Bacteremia is common in severe urinary infections, but its influence on the outcomes is not well established. The aim of this study was to assess the association of bacteremia with outcomes in ...elderly patients admitted to hospital with pyelonephritis or urinary sepsis.
This prospective muticenter observational study was conducted at 5 Spanish hospitals. All patients aged >65 years with pyelonephritis or urinary sepsis admitted to the departments of internal medicine and with urine and blood cultures obtained at admission to hospital were eligible. Transfer to ICU, length of hospital stay, hospital mortality and all cause 30-day mortality in bacteremic and non-bacteremic groups were compared. Risk factors for all cause 30-day mortality was also estimated.
Of the 424 patients included in the study 181 (42.7%) had bacteremia. Neither transfer to ICU (4.4% vs. 2.9%, p = 0.400), nor length of hospital stay (9.7±4.6 days vs. 9.0±7.3 days, p = 0.252), nor hospital mortality (3.3% vs. 6.2%, p = 0.187), nor all cause 30-day mortality (9.4% vs. 13.2%, p = 0.223) were different between bacteremic and non-bacteremic groups. By multivariate analysis, risk factors for all cause 30-day mortality were age (OR 1.05, 95% CI 1.00-1.10), McCabe index ≥2 (OR 10.47, 95% CI 2.96-37.04) and septic shock (OR 8.56, 95% CI 2.86-25.61); whereas, bacteremia was inversely associated with all cause 30-day mortality (OR 0.33, 95% CI 0.15-0.71).
In this cohort, bacteremia was not associated with a worse prognosis in elderly patients with pyelonephritis or urinary sepsis.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Aim
The aim of the study was to determine the rate of inadequate empirical antimicrobial treatment in older nursing home residents with bacteremic urinary tract infection and its influence on ...prognosis.
Methods
We carried out a multicentric prospective observational study in five Spanish hospitals. Patients aged >65 years with pyelonephritis or urinary sepsis with bacteremia were included. Clinical characteristics, the percentage of inadequate empirical antibiotic treatment, length of hospital stay and mortality were evaluated.
Results
A total of 181 patients, 54.7% women, were included in the study, and 35.9% of the patients came from nursing homes. These patients had higher percentages of ultimately or rapidly fatal disease (92.3% vs 53.4%; P < 0.001), were older (83.15 ± 6.97 years vs 79.34 ± 7.25 years; P = 0.001) and had higher Acute Physiology And Chronic Health Evaluation II (28.38 ± 8.57 vs 19.83 ± 5.88). The percentage of extended‐spectrum beta‐lactamases was higher in patients from nursing homes (30.6% vs 16.3%; P = 0.045), as was the percentage of inadequate empirical antibiotic treatment (40% vs 20.7%; P = 0.005). Length of hospital stay was longer (10.82 ± 3.62 days vs 9.04 ± 4.88 days; P < 0.001). However, 30‐day mortality was not related to nursing home by multivariate analysis (OR 1.905, 95% CI 0.563–6.446; P = 0.300).
Conclusions
Nursing home patients with bacteremic urinary tract infections had a higher rate of extended‐spectrum beta‐lactamase‐producing enterobacteriacea and inadequate empirical antimicrobial treatment. Clinicians should consider these findings and avoid inappropriate antimicrobial agents for empirical treatment. Geriatr Gerontol Int 2019; 19: 1112–1117.
Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this ...comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study (“Epidemiological survey of advanced heart failure”) is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan−Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 ± 0.98 vs. 0.51 ± 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies.
