Publications by authors named "Adrián Ceccato"

50 Publications

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients.

Crit Care 2021 09 13;25(1):331. Epub 2021 Sep 13.

Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission.

Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes.

Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO/FiO increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO/FiO variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47).

Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO/FiO variation.
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http://dx.doi.org/10.1186/s13054-021-03727-xDOI Listing
September 2021

Prediction of ventilator-associated pneumonia outcomes according to the early microbiological response: a retrospective observational study.

Eur Respir J 2021 Sep 2. Epub 2021 Sep 2.

August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES), Barcelona, Spain

Ventilator-associated pneumonia is a leading infectious cause of morbidity in critically ill patients; yet current guidelines offer no indications for follow-up cultures.We aimed to evaluate the role of follow-up cultures and microbiological response 3 days after diagnosing ventilator-associated pneumonia as predictors of short- and long-term outcomes.We performed a retrospective analysis of a cohort prospectively collected from 2004 to 2017. Ventilator-associated pneumonia was diagnosed based on clinical, radiographic, and microbiological criteria. For microbiological identification, a tracheobronchial aspirate was performed at diagnosis and repeated after 72 h. We defined three groups when comparing the two tracheobronchial aspirate results: persistence, superinfection, and eradication of causative pathogens.One-hundred-fifty-seven patients were enrolled in the study, among whom microbiological persistence, superinfection, and eradication was present in 67 (48%), 25 (16%), and 65 (41%), respectively, after 72hs. Those with superinfection had the highest mortalities in the intensive care unit (p=0.015) and at 90 days (p=0.036), while also having the fewest ventilation-free days (p=0.024). Multivariable analysis revealed shock at VAP diagnosis (odds ratios [OR] 3.43; 95% confidence interval [CI] 1.25 to 9.40), isolation at VAP diagnosis (OR 2.87; 95%CI 1.06 to 7.75), and hypothermia at VAP diagnosis (OR 0.67; 95%CI 0.48 to 0.95, per +1°C) to be associated with superinfection.Our retrospective analysis suggests that ventilator-associated pneumonia short-term and long-term outcomes may be associated with superinfection in follow-up cultures. Follow-up cultures may help guiding antibiotic therapy and its duration. Further prospective studies are necessary to verify our findings.
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http://dx.doi.org/10.1183/13993003.00620-2021DOI Listing
September 2021

Impact of Cardiovascular Failure in Intensive CareUnit-Acquired Pneumonia: A Single-Center, Prospective Study.

Antibiotics (Basel) 2021 Jun 30;10(7). Epub 2021 Jun 30.

Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, 08036 Barcelona, Spain.

Background: Cardiovascular failure (CVF) may complicate intensive care unit-acquired pneumonia (ICUAP) and radically alters the empirical treatment of this condition. The aim of this study was to determine the impact of CVF on outcome in patients with ICUAP.

Methods: A prospective, single-center, observational study was conducted in six medical and surgical ICUs at a University Hospital. CVS was defined as a score of 3 or more on the cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score. At the onset of ICUAP, CVF was reported as absent, transient (if lasting ≤ 3 days) or persistent (>3 days). The primary outcome was 90-day mortality modelled through a Cox regression analysis. Secondary outcomes were 28-day mortality, hospital mortality, ICU length of stay (LOS) and hospital LOS.

Results: 358 patients were enrolled: 203 (57%) without CVF, 82 (23%) with transient CVF, and 73 (20%) with persistent CVF. Patients with transient and persistent CVF were more severely ill and presented higher inflammatory response than those without CVF. Despite having similar severity and aetiology, the persistent CVF group more frequently received inadequate initial antibiotic treatment and presented more treatment failures than the transient CVF group. In the persistent CVF group, at day 3, a bacterial superinfection was more frequently detected. The 90-day mortality was significantly higher in the persistent CVF group (62%). The 28-day mortality rates for patients without CVF, with transient and with persistent CVF were 19, 35 and 41% respectively and ICU mortality was 60, 38 and 19% respectively. In the multivariate analysis chronic pulmonary conditions, lack of Pa0/FiO improvement at day 3, pulmonary superinfection at day 3 and persistent CVF were independently associated with 90-day mortality in ICUAP patients. : Persistent CVF has a significant impact on the outcome of patients with ICUAP. Patients at risk from persistent CVF should be promptly recognized to optimize treatment and outcomes.
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http://dx.doi.org/10.3390/antibiotics10070798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300830PMC
June 2021

Circulating microRNA profiles predict the severity of COVID-19 in hospitalized patients.

