All-cause Intensive Care Unit Research Articles

P-2305. Study of Prescribing patterns and Effectiveness of Ceftolozane/Tazobactam [C/T] Real-world Analysis Results (SPECTRA): Results of the Immunocompromised Patients

Abstract Background This sub-analysis of the SPECTRA (Study of Prescribing patterns and Effectiveness of Ceftolozane/Tazobactam [C/T] Real-world Analysis) study aimed to describe the clinical characteristics, treatment patterns, and outcomes of hospitalized adult immunocompromised patients.Table 1. Patient characteristics and Microbiology‡ For patients aged 90 or older the HCP was asked not to enter the exact age and to check a specific box. Therefore, patients aged 90 or older are included in 'Missing' and are not considered in the calculation of mean, median, etc. immunocompromised did not include chronic steroid use, age, or diabetes. Positive culture for more than one organism may apply for one patient. Missing data correspond to patients with no microbiological (MB) sample for index infection, that is without any MB sample performed within +/- 14 days around the index infection with a positive culture result and at least one GN antibacterial tested (whatever the susceptibility result is). Methods SPECTRA was a multicenter observational study conducted in 7 countries, with patients (age≥18yrs) who received ≥48-hours C/T treatment (n=617). Medical records were extracted covering a 6-month period prior to the index date, up to 30 days after the last dose of C/T or until death. All-cause in-hospital mortality (ACHM), clinical success, ICU admission, microbiology results, and treatment patterns in immunocompromised patients (IP, n=268) are reported. Immunocompromised patients were defined as patients with a Hematologic Malignancy or Solid Tumor or recipient of transplant. Transplant patients (TP) was 60% (n=160).Table 2. Clinical Outcomes: All-Cause In-Hospital Mortality and Clinical Success*Bile duct anostomic leakage, CMV infection, Post-operative Complication, Digestive hemorrhage, Invasive fungal infection, C difficile colitis(1) More than one criterion may apply for one patient. Results Median age was 57 (IP) and 50.5 years (TP). 66% and 67.5% were male, respectively.28.4% had respiratory-related infections (RRI), 22.7% had sepsis, 27.6% had septic shock, 13.4% had Cystic Fibrosis, 29.4% had pneumonia, 2.6% had bone and joint infection. ACHM was 24% for IP, and 23% for TP. Time from index date to death was a median of 29 and 35, respectively. Leading causes of death were sepsis (31%), multiorgan failure (29%), cancer (12%) for IP. Clinical success was 62.7% for IP. 84% (143/170) were Pseudomonas aeruginosa (PsA), and MDR PsA was 71.8% (n=122). 38.7% (n=98) received optimal dose. Up to 50% of the patients were admitted to ICU during the index hospitalization (n=133), and 46% of the ICU admissions were related to index infection. Median length of stay at ICU was 13 days.Table 3.Treatment patterns and Intensive Care Unit (ICU) Conclusion Treatment with C/T resulted in a high rate of clinical success in this real-world cohort of immunosuppressed patients, despite dosing that frequently deviated from labelled dosing. Pseudomonas aeruginosa including MDR isolates were frequently identified. Based on these results C/T is a useful option for the treatment of GN infections including those due to MDR PsA in the immunosuppressed patient population. Disclosures Emre Yucel, PhD, Merck: I am a full time Merck Employee and own stocks in the retirement plan provided by Merck.|Merck: Stocks/Bonds (Public Company) David Paterson, bioMerieux: Grant/Research Support|bioMerieux: Honoraria|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Shionogi: Grant/Research Support|Shionogi: Honoraria Florian Thalhammer, MD, MSD: Advisor/Consultant Stefan Kluge, Prof. Dr. med., Merck & Co: Advisor/Consultant|Merck & Co: Board Member Mike Allen, PhD, Merck: I am a full time Merck Employee and own stocks in the retirement plan provided by Merck.|Merck: Stocks/Bonds (Public Company) Brune Akrich, MD, Merck: I am a full time Merck Employee and own stocks in the retirement plan provided by Merck.|Merck: Stocks/Bonds (Public Company) Yanbing Zhou, PhD, Merck: I am a full time Merck Employee and own stocks in the retirement plan provided by Merck.|Merck: Stocks/Bonds (Public Company)

Critically ill adult patients with acute leukemia: a systematic review and meta-analysis

