho
- Infectious Diseases Intensive Care Unit of Hospital das Clínicas, Medical School of the University of São Paulo, São Paulo, SP, Brazil
| | - F B de Carvalho
- Intensive Care Unit of Hospital Eduardo de Menezes, Hospital Foundation of the State of Minas Gerais, Belo Horizonte, MG, Brazil
| | - F A Bozza
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil.,Department of Critical Care, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil
| | - A M Japiassú
- Intensive Care Unit of the Evandro Chagas National Institute of Infectology, Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
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15
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Franceschini E, Santoro A, Menozzi M, Bacca E, Venturelli C, Zona S, Bedini A, Digaetano M, Puzzolante C, Meschiari M, Cuomo G, Orlando G, Sarti M, Guaraldi G, Cozzi-Lepri A, Mussini C. Epidemiology and Outcomes of Bloodstream Infections in HIV-Patients during a 13-Year Period. Microorganisms 2020; 8:microorganisms8081210. [PMID: 32784434 PMCID: PMC7463563 DOI: 10.3390/microorganisms8081210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 11/16/2022] Open
Abstract
No data on antibiotic resistance in bloodstream infection (BSI) in people living with HIV (PLWH) exist. The objective of this study was to describe BSI epidemiology in PLWH focusing on multidrug resistant (MDR) organisms. A retrospective, single-center, observational study was conducted including all positive blood isolates in PLWH from 2004 to 2017. Univariable and multivariable GEE models using binomial distribution family were created to evaluate the association between MDR and mortality risk. In total, 263 episodes (299 isolates) from 164 patients were analyzed; 126 (48%) BSI were community-acquired, 137 (52%) hospital-acquired. At diagnosis, 34.7% of the patients had virological failure, median CD4 count was 207/μL. Thirty- and 90-day mortality rates were 24.2% and 32.4%, respectively. Thirty- and 90-day mortality rates for MDR isolates were 33.3% and 46.9%, respectively (p < 0.05). Enterobacteriaceae were the most prevalent microorganisms (29.8%), followed by Coagulase-negative staphylococci (21.4%), and S. aureus (12.7%). In BSI due to MDR organisms, carbapenem-resistant K. pneumoniae and methicillin-resistant S. aureus were associated with mortality after adjustment for age, although this correlation was not confirmed after further adjustment for CD4 < 200/μL. In conclusion, BSI in PLWH is still a major problem in the combination antiretroviral treatment era and it is related to a poor viro-immunological status, posing the question of whether it should be considered as an AIDS-defining event.
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Affiliation(s)
- E. Franceschini
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
- Correspondence:
| | - Antonella Santoro
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Marianna Menozzi
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Erica Bacca
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Claudia Venturelli
- Unit of Microbiology and Virology, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (C.V.); (M.S.)
| | - Stefano Zona
- Primary Care Department, AUSL Modena, 41125 Modena, Italy;
| | - Andrea Bedini
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Margherita Digaetano
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Cinzia Puzzolante
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Marianna Meschiari
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Gianluca Cuomo
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Gabriella Orlando
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Mario Sarti
- Unit of Microbiology and Virology, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (C.V.); (M.S.)
| | - Giovanni Guaraldi
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
| | - Alessandro Cozzi-Lepri
- Research Department of Infection & Population Health, Royal Free and University College Medical School, London 41125, UK;
| | - Cristina Mussini
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria di Modena, 41125 Modena, Italy; (A.S.); (M.M.); (E.B.); (A.B.); (M.D.); (C.P.); (M.M.); (G.C.); (G.O.); (G.G.); (C.M.)
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16
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Barbier F, Mer M, Szychowiak P, Miller RF, Mariotte É, Galicier L, Bouadma L, Tattevin P, Azoulay É. Management of HIV-infected patients in the intensive care unit. Intensive Care Med 2020; 46:329-342. [PMID: 32016535 PMCID: PMC7095039 DOI: 10.1007/s00134-020-05945-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
The widespread use of combination antiretroviral therapies (cART) has converted the prognosis of HIV infection from a rapidly progressive and ultimately fatal disease to a chronic condition with limited impact on life expectancy. Yet, HIV-infected patients remain at high risk for critical illness due to the occurrence of severe opportunistic infections in those with advanced immunosuppression (i.e., inaugural admissions or limited access to cART), a pronounced susceptibility to bacterial sepsis and tuberculosis at every stage of HIV infection, and a rising prevalence of underlying comorbidities such as chronic obstructive pulmonary diseases, atherosclerosis or non-AIDS-defining neoplasms in cART-treated patients aging with controlled viral replication. Several patterns of intensive care have markedly evolved in this patient population over the late cART era, including a steady decline in AIDS-related admissions, an opposite trend in admissions for exacerbated comorbidities, the emergence of additional drivers of immunosuppression (e.g., anti-neoplastic chemotherapy or solid organ transplantation), the management of cART in the acute phase of critical illness, and a dramatic progress in short-term survival that mainly results from general advances in intensive care practices. Besides, there is a lack of data regarding other features of ICU and post-ICU care in these patients, especially on the impact of sociological factors on clinical presentation and prognosis, the optimal timing of cART introduction in AIDS-related admissions, determinants of end-of-life decisions, long-term survival, and functional outcomes. In this narrative review, we sought to depict the current evidence regarding the management of HIV-infected patients admitted to the intensive care unit.
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Affiliation(s)
- François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France.
| | - Mervin Mer
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg University Hospital, Johannesburg, South Africa
| | - Piotr Szychowiak
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Robert F Miller
- Research Department of Infection and Population Health, University College London, London, UK
| | - Éric Mariotte
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Saint-Louis University Hospital, APHP, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, APHP, Paris, France
- Paris Diderot University, IAME-UMR 1137, INSERM, Paris, France
| | - Pierre Tattevin
- Infectious Diseases and Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France.
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic, Sorbonne-Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France.
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17
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Neto NB, Marin LG, de Souza BG, Moro AL, Nedel WL. HIV treatment non-adherence is associated with ICU mortality in HIV-positive critically ill patients. J Intensive Care Soc 2020; 22:47-51. [PMID: 33643432 DOI: 10.1177/1751143719898977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction Combined antiretroviral therapy has led to significant decreases in morbidity and mortality in acquired immunodeficiency syndrome patients. Survival among these patients admitted to intensive care units has also improved in the last years. However, the prognostic predictors of human immunodeficiency vírus patients in intensive care units have not been adequately studied. The main objective of this study was to evaluate if non-adherence to antiretroviral therapy is a predictor of hospital mortality. Methods A unicentric, retrospective, cohort study composed of patients admitted to a 59-bed mixed intensive care unit including all patients with human immunodeficiency vírus infection. Patients were excluded if exclusive palliative care was established before completing 48 h of intensive care unit admission. Clinical and treatment data were obtained, including demographic records, underlying diseases, Simplified Acute Physiology III score at the time of intensive care unit admission, CD4 lymphocyte count, antiretroviral therapy adherence, admission diagnosis, human immunodeficiency vírus-related diseases, sepsis and use of mechanical ventilation and hemodialysis. The outcome analyzed was hospital mortality. Results Overall, 167 patients were included in the study, and intensive care unit mortality was 34.7%. Multivariate analysis indicated that antiretroviral therapy adherence and the Simplified Acute Physiology 3 score were independently related to hospital mortality. antiretroviral therapy adherence was a protective factor (OR 0.2; 95% CI 0.05-0.71; P = 0.01), and Simplified Acute Physiology 3 (OR 1.04; 95% CI 1.01-1.08; P < 0.01) was associated with increased hospital mortality. Conclusion Non-adherence to antiretroviral therapy is associated with hospital mortality in this population. Highly active antiretroviral therapy non-adherence may be associated with other comorbidities that may be associated with a worst prognosis in this scenario.