Transl Res 2021 10 26;236:147-159. Epub 2021 May 26.

CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain; Hospital Universitario de Getafe, Madrid, Spain.

We aimed to examine the circulating microRNA (miRNA) profile of hospitalized COVID-19 patients and evaluate its potential as a source of biomarkers for the management of the disease. This was an observational and multicenter study that included 84 patients with a positive nasopharyngeal swab Polymerase chain reaction (PCR) test for SARS-CoV-2 recruited during the first pandemic wave in Spain (March-June 2020). Patients were stratified according to disease severity: hospitalized patients admitted to the clinical wards without requiring critical care and patients admitted to the intensive care unit (ICU). An additional study was completed including ICU nonsurvivors and survivors. Plasma miRNA profiling was performed using reverse transcription polymerase quantitative chain reaction (RT-qPCR). Predictive models were constructed using least absolute shrinkage and selection operator (LASSO) regression. Ten circulating miRNAs were dysregulated in ICU patients compared to ward patients. LASSO analysis identified a signature of three miRNAs (miR-148a-3p, miR-451a and miR-486-5p) that distinguishes between ICU and ward patients [AUC (95% CI) = 0.89 (0.81-0.97)]. Among critically ill patients, six miRNAs were downregulated between nonsurvivors and survivors. A signature based on two miRNAs (miR-192-5p and miR-323a-3p) differentiated ICU nonsurvivors from survivors [AUC (95% CI) = 0.80 (0.64-0.96)]. The discriminatory potential of the signature was higher than that observed for laboratory parameters such as leukocyte counts, C-reactive protein (CRP) or D-dimer [maximum AUC (95% CI) for these variables = 0.73 (0.55-0.92)]. miRNA levels were correlated with the duration of ICU stay. Specific circulating miRNA profiles are associated with the severity of COVID-19. Plasma miRNA signatures emerge as a novel tool to assist in the early prediction of vital status deterioration among ICU patients.
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http://dx.doi.org/10.1016/j.trsl.2021.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149473PMC
October 2021

Early Bacterial Identification Among Intubated Patients with COVID-19 or Influenza Pneumonia: A European Multicenter Comparative Cohort Study.

Am J Respir Crit Care Med 2021 May 26. Epub 2021 May 26.

Hôpital Pellegrin-Tripode , Service de Reanimation , Bordeaux, France.

Rationale: Early empirical antimicrobial treatment is frequently prescribed to critically ill patients with COVID-19, based on Surviving Sepsis Campaign guidelines.

Objective: We aimed to determine the prevalence of early bacterial identification in intubated patients with SARS-CoV-2 pneumonia, as compared to influenza pneumonia, and to characterize its microbiology and impact on outcomes.

Methods: Multicenter retrospective European cohort performed in 36 ICUs. All adult patients receiving invasive mechanical ventilation >48h were eligible if they had SARS-CoV-2 or influenza pneumonia at ICU admission. Bacterial identification was defined by a positive bacterial culture, within 48h after intubation, in endotracheal aspirates, bronchoalveolar lavage, blood cultures, or a positive pneumococcal or legionella urinary antigen test.

Measurements And Main Results: 1,050 patients were included (568 in SARS-CoV-2 and 482 in influenza groups). The prevalence of bacterial identification was significantly lower in patients with SARS-CoV-2 pneumonia as compared to patients with influenza pneumonia (9.7 vs 33.6%, unadjusted odds ratio (OR) 0.21 (95% confidence interval (CI) 0.15 to 0.30), adjusted OR 0.23 (95% CI 0.16 to 0.33), p<0.0001). Gram-positive cocci were responsible for 58% and 72% of co-infection in patients with SARS-CoV-2 and influenza pneumonia, respectively. Bacterial identification was associated with increased adjusted hazard ratio for 28-day mortality in patients with SARS-CoV-2 pneumonia (1.57 (95% CI 1.01 to 2.44), p=0.043). However, no significant difference was found in heterogeneity of outcomes related to bacterial identification between the two study groups, suggesting that the impact of co-infection on mortality was not different between SARS-CoV-2 and influenza patients.

