RESUMO
OBJECTIVE: To evaluate the impact of obesity on ICU mortality. DESIGN: Observational, retrospective, multicentre study. SETTING: Intensive Care Unit (ICU). PATIENTS: Adults patients admitted with COVID-19 and respiratory failure. INTERVENTIONS: None. PRIMARY VARIABLES OF INTEREST: Collected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. Body mass index (BMI) impact on ICU mortality was studied as (1) a continuous variable, (2) a categorical variable obesity/non-obesity, and (3) as categories defined a priori: underweight, normal, overweight, obesity and Class III obesity. The impact of obesity on mortality was assessed by multiple logistic regression and Smooth Restricted cubic (SRC) splines for Cox hazard regression. RESULTS: 5,206 patients were included, 20 patients (0.4%) as underweight, 887(17.0%) as normal, 2390(46%) as overweight, 1672(32.1) as obese and 237(4.5%) as class III obesity. The obesity group patients (nâ¯=â¯1909) were younger (61 vs. 65 years, pâ¯<â¯0.001) and with lower severity scores APACHE II (13 [9-17] vs. 13[10-17, pâ¯<â¯0.01) than non-obese. Overall ICU mortality was 28.5% and not different for obese (28.9%) or non-obese (28.3%, pâ¯=â¯0.65). Only Class III obesity (ORâ¯=â¯2.19, 95%CI 1.44-3.34) was associated with ICU mortality in the multivariate and SRC analysis. CONCLUSIONS: COVID-19 patients with a BMIâ¯>â¯40 are at high risk of poor outcomes in the ICU. An effective vaccination schedule and prolonged social distancing should be recommended.
Assuntos
COVID-19, Sobrepeso, Adulto, Humanos, Sobrepeso/complicações, Sobrepeso/epidemiologia, Estado Terminal, Estudos Retrospectivos, Magreza/complicações, COVID-19/complicações, Obesidade/complicações, Obesidade/epidemiologiaRESUMO
BACKGROUND: Coronavirus disease (COVID-19) is the pandemic caused by SARS-CoV-2 that has caused more than 2.2 million deaths worldwide. We summarize the reported pathologic findings on biopsy and autopsy in patients with severe/fatal COVID-19 and documented the presence and/or effect of SARS-CoV-2 in all organs. METHODS AND FINDINGS: A systematic search of the PubMed, Embase, MedRxiv, Lilacs and Epistemonikos databases from January to August 2020 for all case reports and case series that reported histopathologic findings of COVID-19 infection at autopsy or tissue biopsy was performed. 603 COVID-19 cases from 75 of 451 screened studies met inclusion criteria. The most common pathologic findings were lungs: diffuse alveolar damage (DAD) (92%) and superimposed acute bronchopneumonia (27%); liver: hepatitis (21%), heart: myocarditis (11.4%). Vasculitis was common only in skin biopsies (25%). Microthrombi were described in the placenta (57.9%), lung (38%), kidney (20%), Central Nervous System (CNS) (18%), and gastrointestinal (GI) tract (2%). Injury of endothelial cells was common in the lung (18%) and heart (4%). Hemodynamic changes such as necrosis due to hypoxia/hypoperfusion, edema and congestion were common in kidney (53%), liver (48%), CNS (31%) and GI tract (18%). SARS-CoV-2 viral particles were demonstrated within organ-specific cells in the trachea, lung, liver, large intestine, kidney, CNS either by electron microscopy, immunofluorescence, or immunohistochemistry. Additional tissues were positive by Polymerase Chain Reaction (PCR) tests only. The included studies were from numerous countries, some were not peer reviewed, and some studies were performed by subspecialists, resulting in variable and inconsistent reporting or over statement of the reported findings. CONCLUSIONS: The main pathologic findings of severe/fatal COVID-19 infection are DAD, changes related to coagulopathy and/or hemodynamic compromise. In addition, according to the observed organ damage myocarditis may be associated with sequelae.
