Prognostic factors in patients hospitalised with group A Streptococcus bacteraemia in tropical Australia.

PurposeFollowing the COVID-19 pandemic, group A Streptococcus (GAS) infection has been surging worldwide. We aimed to compare the disease burden between notified cases of streptococcal toxic shock syndrome (STSS) and unreported GAS infections.MethodsThis is a multicentral observational study, retrospectively performed at seven hospitals in Okayama prefecture in Japan from January 2022, to June 2024. Clinical and microbiological data of patients with positive cultures of GAS were collected from the medical records. Primary outcomes were defined as rates of surgical procedures, intensive care unit (ICU) admission, and in-hospital mortality, which were compared among patients with locally-defined STSS, invasive GAS (iGAS), and non-iGAS infection.ResultsGAS was detected in 181 patients, with 154 active cases of GAS infection. The number of patients with GAS infection surged in late 2023. The most common source of infection was skin and soft tissue infections, accounting for 83 cases, including 15 cases of necrotizing fasciitis, and 12 cases (7.8%) were notified to public health authorities as STSS. Among the 25 unreported iGAS cases, 9 (36.0%) underwent surgical intervention, and 4 patients (16.0%) required ICU admission. The mortality rates in the unreported iGAS cases were comparable to those observed in the notified STSS.ConclusionsWe highlighted that the number of iGAS infections was twofold higher than that of notified STSS, with comparable mortality rate between these groups, indicating substantial underestimation of the true burden of iGAS. This epidemiological investigation has significant implications for enhancing infectious disease surveillance frameworks and public health policy development.

Invasive Group A Streptococcal infection (iGAS) is an uncommon but serious infection with Streptococcus pyogenes in a normally sterile body site. Manifestations include bacteraemia, necrotising fasciitis and toxic shock syndrome with attendant serious morbidity and mortality. An increasing incidence of iGAS has been observed in some regions of Australia. iGAS became a nationally notifiable condition from 1 July 2021. To determine if regional incidence has increased, and to identify priority populations, we undertook a retrospective data analysis of Group A Streptococcal (GAS) bacteraemia cases in Hunter New England Local Health District (HNELHD), New South Wales, Australia, from 1 January 2008 to 31 December 2019, as identified by NSW Health Pathology, John Hunter Hospital. A total of 486 cases were identified (age-standardised rate: 4.05 cases per 100,000 population per year). Incidence in HNELHD gradually increased over the study period (adjusted incidence rate ratio: 1.04; 95% confidence interval: 1.01-1.07) and was significantly higher in children under 5 years of age; in adults over 70 years of age; in males; and in First Nations peoples. A significant peak occurred in 2017 (9.00 cases per 100,000 population), the cause of which remains unclear. GAS bacteraemia is uncommon but severe, and incidence in HNELHD has slowly increased. Public health and clinical guidelines must address the needs of priority populations, which include young children, older adults and First Nations peoples. Routine surveillance and genomic analysis will help improve our understanding of iGAS and inform best public health management.

In this paper we present a prospective evaluation of 100 patients with Group A Streptococcal (GAS) bacteremia evaluated in our hospital over a 10-year period. Sixty-two patients were intravenous drug users (IVDU); all but 1 of these had an obvious cutaneous portal of entry related to the injection of illicit drugs. Twenty-seven patients had infectious metastasis, and the presence of septic pulmonary embolism was associated with suppurative phlebitis. Four of these patients had endocarditis. In the non-IVDU group, 24 patients had an underlying disease, and 12 were immunosuppressed. In 14 cases the infection was of hospital acquisition; in 35% infection was related to medical manipulations. Comparing the IVDU and non-IVDU groups, GAS bacteremia in IVDU patients is associated with a more benign outcome, a longer time of evolution before diagnosis, and a lower frequency of septic shock and mortality than in non-IVDU patients. Although in the univariate analysis GAS bacteremia was associated with several variables, in the multivariate analysis only the presence of shock and nosocomial acquisition of the infection were independently associated with a fatal outcome. Fifty-two patients were infected with human immunodeficiency virus (HIV); 5 of these were in the non-IVDU group. During the last 5 years of study, GAS bacteremia in our hospital was 39 times more frequent in HIV-infected patients than in patients without HIV. Nine patients presented clinical criteria corresponding to Streptococcal toxic shock syndrome (STSS), although its incidence was lower in the IVDU group. In the non-IVDU group, STSS was more frequent in patients with a necrotizing portal of entry, an age between 20 and 40 years, women, and when the origin of the infection was the skin or soft tissue. Six patients with STSS died, and death was associated with the presence of necrotizing lesions and lower counts of white cells, platelets, or hemoglobin.

