Influenza season 2019. Analysis of 143 hospitalized patients.

Influenza infection is a latent public health problem, affecting millions of people throughout the world, which imposes high morbidity and economic burden on the region. In Argentina, influenza-associated mortality is estimated at 6/100 000 person-years, and is higher among men = 65 years old. The knowledge of the baseline characteristics and outcomes of hospitalized patients is crucial for public health officials planning interventions to address local outbreaks. Thus, in this retrospective, single-center study, performed in a highcomplexity university hospital, we aimed to analyze clinical characteristics, image findings, and laboratory variables of patients with laboratory-confirmed influenza requiring hospitalization in our hospital during 2019. Cases were confirmed by real-time reverse transcription-polymerase chain reaction. One hundred and forty-three patients with influenza were hospitalized during the study period; 141 (98.6%) were infected with influenza virus type A, including 88 (61.5%) with the H1N1 subtype. The median age was 71 years (IQR 60- 82), 111 (77.6%) were older than 70 years, and 126 (88.1%) had at least one coexisting illness; 56 (39.1%) patients required intensive care unit, 16 (11.1%) invasive mechanical ventilation, and 6 (4.1%) died during hospitalization. In this study, in-hospital mortality was similar to that reported in previous series of non-pandemic influenza, even though the majority of the cases in this study were older than 70 years and had at least one coexisting illness.

La influenza es un problema latente de salud pública que afecta a millones de personas en todo el planeta e impone una alta morbilidad y carga económica para la región. En Argentina, la mortalidad asociada a la influenza se estima en 6/100 000 personas-año y es mayor entre los hombres mayores de 65 años. El conocimiento de las características clínicas y la evolución de los pacientes hospitalizados es fundamental para planificar el abordaje de los brotes locales. En este estudio retrospectivo, realizado en un hospital universitario de alta complejidad, nuestro objetivo fue analizar las características clínicas, los hallazgos de imágenes y las variables de laboratorio en 143 pacientes con influenza confirmada por laboratorio que requirieron hospitalización durante 2019. Los casos fueron confirmados mediante la reacción en cadena de la polimerasa con transcripción inversa en tiempo real. El 98.6% (n: 141) estaban infectados por influenza tipo A y 61.5% (n: 88) correspondía al subtipo H1N1. La mediana de edad fue 71 años (IQR 60-82), el 77.6% (n: 111) tenía más de 70 años y el 88.1% (n: 126) al menos una enfermedad coexistente. El 39.1% (n: 56) requirió internación en unidad de cuidados intensivos, el 11.1% (n: 16) ventilación mecánica invasiva y seis pacientes (4.1%) fallecieron durante la hospitalización. En este estudio, la mortalidad hospitalaria fue similar a la publicada en series previas de influenza no pandémica, aunque la mayoría de los pacientes eran mayores de 70 años y presentaban al menos una enfermedad coexistente.

Influenza season 2019. Analysis of 143 hospitalized patients / Temporada de influenza 2019. Análisis de 143 pacientes hospitalizados

Abstract Influenza infection is a latent public health problem, affecting millions of people throughout the world, which imposes high morbidity and economic burden on the region. In Argentina, influenza‐associ ated mortality is estimated at 6/100 000 person‐years, and is higher among men ≥ 65 years old. The knowledge of the baseline characteristics and outcomes of hospitalized patients is crucial for public health officials planning interventions to address local outbreaks. Thus, in this retrospective, single-center study, performed in a high-complexity university hospital, we aimed to analyze clinical characteristics, image findings, and laboratory variables of patients with laboratory-confirmed influenza requiring hospitalization in our hospital during 2019. Cases were confirmed by real-time reverse transcription-polymerase chain reaction. One hundred and forty-three patients with influenza were hospitalized during the study period; 141 (98.6%) were infected with influenza virus type A, including 88 (61.5%) with the H1N1 subtype. The median age was 71 years (IQR 60- 82), 111 (77.6%) were older than 70 years, and 126 (88.1%) had at least one coexisting illness; 56 (39.1%) patients required intensive care unit, 16 (11.1%) invasive mechanical ventilation, and 6 (4.1%) died during hospitalization. In this study, in-hospital mortality was similar to that reported in previous series of non-pandemic influenza, even though the majority of the cases in this study were older than 70 years and had at least one coexisting illness.