Conclusions: Bacterial identification within 48h after intubation is significantly less frequent in patients with SARS-CoV-2 pneumonia as compared to patients with influenza pneumonia. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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http://dx.doi.org/10.1164/rccm.202101-0030OCDOI Listing
May 2021

Relationship between ventilator-associated pneumonia and mortality in COVID-19 patients: a planned ancillary analysis of the coVAPid cohort.

Crit Care 2021 05 25;25(1):177. Epub 2021 May 25.

Département de Médecine Intensive-Réanimation, CHU D'Angers, Université D'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.

Background: Patients with SARS-CoV-2 infection are at higher risk for ventilator-associated pneumonia (VAP). No study has evaluated the relationship between VAP and mortality in this population, or compared this relationship between SARS-CoV-2 patients and other populations. The main objective of our study was to determine the relationship between VAP and mortality in SARS-CoV-2 patients.

Methods: Planned ancillary analysis of a multicenter retrospective European cohort. VAP was diagnosed using clinical, radiological and quantitative microbiological criteria. Univariable and multivariable marginal Cox's regression models, with cause-specific hazard for duration of mechanical ventilation and ICU stay, were used to compare outcomes between study groups. Extubation, and ICU discharge alive were considered as events of interest, and mortality as competing event.

Findings: Of 1576 included patients, 568 were SARS-CoV-2 pneumonia, 482 influenza pneumonia, and 526 no evidence of viral infection at ICU admission. VAP was associated with significantly higher risk for 28-day mortality in SARS-CoV-2 (adjusted HR 1.70 (95% CI 1.16-2.47), p = 0.006), and influenza groups (1.75 (1.03-3.02), p = 0.045), but not in the no viral infection group (1.07 (0.64-1.78), p = 0.79). VAP was associated with significantly longer duration of mechanical ventilation in the SARS-CoV-2 group, but not in the influenza or no viral infection groups. VAP was associated with significantly longer duration of ICU stay in the 3 study groups. No significant difference was found in heterogeneity of outcomes related to VAP between the 3 groups, suggesting that the impact of VAP on mortality was not different between study groups.

Interpretation: VAP was associated with significantly increased 28-day mortality rate in SARS-CoV-2 patients. However, SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, did not significantly modify the relationship between VAP and 28-day mortality.

Clinical Trial Registration: The study was registered at ClinicalTrials.gov, number NCT04359693.
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http://dx.doi.org/10.1186/s13054-021-03588-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146175PMC
May 2021

Pulmonary Function and Radiologic Features in Survivors of Critical COVID-19: A 3-Month Prospective Cohort.

Chest 2021 07 4;160(1):187-198. Epub 2021 Mar 4.

Pulmonary Department, Hospital Universitari Arnau de Vilanova and Santa Maria, Lleida, Spain; Translational Research in Respiratory Medicine Group (TRRM), Lleida, Spain; Lleida Biomedical Research Institute (IRBLleida), Lleida, Spain; CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain. Electronic address:

Background: More than 20% of hospitalized patients with COVID-19 demonstrate ARDS requiring ICU admission. The long-term respiratory sequelae in such patients remain unclear.

Research Question: What are the major long-term pulmonary sequelae in critical patients who survive COVID-19?

Study Design And Methods: Consecutive patients with COVID-19 requiring ICU admission were recruited and evaluated 3 months after hospitalization discharge. The follow-up comprised symptom and quality of life, anxiety and depression questionnaires, pulmonary function tests, exercise test (6-min walking test [6MWT]), and chest CT imaging.

Results: One hundred twenty-five patients admitted to the ICU with ARDS secondary to COVID-19 were recruited between March and June 2020. At the 3-month follow-up, 62 patients were available for pulmonary evaluation. The most frequent symptoms were dyspnea (46.7%) and cough (34.4%). Eighty-two percent of patients showed a lung diffusing capacity of less than 80%. The median distance in the 6MWT was 400 m (interquartile range, 362-440 m). CT scans showed abnormal results in 70.2% of patients, demonstrating reticular lesions in 49.1% and fibrotic patterns in 21.1%. Patients with more severe alterations on chest CT scan showed worse pulmonary function and presented more degrees of desaturation in the 6MWT. Factors associated with the severity of lung damage on chest CT scan were age and length of invasive mechanical ventilation during the ICU stay.