Assuntos
COVID-19/metabolismo, COVID-19/fisiopatologia, Autopsia/métodos, Biópsia/métodos, Sistema Nervoso Central/virologia, Células Endoteliais/virologia, Feminino, Trato Gastrointestinal/virologia, Coração/virologia, Humanos, Rim/virologia, Fígado/virologia, Pulmão/virologia, Pandemias/estatística & dados numéricos, Placenta/virologia, Gravidez, SARS-CoV-2/patogenicidade, Coloração e Rotulagem/métodos, Traqueia/virologiaRESUMO
OBJECTIVES: Antibiotic treatment is vital in patients with severe sepsis/septic shock. The objectives were to assess the degree of concordance between antibiotic prescribed in emergencies and post requirements; to relate it to health outcomes (mortality) and to analyze the reasons for disagreement. MATERIAL AND METHODS: Retrospective descriptive study of antibiotic treatment prescribed in emergencies and the subsequent treatment in patients with criteria of severe sepsis/septic shock in 2013. We collected patient demographic characteristics, infectious focus, antibiotic prescribed from emergencies and subsequent changes. It was considered concordant if there were no changes, if there were changes, but the initial antibiotic was right and suspensions for end of treatment. Mortality and evolution were analyzed. RESULTS: Six hundred patients were included. A 60% experienced changes respect to the antibiotic treatment initiated in emergencies (87.6% justified), with a degree of overall antibiotic concordance of 47.5% The mortality rate at end-point was 9.83%, with no statistically significant relationship with the degree of concordance (OR=0.864 (0.503-1.484)/χ2=0.28; p=0.597). Reasons for change of antibiotic: clinical outcome (17.96%), change of spectrum (35.03%), de-escalation (41.32%), sequential therapy (8.68%). An 11% required ICU admission. Clinical outcomes: resolution of the disease (79.2%), readmission after 30 days (7.7%) and transfer to health centers (4.5%). The median hospital stay was 7 days. CONCLUSIONS: The degree of concordance antibiotic was quite high, and the mortality rate was lower than that described in the literature, without relating to the discordance. The presence of concordance was associated with fewer readmissions and ICU admissions. The main reasons for disagreement were inadequate spectrum selection and change after microbiological crops.
Assuntos
Antibacterianos/uso terapêutico, Emergências, Sepse/tratamento farmacológico, Adolescente, Adulto, Idoso, Idoso de 80 Anos ou mais, Prescrições de Medicamentos/estatística & dados numéricos, Substituição de Medicamentos, Feminino, Humanos, Tempo de Internação/estatística & dados numéricos, Masculino, Pessoa de Meia-Idade, Readmissão do Paciente/estatística & dados numéricos, Estudos Retrospectivos, Sepse/mortalidade, Espanha/epidemiologia, Análise de Sobrevida, Resultado do Tratamento, Adulto JovemRESUMO
Objetivos. El tratamiento antibiótico resulta de vital importancia en pacientes con sepsis grave/shock séptico. Los objetivos fueron evaluar el grado de concordancia entre la prescripción de antibióticos realizada en urgencias y prescripciones posteriores; relacionarlo con resultados en salud (mortalidad) y analizar los motivos de discordancia. Material y métodos. Estudio descriptivo retrospectivo del tratamiento antibiótico prescrito desde urgencias y el prescrito posteriormente en pacientes con criterios de sepsis grave/shock séptico en el año 2013. Se recogieron características demográficas, foco infeccioso, antibiótico prescrito desde urgencias y los cambios posteriores, considerándose concordante cuando no había cambio, si había cambio pero el antibiótico inicial era correcto y suspensiones por fin de tratamiento. Se analizó mortalidad y evolución del cuadro. Resultados. Se incluyeron 600 pacientes. El 60% sufrió cambio de tratamiento antibiótico respecto al iniciado en urgencias (87,6% justificados), con un grado de concordancia antibiótica global del 47,5%. La tasa de mortalidad al final del estudio fue 9,83%, no encontrándose relación estadísticamente significativa con el grado de concordancia (OR=0,864 (0,503-1,484)/X2=0,28, p=0,597). Motivos de cambio de antibiótico: evolución clínica (17,96%), cambio de espectro (35,03%), desescalada (41,32%), terapia secuencial (8,68%). El 11% requirió ingreso en Unidad de Cuidados Intensivos (UCI). Evoluciones clínicas: resolución del cuadro (79,2%), reingreso antes de 30 días (7,7%) y traslado a centros sociosanitarios (4,5%). La mediana de estancia hospitalaria fue 7 días. Conclusiones. El grado de concordancia antibiótica resultó bastante alto y la tasa de mortalidad inferior a la descrita en la literatura, sin relacionarse con la discordancia. La presencia de concordancia se asoció a menos reingresos e ingresos en UCI. Los principales motivos de discordancia fueron selección del espectro inadecuado y el cambio tras cultivos microbiológicos (AU)