BackgroundTo describe the use of life-sustaining therapies and mortality in patients with acute leukemia admitted to the intensive care unit (ICU).MethodsThe PubMed database was searched from January 1st, 2000 to July 1st, 2023. All studies including adult critically ill patients with acute leukemia were included. Two reviewers independently selected the studies, assessed bias using the Newcastle-Ottawa scale for cohort studies, and performed data extraction from full-text reading. We performed a proportional meta-analysis using a random effects model. The primary outcome was all-cause ICU mortality. Secondary outcomes included reasons for ICU admission, use of organ support therapies (mechanical ventilation, vasopressors and renal replacement therapy), hospital, day-90 and one-year mortality rates.ResultsOf the 1,331 studies screened, 136 (24,861 patients) met the inclusion criteria and were included in the meta-analysis. Acute myeloid leukemia affected 16,269 (66%) patients, acute lymphoblastic leukemia affected 835 (3%) patients, and the type of leukemia was not specified in 7,757 (31%) patients. Acute respiratory failure (70%) and acute circulatory failure (25%) were the main reasons for ICU admission. Invasive mechanical ventilation, vasopressors and renal replacement therapy, were needed in 65%, 53%, and 23% of the patients, respectively. ICU mortality was available in 51 studies (6,668 patients, of whom 2,956 died throughout their ICU stay), resulting in a metanalytical proportion of 52% (95% CI [47%; 57%]; I2 93%). In a meta-regression, variables that influenced ICU mortality included year of publication, and intubation rate.ConclusionAcute respiratory failure is the main reason for ICU admission in patients with acute leukemia. Mechanical ventilation is the first life-sustaining therapy to be used, and also a strong predictor of mortality.Trial registrationThis study’s protocol was preregistered on PROSPERO (CRD42023439630).

Whole blood ratio of CDK1/CX3CR1 mRNA expression combined to lactate refines the prediction of ICU mortality in septic patients in the Sepsis-3 era: a proof-of-concept study.

Transcriptomics biomarkers have been widely used to predict mortality in patients with sepsis. However, the association between mRNA levels and outcomes shows substantial variability over the course of sepsis, limiting their predictive performance. We aimed to: (a) identify and validate an mRNA biomarker signature whose association with all-cause intensive care unit (ICU) mortality is consistent at several timepoints; and (b) evaluate how this mRNA signature could be used in association with lactate levels for predictive and prognostic enrichment in sepsis. We conducted a gene expression analysis study at two timepoints (day 1 and day 2-3 following ICU admission) using microarray data from adult septic patients to identify candidate biomarkers predictive of all-cause ICU mortality. We validated mRNA biomarkers using reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) on an external validation cohort. The predictive performance of the mRNA biomarkers combination was assessed in association with lactate level to refine ICU mortality prediction. Among 180 chips from 100 septic patients, we identified 39 upregulated and 2 downregulated differentially expressed genes (DEGs) in survivors vs. non-survivors, both at day 1 and days 2-3 following ICU admission. We combined CDK1, the hub gene of upregulated DEGs, and CX3CR1 and IL1b to compute expression ratios. The CDK1/CX3CR1 ratio had the best performance to predict all-cause ICU mortality, with an area under the ROC curve (AUROC) of 0.77 (95% confidence interval [CI] 0.88-0.66) at day 1 and of 0.82 (95% CI 0.91-0.72) at days 2-3 after ICU admission. This performance was better than that of each individual mRNA biomarker. In the external validation cohort, the predictive performance of the CDK1/CX3CR1 ratio, measured using RT-qPCR, was similar to that of lactate when measure at day 1, and higher when measured at days 2-3. Combining lactate levels and the CDK1/CX3CR1 ratio, we identify 3 groups of patients with an increasing risk of ICU-mortality, ranging from 9 to 60% with an intermediate-risk group mortality rate of 28%. With stable predictive performance over the first 3 days following ICU admission, the CDK1/CX3CR1 ratio identifies three groups of septic patients with increasing ICU mortality risk. In combination with lactate, this novel biomarker strategy may be useful for sepsis patient stratification for personalized medicine trials and ICU management.

PRISMA-7 is a predictor of intensive care unit admission and mortality in older patients in an emergency department.

To compare the performance of the Programme of Research on the Integration of Services for the Maintenance of Autonomy (PRISMA-7), which is used to assess the frailty of older patients visiting emergency departments, with the quick Sepsis Related Organ Failure Assessment (qSOFA) and Emergency Severity Index (ESI) in terms of 28-day mortality and intensive care unit (ICU) admission. This study was prospective and observational. All patients above the age of 65 who were admitted to the Sivas Republic University Medical Faculty Hospital from March 1 to April 30 in the year 2024 were included in the study. Patients' all-cause mortality values and ICU acceptance rates were evaluated for a 28-day period following their applications. The area under the receiver operating characteristic curve stood for the 28-day mortality, while the values for PRISMA-7, ESI, and qSOFA were, respectively, 0.81 (95% confidence interval [CI]: 0.78-0.84), 0.78 (95% CI: 0.72-0.83), and 0.71 (95% CI: 0.65-0.77). Our findings have demonstrated PRISMA-7 to be more effective than ESI and qSOFA in terms of hospitalization predictions. However, while it was found to be more effective than qSOFA in mortality predictions, it was determined that, despite PRISMA-7 having a larger AUC than ESI, no meaningful difference existed between PRISMA-7 and ESI. In conclusion, PRISMA-7, which is thought of as a reliable and valid tool for the determination of frailty in emergency departments, has predictive value for individuals' 28-day mortality risk as well as for their acceptance to the ICU. Geriatr Gerontol Int 2025; 25: 61-66.

