Secondary infections in a cohort of patients with COVID-19 admitted to an intensive care unit: impact of gram-negative bacterial resistance

ABSTRACT Some studies have shown that secondary infections during the COVID-19 pandemic may have contributed to the high mortality. Our objective was to identify the frequency, types and etiology of bacterial infections in patients with COVID-19 admitted to an intensive care unit (ICU) and to evaluate the results of ICU stay, duration of mechanical ventilation (MV) and in-hospital mortality. It was a single-center study with a retrospective cohort of patients admitted consecutively to the ICU for more than 48 h between March and May 2020. Comparisons of groups with and without ICU- acquired infection were performed. A total of 191 patients with laboratory-confirmed COVID-19 were included and 57 patients had 97 secondary infectious events. The most frequent agents were Acinetobacter baumannii (28.9%), Pseudomonas aeruginosa (22.7%) and Klebsiella pneumoniae (14.4%); multi-drug resistance was present in 96% of A. baumannii and in 57% of K. pneumoniae. The most prevalent infection was ventilator-associated pneumonia in 57.9% of patients with bacterial infections, or 17.3% of all COVID-19 patients admitted to the ICU, followed by tracheobronchitis (26.3%). Patients with secondary infections had a longer ICU stay (40.0 vs. 17 days; p < 0.001), as well as a longer duration of MV (24.0 vs 9.0 days; p= 0.003). There were 68 (35.6%) deaths overall, of which 27 (39.7%) patients had bacterial infections. Among the 123 survivors, 30 (24.4%) had a secondary infections (OR 2.041; 95% CI 1.080 - 3.859). A high incidence of secondary infections, mainly caused by gram-negative bacteria has been observed. Secondary infections were associated with longer ICU stay, MV use and higher mortality.

Acute kidney injury in patients with Covid-19 in a Brazilian ICU: incidence, predictors and in-hospital mortality / Lesão renal aguda em pacientes com Covid-19 de uma UTI no Brasil: incidência, preditores e mortalidade hospitalar

Abstract Introduction: There is little data in the literature on acute kidney injury (AKI) in Covid-19 cases, although relevant in clinical practice in the ICU, especially in Brazil. Our goal was to identify the incidence of AKI, predictive factors and impact on hospital mortality. Method: Retrospective cohort of patients with Covid-19 admitted to the ICU. AKI was defined according to KDIGO criteria. Data was collected from electronic medical records between March 17 and April 26. Results: Of the 102 patients, 55.9% progressed with AKI, and the majority (66.7%) was classified as stage 3. Multivariate logistic regression showed age (RC 1.101; 95% CI 1.026 - 1.181; p = 0.0070), estimated glomerular filtration rate - eGFR (RC 1.127; 95% CI 1.022 - 1.243; p = 0.0170) and hypertension (RC 3.212; 95% CI 1.065 - 9.690; p = 0.0380) as independent predictors of AKI. Twenty-three patients died. In the group without kidney injury, there were 8.9% deaths, while in the group with AKI, 33.3% of patients died (RR 5.125; 95% CI 1.598 - 16.431; p = 0.0060). The average survival, in days, was higher in the group without AKI. Cox multivariate analysis showed age (RR 1.054; 95% CI 1.014 - 1.095; p = 0.0080) and severe acute respiratory distress syndrome (RR 8.953; 95% CI 1.128 - 71.048; p = 0.0380) as predictors of hospital mortality. Conclusion: We found a high incidence of AKI; and as predictive factors for its occurrence: age, eGFR and hypertension. AKI was associated with higher hospital mortality.

