Trends in mortality in septic patients according to the different organ failure during 15 years.

BACKGROUND: The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality. METHODS: A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes. RESULTS: Of 11.916.974 discharges from all acute-care hospitals during the study period (2005-2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (p < 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (p < 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (p < 0.0001). CONCLUSIONS: The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant.

Non-invasive oxygenation support in acutely hypoxemic COVID-19 patients admitted to the ICU: a multicenter observational retrospective study.

BACKGROUND: Non-invasive oxygenation strategies have a prominent role in the treatment of acute hypoxemic respiratory failure during the coronavirus disease 2019 (COVID-19). While the efficacy of these therapies has been studied in hospitalized patients with COVID-19, the clinical outcomes associated with oxygen masks, high-flow oxygen therapy by nasal cannula and non-invasive mechanical ventilation in critically ill intensive care unit (ICU) patients remain unclear. METHODS: In this retrospective study, we used the best of nine covariate balancing algorithms on all baseline covariates in critically ill COVID-19 patients supported with > 10 L of supplemental oxygen at one of the 26 participating ICUs in Catalonia, Spain, between March 14 and April 15, 2020. RESULTS: Of the 1093 non-invasively oxygenated patients at ICU admission treated with one of the three stand-alone non-invasive oxygenation strategies, 897 (82%) required endotracheal intubation and 310 (28%) died during the ICU stay. High-flow oxygen therapy by nasal cannula (n = 439) and non-invasive mechanical ventilation (n = 101) were associated with a lower rate of endotracheal intubation (70% and 88%, respectively) than oxygen masks (n = 553 and 91% intubated), p < 0.001. Compared to oxygen masks, high-flow oxygen therapy by nasal cannula was associated with lower ICU mortality (hazard ratio 0.75 [95% CI 0.58-0.98), and the hazard ratio for ICU mortality was 1.21 [95% CI 0.80-1.83] for non-invasive mechanical ventilation. CONCLUSION: In critically ill COVID-19 ICU patients and, in the absence of conclusive data, high-flow oxygen therapy by nasal cannula may be the approach of choice as the primary non-invasive oxygenation support strategy.

Individuals With SARS-CoV-2 Infection During the First and Second Waves in Catalonia, Spain: Retrospective Observational Study Using Daily Updated Data.

BACKGROUND: A description of individuals with SARS-CoV-2 infection comparing the first and second waves could help adapt health services to manage this highly transmissible infection. OBJECTIVE: We aimed to describe the epidemiology of individuals with suspected SARS-CoV-2 infection, and the characteristics of patients with a positive test comparing the first and second waves in Catalonia, Spain. METHODS: This study had 2 stages. First, we analyzed daily updated data on SARS-CoV-2 infection in individuals from Girona (Catalonia). Second, we compared 2 retrospective cohorts of patients with a positive reverse-transcription polymerase chain reaction or rapid antigen test for SARS-CoV-2. The severity of patients with a positive test was defined by their admission to hospital, admission to intermediate respiratory care, admission to the intensive care unit, or death. The first wave was from March 1, 2020, to June 24, 2020, and the second wave was from June 25, 2020, to December 8, 2020. RESULTS: The numbers of tests and cases were lower in the first wave than in the second wave (26,096 tests and 3140 cases in the first wave versus 140,332 tests and 11,800 cases in the second wave), but the percentage of positive results was higher in the first wave than in the second wave (12.0% versus 8.4%). Among individuals with a positive diagnostic test, 818 needed hospitalization in the first wave and 680 in the second; however, the percentage of hospitalized individuals was higher in the first wave than in the second wave (26.1% versus 5.8%). The group that was not admitted to hospital included older people and those with a higher percentage of comorbidities in the first wave, whereas the characteristics of the groups admitted to hospital were more alike. CONCLUSIONS: Screening systems for SARS-CoV-2 infection were scarce during the first wave, but were more adequate during the second wave, reflecting the usefulness of surveillance systems to detect a high number of asymptomatic infected individuals and their contacts, to help control this pandemic. The characteristics of individuals with SARS-CoV-2 infection in the first and second waves differed substantially; individuals in the first wave were older and had a worse health condition.

