Infectious Diseases Intensive Care Unit Research Articles

Colonization, Infection and Risk Factors for Death in an Infectious Disease ICU in Romania

Knowing the bacterial strains in the intensive care unit (ICU) is important for reducing the rate of bacterial transmission and the risk of healthcare-associated infections (HAIs), allowing for targeted interventions to reduce the risk of death by HAIs. W

Upper gastrointestinal bleeding in adults treated with veno-arterial extracorporeal membrane oxygenation: a cohort study.

Upper gastrointestinal bleeding is a common complication in adults treated with veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for refractory cardiogenic shock or cardiac arrest. We aimed to determine risk factors, prevalence and outcomes associated VA-ECMO-associated upper gastrointestinal bleeding (UGIB) in adult patients. We conducted a retrospective cohort study (2014-2022) on consecutive VA-ECMO patients in the Medical and Infectious Disease intensive care unit of university hospital Bichat-Claude Bernard in Paris, France. UGIB was defined as 1) an overt bleeding (hematemesis, melena, hematochezia), or 2) acute anemia associated with a lesion diagnosed on upper gastrointestinal endoscopy. VA-ECMO-associated UGIB was defined as an UGIB occurring during VA-ECMO, or up to ten days after decannulation in patients weaned-off ECMO. Cause-specific models were used to identify factors associated with UGIB and death, respectively. Among the 455 patients included, 48 (10%) were diagnosed with UGIB after a median of 12 [7; 23] days following ECMO cannulation. Mortality occurred in 36 (75%) patients with UGIB and 243 (60%) patients without. UGIB patients had longer ICU stays (32 [19; 60] vs 18 [7; 37] days; p<.01), longer ECMO (14 [9; 18] vs 7 [4; 11] days; p <.01) and mechanical ventilation durations (21 [16; 36] vs. 10 [5; 20] days; p <.01), as compared to non-UGIB patients. Ninety upper gastrointestinal endoscopies (UGE) were performed, and the most frequent lesions detected were gastro-duodenal ulcers (n = 23, 26%), leading to 11/90 therapeutic procedures. By multivariable analysis, a history of peptic ulcer (Cause-specific hazard ratio (CSHR) 2.93, 95%CI 1.01; 8.51), a dual antiplatelet therapy (CSHR 2.0, 95%CI 1.07; 3.72]) and extracorporeal cardiopulmonary resuscitation (ECPR) (CSHR 2.78, 95%CI 1.42; 5.45) were independently associated with an increased risk of UGIB. In adult patients under VA-ECMO, a history of gastric ulcer, dual antiplatelet therapy and ECPR were independently associated with an increased risk of UGIB. This study highlights the potential role of acute ischemia reperfusion injury in the pathophysiology of VA-ECMO-associated UGIB.

Should Preventive Antifungal Treatment Be Given to Patients With Abdominal Contamination in the Intensive Care Unit?

Background Intra-abdominal contamination is a critical risk factor for candidemia. Because of the high mortality of candidemia and delayed results of cultures, preventive antifungal (AF) treatment can be administered. Especially in the intensive care unit (ICU), it may be necessary to determine the preventive AF approach due to the poor clinical condition of the patients. However, this practice is not standard among clinicians, and it is controversial whether it is beneficial or not. This study aimed to evaluate the effects of different AF treatment approaches (prophylactic, empirical, and culture-directed) on mortality, development of candidemia, and length of hospital stay in these patients. The primary outcome of the study was mortality, and the secondary outcomes were the development of candidemia and length of hospital stay. Methodology This is a retrospective, single-center, cohort study. Adult patients who were hospitalized in the ICU with the diagnosis of intra-abdominal contamination between January 1, 2017, and December 31, 2020, were reviewed retrospectively from electronic hospital records and Infectious Diseases ICU patient follow-up forms. Age, gender, comorbid diseases, the reason for hospitalization, history of surgical operation, surgical procedure type, length of hospital stay, culture results of blood and intraoperative intra-abdominal samples (pus, peritoneal fluid, abscess), type of AF agents, and mortality status of the patients were recorded. Furthermore, white blood cell (WBC) count, platelet count, C-reactive protein (CRP) level, procalcitonin (PCT) level, and serum albumin levels in blood samples taken on three different days (the day of diagnosis, the day of operation, and the day of candidemia) were examined. The patients were grouped as without AF, receiving prophylactic AF, receiving empirical AF, and receiving culture-directed AF. Additionally, the study population was evaluated by dividing it into two groups, namely, those who developed candidemia and those who did not. The patients were evaluated regarding the development of candidemia, AF treatment approach, length of hospital stay, and mortality. Results A total of 196 patients were included in the study. Candidemia was determined in 31.6% of the patients. Candidemia was more common in patients with a history of previous surgery and presenting with acute abdominal pain than other causes. It was determined that 70% of the patients who developed candidemia had perforation, with the most common being colonic perforation. The hospital stay was longer in patients with candidemia than without candidemia (47.9 vs. 22.4 days; p < 0.001). When empirical and prophylactic AF recipients were compared, there was no difference in mortality and length of hospital stay. Prolongation of the time to empirical treatment after perforation/leak was associated with increased candidemia (p = 0.004). Furthermore, patients with a waiting time of ≥4.5 days until surgical operation were at a higher risk of developing candidemia. Conclusions Although the study did not demonstrate a difference in terms of reducing mortality, it was concluded that preventive AF therapy can be administered to reduce the risk of candidemia and hospitalization duration, especially in patients with a history of previous surgical operations and abdominal contamination with a prolonged waiting period until the surgical operation.