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Affiliation(s)
- Nelson Bf Neto
- Intensive Care Unit, Hospital Bruno Born, Lajeado/RS, Brazil
| | - Luiz G Marin
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil
| | - Bruna G de Souza
- Infectious Disease Department, Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil
| | - Ana Ld Moro
- Intensive Care Unit, Hospital Bruno Born, Lajeado/RS, Brazil
| | - Wagner L Nedel
- Intensive Care Unit, Hospital Nossa Senhora da Conceição, Porto Alegre/RS, Brazil.,Postgraduate Program in Biochemistry, Universidade Federal do Rio Grande do Sul, Porto Alegre/RS, Brazil
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18
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Azoulay É, de Castro N, Barbier F. Critically Ill Patients With HIV: 40 Years Later. Chest 2019; 157:293-309. [PMID: 31421114 DOI: 10.1016/j.chest.2019.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 01/27/2023] Open
Abstract
The development of combination antiretroviral therapies (cARTs) in the mid-1990s has dramatically modified the clinical presentation of critically ill, HIV-infected patients. Most cART-treated patients aging with controlled HIV replication are currently admitted to the ICU for non-AIDS-related events, mostly bacterial pneumonia and exacerbation of comorbidities, variably affected by chronic HIV infection (COPD, cardiovascular diseases, or solid neoplasms). Today, Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis, TB, and other severe opportunistic infections only occur in patients with unknown viral status, limited access to cART, viral resistance, or compliance issues. Acute respiratory failure, neurological disorders, and sepsis remain the main conditions that lead HIV-infected patients to the ICU, although admissions for liver diseases or acute kidney injury are increasing. Case fatality dropped substantially over the past decades, reaching figures of HIV-uninfected critically ill patients with similar demographic characteristics, comorbidities, and level of organ dysfunctions. Several other facets of critical care management have evolved in this population, including diagnostic procedures, cART management at the acute phase of critical illness, and ethical considerations. The goal of this narrative review was to depict the current evidence and emerging challenges for the management of critically ill, HIV-infected patients, almost 40 years following the onset of the AIDS epidemic.
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Affiliation(s)
- Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France; ECSTRA, SBIM, and the Saint-Louis Hospital, APHP, Paris, France.
| | - Nathalie de Castro
- Department of Infectious Diseases, Saint-Louis Hospital, APHP, Paris, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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de Castro-Lima VAC, Borges IC, Joelsons D, Sales VV, Guimaraes T, Ho YL, Costa SF, Moura MLN. Impact of human immunodeficiency virus infection on mortality of patients who acquired healthcare associated-infection in critical care unit. Medicine (Baltimore) 2019; 98:e15801. [PMID: 31169679 PMCID: PMC6571254 DOI: 10.1097/md.0000000000015801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/18/2019] [Accepted: 05/01/2019] [Indexed: 01/06/2023] Open
Abstract
To evaluate 30-day mortality in human immunodeficiency virus (HIV) and non-HIV patients who acquired a healthcare-associated infection (HAI) while in an intensive care unit (ICU), and to describe the epidemiological and microbiological features of HAI in a population with HIV.This was a retrospective cohort study that evaluated patients who acquired HAI during their stay in an Infectious Diseases ICU from July 2013 to December 2017 at a teaching hospital in Brazil.Data were obtained from hospital infection control committee reports and medical records. Statistical analysis was performed using SPSS and a multivariate model was used to evaluate risk factors associated with 30-day mortality. Epidemiological, clinical, and microbiological characteristics of HAI in HIV and non-HIV patients and 30-day mortality were also evaluated.Among 1045 patients, 77 (25 HIV, 52 non-HIV) patients acquired 106 HAI (31 HIV, 75 non-HIV patients). HIV patients were younger (45 vs 58 years, P = .002) and had more respiratory distress than non-HIV patients (60.0% vs 34.6%, P = .035). A high 30-day mortality was observed and there was no difference between groups (HIV, 52.0% vs non-HIV, 54.9%; P = .812). Ventilator-associated pneumonia (VAP) was more frequent in the HIV group compared with the non-HIV group (45.2% vs 26.7%, P = .063), with a predominance of Gram-negative organisms. Gram-positive agents were the most frequent cause of catheter associated-bloodstream infections in HIV patients. Although there was a high frequency of HAI caused by multidrug-resistant organisms (MDRO), no difference was observed between the groups (HIV, 77.8% vs non-HIV, 64.3%; P = .214). Age was the only independent factor associated with 30-day mortality (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.1, P = .017), while diabetes mellitus (OR: 3.64, 95% CI: 0.84-15.8, P = .085) and the Sequential Organ-Failure Assessment (SOFA) score (OR: 1.16, 95% CI: 0.99-1.37, P = .071) had a tendency to be associated with death.HIV infection was not associated with a higher 30-day mortality in critical care patients with a HAI. Age was the only independent risk factor associated with death. VAP was more frequent in HIV patients, probably because of the higher frequency of respiratory conditions at admission, with a predominance of Gram-negative organisms.
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Mesquita EC, Coelho LE, Amancio RT, Veloso V, Grinsztejn B, Luz P, Bozza FA. Severe infection increases cardiovascular risk among HIV-infected individuals. BMC Infect Dis 2019; 19:319. [PMID: 30975092 PMCID: PMC6460818 DOI: 10.1186/s12879-019-3894-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 03/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The identification and management of cardiovascular risk factors became a major clinical issue among HIV-infected individuals in the post-cART era. As in the past decades the link between acute infections and cardiovascular diseases became clear in the general population, we sorted to investigate the role of severe infections on incident cardiovascular diseases (CVDs) among HIV-infected individuals. METHODS HIV-infected individuals aged ≥18 years, with no history of CVD were followed from January 2000 to December 2013 until the occurrence of the first CVD event, death or end of study, whichever occurred first. To explore the effect of severe infections on the incidence of CVD we used extended Cox regression models and stratified post-hospitalization follow-up time into three periods: < 3 months, 3-12 months and > 12 months post discharge. RESULTS One hundred-eighty four persons from 3384 HIV-infected individuals developed incident CVD events during the follow-up (incidence rate = 11.10/1000 PY (95%CI: 9.60-12.82)). Risk of an incident CVD was 4-fold higher at < 3 months post-hospitalization for severe infections (adjusted hazard ratio [aHR], 4.52; 95% confidence interval [CI] 2.46-8.30), after adjusting for sociodemographic and clinical factors as well as comorbidities. This risk remained significant up to one year (3-12 months post hospital discharge aHR 2.39, 95% CI 1.30-4.38). Additionally, non-white race/ethnicity (aHR 1.49, 95% CI 1.10-2.02), age ≥ 60 years (aHR 2.01, 95% CI 1.01-3.97) and hypertension (aHR 1.90, 95% CI 1.38-2.60) were associated with an increased risk of CVD events. High CD4 (≥ 500 cells/mm3: aHR 0.41, 95% CI 0.27-0.62) and cART use (aHR 0.21, 95% CI 0.14-0.31) reduced the risk of CVD events. CONCLUSIONS We provide evidence for a time-dependent association between severe infection and incident cardiovascular disease in HIV-infected individuals. cART use, and high CD4 count were significantly associated with reduced hazards of CVD.
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Affiliation(s)
- Emersom Cicilini Mesquita
- Laboratório de Pesquisa Clínica em Medicina Intensiva, Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Lara Esteves Coelho
- Laboratório de HIV, Instituto de Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Rodrigo Teixeira Amancio
- Laboratório de Pesquisa Clínica em Medicina Intensiva, Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Valdilea Veloso
- Laboratório de HIV, Instituto de Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Laboratório de HIV, Instituto de Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Paula Luz
- Laboratório de HIV, Instituto de Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Fernando Augusto Bozza
- Laboratório de Pesquisa Clínica em Medicina Intensiva, Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
- Instituto D’Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
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Vidal-Cortés P, Álvarez-Rocha LA, Fernández-Ugidos P, Pérez-Veloso MA, Suárez-Paul IM, Virgós-Pedreira A, Pértega-Díaz S, Castro-Iglesias ÁC. Epidemiology and outcome of HIV-infected patients admitted to the ICU in the current highly active antiretroviral therapy era. Med Intensiva 2019; 44:283-293. [PMID: 30971339 DOI: 10.1016/j.medin.2019.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the epidemiology of critical disease in HIV-infected patients during the current highly active antiretroviral therapy (HAART) era and to identify hospital mortality predictors. METHODS A longitudinal, retrospective observational study was made of HIV-infected adults admitted to the ICU in two Spanish hospitals between 1 January 2000 and 31 December 2014. Demographic and HIV-related variables were analyzed, together with comorbidities, severity scores, reasons for admission and need for organ support. The chi-squared test was used to compare categorical variables, while continuous variables were contrasted with the Student's t-test, Mann-Whitney U-test or Kruskal-Wallis test, assuming an alpha level=0.05. Multivariate logistic regression analysis was used to calculate odds ratios for assessing correlations to mortality during hospital stay. Joinpoint regression analysis was used to study mortality trends over time. RESULTS A total of 283 episodes were included for analyses. Hospital mortality was 32.9% (95%CI: 21.2-38.5). Only admission from a site other than the Emergency Care Department (OR 3.64, 95%CI: 1.30-10.20; p=0.01), moderate-severe liver disease (OR 5.65, 95%CI: 1.11-28.87; p=0.04) and the APACHE II score (OR 1.14, 95%CI: 1.04-1.26; p<0.01) and SOFA score at 72h (OR 1.19, 95%CI: 1.02-1.40; p=0.03) maintained a statistically significant relationship with hospital mortality. CONCLUSIONS Delayed ICU admission, comorbidities and the severity of critical illness determine the prognosis of HIV-infected patients admitted to the ICU. Based on these data, HIV-infected patients should receive the same level of care as non-HIV-infected patients, regardless of their immunological or nutritional condition.