Objectives. Antibiotic treatment is vital in patients with severe sepsis/septic shock. The objectives were to assess the degree of concordance between antibiotic prescribed in emergencies and post requirements; to relate it to health outcomes (mortality) and to analyze the reasons for disagreement. Material and methods. Retrospective descriptive study of antibiotic treatment prescribed in emergencies and the subsequent treatment in patients with criteria of severe sepsis/septic shock in 2013. We collected patient demographic characteristics, infectious focus, antibiotic prescribed from emergencies and subsequent changes. It was considered concordant if there were no changes, if there were changes, but the initial antibiotic was right and suspensions for end of treatment. Mortality and evolution were analyzed. Results. Six hundred patients were included. A 60% experienced changes respect to the antibiotic treatment initiated in emergencies (87.6% justified), with a degree of overall antibiotic concordance of 47.5% The mortality rate at endpoint was 9.83%, with no statistically significant relationship with the degree of concordance (OR=0.864 (0.503-1.484)/χ2=0.28; p=0.597). Reasons for change of antibiotic: clinical outcome (17.96%), change of spectrum (35.03%), de-escalation (41.32%), sequential therapy (8.68%). An 11% required ICU admission. Clinical outcomes: resolution of the disease (79.2%), readmission after 30 days (7.7%) and transfer to health centers (4.5%). The median hospital stay was 7 days. Conclusions. The degree of concordance antibiotic was quite high, and the mortality rate was lower than that described in the literature, without relating to the discordance. The presence of concordance was associated with fewer readmissions and ICU admissions. The main reasons for disagreement were inadequate spectrum selection and change after microbiological crops (AU)
Assuntos
Humanos, Sepse/tratamento farmacológico, Antibacterianos/farmacocinética, Serviços Médicos de Emergência/estatística & dados numéricos, Tratamento de Emergência/métodosRESUMO
The spread of multidrug-resistant Enterobacteriaceae related to the production of extended-spectrum beta-lactamases and carbapenemases is a serious public health problem worldwide. Microbiological diagnosis and therapy of these infections are challenging and controversial. Clinically relevant questions were selected and the literature was reviewed for each of them. The information from the selected articles was extracted and recommendations were provided and graded according to the strength of the recommendations and quality of the evidence. The document was opened to comments from the members from the Spanish Society of Infectious Diseases and Clinical Microbiology, which were considered for inclusion in the final version. Evidence-based recommendations are provided for the use of microbiological techniques for the detection of extended-spectrum beta-lactamases and carbapenemases in Enterobacteriaceae, and for antibiotic therapy for invasive/severe infections caused by these organisms. The absence of randomised controlled trials is noteworthy; thus, recommendations are mainly based on observational studies (that have important methodological limitations), pharmacokinetic and pharmacodynamics models, and data from animal studies. Additionally, areas for future research were identified
La diseminación de Enterobacteriaceae multirresistentes en relación con la producción de beta-lactamasas de espectro extendido y carbapenemasas es un importante problema de salud pública en todo el mundo. Tanto el diagnóstico microbiológico como el tratamiento de estas infecciones son complicados y controvertidos. Los autores seleccionaron preguntas clínicamente relevantes, realizándose una revisión de la literatura para cada una de ellas; se obtuvo información de los artículos seleccionados y se realizaron recomendaciones que se clasificaron de acuerdo con la fuerza de la recomendación y la calidad de la evidencia. El documento estuvo abierto para los comentarios de los socios de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, los cuales se consideraron para su inclusión en la versión final. Se proporcionan recomendaciones basadas en la evidencia para el uso de técnicas microbiológicas cara a la detección de beta-lactamasas de espectro extendido y carbapenemasas en Enterobacteriaceae, y para el tratamiento antimicrobiano de las infecciones graves o invasivas causadas por estos microorganismos. Es llamativa la ausencia de ensayos aleatorizados, por lo que las recomendaciones se basan principalmente en estudios observacionales que tienen importantes limitaciones metodológicas, modelos farmacocinéticos y farmacodinámicos, y datos de estudios en animales. Además, se identificaron áreas prioritarias para la investigación futura
