ICU-hospitalized Patients Research Articles

Ability of the SMART-COP score to predict the need for intensive care unit admission and mortality in older patients with non-ventilator-associated hospital-acquired pneumonia: A retrospective observational study.

To evaluate the ability of SMART-COP (systolic blood pressure, multilobar infiltrates, albumin, respiratory rate, tachycardia, confusion, oxygen and pH) score to predict the need for intensive care unit (ICU) admission and mortality among patients with non-ventilator-associated hospital-acquired pneumonia (NV-HAP) and to compare ICU-hospitalized patients with those followed-up in the clinic, as well as the patients who survived with those who died in the ICU, in terms of clinical and laboratory parameters. A total of 203 patients (aged > 65 years) who were diagnosed with NV-HAP while staying in the geriatric clinic were enrolled in this retrospective observational study. Patient information was retrieved from hospital files. In a total of 203 patients with NV-HAP, the rate of ICU admission was 77.3% and the rate of mortality was 40.9%. The SMART-COP score was significantly higher in those admitted to the ICU and those died in the ICU (ICU nonsurvivors). The rate of ICU mortality was 52.9%. The SMART-COP score had significantly poor to moderate ability to predict the need for ICU admission (area under the curve [AUC] = 0.583) and both in-hospital mortality (AUC = 0.633) and ICU mortality (AUC = 0.617) with low sensitivity. The regression analysis revealed that a one-unit increase in SMART-COP score resulted in a 1.2-fold increase in both the hospital and ICU mortality (P < 0.05 for both) and 1.1-fold increase in ICU admission (P = 0.154). The SMART-COP score has poor to moderate ability to predict the need for ICU admission, in-hospital mortality and ICU mortality, and a one-unit increase in the SMART-COP score significantly increases the risk of both hospital and ICU mortality. Geriatr Gerontol Int 2024; ••: ••-••.

Invasive pulmonary aspergillosis among patients with severe community-acquired pneumonia and influenza in ICUs: a retrospective cohort study

RationaleThe prevalence, clinical characteristics, and outcomes of invasive pulmonary aspergillosis in patients with severe community-acquired pneumonia (CAP) in intensive care units remain underestimated because of the lack of a disease-recognition scheme and the inadequacy of diagnostic tests.ObjectivesTo identify the prevalence, risk factors, and outcomes of severe CAP complicated with invasive pulmonary aspergillosis (IPA) in intensive care units (ICUs).MethodsWe conducted a retrospective cohort study including recruited 311 ICU-hospitalized patients with severe CAP without influenza or with influenza. Bronchoalveolar lavage fluid (BALF) samples were from all patients and subjected to mycological testing. Patients were categorized as having proven or probable Aspergillus infection using a modified form of the AspICU algorithm comprising clinical, radiological, and mycological criteria.Measurements and main resultsOf the 252 patients with severe CAP and 59 influenza patients evaluated, 24 met the diagnostic criteria for proven or probable Aspergillus infection in the CAP group and 9 patients in the influenza group, giving estimated prevalence values of 9.5% and 15.3%, respectively. COPD and the use of inhaled corticosteroids were independent risk factors for IPA. IPA in patients with severe CAP was significantly associated with the duration of mechanical support, the length of ICU stay, and the 28-day mortality.ConclusionsAn aggressive diagnostic approach for IPA patients with severe CAP and not only influenza or COVID-19 should be pursued. Further randomized controlled trials need to evaluate the timing, safety, and efficacy of antifungal therapy in reducing IPA incidence and improving clinical outcomes.

Tocilizumab in ICU-admitted COVID-19 Patients: A Retrospective Study.