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Affiliation(s)
- P Vidal-Cortés
- Intensive Care Unit, Complexo Hospitalario Universitario de Ourense (CHUO), SERGAS, Spain.
| | - L A Álvarez-Rocha
- Intensive Care Unit, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Spain
| | - P Fernández-Ugidos
- Intensive Care Unit, Complexo Hospitalario Universitario de Ourense (CHUO), SERGAS, Spain
| | - M A Pérez-Veloso
- Intensive Care Unit, Complexo Hospitalario Universitario de Ourense (CHUO), SERGAS, Spain
| | - I M Suárez-Paul
- Intensive Care Unit, Hospital San Juan de Dios, Córdoba, Spain
| | - A Virgós-Pedreira
- Intensive Care Unit, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), SERGAS, Spain
| | - S Pértega-Díaz
- Clinical Epidemiology and Biostatistics Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade de A Coruña, Spain
| | - Á C Castro-Iglesias
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INBIC) - Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, Universidade de A Coruña, Spain
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Ramya I, Mitra S, D'Sa S, Sathyendra S, Zachariah A, Kumar CV, Carey RAB, Verghese GM. Outcomes and factors influencing outcomes of critically ill HIV-positive patients in a tertiary care center in South India. J Family Med Prim Care 2019; 8:97-101. [PMID: 30911487 PMCID: PMC6396590 DOI: 10.4103/jfmpc.jfmpc_156_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The incidence of (Human immune deficiency) HIV in India has fallen by 58% since the onset of the HIV epidemic. As of 2016 there are 2.1 million people living in India with HIV and only 49% of the adults with HIV are on ART (1). The HIV infected individuals may require intensive care due to various reasons. This study attempts to look at the outcomes of these patients admitted in the intensive care unit and the predictors of these outcomes.
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Affiliation(s)
- I Ramya
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shubankar Mitra
- Department of Accident and Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shilpa D'Sa
- Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sowmya Sathyendra
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Zachariah
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - C Vignesh Kumar
- Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - George M Verghese
- Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
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Factors Underlying Racial Disparities in Sepsis Management. Healthcare (Basel) 2018; 6:healthcare6040133. [PMID: 30463180 PMCID: PMC6315577 DOI: 10.3390/healthcare6040133] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/10/2018] [Accepted: 11/14/2018] [Indexed: 12/13/2022] Open
Abstract
Sepsis, a syndrome characterized by systemic inflammation during infection, continues to be one of the most common causes of patient mortality in hospitals across the United States. While standardized treatment protocols have been implemented, a wide variability in clinical outcomes persists across racial groups. Specifically, black and Hispanic populations are frequently associated with higher rates of morbidity and mortality in sepsis compared to the white population. While this is often attributed to systemic bias against minority groups, a growing body of literature has found patient, community, and hospital-based factors to be driving racial differences. In this article, we provide a focused review on some of the factors driving racial disparities in sepsis. We also suggest potential interventions aimed at reducing health disparities in the prevention, early identification, and clinical management of sepsis.
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Raeven P, Zipperle J, Drechsler S. Extracellular Vesicles as Markers and Mediators in Sepsis. Am J Cancer Res 2018; 8:3348-3365. [PMID: 29930734 PMCID: PMC6010985 DOI: 10.7150/thno.23453] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/14/2018] [Indexed: 01/28/2023] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. It remains a highly lethal condition in which current tools for early diagnosis and therapeutic decision-making are far from ideal. Extracellular vesicles (EVs), 30 nm to several micrometers in size, are released from cells upon activation and apoptosis and express membrane epitopes specific for their parental cells. Since their discovery two decades ago, their role as biomarkers and mediators in various diseases has been intensively studied. However, their potential importance in the sepsis syndrome has gained attention only recently. Sepsis and EVs are both complex fields in which standardization has long been overdue. In this review, several topics are discussed. First, we review current studies on EVs in septic patients with emphasis on their variable quality and clinical utility. Second, we discuss the diagnostic and therapeutic potential of EVs as well as their role as facilitators of cell communication via micro RNA and the relevance of micro-organism-derived EVs. Third, we give an overview over the potential beneficial but also detrimental roles of EVs in sepsis. Finally, we focus on the role of EVs in selected intensive care scenarios such as coagulopathy, mechanical ventilation and blood transfusion. Overall, the prospect for EV use in septic patients is bright, ranging from rapid and precise (point-of-care) diagnostics, prevention of harmful iatrogenic interventions, to using EVs as guides of individualized therapy. Before the above is achieved, however, the EV research field requires reliable standardization of the current methods and development of new analytical procedures that can close the existing technological gaps.
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25
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Aluisio AR, Garbern S, Wiskel T, Mutabazi ZA, Umuhire O, Ch'ng CC, Rudd KE, D'Arc Nyinawankusi J, Byiringiro JC, Levine AC. Mortality outcomes based on ED qSOFA score and HIV status in a developing low income country. Am J Emerg Med 2018; 36:2010-2019. [PMID: 29576257 DOI: 10.1016/j.ajem.2018.03.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/27/2018] [Accepted: 03/07/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate the utility of the quick Sepsis-related Organ Failure Assessment (qSOFA) score to predict risks for emergency department (ED) and hospital mortality among patients in a sub-Saharan Africa (SSA) setting. METHODS This retrospective cohort study was carried out at a tertiary-care hospital, in Kigali, Rwanda and included patients ≥15years, presenting for ED care during 2013 with an infectious disease (ID). ED and overall hospital mortality were evaluated using multivariable regression, with qSOFA scores as the primary predictor (reference: qSOFA=0), to yield adjusted relative risks (aRR) with 95% confidence intervals (CI). Analyses were performed for the overall population and stratified by HIV status. RESULTS Among 15,748 cases, 760 met inclusion (HIV infected 197). The most common diagnoses were malaria and intra-abdominal infections. Prevalence of ED and hospital mortality were 12.5% and 25.4% respectively. In the overall population, ED mortality aRR was 4.8 (95% CI 1.9-12.0) for qSOFA scores equal to 1 and 7.8 (95% CI 3.1-19.7) for qSOFA scores ≥2. The aRR for hospital mortality in the overall cohort was 2.6 (95% 1.6-4.1) for qSOFA scores equal to 1 and 3.8 (95% 2.4-6.0) for qSOFA scores ≥2. For HIV infected cases, although proportional mortality increased with greater qSOFA score, statistically significant risk differences were not identified. CONCLUSION The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed.