Background: Intensive care unit (ICU) admission during hematopoietic stem cell transplant (HSCT) is associated with poor prognosis1,2. Published series report a range of ICU admission rates from 24-40% of transplant patients, most frequent reasons involving septic shock, respiratory failure and veno-occlusive disease3. In addition, patients undergoing HSCT are at a high risk of severe morbidity and mortality associated with COVID-194. Aims: The aim of this study was to analyze outcome of HSCT patients requiring ICU admission in our center. Methods: We retrospectively analysed outcome of 752 patients who underwent HSCT in our centre from January/2008 to June/2021. Data were collected from patients’ clinical histories. Results: 103 (14%) patients required ICU admission (baseline and HSCT characteristics on table). Median time to ICU admission was 42 days (-2-1765). Seven of these patients were admitted to ICU on two occasions giving a total of 110 consecutive ICU admissions available for analysis. Main reason for ICU admission was respiratory distress (74; 67%), mainly due to pneumonia (53%) including a 3% caused by COVID19, pulmonary edema (26%) and pulmonary haemorrhage (8%). Septic shock was second most common cause for ICU admission (26; 24%) due to gram-negative bacilli (47%), fungal (15%) gram-positive bacteria (13%), virus (10%) and others/idiopathic (16%). Other less frequent causes were veno-occlusive disease (11; 10%), hepatic failure/encephalopathy (8; 7%), haemorrhagic complications (6; 5%), cardiorespiratory arrest (2%), GVHD (2%), cardiogenic shock (2%). Of the 110 ICU admissions, 37 (34%) required hemofiltration, of which 30 (81%) died; and 77 (70%) required orotracheal intubation, of which 59 (77%) died. During the 110 ICU admissions, 67 patients (61%) died in the ICU; of these, 40 (37%) received unrelated donor HSCT, 36 (33%) sibling donor, 16 (15%) haploidentical and 17 (16%) autologous. Median ICU length of stay of these patients was 13 days (range 1-76). The cause of death was the same reason for ICU admission. Eighteen (16%) patients were discharged from ICU and died prior to hospital discharge and 24 (22%) survived to hospital discharge and were classified as post-discharge survivors. Of these 24 cases, 19 (79%) remain alive while the others (5; 21%) succumbed to underlying disease or complications post-HSCT. Off note, both patients with COVID19 pneumonia (haploidentical and autologous HSCT respectively) were discharged from ICU and remain alive to date, without major complications. Image:Summary/Conclusion: In our study 14% of transplant recipients required ICU admission, slightly lower than previous reports. Most common cause of admission was respiratory failure, consistent with reported. Mortality rate during ICU admission was 61%; higher death rate observed in allogeneic transplantation and those requiring aggressive ICU treatments such as mechanical ventilation or hemofiltration. Although patients with COVID19 pneumoniae who require ICU admission are usually associated with adverse outcome, in our series they responded successfully to intensive treatment. ICU admission following HSCT is associated with poor prognosis, but should not be considered futile.