Assuntos
Humanos, Enterobacteriaceae/patogenicidade, Infecções por Enterobacteriaceae/tratamento farmacológico, Infecções por Enterobacteriaceae/diagnóstico, Resistência a Múltiplos Medicamentos, Carbapenêmicos/uso terapêutico, beta-Lactamas/uso terapêuticoRESUMO
The spread of multidrug-resistant Enterobacteriaceae related to the production of extended-spectrum beta-lactamases (ESBL) and carbapenemases is a serious public health problem worldwide. Microbiological diagnosis and therapy of these infections are challenging and controversial. After the selection of clinically relevant questions, this document provides evidence-based recommendations for the use of microbiological techniques for the detection of ESBL- and carbapenemase-producing Enterobacteriaceae, and for antibiotic therapy for invasive infections caused by these organisms. The absence of randomized-controlled trials is noteworthy, thus recommendations are mainly based on observational studies, that have important methodological limitations, pharmacokinetic and pharmacodynamics models, and data from animal studies. Additionally, areas for future research were identified
La diseminación de Enterobacteriaceae multirresistentes en relación con la producción de beta-lactamasas de espectro extendido (BLEE) y carbapenemasas es un importante problema de salud pública en todo el mundo. Tanto el diagnóstico microbiológico como el tratamiento de estas infecciones son complicados y controvertidos. Tras una selección de preguntas clínicamente relevantes, este documento proporciona recomendaciones basadas en la evidencia para el uso de técnicas microbiológicas para la detección de Enterobacteriaceae productoras de BLEE y carbapenemasas, y para el tratamiento antibiótico de las infecciones invasivas causadas por estos microorganismos. Es llamativa la ausencia de ensayos aleatorizados controlados, por lo que las recomendaciones se basan principalmente en estudios observacionales con importantes limitaciones metodológicas, modelos farmacocinéticos y farmacodinámicos y estudios en animales. Además, se han identificado áreas prioritarias de investigación futura
Assuntos
Humanos, Enterobacteriaceae/patogenicidade, Infecções por Enterobacteriaceae/tratamento farmacológico, Infecções por Enterobacteriaceae/diagnóstico, Resistência a Múltiplos Medicamentos, Carbapenêmicos/uso terapêutico, beta-Lactamas/uso terapêuticoRESUMO
The spread of multidrug-resistant Enterobacteriaceae related to the production of extended-spectrum ß-lactamases and carbapenemases is a serious public health problem worldwide. Microbiological diagnosis and therapy of these infections are challenging and controversial. Clinically relevant questions were selected and the literature was reviewed for each of them. The information from the selected articles was extracted and recommendations were provided and graded according to the strength of the recommendations and quality of the evidence. The document was opened to comments from the members from the Spanish Society of Infectious Diseases and Clinical Microbiology, which were considered for inclusion in the final version. Evidence-based recommendations are provided for the use of microbiological techniques for the detection of extended-spectrum ß-lactamases and carbapenemases in Enterobacteriaceae, and for antibiotic therapy for invasive/severe infections caused by these organisms. The absence of randomised controlled trials is noteworthy; thus, recommendations are mainly based on observational studies (that have important methodological limitations), pharmacokinetic and pharmacodynamics models, and data from animal studies. Additionally, areas for future research were identified.
Assuntos
Farmacorresistência Bacteriana Múltipla, Infecções por Enterobacteriaceae/diagnóstico, Infecções por Enterobacteriaceae/tratamento farmacológico, Enterobacteriaceae/efeitos dos fármacos, Infecções por Enterobacteriaceae/microbiologia, HumanosRESUMO
The spread of multidrug-resistant Enterobacteriaceae related to the production of extended-spectrum ß-lactamases (ESBL) and carbapenemases is a serious public health problem worldwide. Microbiological diagnosis and therapy of these infections are challenging and controversial. After the selection of clinically relevant questions, this document provides evidence-based recommendations for the use of microbiological techniques for the detection of ESBL- and carbapenemase-producing Enterobacteriaceae, and for antibiotic therapy for invasive infections caused by these organisms. The absence of randomized-controlled trials is noteworthy, thus recommendations are mainly based on observational studies, that have important methodological limitations, pharmacokinetic and pharmacodynamics models, and data from animal studies. Additionally, areas for future research were identified.
