Acute encephalitis, myoclonus and Sweet syndrome after mRNA-1273 vaccine.

A patient presented with fever, generalised rash, confusion, orofacial movements and myoclonus after receiving the first dose of mRNA-1273 vaccine from Moderna. MRI was unremarkable while cerebrospinal fluid showed leucocytosis with lymphocyte predominance and hyperproteinorrachia. The skin evidenced red, non-scaly, oedematous papules coalescing into plaques with scattered non-follicular pustules. Skin biopsy was consistent with a neutrophilic dermatosis. The patient fulfilled the criteria for Sweet syndrome. A thorough evaluation ruled out alternative infectious, autoimmune or malignant aetiologies, and all manifestations resolved with glucocorticoids. While we cannot prove causality, there was a temporal correlation between the vaccination and the clinical findings.

Continuous-flow left ventricular assist device systems infections: current outcomes and management strategies.

Left ventricular assisted devices (LVADs) are increasingly used for management of patients with advanced heart failure. However, infection remains one of the most commonly reported complications. Diagnosis, as well as treatment of LVAD infections is challenging. There are multiple diagnostic modalities that have been used to assist with accurate diagnosis of LVAD infections. Treatment of the infection can be especially challenging in these patients, given the presence of the implantable device that cannot be easily replaced or removed. There are no clinical trials assessing the best approach to diagnosis, treatment or long-term management of LVAD infections. In this article we review the most recent diagnostic modalities and treatment approaches, as well as offer our guidance on diagnosis and treatment of LVAD infections.

Temporal Trends of Infective Endocarditis in Olmsted County, Minnesota, Between 1970 and 2018: A Population-Based Analysis.

BACKGROUND: A population-based study of infective endocarditis (IE) in Olmsted County, Minnesota, provides a unique opportunity to define temporal and seasonal variations in IE incidence over an extended time period. METHODS: This was a population-based review of all adults (≥18 years) residing in Olmsted County, Minnesota, with definite or possible IE using the Rochester Epidemiology Project from January 1, 1970, through December 31, 2018. Poisson regression was used to characterize the trends in IE incidence; models were fitted with age, sex, calendar time, and season, allowing for nonlinearity and nonadditivity of their effects. RESULTS: Overall, 269 cases of IE were identified over a 49-year study period. The median age of IE cases was 67.2 years, and 33.8% were female. The overall age- and sex-adjusted incidence of IE was 7.9 cases per 100 000 person-years (95% CI, 7.0-8.9), with corresponding rates of 2.4, 2.4, 0.9, and 0.7 per 100 000 person-years for Staphylococcus aureus, viridans group streptococci (VGS), Enterococcus species, and coagulase-negative staphylococci IE, respectively. Temporal trends varied by age, sex, and season, but on average IE incidence increased over time (P = .021). Enterococcal IE increased the most (P = .018), while S. aureus IE appeared to increase but mostly in the winter months (P = .018). Between 1996 and 2018, the incidence of VGS IE was relatively stable, with no statistically significant difference in the trends before and after the 2007 AHA IE prevention guidelines. CONCLUSIONS: Overall, IE incidence, and specifically enterococcal IE, increased over time, while S. aureus IE was seasonally dependent. There was no statistically significant difference in VGS IE incidence in the periods before and after publication of the 2007 AHA IE prevention guidelines.

Antibiotic-Eluting Envelopes to Prevent Cardiac-Implantable Electronic Device Infection: Past, Present, and Future.

OBJECTIVE: Cardiac-implantable electronic device (CIED) infections are associated with significant morbidity and mortality. In this review, we describe the risk factors and pathogenesis of CIED infections and review the rationale and the evidence for the use of antibiotic-eluting envelopes (ABEs) in patients at increased risk for CIED infections. FINDINGS: The majority of CIED infections are caused by staphylococci that involve generator pocket and occur due to contamination of the device or the pocket tissues at the time of implantation. Clinical trials have shown that extending the duration of post-operative systemic antibacterial therapy is not beneficial in reducing CIED infection rate. However, ABEs that reduce device migration after implantation and provide sustained local delivery of prophylactic antibiotics at the pocket site, may provide benefit in reducing infection. Currently, there are two types of commercially available CIED envelope devices in the United States. The first ABE device (TYRX™, Medtronic Inc., Monmouth Junction, NJ) is composed of a synthetic absorbable mesh envelope that elutes minocycline and rifampin and has been shown to reduce CIED pocket infections in a large multi-center randomized clinical trial. The second ABE device (CanGaroo-G™, Aziyo Biologics, Silver Spring, MD) is composed of decellularized extracellular matrix (ECM) and was originally designed to stabilize the device within the pocket, limiting risk for migration or erosion, and providing a substrate for tissue ingrowth in a preclinical study. This device has shown promising results in a preclinical study with local delivery of gentamicin. Compared with artificial materials, such as synthetic surgical mesh, biologic ECM has been shown to foster greater tissue integration and vascular ingrowth, a reduced inflammatory response, and more rapid clearance of bacteria. CONCLUSIONS AND RELEVANCE: ABE devices provide sustained local delivery of antibiotics at the generator pocket site and appear beneficial in reducing CIED pocket infections. Given the continued increase in the use of CIED therapy and resultant infectious complications, innovative approaches to infection prevention are critical.