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Affiliation(s)
- Adam R Aluisio
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA.
| | - Stephanie Garbern
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
| | - Tess Wiskel
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
| | - Zeta A Mutabazi
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | - Olivier Umuhire
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | | | - Kristina E Rudd
- Department of Medicine, University of Washington, Seattle, USA
| | | | | | - Adam C Levine
- Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA
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Andrade HB, Shinotsuka CR, da Silva IRF, Donini CS, Yeh Li H, de Carvalho FB, Americano do Brasil PEA, Bozza FA, Miguel Japiassu A. Highly active antiretroviral therapy for critically ill HIV patients: A systematic review and meta-analysis. PLoS One 2017; 12:e0186968. [PMID: 29065165 PMCID: PMC5655356 DOI: 10.1371/journal.pone.0186968] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/11/2017] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION It is unclear whether the treatment of an HIV infection with highly active antiretroviral therapy (HAART) affects intensive care unit (ICU) outcomes. In this paper, we report the results of a systematic review and meta-analysis performed to summarize the effects of HAART on the prognosis of critically ill HIV positive patients. MATERIALS AND METHODS A bibliographic search was performed in 3 databases (PubMed, Web of Science and Scopus) to identify articles that investigated the use of HAART during ICU admissions for short- and long-term mortality or survival. Eligible articles were selected in a staged process and were independently assessed by two investigators. The methodological quality of the selected articles was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS Twelve articles met the systematic review inclusion criteria and examined short-term mortality. Six of them also examined long-term mortality (≥90 days) after ICU discharge. The short-term mortality meta-analysis showed a significant beneficial effect of initiating or maintaining HAART during the ICU stay (random effects odds ratio 0.53, p = 0.02). The data analysis of long-term outcomes also suggested a reduced mortality when HAART was used, but the effect of HAART on long-term mortality of HIV positive critically ill patients remains uncertain. CONCLUSIONS This meta-analysis suggests improved survival rates for HIV positive patients who were treated with HAART during their ICU admission.
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Affiliation(s)
- Hugo Boechat Andrade
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Cassia Righy Shinotsuka
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Ivan Rocha Ferreira da Silva
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Camila Sunaitis Donini
- Infectious Diseases Intensive Care Unit of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Ho Yeh Li
- Infectious Diseases Intensive Care Unit of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, SP, Brazil
| | - Frederico Bruzzi de Carvalho
- Intensive Care Unit of Hospital Eduardo de Menezes da Fundação Hospitalar do Estado de Minas Gerais. Belo Horizonte, MG, Brazil
| | | | - Fernando Augusto Bozza
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
| | - Andre Miguel Japiassu
- Intensive Care Unit of Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz). Rio de Janeiro, RJ, Brazil
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Calik Basaran N, Ascioglu S. Epidemiology and management of healthcare-associated bloodstream infections in non-neutropenic immunosuppressed patients: a review of the literature. Ther Adv Infect Dis 2017; 4:171-191. [PMID: 29662673 DOI: 10.1177/2049936117733394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Advancements in medicine have led to a considerable increase in the proportion of patients living with severe chronic diseases, malignancies, and HIV infections. Most of these conditions are associated with acquired immune-deficient states and treatment-related immunosuppression. Although infections as a result of neutropenia have long been recognized and strategies for management were developed, non-neutropenic immunosuppression has been overlooked. Recently, community-acquired infections in patients with frequent, significant exposure to healthcare settings and procedures have been classified as 'healthcare-associated infections' since they are more similar to hospital-acquired infections. Most of the non-neutropenic immunosuppressed patients have frequent contact with the healthcare system due to their chronic and severe diseases. In this review, we focus on the healthcare-associated bloodstream infections in the most common non-neutropenic immunosuppressive states and provide an update of the recent evidence for the management of these infections.
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Affiliation(s)
- Nursel Calik Basaran
- Department of Internal Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Sibel Ascioglu
- Department of Infectious Diseases and Microbiology, Hacettepe University Medical School, Ankara, Turkey; GlaxoSmithKline Pte Ltd., Singapore
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da Silva Escada RO, Velasque L, Ribeiro SR, Cardoso SW, Marins LMS, Grinsztejn E, da Silva Lourenço MC, Grinsztejn B, Veloso VG. Mortality in patients with HIV-1 and tuberculosis co-infection in Rio de Janeiro, Brazil - associated factors and causes of death. BMC Infect Dis 2017; 17:373. [PMID: 28558689 PMCID: PMC5450415 DOI: 10.1186/s12879-017-2473-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 05/18/2017] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Tuberculosis is the most frequent opportunistic infection and the leading cause of death among persons living with HIV in several low and middle-income countries. Mortality rates during tuberculosis treatment and death causes among HIV-1/TB co-infected patients may differ based on the immunosuppression severity, timing of diagnosis and prompt initiation of tuberculosis and antiretroviral therapy. METHODS This was a retrospective observational study conducted in the clinical cohort of patients with HIV-1/Aids of the National Institute of Infectious Diseases Evandro Chagas, Rio de Janeiro, Brazil. All HIV-1 infected patients who started combination antiretroviral therapy up to 30 days before or within 180 days after the start of tuberculosis treatment from 2000 to 2010 were eligible. Causes of death were categorized according to the "Coding Causes of Death in HIV" (CoDe) protocol. The Cox model was used to estimate the hazard ratio (HR) of selected mortality variables. RESULTS A total of 310 patients were included. Sixty-four patients died during the study period. Mortality rate following tuberculosis treatment initiation was 44 per 100 person-years within the first 30 days, 28.1 per 100 person-years within 31 and 90 days, 6 per 100 person-years within 91 and 365 days and 1.6 per 100 person-years after 365 days. Death probability within one year from tuberculosis treatment initiation was approximately 13%. In the adjusted analysis the associated factors with mortality were: CD4 ≤ 50 cells/mm3 (HR: 3.10; 95% CI: 1.720 to 5.580; p = 0.00); mechanical ventilation (HR: 2.81; 95% CI: 1.170 to 6.760; p = 0.02); and disseminated tuberculosis (HR: 3.70; 95% CI: 1.290 to 10.590, p = 0.01). Invasive bacterial disease was the main immediate cause of death (46.9%). CONCLUSION Our results evidence the high morbidity and mortality among patients co-infected with HIV-1 and tuberculosis in Rio de Janeiro, Brazil. During the first year following tuberculosis diagnosis, mortality was the highest within the first 3 months, being invasive bacterial infection the major cause of death. In order to successfully intervene in this scenario, it is utterly necessary to address the social determinants of health contributing to the inequitable health care access faced by this population.
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Affiliation(s)
| | - Luciane Velasque
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
- Departamento de Matemática e Estatística, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sayonara Rocha Ribeiro
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Eduarda Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Abstracts of the HIV & Hepatitis in the Americas 2017 - Congress. J Int AIDS Soc 2017; 20:21954. [PMID: 28440071 PMCID: PMC5625637 DOI: 10.7448/ias.20.3.21954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Luna LDS, Soares DDS, Junior GBDS, Cavalcante MG, Malveira LRC, Meneses GC, Pereira EDB, Daher EDF. CLINICAL CHARACTERISTICS, OUTCOMES AND RISK FACTORS FOR DEATH AMONG CRITICALLY ILL PATIENTS WITH HIV-RELATED ACUTE KIDNEY INJURY. Rev Inst Med Trop Sao Paulo 2017; 58:52. [PMID: 27410912 PMCID: PMC4964321 DOI: 10.1590/s1678-9946201658052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/15/2016] [Indexed: 12/23/2022] Open
Abstract
Background: The aim of this study is to describe clinical characteristics, outcomes and risk factors for death among patients with HIV-related acute kidney injury (AKI) admitted to an intensive care unit (ICU). Methods: A retrospective study was conducted with HIV-infected AKI patients admitted to the ICU of an infectious diseases hospital in Fortaleza, Brazil. All the patients with confirmed diagnosis of HIV and AKI admitted from January 2004 to December 2011 were included. A comparison between survivors and non-survivors was performed. Risk factors for death were investigated. Results: Among 256 AKI patients admitted to the ICU in the study period, 73 were identified as HIV-infected, with a predominance of male patients (83.6%), and the mean age was 41.2 ± 10.4 years. Non-survivor patients presented higher APACHE II scores (61.4 ± 19 vs. 38.6 ± 18, p = 0.004), used more vasoconstrictors (70.9 vs. 37.5%, p = 0.02) and needed more mechanical ventilation - MV (81.1 vs. 35.3%, p = 0.001). There were 55 deaths (75.3%), most of them (53.4%) due to septic shock. Independent risk factors for mortality were septic shock (OR = 14.2, 95% CI = 2.0-96.9, p = 0.007) and respiratory insufficiency with need of MV (OR = 27.6, 95% CI = 5.0-153.0, p < 0.001). Conclusion: Non-survivor HIV-infected patients with AKI admitted to the ICU presented higher severity APACHE II scores, more respiratory damage and hemodynamic impairment than survivors. Septic shock and respiratory insufficiency were independently associated to death.