Challenges Facing Two Outbreaks of Carbapenem-Resistant Acinetobacter baumannii: From Cefiderocol Susceptibility Testing to the Emergence of Cefiderocol-Resistant Mutants.

Carbapenem-resistant Acinetobacter baumannii (CRAB) infections are associated with poor outcomes depending on patient's conditions, clinical severity and type of infection, and treatment is challenging given the limited therapeutic options available. The aim of this study was to describe the clinical and microbiological characteristics of two outbreaks caused by CRAB in an intensive care unit (ICU). In addition, the mechanisms of resistance detected in these strains and the treatment chosen according to the available therapeutic options were analyzed. Overall, 28 patients were included. Ten patients (35.71%) had ventilator-associated pneumonia (VAP), ten (35.71%) had a bloodstream infection (BSI), and eight (28.57%) were only colonized. Recurrent infection occurred in 25% (5/20) of infected patients. Two different strains of A. baumannii were isolated from the index patient of the first outbreak. The first strain belonged to the ST85 and carried the blaNDM-1 carbapenemase gene, while the second belonged to the ST2 and carried blaOXA-23, and blaOXA-66 carbapenemase genes. The phylogenetic analysis revealed that the ST2 strain was the cause of the major outbreak, and mutations in the AmpC gene were related to progressive increasing minimum inhibitory concentration (MIC) and finally, cefiderocol-resistance in one strain. The CRAB isolates from the second outbreak were also identified as ST2. Cefiderocol-resistant strains tests identified by the disc diffusion method were involved in 24% (6/25) of nosocomial infections. Using broth microdilution (BMD) ComASP® only, 33.3% (2/6) of these strains were cefiderocol-resistant. All-cause ICU mortality was 21.4%. Conclusions: Cefiderocol is the first approved siderophore cephalosporin for the treatment of CRAB infections. Cefiderocol-resistant strains were related with blaNDM-1 carbapenemase and mutations in the AmpC gene. Cefiderocol-resistant strains or that cannot be properly interpreted by disk diffusion, should be retested using BMD for definitive categorization.

The Association of Withdrawing Maintenance Renin-Angiotensin System Inhibitor on All-Cause Mortality and Intensive Care Unit Admission Among Hypertensive Patients Admitted for Mild to Moderate COVID-19 infection:A Meta-analysis of Observational Studies

INTRODUCTION: The pandemic caused by coronavirus disease 2019 (COVID-19) posed a serious challenge to all health care systems in the world. It has been found to be harmful in people with underlying cardiovascular diseases, particularly in patients with systemic hypertension, which may be due to upregulation of angiotensin-converting enzyme 2 (ACE2) expression, which may lead to increased severe acute respiratory syndrome coronavirus 2 virulence. Renin-angiotensin system inhibitor (RASI) acts by blocking the angiotensin-converting enzyme and angiotensin II type 1 receptors, which in turn affects the production of the ACE2 protein. Hence, there have been arguments on whether to continue or discontinue this medication. Given the widespread use of RASIs globally and the fact that they are generally cardioprotective, research into the safety of continuing these maintenance medications in patients hospitalized with mild to moderate COVID-19 is immensely needed. METHODS: This meta-analysis involved review of observational studies among hypertensive patients on maintenance ACE inhibitor or angiotensin-receptor blocker with confirmed mild to moderate COVID-19 infection. Analyses were performed to determine the adjusted hazard ratio of each event using the raw data obtained from each study. Random-effects model and Cochran-Mantel-Haenszel method were utilized at 95% confidence interval. To check for heterogeneity, χ2 test and I2 statistic were calculated. Cochrane ReviewManager (RevMan version 5.3) was used for data analysis, and forest plots were generated. RESULTS: At 95% confidence interval, the adjusted hazard ratios for all-cause mortality and intensive care unit (ICU) admission at 95% confidence interval were 1.64 (1.22, 2.21) and 1.93 (1.34, 2.79), respectively. The tests of overall estimate effect for both outcomes were P < 0.0001 for all-cause mortality and P = 0.0003 for ICU admission. CONCLUSION: Discontinuation of maintenance RASI during hospitalization is associated with increased all-cause mortality and ICU admission among hypertensive patients with mild to moderate COVID-19 infection. KEYWORDS: angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, coronavirus, COVID-19, renin-angiotensin system inhibitor

The Effect of Pulmonary Hypertension on Mortality and Intensive Care Unit Admission in Patients With SARS-CoV-2 Infection: A Systematic Review and Meta-Analysis