Impact of Abandoned Leads on Cardiovascular Implantable Electronic Device Infections: A Propensity Matched Analysis of MEDIC (Multicenter Electrophysiologic Device Infection Cohort).

OBJECTIVES: This study sought to evaluate the impact of abandoned cardiovascular implantable electronic device (CIED) leads on the presentation and management of device-related infections. BACKGROUND: Device infection is a serious consequence of CIEDs and necessitates removal of all hardware for attempted cure. The merits of extracting or retaining presumed sterile but nonfunctioning leads is a subject of ongoing debate. METHODS: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled patients with CIED infections at 10 institutions in the United States and abroad between January 1, 2009, and December 31, 2012. Within a propensity-matched cohort, relevant clinical information was compared between patients who had 1 or more abandoned leads at the time of infection and those who had none. RESULTS: Matching produced a cohort of 264 patients, including 176 with no abandoned leads and 88 with abandoned leads. The groups were balanced with respect to Charlson comorbidity index, oldest lead age, device type, sex, and race. At the time of admission, those with abandoned leads were less likely to demonstrate systemic signs of infection, including leukocytosis (p = 0.023) and positive blood cultures (p = 0.005). Conversely, patients with abandoned leads were more likely to demonstrate local signs of infections, including skin erosion (p = 0.031) and positive pocket cultures (p = 0.015). In addition, patients with abandoned leads were more likely to require laser extraction (p = 0.010). CONCLUSIONS: The results of a large prospective registry of CIED infections demonstrated that patients with abandoned leads may present with different signs, symptoms, and microbiological findings and require laser extraction more than those without abandoned leads.

Single Versus Multidrug Regimen for Surgical Infection Prophylaxis in Left Ventricular Assist Device Implantation.

Infection is a serious complication of left ventricular assist device (LVAD) therapy. However, an optimal antimicrobial surgical infection prophylaxis (SIP) regimen for LVAD implantation is not well established. We retrospectively reviewed all adults who underwent continuous-flow LVAD implantation from February 2007 to March 2015 at Mayo Clinic Rochester. Left ventricular assist device infection (LVADI) was defined using criteria published by the International Society for Heart and Lung Transplant. Patients excluded from the analysis included those who did not have HeartMate II or HeartWare device, patients with incomplete documentation of SIP, and those with an actively treated infection at the time of LVAD implantation. We compared risk of LVAD-specific and LVAD-related infections and all-cause mortality between SIP regimens at postoperative day 90 and 1 year using Kaplan-Meier time-to-event analyses. During study period, 239 adults underwent continuous-flow LVAD implantation at our institution where 199 patients received single-drug and 40 received multidrug SIP regimen. Median patient age was 62 years. Left ventricular assist device infection occurred in three patients (1.5%) in the single-drug group versus two patients (5.0%) in the multidrug group at 90 days (p = 0.4). There was no difference in infection-free (p = 0.4) and overall survival (p = 0.9) between two groups at 1 year. In conclusion, there was no clear benefit of using multidrug regimen as it did not impact infection-free survival or all-cause mortality compared with single-drug regimen. Prospective clinical trials are needed to further define the optimal SIP regimen for LVAD implantation.

Impacts of a care process model and inpatient electrophysiology service on cardiovascular implantable electronic device infections: a preliminary evaluation.