Optimiertes Delirmanagement im psychiatrischen Konsiliardienst im Versorgungskrankenhaus

Im Vergleich zu überwiegend somatischen Fällen beschreibt die Literatur einen deutlich negativen Effekt bei somatisch-psychiatrischer Komorbidität. Betroffen sind die Verweildauer, die Wiederaufnahmewahrscheinlichkeit, die Mortalität und die Pflegebedürftigkeit. Untersucht wurde, ob durch den standardisierten Einsatz psychiatrischer Interventionen eine Verbesserung des psychischen Zustands und des somatischen Krankheitsverlaufs erreicht werden kann.Zusammengearbeitet wurde dafür mit der infektiologischen Intensivstation (ICU, C11) der 4. medizinischen Abteilung mit Infektions- und Tropenmedizin der Klinik Favoriten (Wiener Gesundheitsverbund). Im Rahmen der Akutphase der Behandlung einer COVID-19-Pneumonie und des damit verbundenen internistischen Managements war ein kritischer Punkt das Auftreten eines Delirs. Mithilfe eines psychiatrischen Interventionsprotokolls mit dem Ziel des gezielten Erkennens eines Delirs und spezifisch festgelegter Reaktionen sollte diese kritische Phase schnell und erfolgreich begleitet werden.Im Ergebnis kam es zu einer Qualitätsverbesserung in Bezug auf das Delirmanagement, die Schweregrade der beobachteten Delirien konnten vermindert und eine annehmbarere Gestaltung des Delirsyndroms für die Betroffenen erreicht werden. Die regelhaft angewandten Maßnahmen des Protokolls führten zu einer Effizienzsteigerung. Diese äußerte sich auch in einer Abnahme der Frequenz psychiatrischer Konsile. Die frei werdenden Zeiten konnten zur Bedarfsdeckung an anderen Abteilungen genutzt werden, ohne neue Personalressourcen zur Verfügung stellen zu müssen.

Poor prognosis of patients with severe COVID-19 admitted to an infectious disease intensive care unit during the pandemic caused by the Delta variant in Japan.

During the surge of coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) delta variant, our institution operated an intensive care unit (ICU) for patients with severe COVID-19. The study aim was to determine the survival rate and treatment outcomes of patients with severe COVID-19 treated in the ICU during the surge. A total of 23 consecutive patients with severe COVID-19 were admitted to the ICU between August 5 and October 6, 2021. Patients received multidrug therapy consisting of remdesivir, tocilizumab, heparin, and methylprednisolone. The patients were divided into two groups based on the ordinal scale (OS): a non-invasive oxygen therapy (OS-6) group, and an invasive oxygen therapy (OS-7) group. There were 13 (57%) and 10 (43%) patients in the OS-7 and OS-6 groups, respectively. All patients were unvaccinated. Sixteen patients (70%) were male. The median age was 53 years; the median body mass index (BMI) was 30.3 kg/m2; and the median P/F ratio on admission was 96. The 30-day survival rate was 69% and was significantly poorer in the OS-7 group (54%) than in the OS-6 group (89%; p = 0.05). The prevalence of obesity (p = 0.05) and the Sequential Organ Failure Assessment (SOFA) score on admission (p < 0.01) were significantly higher in the OS-7 group. Seven patients in the OS-7 group (54%) developed bacteremia. A low P/F ratio on admission was a significant unfavorable prognostic factor (hazard ratio: 10.9; p = 0.03). The survival rate was poor, especially in patients requiring invasive oxygen therapy. More measures are needed to improve the treatment outcomes of patients with severe COVID 19.