Severe COVID-19 can cause acute respiratory distress syndrome, hypoxia, systemic complications, and increased mortality. Pulmonary hypertension (PH) is a major global health issue associated with worsening symptoms and increased mortality. This systematic review aimed to assess the influence of PH onset among COVID-19 patients on all-cause mortality and intensive care unit (ICU) admission. An unrestricted search of five databases up to June 2022 was undertaken. Pulmonary hypertension was assessed using transthoracic echocardiogram, computed tomography, or right heart catheterisation. After duplicate screening, data extraction, and risk of bias assessment, random effects meta-analyses of odds ratios (OR) and their 95% confidence intervals (CI) were performed for all-cause mortality and ICU admission. From the 26 studies that were included (3,373 patients, 76% males, median age 62.6 years), PH in COVID-19 patients was significantly associated with higher odds for all-cause mortality (26 studies; OR 3.89; 95% CI 2.85-5.31; p<0.001) and higher odds for ICU admission (six studies; OR 2.50; 95% CI 1.69-3.70; p<0.001). Meta-regression/subgroup analyses by patient demographics, comorbidities, or therapeutic regimens, and sensitivity analyses did not find any differences. Evidence from observational studies indicates that PH in COVID-19 patients is associated with increased odds of mortality and ICU admission.

Evaluating in vivo effectiveness of sotrovimab for the treatment of Omicron subvariant BA.2 versus BA.1: a multicentre, retrospective cohort study

BackgroundIn vitro data suggested reduced neutralizing capacity of sotrovimab, a monoclonal antibody, against Omicron BA.2 subvariant. However, limited in vivo data exist regarding clinical effectiveness of sotrovimab for coronavirus disease 2019 (COVID-19) due to Omicron BA.2.MethodsA multicentre, retrospective cohort study was conducted at three Canadian academic tertiary centres. Electronic medical records were reviewed for patients ≥ 18 years with mild COVID-19 (sequencing-confirmed Omicron BA.1 or BA.2) treated with sotrovimab between February 1 to April 1, 2022. Thirty-day co-primary outcomes included hospitalization due to moderate or severe COVID-19; all-cause intensive care unit (ICU) admission, and all-cause mortality. Risk differences (BA.2 minus BA.1 group) for co-primary outcomes were adjusted with propensity score matching (e.g., age, sex, vaccination, immunocompromised status).ResultsEighty-five patients were included (15 BA.2, 70 BA.1) with similar baseline characteristics between groups. Adjusted risk differences were non-statistically significant between groups for 30-day hospitalization (− 14.3%; 95% confidence interval (CI): − 32.6 to 4.0%), ICU admission (− 7.1%; 95%CI: − 20.6 to 6.3%), and mortality (− 7.1%; 95%CI: − 20.6 to 6.3%).ConclusionsNo differences were demonstrated in hospitalization, ICU admission, or mortality rates within 30 days between sotrovimab-treated patients with BA.1 versus BA.2 infection. More real-world data may be helpful to properly assess sotrovimab’s effectiveness against infections due to specific emerging COVID-19 variants.

Association between serum albumin creatinine ratio and all-cause mortality in intensive care unit patients with heart failure.

The serum albumin creatinine ratio (sACR) has been established as a potential indicator for heart disease, however, its relationship with prognosis in intensive care unit (ICU) patients with heart failure remains uncertain. This study aimed to investigate the association between sACR levels and all-cause mortality ICU patients with heart failure. Clinical data from MIMIC-Ⅳ database was utilized for the analysis of ICU patients with heart failure. Patients were categorized into quartiles (Q1-Q4) based on sACR levels. Kaplan-Meier survival analysis and multivariate adjusted Cox regression models were employed to assess the association between sACR levels and mortality outcomes within 365 days. Subgroup analysis was used to evaluate the prognostic impact of sACR across diverse populations. Restricted cubic spline curves and threshold effect analysis were utilized to quantify the dose-response relationship between sACR levels and risk of all-cause mortality. Mediating effects analysis was conducted to present the involvement of albumin and creatinine in the association between sACR and outcomes. The analysis encompassed a cohort of 4,506 patients, with Kaplan-Meier curves indicating that individuals with lower sACR levels exhibited an elevated risk of all-cause mortality (log-rank p < 0.001). Multivariate adjusted Cox regression and subgroup analysis demonstrated that individuals in Q2 [hazard ratio (HR) 0.82, 95%CI 0.71∼0.96], Q3 (HR 0.76, 95%CI 0.64∼0.91) and Q4 (HR 0.62, 95%CI 0.50∼0.76) had a decreased risk of mortality compared to individuals in Q1 (lower levels of sACR) (p for trend < 0.001), and this inverse relationship was consistently observed across various subgroups. Subsequent restricted cubic spline analysis revealed a negative yet nonlinear relationship between sACR and all-cause mortality (p for nonlinear < 0.001), and threshold effect analysis indicated an effect threshold of 3.75. Additionally, mediating effects analysis emphasized that sACR influenced the outcome not only through serum albumin and creatinine pathways, but also through direct mechanisms. The study found that low levels of sACR were independently associated with an increased risk of one-year all-cause mortality in ICU patients with heart failure, with a threshold effect, which could potentially serve as an early warning indicator for high-risk populations.

Prognostic value of serum phosphate levels in sepsis: a systematic review and meta-analysis.

