Candidemia acquired outside critical care or hematological areas has received much attention in recent years; however, data on candidemia in surgical departments are very scarce. Our objectives were ...to describe episodes of candidemia diagnosed in surgical wards and to compare them with episodes occurring in medical wards. We performed a post hoc analysis of a prospective, multicenter study implemented in Spain during 2010-2011 (CANDIPOP project). Of the 752 episodes of candidemia, 369 (49.1%) occurred in patients admitted to surgical wards (165, 21.9%) or medical wards (204, 27.2%). Clinical characteristics associated with surgical patients were solid tumor as underlying disease, recent surgery, indwelling CVC, and parenteral nutrition. Candidemia was more commonly related to a CVC in the surgical than in the medical wards. The CVC was removed more frequently and early management was more appropriate within 48 hours of blood sampling in the surgical patients. Overall, 30-day mortality in the surgical departments was significantly lower than in medical wards (37.7% vs. 15.8%, p<0.001). Multivariate analysis revealed admission to a surgical ward and appropriate early management of candidemia as factors independently associated with a better outcome. We found that approximately 50% of episodes of candidemia occurred in non-hematological patients outside the ICU and that clinical outcome was better in patients admitted to surgical wards than in those hospitalized in medical wards. These findings can be explained by the lower severity of underlying disease, prompt administration of antifungal therapy, and central venous catheter removal.
Background:
Coronavirus disease 2019 (COVID-19) patients are at high risk of neurological complications consequent to several factors including persistent hypotension. There is a paucity of data on ...the effects of therapeutic interventions designed to optimize systemic hemodynamics on cerebral autoregulation (CA) in this group of patients.
Methods:
Single-center, observational prospective study conducted at San Martino Policlinico Hospital, Genoa, Italy, from October 1 to December 15, 2020. Mechanically ventilated COVID-19 patients, who had at least one episode of hypotension and received a passive leg raising (PLR) test, were included. They were then treated with fluid challenge (FC) and/or norepinephrine (NE), according to patients' clinical conditions, at different moments. The primary outcome was to assess the early effects of PLR test and of FC and NE when clinically indicated to maintain adequate mean arterial pressure (MAP) on CA (CA index) measured by transcranial Doppler (TCD). Secondary outcomes were to evaluate the effects of PLR test, FC, and NE on systemic hemodynamic variables, cerebral oxygenation (rS
o
2
), and non-invasive intracranial pressure (nICP).
Results:
Twenty-three patients were included and underwent PLR test. Of these, 22 patients received FC and 14 were treated with NE. The median age was 62 years (interquartile range = 57–68.5 years), and 78% were male. PLR test led to a low CA index 58% (44–76.3%). FC and NE administration resulted in a CA index of 90.8% (74.2–100%) and 100% (100–100%), respectively. After PLR test, nICP based on pulsatility index and nICP based on flow velocity diastolic formula was increased 18.6 (17.7–19.6) vs. 19.3 (18.2–19.8) mm Hg,
p
= 0.009, and 12.9 (8.5–18) vs. 15 (10.5–19.7) mm Hg,
p
= 0.001, respectively. PLR test, FC, and NE resulted in a significant increase in MAP and rS
o
2
.
Conclusions:
In mechanically ventilated severe COVID-19 patients, PLR test adversely affects CA. An individualized strategy aimed at assessing both the hemodynamic and cerebral needs is warranted in patients at high risk of neurological complications.
Mould infections may follow traumatic injuries, with direct fungal inoculum in the site of injury and subsequent angioinvasion, possibly resulting in tissue necrosis and systemic dissemination. The ...pathogenesis of mould infections following trauma injuries presents unique features compared with classical mould infections occurring in neutropenic or diabetic patients, because a large fraction of post-traumatic mould infections is observed in previously healthy individuals. Most of the published clinical experience and research on mould infections following traumatic injuries regards soldiers and infections after natural disasters. However, following trauma and soil contamination (e.g., agricultural or automotive injuries) other immunocompetent individuals may develop mould infections. In these cases, delays in correct diagnosis and treatment may occur if pertinent signs such as necrosis and absent or reduced response to antibacterial therapy are not promptly recognized. Awareness of mould infections in at-risk populations is needed to rapidly start adequate laboratory workflow and early antifungal therapy in rapidly evolving cases to improve treatment success and reduce mortality.