Resumen La influenza es un problema latente de salud pública que afecta a millones de personas en todo el planeta e impone una alta morbilidad y carga económica para la región. En Argentina, la mortalidad asociada a la influenza se estima en 6/100 000 personas-año y es mayor entre los hombres mayores de 65 años. El conocimiento de las características clínicas y la evolución de los pacientes hospitalizados es fundamental para planificar el abordaje de los brotes locales. En este estudio retrospectivo, realizado en un hospital universitario de alta complejidad, nuestro objetivo fue analizar las características clínicas, los hallazgos de imágenes y las variables de laboratorio en 143 pacientes con influenza confirmada por laboratorio que requirieron hospitalización durante 2019. Los casos fueron confirmados mediante la reacción en cadena de la polimerasa con transcripción inversa en tiempo real. El 98.6% (n: 141) estaban infectados por influenza tipo A y 61.5% (n: 88) correspondía al subtipo H1N1. La mediana de edad fue 71 años (IQR 60-82), el 77.6% (n: 111) tenía más de 70 años y el 88.1% (n: 126) al menos una enfermedad coexistente. El 39.1% (n: 56) requirió internación en unidad de cuidados intensivos, el 11.1% (n: 16) ventilación mecánica invasiva y seis pacientes (4.1%) fallecieron durante la hospitalización. En este estudio, la mortalidad hospitalaria fue similar a la publicada en series previas de influenza no pandémica, aunque la mayoría de los pacientes eran mayores de 70 años y presentaban al menos una enfermedad coexistente.

Kinetics of procalcitonin in infections caused by multidrug-resistant bacteria / Cinética de procalcitonina en infecciones causadas por bacterias multirresistentes

Resumen La cinética de la procalcitonina es útil para reducir la duración de la antibioticoterapia en pacientes críticos, pero no se analizó su rol en infecciones por gérmenes multirresistentes. Se realizó un estudio observacional retrospectivo, analizando las curvas de procalcitonina de pacientes con neumonías asociadas a ventilación mecánica (NAVM) y bacteriemias asociadas a catéter (BAC) con rescate bacteriano durante el período 1/11/16 a 1/7/19. Se estudiaron 16 pacientes con infección por gérmenes sensibles (10 BAC y 6 NAVM) y 10 por gérmenes multirresistentes (10 BAC y 10 NAVM). Los pacientes con BAC generadas por gérmenes multirresistentes presentaron valores de procalcitonina mayores que los pacientes con BAC por gérmenes sensibles: (39 ± 30 μg/l vs. 10.7 ± 11 μg/l, p = 0.02). Los pacientes con NAVM generada por gérmenes sensibles y multirresistentes presentaron valores de procalcitonina similares. El descenso de procalcitonina a niveles 80% menores al valor máximo o menores a 0.5 μg/l (con tratamiento antibiótico efectivo) fue más veloz en pacientes con infección por gérmenes sensibles (5 ± 1.8 días vs. 7.2 ± 2.9 días, p = 0.03). En las infecciones por gérmenes multirresistentes, la respuesta inflamatoria medida por procalcitonina fue más intensa y prolongada, aun con un tratamiento antibiótico efectivo. Sin embargo, el descenso se produjo antes de que finalizaran los esquemas antibióticos convencionales. Por este motivo, se considera necesario estudiar la potencial utilidad de protocolos antibióticos guiados por procalcitonina en pacientes con infecciones por gérmenes multirresistentes para reducir la exposición a antibióticos.

Abstract Procalcitonin guidance stimulates a reduction in the duration of antibiotic treatment in critically ill patients with a presumed bacterial infection, but its role in infections caused by multidrug-resistant bacteria has not been sufficiently explored. In this retrospective observational study, we analyzed procalcitonin curves of 32 patients with culture-confirmed ventilation-associated pneumonia (VAP) and catheter-related bloodstream infections (CRBSI) occurred during the period 11/1/2016 to 7/1/2019. Sixteen infections were caused by multidrug-resistant bacteria (10 CRBSI and 6 VAP) and other 16 by sensitive bacteria (10 CRBSI and 6 VAP). CRBSI generated by multidrug-resistant bacteria elicited significantly higher procalcitonin levels than CRBSI infections caused by sensitive bacteria (39 ± 30 μg/l vs. 10.7 ± 11 μg/l, p = 0.02). Patients with VAP caused by sensitive and multidrug-resistant bacteria elicited similar procalcitonin levels. The time to a decrease in procalcitonin level to less than 80% of the peak value or less than 0.5 μg/l upon effective antibiotic treatment was 7.2 ± 2.9 days in multidrug-resistant bacteria vs. 5 ± 1.8 days in sensitive bacteria (p = 0.03). In multidrug-resistant bacteria, the inflammatory response measured by procalcitonin is stronger and longer, even with an effective antibiotic treatment. However, the decline occurs before the conventional antibiotic scheme is completed. The potential application of antibiotic protocols guided by procalcitonin to these groups of patients grants further studies aimed to reduce exposure to antibiotics in critical multidrug-resistant infections.

[Kinetics of procalcitonin in infections caused by multidrug-resistant bacteria]. / Cinética de procalcitonina en infecciones causadas por bacterias multirresistentes.