Assuntos
Anti-Infecciosos/uso terapêutico, Farmacorresistência Bacteriana Múltipla, Infecções por Enterobacteriaceae/diagnóstico, Infecções por Enterobacteriaceae/tratamento farmacológico, Enterobacteriaceae/efeitos dos fármacos, HumanosRESUMO
INTRODUCCIÓN: Los hemocultivos contaminados (HC) conllevan un incremento de pruebas diagnósticas, tratamientos innecesarios, aumento de la carga asistencial, estancia hospitalaria y costes. Objetivos Disminución de los HC a través de un programa educacional. Material y métodos Periodo preintervención (Ppre): valoración clínica restrospectiva de los hemocultivos positivos y análisis de indicadores de contaminación. Periodo postintervención (Ppos), tras programa educacional, se comparó la incidencia de contaminación entre ambos periodos. La formación comprendió: un cuestionario donde se valoraba el grado de conocimientos acerca de la técnica de extracción, el significado de los HC, su diagnóstico y prevención, la impartición de sesiones y la revisión de resultados. ResultadosSe impartieron sesiones formativas en todas las unidades de hospitalización. La mediana de participación fue del 64% (40,8-78,5). La mediana de aciertos en el cuestionario fue del 69% en el Ppre (54,1-83,3) y de 85,7% (83,3-100) en el Ppos, mejorando en el 85,7% de las unidades que pudieron compararse. Durante el Ppre hubo 136 (4,2%) HC y 186 (6,05%) fueron HC en el Ppos (p = 0,005). La mediana de HC por unidades entre 2011 y 2012 fue del 5 vs. 7,5% (p = 0,79). Solo en 2 unidades se objetivó una reducción del 2 y del 2,5% que no fue significativa. CONCLUSIONES: Nuestro programa formativo no consiguió reducir los HC en el periodo del estudio pero logró una mejoría en la capacitación de las enfermeras. Los resultados nos permitieron identificar los problemas que necesitan modificarse de cara a conseguir mejores resultados y poder implantar un programa continuado
INTRODUCTION: Blood culture contaminations can lead to unnecessary diagnostic procedures and treatments, increasing workload, length of stay, and costs. OBJETIVES: Development of an educational program to reduce contamination rates. MATERIAL AND METHODS: Our study compared contamination rates (CR) between a pre-intervention period (Ppre) and post-intervention period (Ppos), where clinical charts from patients with positive blood cultures were reviewed. Intervention consisted of a questionnaire where knowledge of blood culture practice and its significance was assessed. Results are discussed and explained. RESULTS: A presentation on blood culture guidelines was discussed in every nurse station. There was a median of 64% (40.8-78.5) attendance rate. The median of correct answers was 69% in the Ppre (54.1-83.3) with 85.7% (83.3-100) in the Ppos, indicating an improvement in 85.7% of the departments that could be compared. There were 136 (4.2%) contaminants in the Ppre and 186 (6.05%) in the Ppos (P=.005). Among the different departments the average of CR varied from 5% vs 7.5% (P=.79) between 2011 and 2012. Only 2 departments reduced CR by 2% to 2.5%, the difference was not significant. CONCLUSIONS: The intervention failed to reduce overall contamination rates, but knowledge of blood culture practice improved. Our results identified the errors that will help us to design a successful approach in future follow-up programs
Assuntos
Humanos, Manejo de Espécimes/métodos, Coleta de Amostras Sanguíneas/métodos, Métodos Analíticos de Preparação de Amostras/métodos, Poluentes Ambientais/efeitos adversos, Técnicas Microbiológicas/métodos, Reações Falso-PositivasRESUMO
INTRODUCTION: Blood culture contaminations can lead to unnecessary diagnostic procedures and treatments, increasing workload, length of stay, and costs. OBJETIVES: Development of an educational program to reduce contamination rates. MATERIAL AND METHODS: Our study compared contamination rates (CR) between a pre-intervention period (Ppre) and post-intervention period (Ppos), where clinical charts from patients with positive blood cultures were reviewed. Intervention consisted of a questionnaire where knowledge of blood culture practice and its significance was assessed. Results are discussed and explained. RESULTS: A presentation on blood culture guidelines was discussed in every nurse station. There was a median of 64% (40.8-78.5) attendance rate. The median of correct answers was 69% in the Ppre (54.1-83.3) with 85.7% (83.3-100) in the Ppos, indicating an improvement in 85.7% of the departments that could be compared. There were 136 (4.2%) contaminants in the Ppre and 186 (6.05%) in the Ppos (P=.005). Among the different departments the average of CR varied from 5% vs 7.5% (P=.79) between 2011 and 2012. Only 2 departments reduced CR by 2% to 2.5%, the difference was not significant. CONCLUSIONS: The intervention failed to reduce overall contamination rates, but knowledge of blood culture practice improved. Our results identified the errors that will help us to design a successful approach in future follow-up programs.