Delirium severity in critical patients with COVID-19 from an Infectious Disease Intensive Care Unit

BackgroundCOVID-19 is mainly characterized by respiratory manifestations. Nevertheless, neurologic complications have been described, including delirium, which appears to be frequent, prolonged, and severe. MethodsWe conducted a retrospective analysis of demographic, clinical, and laboratory data of two cohorts: patients with COVID-19 admitted to the infectious disease intensive care unit (ID-ICU) and patients admitted to the ID-ICU with other respiratory infections in 2018-2019. Outcomes were defined as the presence, duration, and severity of delirium. Doses of antipsychotics used to control delirium were converted to equivalents and used as delirium severity. Logistics regression models were used to correlate COVID-19 with the outcomes. ResultsNinety-nine patients with COVID-19 and 40 patients without COVID-19 were included. The mean age of the COVID-19 cohort was 63 years, with a male predominance. Delirium developed in 42%, with a median duration of 3 days and an equivalent dose of olanzapine use of 10 mg/day.In univariate analysis, COVID-19 was not associated with the development or different duration of delirium when compared with patients without COVID-19. There was an association between COVID-19 and severity of delirium in a binary logistic regression model controlled to confounding variables. ConclusionCOVID-19 is not associated with a higher prevalence or duration of delirium than in cohorts without COVID-19. However, it is associated with more severe forms of delirium.

Central nervous system infection in the intensive care unit: Development and validation of a multi-parameter diagnostic prediction tool to identify suspected patients.

Central nervous system infections (CNSI) are diseases with high morbidity and mortality, and their diagnosis in the intensive care environment can be challenging. Objective: To develop and validate a diagnostic model to quickly screen intensive care patients with suspected CNSI using readily available clinical data. Derivation cohort: 783 patients admitted to an infectious diseases intensive care unit (ICU) in Oswaldo Cruz Foundation, Rio de Janeiro RJ, Brazil, for any reason, between 01/01/2012 and 06/30/2019, with a prevalence of 97 (12.4%) CNSI cases. Validation cohort 1: 163 patients prospectively collected, between 07/01/2019 and 07/01/2020, from the same ICU, with 15 (9.2%) CNSI cases. Validation cohort 2: 7,270 patients with 88 CNSI (1.21%) admitted to a neuro ICU in Chicago, IL, USA between 01/01/2014 and 06/30/2019. Prediction model: Multivariate logistic regression analysis was performed to construct the model, and Receiver Operating Characteristic (ROC) curve analysis was used for model validation. Eight predictors-age <56 years old, cerebrospinal fluid white blood cell count >2 cells/mm3, fever (≥38°C/100.4°F), focal neurologic deficit, Glasgow Coma Scale <14 points, AIDS/HIV, and seizure-were included in the development diagnostic model (P<0.05). The pool data's model had an Area Under the Receiver Operating Characteristics (AUC) curve of 0.892 (95% confidence interval 0.864-0.921, P<0.0001). A promising and straightforward screening tool for central nervous system infections, with few and readily available clinical variables, was developed and had good accuracy, with internal and external validity.