e18709 Background: The mortality rate of cancer patients diagnosed with COVID-19 infection has reached 25%. The time from symptom onset to admission to the intensive care unit (ICU) was on average 10 days, with approximately 26% of patients requiring ICU admission. A higher mortality attributed to COVID-19 was seen in older patients, patients with certain cancer types, and patients with a higher Charslon comorbidity score. Moreover, male sex and leukopenia at diagnosis were associated with an increased risk of worse clinical outcomes. Furthermore, a study done at Memorial Sloan Kettering showed that patients with hematological malignancies had a worse prognosis than those with solid tumors. Our aim is to identify the predictive factors for ICU admission in the setting of positive COVID-19 infection in cancer patients. Differences in prognosis were compared between cancer and non-cancer patients admitted to the ICU due to COVID-19 infection. We also compared the overall outcome between patients with solid cancers and hematologic malignancies. Methods: This is a single institution retrospective study based on chart review analysis conducted at the American University of Beirut Medical Center (AUBMC). 248 patients were diagnosed with COVID-19 from 1 January 2020 to 31 December 2021. The patient groups were (1) all cancer patients admitted to the COVID unit, (2) all cancer patients admitted to ICU, and (3) all other patients without cancer admitted to the ICU. The main outcomes were ICU admission and mortality. Results: 173 cancer patients were admitted to our institution for the management of COVID-19 with a mean age of 63 years. 52 patients (30%) required ICU admission and 50 patients (29%) died during hospital stay or 1 month following discharge. The time from symptom onset to ICU admission and death were 12.8 and 35 days, respectively. Patients admitted to the ICU were more likely to have anemia (Hb < 8 g/dL) and thrombocytopenia (< 50,000/mm3) on admission (p = 0.001). Age, male sex and history of smoking, diabetes or cardiopulmonary diseases were not associated with greater risk of ICU admission or death. Among cancer patients, those with uncontrolled disease at the onset of COVID-19 had greater risk of death from COVID-19 (p = 0.001). Cancer type, number of lines of treatment, history of radiation to the chest, recent cytotoxic therapy, and neutropenia were not associated with ICU admission or death from COVID-19. There was no statistical significance in mortality or disease progression between patients with solid or hematologic malignancies. Conclusions: Our data reaffirms previously reported findings of high mortality in cancer patients who contract COVID-19. In particular, patients with anemia, thrombocytopenia, and uncontrolled disease at diagnosis had unfavorable outcomes. Contrary to the literature, age, male sex, cancer type, and neutropenia were not predictive factors for mortality in cancer patients in the setting of COVID-19 infections.

Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-Acquired Pneumonia

<b>Background:</b> The 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria (1 major criterion or 3 minor criteria). We aimed to validate the accuracy of IDSA/ATS criteria in very elderly patients (VEP, i.e. ≥80 years) with CAP. <b>Study design and methods:</b> Prospective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. <b>Results:</b> Of the 1797 VEP with CAP, 503 (28%) met severe CAP criteria, while 199 (11%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1397 (78%) cases (k coefficient, 0.32; sensitivity, 76%; specificity 78%). All patients with invasive mechanical ventilation received care in ICUs, while 45 (42%) patients with septic shock—previously stabilized in the emergency room—did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (8 [30%] vs. 27 [60%], p=0.013). In contrast, regardless of the site of care, patients with severe CAP and only minor criteria had similar mortality. <b>Conclusion:</b> IDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock should warrant ICU admission, even if previously stabilized, severe CAP without major severity criteria may be acceptably manageable in wards.