La sepsis es importante, pero hay más / Sepsis is important, but there is more

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Efficacy and safety of trimodulin, a novel polyclonal antibody preparation, in patients with severe community-acquired pneumonia: a randomized, placebo-controlled, double-blind, multicenter, phase II trial (CIGMA study).

PURPOSE: The CIGMA study investigated a novel human polyclonal antibody preparation (trimodulin) containing ~ 23% immunoglobulin (Ig) M, ~ 21% IgA, and ~ 56% IgG as add-on therapy for patients with severe community-acquired pneumonia (sCAP). METHODS: In this double-blind, phase II study (NCT01420744), 160 patients with sCAP requiring invasive mechanical ventilation were randomized (1:1) to trimodulin (42 mg IgM/kg/day) or placebo for five consecutive days. Primary endpoint was ventilator-free days (VFDs). Secondary endpoints included 28-day all-cause and pneumonia-related mortality. Safety and tolerability were monitored. Exploratory post hoc analyses were performed in subsets stratified by baseline C-reactive protein (CRP; ≥ 70 mg/L) and/or IgM (≤ 0.8 g/L). RESULTS: Overall, there was no statistically significant difference in VFDs between trimodulin (mean 11.0, median 11 [n = 81]) and placebo (mean 9.6; median 8 [n = 79]; p = 0.173). Twenty-eight-day all-cause mortality was 22.2% vs. 27.8%, respectively (p = 0.465). Time to discharge from intensive care unit and mean duration of hospitalization were comparable between groups. Adverse-event incidences were comparable. Post hoc subset analyses, which included the majority of patients (58-78%), showed significant reductions in all-cause mortality (trimodulin vs. placebo) in patients with high CRP, low IgM, and high CRP/low IgM at baseline. CONCLUSIONS: No significant differences were found in VFDs and mortality between trimodulin and placebo groups. Post hoc analyses supported improved outcome regarding mortality with trimodulin in subsets of patients with elevated CRP, reduced IgM, or both. These findings warrant further investigation. TRIAL REGISTRATION: NCT01420744.

Multicenter, randomized, placebo-controlled phase III study of pyridoxalated hemoglobin polyoxyethylene in distributive shock (PHOENIX).

OBJECTIVE: To compare the effectiveness and safety of the hemoglobin-based nitric oxide scavenger, pyridoxalated hemoglobin polyoxyethylene, against placebo in patients with vasopressor-dependent distributive shock. DESIGN: Multicenter, randomized, placebo-controlled, open-label study. SETTING: Sixty-one participating ICUs in six European countries (Austria, Belgium, Germany, the Netherlands, Spain, and United Kingdom). PATIENTS: All patients admitted with distributive shock, defined as the presence of at least two systemic inflammatory response syndrome criteria, persisting norepinephrine dependence and evidence of organ dysfunction/hypoperfusion despite adequate fluid resuscitation. INTERVENTIONS: Patients were randomized to receive 0.25 mL/kg/hr pyridoxalated hemoglobin polyoxyethylene (20 mg Hb/kg/hr) or an equal volume of placebo, infused for up to 150 hours, in addition to conventional vasopressor therapy. MEASUREMENTS AND MAIN RESULTS: The study was stopped after interim analysis showed higher mortality in the pyridoxalated hemoglobin polyoxyethylene group and an increased prevalence of adverse events. At this time, 377 patients had been randomized to pyridoxalated hemoglobin polyoxyethylene (n = 183) or placebo (n = 194). Age, gender, type of patient (medical/surgical), and Acute Physiology and Chronic Health Evaluation II scores were similar between groups. Twenty-eight-day mortality rate was 44.3% in the pyridoxalated hemoglobin polyoxyethylene group versus 37.6% in the placebo group (OR, 1.29; 95% CI, 0.85-1.95; p = 0.227). In patients with higher organ dysfunction scores (Sepsis-related Organ Failure Assessment > 13), mortality rates were significantly higher in the pyridoxalated hemoglobin polyoxyethylene group when compared with those in placebo-treated patients (60.9% vs 39.2%; p = 0.014). Survivors who received pyridoxalated hemoglobin polyoxyethylene had a longer vasopressor-free time (21.3 vs 19.7 d; p = 0.035). CONCLUSIONS: In this randomized, controlled phase III trial in patients with vasopressor-dependent distributive shock, administration of a pyridoxalated hemoglobin solution decreased the need for vasopressors but was associated with a trend to increased mortality.