PURPOSE: Cardiovascular implantable electronic device infection (CIEDI) rates are rising. To improve outcomes, our institution developed an online care process model (CPM) and a specialized inpatient heart rhythm service (HRS). METHODS: This retrospective review compared hospital length of stay (LOS), mortality, and times to subspecialty consultation and procedures before and after CPM and HRS availability. RESULTS: CPM use was associated with shortened time to surgical consultation (median 2 days post-CPM vs. 3 days pre-CPM, p = 0.0152), pocket closure (median 4 vs. 5 days, p < 0.0001), and days to new CIED implant (median 7 vs. 8 days, p = 0.0126). Post-HRS patients were more likely to have a surgical consultation (OR 7.01, 95% CI 1.56-31.5, p = 0.011) and shortened time to pocket closure (coefficient - 2.21 days, 95% CI - 3.33 to - 1.09, p < 0.001), compared to pre-HRS. CONCLUSIONS: The CPM and HRS were associated with favorable outcomes, but further integration of CPM features into hospital workflow is needed.

Reimplantation and Repeat Infection After Cardiac-Implantable Electronic Device Infections: Experience From the MEDIC (Multicenter Electrophysiologic Device Infection Cohort) Database.

BACKGROUND: Infection is a serious complication of cardiovascular-implantable electronic device implantation and necessitates removal of all hardware for optimal treatment. Strategies for reimplanting hardware after infection vary widely and have not previously been analyzed using a large, multicenter study. METHODS AND RESULTS: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with cardiovascular-implantable electronic device infections at multiple institutions in the United States and abroad between 2009 and 2012. Reimplantation strategies were evaluated overall, and every patient who relapsed within 6 months was individually examined for clinical information that could help explain the negative outcome. Overall, 434 patients with cardiovascular-implantable electronic device infections were prospectively enrolled at participating centers. During the initial course of therapy, complete device removal was done in 381 patients (87.8%), and 220 of them (57.7%) were ultimately reimplanted with new devices. Overall, the median time between removal and reimplantation was 10 days, with an interquartile range of 6 to 19 days. Eleven of the 434 patients had another infection within 6 months, but only 4 of them were managed with cardiovascular-implantable electronic device removal and reimplantation during the initial infection. Thus, the repeat infection rate was low (1.8%) in those who were reimplanted. Patients who retained original hardware had a 11.3% repeat infection rate. CONCLUSIONS: Our study findings confirm that a broad range of reimplant strategies are used in clinical practice. They suggest that it is safe to reimplant cardiac devices after extraction of previously infected hardware and that the risk of a second infection is low, regardless of reimplant timing.

Beta-haemolytic streptococcal endocarditis: clinical presentation, management and outcomes.

BACKGROUND: Beta-haemolytic streptococcal (BHS) endocarditis is rare, but well-recognised for its high morbidity and mortality. This study sought to further characterise clinical features, management and outcomes of BHS endocarditis. METHODS: Retrospective review of all adultpatients (≥ 18 years old) with BHS endocarditis treated at the Mayo Clinic from 1 January 2000 to 31 December 2014. RESULTS: Forty-nine cases of BHS endocarditis were identified with a mean (± SD) age of 64 (± 14.9) years and 65% were males. The infection was community acquired in 92% of the cases, with a median (IQR) time to diagnosis from symptom onset of 6 days (5-10). Associated conditions included the presence of a prosthetic valve (41%), malignancy (33%) and diabetes mellitus (DM) (31%). Median (IQR) vegetation size was 12 mm (9-17 mm). In a univariate analysis patients with DM had larger vegetations, median (IQR) = 17 mm (10.5-26 mm) compared to non-diabetic patients, median (IQR) = 11 mm (8-15 mm) (p = 0.01). Septic brain emboli occurred in 43% of cases. Eighteen patients (37%) underwent early (within 30 days) surgery. All-cause 1 month and 6 month mortality rates were 25% and 31%, respectively. CONCLUSION: BHS endocarditis has an acute onset and is complicated by relatively large vegetations with a high rate of systemic embolisation. DM was the second most common associated medical condition and patients with DM had larger vegetations. Despite medical and surgical advances, mortality due to BHS endocarditis remains high, particularly within 30 days of diagnosis.

Infective Endocarditis Involving the Pulmonary Valve.