Interpretation: Three months after hospital discharge, pulmonary structural abnormalities and functional impairment are highly prevalent in patients with ARDS secondary to COVID-19 who required an ICU stay. Pulmonary evaluation should be considered for all critical COVID-19 survivors 3 months after discharge.
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http://dx.doi.org/10.1016/j.chest.2021.02.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930807PMC
July 2021

Relationship between SARS-CoV-2 infection and the incidence of ventilator-associated lower respiratory tract infections: a European multicenter cohort study.

Intensive Care Med 2021 02 3;47(2):188-198. Epub 2021 Jan 3.

Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de réanimation médicale, Créteil, France.

Purpose: Although patients with SARS-CoV-2 infection have several risk factors for ventilator-associated lower respiratory tract infections (VA-LRTI), the reported incidence of hospital-acquired infections is low. We aimed to determine the relationship between SARS-CoV-2 pneumonia, as compared to influenza pneumonia or no viral infection, and the incidence of VA-LRTI.

Methods: Multicenter retrospective European cohort performed in 36 ICUs. All adult patients receiving invasive mechanical ventilation > 48 h were eligible if they had: SARS-CoV-2 pneumonia, influenza pneumonia, or no viral infection at ICU admission. VA-LRTI, including ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP), were diagnosed using clinical, radiological and quantitative microbiological criteria. All VA-LRTI were prospectively identified, and chest-X rays were analyzed by at least two physicians. Cumulative incidence of first episodes of VA-LRTI was estimated using the Kalbfleisch and Prentice method, and compared using Fine-and Gray models.

Results: 1576 patients were included (568 in SARS-CoV-2, 482 in influenza, and 526 in no viral infection groups). VA-LRTI incidence was significantly higher in SARS-CoV-2 patients (287, 50.5%), as compared to influenza patients (146, 30.3%, adjusted sub hazard ratio (sHR) 1.60 (95% confidence interval (CI) 1.26 to 2.04)) or patients with no viral infection (133, 25.3%, adjusted sHR 1.7 (95% CI 1.2 to 2.39)). Gram-negative bacilli were responsible for a large proportion (82% to 89.7%) of VA-LRTI, mainly Pseudomonas aeruginosa, Enterobacter spp., and Klebsiella spp.

Conclusions: The incidence of VA-LRTI is significantly higher in patients with SARS-CoV-2 infection, as compared to patients with influenza pneumonia, or no viral infection after statistical adjustment, but residual confounding may still play a role in the effect estimates.
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http://dx.doi.org/10.1007/s00134-020-06323-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778569PMC
February 2021

CIBERESUCICOVID: A strategic project for a better understanding and clinical management of COVID-19 in critical patients.

Arch Bronconeumol 2021 04 11;57 Suppl 2:1-2. Epub 2020 Nov 11.

Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, España; Group of Translational Research in Respiratory Medicine, Hospital Universitari Arnau de Vilanova y Santa Maria, IRB Lleida, Lleida, España.

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http://dx.doi.org/10.1016/j.arbres.2020.10.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657609PMC
April 2021

Predictive Performance of Risk Factors for Multidrug-Resistant Pathogens in Nosocomial Pneumonia.

Ann Am Thorac Soc 2021 05;18(5):807-814

August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), Barcelona, Spain.

In 2017, the International European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Latin American Thoracic Society (European) guidelines defined new risk factors for multidrug-resistant (MDR) pathogens in patients with nosocomial pneumonia. To assess the predictive performance of these newly defined risk factors for MDR pathogens. We enrolled 507 adult patients with nosocomial pneumonia who were treated in six intensive care units at the Hospital Clinic of Barcelona in Spain. Of the 503 patients at high MDR pathogen and mortality risk, 275 (54%) had no septic shock and 228 (46%) had septic shock. Admission to hospital settings with high rates of MDR pathogens ( = 421; 83%) and prior antibiotic use ( = 399; 79%) showed the highest prevalence in the overall population, with sensitivities of 92% and 85% and negative predictive values of 85% and 82%, respectively. However, low specificities and low positive predictive values were found. Previous respiratory MDR pathogen isolation was less common ( = 17; 3%) but presented a specificity and positive predictive value of 100%. The area under the receiver operating characteristic curve was less than 0.6 for all risk factors and combinations. The risk factors proposed by the European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Latin American Thoracic Society showed low accuracy for predicting MDR pathogens in intensive care unit acquired pneumonia (ICU-AP). Admission to hospital settings with high rates of MDR pathogens and prior antibiotic use were the most prevalent risk factors, with a high sensitivity for predicting these microorganisms; prior positive cultures for MDR pathogens showed high specificity but very low sensitivity. Combinations of risk factors did not show any great accuracy for predicting these microorganisms. Further studies assessing combined strategies of risk stratification and complementary methods are now warranted.
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http://dx.doi.org/10.1513/AnnalsATS.202002-181OCDOI Listing
May 2021

Safety considerations of current drug treatment strategies for nosocomial pneumonia.