Fluid balance in sepsis and septic shock as a determining factor of mortality.

OBJECTIVE: The objective was to assess whether fluid balance had a determinant impact on mortality rate in a cohort of critically ill patients with severe sepsis or septic shock. DESIGN: A prospective and observational study was carried out on an inception cohort. SETTING: The setting was an intensive care unit of a university hospital. PATIENTS: Patients admitted consecutively in the intensive care unit who were diagnosed with severe sepsis or septic shock were included. INTERVENTIONS: Demographic, laboratory, and clinical data were registered, as well as time of septic shock onset, illness severity (Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment), and comorbidities. Daily and accumulated fluid balance was registered at 24, 48, 72, and 96 hours. Survival curves representing 28-day mortality were built according to the Kaplan-Meier method. RESULTS: A total of 42 patients were included in the analysis: men, 64.3%; mean age, 61.8±15.9 years. Septic shock was predominant in 69% of the cases. Positive blood cultures were obtained in 17 patients (40.5%). No age, sex, Sepsis-related Organ Failure Assessment, creatinine, lactate, venous saturation of O2, and troponin differences were observed upon admission between survivors and nonsurvivors. However, higher Simplified Acute Physiology Score II was observed in nonsurvivors, P=.016. Nonsurvivors also showed higher accumulated positive fluid balance at 48, 72, and 96 hours with statistically significant differences. Besides, significant differences (P=.02) were observed in the survival curve with the risk of mortality at 72 hours between patients with greater than 2.5 L and less than 2.5 L of accumulated fluid balance. CONCLUSIONS: Fluid administration at the onset of severe sepsis or septic shock is the first line of hemodynamic treatment. However, the accumulated positive fluid balance in the first 48, 72, and 96 hours is associated with higher mortality in these critically ill patients.

Successful empirical erlotinib treatment of a mechanically ventilated patient newly diagnosed with metastatic lung adenocarcinoma.

BACKGROUND: Lung cancer is the most common solid tumor in critically ill cancer patients who are admitted to intensive care units (ICUs). An ICU trial consists of unlimited ICU support for a limited time period. CASE REPORT: We present the case of a 60-year-old woman with newly diagnosed metastatic lung adenocarcinoma who required mechanical ventilation due to respiratory failure. Empirical erlotinib treatment was administered through a nasogastric feeding tube as part of an ICU trial, which led to a dramatic and durable response. CONCLUSION: Empirical erlotinib should be considered when epidermal growth factor receptor (EGFR) mutations are suspected in ICU newly diagnosed patients with lung adenocarcinoma.

Importancia de la hemodiafiltración precoz en el tratamiento de la acidosis láctica asociada a la administración de metformina / The importance of early haemodiafiltration in the treatment of lactic acidosis associated with the administration of metformin