Resumo Introdução: A lesão renal aguda (LRA)na Covid-19, apesar de relevante na prática clínica em UTI, dispõe de poucos dados na literatura, sobretudo no Brasil. Objetivo foi identificar a incidência de LRA, fatores preditores e impacto na mortalidade hospitalar. Método: Coorte retrospectiva de pacientes com Covid-19 internados em UTI. LRA foi definida segundo critérios de KDIGO. Dados coletados de registros de prontuários eletrônicos entre 17 de março e 26 de abril. Resultados: Dos 102 pacientes, 55,9% evoluíram com LRA e a maioria (66,7%) foi classificada como estágio 3. Regressão logística multivariada mostrou idade (RC 1,101; IC 95% 1,026 - 1,181; p = 0,0070), taxa de filtração glomerular estimada - TFGe (RC 1,127; IC 95% 1,022 - 1,243; p = 0,0170) e hipertensão (RC 3,212; IC 95% 1,065 - 9,690; p = 0,0380) como preditores independentes de LRA. Vinte e três pacientes faleceram. No grupo sem lesão renal ocorreu 8,9% de óbitos, enquanto que no grupo com LRA 33,3% dos pacientes morreram (RR 5,125; IC 95% 1,598 - 16,431; p = 0,0060). A média de sobrevida, em dias, foi maior no grupo sem LRA. Análise multivariada de Cox mostrou idade (RR 1,054; IC 95% 1,014 - 1,095; p = 0,0080) e síndrome do desconforto respiratório agudo grave (RR 8,953; IC 95% 1,128 - 71,048; p = 0,0380) como preditores de mortalidade hospitalar. Conclusão: Encontramos alta incidência de LRA; e como fatores preditores para sua ocorrência: idade, TFGe e hipertensão. A LRA estava associada a maior mortalidade hospitalar.

COVID-19 e Injúria Miocárdica em UTI Brasileira: Alta Incidência e Maior Risco de Mortalidade Intra-Hospitalar / COVID-19 and Myocardial Injury in a Brazilian ICU: High Incidence and Higher Risk of In-Hospital Mortality

Resumo Fundamentos A incidência de injúria miocárdica (IM) em pacientes com COVID-19 no Brasil é pouco conhecida e o impacto prognóstico da IM, mal elucidado. Objetivos Descrever a incidência de IM em pacientes com COVID-19 em unidade de terapia intensiva (UTI) e identificar variáveis associadas à sua ocorrência. O objetivo secundário foi avaliar a troponina I ultrassensível (US) como preditor de mortalidade intra-hospitalar. Métodos Estudo observacional, retrospectivo, entre março e abril de 2020, com casos confirmados de COVID-19 internados em UTI. Variáveis numéricas foram comparadas com teste t de Student ou U de Mann-Whitney, sendo o teste X2 empregado para as categóricas. Realizou-se análise multivariada com as variáveis associadas à IM e p<0,2 objetivando determinar preditores de IM. Curva ROC foi empregada para determinar o valor da troponina capaz de predizer maior mortalidade intra-hospitalar. Funções de sobrevida foram estimadas pelo método de Kaplan-Meier a partir do ponto de corte apontado pela curva ROC. Resultados Este estudo avaliou 61 pacientes (63,9% do sexo masculino, média de idade de 66,1±15,5 anos). A IM esteve presente em 36% dos casos. Hipertensão arterial sistêmica (HAS) [RC 1,198; IC95%: 2,246-37,665] e índice de massa corporal (IMC) [RC 1,143; IC95%: 1,013-1,289] foram preditores independentes de risco. Troponina I US >48,3 ng/ml, valor determinado pela curva ROC, prediz maior mortalidade intra-hospitalar [AUC 0,786; p<0,05]. A sobrevida no grupo com troponina I US >48,3 ng/ml foi inferior à do grupo com valores ≤48,3 ng/dl [20,3 x 43,5 dias, respectivamente; p<0,05]. Conclusão Observou-se alta incidência de IM na COVID-19 grave com impacto em maior mortalidade intra-hospitalar. HAS e IMC foram preditores independentes de risco de sua ocorrência. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background The incidence of myocardial injury (MI) in patients with COVID-19 in Brazil and the prognostic impact of MI have not been elucidated. Objectives To describe the incidence of MI in patients with COVID-19 in the intensive care unit (ICU) and to identify variables associated with its occurrence. The secondary objective was to assess high-sensitivity troponin I as a predictor of in-hospital mortality. Methods Retrospective, observational study conducted between March and April 2020 with cases of confirmed COVID-19 admitted to the ICU. Numerical variables were compared by using Student t test or Mann-Whitney U test. The chi-square test was used for categorical variables. Multivariate analysis was performed with variables associated with MI and p<0.2 to determine predictors of MI. The ROC curve was used to determine the troponin value capable of predicting higher in-hospital mortality. Survival functions were estimated by use of the Kaplan-Meier method from the cut-off point indicated in the ROC curve. Results This study assessed 61 patients (63.9% of the male sex, mean age of 66.1±15.5 years). Myocardial injury was present in 36% of the patients. Systemic arterial hypertension (HAS) [OR 1.198; 95%CI: 2.246-37.665] and body mass index (BMI) [OR 1.143; 95%CI: 1.013-1.289] were independent risk predictors. High-sensitivity troponin I >48.3 ng/mL, which was determined in the ROC curve, predicts higher in-hospital mortality [AUC 0.786; p<0.05]. Survival in the group with high-sensitivity troponin I >48.3 ng/mL was lower than that in the group with values ≤48.3 ng/dL [20.3 x 43.5 days, respectively; p<0.05]. Conclusion There was a high incidence of MI in severe COVID-19 with impact on higher in-hospital mortality. The independent risk predictors of MI were SAH and BMI. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Impacto da Hipertensão Pulmonar na Mortalidade Cirúrgica e na Sobrevida em Três Anos Pós-Cirurgia de Troca Valvar Aórtica / Impact of Pulmonary Hypertension on Surgical Mortality and 3-Year Survival After Aortic Valve Replacement