Assuntos
Coleta de Amostras Sanguíneas/normas, Sangue/microbiologia, Pessoal de Saúde/educação, Testes Hematológicos/normas, Competência Clínica, Reações Falso-Positivas, Humanos, Estudos Retrospectivos, Inquéritos e QuestionáriosRESUMO
Antecedentes. La infección fúngica invasiva (IFI) es una entidad que engloba diferentes tipos de infecciones por hongos patógenos habituales en el ser humano. En el entorno del paciente crítico, con múltiples y muchas veces simultáneos factores de riesgo y comorbilidades, las más frecuentes son las causadas por especies de Candida y Aspergillus. Entre las particularidades de la IFI en pacientes críticos podemos destacar tres aspectos: a) el relacionado con el huésped (por ejemplo, factores de riesgo, gravedad clínica); b) el relacionado con el patógeno (sensibilidad, virulencia), o c) el relacionado con el tratamiento antifúngico (espectro de actividad, características PK/PD, seguridad e interacciones). Candida es el género fúngico que de modo más frecuente causa IFI en pacientes críticos, y la candidemia, la peritonitis candidiásica y la infección secundaria a catéter son los tipos de infección más comunes. En los últimos años los nuevos tratamientos antifúngicos han ampliado las posibilidades de tratamiento y actualmente las candinas son una clara opción en los pacientes graves con IFI, que en la mayoría de las guías terapéuticas publicadas se han convertido en la primera opción terapéutica. Caso clínico. Se presenta un caso de un paciente crítico, con los factores de riesgo más habituales, disfunción multiorgánica (DMO) y desarrollo de IFI. Se comenta la dificultad para establecer un tratamiento antifúngico desde el inicio, su ajuste y se consideran las diferentes posibilidades terapéuticas según la DMO del paciente. Además, se valoran y discuten las opciones del tratamiento antifúngico según las actuales guías y recomendaciones. Conclusiones. La candidiasis invasora es la infección fúngica más habitual en los pacientes críticos; las presentaciones clínicas más comunes son la candidemia y la peritonitis candidiásica. Las candinas, gracias a su eficacia y seguridad clínica, han abierto nuevas posibilidades terapéuticas en el tratamiento de estas infecciones en este tipo de pacientes(AU)
Invasive fungal infection (IFI) is an entity that encompasses different types of infections caused by different types of those fungi pathogenic for humans. In the setting of critically ill patients with multiple and oftenconcurrent risk factors and comorbidities the most common are those caused by the Candida and Aspergillus species. Among the characteristics of IFI in critically ill patients, three aspects can be highlighted: those related to the host (e.g.: risk factors, clinical severity), those related with the pathogen (sensitivity, virulence), or those concerning antifungal treatment (spectrum, features PK / PD, safety, interactions). The fungus that most often causes an IFI in critically ill patients is Candida; the most common type infections are candidemia, Candida peritonitis and catheter-related infections. In recent years new antifungal treatments have expanded the therapeutic options, with echinocandins as a clear choice, often the first in the latest guidelines in critically ill patients with IFI. Case report. We report the case of a critically ill patient having the most common risk factors, multiple organ dysfunction and development of an IFI. The complexity of establishing an antifungal treatment from the moment of its inception, its setting, and the considerations of the different therapeutic possibilities according to organ dysfunction of the patient are discussed. The antifungal treatment options mentioned in the current guidelines and recommendations are also evaluated. Conclusions. The most common fungal infection in critically ill patients is invasive candidiasis, with candidemia or candida peritonitis being the most frequent clinical presentations. Candins have brought new possibilities for treating these complex patients due to their good safety profile and clinical efficacy(AU)
Assuntos
Humanos, Masculino, Pessoa de Meia-Idade, Cuidados Críticos/métodos, Infecções/tratamento farmacológico, Anti-Infecciosos/uso terapêutico, Fatores de Risco, Candidíase Invasiva/tratamento farmacológico, Candidemia/tratamento farmacológico, Peritonite/complicações, Peritonite/diagnóstico, Candidemia/diagnóstico, Candidemia/microbiologia, Antifúngicos/uso terapêutico, Radiografia Torácica, Estudos ProspectivosRESUMO