La metformina es un fármaco muy utilizado en pacientes con diabetes tipo 2. La acidosis láctica asociada a metformina (ALAM) en pacientes diabéticos es poco frecuente, pero puede llegar a ser grave. De todas formas, la relación entre metformina y acidosis láctica ha sido muy controvertida. Presentamos siete casos de pacientes con ALAM que llegaron a nuestro centro en un período de un año y que fueron tratados de forma precoz con hemofiltración. Existen algunos factores de riesgo que parecen predisponer a esa patología, como fracaso renal agudo, situaciones de hipoxemia y sepsis, insuficiencia cardíaca o respiratoria, historia previa de acidosis láctica, hepatopatía y en cuadros de deshidratación. Es por ello por lo que se desaconseja su utilización en pacientes con filtrado glomerular inferior a 30 ml/min/1,73 m2. Todos los pacientes que presentamos fueron tratados de forma precoz con hemofiltración. La mortalidad de nuestra serie fue del 16,6%. Consideramos que la ALAM es una enfermedad grave que requiere un diagnóstico y un tratamiento precoces. El tratamiento renal sustitutivo no es la solución para todos los pacientes, pero puede mejorar el pronóstico en aquellos que están más graves si se inicia de forma precoz. Creemos importante limitar el uso de la metformina en los pacientes diabéticos con función renal alterada, a pesar de que todavía existe controversia en los distintos estudios publicados (AU)

Metformin is a drug widely used in type 2 diabetic patients. The metformin-associated lactic acidosis (MALA) in diabetic patients is rare but can be serious. However, the relationship between metformin and lactic acidosis has been controversial. We present seven cases of patients with ALAM who came to our centre over a period of one year and who were treated early with haemodiafiltration. There are some risk factors that appear to predispose to this pathology, such as: acute renal failure, hypoxemia and sepsis situations, cardiac or respiratory failure, previous history of lactic acidosis, liver disease and dehydration boxes. That is why their use is discouraged in patients with GFR below 30ml/min/1.73m2. All patients described were treated early with haemodiafiltration. The mortality in our series was 16.6%. We believe that ALAM is a serious condition that requires prompt diagnosis and early treatment. Renal replacement therapy is not the solution for all patients, but can improve prognosis in more severe if started early. We should limit the use of metformin in diabetic patients with impaired renal function, although there is still controversy in the various published studies (AU)

The importance of early haemodiafiltration in the treatment of lactic acidosis associated with the administration of metformin.

Metformin is a drug widely used in type 2 diabetic patients. Metformin-associated lactic acidosis (MALA) in diabetic patients is rare but can be serious. However, the relationship between metformin and lactic acidosis is under debate. We present seven cases of patients with MALA who came to our centre over a period of one year and who were treated early with haemodiafiltration. There are some risk factors that appear to predispose patients to this pathology, such as: acute renal failure, situations of hypoxemia and sepsis, cardiac or respiratory failure, previous history of lactic acidosis, liver disease and dehydration. As such, the use of metformin is discouraged in patients with GFR below 30 ml/min/1.73 m(2). All patients in our study were treated early with haemodiafiltration. The mortality in our study was 16.6%. We believe that MALA is a serious condition that requires prompt diagnosis and early treatment. Renal replacement therapy is not the solution for all patients, but can improve prognosis in more severe cases if started early. We should limit the use of metformin in diabetic patients with impaired renal function, although there is still controversy in the medical literature.

Real-time continuous glucose monitoring in an intensive care unit: better accuracy in patients with septic shock.

OBJECTIVE: This study assessed the accuracy of real-time continuous glucose monitoring system (RTCGMS) devices in an intensive care unit (ICU) to determine whether the septic status of the patient has any influence on the accuracy of the RTCGMS. SUBJECTS AND METHODS: In total, 41 patients on insulin therapy were included. Patients were monitored for 72 h using RTCGMS. Arterial blood glucose (ABG) samples were obtained following the protocol established in the ICU. The results were evaluated using paired values (excluding those used for calibration) with the performance assessed using numerical accuracy. Nonparametric tests were used to determine statistically significant differences in accuracy. RESULTS: In total, 956 ABG/RTCGMS pairs were analyzed. The overall median relative absolute difference (RAD) was 13.5%, and the International Organization for Standardization (ISO) criteria were 68.1%. The median RADs reported for patients with septic shock, with sepsis, and without sepsis were 11.2%, 14.3%, and 16.3%, respectively (P<0.05). Measurements meeting the ISO criteria were 74.5%, 65.6%, and 63.7% for patients with septic shock, with sepsis, and without sepsis, respectively (P<0.05). CONCLUSIONS: The results showed that the septic status of patients influenced the accuracy of the RTCGMS in the ICU. Accuracy was significantly better in patients with septic shock in comparison with the other patient cohorts.