Severe and critically-ill COVID-19 patients are characterized by a severe inflammatory response. Pharmacologic inhibition of acute-phase inflammatory pathways such as IL-6 receptor inhibitor, Tocilizumab (TCZ) may improve patient outcomes in these cases. Consequently, the therapeutic benefit of TCZ was evaluated in this study. We evaluated intravenous tocilizumab in severe and critically ill adult COVID-19 patients who met pre-defined stringent CRS criteria. A single-center, prospective, observational cohort study was carried out among consecutive adult (≥18 years of age) in-patients with COVID-19 between March 20, 2020 and March 20, 2021. In total, 354 patients were included in our study. Mortality and time to hospital discharge were compared between patients who received tocilizumab treatment (n = 177) and those who did not (n = 177). A total of 354 patients were analyzed whereas 177 patients were included in each group. In those receiving TCZ, all-cause mortality was significantly reduced, corresponding to an adjusted hazard ratio (HR) of 0.57, (95% confidence interval (CI): 0.43-0.76; P < 0.001). Furthermore, time to discharge was significantly improved in the TCZ group (HR: 1.66; 95%CI: 1.17-2.36, P = 0.004). Invasive mechanical ventilation was not statistically different among the study groups after adjusting for confounding variables (HR: 1.38; 95%CI: 0.89-2.14; P = 0.139). Dosing frequency was independent of survival status (P = 0.676). The use of TCZ in ICU-hospitalized patients resulted in improved patient survival and reduced duration of hospitalization. Further studies are needed to confirm the efficacy of TCZ in severe and critical COVID-19 cases.

SARS-CoV-2 infection and increasing autoimmune disorders among ICU-hospitalized COVID-19 patients.

In acute conditions, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes multi-organ damage due to the induction of inappropriate immune responses, particularly lung tissue fibrosis. To evaluate the consequence of the deterioration of the immune system, autoimmune markers were assessed. In a case-control study, 108 patients with coronavirus disease 2019 (COVID-19) were admitted to the intensive care unit (ICU), and 158 outpatients with mild clinical symptoms, with SARS-CoV-2 reverse transcription quantitative polymerase chain reaction (RT-qPCR) positive tests, were included for comparison. The demographic and hematologic variables and presence of the main autoantibodies in sera of 40 eligible ICU-hospitalized COVID-19 patients and 40 COVID-19 outpatients were assessed. Out of 108 COVID-19 ICU-hospitalized patients, 40 were selected as the control group (40/158) who had no underlying diseases before hospitalization, according to their self-declaration and clinical records at the time of admission. The results demonstrated that the main complete blood count indices, such as red blood cells and platelets, decreased dramatically in ICU-hospitalized patients. Furthermore, the autoantibody profiles were positive in 45% and 15% of ICU-admitted patients for antinuclear antibodies and antineutrophilic cytoplasmic autoantibodies, respectively. In ICU patients, anti-PM/Scl 100 or AMA-M2 was 33%. Anti SS-A, anti-SS-B, anti-Ro-52, and anti-Jo-1 in 11.5% for each one were reactive. Other autoantibodies of the ICU group were as follows: CENP (5.6%), Rib-protein (5.6%), and nucleosome (5.6%). However, only two individuals in the control group had positive results for SS-A and SS-B (5%). Induction of such particular autoantibodies by the virus can justify the multi-organ involvement and severity of the disease in ICU patients, which may also cause other organ involvement in the long term.

Investigation of Virulence Factors and Antibiotic Resistance of Pseudomonas aeruginosa Isolated from A Range of Clinical Samples