The utilization of host-cell machinery during SARS-CoV-2 infection can overwhelm the protein-folding capacity of the endoplasmic reticulum and activate the unfolded protein response (UPR). The ...IRE1α-XBP1 arm of the UPR could also be activated by viral RNA via Toll-like receptors. Based on these premises, a study to gain insight into the pathogenesis of COVID-19 disease was conducted using nasopharyngeal exudates and bronchioloalveolar aspirates. The presence of the mRNA of spliced XBP1 and a high expression of cytokine mRNAs were observed during active infection. TLR8 mRNA showed an overwhelming expression in comparison with TLR7 mRNA in bronchioloalveolar aspirates of COVID-19 patients, thus suggesting the presence of monocytes and monocyte-derived dendritic cells (MDDCs). In vitro experiments in MDDCs activated with ssRNA40, a synthetic mimic of SARS-CoV-2 RNA, showed induction of XBP1 splicing and the expression of proinflammatory cytokines. These responses were blunted by the IRE1α inhibitor MKC8866, the TLR8 antagonist CU-CPT9a, and knockdown of TLR8 receptor. In contrast, the IRE1α-XBP1 activator IXA4 enhanced these responses. Based on these findings, the TLR8/IRE1α system seems to play a significant role in the induction of the proinflammatory cytokines associated with severe COVID-19 disease and might be a druggable target to control cytokine storm.
To evaluate if the detection of N antigen of SARS-CoV-2 in plasma by a rapid lateral flow test predicts 90-day mortality in COVID-19 patients hospitalized at the wards.
The presence of N-antigenemia ...was evaluated in the first 36 hours after hospitalization in 600 unvaccinated COVID-19 patients, by using the Panbio COVID-19 Ag Rapid Test Device from Abbott (Abbott Laboratories Inc., Chicago, IL, USA). The impact of N-antigenemia on 90-day mortality was assessed by multivariable Cox regression analysis.
Prevalence of N-antigenemia at hospitalization was higher in nonsurvivors (69% (82/118) vs. 52% (250/482); p < 0.001). The patients with N-antigenemia showed more frequently RNAemia (45.7% (148/324) vs. 19.8% (51/257); p < 0.001), absence of anti-SARS-CoV-2 N antibodies (80.7% (264/327) vs. 26.6% (69/259); p < 0.001) and absence of S1 antibodies (73.4% (240/327) vs. 23.6% (61/259); p < 0.001). The patients with antigenemia showed more frequently acute respiratory distress syndrome (30.1% (100/332) vs. 18.7% (50/268); p = 0.001) and nosocomial infections (13.6% (45/331) vs. 7.9% (21/267); p = 0.026). N-antigenemia was a risk factor for increased 90-day mortality in the multivariable analysis (HR, 1.99 (95% CI,1.09–3.61), whereas the presence of anti-SARS-CoV-2 N-antibodies represented a protective factor (HR, 0.47 (95% CI, 0.26–0.85).
The presence of N-antigenemia or the absence of anti-SARS-CoV-2 N-antibodies after hospitalization is associated to increased 90-day mortality in unvaccinated COVID-19 patients. Detection of N-antigenemia by using lateral flow tests is a quick, widely available tool that could contribute to early identify those COVID-19 patients at risk of deterioration.
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Since the first cases of COVID-19 were reported in Wuhan, the nutritional status of individuals infected with the virus has not been included in the risk profiles prepared. However, nutritional ...status, along with other factors, is decisive in the evolution of patients with other infectious diseases. The nutritional status of individuals is considered an indicator of health status. Furthermore, optimal nutritional status transcends the individual, and poor diet in a population can be considered a group risk factor. Evidence exists on the influence that diet has on the immune system and susceptibility to disease.
To evaluate the nutritional status of patients older than 65 years who were admitted due to COVID-19 and how this has influenced the evolution of patients.
This prospective and observational study was performed in patients with COVID-19 infection confirmed by real-time polymerase chain reaction. Data were collected from the first 24 h of admission. All patients admitted during one month to the wards assigned to COVID-19 infection were included.