Linezolid more efficacious than vancomycin to eradicate infecting organism in critically ill patients with Gram-positive infections.

OBJECTIVE: A prospective and observational study has been conducted to analyze the efficacious of linezolid compared to vancomycin to eradicate the infecting organism in critically ill patients with Gram-positive infections. PATIENTS AND METHODS: Prospective, observational and non-controlled study in a medical-surgical intensive care unit (ICU) in a university hospital. A total number of 53 critically ill patients with therapy to proven Gram-positive bacterial infection were studied. Infected patients were diagnosed and treated according to international guidelines, following standard protocol for the critically ill infected patients. Microbiologic eradication of the infecting organism at the seventh day of treatment and patients' clinical outcome were analysed. RESULTS: Twenty-seventh patients received linezolid and twenty-six received vancomycin. Infection-site diagnoses were: hospital-acquired pneumonia (21 cases: 39.6%), complicated surgical-site infection (19 cases: 35.8%) and catheter-related bacteraemia (13 cases: 24.5%). The most important isolated microorganism was methicillin-resistant Staphylococcus aureus (MRSA) (28 cases: 52.8%). Clinical success was 20/ 27 (74.1%) in the linezolid group and 16/ 26 (61.5 %) in the vancomycin group, with p = 0.3. The adjusted logistic regression model demonstrated that the treatment with linezolid is associated to microbiologic eradication of the infecting organism at the seventh day of treatment [OR = 7.88 (95% CI 1.86-33.52)] and p = 0.005. In this model, the length of hospital stay was lower in the group with microbiologic eradication at the seventh day (p = 0.015). Drug-related adverse events were comparable in both groups of treatment. CONCLUSION: Treatment with linezolid in critically ill patients with Gram-positive infections was equivalent to vancomycin in terms of efficacy and safety, but linezolid was associated to a higher rate of microbiologic eradication of the infecting organism at the seventh day of treatment.

Linezolid more efficacious than vancomycin to eradicate infecting organism in critically ill patients with Gram-positive infections

Objetivo: Se realizó un estudio prospectivo y observacionalcon el objetivo de analizar la eficacia de linezolid comparadocon vancomicina para erradicar los organismos infectantesen los pacientes críticos con infecciones por grampositivos.Pacientes y Métodos: Estudio prospectivo, observacional yno controlado en una unidad de cuidados intensivos (UCI) deun hospital universitario. Se estudiaron un total de 53 pacientescríticos con tratamiento para una infección bacteriana probaday producida por grampositivos. Los pacientes infectadosfueron diagnosticados y tratados siguiendo las guías internacionalesy los protocolos estándares locales establecidos paralas infecciones de los pacientes críticos. Se analizó la erradicaciónmicrobiológica del organismo infectante al séptimo día detratamiento y la evolución clínica.Resultados: Veintisiete pacientes recibieron tratamientocon linezolid y veintiséis recibieron vancomicina. Los focos infecciososfueron: neumonía adquirida en el hospital (21 casos:39.6 %), infección quirúrgica complicada (19 casos: 35.8 %) ybacteriemia relacionada con el catéter (13 casos: 24.5 %). Elmicroorganismo más frecuentemente aislado fue Staphylococcusaureus (SARM) (28 casos: 52.8 %). El éxito clínico seobtuvo en 20/27 pacientes (74.1 %) en el grupo de linezolid y en 16/26 pacientes (61.5 %) en el grupo de vancomicina, conuna p = 0.3. El modelo de regresión logística mostró que el tratamientocon linezolid se asoció de forma significativa a unaerradicación microbiológica del organismo infectante al séptimodía de tratamiento [OR = 7.88 (95 % CI 1.86-33.52)], p =0.005. En este modelo, la estancia en el hospital fue más bajaen el grupo de pacientes con erradicación microbiológica alséptimo día, (p = 0.015). Los efectos adversos observados fueronsimilares en ambos grupos de tratamiento...(AU)