Objective: Pseudomonas aeruginosa is an opportunistic pathogen, is one of the leading nosocomial infection-causing agents and over time has developed multidrug resistance. One of the most common patient groups affected by P. aeruginosa are on the intensive care unit (ICU), an optimal environment for the development of antibiotic resistance. The aim of this study was to investigate virulence factors and antibiotic resistance profiles of P. aeruginosa isolated from hospitalized patients in Turkey. Methods: Samples from the general wards and ICU-hospitalized patients were included. A nutrient agar-elastin method was used for the biochemical activity of elastase. For las B assessment PCR was used while special production medium was used to assay pyoverdine and pyocyanin. Isolate biofilm production was tested with the crystal violet method. Standard broth microdilution was used for antibiotic susceptibility. Results: A total of 208 samples were assessed. The virulence factor frequencies in ICU and ward isolates, were: pyocyanin 86.2% and 86.7%, pyoverdine 90.1%, and 89.6%, elastase 68.6% and 67.9%, las B 93.1% and 89.6%, and biofilm production 51.9% and 48.1%, respectively. Antibiotic resistance rates in ICU and ward were: meropenem 41.1% and 28.9%, colistin 11.7% and 13.2%, ceftazidime 43.1%,and 41.1%, and cefepime 52.9% and 48.5%. Conclusion: Virulence factors were present in most of the hospitalized patient samples. However, antibiotic resistance rates were below 50%, except for cefepime. In addition, low rates of colistin resistance suggest that colistin resistance is not yet widespread in our hospital.

Association Between Neutrophil Density and Survival in Trauma Patients Admitted to the Intensive Care Unit; a Retrospective Cohort Study.

Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immune responses to trauma. This study aimed to evaluate the association of neutrophil changes with patients' survival in severe multiple trauma cases. The current retrospective cohort study was conducted using data from patients admitted in the intensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into three groups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and the association of neutrophil count with in-hospital mortality was analyzed. 2176 patients with the mean age of 37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in this series was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia (n = 14). There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p = 0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groups were 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank test showed a statistically significant difference between the three groups adjustment for ISS (p ≤ 0.001). For each unit increase in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also, in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients. In general, the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment was higher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was 15 times higher than the normal group.

Endocrine Aspects of ICU-Hospitalized COVID-19 Patients.

The unprecedented scale of the current SARS-CoV-2/COVID-19 pandemic has led to an extensive—yet fragmented—assessment of its endocrine repercussions; in many reports, the endocrine aspects of COVID-19 are lumped together in intensive care unit (ICU) patients and non-ICU patients. In this brief review, we aimed to present endocrine alterations in ICU-hospitalized patients with COVID-19. There are tangible endocrine disturbances that may provide fertile ground for COVID-19, such as preexisting diabetes. Other endocrine disturbances accompany the disease and more particularly its severe forms. Up to the time of writing, no isolated robust endocrine/hormonal biomarkers for the prognosis of COVID-19 have been presented. Among those which may be easily available are admission glycemia, thyroid hormones, and maybe (OH)25-vitamin D3. Their overlap among patients with severe and less severe forms of COVID-19 may be considerable, so their levels may be indicative only. We have shown that insulin-like growth factor 1 may have prognostic value, but this is not a routine measurement. Possibly, as our current knowledge is expanding, the inclusion of selected routine endocrine/hormonal measurements into artificial intelligence/machine learning models may provide further information.

Unique presentations of aspergillosis endogenous endophthalmitis in two hospitalized patients with severe COVID-19

We present two ICU-hospitalized patients with coronavirus disease-19 (COVID-19) presenting with endogenous endophthalmitis in one eye and variable manifestations of chorioretinitis in the fellow eye. Two diabetic patients (57 and 62 years old) showed anterior uveitis and yellowish-white subretinal infiltrations. The fellow eye of one patient showed patches of choroiditis, while the other showed full retinal thickness infiltrations. A workup yielded high serum titers of galactomannan, diagnostic of aspergillosis. The widespread use of high doses of corticosteroids in the management of COVID-19 may predispose to various secondary fungal opportunistic infections and may manifest in different forms of chorioretinal infiltration.

Persistently elevated complement alternative pathway biomarkers in COVID-19 correlate with hypoxemia and predict in-hospital mortality.