A total of 83 patients were studied. The statistical study of mortality showed associations with age (p = .005), living in a nursing home (p = .022), a high Charlson Comorbidity Index (p = .039), hypertension (p = .032), comorbidities of dementia (p = .019) and cerebral vascular disease (p = .041), and Barthel Index (p = .010). The analysis of the influence of the nutritional state on mortality revealed a statistical association between malnutrition and mortality in the pooled data analysis (p = .005) and analysis by degrees of malnutrition (p = .27).
Malnutrition was a risk factor as powerful as others such as hypertension, age, and different comorbidities. We must evaluate and treat the nutritional status of elderly patients with COVID-19 infection since it directly affects their evolution.
Summary Objectives To assess the appropriateness of antibiotic prescription for urinary tract infections in several hospital emergency services and to evaluate the variability of antibiotic ...prescription among these services. Methods A cross-sectional study was carried out in the emergency services of 10 hospitals from different Spanish regions. The sample was composed of patients diagnosed with acute urinary infection, aged ≥ 14 years. A Consensus Conference, held by a panel of experts, established first-choice, second-choice and inappropriate antibiotic treatments for each type of urinary tract infection, based on the available scientific evidence. All the observed prescriptions in our study were classified according to this pattern. The main variables were: type of urinary infection, antibiotic prescription, urine culture request, comorbidity and hospital admission. Results A sample of 3797 acute urinary tract infections was studied. Eighty-one percent were lower urinary tract infections. The most commonly used antibiotics were ciprofloxacin and amoxicillin–clavulanate. The global percentages of first-choice, alternative-choice and inappropriate antibiotic prescriptions were: 42.4% (95% CI: 40.8–43.9), 44.1 (95% CI: 42.5–45.7) and 13.6% (95% CI: 12.5–14.7), respectively. We observed a significant variability in appropriateness of antibiotic prescriptions among the participating centres ( p < 0.001). Conclusions Physicians at Spanish emergency rooms prescribe an excessive number of second-choice antibiotics for urinary tract infection treatment. There exists a high variability in antibiotic prescription among hospitals from different regions.
Abstract Aims Few studies have evaluated how physicians prioritize renal function among other patient-related factors when stepping-up in antidiabetic treatment. Methods The REDIM Spanish national ...online survey included 550 internists. We firstly tested proficiency in chronic kidney disease (Agrawal's Questionnaire) and motivation in diabetes (DAS-3p Questionnaire). We then analyzed how physicians prioritized renal function, age, weight, glycemic control, non-renal co-morbidities and patient perceptions in five varying fictitious clinical scenarios (generic; ambulatory vs. high cardiovascular risk hospitalized patient, for estimated glomerular filtration rates (eGFRs) = 50 vs. 25 ml/min/1.73 m2 ). We assigned every item a score (from 5 to 0, highest to lowest relevance) per-physician and compared mean values between clinical scenarios using the t -test for independent means (nominal significance at p < 0.05). Results Completion rate was 57.5% ( N = 316; mean age, 46.3 years; men, 71%). Average scores were 22.6 ± 3.9 (possible range 0–30) for Agrawal's Questionnaire and 4.1 ± 0.6 (range 1–5) for DAS-3p Questionnaire. In the generic scenario, renal function had the highest priority (mean = 3.36 ± 1.66, range 0–5). When eGFR was set at 50 ml/min/1.73 m2 , physicians prioritized glycemic control for ambulatory (mean = 3.23 ± 1.59) and non-renal co-morbidities for hospitalized patients (mean = 3.20 ± 1.68) over renal function (mean = 3.18 ± 1.77 for ambulatory, p = 0.032; mean = 3.11 ± 1.65 for hospitalized patients, p = 0.002). When eGFR was subsequently lowered to 25 ml/min/1.73 m2 , renal function again led priorities (mean values = 3.73 ± 2.05 for ambulatory and 3.75 ± 1.96 for hospitalized patients; both p < 0.001). Conclusions Knowledge of the degree of renal function impairment induced physicians to prioritize patient-related factors differently when adding a second antidiabetic drug. Renal function led priorities when severely impaired.
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