Effects of using the 2007 IDSA/ATS minor criteria to manage severe community-acquired pneumonia

BackgroundInfluenza is a common cause of hospital admissions globally with regional variations in epidemiology and clinical profile. We evaluated the characteristics and outcomes of patients with influenza admitted to a tertiary-care center in Riyadh, Saudi Arabia.MethodsThis was a retrospective cohort of adult patients admitted with polymerase chain reaction-confirmed influenza to King Abdulaziz Medical City-Riyadh between January 1, 2018, and May 31, 2022. We compared patients who required intensive care unit (ICU) admission to those who did not and performed multivariable logistic regression to assess the predictors of ICU admission and hospital mortality.ResultsDuring the study period, 675 adult patients were hospitalized with influenza (median age 68.0 years, females 53.8%, hypertension 59.9%, diabetes 55.1%, and chronic respiratory disease 31.1%). Most admissions (83.0%) were in the colder months (October to March) in Riyadh with inter-seasonal cases even in the summertime (June to August). Influenza A was responsible for 79.0% of cases, with H3N2 and H1N1 subtypes commonly circulating in the study period. Respiratory viral coinfection occurred in 12 patients (1.8%) and bacterial coinfection in 42 patients (17.4%). 151 patients (22.4%) required ICU admission, of which 62.3% received vasopressors and 48.0% mechanical ventilation. Risk factors for ICU admission were younger age, hypertension, bilateral lung infiltrates on chest X-ray, and Pneumonia Severity Index. The overall hospital mortality was 7.4% (22.5% for ICU patients, p < 0.0001). Mortality was 45.0% in patients with bacterial coinfection, 30.9% in those requiring vasopressors, and 29.2% in those who received mechanical ventilation. Female sex (odds ratio [OR], 2.096; 95% confidence interval [CI] 1.070, 4.104), ischemic heart disease (OR, 3.053; 95% CI 1.457, 6.394), immunosuppressed state (OR, 7.102; 95% CI 1.803, 27.975), Pneumonia Severity Index (OR, 1.029; 95% CI, 1.017, 1.041), leukocyte count and serum lactate level (OR, 1.394; 95% CI, 1.163, 1.671) were independently associated with hospital mortality.ConclusionsInfluenza followed a seasonal pattern in Saudi Arabia, with H3N2 and H1N1 being the predominant circulating strains during the study period. ICU admission was required for > 20%. Female sex, high Pneumonia Severity Index, ischemic heart disease, and immunosuppressed state were associated with increased mortality.

Little is known about patients with sickle cell disease (SCD) who require intensive care unit (ICU) admission. The goals of this study were to assess outcomes in patients admitted to the ICU for acute complications of SCD and to identify factors associated with adverse outcomes. This multicenter retrospective study included consecutive adults with SCD admitted to one of 17 participating ICUs. An adverse outcome was defined as death or a need for life-sustaining therapies (non-invasive or invasive ventilation, vasoactive drugs, renal replacement therapy, and/or extracorporeal membrane oxygenation). Factors associated with adverse outcomes were identified by mixed multivariable logistic regression. We included 488 patients admitted in 2015–2017. The main reasons for ICU admission were acute chest syndrome (47.5%) and severely painful vaso-occlusive event (21.3%). Sixteen (3.3%) patients died in the ICU, mainly of multi-organ failure following a painful vaso-occlusive event or sepsis. An adverse outcome occurred in 81 (16.6%; 95% confidence interval [95% CI], 13.3%–19.9%) patients. Independent factors associated with adverse outcomes were low mean arterial blood pressure (adjusted odds ratio [aOR], 0.98; 95% CI 0.95–0.99; p = 0.027), faster respiratory rate (aOR, 1.09; 95% CI 1.05–1.14; p < 0.0001), higher haemoglobin level (aOR, 1.22; 95% CI 1.01–1.48; p = 0.038), impaired creatinine clearance at ICU admission (aOR, 0.98; 95% CI 0.97–0.98; p < 0.0001), and red blood cell exchange before ICU admission (aOR, 5.16; 95% CI 1.16–22.94; p = 0.031). Patients with SCD have a substantial risk of adverse outcomes if they require ICU admission. Early ICU admission should be encouraged in patients who develop abnormal physiological parameters.