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Affiliation(s)
- Leonardo Duarte Sobreira Luna
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ;
| | - Douglas de Sousa Soares
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ;
| | | | - Malena Gadelha Cavalcante
- Federal University of Ceará, School of Medicine, Medical Sciences and Pharmacology Graduate Program. Fortaleza, CE, Brazil. E-mails: ;
| | - Lara Raissa Cavalcante Malveira
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ;
| | - Gdayllon Cavalcante Meneses
- Federal University of Ceará, School of Medicine, Medical Sciences and Pharmacology Graduate Program. Fortaleza, CE, Brazil. E-mails: ;
| | - Eanes Delgado Barros Pereira
- University of Fortaleza, School of Medicine, Public Health Graduate Program. Fortaleza, CE, Brazil. E-mails: ; ;
| | - Elizabeth De Francesco Daher
- Federal University of Ceará, School of Medicine, Division of Nephrology, Department of Internal Medicine. Fortaleza, CE, Brazil. E-mails: ; ; ; .,University of Fortaleza, School of Medicine, Public Health Graduate Program. Fortaleza, CE, Brazil. E-mails: ; ;
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Staphylococcus aureus bacteremia in immunosuppressed patients: a multicenter, retrospective cohort study. Eur J Clin Microbiol Infect Dis 2017; 36:1231-1241. [PMID: 28251359 DOI: 10.1007/s10096-017-2914-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/23/2017] [Indexed: 12/20/2022]
Abstract
Staphylococcus aureus bacteremia (SAB) causes significant morbidity and mortality. We assessed the disease severity and clinical outcomes of SAB in patients with pre-existing immunosuppression, compared with immunocompetent patients. A retrospective cohort investigation studied consecutive patients with SAB hospitalized across six hospitals in Toronto, Canada from 2007 to 2010. Patients were divided into immunosuppressed (IS) and immunocompetent (IC) cohorts; the IS cohort was subdivided into presence of one and two or more immunosuppressive conditions. Clinical parameters were compared between cohorts and between IS subgroups. A competing risk model compared in-hospital mortality and time to discharge. A total of 907 patients were included, 716 (79%) were IC and 191 (21%) were IS. Within the IS cohort, 111 (58%) had one immunosuppressive condition and 80 (42%) had two or more conditions. The overall in-hospital mortality was 29%, with no differences between groups (IS 32%, IC 28%, p = 0.4211). There were no differences in in-hospital mortality (sub-distribution hazard ratio [sHR] 1.17, 95% confidence interval [CI] 0.88-1.56, p = 0.2827) or time to discharge (sHR 0.94, 95% CI 0.78-1.15, p = 0.5570). Independent mortality predictors for both cohorts included hypotension at 72 h (IS: p < 0.0001, IC: p < 0.0001) and early embolic stroke (IS: p < 0.0001, IC: p = 0.0272). Congestive heart failure was a mortality predictor in the IS cohort (p = 0.0089). Fever within 24 h (p = 0.0092) and early skin and soft tissue infections (p < 0.0001) were survival predictors in the IS cohort. SAB causes significant mortality regardless of pre-existing immune status, but immunosuppressed patients do not have an elevated risk of mortality relative to immunocompetent patients.
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Epidemiology and Outcomes in Critically Ill Patients with Human Immunodeficiency Virus Infection in the Era of Combination Antiretroviral Therapy. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2017; 2017:7868954. [PMID: 28348607 PMCID: PMC5350334 DOI: 10.1155/2017/7868954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/30/2017] [Accepted: 02/08/2017] [Indexed: 11/18/2022]
Abstract
Purpose. The impact of critical illness on survival of HIV-infected patients in the era of antiretroviral therapy remains uncertain. We describe the epidemiology of critical illness in this population and identify predictors of mortality. Materials and Methods. Retrospective cohort of HIV-infected patients was admitted to intensive care from 2002 to 2014. Patient sociodemographics, comorbidities, case-mix, illness severity, and 30-day mortality were captured. Multivariable Cox regression analyses were performed to identify predictors of mortality. Results. Of 282 patients, mean age was 44 years (SD 10) and 169 (59%) were male. Median (IQR) CD4 count and plasma viral load (PVL) were 125 cells/mm3 (30–300) and 28,000 copies/mL (110–270,000). Fifty-five (20%) patients died within 30 days. Factors independently associated with mortality included APACHE II score (adjusted hazard ratio [aHR] 1.12; 95% CI 1.08–1.16; p < 0.001), cirrhosis (aHR 2.30; 95% CI 1.12–4.73; p = 0.024), coronary artery disease (aHR 6.98; 95% CI 2.20–22.13; p = 0.001), and duration of HIV infection (aHR 1.07 per year; 95% CI 1.02–1.13; p = 0.01). CD4 count and PVL were not associated with mortality. Conclusions. Mortality from an episode of critical illness in HIV-infected patients remains high but appears to be driven by acute illness severity and HIV-unrelated comorbid disease rather than degree of immune suppression.
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Meier B, Staton C. Sepsis Resuscitation in Resource-Limited Settings. Emerg Med Clin North Am 2017; 35:159-173. [DOI: 10.1016/j.emc.2016.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Impact of HIV infection on the presentation, outcome and host response in patients admitted to the intensive care unit with sepsis; a case control study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:322. [PMID: 27719675 PMCID: PMC5056483 DOI: 10.1186/s13054-016-1469-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/26/2016] [Indexed: 01/05/2023]
Abstract
Background Sepsis is a prominent reason for intensive care unit (ICU) admission in patients with HIV. We aimed to investigate the impact of HIV infection on presentation, outcome and host response in sepsis. Methods We performed a prospective observational study in the ICUs of two tertiary hospitals. For the current analyses, we selected all patients diagnosed with sepsis within 24 hours after admission. Host response biomarkers were analyzed in a more homogeneous subgroup of admissions involving HIV-positive patients with pneumosepsis, matched to admissions of HIV-negative patients for age, gender and race. Matching was done by nearest neighbor matching with R package “MatchIt”. Results We analyzed 2251 sepsis admissions including 41 (1.8 %) with HIV infection (32 unique patients). HIV-positive patients were younger and admission of HIV-positive patients more frequently involved pneumonia (73.2 % versus 48.8 % of admissions of HIV-negative patients, P = 0.004). Disease severity and mortality up to one year after admission did not differ according to HIV status. Furthermore, sequential plasma levels of host response biomarkers, providing insight into activation of the cytokine network, the vascular endothelium and the coagulation system, were largely similar in matched admissions of HIV-positive and HIV-negative patients with pneumosepsis. Conclusions Sepsis is more often caused by pneumonia in HIV-positive patients. HIV infection has little impact on the disease severity, mortality and host response during sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1469-0) contains supplementary material, which is available to authorized users.
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Pecego AC, Amancio RT, Ribeiro C, Mesquita EC, Medeiros DM, Cerbino J, Grinsztejn B, Bozza FA, Japiassu AM. Six-month survival of critically ill patients with HIV-related disease and tuberculosis: a retrospective study. BMC Infect Dis 2016; 16:270. [PMID: 27286652 PMCID: PMC4902956 DOI: 10.1186/s12879-016-1644-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 06/08/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Tuberculosis is one of the leading causes of death from infectious diseases worldwide, mainly after the human immunodeficiency virus (HIV) epidemics. Patient with HIV-related illness are more likely to present with severe TB due to immunosuppression. Very few studies have explored HIV/TB co-infection in critically ill patients. The goal of this study was to analyze factors associated with long-term mortality in critically ill patient with HIV-related disease coinfected with TB. METHODS We conducted a retrospective study in an infectious disease reference center in Brazil that included all patient with HIV-related illness admitted to the ICU with laboratory-confirmed tuberculosis from March 2007 until June 2012. Clinical and laboratory variables were analyzed based on six-month survival. RESULTS Forty-four patients with HIV-related illness with a confirmed diagnosis of tuberculosis were analyzed. The six-month mortality was 52 % (23 patients). The main causes of admission were respiratory failure (41 %), severe sepsis/septic shock (32 %) and coma/torpor (14 %). The median time between HIV diagnosis and ICU admission was 5 (1-60) months, and 41 % of patients received their HIV infection diagnosis ≤ 30 days before admission. The median CD4 count was 72 (IQR: 23-136) cells/mm(3). The clinical presentation was pulmonary tuberculosis in 22 patients (50 %) and disseminated TB in 20 patients (45.5 %). No aspect of TB diagnosis or treatment was different between survivors and nonsurvivors. Neurological dysfunction was more prevalent among nonsurvivors (43 % vs. 14 %, p = 0.04). The nadir CD4 cell count lower than 50 cells/mm(3) was independently associated with Six-month mortality (hazard ratio 4.58 [1.64-12.74], p < 0.01), while HIV diagnosis less than three months after positive serology was protective (hazard ratio 0.27, CI 95 % [0.10-0.72], p = 0.01). CONCLUSION The Six-month mortality of HIV critically ill patients with TB coinfection is high and strongly associated with the nadir CD4 cell count less than 50 cels/mm(3).