Mechanisms underlying the SARS-CoV-2-triggered hyperacute thrombo-inflammatory response that causes multi-organ damage in coronavirus disease 2019 (COVID-19) are poorly understood. Several lines of evidence implicate overactivation of complement. To delineate the involvement of complement in COVID-19, we prospectively studied 25 ICU-hospitalized patients for up to 21 days. Complement biomarkers in patient sera and healthy controls were quantified by enzyme-linked immunosorbent assays. Correlations with respiratory function and mortality were analyzed. Activation of complement via the classical/lectin pathways was variably increased. Strikingly, all patients had increased activation of the alternative pathway (AP) with elevated levels of activation fragments, Ba and Bb. This was associated with a reduction of the AP negative regulator, factor (F) H. Correspondingly, terminal pathway biomarkers of complement activation, C5a and sC5b-9, were significantly elevated in all COVID-19 patient sera. C5a and AP constituents Ba and Bb, were significantly associated with hypoxemia. Ba and FD at the time of ICU admission were strong independent predictors of mortality in the following 30 days. Levels of all complement activation markers were sustained throughout the patients’ ICU stays, contrasting with the varying serum levels of IL-6, C-reactive protein, and ferritin. Severely ill COVID-19 patients have increased and persistent activation of complement, mediated strongly via the AP. Complement activation biomarkers may be valuable measures of severity of lung disease and the risk of mortality. Large-scale studies will reveal the relevance of these findings to thrombo-inflammation in acute and post-acute COVID-19.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00430-021-00725-2.

The evaluation of vancomycin-resistant enterococci and carbapenamase producing Klebsiella colonization among ICU-Hospitalized Patients.

Multi-drug resistant organisms, especially Vancomycin-Resistant Enterococcus (VRE) and Carbapenam Resistant Klebsiella pneumoniae (KPC), are serious health threat. Early detection of resistant bacteria colonization among patients in intensive care units (ICUs) not only enables effective treatment but more importantly prevents disease and limits transmission. Therefore, we aimed to to assess the frequency of VRE and KPC colonization via rectal swab sampling. The study was carried out in ICUs of a tertiary hospital. Two rectal swab samples were collected within the first 24 hours of admission and another one was taken every subsequent 15 days to test for for VRE and KPC carriage. A total 316 rectal swab samples taken from 230 patients. Forty-seven patients were screened at least 2 times. 183 patients were not further screened due to discharge, exitus or transfer to other wards. Thirty-six patients (16%) were determined to be VRE (+). The most frequently isolated strain was E. faecium (80.5%) and its most common genotype was VanA (87.5%). Seven patients (3%) were identified as KPC (+). OXA-48 type crbapenamase was confirmed in all KPC isolates. This study shows that VRE and KPC colonization continues to be a serious threat in ICUs.

Analytical and clinical evaluation of four commercial SARS-CoV-2 serological immunoassays in hospitalized patients and ambulatory individuals

BackgroundThis study aimed to compare four anti-SARS-CoV-2 immunoassays in populations presenting different clinical severity levels. MethodsThree populations were included: “severe-to-critical” ICU-hospitalized patients (n = 18), “mild-to-moderate” hospitalized patients (n = 16) and non-hospitalized symptomatic patients (n = 24). Four commercial immunoassays were analyzed and validated: anti-IgG ARCHITECT® (Abbott), anti-Total antibodies (Ab) VITROS® (Ortho Clinical Diagnostics), anti-IgG NovaLisa® (NovaTec Immundiagnostica) and Healgen® IgM and IgG (Zhejiang Orient Gene Biotech). Sensitivities were evaluated according to days post-symptoms onset (pso). Specificities were evaluated on SARS-CoV-2-negative control sera collected before January 2020. ResultsA majority of severe-to-critically ill patients showed detectable Ab already at day 14 and sensitivities reached 100 % after 22 days pso. For patients with “mild-to-moderate” illness, sensitivities increased by at least 5-fold from day 0 to day 14 pso. Non-hospitalized symptomatic individuals already seroconverted at day 14 days pso with 100 % sensitivities for Total Ab VITROS®. Specificities were evaluated at 97 % for ARCHITECT® and NovaLisa®, 98 % for VITROS® and at 94 % for Healgen® combined IgM and IgG. Five “severe-to-critically” ill patients presented high positive Ab levels for at least 16 weeks pso. ConclusionThe Ab levels and the evaluated sensitivities, representing the true positive rate, increased overtime and were related to the COVID-19 severity. Automated Total Ab immunoassay showed better sensitivities and specificity for immunological surveillance and vaccine evaluation.