There remain controversies over the conclusion of different serum phosphate levels as prognostic predictors of sepsis patients. As such, this study investigated the association between different serum phosphate and the prognosis of sepsis. Data from PubMed, Embase, Cochrane Library, and Web of Science were systematically retrieved from the inception of databases to June 1, 2023 and independently screened and extracted by two authors. Binary variables in the study were estimated as relative risk ratio (RR) and 95% confidence interval (CI), and continuous variables were estimated as mean and standard deviation. The Newcastle-Ottawa Scale (NOS) was employed to evaluate the quality of the included studies, and subgroup analysis and sensitivity analysis were performed for all outcomes to explore the sources of heterogeneity. Ten studies were included in this study including 38,320 patients with sepsis or septic shock. Against normal serum phosphate levels, a high serum phosphate level was associated with an elevated all-cause mortality risk (RR = 1.46; 95% CI [1.22-1.74]; P = 0.000) and prolonged Intensive Care Unit (ICU) length of stay (LOS) (WMD = 0.63; 95% CI [0.27-0.98]; P = 0.001). However, there was no significant difference in the in-hospital LOS (WMD = 0.22; 95% CI [-0.61-1.05]; P = 0.609). A low serum phosphate level was not significantly associated with the all-cause mortality risk (RR = 0.97; 95% CI [0.86-1.09]; P = 0.588), ICU LOS (WMD = -0.23; 95% CI [-0.75-0.29]; P = 0.394) and in-hospital LOS (WMD = -0.62; 95% CI [-1.72-0.49]; P = 0.274). Sepsis patients with high serum phosphate levels before therapeutic interventions were associated with a significant increase in the all-cause mortality risk, prolonged ICU LOS, and no significant difference in in-hospital LOS. Sepsis patients with low serum phosphate levels before interventions may have a reduced risk of all-cause mortality, shorter ICU LOS, and in-hospital LOS, but the results were not statistically significant.

Treatment with prophylactic oral anticoagulants and the risk of mortality in COVID-19 patients: a nationwide cohort study.

Venous thromboembolism has been reported in patients with coronavirus disease 2019 (COVID-19). It remains unclear if premorbid use of prophylactic oral anticoagulation, for reasons other than COVID-19, protects against death in patients with COVID-19. The aim of this study was to estimate if the risk of all-cause mortality, hospital admission or intensive care unit (ICU) admission for individuals with verified SARS-CoV-2 was lower if patients used oral anticoagulant (OAC) therapy prior to a positive COVID-19 status. Data were obtained using national health registries. Cohort entry was the day of a positive SARS-CoV-2 test, and individuals were followed for 14 days or until death or hospital admission. Adjusted Cox proportional hazard regressions and competing risk analyses were used to estimate the risk of all-cause mortality, hospital admission and ICU admission in OAC users compared with patients with no use of OAC. In this nationwide cohort study a total of 244 522 individuals were included (median age 35 years (interquartile range 21-52); 124 095 (51%) female), among whom 3710 (1.5%) were OAC users. In the adjusted Cox regression cohort, there was no difference in risk of all-cause mortality in OAC versus non-OAC users. (hazard ratio (HR) 1.13, 95% CI 0.99-1.30). Hospital admission risk (HR 1.11, 95% CI 1.02-1.20) was slightly increased in OAC users, and there was no difference between the groups regarding the risk of ICU admission (HR 0.96, 95% CI 0.74-1.24). In individuals with confirmed SARS-CoV-2, pre-existing treatment with OAC was not associated with prophylactic benefits in the prevention of hospital admission, ICU admissions or death. Prescription patterns should remain unchanged.

Major adverse cardiac events in critically ill COVID-19 patients

Abstract Background Critically ill patients hospitalized with COVID-19 are at high risk of developing major adverse cardiac events (MACE). Purpose This study aimed to identify independent predictors of MACE after intensive care unit (ICU) admission which could be used to identify high-risk patients who may benefit from preventive strategies. Methods We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded. Logistic regression analysis was performed to evaluate which clinical characteristics predicted MACE. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic). Results A total of 297 patients was included in the analysis. Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). From a total of 297 patients, 108 (36.4%) developed at least one MACE: ICU all-cause mortality (92 patients, 31.0%), new-onset heart failure (27 patients, 9.1%), acute coronary syndrome (7 patients, 2.4%), ventricular arrythmias (7 patients, 2.4%), pulmonary embolism (13 patients, 4.4%), myocarditis (4 patients, 1.3%), and stroke (5 patients, 1.7%). Univariate logistic regression analysis showed that the clinical variables associated with MACE were male sex, older age, APACHE II score, SAPS II score, hypertension, hyperlipidemia, known coronary artery disease, heart failure, new-onset atrial fibrillation, need for invasive mechanical ventilation, duration of mechanical ventilation, and vasopressor use. In multivariate logistic regression analysis, we found that the MACE's independent predictors were older age, higher APACHE II score, and new-onset atrial fibrillation. Main results are presented in Table 1. Conclusion(s) Among critically ill COVID-19 patients, older age, higher APACHE II score, and new-onset atrial fibrillation independently predicted MACE. Funding Acknowledgement Type of funding sources: None.

