Severe acute respiratory infections (SARI) from influenza in adult patients in Chile: the experience of a sentinel hospital / La infección respiratoria aguda grave asociada a la gripe en pacientes adultos en Chile: experiencia de un hospital centinela / Infecção respiratória aguda grave (SARI) decorrente da influenza em pacientes adultos no Chile: experiência de um hospital-sentinela

ABSTRACT Objective To 1) describe clinical characteristics of adult patients in Chile with severe acute respiratory infections (SARI) associated with influenza viruses, and 2) analyze virus subtypes identified in specimens collected from those patients, hospital resources used in clinical management, clinical evolution, and risk factors associated with a fatal outcome, using observational data from the SARI surveillance network (SARInet). Methods Adults hospitalized from 1 July 2011 to 31 December 2015 with influenza-associated SARI at a SARI sentinel surveillance hospital in Santiago were identified and the presence of influenza in all cases confirmed by reverse transcription polymerase chain reaction (RT-PCR), using respiratory samples. Results A total of 221 patients (mean age: 74.1 years) were hospitalized with influenza-associated SARI during the study period. Of this study cohort, 91.4% had risk factors for complications and 34.3% had been vaccinated during the most recent campaign. Pneumonia was the most frequent clinical manifestation, occurring in 57.0% of the cohort; other manifestations included influenza-like illness, exacerbated chronic bronchitis, decompensated heart failure, and asthmatic crisis. Cases occurred year-round, with an epidemic peak during autumn-winter. Both influenza A (H1N1pdm09 and H3N2) and B virus co-circulated. Critical care beds were required for 26.7% of the cohort, and 19.5% needed ventilatory assistance. Multivariate analysis identified four significant factors associated with in-hospital mortality: 1) being bedridden (adjusted odds ratio (aOR): 22.3; 95% confidence interval (CI): 3.0-164); 2) admission to critical care unit (aOR: 8.9; CI: 1.44-55); 3) Pa02/Fi02 ratio < 250 (aOR: 5.8; CI: 1.02-33); and 4) increased serum creatinine concentration (> 1 mg/dL) (aOR: 5.47; CI: 1.20-24). Seasonal influenza vaccine was identified as a significant protective factor (aOR: 0.14; CI: 0.021-0.90). Conclusions Influenza-associated SARI affected mainly elderly patients with underlying conditions. Most patients evolved to respiratory failure and more than one-quarter required critical care beds. Clinical presentation was variable. Death was associated with host characteristics and disease-associated conditions, and vaccine was protective. Virus type did not influence outcome.

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RESUMO Objetivo Descrever as características clínicas de pacientes adultos com infecção respiratória aguda grave (SARI) associada ao vírus da influenza e analisar os subtipos virais identificados em amostras coletadas destes pacientes, os recursos hospitalares empregados no tratamento clínico, a evolução clínica e os fatores de risco clínicos associados a um desfecho fatal, a partir de dados observacionais da rede de vigilância de SARI (SARInet) no Chile. Métodos Foram identificados os adultos hospitalizados com SARI associada a influenza em um hospital-sentinela de vigilância de SARI, em Santiago, de 1o de julho de 2011 a 31 de dezembro de 2015. A ocorrência de influenza foi confirmada em amostras respiratórias em todos os casos com a reação em cadeia da polimerase via transcriptase reversa (RT-RCP). Resultados Ao todo, 221 pacientes (idade média de 74,1 anos) foram hospitalizados com SARI associada a influenza no período de estudo. Nesta coorte, 91,4% apresentavam fatores de risco para complicação e 34,3% haviam sido vacinados na última campanha de vacinação. Pneumonia foi a manifestação clínica mais frequente, ocorrendo em 57,0% da coorte. Outras manifestações foram doença gripal, bronquite crônica exacerbada, insuficiência cardíaca descompensada e crise asmática. Os casos estiveram distribuídos ao longo do ano, com pico epidêmico no outono-inverno. Houve circulação simultânea dos vírus da influenza A (H1N1pdm09 e H3N2) e B. Leitos de terapia intensiva foram necessários em 26,7% da coorte e suporte ventilatório, em 19,5%. Na análise multivariada, quatro fatores importantes associados à mortalidade hospitalar foram identificados: estar restrito ao leito (odds ratio ajustado [ORaj] 22.3; intervalo de confiança de 95% [IC 95%] 3.0-164); ser admitido na unidade de terapia intensiva (ORaj 8.9, IC 95% 1.4 4-55); relação Pa02/Fi02 <250 (ORaj 5.8; IC 95% 1.02-33) e aumento da creatinina sérica (>1 mg/dl) (ORaj 5.47; IC 95% 1.20-24). A vacinação sazonal contra influenza foi identificada como importante fator de proteção (ORaj 0.14; IC 95% 0.021-0.90). Conclusões A SARI associada a influenza acometeu sobretudo pacientes idosos com doenças preexistentes. A maioria dos pacientes evoluiu com insuficiência respiratória e mais de um quarto precisou de cuidados intensivos. O quadro clínico foi variável. Morte foi associada às características do hospedeiro e problemas relacionados à doença. A vacinação teve efeito protetor e o tipo viral não influiu no desfecho.