Changes in the clinical presentation and outcomes of patients treated for severe malaria in a referral French university intensive care unit from 2004 to 2017

BackgroundIn France, the incidence of severe imported malaria cases increased since early 2000. Artesunate was available (temporarily use authorization) since mid-2011 in France and commonly used for severe malaria since early 2013. Thus, the study objectives were to describe the patients with severe imported malaria admitted in intensive care unit (ICU) and assess the changes in clinical presentation and outcomes before and after this date.MethodsRetrospective observational single-center study in the infectious diseases ICU of a referral university hospital, conducted on patients admitted for severe imported malaria from 2004 to 2017. Demographic variables, severity scores, WHO’s severity criteria on admission, treatment, and ICU and hospital lengths of stay were collected. Patients’ characteristics and outcomes were compared between both periods. A poor outcome was defined as the composite endpoint of death, or requirement for vasopressors, invasive mechanical ventilation and/or renal replacement therapy.Results189 patients were included, 98 in 2004–2012 and 91 in 2013–2017, most often from West and Central African countries (96%). The number of WHO criteria for severe malaria was comparable in both groups, but SAPS II, SOFA and ICU length of stay were significantly higher in 2004–2012, while patients of African origin living in France were less frequent (p < 0.01). The outcome was poor for 41/98 cases in 2004–2012 and 12/91 cases in 2013–2017 (p < 0.01). The risk factors of poor outcome on the multivariate logistic regression were a neurological failure (adjusted odds ratio (adjOR = 3.23; 95% CI (1.03–10.08), p = 0.004), cardio-circulatory failure (adjOR = 9.92; 95% CI (2.34–42), p = <0.01) and creatinine blood levels > 265 µmol/L (adjOR = 10.76; 95% CI (3.17–36.53), p < 0.01). In the multivariate analysis, IV artesunate was not associated with a better outcome. Patients of African origin did not seem to have a better outcome than Caucasian patients or those from other origins (adjOR = 0.59; 95% CI (0.21–1.65), p = 0.31).ConclusionPatients with imported malaria admitted in ICU in 2013–2017 were less severely ill than those in 2004–2012. These trends could be partially explained by the increasing proportion of African patients visiting friends or relatives or living in endemic areas.

2118. Heathcare-Associated Infection in Intensive Care Patients Infected and Non-infected by Human Immunodefficiency Virus

BackgroundHealthcare-associated infections (HAI) are related with high mortality and emergence of multidrug-resistant (MDR) organisms, mainly in critical care patients. Human immunodeficiency virus (HIV) infection is a frequent cause of intensive care unit (ICU) admission, but data about HAI in this population is scarce. We aimed to evaluate HAI mortality in patients infected and non-infected by HIV in an ICU in a Brazilian public hospital and describe their epidemiological and microbiological characteristics.MethodsThis retrospective cohort included patients admitted in an Infectious Diseases ICU from July 2013 to December 2017 who acquired HAI. A database was created using SPSS and multivariate analysis was performed. Primary outcome was 30-day mortality after onset of infection. Secondary outcomes were infection caused by MDR organisms and device-associated HAI.ResultsDuring the study period, 77 ICU-patients (25 HIV and 52 non-HIV) acquired 106 HAI. HIV-patients were younger than non-HIV (45 vs. 58 years old, P = 0.002) and had more respiratory distress at admission (60.0% vs. 34.6%, P = 0.035). There was a high 30-day mortality and no difference among groups (HIV 52.0% vs. non-HIV 54.9%, P = 0.812), which was confirmed after adjusting for age, sequential organ failure assessment (SOFA) score in the day of HAI, MDR infection and more than one HAI. Central-line associated bloodstream infections (CLA-BSI) was the most frequent HAI in general population (39.6%), moreover, ventilator-associated pneumonia (VAP) was more frequent in HIV group (45.2% vs. 26.7%, P = 0.063), with similar period of invasive devices. Enterococcus faecalis was the most frequent cause of CLA-BSI in HIV group (30.0%), while Klebsiella pneumoniae was in non-HIV group (28.1%). Acinetobacter baumannii and K. pneumoniae (each 35.7%) were the predominant agents of VAP in HIV group, as Pseudomonas aeruginosa (35.0%) was in non-HIV group. Although there was a high frequency of HAI caused by MDR organisms, there was no difference among the groups (HIV 77.8% vs. non-HIV 64.3%, P = 0.214).ConclusionHIV was not associated with higher mortality in critical care patients who acquired HAI. VAP was more frequent in HIV patients, probably due to higher prevalence of respiratory conditions at admission. Infection by HIV does not increase the chance to acquire an HAI by MDR organism.Disclosures All authors: No reported disclosures.