BACKGROUND: Invasive fungal infection (IFI) is an entity that encompasses different types of infections caused by different types of those fungi pathogenic for humans. In the setting of critically ill patients with multiple and often-concurrent risk factors and comorbidities the most common are those caused by the Candida and Aspergillus species. Among the characteristics of IFI in critically ill patients, three aspects can be highlighted: those related to the host (e.g.: risk factors, clinical severity), those related with the pathogen (sensitivity, virulence), or those concerning antifungal treatment (spectrum, features PK / PD, safety, interactions). The fungus that most often causes an IFI in critically ill patients is Candida; the most common type infections are candidemia, Candida peritonitis and catheter-related infections. In recent years new antifungal treatments have expanded the therapeutic options, with echinocandins as a clear choice, often the first in the latest guidelines in critically ill patients with IFI. CASE REPORT: We report the case of a critically ill patient having the most common risk factors, multiple organ dysfunction and development of an IFI. The complexity of establishing an antifungal treatment from the moment of its inception, its setting, and the considerations of the different therapeutic possibilities according to organ dysfunction of the patient are discussed. The antifungal treatment options mentioned in the current guidelines and recommendations are also evaluated. CONCLUSIONS: The most common fungal infection in critically ill patients is invasive candidiasis, with candidemia or candida peritonitis being the most frequent clinical presentations. Candins have brought new possibilities for treating these complex patients due to their good safety profile and clinical efficacy.
Assuntos
Candidíase Invasiva/diagnóstico, Candidíase Invasiva/tratamento farmacológico, Estado Terminal, Humanos, Guias de Prática Clínica como AssuntoAssuntos
Antibacterianos/administração & dosagem, Antifúngicos/administração & dosagem, Candidíase/diagnóstico, Neoplasias Colorretais/complicações, Infecções por Escherichia coli/diagnóstico, Infecções por Bactérias Gram-Positivas/diagnóstico, Peritonite/diagnóstico, Candida albicans/isolamento & purificação, Candida glabrata/isolamento & purificação, Candidíase/tratamento farmacológico, Candidíase/microbiologia, Candidíase/patologia, Neoplasias Colorretais/cirurgia, Enterococcus faecalis/isolamento & purificação, Escherichia coli/isolamento & purificação, Infecções por Escherichia coli/tratamento farmacológico, Infecções por Escherichia coli/microbiologia, Infecções por Escherichia coli/patologia, Infecções por Bactérias Gram-Positivas/tratamento farmacológico, Infecções por Bactérias Gram-Positivas/microbiologia, Infecções por Bactérias Gram-Positivas/patologia, Humanos, Hospedeiro Imunocomprometido, Masculino, Testes de Sensibilidade Microbiana, Pessoa de Meia-Idade, Peritonite/microbiologia, Infecção da Ferida Cirúrgica/diagnóstico, Infecção da Ferida Cirúrgica/microbiologia, Resultado do TratamentoRESUMO
BACKGROUND: Invasive candidiasis and candidemia are frequently encountered in the nosocomial setting particularly in the intensive care unit (ICU). OBJECTIVE AND METHODS: To review the current management of invasive candidiasis and candidemia in non-neutropenic adult ICU patients based on a review of the literature and an European expert panel discussion. RESULTS AND CONCLUSIONS: Empiric and directed treatment for invasive candidiasis are predicated on the hemodynamic status of the patient. Unstable patients may benefit from broad-spectrum antifungal agents, which can be narrowed once the patient has stabilized and the identity of the infecting species is established. In stable patients, a more classical approach using fluconazole may be satisfactory provided that the patient is not colonized with fluconazole resistant strains or there has been recent past exposure to an azole (<30 days). In contrast, pre-emptive therapy is based on the presence of surrogate markers.