Introduction
To evaluate the clinical impact of a comprehensive care bundle for the management of candidemia.
Methods
A quasi-experimental pre-post study was implemented. During the pre-intervention ...period (May 2014–September 2015), a non-mandatory antifungal stewardship program (ASP) was implemented, and patients with candidemia were visited by an infectious disease specialist who provided diagnostic and therapeutic advice according to standard of care as soon as possible. During the post-intervention period (October 2015–May 2017), patients were managed according to a candidemia care bundle with clear and structured recommendations written in their medical history.
Results
Overall, 109 patients were included, 56 in the pre-intervention and 53 in the post-intervention period. Overall, compliance with the
Candida
bundle significantly improved between the pre- 27/56 (48.2%) and post-intervention 43/53 (81.1%);
p
= 0.01 period. Individual bundle components that significantly improved in the post-intervention period were early adequate antifungal therapy 47/56 (83.9%) vs. 51/53 (96.2%),
p
= 0.05, early adequate source control of the infection 37/56 (82.2%) vs. 41/53 (97.6%),
p
= 0.03 and appropriate duration of therapy 27/56 (48.2%) vs. 43/53 (81.1%),
p
= 0.01. Adherence to follow-up blood cultures, ophthalmologic examination and echocardiography improved in the post-intervention period, but the difference was not statistically significant. Multivariate analysis revealed that being managed according to candidemia bundle had a favorable impact on 14-day mortality (HR 0.08, 95% CI 0.01–0.45,
p
= 0.02) and 30-day mortality (HR 0.40, 95% CI 0.18–0.89,
p
= 0.02).
Conclusions
A simple bundle focused on increasing adherence to a few evidence-based interventions contributed to a significant reduction in 14- and 30-day mortality in patients with candidemia.
Information on the efficacy and safety of molnupiravir in daily clinical practice is very scarce. We aimed to describe the clinical characteristics and outcomes of fully vaccinated patients with mild ...to moderate breakthrough COVID-19 treated with molnupiravir between January 2022 and February 2022. Overall, 145 patients were enrolled. Their median age was 71.0 years, and 60.7% were males. The most common underlying condition was a severe cardiovascular disease (37.2%), followed by primary or acquired immunodeficiency (22.8%), and oncological/onco-hematological disease in the active phase (22.1%). At 30 days after breakthrough COVID-19 diagnosis, only 4 out of 145 patients (2.7%) required hospital admission. No patients developed severe COVID-19, were admitted to the ICU, or died during the follow-up period. Adverse events, mild in intensity, occurred in 2 patients (1.4%). Our results support the current evidence establishing positive clinical and safety outcomes of molnupiravir in fully vaccinated patients with mild or moderate breakthrough COVID-19.
Sepsis is a major cause of death worldwide. Over the past years, prediction of clinically relevant events through machine learning models has gained particular attention. In the present perspective, ...we provide a brief, clinician-oriented vision on the following relevant aspects concerning the use of machine learning predictive models for the early detection of sepsis in the daily practice: (i) the controversy of sepsis definition and its influence on the development of prediction models; (ii) the choice and availability of input features; (iii) the measure of the model performance, the output, and their usefulness in the clinical practice. The increasing involvement of artificial intelligence and machine learning in health care cannot be disregarded, despite important pitfalls that should be always carefully taken into consideration. In the long run, a rigorous multidisciplinary approach to enrich our understanding in the application of machine learning techniques for the early recognition of sepsis may show potential to augment medical decision-making when facing this heterogeneous and complex syndrome.