Characteristics of the patients in an Infectious Diseases Intensive Care Unit

Background: Infectious Diseases Intensive Care Unit (IDICU) is different from a usual ICU due to the pathology and rate of mortality. The aim of our study was to characterize the most frequent admisssion causes in an IDICU and to identify prognostic factors for patients’ outcomes. Methods & Materials: We conducted a retrospective analysis of patients admitted between November 2014–August 2016 in IDICU of “Dr Victor Babes” Clinical Hospital of Infectious and Tropical Diseases from Bucharest. Results: 432 patients (254 male) were included. The main reasons for ICU admission were acute respiratory failure (requiring ventilatory support) in 212 patients, multisystem organ failure (MSOF) in 93 cases, neurologic disorders (coma with altered mental status or respiratory compromise) in 75 cases and acute congestive heart failure (respiratory failure and/or requiring hemodynamic support) in 28 cases. The main diagnosis was sepsis (29.6% of the cases), neurologic infections (16%), bacterial inferior respiratory infections (10.9%), influenza (10.2%), infectious endocarditis (8.1%), acute enterocolitis (7.2%), acute respiratory failure in chronically pulmonary diseases (4.4%) and HIV complications (3.5%). ANOVA test highlights a longer length of stay in ICU for neurologic infections and infective endocarditis (p < 0.037). The overall mortality rate was 40.7% (176 deaths). The mortality rate was significantly lower in patients with neurologic infections (27% vs. 56% in those with sepsis and 80% in those with HIV complications,p < 0.05). After performing a multinomial logistic analysis, independent predictors of good outcome were: main diagnosis of neurological infections and acute enterocolitis (p < 0.001), age (p = 0.026) and length of hospital stay (p = 0.010). Regarding main reason for ICU admission, patients with neurologic disorders are statistically significant (p < 0.001) a lower death outcome compared to MSOF patients. Conclusion: In an IDICU, acute respiratory failure, MSOF and neurologic disorders are the main reasons for admission, while sepsis, neurologic infections, respiratory infections, influenza and infectious endocarditis represent the main diagnosis. The overall mortality rate is higher than in a general ICU, with significant increases in patients with sepsis and HIV complications; patient age and the length of hospitalization are independent predictors of outcome.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality. This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated. A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score. AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

Letalidade e complicações osteomusculares e cardiovasculares no tétano

Despite the decline in the incidence of tetanus, this disease is still neglected in the developing world and remains a major cause of morbidity and mortality. With improvements in intensive care, it is important to better understand the complications of this serious condition. We aim to evaluate 1) the lethality and osteomuscular and cardiovascular complications of patients with tetanus who are admitted to the intensive care unit (ICU) and 2) the risk factors associated with a poor prognosis. This was a retrospective study that analyzed the medical records of all of the patients diagnosed with tetanus who were admitted to an infectious diseases ICU between January 2000 and December 2001. A standardized form that included demographic, clinical and laboratory data was completed. The clinical variables that were related to lethality and osteomuscular and cardiovascular complications were described. A total of 22 tetanus patients were admitted (81.8% male, mean age of 47.8 years).The tetanus infection was associated with professional activities in 54.5% of cases. The majority of patients (20 patients) presented with the generalized form of disease. Eighty-one percent of the patients had never received a tetanus vaccine or were unaware of their vaccine status. Following the injury, none had received appropriated passive prophylaxis, only two patients had received surgical debridement of wound and six patients received antibiotic therapy. Eleven patients (52.4%) experienced some cardiovascular complication. A pressure ulcer was the most frequent cardiovascular complication (38.1%), followed by arrhythmias (28.6%). Two of the patients developed bone fractures secondary to tetanus spasms, corresponding to 9.6% of sample. The tetanus lethality rate was 9.1%. Higher APACHE II severity scores and very severe status based on the Veronesi tetanus classification were significantly associated with the risk of death (p=0.04 and 0.03, respectively). The Veronesi classification was also associated with the risk of cardiovascular complications (p=0.013) and the length of the ICU stay (p=0.009). The present study demonstrates the failure of primary medical care in vaccination and post-traumatic tetanus prophylaxis. Despite improvements in intensive care support, cardiovascular complications are still frequent in these patients. Individuals exhibiting high APACHE II scores and severe clinical forms of tetanus should be monitored closely due to a risk of death and cardiovascular complications.