BackgroundGroup A Streptococcus is responsible for severe and potentially lethal invasive conditions requiring intensive care unit (ICU) admission, such as streptococcal toxic shock-like syndrome (STSS). A rebound of invasive group A streptococcal (iGAS) infection after COVID-19-associated barrier measures has been observed in children. Several intensivists of French adult ICUs have reported similar bedside impressions without objective data. We aimed to compare the incidence of iGAS infection before and after the COVID-19 pandemic, describe iGAS patients’ characteristics, and determine ICU mortality associated factors.MethodsWe performed a retrospective multicenter cohort study in 37 French ICUs, including all patients admitted for iGAS infections for two periods: two years before period (October 2018 to March 2019 and October 2019 to March 2020) and a one-year after period (October 2022 to March 2023) COVID-19 pandemic. iGAS infection was defined by Group A Streptococcus isolation from a normally sterile site. iGAS infections were identified using the International Classification of Diseases and confirmed with each center's microbiology laboratory databases. The incidence of iGAS infections was expressed in case rate.ResultsTwo hundred and twenty-two patients were admitted to ICU for iGAS infections: 73 before and 149 after COVID-19 pandemic. Their case rate during the period before and after COVID-19 pandemic was 205 and 949/100,000 ICU admissions, respectively (p < 0.001), with more frequent STSS after the COVID-19 pandemic (61% vs. 45%, p = 0.015). iGAS patients (n = 222) had a median SOFA score of 8 (5–13), invasive mechanical ventilation and norepinephrine in 61% and 74% of patients. ICU mortality in iGAS patients was 19% (14% before and 22% after COVID-19 pandemic; p = 0.135). In multivariate analysis, invasive mechanical ventilation (OR = 6.08 (1.71–21.60), p = 0.005), STSS (OR = 5.75 (1.71–19.22), p = 0.005), acute kidney injury (OR = 4.85 (1.05–22.42), p = 0.043), immunosuppression (OR = 4.02 (1.03–15.59), p = 0.044), and diabetes (OR = 3.92 (1.42–10.79), p = 0.008) were significantly associated with ICU mortality.ConclusionThe incidence of iGAS infections requiring ICU admission increased by 4 to 5 after the COVID-19 pandemic. After the COVID-19 pandemic, the rate of STSS was higher, with no significant increase in ICU mortality rate.

Timely and appropriate assessment and management within the ED impacts patient outcomes including in-hospital mortality and length of stay (LOS). Within the ED, several processes facilitate timely recognition of the need for intensive care unit (ICU) admission. This study describes characteristics and outcomes for patient presentations admitted to ICU from ED, categorised by Australasian Triage Score (ATS), ICU admission time and ICU admission source. A retrospective observational cohort study with linked health data of adult ICU admissions during 2012. Outcomes measured included: ED, ICU and hospital LOS, time to see ED clinician, ICU readmission and ICU and hospital mortality rates. In total, 423 ICU admissions occurred within 24 h of ED arrival; 395 were admitted directly to ICU; 28 were admitted to the ward before ICU admission. ATS 3/4/5 patients comprised 26.7% of ICU admissions and experienced longer waits to be seen, longer total ED LOS, shorter ICU LOS and a lower mortality rate than those triaged ATS 1/2. Compared to ICU admissions during business hours, admissions outside hours did not differ significantly for any outcome measured. Patients admitted to the ward before ICU experienced longer waits to be seen and longer ED LOS. Most patients are appropriately identified in ED as requiring ICU admission, although around one in four were triaged ATS 3/4. Patients admitted to the ward first tended to have poorer outcomes than those directly admitted to ICU. Factors predicting the need for ICU admission should be identified to support clinical decision-making.