A hipertensão pulmonar (HP) grave contribui para significante morbidade e mortalidade, e podeaumentar o número de complicações e morte na cirurgia cardíaca. Objetivo: Avaliar o impacto da HP na mortalidade cirúrgica e na sobrevida em três anos, após cirurgia de troca valvar aórtica.Métodos: Estudo de coorte retrospectiva realizado com pacientes submetidos à cirurgia de troca valvar aórtica, demaio de 2011 a dezembro de 2012, no Instituto Nacional de Cardiologia, RJ. A população estudada foi estratificadaem dois grupos, de acordo com a pressão sistólica da artéria pulmonar (PSAP) em: <45 mmHg e ≥45 mmHg. Foi utilizado o teste do qui-quadrado para a comparação entre os grupos; a mortalidade e cirúrgica foi estudada por regressão logística e a sobrevida pela curva de Kaplan-Meier e teste de log-rank; e a razão de risco pelo método de Cox. Resultados: Estudados 182 pacientes, 57,0% do sexo masculino, idade 61,0±13,0 anos, com hipertensão arterial sistêmica (72,0%), diabetes mellitus (22,0%), classe funcional pela New York Heart Association III/IV (61,1%), PSAP≥45mmHg (14,3%). A mortalidade geral foi 12,0%. A sobrevida foi maior no grupo com PSAP <45mmHg – 89,0%em um ano e 86,0% em três anos, comparado com o grupo com PSAP ≥45mmHg – 68,8% em um ano e 58,1%(35,1% a 75,4%) em três anos (p=0,0004). Conclusão: Pacientes com PSAP ≥45mmHg apresentaram maior mortalidade cirúrgica e pior sobrevida em três anos após cirurgia de troca valvar aórtica...

Background: Severe pulmonary hypertension (PH) contributes to significant morbidity and mortality and may increase the number of complications and death in heart surgery.Objective: To evaluate the impact of PH on surgical mortality and three-year survival after aortic valve replacement surgery. Methods: Retrospective cohort study of patients undergoing aortic valve replacement surgery from May 2011 to December 2012 at Instituto Nacional de Cardiologia, RJ. The study population was stratified into two groups according to the systolic pulmonary artery pressure (SPAP): <45mmHg and ≥45mmHg. The chi-square test was used for comparison between groups; surgical mortality was studied by logistic regression and survival by Kaplan-Meier method and log-rank test; the hazard ratio was examined using the Cox method. Results: The study included 182 patients, 57.0% were males aged 61.0±13.0 years, with systemic arterial hypertension (72.0%), diabetes mellitus (22.0%), functional class by the New York Heart Association III/IV (61.1%), SPAP ≥45mmHg (14.3%). Overallmortality rate was 12.0%. Survival rate was higher in the group with SPAP <45mmHg — 89.0% at one year and 86.0% at three year compared with the group with SPAP ≥45mmHg — 68.8% at one year and 58.1% (35.1% to 75.4%) at three years (p=0.0004). Conclusion: Patients with SPAP ≥45mmHg had higher surgical mortality and worse survival at three years after aortic valvereplacement surgery...