Long-term risk of mortality after acute kidney injury in patients with sepsis: a contemporary analysis

BackgroundAcute kidney injury (AKI) is associated with increased short-term mortality of septic patients; however, the exact influence of AKI on long-term mortality in such patients has not yet been determined.MethodsWe retrospectively evaluated the impact of AKI, defined by the "Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease" (RIFLE) classification based on creatinine criteria, on 2-year mortality in a cohort of 234 hospital surviving septic patients who had been hospitalized at the Infectious Disease Intensive Care Unit of our Hospital.ResultsMean-follow-up was 21 ± 6.4 months. During this period, 32 patients (13.7%) died. At 6 months, 1 and 2 years of follow-up, the cumulative probability of death of patients with previous AKI was 8.3, 16.9 and 34.2%, respectively, as compared with 2.2, 6 and 8.9% in patients without previous AKI (log-rank, P < 0.0001). In the univariate analysis, age (hazard ratio 1.4, 95% CI 1.2-1.7, P < 0.0001), as well as pre-existing cardiovascular disease (hazard ratio 3.6, 95% CI 1.4-9.4, P = 0.009), illness severity as evaluated by nonrenal APACHE II (hazard ratio 1.3, 95% CI 1.1-1.6, P = 0.002), and previous AKI (hazard ratio 4.2, 95% CI 2.1-8.5, P < 0.0001) were associated with increased 2-year mortality, while gender, race, pre-existing hypertension, cirrhosis, HIV infection, neoplasm, and baseline glomerular filtration rate did not. In the multivariate analysis, however, only previous AKI (hazard ratio 3.2, 95% CI 1.6-6.5, P = 0.001) and age (hazard ratio 1.4, 95% CI 1.2-1.6, P < 0.0001) emerged as independent predictors of 2-year mortality.ConclusionsAcute kidney injury had a negative impact on long-term mortality of patients with sepsis.

Acute kidney injury in patients with sepsis: a contemporary analysis

To analyze the clinical characteristics of septic acute kidney injury (AKI) according to the Acute Kidney Injury Network (AKIN) classification, and to evaluate the capacity of this system in predicting in-hospital mortality of septic patients. Patients with sepsis admitted to the infectious diseases intensive care unit (ICU) of our hospital between January 2004 and June 2007 were retrospectively studied. Maximum AKIN stage within the first three days of hospitalization was recorded. Three hundred fifteen patients were evaluated. According to AKIN criteria, 99 patients (31.4%) had AKI: 26.2% at stage 1, 20.2% at stage 2, and 53.6% at stage 3. Four patients (1.9%) with no AKI progressed to stage 1, two patients (7.7%) at stage 1 progressed to stage 2, one patient (3.8%) at stage 1 progressed to stage 3, and one patient at stage 2 (5%) progressed to stage 3. The mortality rate was 25.3% and increased significantly from normal renal function to stage 3 (normal, 12.5%; stage 1, 34.6%; stage 2, 45%; stage 3, 64.1%; p<0.0001). After adjusting for age, gender, race, pre-existing chronic kidney disease, illness severity as evaluated by acute physiology and chronic health evaluation, version II (APACHE II) score, need for mechanical ventilation, and vasopressor use, AKIN stage 1 (odds ratio (OR) 3.03, 95% confidence interval (CI) 1.12-8.19, p=0.029), stage 2 (OR 3.3, 95% CI 1.11-9.78, p=0.031), and stage 3 (OR 7.35, 95% CI 3.13-17.25, p<0.0001) predicted mortality. AKIN criteria are a useful tool to characterize and stratify septic patients according to the risk of death.

Acute kidney injury in an infectious disease intensive care unit - an assessment of prognostic factors.