Molecular detection of vanA and vanB genes among vancomycin-resistant enterococci in ICU-hospitalized patients in Ahvaz in southwest of Iran.

ObjectiveNosocomial infections due to vancomycin-resistant enterococci (VRE) are known as a source of spreading these bacteria. The aim of this prospective study was molecular detection of vanA and vanB genes among VRE isolated from patients admitted to intensive care units (ICUs) in Ahvaz in southwest of Iran.Materials and methodsOverall, 243 non-duplicate rectal swab specimens were collected from ICU-hospitalized patients in teaching hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences, Iran. The specimens were inoculated on suitable culture media, and isolates were identified by standard biochemical tests. The susceptibility and resistance of enterococci to 10 antibiotics were determined based on the Clinical and Laboratory Standards Institute guidelines. Resistance to vancomycin was phenotypically detected by vancomycin screening test, and the vanA and vanB genes in vancomycin-resistant isolates were amplified by multiplex PCR method.ResultsOf 175 specimens containing enterococci, 129 (73.7%) isolates were detected as Enterococcus faecium and Enterococcus faecalis and 46 (26.3%) isolates as Enterococcus spp. The results of susceptibility test showed high rates of resistance to tetracycline, erythromycin, ciprofloxacin, and ampicillin. Moreover, based on this test, out of 129 Enterococcus isolates, 56 (43.4%) were resistant to vancomycin and teicoplanin. Also, among 59 vancomycin-resistant or semi-susceptible isolates, vanA gene was detected in 54 (91.5%) isolates, while none of the isolates had vanB gene.ConclusionAccording to the results of this study, to prevent the spread of vancomycin-resistant Enterococcus strains, especially in nosocomial infections, the susceptibility of isolates should be determined before vancomycin prescription.

Effects of early enteral bovine colostrum supplementation on intestinal permeability in critically ill patients: A randomized, double-blind, placebo-controlled study.

In this study we sought to investigate the effect of early enteral bovine colostrum supplementation on intestinal permeability in intensive care unit (ICU)-hospitalized patients. A total of 70 ICU-hospitalized adult patients were randomly assigned to receive a bovine colostrum supplement or placebo according to the stratified blocked randomization by age and admission category. Plasma endotoxin and zonulin concentrations were measured on days 5 and 10 of intervention. Out of 70 participants, 32 patients in the colostrum group and 30 patients in the control group were included in the final analysis of the outcomes. Plasma endotoxin concentration decreased significantly in the colostrum group on the 10th day (P < 0.05). Furthermore, plasma levels of zonulin reduced in the colostrum group significantly compared with the placebo group (P < 0.001).The incidence of diarrhea was significantly lower in the colostrum group than in the control group (P = 0.02). Our results provide evidence that bovine colostrum supplementation may have beneficial effects on intestinal permeability and gastrointestinal complications in ICU-hospitalized patients. Further studies are needed to investigate the exact mechanism of action of these effects.

Colonization With Methicillin-Resistant Staphylococcus aureus Upon Intensive Care Unit Admission: Incidence and Risk Factors