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Affiliation(s)
- Ana Carla Pecego
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Rodrigo T Amancio
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Camila Ribeiro
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Emersom C Mesquita
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Denise M Medeiros
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - José Cerbino
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Beatriz Grinsztejn
- STD/AIDS Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil
| | - Fernando A Bozza
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil.,Instituto D'Or de Pesquisa e Ensino, Rua Diniz Cordeiro, n° 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil
| | - Andre M Japiassu
- Intensive Care Clinical Research Laboratory, National Institute of Infectious Diseases (NIID), Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, 21045-900, Brazil.
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Balkema CA, Irusen EM, Taljaard JJ, Zeier MD, Koegelenberg CF. A prospective study on the outcome of human immunodeficiency virus-infected patients requiring mechanical ventilation in a high-burden setting. QJM 2016; 109:35-40. [PMID: 25979269 DOI: 10.1093/qjmed/hcv086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is a paucity of data on the mortality of patients admitted to the intensive care unit (ICU), despite the fact that human immunodeficiency virus (HIV)-related diseases represent a significant burden to health care resources particularly in sub-Saharan Africa. AIM To describe the outcome and prognostic factors of HIV-infected patients requiring mechanical ventilation in an ICU. DESIGN Prospective observational study. METHODS All 54 patients (34.8 ± 10.4 years, 38 females) admitted with confirmed HIV from October 2012 until May 2013 were enrolled. Disease severity was graded according to APACHEII score. Admission diagnoses, clinical features and laboratory investigations, complications and outcomes were recorded. RESULTS The mean length of ICU stay was 11.0 days (range: 1-49 days), and 33 patients survived (ICU mortality: 38.9%). The in-hospital mortality at 30 days was 48.1%. ICU mortality was associated with an AIDS-defining diagnosis (OR = 7.97, P = 0.003). Non-survivors had higher APACHEII scores (25.8 vs. 18.6, P = 0.001) and lower mean admission CD4 counts (102.5 vs. 225.2, P = 0.014). Multiple logistical regression analysis confirmed the independent predictive value of WHO stage 4 disease (P = 0.008), lower mean CD4 count on admission (P = 0.057) and higher APACHEII score (P = 0.010) on ICU mortality, and WHO stage 4 (P = 0.007) and higher APACHE II score (P = 0.003) on 30-day mortality. CONCLUSIONS The ICU mortality of mechanically ventilated HIV-positive patients was high. WHO stage 4 disease and a higher APACHEII score were predictive of both ICU and 30-day mortality, whereas a low CD4 count on admission was associated with ICU mortality.
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Affiliation(s)
| | | | - J J Taljaard
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Western Cape Province, Cape Town, South Africa
| | - M D Zeier
- Division of Infectious Diseases, Department of Medicine, Stellenbosch University & Tygerberg Academic Hospital, Western Cape Province, Cape Town, South Africa
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Oh SY, Cho S, Lee H, Chang EJ, Min SH, Ryu HG. Sepsis in Patients Receiving Immunosuppressive Drugs in Korea: Analysis of the National Insurance Database from 2009 to 2013. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.4.249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Characteristics and Outcomes of HIV-Infected Patients With Severe Sepsis: Continued Risk in the Post-Highly Active Antiretroviral Therapy Era. Crit Care Med 2015; 43:1638-45. [PMID: 25853590 DOI: 10.1097/ccm.0000000000001003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Although highly active antiretroviral therapy has led to improved survival in HIV-infected individuals, outcomes for HIV-infected patients with sepsis in the post-highly active antiretroviral therapy era are conflicting. Access to highly active antiretroviral therapy and healthcare disparities continue to affect outcomes. We hypothesized that HIV-infected patients with severe sepsis would have worse outcomes compared with their HIV-uninfected counterparts in a large safety-net hospital where access to healthcare is low and delivery of critical care is delayed. DESIGN Secondary analysis of an ongoing prospective observational study between 2006 and 2010. SETTING Three adult ICUs (medical ICU, surgical ICU, and neurologic ICU) at Grady Memorial Hospital, Atlanta, GA. PATIENTS Adult patients with severe sepsis in the ICU. INTERVENTIONS Baseline patient characteristics and clinical outcomes were collected. HIV-infected and HIV-uninfected patients with sepsis were compared using t tests, chi-square tests, and logistic regression; p values less than 0.05 indicated significance. MEASUREMENTS AND MAIN RESULTS Of 1,095 patients with severe sepsis enrolled, 165 (15%) were positive for HIV, with a median CD4 count of 41 (8-167). Twenty-two percent of HIV-infected patients were on highly active antiretroviral therapy prior to admission, and 80% had a CD4 count less than 200. HIV-infected patients had a greater hospital mortality (50% vs 38%; p < 0.01). HIV infection (odds ratio = 1.78; p = 0.005) was an independent predictor of mortality by multivariate regression modeling after adjusting for age, history of pneumonia, history of hospital-acquired infection, and history of sepsis. CONCLUSIONS HIV-infected patients with severe sepsis continue to suffer worse outcomes compared with HIV-uninfected patients in a large urban safety-net hospital caring for patients with limited access to medical care. Further studies need to be done to investigate the effect of socioeconomic status and mitigate healthcare disparities among critically ill HIV-infected patients.
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Evans EE, Wang XQ, Moore CC. Distance from care predicts in-hospital mortality in HIV-infected patients with severe sepsis from rural and semi-rural Virginia, USA. Int J STD AIDS 2015; 27:370-6. [PMID: 25931237 DOI: 10.1177/0956462415584489] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/02/2015] [Indexed: 11/16/2022]
Abstract
There are few data regarding outcomes from severe sepsis for HIV-infected patients living in rural or semi-rural settings. We aim to describe the characteristics and predictors of mortality in HIV-infected patients admitted with severe sepsis to the University of Virginia located in semi-rural Charlottesville, Virginia, USA. We queried the University of Virginia Clinical Data Repository for cases with ICD-9 codes that included: (1) infection, (2) acute organ dysfunction, and (3) HIV infection. We reviewed each case to confirm the presence of HIV infection and severe sepsis. We recorded socio-demographic, clinical, and laboratory data. We used a generalised linear mixed-effects model to assess pre-specified predictors of mortality. We identified 74 cases of severe sepsis in HIV-infected patients admitted to University of Virginia since 2001. The median (IQR) age was 44 (36-49), 32 (43%) were women, and 56 (76%) were from ethnic minorities. The median (IQR) CD4+ T-cell count was 81 (7-281) cells/µL. In-hospital mortality was 20%. When adjusted for severity of illness and respiratory failure, patients who lived >40 miles away from care or had a CD4+ T cell count <50 cells/µL had > four-fold increased risk of death compared to the rest of the study population (AOR = 4.18, 95% CI: 1.09-16.07, p = 0.037; AOR = 4.33, 95% CI: 1.15-16.29, p = 0.03). In HIV-infected patients from rural and semi-rural Virginia with severe sepsis, mortality was increased in those that lived far from University of Virginia or had a low CD4+ T cell counts. Our data suggest that rural HIV-infected patients may have limited access to care, which predisposes them to critical illness and a high associated mortality.