Acute kidney injury (AKI) is a common complication in many infectious diseases. There are few studies to investigate risk factors for death in infectious diseases-associated AKI. This is a retrospective study including all patients with acute kidney injury (AKI) admitted to an infectious diseases intensive care unit (ICU) in Brazil between October 2003 and September 2006. A total of 722 patients were admitted to the infectious disease ICU in the study period. AKI occurred in 147 cases (17.7%). The mean age was 45 +/- 5.6 years, and 77% were male. The mean length of hospital stay was 11.5 +/- 10.3 days. The main causes of ICU hospitalization were acquired immunodeficiency syndrome (AIDS)-related diseases (28 .6%), pneumonia 13%), leptospirosis (11.6%), meningitis (8.2%), disseminated histoplasmosis (6.8%) and tetanus (5.4%). The main cause of AKI was sepsis (41.5%). Patients were classified according to RIFLE as "Risk" (5.6%), "Injury" (21.7%) and "Failure" (72.7%). Patients in "Failure" showed a higher mortality (p = 0.007). Multivariate analysis showed that dependent risk factors for death were oliguria (OR = 5.59, P = 0.002), metabolic acidosis (OR = 5.13, P = 0.01), sepsis (OR = 4.79, P = 0.001), hypovolaemia (OR = 4.11, P = 0.01), use of vasoactive drugs (OR = 3.34, P = 0.02), use of mechanical ventilation (OR = 2.94, P = 0.03) and high APACHE II score (OR = 1.14, P = 0.001). There are important risk factors for death among critically ill patients with infectious diseases associated with AKI.

Acute kidney injury in an infectious disease intensive care unit - an assessment of prognostic factors.

Acute kidney injury (AKI) is a common complication in many infectious diseases. There are few studies to investigate risk factors for death in infectious diseases-associated AKI. This is a retrospective study including all patients with acute kidney injury (AKI) admitted to an infectious diseases intensive care unit (ICU) in Brazil between October 2003 and September 2006. A total of 722 patients were admitted to the infectious disease ICU in the study period. AKI occurred in 147 cases (17.7%). The mean age was 45 +/- 5.6 years, and 77% were male. The mean length of hospital stay was 11.5 +/- 10.3 days. The main causes of ICU hospitalization were acquired immunodeficiency syndrome (AIDS)-related diseases (28 .6%), pneumonia 13%), leptospirosis (11.6%), meningitis (8.2%), disseminated histoplasmosis (6.8%) and tetanus (5.4%). The main cause of AKI was sepsis (41.5%). Patients were classified according to RIFLE as "Risk" (5.6%), "Injury" (21.7%) and "Failure" (72.7%). Patients in "Failure" showed a higher mortality (p = 0.007). Multivariate analysis showed that dependent risk factors for death were oliguria (OR = 5.59, P = 0.002), metabolic acidosis (OR = 5.13, P = 0.01), sepsis (OR = 4.79, P = 0.001), hypovolaemia (OR = 4.11, P = 0.01), use of vasoactive drugs (OR = 3.34, P = 0.02), use of mechanical ventilation (OR = 2.94, P = 0.03) and high APACHE II score (OR = 1.14, P = 0.001). There are important risk factors for death among critically ill patients with infectious diseases associated with AKI.

Acute renal failure in patients with sepsis

The evaluation of acute renal failure (ARF) by the newly developed classification for ARF (RIFLE, standing for 'risk, injury, failure, loss, end-stage kidney disease') [1] in patients with sepsis has not yet been performed. We evaluated, retrospectively, the incidence of ARF and its risk factors, therapy, and outcome among patients with sepsis admitted to the Infectious Diseases Intensive Care Unit of the Hospital de Santa Maria between January 2005 and December 2006. ARF was defined by means of the RIFLE classification [1]. Sepsis was classified in accordance with the American College of Chest Physicians and the Society of Critical Care Medicine consensus [2]. In all, 182 patients (aged 56.2 ± 18.56 years (mean ± SD), 120 male, 162 Caucasian) were analyzed. Baseline characteristics of the patients are summarized in Table ​Table1.1. Sixty-eight patients (37.4%) had ARF. By multivariate analysis, age more than 60 years (odds ratio (OR) 0.39, 95% confidence interval (CI) 0.17 to 0.87, P = 0.002), male (OR 5.5, 95% CI 2.2 to 13.5, P 50 (OR 0.14, 95% CI 0.06 to 0.31, P 50, comorbidity (namely cardiovascular disease), and ARF showed that SAPS II > 50 (OR 0.12, 95% CI 0.05 to 0.29, P < 0.0001) and ARF (OR 0.26, 95% CI 0.11 to 0.63, P = 0.003) were independent predictors of mortality. Table 1 Baseline characteristics Thus, ARF as determined by RIFLE is common among patients with sepsis, and increases mortality. Age, gender, chronic kidney disease, Gram-negative-related infection and severity of illness are independently associated with ARF in this setting.