Pacientes con infección por VIH/SIDA en una Unidad de Pacientes Críticos: La experiencia de un hospital general en un país en desarrollo / HIV/AIDS patients in a Critical Care Unit: The experience of a general hospital in a developing country

Introduction and aims: Despite general availability of HAART in Chile, admissions of HIV/AIDS patients to Intensive-Intermediate Care Units (IICU) are still happening, and a characterization of patient's profile, mortality and potentially avoidable admissions is necessary. Methods: Observational retrospective study in one general hospital in Chile of HIV/AIDS patients admitted to IICU during 9 years. Results: During 2005-2013, 32 patients were admitted to IICU, with 87,5% in AIDS stage, only 53,1% knew his/her condition, 43,8% were receiving HAART and 16.6% chemoprophylaxis for opportunistic infections, A CD4 count < 200/µL was registered in 75,9% of patients. Most admissions were driven by infectious conditions (84,4%) and 48,1% developed septic shock, IICU hospitalizations were motivated by respiratory failure, neurologic compromise, sepsis or a mixture of them (87,5%), By univariate analysis, admissions by respiratory failure were associated to no HAART, oral candidiasis or CD4 < 250/µL (p < 0.01). Eight patients died during their first hospitalization (25%) and other 5 in the following month after discharge. Death during hospitalization was significantly associated to vasoactive drug use ≥ 7 days (OR 16.5; IC95 2.1-128 p < 0.01). In multivariate analysis, APACHE score ≥ 18 was associated with death during hospitalization of after discharge (OR 3,3 IC95 1,1-10; p < 0,05), Four patients (12,5%) had potentially avoidable admissions. Conclusions: Despite HAART availability in Chile, hospitalizations of patients with HIV/AIDS are still happening, affecting those that either are unaware of his/her condition, are not receiving HAART and/or chemoprophylaxis. These admissions generate premature deaths and happen even after discharge in severely ill patients.

Antecedentes y Objetivos: A pesar de la disponibilidad de la terapia viral de gran actividad (TARGA) en Chile el ingreso de pacientes con infección por VIH/SIDA a la Unidad de Pacientes Críticos (UPC) siguen ocurriendo. Se necesita mayor información en Chile sobre el perfil de estos pacientes, su mortalidad y el porcentaje de ingresos evitables. Método: Estudio observacional retrospectivo de pacientes adultos que ingresaron a la UPC en un hospital general durante 9 años. Resultados: En el período 2005-2013 se identificaron 32 pacientes que ingresaron a UPC. El 87,5% estaba en etapa SIDA al ingreso, 53,1% sabía su diagnóstico, sólo 43,8% recibía terapia TARGA y 16,6% quimioprofilaxis. Un 75,9% tenía un recuento CD4 < 200/µL. La mayoría de los ingresos fue por una causa infecciosa (84,4%) y 48,1% presentaron shock séptico. Por sistemas, los ingresos a UPC fueron liderados por falla respiratoria, compromiso neurológico, sepsis o una mezcla de ellos (87,5%). Por análisis univariado, el ingreso por falla respiratoria se asoció a ausencia de HAART, candidiasis oral o un recuento CD4 < 250/µL (p < 0,01). Ocho pacientes fallecieron en la primera hospitalización (25%) y otros cinco en los meses siguientes al alta. El desenlace fatal en el hospital estuvo significativamente asociado al uso de fármacos vasoactivos por ≥ 7 días (OR 16,5; IC 95 2,1-128 p < 0,01). En el análisis multivariado, un score APACHE ≥ 18 se asoció en forma independiente a fallecimiento en el hospital o post alta (OR 3,3 IC 95 1,1-10; p < 0,05). Cuatro pacientes (12,5%), tuvieron hospitalizaciones potencialmente evitables. Conclusiones: Las hospitalizaciones de pacientes con infección VIH a UPC siguen ocurriendo a pesar de la disponibilidad de TARGA en Chile, afectando a pacientes que desconocen su condición, no están en tratamiento o con profilaxis. Estos ingresos generan muertes prematuras, las que ocurren incluso después del alta en los pacientes más graves.