Pulmonary valve (PV) infective endocarditis (IE) is a rare entity, accounting for 1.5% to 2% of cases of IE. Published data are limited to a few case series and reports. We sought to review the Mayo Clinic experience and describe clinical, echocardiographic, and microbiologic features. We included all patients aged ≥18 years seen from 2000 to 2014 who had a diagnosis of native PV IE and unequivocal echocardiographic involvement of the PV. Nine patients with PV IE were identified. Isolated PV IE was present in 7 (78%) of 9 cases. The median age was 59 years and 22% were women. Three patients had congenital heart disease, 2 had central venous catheters, and 3 had cardiovascular implantable electronic devices. Five patients (56%) received chronic immunosuppressive therapy. Enterococcus faecalis and viridans group streptococci were the most common pathogens, isolated in 22% of cases each. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were done in 6 and 7 patients, respectively. Four patients underwent both procedures. TTE was diagnostic in all cases, but TEE failed to detect PV involvement in 1 patient. Median follow-up was 1.8 years. Five patients (56%) underwent PV replacement. There were no operative deaths. One patient had sudden death during follow-up, unrelated to his PV IE episode. Our results suggest that PV IE is rare but carries significant morbidity. TTE and TEE provide complementary information with TEE providing better visualization of other cardiac structures. Our findings of a high prevalence of immunosuppressive therapy and cardiovascular implantable electronic devices have not been previously reported and deserve further investigation.

Temporal trends in infective endocarditis epidemiology from 2007 to 2013 in Olmsted County, MN.

BACKGROUND: The aim of this study is to determine if there have been contemporary shifts in infective endocarditis (IE) epidemiology in our local population; an analysis of cases from 2007 to 2013 was conducted. METHODS: This is a population-based review of all adults (≥18 years) residing in Olmsted County, MN, with definite or possible IE using the Rochester Epidemiology Project from January 1, 2007, to December 31, 2013. RESULTS: We identified 51 cases of IE in Olmsted County, MN, between 2007 and 2013. Median age of IE cases was 68.8 years (interquartile range 55.6-76.5), and 41% were females. Age- and sex-adjusted incidence of IE was 7.4 (95% CI 5.3-9.4) cases per 100,000 person-years. From a multivariable Poisson regression model, incidence of IE did not change significantly during the study period (P = .222) but was significantly higher in males and those of older age (P < .001). The annual incidences (per 100,000 person-years) were 2.5 for Staphylococcus aureus, 1.1 for viridans group streptococci, 1.6 for Enterococcus species, and 0.8 for coagulase-negative staphylococci. Only 19.6% (10/51) of Olmsted County patients underwent valve surgery between 2007 and 2013 as compared with 44.4% (197/444) of non-Olmsted County patients treated at Mayo Clinic Rochester. CONCLUSION: In this population-based study, no significant change in the overall incidence of IE in Olmsted County, MN, between 2007 and 2013 was seen, and it was similar to that seen between 1970 and 2006. Male gender and older age were associated with increased IE risk. With a lesser extent of cases attributable to viridans group streptococcal IE compared with previous years, S aureus was the predominant pathogen in IE cases during 2007 to 2013. The relatively low valve surgery rate was disparate from that reported from large, tertiary care centers (including our own) with non-population-based cohorts, which are subject to referral bias and can influence the expected characterization of IE.

Incidence of Infective Endocarditis Due to Viridans Group Streptococci Before and After the 2007 American Heart Association's Prevention Guidelines: An Extended Evaluation of the Olmsted County, Minnesota, Population and Nationwide Inpatient Sample.

OBJECTIVE: To determine whether the incidence of infective endocarditis (IE) due to viridans group streptococci (VGS) increased after the publication of the 2007 American Heart Association (AHA) IE prevention guidelines. PATIENTS AND METHODS: We performed a population-based survey of all adults (18 years and older) residing in Olmsted County, Minnesota, from January 1, 1999, through December 31, 2013, to identify definite or possible cases of VGS-IE using the Rochester Epidemiology Project. The National (Nationwide) Inpatient Sample hospital discharge database was examined to determine the number of VGS-IE cases in the United States between 2000 and 2011. RESULTS: Rates of incidence (per 100,000 person-years) during the intervals of 1999-2002, 2003-2006, 2007-2010, and 2011-2013 were 3.6 (95% CI, 1.3-5.9), 2.7 (95% CI, 0.9-4.4), 0.7 (95% CI, 0.0-1.6), and 1.5 (95% CI, 0.2-2.9), respectively, reflecting an overall significant decrease (P=.03 from Poisson regression). Likewise, nationwide estimates of hospital discharges with a VGS-IE diagnosis trended downward during 2000-2011, with a mean number per year of 15,853 and 16,157 for 2000-2003 and 2004-2007, respectively, decreasing to 14,231 in 2008-2011 (P=.05 from linear regression using weighted least squares method). CONCLUSION: Despite major reductions in the number of indications for antibiotic prophylaxis for invasive dental procedures espoused by the 2007 AHA IE prevention guidelines, both local and national data indicate that the incidence of VGS-IE has not increased.