Prognostic utility of RIFLE for acute renal failure in patients with sepsis

Acute renal failure (ARF) is common among patients with sepsis and increases mortality [1]. However, the prognostic utility of the newly released classification for ARF, entitled RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) [2], in predicting mortality in such patients has not yet been assessed. We sought to evaluate retrospectively the usefulness of RIFLE in predicting mortality in patients with sepsis admitted to the infectious disease intensive care unit (ICU) of our hospital between January 2005 and December 2006. Data were collected from the unit database. Sepsis was classified in accordance with American College of Chest Physicians and the Society of Critical Care Medicine consensus [3]. Patients with chronic kidney disease on dialysis were excluded from the analysis. The Simplified Acute Physiology Score (SAPS) version II was calculated based on the worst variables recorded during the first 24 hours of ICU admission. Mortality was assessed at day 60 [2]. Forward stepwise multivariate regression analysis was employed to evaluate independent predictors of mortality. The goodness-of-fit was tested by means of the Hosmer-Lemeshaw statistic. Area under the receiver operating characteristic curve (AUROC) was employed to evaluate the prognostic accuracy of RIFLE and SAPS II. A two-tailed P < 0.05 was considered statistically significant. One-hundred and eighty-two patients (mean age 56.2 ± 18.56 years; 120 male; 162 white) were analyzed. Fourteen patients had sepsis, 108 patients had severe sepsis and 60 patients had septic shock. Sixty-eight patients (37.4%) had ARF: 11 patients were in class 'risk' (in RIFLE), 21 patients were in class 'injury', and 36 patients were in class 'failure'. The mortality rate was 37.4%, and increased from classes 'normal' to 'failure' (normal, 9.6%; risk, 27.3%; injury, 28.6%; failure, 55%; P < 0.0001). Multivariate analysis including age above 60 years, sex, SAPS II above 50, comorbidity (namely cardiovascular disease), and RIFLE class revealed that SAPS II score above 50 (odds ratio 0.12, 95% confidence interval [CI] 0.04–0.29; P < 0.0001) and class 'failure' (odds ratio 3.59, 95% CI 1.44–8.94; P = 0.006) were independent predictors of mortality. Similarly, SAPS II score above 50 (AUROC 0.778, 95% CI 0.694–0.863; P < 0.0001) and ARF according to RIFLE (AUROC 0.725, 95% CI 0.63–0.81; P < 0.0001) had good prognostic accuracy. In summary, ARF, based on RIFLE criteria, is common in patients with sepsis, and is associated with increased mortality. RIFLE appears to be a useful prognostic tool in such patients.

An assessment of the RIFLE criteria for acute renal failure in critically ill HIV-infected patients

Acute renal failure is common among hospitalized patients with HIV infection, particularly in the intensive care unit (ICU) setting, and increases mortality. Recently, the Acute Dialysis and Quality Initiative (ADQI) group [1] formulated a new classification for acute renal failure - the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) classification that defines three grades of severity - class R (risk), class F (failure), and class I (injury) - and two outcome classes - loss and end-stage kidney disease. Some studies [2,3] have applied the RIFLE criteria in hospitalized patients, particularly in ICU patients, but the clinical ability of these criteria to predict outcome of ICU HIV-infected patients has not yet been assessed. We sought to evaluate retrospectively the ability of the RIFLE criteria (Table 1) to predict outcome of the HIV-infected patients admitted to the Infectious Diseases ICU

Actividade de uma Unidade de Cuidados Intensivos de Doenças Infecciosas (1988-1997).

The practice of an Infectious Diseases Intensive Care Unit for a period of ten years (1988-1997) is reviewed. In this time 1,191 patients were treated--822 had more than 15 years of age and 369 were younger. The occupation rate ranged between 74.4% and 90.8%, and the mean patient stay in the UCI ranged between 6.7 and 12.5 days. Nine hundred and forty-four patients were discharged cured or improved during the stay and 247 (20.7%) died. The most frequent pathologies were: meningitis--371 patients (33.6%); encephalitis--103 (8.6%); and tetanus 143 (12.0%) patients. The morbidity and mortality of different pathologies admitted to the Intensive Care Unit are presented. The mortality rate of the two most common diseases (meningitis and tetanus) is discussed. The need for Intensive Care in the field of Infectious Diseases is stressed.