Expert Opin Drug Saf 2021 Feb 6;20(2):181-190. Epub 2021 Jan 6.

Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona (UB) , Barcelona, Spain.

: Nosocomial pneumonia unfortunately remains a frequent event for which appropriate antibiotic treatment is central to improving outcomes. Physicians must choose an early and appropriate empirical treatment, basing their decision on the safety profile and possible side effects. : In this review, we analyzed the safety profiles of the most common antimicrobials for treating nosocomial pneumonia. Beta-lactams are used most often for these infections, with a high percentage (6% to 25%) of patients reporting allergy or hypersensitivity reactions; however, exhaustive evaluation is key because it seems possible to de-label as many as 90% by proper assessment. Combinations including a beta-lactam are recommended in patients with risk factors for drug-resistant microorganisms and septic shock. Although aminoglycosides are safe for 3-5 days of therapy, renal function should be monitored. Fluoroquinolones must also be used with care given the risk of collagen degradation and cardiovascular events, mainly aneurysm or aortic dissection. Linezolid or vancomycin are both viable for the treatment of methicillin-resistant , but linezolid seems to be the superior option. Antibiotic stewardships programs must be developed for each center. : Choosing the most appropriate antimicrobial based on information from national and international guidelines, local microbiology data, and stewardship programs may reduce the use of broad-spectrum antibiotics. Daily assessment for the emergence of adverse events related to antimicrobial use is essential.
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http://dx.doi.org/10.1080/14740338.2021.1857362DOI Listing
February 2021

Characteristics and Outcomes in Patients with Ventilator-Associated Pneumonia Who Do or Do Not Develop Acute Respiratory Distress Syndrome. An Observational Study.

J Clin Med 2020 Oct 29;9(11). Epub 2020 Oct 29.

Department of Pneumology and Respiratory Intensive Care Unit, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, 08036 Barcelona, Spain.

Ventilator-associated pneumonia (VAP) is a well-known complication of patients on invasive mechanical ventilation. The main cause of acute respiratory distress syndrome (ARDS) is pneumonia. ARDS can occur in patients with community-acquired or nosocomial pneumonia. Data regarding ARDS incidence, related pathogens, and specific outcomes in patients with VAP is limited. This is a cohort study in which patients with VAP were evaluated in an 800-bed tertiary teaching hospital between 2004 and 2016. Clinical outcomes, microbiological and epidemiological data were assessed among those who developed ARDS and those who did not. Forty-one (13.6%) out of 301 VAP patients developed ARDS. Patients who developed ARDS were younger and presented with higher prevalence of chronic liver disease. Pseudomonas aeruginosa was the most frequently isolated pathogen, but without any difference between groups. Appropriate empirical antibiotic treatment was prescribed to ARDS patients as frequently as to those without ARDS. Ninety-day mortality did not significantly vary among patients with or without ARDS. Additionally, patients with ARDS did not have significantly higher intensive care unit (ICU) and 28-day mortality, ICU, and hospital length of stay, ventilation-free days, and duration of mechanical ventilation. In summary, ARDS deriving from VAP occurs in 13.6% of patients. Although significant differences in clinical outcomes were not observed between both groups, further studies with a higher number of patients are needed due to the possibility of the study being underpowered.
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http://dx.doi.org/10.3390/jcm9113508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7692126PMC
October 2020

Validation of a Prediction Score for Drug-Resistant Microorganisms in Community-acquired Pneumonia.

Ann Am Thorac Soc 2021 02;18(2):257-265

Centro de Investigacíon Biomédica en Red de Enfermedades Respiratorias (CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universidad de Barcelona, Barcelona, Spain.