Association of Mitral Valve Prolapse With Infective Endocarditis Due to Viridans Group Streptococci.

Although patients with certain cardiac valve abnormalities have increased risk of infective endocarditis (IE), it is unknown whether these abnormalities are associated with specific pathogens in IE cases. We report a strong association between mitral valve prolapse and viridans group streptococcal IE in a population-based cohort from Olmsted County, Minnesota.

Stability in the cumulative incidence, severity and mortality of 101 cases of invasive mucormycosis in high-risk patients from 1995 to 2011: a comparison of eras immediately before and after the availability of voriconazole and echinocandin-amphotericin combination therapies.

As invasive mucormycosis (IM) numbers rise, clinicians suspect prior voriconazole worsens IM incidence and severity, and believe combination anti-fungal therapy improves IM survival. To compare the cumulative incidence (CI), severity and mortality of IM in eras immediately before and after the commercial availability of voriconazole all IM cases from 1995 to 2011 were analysed across four risk-groups (hematologic/oncologic malignancy (H/O), stem cell transplantation (SCT), solid organ transplantation (SOT) and other), and two eras, E1 (1995-2003) and E2, (2004-2011). Of 101 IM cases, (79 proven, 22 probable): 30 were in E1 (3.3/year) and 71 in E2 (8.9/year). Between eras, the proportion with H/O or SCT rose from 47% to 73%, while 'other' dropped from 33% to 11% (P = 0.036). Between eras, the CI of IM did not significantly increase in SCT (P = 0.27) or SOT (P = 0.30), and patterns of anatomic location (P = 0.122) and surgical debridement (P = 0.200) were similar. Significantly more patients received amphotericin-echinocandin combination therapy in E2 (31% vs. 5%, P = 0.01); however, 90-day survival did not improve (54% vs. 59%, P = 0.67). Since 2003, the rise of IM reflects increasing numbers at risk, not prior use of voriconazole. Frequent combination of anti-fungal therapy has not improved survival.

Pregnancy and postpartum infective endocarditis: a systematic review.

The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.

Variability in clinical features of early versus late cardiovascular implantable electronic device pocket infections.

BACKGROUND: Cardiovascular implantable electronic device (CIED) pocket infections are often related to recent CIED placement or manipulation, but these infections are not well characterized. The clinical presentation of CIED pocket infection, based on temporal onset related to last CIED procedure, deserves further study. METHODS: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with CIED infection. Subjects were stratified into those whose infection occurred <12 months (early) or ≥ 12 months (late) since their last CIED-related procedure. RESULTS: There were 132 subjects in the early group and 106 in the late group. There were more females (P = 0.009) and anticoagulation use (P = 0.039) in the early group. Subjects with early infections were more likely to have had a generator change or lead addition as their last procedure (P = 0.03) and had more prior CIED procedures (P = 0.023). Early infections were more likely to present with pocket erythema (P < 0.001), swelling (P < 0.001), and pain (P = 0.007). Late infections were more likely to have pocket erosion (P = 0.005) and valvular vegetations (P = 0.009). In bacteremic subjects, early infections were more likely healthcare-associated (P < 0.001). In-hospital and 6-month mortality were equivalent. CONCLUSION: A total of 45% of patients with CIED pocket infection presented >12 months following their last CIED-related procedure. Patients with early infection were more likely to be female, on anticoagulation, and present with localized inflammation, whereas those with late infection were more likely to have CIED erosion or valvular endocarditis.

Palivizumab prophylaxis during nosocomial outbreaks of respiratory syncytial virus in a neonatal intensive care unit: predicting effectiveness with an artificial neural network model.

STUDY OBJECTIVE: To identify subgroups of premature infants who may benefit from palivizumab prophylaxis during nosocomial outbreaks of respiratory syncytial virus (RSV) infection. DESIGN: Retrospective analysis using an artificial intelligence model. SETTING: Level IIIB, 35-bed, neonatal intensive care unit (NICU) at a tertiary care hospital in the United Arab Emirates. PATIENTS: One hundred seventy six premature infants, born at a gestational age of 22-34 weeks, and hospitalized during four RSV outbreaks that occurred between April 2005 and July 2007. MEASUREMENTS AND MAIN RESULTS: We collected demographic and clinical data for each patient by using a standardized form. Input data consisted of seven categoric and continuous variables each. We trained, tested, and validated artificial neural networks for three outcomes of interest: mortality, days of supplemental oxygen, and length of NICU stay after the index case was identified. We compared variable impacts and performed reassignments with live predictions to evaluate the effect of palivizumab. Of the 176 infants, 31 (17.6%) received palivizumab during the outbreaks. All neural network configurations converged within 4 seconds in less than 400 training cycles. Infants who received palivizumab required supplemental oxygen for a shorter duration compared with controls (105.2 ± 7.2 days vs 113.2 ± 10.4 days, p=0.003). This benefit was statistically significant in male infants whose birth weight was less than 0.7 kg and who had hemodynamically significant congenital heart disease. Length of NICU stay after identification of the index case and mortality were independent of palivizumab use. CONCLUSION: Palivizumab may be an effective intervention during nosocomial outbreaks of RSV in a subgroup of extremely low-birth-weight male infants with hemodynamically significant congenital heart disease.