Atrial fibrillation in COVID-19 patients admitted to an intensive care unit: prevalence and prognosis

Abstract Background The association between atrial fibrillation (AF) and prognosis has been studied in non-COVID-19 patients, but few studies reflect the reality of critically ill COVID-19 patients admitted to a general intensive care unit (ICU). Purpose This study sought to investigate the relationship between previous and new-onset AF in COVID-19 patients admitted to an ICU and prognosis. Methods We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded from the analysis. Three groups were identified: without AF (G1), with prior history of AF (G2), and with new-onset AF (G3). Groups were compared, with special interest regarding ICU mortality, duration of mechanical ventilation, length of hospitalization, major adverse cardiac events (MACE), and re-hospitalization. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrhythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic). Results A total of 297 patients was included in the analysis: without AF (248 patients, 83.5%), with prior history of AF (15 patients, 5.1%), and with new-onset AF (34 patients, 11.4%). Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). Patients with a prior history of AF were older [median (IQR), G1 60 (16), G2 71 (12), G3 67 (15) years, p=0.001], were more likely to have a history of coronary artery disease (G1 4.9%, G2 26.7%, G3 11.8%, p=0.002), and history of heart failure (G1 6.5%, G2 33.3%, G3 17.6%, p&amp;lt;0.001). Patients with new-onset AF had a longer duration of mechanical ventilation [median (IQR), G1 9 (13), G2 11 (16), G3 18 (12) days, p&amp;lt;0.001), longer ICU length of stay [median (IQR), G1 12 (10), G2 13 (12), G3 19 (15), p=0.001], higher ICU mortality rate (G1 27.0%, G2 33.3%, G3 58.8%, p=0.001), and higher rate of MACE (G1 31.9%, G2 33.3%, G3 70.6%, p&amp;lt;0.001), compared to the other groups. There were no differences regarding sex distribution, other baseline comorbidities, need for invasive mechanical ventilation, vasopressor use, and re-hospitalization rates among groups. Most AF patients were treated with beta-blockers (39.6%) and amiodarone (77.1%), but only 68.8% of patients received anticoagulation (G2 92.9%, G3 58.8%), which may reflect that physicians underestimate the prognosis of new-onset AF. In multivariate analysis, new-onset AF (OR 3.07, 95% CI 1.42–6.67, p=0.005) and older age (OR 1.07, 95% CI 1.04–1.09, p&amp;lt;0.001) remained independent predictors of ICU mortality. Main results are presented in Table 1. Kaplan-Meier survival curves are presented in Figure 1. Conclusion(s) This study shows that critically ill COVID-19 patients with AF present a worse prognosis compared to patients without AF, and new-onset AF is an independent predictor of ICU mortality and MACE. Funding Acknowledgement Type of funding sources: None.

The Combined Use of Interleukin-6 with Serum Albumin for Mortality Prediction in Critically Ill Elderly Patients: The Interleukin-6-to-albumin Ratio.

The association between interleukin-6 (IL-6) and serum albumin (ALB) with mortality in critically ill elderly patients, either as stand-alone biomarkers or in combination, has been scarcely reported. We, therefore, aimed to investigate the prognostic value of the IL-6-to-albumin ratio in this special population. This was a cross-sectional study conducted in the mixed intensive care unit (ICU) of two university-affiliated hospitals in Malaysia. Consecutive elderly patients (aged above or equal to 60 years) admitted to the ICU, who underwent simultaneous measurement of plasma IL-6 and serum ALB, were recruited. The prognostic value of the IL-6-to-albumin ratio was assessed by analysis of the receiver-operating characteristic (ROC) curve. A total of 112 critically ill elderly patients were recruited. The outcome of all-cause ICU mortality was 22.3%. The calculated IL-6-to-albumin ratio was significantly higher in the non-survivors compared to the survivors {14.1 [interquartile range (IQR), 6.5-26.7] vs 2.5 [(IQR, 0.6-9.2) pg/mL, p <0.001]}. The area under the curve (AUC) of IL-6-to-albumin ratio for discrimination of ICU mortality was 0.766 [95% confidence interval (CI), 0.667-0.865, p <0.001] which was slightly higher than that of IL-6 and albumin alone. The ideal cut-off value of the IL-6-to-albumin ratio was above 5.7 with a sensitivity of 80.0% and specificity of 64.4%. After adjusting for severity of illness, the IL-6-to-albumin ratio remained as an independent predictor of ICU mortality with an adjusted odd ratio of 0.975 (95% CI, 0.952-0.999, p = 0.039). The IL-6-to-albumin ratio offers a slight improvement in mortality prediction than either of its constituent individual biomarkers and as such, it may be a potential tool to aid in the prognostication of critically ill elderly patients although this requires further validation in a larger prospective study. Lim KY, Shukeri WFWM, Hassan WMNW, Mat-Nor MB, Hanafi MH. The Combined Use of Interleukin-6 with Serum Albumin for Mortality Prediction in Critically Ill Elderly Patients: The Interleukin-6-to-albumin Ratio. Indian J Crit Care Med 2022;26(10):1126-1130.