Fisiopatologia e manejo de trombose em pacientes oncológicos / Physiopathology and management of thrombosis in patients

O estado trombofílico destes doentes é caracterizado por uma interação entre a célula neoplásica e o sistema hemostático que aumenta o risco de eventos trombóticos. Além de fazer uma breve revisão sobre a fisiopatologia da trombose nos pacientes com câncer, este trabalho apresenta, de forma sucinta, as recomendações da Sociedade Americana de Oncologia Clínica relacionadas à profilaxia antitrombótica nos portadores de doença maligna.

The Venous Thromboembolism (VTE) is a major cause of death in cancer patients. The thrombophilic state of these patients is characterized by an interaction between the neoplastic cells and the hemostatic system, which is related to increased risk of thrombotic events. This work presents a brief review of the pathophysiology of thrombosis in patients with cancer. Additionally, we address the American Society of Clinical Oncology recommendations related to antithrombotic prophylaxis in patients with malignant disease.

Neurofibromatose tipo I com manifestação parafaríngea na infância / Neurofibomatosis type 1 with parapharyngeal manifestation in childhood

Objetivos: apresentar um caso raro de comprometimento parafaríngeo em uma criança com neurofibromatose tipo I.Descrição do caso: uma menina de um ano e quatro meses foi trazida ao consultório de otorrinolaringologia no Hospital São Lucas da PUCRS por aumento de volume em região parotídea esquerda, observado há aproximadamente 30 dias. Ao exame apresentava bom estado geral e na inspeção observou-se tumoração em região parotídea à esquerda, com pouca mobilidade. Uma tomografia computadorizada com contraste revelou tumoração extensa, com aparência sólida, desvio da artéria carótida interna para linha média com envolvimento da glândula parótida e extensão para o espaço parafaríngeo. A biópsia excisional transoperatória revelou neoplasia benigna de tecido neural e o resultado anatomopatológico mostrou neuroma plexiforme. Revisando-se o exame físico foram observadas três máculas hiperpigmentadas (manchas café com leite) em região abdominal, apontado para o diagnóstico clínico de neurofibromatose tipo I, ou doença de Von Recklinghausen.Conclusões: o neurofibroma do espaço parafaríngeo é uma complicação rara de neurofibromatose tipo I, ocorrendo em menos de 5% das neoplasias de espaço parafaríngeo. Com este relato de caso mostra-se a importância da correlação clínica para o diagnóstico de uma doença rara, especialmente na faixa etária pediátrica.

Aims: To present a rare case of parapharyngeal involvement in a child with neurofibromatosis type I.Case description: a girl one year and four months old was brought to the clinic of otolaryngology at the Hospital São Lucas da PUCRS because of a swelling in the left parotid region, observed for approximately 30 days. On examination she appeared healthy, and the inspection showed a tumor on the left parotid region, with little mobility. A computed tomography scan with contrast revealed extensive tumor with solid appearance, internal carotid artery bypass to the midline with involvement of the parotid gland and extension into the parapharyngeal space. Excisional biopsy examination with trans-operative freezing revealed a benign neoplasm of neural tissue and the pathological result showed plexiform neuroma. Reviewing the physical examination, three hyperpigmented macules (café au lait spots) were observed in the abdominal region, pointing to the clinical diagnosis of neurofibromatosis type I, or Von Recklinghausen?s disease.Conclusions: Neurofibroma of the parapharyngeal space is a rare complication of neurofibromatosis type I, occurring in less than 5% of tumors of the parapharyngeal space. This case report showed the importance of clinical correlation for diagnosis of a rare disease, especially in pediatric patients.