is an extremely virulent pathogen that is capable of quickly evolving and developing antibiotic resistance. To overcome this problem, new antibiotics have been developed. Some of these have been ...licenced for use in clinical practice, mainly for the treatment of adults with acute skin and soft tissue infections, in addition to both community-acquired pneumonia (CAP) and nosocomial pneumonia (hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia). In this paper, the main characteristics and clinical use of new licenced anti-staphylococcal drugs have been discussed. In vitro studies have demonstrated that some new anti-staphylococcal antibiotics have better antimicrobial activity and, at least in certain cases, more favourable pharmacokinetic properties and higher safety and tolerability than the presently available anti-staphylococcal drugs. This suggests that they may have a potential use in reducing the risk of failure of
therapy. However, an in-depth analysis of microbiological and clinical studies carried out with these new drugs seems to indicate that further studies need to be conducted before the problem of resistance of
to the antibiotics available today can be completely solved. Considering the overall available research, the drugs that are active against
appear to present a great therapeutic opportunity for overcoming resistance to traditional therapy. There are advantages in the pharmacokinetic characteristics of some of these drugs and they have the potential to reduce hospital stays and economic costs associated with their use.
HIV and non-HIV-related factors have been related to weight gain (WG); however, their specific impact on people with HIV (PWH) who are overweight or obese remains unclear.
This is a single-center ...observational study enrolling PWH with a BMI > 25 kg/m
. A generalized linear model was used to assess variables related to greater WG during 12 years of observation.
A total of 321 PWH were enrolled, 67% overweight and 33% obese, who gained an average of 0.2 ± 1.3 and 1.7 ± 1.5 kg/year, respectively (
< 0.0001). Years since HIV infection were the only variable significantly associated with WG (β -0.048, 95% CI -0.083; -0.013) during the study period, while type of ART did not influence the outcome. Narrowing the observation to the period of the SARS-CoV-2 pandemic, PWH with a longer duration of infection (β 0.075, 95% CI 0.033; 0.117) and a greater increase in triglycerides (β 0.005; 95% CI 0.000; 0.011) gained more weight, while higher BMI (β -0.256, 95% CI -0.352; -0.160), obesity (β -1.363, 95% CI -2.319; -0.408), diabetes mellitus (β -1.538, 95% CI -2.797; -0.278), and greater abdominal circumference (β -0.086, 95% CI -0.142; -0.030) resulted in protection.
Among overweight and obese PWH, the amount of WG was higher in the first years after diagnosis of HIV and decreased thereafter, despite aging, regardless of the type of ART.
Serum beta-D-glucan (BDG) determination plays an important role in the diagnosis of candidemia among critically ill patients admitted to the intensive care unit (ICU). However, BDG levels measured ...may be lower in the case of infections caused by some non-albicans species, such as C. parapsilosis and C. auris. The aim of this single-center study was to investigate the sensitivity of serum BDG for the diagnosis of candidemia stratified according to causative Candida species in ICU patients. This was a single-center, retrospective study, including all adult patients admitted to ICU during the period 2018–2021. All episodes of candidemia with a determination of BDG available within 3 days before or after positive blood culture were recorded. The preplanned primary objective was to investigate the sensitivity of serum BDG to detect candidemia early and the effect of different Candida species. The secondary objective was to measure serum BDG in patients with candidemia from different Candida species. In total, 146 candidemia episodes in 118 patients were analyzed. Median BDG value for C. albicans candidemia (182 pg/mL) was higher than that observed for C. parapsilosis (78 pg/mL, p = 0.015) and C. auris (48 pg/mL, p = 0.022). The overall sensitivity of BDG for the diagnosis of candidemia was low (47%, 95% CI 39–55%). In conclusion, in critically ill patients admitted to ICU, serum BDG levels for candidemia were different among species, with lower levels confirmed for C. parapsilosis and C. auris. Serum BDG sensitivity for early detection of candidemia was lower than previously reported in other ICU populations.
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