Neutrophil-to-lymphocyte ratio as a predictor of clinical outcomes in critically ill COVID-19 patients: A retrospective observational study.

BackgroundTimely identification of patients at risk of worse clinical outcomes is vital in managing coronavirus disease 2019 (COVID‐19). The neutrophil‐to‐lymphocyte ratio (NLR) calculated from complete blood count can predict the degree of systemic inflammation and guide therapy accordingly. Hence, we did a study to investigate the role of NLR value on intensive care unit (ICU) admission in predicting clinical outcomes of critically ill COVID‐19 patients.MethodsWe conducted a retrospective analysis of electronic health records of COVID‐19 patients admitted to ICUs at Hazm Mebaireek General Hospital, Qatar, from March 7, 2020 to July 18, 2020. Patients with an NLR equal to or higher than the cut‐off value derived from the receiver operating characteristic curve were compared to those with an NLR value below the cut‐off. The primary outcome studied was all‐cause ICU mortality. The secondary outcomes evaluated were the requirement of mechanical ventilation and ICU length of stay (LOS).ResultsFive hundred and nineteen patients were admitted to ICUs with severe COVID‐19 infection during the study period. Overall, ICU mortality in the study population was 14.6% (76/519). NLR on ICU admission of ≥6.55 was obtained using Youden's index to predict ICU mortality, with a sensitivity of 81% and specificity of 41%. Mortality was significantly higher in patients with age ≥60 years (p < 0.001), chronic kidney disease (p = 0.03), malignancy (p < 0.002), and NLR ≥ 6.55 (p < 0.003). There was also a significant association between the requirement of mechanical ventilation (34.7% vs. 51.8%, p < 0.001) and increased ICU LOS (8 vs. 10 days, p < 0.01) in patients with ICU admission NLR ≥ 6.55.ConclusionHigher NLR values on ICU admission are associated with worse clinical outcomes in critically ill COVID‐19 patients.

Ability of a modified Sequential Organ Failure Assessment score to predict mortality among sepsis patients in a resource-limited setting.

BackgroundSome variables of the Sequential Organ Failure Assessment (SOFA) score are not routinely measured in sepsis patients, especially in countries with limited resources. Therefore, this study was conducted to evaluate the accuracy of the modified SOFA (mSOFA) and compared its ability to predict mortality in sepsis patients to that of the original SOFA score.MethodsSepsis patients admitted to the medical intensive care unit of Songklanagarind Hospital between 2011 and 2018 were retrospectively analyzed. The primary outcome was all-cause in-hospital mortality.ResultsA total of 1,522 sepsis patients were enrolled. The mean SOFA and mSOFA scores were 9.7±4.3 and 8.8±3.9, respectively. The discrimination of the mSOFA score was significantly higher than that of the SOFA score for all-cause in-hospital mortality(area under the receiver operating characteristic curve, 0.891 [95% confidence interval, 0.875–0.907] vs. 0.879 [0.862–0.896]; P<0.001), all-cause intensive care unit (ICU) mortality (0.880 [0.863–0.898] vs. 0.871 [0.853–0.889], P=0.01) and all-cause 28-day mortality (0.887 [0.871–0.904] vs. 0.874 [0.856–0.892], P<0.001). The ability of mSOFA score to predict all-cause in-hospital and 28-day mortality was higher than that of the SOFA score within the subgroups of sepsis according to age, sepsis severity and serum lactate levels. The mSOFA score was demonstrated to have a performance similar to the original SOFA score regarding the prediction of mortality in sepsis patients with cirrhosis or hepatic dysfunction.ConclusionsThe mSOFA score was a good alternative to the original SOFA core in predicting mortality among sepsis patients admitted to the ICU.

Carbapenem-Resistant Enterobacteriaceae: A Retrospective Review of Presentation, Treatment, and Clinical Outcomes in a Tertiary Care Referral Hospital

Background: Carbapenem-resistant Enterobacteriaceae (CRE) is an emerging infectious threat with an increasing incidence locally and worldwide. It carries a high morbidity and mortality; focusing on this topic should be a priority in clinical research as local data are not widely available. The objective of this study is to describe the presentation, risk factors, treatment pattern and clinical outcomes associated with CRE infections.Methods: We conducted a cross-sectional retrospective study in a single center tertiary referral hospital. We included adult patients above 18 years of age with infection due to CRE between January 1, 2018, to December 30, 2019. Results: During this period, 76 cases were studied. The mean age of the cases was 54 years. The majority were immunosuppressed and admitted to the intensive care unit. The most frequent risk factors associated with CRE infection among study subjects included prior antibiotics in the preceding three months and prior hospital admission in the last one year. Klebsiella pneumoniae (77%) represented the most isolated organism. All-cause intensive care unit and in-hospital mortality were significantly higher among patients with pneumonia and bacteremia. Conclusions: CRE infections are associated with higher morbidity and mortality specifically in patients who presented with pneumonia and bacteremia. High resistance rate and limited treatment options have made a great variability in the clinical practice. Appropriate definitive treatment of CRE infections, strict infection control measures, and antimicrobial stewardship program activation are essential.