Objetive: A prospective and observational study hasbeen conducted to analyze the efficacious of linezolidcompared to vancomycin to eradicate the infecting organismin critically ill patients with Gram-positive infections.Patients and Methods: Prospective, observationaland non-controlled study in a medical-surgical intensivecare unit (ICU) in a university hospital. A total numberof 53 critically ill patients with therapy to proven Grampositivebacterial infection were studied. Infected patientswere diagnosed and treated according to internationalguidelines, following standard protocol for thecritically ill infected patients. Microbiologic eradicationof the infecting organism at the seventh day of treatmentand patients’ clinical outcome were analysed.Results: Twenty-seventh patients received linezolidand twenty-six received vancomycin. Infection-site diagnoseswere: hospital-acquired pneumonia (21 cases:39.6%), complicated surgical-site infection (19 cases:35.8%) and catheter-related bacteraemia (13 cases: 24.5%).The most important isolated microorganism was methicillin-resistant Staphylococcus aureus (MRSA) (28 cases:52.8%). Clinical success was 20/27 (74.1%) in the linezolidgroup and 16/26 (61.5 %) in the vancomycin group, with p= 0.3. The adjusted logistic regression model demonstratedthat the treatment with linezolid is associated to microbiologiceradication of the infecting organism at the seventhday of treatment [OR = 7.88 (95% CI 1.86-33.52)] and p =0.005. In this model, the length of hospital stay was lowerin the group with microbiologic eradication at the seventhday (p = 0.015). Drug-related adverse events were comparablein both groups of treatment...(AU)

Effectiveness of treatments for severe sepsis: a prospective, multicenter, observational study.

RATIONALE: Several Surviving Sepsis Campaign Guidelines recommendations are reevaluated. OBJECTIVES: To analyze the effectiveness of treatments recommended in the sepsis guidelines. METHODS: In a prospective observational study, we studied all adult patients with severe sepsis from 77 intensive care units. We recorded compliance with four therapeutic goals (central venous pressure 8 mm Hg or greater for persistent hypotension despite fluid resuscitation and/or lactate greater than 36 mg/dl, central venous oxygen saturation 70% or greater for persistent hypotension despite fluid resuscitation and/or lactate greater than 36 mg/dl, blood glucose greater than or equal to the lower limit of normal but less than 150 mg/dl, and inspiratory plateau pressure less than 30 cm H(2)O for mechanically ventilated patients) and four treatments (early broad-spectrum antibiotics, fluid challenge in the event of hypotension and/or lactate greater than 36 mg/dl, low-dose steroids for septic shock, drotrecogin alfa [activated] for multiorgan failure). The primary outcome measure was hospital mortality. The effectiveness of each treatment was estimated using propensity scores. MEASUREMENTS AND MAIN RESULTS: Of 2,796 patients, 41.6% died before hospital discharge. Treatments associated with lower hospital mortality were early broad-spectrum antibiotic treatment (treatment within 1 hour vs. no treatment within first 6 hours of diagnosis; odds ratio, 0.67; 95% confidence interval, 0.50-0.90; P = 0.008) and drotrecogin alfa (activated) (odds ratio, 0.59; 95% confidence interval, 0.41-0.84; P = 0.004). Fluid challenge and low-dose steroids showed no benefits. CONCLUSIONS: In severe sepsis, early administration of broad-spectrum antibiotics in all patients and administration of drotrecogin alfa (activated) in the most severe patients reduce mortality.