Characteristics, management and outcomes of critically ill patients who are 80 years and older: a retrospective comparative cohort study.

BACKGROUND: Older age is associated with chronic illnesses and disability, which contribute to increased admission to the intensive care unit (ICU). Our primary objective was to compare the characteristics, ICU management and outcomes of critically ill patients ≥ 80 year-old with those of younger patients. METHODS: This was a retrospective cohort study of patients admitted to a tertiary-care ICU from 1999 to 2011. The characteristics, ICU management and outcomes of patients ≥ 80 year-old were compared with those 50-64.9 and 65-79.9 year-old. Multivariate analysis was performed to determine the adjusted risk of Do-Not-Resuscitate orders and hospital mortality in patients ≥ 80 year-old compared with the younger groups. RESULTS: During the study period, patients aged ≥ 80 years (N = 748) represented 7.9% of all ICU admissions and 12.8% of patients aged ≥ 50 years. Chronic cardiac (32.2%) and respiratory (21.8%) diseases were more prevalent in them than the younger groups (p < 0.0001). The most common reasons for their ICU admission were cardiovascular (30.9%) and respiratory (40.4%) conditions. Sepsis was commonly present in them on admission (32.9%). Mechanical ventilation and renal replacement therapy were commonly provided (76.9% and 16.0%, respectively). During ICU stay, Do-Not-Resuscitate orders were more frequently written for patients aged ≥ 80 years (35.0%) compared with 21.9% for 50-64.9 year-old group, p < 0.0001, and 25.4% for the 60-79.9 year-old group, p < 0.0001. On multivariate analysis, patients aged ≥ 80 years were more likely to receive these order compared with the 50-64.9 year-old patients (adjusted OR, 1.83; 95% CI, 1.45-2.31) and the 65-80 year-old patients (adjusted OR, 1.64; 95% CI, 1.32-2.04). The hospital mortality increased gradually with age and was highest (54.6%) in patients ≥ 80 year-old (p < 0.0001). Patients ≥ 80 year-old had higher risk of hospital mortality compared with patients aged 50-64.9 years (adjusted OR, 2.16; 95% CI, 1.73-2.69) and with those aged 65-79.9 years (adjusted OR, 1.51; 95% CI, 1.23-1.86). CONCLUSIONS: Patients ≥ 80 year-old represented a significant proportion of ICU admissions. Although they received life sustaining measures similar to younger groups, they had higher adjusted mortality risk compared with the younger groups.

Demographics and outcomes of critically ill patients transferred from other hospitals to a tertiary care academic referral center in Saudi Arabia.

BACKGROUND: The objective of this study was to examine the outcomes of critically ill patients who were transferred from other hospitals to a tertiary care center in Saudi Arabia as a quality improvement project. METHODS: This was a retrospective study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care hospital. Patients were divided according to the source of referral into three groups: transfers from other hospitals, and direct admissions from emergency department (ED) and from hospital wards. Standardized mortality ratio (SMR) was calculated. Multivariate analysis was performed to determine the independent predictors of mortality. RESULTS: Of the 7,654 patients admitted to the ICU, 611 patients (8%) were transferred from other hospitals, 2,703 (35.3%) were direct admissions from ED and 4,340 (56.7%) from hospital wards. Hospital mortality for patients transferred from other hospitals was not significantly different from those who were directly admitted from ED (35% vs. 33.1%, p = 0.37) but was lower than those who were directly admitted from hospital wards (35% vs. 51.2%, p < 0.0001). SMRs did not differ significantly across the three groups. CONCLUSIONS: Critically ill patients who were transferred from other hospitals constituted 8% of all ICU admissions. Mortality of these patients was similar to patients with direct admission from the ED and lower than that of patients with direct admission from hospital wards. However, risk-adjusted mortality was not different from the other two groups.