A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit.

Sepsis leads to left and/or right ventricular systolic and/or diastolic dysfunction resulting in adverse outcomes. Myocardial dysfunction can be diagnosed by echocardiography (ECHO) and early intervention can be planned. There are lacunae in Indian literature regarding the true incidence of septic cardiomyopathy and its influence on the outcome of patients admitted to intensive care unit (ICU). This prospective observational study was conducted on patients consecutively admitted with sepsis to the ICU of a tertiary care hospital in North India. In these patients, ECHO was performed after 48-72 hours to establish left ventricular (LV) dysfunction, in whom the ICU outcome was analyzed. The incidence of LV dysfunction was 14%. About 42.86% of patients had isolated systolic dysfunction, 7.14% of patients had isolated diastolic dysfunction, and 50.00% of patients had combined LV systolic and diastolic dysfunctions. The average days of mechanical ventilation in patients without LV dysfunction group (group I) was 2.41 ± 3.82 days as compared to 4.43 ± 4.27 days in patients with LV dysfunction (group II) (p = 0.034). Incidence of all-cause ICU mortality was 11 (12.79%) in group I and 3 (21.43%) in group II (p = 0.409). The mean duration of stay in ICU was 8.26 ± 4.41 days in group I as compared to 13.21 ± 6.83 days in group II. We concluded that sepsis-induced cardiomyopathy (SICM) in ICU is quite prevalent and clinically significant. All-cause ICU mortality and length of ICU stay are prolonged in patients with SICM. Bansal S, Varshney S, Shrivastava A. A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit. Indian J Crit Care Med 2022;26(7):798-803.

Clinical outcomes of severe sepsis and septic shock patients with left ventricular dysfunction undergoing continuous renal replacement therapy

Baseline left ventricular (LV) dysfunction is associated with subsequent risks of acute kidney injury (AKI) and mortality in patients with sepsis. This study investigated the therapeutic effects of continuous renal replacement therapy (CRRT) in hemodynamically unstable patients with severe sepsis and septic shock combined with LV dysfunction. In this multicenter retrospective study, severe sepsis and septic shock patients with LV dysfunction were classified into one of two groups according to the timing of CRRT: the early group (before AKI was detected) or the control group (patients with AKI). Patients from the control group received an accelerated strategy or a standard strategy of CRRT. The primary outcome was all-cause intensive care unit (ICU) mortality. Patients were weighted by stabilized inverse probability of treatment weights (sIPTW) to overcome differences in baseline characteristics. After sIPTW analysis, the ICU mortality was significantly lower in the early group than the control group (27.7% vs. 63.5%, p < 0.001). Weighted multivariable analysis showed that early CRRT initiation was a protective factor for the risk of ICU mortality (OR 0.149; 95% CI 0.051–0.434; p < 0.001). The ICU mortality was not different between the accelerated- and standard-strategy group (52.5% vs. 52.9%, p = 0.970). Early CRRT in the absence of AKI is suggested for hemodynamically unstable patients with severe sepsis and septic shock combined with LV dysfunction since it benefits survival outcomes.

Delayed intubation is associated with mortality in patients with severe COVID-19: A single-centre observational study in Switzerland

IntroductionSwitzerland experienced two waves of COVID-19 in 2020, but with a different ICU admission and treatment management strategy. The timing of ICU admission and intubation remains a matter of debate in severe patients. The aim of our study was to describe the characteristics of ICU patients between two subsequent waves of COVID-19 who underwent a different management strategy and to assess whether the timing of intubation was associated with differences in mortality.Patients and methodsWe conducted a prospective observational study of all adult patients with acute respiratory failure due to COVID-19 who required intubation between the 9th of March 2020 and the 9th of January 2021 in the intensive care unit (ICU) at Geneva University Hospitals, Switzerland.ResultsTwo hundred twenty-three patients were intubated during the study period; 124 during the first wave, and 99 during the second wave. Patients admitted to the ICU during the second wave had a higher SAPS II severity score (52.5 vs. 60; p = 0.01). The time from hospital admission to intubation was significantly longer during the second compared to the first wave (4 days [IQR, 1-7] vs. 2 days [IQR, 0-4]; p < 0.01). All-cause ICU mortality was significantly higher during the second wave (42% vs. 23%; p < 0.01). In a multivariate analysis, the delay between hospital admission and intubation was significantly associated with ICU mortality (OR 3.25 [95% CI, 1.38-7.67]; p < 0.05).ConclusionsIn this observational study, delayed intubation was associated with increased mortality in patients with severe COVID-19. Further randomised controlled trials are needed.