The case-fatality rate of severe leptospirosis can exceed 50%. This retrospective cohort study examined 111 individuals with laboratory-confirmed leptospirosis admitted to Cairns Hospital, a referral hospital in tropical Australia, between January 2015 and June 2024. We examined the patients’ demographic, clinical, laboratory and imaging findings at presentation and then correlated them with the patients’ subsequent clinical course. Severe disease was defined as the presence of pulmonary haemorrhage or a requirement for intensive care unit (ICU) admission. The patients’ median (interquartile range) age was 38 (24–55) years; 85/111 (77%) were transferred from another health facility. Only 13/111 (12%) had any comorbidities. There were 63/111 (57%) with severe disease, including 56/111 (50%) requiring ICU admission. Overall, 56/111 (50%) required vasopressor support, 18/111 (16%) needed renal replacement therapy, 14/111 (13%) required mechanical ventilation and 2/111 (2%) needed extracorporeal membrane oxygenation. Older age—but not comorbidity—was associated with the presence of severe disease. Hypotension, respiratory involvement, renal involvement and myocardial injury—but not liver involvement—frequently heralded a requirement for ICU care. Every patient in the cohort survived to hospital discharge. Leptospirosis can cause multi-organ failure in otherwise well young people in tropical Australia; however, patient outcomes are usually excellent in the country’s well-resourced health system.

Introduction. Life-threatening complications of allogeneic hematopoietic stem cell transplantation (allo-HSCT) can have a significant influence on the short-term and long-term prognosis in recipients of hematopoietic stem cells (allo-HSCs).Aim — to determine the life-threatening complications and the risk factors of their occurrence and to evaluate the short-term and long-term prognosis in critically ill allo-HSCs recipients.Materials and methods. All patients over the age of 18 who underwent allo-HSCT from 01.01.2012 to 01.01.2022 were included in the retrospective study. Patients were divided into two groups: those who required intensive care unit (ICU) admission and those who did not require ICU admission. In the group of ICU admitted allo-HSCs recipients the reasons of ICU admission, timing of their occurrence and the results of life support were recorded. The risk factors of life-threatening complications occurrence and prognostic factors were analyzed.Results. In total, 174 (26.7 %) of 652 allo-HSCs recipients required ICU admission. The risk factors of life-threatening complications were: allo-HSCT in patients with acute leukemia who did not achieve complete remission (hazard ratio (HR) = 2.10; 95 % confidence interval (95% CI): 1.28–3.44; p = 0.003), allo-HSCT without conditioning in patients with hematopoietic aplasia after chemotherapy (HR = 30.63; 95% CI: 8.787–107.04; p &lt; 0.001), graft failure (HR = 2.51; 95% CI: 1.58–3.97; p &lt; 0.001) and poor graft function (HR = 2.85; 95% CI: 1.6–5.05; p &lt; 0.001), acute graft versus host disease (GVHD) (HR = 2.04; 95% CI: 1.459–2.85; p &lt; 0.001). The main reasons of ICU admission were sepsis and/or septic shock (SS) (27.9 %), acute respiratory failure (23.9 %), neurological disorders (17.7 %). The type and periods of allo-HSCT influenced the timing and structure of critical illnesses. The ICU mortality rate after all ICU admissions and readmissions was 59.8 % with a maximum follow-up of 9 years. The risk factors of ICU mortality were the occurrence of critical conditions after +30 days of allo-HSCT, the need for mechanical ventilation and vasopressors. The overall survival (OS) rate of ICU admitted allo-HSCs recipients was 13.8 %. Sepsis and/or SS that occurred in the early phase after allo-HSCT were characterized by the most favorable long-term outcome (OS — 43.8 %) among all complications of the peritransplantation period. The OS of patients discharged from the ICU was worse than OS of patients who did not require ICU admission (34.6 % vs. 58.3 %; p = 0.0013). Conclusion. Transplant centers should have a specialized ICU because more than a quarter of allo-HSCT recipients experience life-threatening complications at different allo-HSCT periods. Sepsis and SS occurring in the early pre-engraftment phase had a more favorable prognosis than other life-threatening complications. The long-term outcomes in allo-HSCs recipients who survived critical illness are worse than in recipients who did not require ICU admission.

Group A streptococcus bacteraemia: comparison of adults and children in a single medical centre