Procalcitonin guidance stimulates a reduction in the duration of antibiotic treatment in critically ill patients with a presumed bacterial infection, but its role in infections caused by multidrug-resistant bacteria has not been sufficiently explored. In this retrospective observational study, we analyzed procalcitonin curves of 32 patients with culture-confirmed ventilation-associated pneumonia (VAP) and catheter-related bloodstream infections (CRBSI) occurred during the period 11/1/2016 to 7/1/2019. Sixteen infections were caused by multidrug-resistant bacteria (10 CRBSI and 6 VAP) and other 16 by sensitive bacteria (10 CRBSI and 6 VAP). CRBSI generated by multidrug-resistant bacteria elicited significantly higher procalcitonin levels than CRBSI infections caused by sensitive bacteria (39 ± 30 υg/l vs. 10.7 ± 11 υg/l, p = 0.02). Patients with VAP caused by sensitive and multidrug-resistant bacteria elicited similar procalcitonin levels. The time to a decrease in procalcitonin level to less than 80% of the peak value or less than 0.5 υg/l upon effective antibiotic treatment was 7.2 ± 2.9 days in multidrug-resistant bacteria vs. 5 ± 1.8 days in sensitive bacteria (p = 0.03). In multidrug-resistant bacteria, the inflammatory response measured by procalcitonin is stronger and longer, even with an effective antibiotic treatment. However, the decline occurs before the conventional antibiotic scheme is completed. The potential application of antibiotic protocols guided by procalcitonin to these groups of patients grants further studies aimed to reduce exposure to antibiotics in critical multidrug-resistant infections.

La cinética de la procalcitonina es útil para reducir la duración de la antibioticoterapia en pacientes críticos, pero no se analizó su rol en infecciones por gérmenes multirresistentes. Se realizó un estudio observacional retrospectivo, analizando las curvas de procalcitonina de pacientes con neumonías asociadas a ventilación mecánica (NAVM) y bacteriemias asociadas a catéter (BAC) con rescate bacteriano durante el período 1/11/16 a 1/7/19. Se estudiaron 16 pacientes con infección por gérmenes sensibles (10 BAC y 6 NAVM) y 10 por gérmenes multirresistentes (10 BAC y 10 NAVM). Los pacientes con BAC generadas por gérmenes multirresistentes presentaron valores de procalcitonina mayores que los pacientes con BAC por gérmenes sensibles: (39 ± 30 υg/l vs. 10.7 ± 11 υg/l, p = 0.02). Los pacientes con NAVM generada por gérmenes sensibles y multirresistentes presentaron valores de procalcitonina similares. El descenso de procalcitonina a niveles 80% menores al valor máximo o menores a 0.5 υg/l (con tratamiento antibiótico efectivo) fue más veloz en pacientes con infección por gérmenes sensibles (5 ± 1.8 días vs. 7.2 ± 2.9 días, p = 0.03). En las infecciones por gérmenes multirresistentes, la respuesta inflamatoria medida por procalcitonina fue más intensa y prolongada, aun con un tratamiento antibiótico efectivo. Sin embargo, el descenso se produjo antes de que finalizaran los esquemas antibióticos convencionales. Por este motivo, se considera necesario estudiar la potencial utilidad de protocolos antibióticos guiados por procalcitonina en pacientes con infecciones por gérmenes multirresistentes para reducir la exposición a antibióticos.

Implementation of an experiential learning strategy to reduce the risk of ventilator-associated pneumonia in critically ill adult patients.

OBJECTIVE: We evaluated the impact of an experiential learning strategy on both the adherence to the use of bundles and the incidence of ventilator-associated pneumonia in critically ill adult patients. METHODS: Longitudinal, quasi-experimental interrupted time-series study in a tertiary teaching hospital in Buenos Aires, Argentina. Successive measurements were made before and after the intervention was implemented between January 2016 and December 2018. Our main exposure was experiential learning, which was based on a combination of play activities, simulation models, knowledge and attitude competencies, role-playing and feedback. The adherence to the bundle for the care of mechanically ventilated critically-ill adult patients and the occurrence of ventilator-associated pneumonia were the main outcomes of interest. We used generalized linear models including time as a linear spline to estimate the effect of the experiential learning strategy both on the adherence to the bundle of care and the occurrence of ventilator-associated pneumonia during long-term follow-up. RESULTS: The overall proportion of adequate bundle use before and after the implementation of the intervention was 60.8% (95% CI: 56.9-64.7) and 85.6% (95% CI: 81.2-90.1), respectively. The incidence rate of ventilator-associated pneumonia before and after the intervention was 6.11 (95% CI: 5.82-6.40) and 3.55 (95% CI: 2.96-4.14) every 1000 days of mechanical ventilation, respectively. The estimated baseline monthly change in the adherence to the mechanical ventilation bundle was 0.4% (95%CI: -0.3-1.2%, p = 0.31) and 1.1% (95% CI: 0.2-2.2%, p < 0.01) before and after the implementation of the intervention, respectively. These results were consistent across our statistical quality control analysis. CONCLUSIONS: The implementation of experiential learning strategies improves the adherence to bundles in the care of mechanically ventilated critically ill adult patients. Such strategies also decrease the incidence rate of ventilator-associated pneumonia. Both effects appear to remain constant during long-term follow-up.