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Affiliation(s)
- Emily E Evans
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Xin-Qun Wang
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Christopher C Moore
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Tolsma V, Schwebel C, Azoulay E, Darmon M, Souweine B, Vesin A, Goldgran-Toledano D, Lugosi M, Jamali S, Cheval C, Adrie C, Kallel H, Descorps-Declere A, Garrouste-Orgeas M, Bouadma L, Timsit JF. Sepsis severe or septic shock: outcome according to immune status and immunodeficiency profile. Chest 2015; 146:1205-1213. [PMID: 25033349 DOI: 10.1378/chest.13-2618] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES This study evaluated the influence of the immune profile on the outcome at day 28 (D28) of patients admitted to the ICU for septic shock or severe sepsis. METHODS We conducted an observational study using a prospective multicenter database and included all patients admitted to 11 ICUs for severe sepsis or septic shock from January 1997 to August 2011. Seven profiles of immunodeficiency were defined. The prognostic analysis used a competitive risk model (Fine and Gray), in which being alive at ICU or hospital discharge before D28 competed with death. RESULTS Among the 1,981 included patients, 607 (31%) were immunocompromised (including nonneutropenic solid tumor [19.6%], nonneutropenic hematologic malignancies [26.3%], and all-cause neutropenia [28%]). Compared with immunocompetent patients, immunocompromised patients were younger, with less comorbidity, were more often admitted for medical reasons, and presented less often with septic shock. The D28 crude mortality was 31.3% in immunocompromised patients and 28.8% in immunocompetent patients (P = .26). However, after adjustment for other prognostic factors, immunodeficiency was an independent risk factor for death at D28 (subdistribution hazard ratio [sHR], 1.37; 95% CI, 1.12-1.67). The immunodeficiency profiles independently associated with death were AIDS (sHR = 1.9), non-neutropenic solid tumor (sHR = 1.8), nonneutropenic hematologic malignancies (sHR = 1.4), and all-cause neutropenia (sHR = 1.7). CONCLUSIONS Immunodeficiency is common in patients with severe sepsis or septic shock. Despite a similar crude mortality, immunodeficiency was associated with an increased risk of short-term mortality after multivariate analysis. Neutropenia and specific, but not all, profiles of immunodeficiency were independently associated with an increased risk of death.
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Affiliation(s)
- Violaine Tolsma
- From the A. Michallon University Hospital, INSERM U823 and Joseph Fourier University, Grenoble
| | - Carole Schwebel
- From the A. Michallon University Hospital, INSERM U823 and Joseph Fourier University, Grenoble
| | | | | | | | - Aurélien Vesin
- From the A. Michallon University Hospital, INSERM U823 and Joseph Fourier University, Grenoble
| | | | - Maxime Lugosi
- From the A. Michallon University Hospital, INSERM U823 and Joseph Fourier University, Grenoble
| | | | | | | | | | | | - Maïté Garrouste-Orgeas
- Saint-Joseph Hospital Network, Paris; IAME UMR 1137, University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - Lila Bouadma
- AP-HP, Bichat Hospital Medical and Infectious Diseases ICU, F-75018, Paris; IAME UMR 1137, University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - Jean-François Timsit
- From the A. Michallon University Hospital, INSERM U823 and Joseph Fourier University, Grenoble; AP-HP, Bichat Hospital Medical and Infectious Diseases ICU, F-75018, Paris; IAME UMR 1137, University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France.
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Bhagwanjee S, Ugarte S. Sepsis in vulnerable populations. Glob Heart 2014; 9:281-8. [PMID: 25667179 DOI: 10.1016/j.gheart.2014.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/18/2014] [Indexed: 12/29/2022] Open
Abstract
Despite the acquisition of a large body of evidence, there are many unanswered questions about sepsis. The definition of this disease is plagued by the lack of a simple pathophysiological description linking cause to effect and the activation of host immune responses that hinders disease progression at the same time producing multiorgan dysfunction. A plethora of inconsistent clinical features has served to obfuscate rather than illuminate. The Surviving Sepsis Guidelines (SSG) are a major advance because it comprehensively interrogates all aspects of care for the critically ill. For vulnerable populations living in low- and middle-income countries, this guideline is ineffectual because of the lack of region-specific data, differences in etiology of sepsis and burden of disease, limited human capacity and infrastructure, as well as socioeconomic realities. Appropriate care must be guided by common sense guidelines that are sensitive to local realities and adapted as relevant data are acquired.
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Affiliation(s)
- Satish Bhagwanjee
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
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Medrano J, Álvaro-Meca A, Boyer A, Jiménez-Sousa MA, Resino S. Mortality of patients infected with HIV in the intensive care unit (2005 through 2010): significant role of chronic hepatitis C and severe sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:475. [PMID: 25159592 PMCID: PMC4176576 DOI: 10.1186/s13054-014-0475-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/23/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The combination antiretroviral therapy (cART) has led to decreased opportunistic infections and hospital admissions in human immunodeficiency virus (HIV)-infected patients, but the intensive care unit (ICU) admission rate remains constant (or even increased in some instances) during the cART era. Hepatitis C virus (HCV) infection is associated with an increased risk for hospital admission and/or mortality (particularly those related to severe liver disease) compared with the general population. The aim of this study was to assess the mortality among HIV-infected patients in ICU, and to evaluate the impact of HIV/HCV coinfection and severe sepsis on ICU mortality. METHODS We carried out a retrospective study based on patients admitted to ICU who were recorded in the Minimum Basic Data Set (2005 through 2010) in Spain. HIV-infected patients (All-HIV-group (n = 1,891)) were divided into two groups: HIV-monoinfected patients (HIV group (n = 1,191)) and HIV/HCV-coinfected patients (HIV/HCV group (n = 700)). A control group (HIV(-)/HCV(-)) was also included (n = 7,496). RESULTS All-HIV group had higher frequencies of severe sepsis (57.7% versus 39.4%; P < 0.001) than did the control group. Overall, ICU mortality in patients with severe sepsis was much more frequent than that in patients without severe sepsis (other causes) at days 30 and 90 in HIV-infected patients and the control group (P < 0.001). Moreover, the all-HIV group in the presence or absence of severe sepsis had a higher percentage of death than did the control group at days 7 (P < 0.001), 30 (P < 0.001) and 90 (P < 0.001). Besides, the HIV/HCV group had a higher percentage of death, both in patients with severe sepsis and in patients without severe sepsis compared with the HIV group at days 7 (P < 0.001) and 30 (P < 0.001), whereas no differences were found at day 90. In a bayesian competing-risk model, the HIV/HCV group had a higher mortality risk (adjusted hazard ratio (aHR) = 1.44 (95% CI = 1.30 to 1.59) and aHR = 1.57 (95% CI = 1.38 to 1.78) for patients with and without severe sepsis, respectively). CONCLUSIONS HIV infection was related to a higher frequency of severe sepsis and death among patients admitted to the ICU. Besides, HIV/HCV coinfection contributed to an increased risk of death in both the presence and the absence of severe sepsis.
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Moreira J. The burden of sepsis in critically ill human immunodeficiency virus-infected patients--a brief review. Braz J Infect Dis 2014; 19:77-81. [PMID: 25022567 PMCID: PMC9425204 DOI: 10.1016/j.bjid.2014.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/05/2014] [Accepted: 05/19/2014] [Indexed: 02/02/2023] Open
Abstract
Since the advent of highly active antiretroviral therapy in 1996, we have seen dramatic changes in morbi-mortality rates from human immunodeficiency virus-positive patients. If on the one hand, the immunologic preservation-associated with the use of current antiretroviral therapy markedly diminishes the incidence of opportunistic infections, on the other hand it extended life expectancy of human immunodeficiency virus-infected individuals similarly to the general population. However, the management of critically ill human immunodeficiency virus-infected patients remains challenging and troublesome for practicing clinician. Sepsis - a complex systemic inflammatory syndrome in response to infection - is the second leading cause of intensive care unit admission in both human immunodeficiency virus-infected and uninfected populations. Recent data have emerged describing a substantial burden of sepsis in the infected population, in addition, to a much poorer prognosis in this group. Many factors contribute to this outcome, including specific etiologies, patterns of inflammation, underlying immune dysregulation related to chronic human immunodeficiency virus infection and delays in prompt diagnosis and treatment. This brief review explores the impact of sepsis in the context of human immunodeficiency virus infection, and proposes future directions for better management and prevention of human immunodeficiency virus-associated sepsis.
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Affiliation(s)
- José Moreira
- Instituto Nacional de Infectologia Evandro Chagas, Hospital Evandro Chagas, Rio de Janeiro, RJ, Brazil.
