Predicting high risk of exacerbations in bronchiectasis: the E-FACED score

Background

Although the FACED score has demonstrated a great prognostic capacity in bronchiectasis, it does not include the number or severity of exacerbations as a separate variable, which is important in the natural history of these patients.

Objective

Construction and external validation of a new index, the E-FACED, to evaluate the predictive capacity of exacerbations and mortality.

Methods

The new score was constructed on the basis of the complete cohort for the construction of the original FACED score, while the external validation was undertaken with six cohorts from three countries (Brazil, Argentina, and Chile). The main outcome was the number of annual exacerbations/hospitalizations, with all-cause and respiratory-related deaths as the secondary outcomes. A statistical evaluation comprised the relative weight and ideal cut-off point for the number or severity of the exacerbations and was incorporated into the FACED score (E-FACED). The results obtained after the application of FACED and E-FACED were compared in both the cohorts.

Results

A total of 1,470 patients with bronchiectasis (819 from the construction cohorts and 651 from the external validation cohorts) were followed up for 5 years after diagnosis. The best cut-off point was at least two exacerbations in the previous year (two additional points), meaning that the E-FACED has nine points of growing severity. E-FACED presented an excellent prognostic capacity for exacerbations (areas under the receiver operating characteristic curve: 0.82 for at least two exacerbations in 1 year and 0.87 for at least one hospitalization in 1 year) that was statistically better than that of the FACED score (0.72 and 0.78, P<0.05, respectively). The predictive capacities for all-cause and respiratory mortality were 0.87 and 0.86, respectively, with both being similar to those of the FACED.

Conclusion

E-FACED score significantly increases the FACED capacity to predict future yearly exacerbations while maintaining the score’s simplicity and prognostic capacity for death.

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study

OBJECTIVE

To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza A (H1N1) viral pneumonia requiring mechanical ventilation.

DESIGN

Observational cohort study.

PATIENTS AND METHODS

AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day 2 or before, or after ICU day 2, respectively. Demographic data and information on organ dysfunction were collected daily.

RESULTS

Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and ICU mortality (72% versus 39%, p < 0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p < 0.001). On multivariate analysis, only APACHE II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0-1.1) and 15.1 (1.8-130.7), respectively] were associated with mortality.

CONCLUSIONS

AKI is a frequent complication of 2009 influenza A (H1N1) viral pneumonia. AKI developing after 2 days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.

Prescription of antibiotics in intensive care units in Latin America: an observational study

A one-day point prevalence study to investigate the patterns of antibiotic use was undertaken in 43 latin American (LA) intensive care units. Of 510 patients admitted, 231 received antibiotic treatment on the day of the study (45%); in 125 cases (54%) due to nosocomial-acquired infections. The most frequent infection reported was nosocomial pneumonia (43%). Only in 122 patients (53%) were cultures performed before starting antibiotic treatment. 33% of the isolated microorganisms were enterobacteriaceae (40% extended-spectrum beta-lactamase-producing), 23% methicillin-resistant Staphylococcus aureus and 17% carbapenems-resistant non-fermentative Gram-negatives. The antibiotics most frequently prescribed were carbapenems (99/231, 43%); alone (60/99, 60%) or in combination with vancomycin (39/99, 40%). "Restricted" antibiotics (carbapenems, vancomycin, piperacillin-tazobactam, broad-spectrum cephalosporins, tigecycline, polymixins and linezolid) were most frequently indicated in severely ill patients (APACHE II score at admission >15, p=0.0007 and, SOFA score at the beginning of the antibiotic treatment >3, p=0.0000). Only 36% of antibiotic treatments were cultured-directed.Our findings help explain the high rates of multidrug-resistant pathogens in LA settings (i.e. ESBL-producing Gram-negatives) and the severity of the registered patients illnesses.

Bronchial bacterial colonization in patients with resectable lung carcinoma

The pattern and clinical implications of bronchial bacterial colonization have been widely investigated in patients with chronic lung disease, particularly chronic obstructive pulmonary disease. The main aim of this study was to determine the frequency and risk factors for bronchial colonization in lung cancer patients who have undergone surgical resection. Forty-one patients with resectable lung cancer (22 (54%) active smokers, 52+/-23 pack-yrs) with a mean forced expiratory volume in one second of 80+/-16% predicted, were studied with bilateral protected specimen brush and lung tissue biopsy during the surgical procedure. Quantitative bacterial culture, susceptibility tests and histological examination of samples were performed. Bronchial colonization with > or = 1 potential pathogenic micro-organism was found in 17 of 41 (41%) patients. The most frequent strains isolated were: Haemophilus influenzae (35%), Streptococcus pneumoniae (13%) and Pseudomonas spp. (9%). The risk factors for bronchial colonization were central location of the tumour (odds ratio (OR)=9.2, confidence interval (CI) 95%=2.1-39.6, p=1.003) and increased body mass index (OR=1.6, CI 95%=1.2-2.2, p=0.005). The frequency of postoperative infectious pulmonary complications was low (five cases (12%)) and no relationship was observed with bronchial colonization. Patients with resectable lung carcinoma had a high rate of bronchial colonization (41%), mainly with potential pathogenic microorganisms. The independent risk factors for colonization in these patients were central location of the tumour and a high body mass index.

Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications

The aim of the study was to determine the causes and prognostic implications of antimicrobial treatment failures in patients with nonresponding and progressive life-threatening, community-acquired pneumonia. Forty-nine patients hospitalized with a presumptive diagnosis of community-acquired pneumonia during a 16-mo period, failure to respond to antimicrobial treatment, and documented repeated microbial investigation >/= 72 h after initiation of in-hospital antimicrobial treatment were recorded. A definite etiology of treatment failure could be established in 32 of 49 (65%) patients, and nine additional patients (18%) had a probable etiology. Treatment failures were mainly infectious in origin and included primary, persistent, and nosocomial infections (n = 10 [19%], 13 [24%], and 11 [20%] of causes, respectively). Definite but not probable persistent infections were mostly due to microbial resistance to the administered initial empiric antimicrobial treatment. Nosocomial infections were particularly frequent in patients with progressive pneumonia. Definite persistent infections and nosocomial infections had the highest associated mortality rates (75 and 88%, respectively). Nosocomial pneumonia was the only cause of treatment failure independently associated with death in multivariate analysis (RR, 16.7; 95% CI, 1.4 to 194.9; p = 0.03). We conclude that the detection of microbial resistance and the diagnosis of nosocomial pneumonia are the two major challenges in hospitalized patients with community-acquired pneumonia who do not respond to initial antimicrobial treatment. In order to establish these potentially life-threatening etiologies, a regular microbial reinvestigation seems mandatory for all patients presenting with antimicrobial treatment failures.

Capnometric recirculation gas tonometry and weaning from mechanical ventilation

The aim of this study was to describe changes in regional intramucosal PCO(2) (Pr(CO(2)) measured with capnometric recirculation gas tonometry [CRGT]) in patients with acute respiratory failure, who proceed from mechanical ventilation to weaning. In addition, we compared the predictive power for the weaning outcome of CRGT measurements obtained during mechanical ventilation to the frequency/ tidal volume (f/VT) ratio. A total of 24 patients (31 weaning trials) were included in the study, but four of the 24 patients (17%) were excluded because of extubation failure. Of the remaining 27 weaning trials in 20 patients, 12 (44%) were unsuccessful. Changes observed in patients with weaning failure (increase in Pr(CO(2)) from 60.4 +/- 15.0 mm Hg in mechanical ventilation to 67.4 +/- 21.0 mm Hg, in weaning) were significantly different (p = 0.046) from those observed in patients with weaning success (fall in Pr(CO(2)) from 61.5 +/- 15.0 mm Hg in mechanical ventilation to 56.3 +/- 16.7 mm Hg in weaning). However, absolute values of Pr(CO(2)) were not significantly different between patients with weaning success and failure, neither during mechanical ventilation (success, 61.5 +/- 15.0 versus failure, 60.4 +/- 15.0 mm Hg, p = 0.848) nor during weaning (success, 56.3 +/- 16.7 versus failure, 67.4 +/- 21.0 mm Hg, p = 0.135). The best single predictor for weaning outcome was the f/VT ratio measured early during weaning (area under the curve: 0.844 +/- 0.081; adjusted odds ratio for threshold value </= 105: 42.0, 95% CI 3.8 to 469.1, p = 0.002). CRGT could confirm a significant increase in Pr(CO(2)) during weaning in patients who finally failed the weaning trial. However, differences between patients with weaning success and failure were small and CRGT did not replace or improve the predictive power of the f/VT ratio for weaning outcome.

Severe community-acquired pneumonia. Risk factors and follow-up epidemiology

The aim of the study was to determine risk factors for severe community-acquired pneumonia (CAP) as well as to compare microbial patterns of severe CAP to a previous study from our respiratory intensive care unit (ICU) originating from 1984 to 1987. Patients admitted to the ICU according to clinical judgment were defined as having severe CAP. For the study of risk factors, a hospital-based case-control design was used, matching each patient with severe CAP to a patient hospitalized with CAP but not requiring ICU admission. Microbial investigation included noninvasive and invasive techniques. Overall, 89 patients with severe CAP were successfully matched to a control patient. The presence of an alcohol ingestion of >/= 80 g/d (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.4 to 10.6, p = 0.008) was found to be an independent risk factor for severe CAP and prior ambulatory antimicrobial treatment (OR 0.37, 95% CI 0.17 to 0.79, p = 0.009) to be protective. Streptococcus pneumoniae (24%) continued to be the most frequent pathogen; however, 48% of strains were drug-resistant. "Atypical" bacterial pathogens were significantly more common (17% versus 6%, p = 0.006) and Legionella spp. less common (2% versus 14%, p = 0.004) than in our previous study, whereas gram-negative enteric bacilli (GNEB) and Pseudomonas aeruginosa continued to represent important pathogens (6% and 5%, respectively). Our findings provide additional evidence for the importance of the initiation of early empiric antimicrobial treatment for a favorable outcome of CAP. Variations of microbial patterns are only in part due to different epidemiological settings. Therefore, initial empiric antimicrobial treatment will also have to take into account local trends of changing microbial patterns.

Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity

The aim of this study was to determine the etiology of community-acquired pneumonia (CAP) and the impact of age, comorbidity, and severity on microbial etiologies of such pneumonia. Overall, 395 consecutive patients with CAP were studied prospectively during a 15-mo period. Regular microbial investigation included examination of sputum, blood culture, and serology. Sampling of pleural fluid, transthoracic puncture, tracheobronchial aspiration, and protected specimen brush (PSB) sampling were performed in selected patients. The microbial etiology was determined in 182 of 395 (46%) cases, and 227 pathogens were detected. The five most frequent pathogens were Streptococcus pneumoniae (65 patients [29%]), Haemophilus influenzae (25 patients [11%]), Influenza virus A and B (23 patients [10%]), Legionella sp. (17 patients [8%]), and Chlamydia pneumoniae (15 patients [7%]). Gram-negative enteric bacilli (GNEB) accounted for 13 cases (6%) and Pseudomonas aeruginosa for 12 cases of pneumonia (5%). Patients aged < 60 yr were at risk for an "atypical" bacterial etiology (odds ratio [OR]: 2.3; 95% confidence interval [CI]: 1.2 to 4.5), especially Mycoplasma pneumoniae (OR: 5.3; 95% CI: 1.7 to 16.8). Comorbid pulmonary, hepatic, and central nervous illnesses, as well as current cigarette smoking and alcohol abuse, were all associated with distinct etiologic patterns. Pneumonia requiring admission to the intensive care unit was independently associated with the pathogens S. pneumoniae (OR: 2.5; 95% CI: 1.3 to 4.7), gram-negative enteric bacilli, and P. aeruginosa (OR: 2.5; 95% CI: 0.99 to 6.5). Clinical and radiographic features of "typical" pneumonia were neither sensitive nor specific for the differentiation of pneumococcal and nonpneumococcal etiologies. These results support a management approach based on the associations between etiology and age, comorbidity, and severity, instead of the traditional syndromic approach to CAP.

Severe community-acquired pneumonia. Assessment of severity criteria

The purpose of the study was to validate the criteria used in the guidelines of the American Thoracic Society (ATS) for severe community-acquired pneumonia (CAP). Severe pneumonia was defined as admission to the intensive care unit (ICU). Overall 331 nonsevere (84%) and 64 severe cases (16%) of CAP were prospectively studied. Mortality was 19 of 395 (5%) and 19 of 64 (30%), respectively. Single severity criteria as well as the ATS definition of severe pneumonia were assessed calculating the operative indices. A modified prediction rule including minor (baseline) and major (baseline or evolutionary) criteria was derived. Single minor criteria at admission had a low sensitivity and positive predictive value. Defining severe pneumonia according to the ATS guidelines had a high sensitivity (98%). However, specificity and positive predictive value were low (32% and 24%, respectively). A modified prediction rule (presence of two or three minor criteria [systolic blood pressure < 90 mm Hg, multilobar involvement, PaO2/FIO2 < 250] or one of two major criteria [requirement of mechanical ventilation, presence of septic shock]) had a sensitivity of 78%, a specificity of 94%, a positive predictive value of 75%, and a negative predictive value of 95%. The ATS definition of severe pneumonia was highly sensitive but insufficiently specific and had a low positive predictive value. Our suggested modified rule had a more balanced performance and, if validated in an independent population, may represent a more accurate definition of severe CAP.

[Congenital hepatic fibrosis: an uncommon cause of portal hypertension]

Congenital hepatic fibrosis is an autosomic recessive disease, manifested in children or in young adults by hematemesis due to rupture of esophageal varices. Bacterial cholangitis may occur in some patients. Early diagnosis and treatment with portosystemic anastomosis and/or antibiotics may lead to a long survival with a good quality of life. Diagnosis requires histologic confirmation: normal hepatic lobules are surrounded by broad fibrous bands, and an increased number of bile ducts is usually seen in the portal tracts. Liver function remains well preserved. This report consists of 3 patients: a 17-year-old woman, a 10-year-old boy and a 24-year-old woman who developed severe upper GI bleeding due to ruptured esophageal varices. The first two patients were successfully operated on using the Sugiura technique for portal decompression. Their current survival after surgery is 3 and 9 years, respectively, with normal physical examination and liver function tests. The third patient died shortly after admission, due to the concurrence of a severe suppurative cholangitis.