Assuntos
Anfotericina B/uso terapêutico, Antifúngicos/uso terapêutico, Bacteriemia/sangue, Bacteriemia/microbiologia, Candida albicans/isolamento & purificação, Candidíase/tratamento farmacológico, Candidíase/microbiologia, Fluconazol/uso terapêutico, Unidades de Terapia Intensiva, HumanosRESUMO
BACKGROUND: Invasive candidiasis and candidemia are frequently encountered in the nosocomial setting, particularly in the intensive care unit (ICU). OBJECTIVES AND METHODS: To review the current management of invasive candidiasis and candidemia in non-neutropenic adult ICU patients based on a review of the literature and a European expert panel discussion. RESULTS AND CONCLUSIONS: Candida albicans remains the most frequently isolated fungal species followed by C. glabrata. The diagnosis of invasive candidiasis involves both clinical and laboratory parameters, but neither of these are specific. One of the main features in diagnosis is the evaluation of risk factor for infection which will identify patients in need of pre-emptive or empiric treatment. Clinical scores were built from those risk factors. Among laboratory diagnosis, a positive blood culture from a normally sterile site provides positive evidence. Surrogate markers have also been proposed like 1,3 beta-D: glucan level, mannans, or PCR testing. Invasive candidiasis and candidemia is a growing concern in the ICU, apart from cases with positive blood cultures or fluid/tissue biopsy, diagnosis is neither sensitive nor specific. The diagnosis remains difficult and is usually based on the evaluation of risk factors.
Assuntos
Candidíase/diagnóstico, Candidíase/epidemiologia, Fungemia/diagnóstico, Fungemia/epidemiologia, Unidades de Terapia Intensiva, Biomarcadores/sangue, Infecção Hospitalar/microbiologia, Europa (Continente)/epidemiologia, Fungemia/microbiologia, Humanos, Prevalência, Turquia/epidemiologiaRESUMO
Las infecciones fúngicas invasoras más frecuentes en pacientes críticos son las candidiasis invasivas (CI), entre las que se encuentra la candidemia. En los últimos años, se ha incrementado el porcentaje de estas infecciones en unidades de cuidados intensivos (UCI), con especies distintas de Candida albicans. Este hecho puede conllevar la aparición de especies resistentes a los antifúngicos. Para iniciar el tratamiento más adecuado, se necesita diagnosticar precozmente la infección, con lo que se disminuirían los tratamientos antibióticos empíricos y aumentaría la proporción de la terapia anticipada o dirigida. Ante la escasa fiabilidad de las técnicas diagnósticas disponibles, se están aplicando nuevas estrategias actualmente en la UCI, como el uso de scores para evaluar la presencia de la infección fúngica. El arsenal terapéutico se ha ampliado y la introducción de anidulafungina ha aportado un fármaco con características muy adecuadas para el tratamiento de la CI en pacientes críticos no inmunodeprimidos
The most frequent invasive fungal infections in critically ill patients are invasive candidiasis, among which is candidemia. In the last few years, these infections have become more common in intensive care units (ICU), including those produced by species other than Candida albicans. This phenomenon may lead to the development of species resistant to antifungal agents. To start the most appropriate treatment, early diagnosis of the infection is essential, which would reduce empirical antibiotic treatment and increase the proportion of advanced or directed antibiotic therapy. Given the poor reliability of the available diagnostic techniques, new strategies are currently being employed in the ICU, such as the use of scores to evaluate the presence of fungal infections. The therapeutic arsenal against these infections has been increased and the introduction of anidulafungin represents the addition of a highly appropriate drug for the treatment of invasive candidiasis in immunocompetent critically ill patients
Assuntos
Humanos, Equinocandinas/farmacologia, Infecções Fúngicas Invasivas/tratamento farmacológico, Estado Terminal/terapia, Infecções Fúngicas Invasivas/epidemiologia, Candidemia/tratamento farmacológico, Candidemia/epidemiologia, Cuidados Críticos, Candida albicans/patogenicidade, Candidíase Invasiva/tratamento farmacológico, Candidíase Invasiva/epidemiologiaRESUMO
The most frequent invasive fungal infections in critically ill patients are invasive candidiasis, among which is candidemia. In the last few years, these infections have become more common in intensive care units (ICU), including those produced by species other than Candida albicans. This phenomenon may lead to the development of species resistant to antifungal agents. To start the most appropriate treatment, early diagnosis of the infection is essential, which would reduce empirical antibiotic treatment and increase the proportion of advanced or directed antibiotic therapy. Given the poor reliability of the available diagnostic techniques, new strategies are currently being employed in the ICU, such as the use of scores to evaluate the presence of fungal infections. The therapeutic arsenal against these infections has been increased and the introduction of anidulafungin represents the addition of a highly appropriate drug for the treatment of invasive candidiasis in immunocompetent critically ill patients.