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Luz PM, Bruyand M, Ribeiro S, Bonnet F, Moreira RI, Hessamfar M, Campos DP, Greib C, Cazanave C, Veloso VG, Dabis F, Grinsztejn B, Chêne G. AIDS and non-AIDS severe morbidity associated with hospitalizations among HIV-infected patients in two regions with universal access to care and antiretroviral therapy, France and Brazil, 2000-2008: hospital-based cohort studies. BMC Infect Dis 2014; 14:278. [PMID: 24885790 PMCID: PMC4032588 DOI: 10.1186/1471-2334-14-278] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 05/06/2014] [Indexed: 11/26/2022] Open
Abstract
Background In high-income settings, the spectrum of morbidity and mortality experienced by Human Immunodeficiency Virus (HIV)-infected individuals receiving combination antiretroviral therapy (cART) has switched from predominantly AIDS-related to non-AIDS-related conditions. In the context of universal access to care, we evaluated whether that shift would apply in Brazil, a middle-income country with universal access to treatment, as compared to France. Methods Two hospital-based cohorts of HIV-infected individuals were used for this analysis: the ANRS CO3 Aquitaine Cohort in South Western France and the Evandro Chagas Research Institute (IPEC) Cohort of the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. Severe morbid events (AIDS- and non-AIDS-related) were defined as all clinical diagnoses associated with a hospitalization of ≥48 hours. Trends in the incidence rate of events and their determinants were estimated while adjusting for within-subject correlation using generalized estimating equations models with an auto-regressive correlation structure and robust standard errors. Result Between January 2000 and December 2008, 7812 adult patients were followed for a total of 41,668 person-years (PY) of follow-up. Throughout the study period, 90% of the patients were treated with cART. The annual incidence rate of AIDS and non-AIDS events, and of deaths significantly decreased over the years, from 6.2, 21.1, and 1.9 AIDS, non-AIDS events, and deaths per 100 PY in 2000 to 4.3, 14.9, and 1.5/100 PY in 2008. The annual incidence rates of non-AIDS events surpassed that of AIDS-events during the entire study period. High CD4 cell counts were associated with a lower incidence rate of AIDS and non-AIDS events as well as with lower rates of specific non-AIDS events, such as bacterial, hepatic, viral, neurological, and cardiovascular conditions. Adjusted analysis showed that severe morbidity was associated with lower CD4 counts and higher plasma HIV RNAs but not with setting (IPEC versus Aquitaine). Conclusions As information on severe morbidities for HIV-infected patients remain scarce, data on hospitalizations are valuable to identify priorities for case management and to improve the quality of life of patients with a chronic disease requiring life-long treatment. Immune restoration is highly effective in reducing AIDS and non-AIDS severe morbid events irrespective of the setting.
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Affiliation(s)
- Paula Mendes Luz
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040, Rio de Janeiro, Brasil.
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Ribeiro SR, Luz PM, Campos DP, Moreira RI, Coelho L, Japiassu A, Bozza F, Veloso VG, Chene G, Grinsztejn B. Incidence and determinants of severe morbidity among HIV-infected patients from Rio de Janeiro, Brazil, 2000-2010. Antivir Ther 2014; 19:387-97. [PMID: 24445387 DOI: 10.3851/imp2716] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Reliable information on severe morbidity is essential for identifying priorities for case management and to guide resource allocation within the health sector. METHODS This study describes overall, AIDS- and non-AIDS-related severe morbidity as well as mortality and its determinants in an urban cohort of HIV-infected individuals from a public healthcare institution, the Evandro Chagas Research Institute (IPEC) of the Oswaldo Cruz Foundation, Rio de Janeiro, Brazil. Severe morbid events were defined as all clinical diagnoses listed in hospitalization discharge records; all diagnoses were checked and validated. Generalized estimating equation models were used to estimate incidence rates while adjusting for within-subject correlation. RESULTS Between 2000 and 2010, 3,537 patients were followed for a total of 16,960 person-years (PY) of follow-up. Over the years, annual incidence rate of severe morbid events, AIDS-related events, non-AIDS-related events, and deaths significantly decreased from, respectively, 36.6, 12.9, 23.7 and 3.2 per 100 PY in 2000 to 25.3, 7.9, 17.4 and 1.9 per 100 PY in 2010. Patients' immunological profiles significantly improved with time; 84% of the patients used combination antiretroviral therapy (cART) per year. Immunodeficiency was associated with a higher incidence rate of AIDS- and non-AIDS-related events as well as with the incidence rate of specific non-AIDS events (bacterial infections, toxicities, cardiovascular, renal and respiratory diseases). CONCLUSIONS Our results show that in a middle income country with access to cART, non-AIDS-related events represent an important cause of severe morbidity alongside a still high incidence rate of AIDS-related events.
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Affiliation(s)
- Sayonara R Ribeiro
- Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Abstract
Severe sepsis is a leading cause of death in the United States and the most common cause of death among critically ill patients in non-coronary intensive care units (ICU). Respiratory tract infections, particularly pneumonia, are the most common site of infection, and associated with the highest mortality. The type of organism causing severe sepsis is an important determinant of outcome, and gram-positive organisms as a cause of sepsis have increased in frequency over time and are now more common than gram-negative infections.
Recent studies suggest that acute infections worsen pre-existing chronic diseases or result in new chronic diseases, leading to poor long-term outcomes in acute illness survivors. People of older age, male gender, black race, and preexisting chronic health conditions are particularly prone to develop severe sepsis; hence prevention strategies should be targeted at these vulnerable populations in future studies.
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Affiliation(s)
- Florian B Mayr
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; University of Pittsburgh; Pittsburgh, PA USA; Department of Critical Care Medicine; University of Pittsburgh, Pittsburgh, PA USA; Department of Medicine; University of Pittsburgh; Pittsburgh, PA USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; University of Pittsburgh; Pittsburgh, PA USA; Department of Critical Care Medicine; University of Pittsburgh, Pittsburgh, PA USA
| | - Derek C Angus
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; University of Pittsburgh; Pittsburgh, PA USA; Department of Critical Care Medicine; University of Pittsburgh, Pittsburgh, PA USA
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Cobos-Trigueros N, Rinaudo M, Solé M, Castro P, Pumarol J, Hernández C, Fernández S, Nicolás JM, Mallolas J, Vila J, Morata L, Gatell JM, Soriano A, Mensa J, Martínez JA. Acquisition of resistant microorganisms and infections in HIV-infected patients admitted to the ICU. Eur J Clin Microbiol Infect Dis 2013; 33:611-20. [DOI: 10.1007/s10096-013-1995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 10/07/2013] [Indexed: 11/29/2022]
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Huson MAM, Stolp SM, van der Poll T, Grobusch MP. Community-acquired bacterial bloodstream infections in HIV-infected patients: a systematic review. Clin Infect Dis 2013; 58:79-92. [PMID: 24046307 DOI: 10.1093/cid/cit596] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Information on community-acquired bacterial bloodstream infections (BSIs) in individuals infected with human immunodeficiency virus (HIV) is limited. We conducted a systematic literature review. The case fraction of community-acquired bacterial BSIs in hospitalized patients is 20% and 30% in adults and children, respectively, compared to 9% in HIV-negative adults and children. Worldwide, the main pathogens of community-acquired BSI are nontyphoid salmonellae (NTS), Streptococcus pneumoniae, Escherichia coli, and Staphylococcus aureus, but regional differences are apparent, especially for S. pneumoniae. Compared to HIV-negative populations, HIV patients are particularly at risk to develop NTS bacteremia. Bacteremia incidence is related to immunosuppression, and antiretroviral therapy reduces the incidence of BSI in HIV patients (rate ratios, 0.63-0.02). Mortality rates varied between 7% and 46%. These results suggest that bacterial BSI is more likely to be found in HIV-positive than in HIV-negative patients upon hospitalization, and that causative pathogens vary by region.
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Affiliation(s)
- Michaëla A M Huson
- Division of Infectious Diseases, Center of Experimental and Molecular Medicine, Center of Infection and Immunity and Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
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Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit. Interdiscip Perspect Infect Dis 2013; 2013:732421. [PMID: 24065988 PMCID: PMC3771454 DOI: 10.1155/2013/732421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 07/25/2013] [Indexed: 12/15/2022] Open
Abstract
Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/ μ L (mean 205.7, range 2.0-694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20-367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU.
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