Background: Since earlier identification of methicillin-resistant Staphylococcus aureus (MRSA)-colonized patients could be helpful for reducing the overall frequency of S.aureus infections, the investigation of persons colonized with MRSA is considered to be a key component of MRSA infection prevention programs, particularly among ICU patients. Objectives: The aim of the present study was to evaluate the prevalence of nasal and extra-nasal carriers of MRSA and risk factors associated with MRSA colonization among adult patients admitted to the ICU. Methods: In a cross-sectional study, 164 adult patients who were admitted to the ICU of a teaching hospital were screened for nasal and extra-nasal carriage of MRSA. In addition, the ICU-hospitalized patients were evaluated for MRSA acquisition during their ICU stay. Results: Out of the 164 patients admitted to the ICU, 12 (7.3%) patients were methicillin-susceptible Staphylococcus aureus (MSSA) carriers, and 12 (7.3%) patients carried MRSA. Four (16.6%) patients were colonized at single or multiple extra-nasal sites based on neg- ative nares screening. Of the 15 remaining patients hospitalized at the ICU, one (6.7%) patient acquired MRSA. The patients colonized with MRSA had more advanced ages (P = 0.008), longer hospital stays before being transferred to the ICU (P > 0.001), more under- lying diseases with chronic obstructive pulmonary disease (COPD) (P = 0.028), and had undergone surgery (P = 0.003). Patients transferred from the surgical wards to the ICU were found to have significantly higher carriage rates of MRSA (P = 0.041). Conclusions: The prevalence of MRSA colonization upon ICU admission at our hospital was relatively high, and routine MRSA screening is suggested, especially for patients who have certain risk factors. In addition, extra-nasal MRSA screenings upon ICU admission will help in the early detection of MRSA.

Improved survival among ICU-hospitalized patients with community-acquired pneumonia by unidentified organisms: a multicenter case-control study.

A retrospective analysis from prospectively collected data was conducted in intensive care units (ICUs) at 33 hospitals in Europe comparing the trend in ICU survival among adults with severe community-acquired pneumonia (CAP) due to unknown organisms from 2000 to 2015. The secondary objective was to establish whether changes in antibiotic policies were associated with different outcomes. ICU mortality decreased (p = 0.02) from 26.9% in the first study period (2000-2002) to 15.7% in the second period (2008-2015). Demographic data and clinical severity at admission were comparable between groups, except for age over 65 years and incidence of cardiomyopathy. Over time, patients received higher rates of combination therapy (94.3 vs. 77.2%; p < 0.01) and early (<3h) antibiotic delivery (72.9 vs. 50.3%; p < 0.01); likewise, the 2008-2015 group was more likely to receive adequate antibiotic prescription [as defined by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines] than the 2000-2002 group (70.7 vs. 48.2%; p < 0.01). Multivariate analysis showed an independent association between decreased ICU mortality and early (<3h) antibiotic administration [odds ratio (OR) 3.48 [1.70-7.15], p < 0.01] or adequate antibiotic prescription according to guidelines (OR 2.22 [1.11-4.43], p = 0.02). In conclusion, our findings suggest that ICU mortality in severe CAP due to unidentified organisms has decreased in the last 15years. Several changes in management and better compliance with guidelines over time were associated with increased survival.

Clonal Relatedness among Imipenem-Resistant Pseudomonas aeruginosa Isolated from ICU-Hospitalized Patients.

Imipenem-resistant Pseudomonas aeruginosa (P. aeruginosa) has become an increasingly important problem in healthcare settings worldwide. The aim of the present study was to evaluate clonal spread among imipenem-resistant P. aeruginosa isolated from ICU-hospitalized patients. Totally, 150 wound specimens were analyzed. Antibiotic resistance profiles and clonal diversity were evaluated using Kirby-Bauer's disk diffusion method and Random Amplified Polymorphic DNA- (RAPD-) PCR, respectively. The isolates showed a high frequency of antibiotic resistance against meropenem, and imipenem (100%) followed by ciprofloxacin, and ceftazidime (90%); meanwhile resistance to polymyxin B was not observed. Eighteen (40%) of P. aeruginosa isolates were MBL-positive via ethylenediaminetetraacetic acid (EDTA) combined disk test. Our findings showed high genetic diversity, with 37 different RAPD types detected. RAPD typing results showed cross-acquisition of P. aeruginosa in investigated hospital, suggesting failure in infection control practices. Incidence of MBL-positive isolates is high and should be regarded as a threat to hospitalized patients.