Recommended initial empiric antimicrobial treatment covers the most common bacterial pathogens; however, community-acquired pneumonia (CAP) may be caused by microorganisms not targeted by this treatment. Developed in 2015, the PES (, extended-spectrum β-lactamase-producing , and methicillin-resistant ) score was developed in 2015 to predict the microbiological etiology of CAP caused by PES microorganisms. To validate the usefulness of the PES score for predicting PES microorganisms in two cohorts of patients with CAP from Valencia and Mataró. We analyzed two prospective observational cohorts of patients with CAP from Valencia and Mataró. Patients in the Mataró cohort were all admitted to an intensive care unit (ICU). Of the 1,024 patients in the Valencia cohort, 505 (51%) had a microbiological etiology and 31 (6%) had a PES microorganism isolated. The area under the receiver operating characteristic curve was 0.81 (95% confidence interval [95% CI], 0.74-0.88). For a PES score ≥5, sensitivity, specificity, the negative and positive predictive values as well as the negative and positive likelihood ratios were 72%, 74%, 98%, 14%, 0.38, and 2.75, respectively. Of the 299 patients in the Mataró cohort, 213 (71%) had a microbiological etiology and 11 (5%) had a PES microorganism isolated. The area under the receiver operating characteristic curve was 0.73 (95% CI 0.61-0.86). For a PES score ≥ 5, sensitivity, specificity, the negative and positive predictive values, and the negative and positive likelihood ratios were 36%, 83%, 96%, 11%, 0.77, and 2.09, respectively. The best cutoff for patients admitted to the ICU was 4 points, which improved sensitivity to 86%. The hypothetical application of the PES score showed high rates of overtreatment in both cohorts (26% and 35%, respectively) and similar rates of undertreatment. The PES score showed good accuracy in predicting the risk for microorganisms that required different empirical therapy; however, its use as a single strategy for detecting noncore pathogens could lead to high rates of overtreatment. Given its high negative predictive value, the PES score may be used as a first step of a wider strategy that includes subsequent advanced diagnostic tests.
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http://dx.doi.org/10.1513/AnnalsATS.202005-558OCDOI Listing
February 2021

Diagnostic accuracy of Gram staining when predicting staphylococcal hospital-acquired pneumonia and ventilator-associated pneumonia: a systematic review and meta-analysis.

Clin Microbiol Infect 2020 Nov 19;26(11):1456-1463. Epub 2020 Aug 19.

Department of Pneumology, Institut Clinic de Respiratori Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain; University of Barcelona, Barcelona, Spain. Electronic address:

Background: There is no clear guidance on empirical antibiotic coverage against Staphylococcus aureus for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP).

Objective: To evaluate whether the presence of clusters of Gram-positive cocci in Gram staining of respiratory samples predicts S. aureus as HAP/VAP pathogen.

Methods: Data sources were MEDLINE, PubMed, Embase, Scielo, CINAHL and Scopus, from inception to 15/07/2017 (update on 31/10/2019), and original data from a single-centre database (PROSPERO: CRD42017072138). We included studies reporting the diagnostic accuracy of a Gram-staining evaluation suggestive of Staphylococcus compared with a positive culture for S. aureus in any type of lower respiratory tract sample. Participants were adult patients with HAP/VAP. The index test was morphological evaluation of Gram staining of respiratory samples. We followed PRISMA guidelines and assessed risk of bias and applicability with the QUADAS-2 tool. We conducted a meta-analysis using a bivariate random effects model.

Results: We selected five studies that included only VAP and data from a single-centre database including VAP and HAP. We pooled six studies for VAP and analysed 1665 respiratory samples. Pooled sensitivity was 68% (95%CI 49-83 and specificity 95% (95%CI 86-98). The pooled positive likelihood ratio was 12.7 (95%CI 5.1-31.6), negative likelihood ratio 0.34 (95%CI 0.20-0.57), diagnostic odds ratio 38 (95%CI 13-106) and area under the summary receiver operating curve (SROC) 0.91 (95%CI 0.88-0.93). There was great heterogeneity between sensitivity and specificity. In scenarios in which the prevalence of S. aureus was between 5% and 20%, the positive and negative predictive values were 62% (95%CI 47-77) and 95% (95%CI 82-100), respectively.

Conclusions: Detection of Gram-positive cocci in clusters in respiratory samples of patients with VAP has the potential to guide risk assessments of S. aureus for more personalized antibiotic coverage. Randomized clinical trials with patient-centred outcomes are needed for strong clinical recommendations.
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http://dx.doi.org/10.1016/j.cmi.2020.08.015DOI Listing
November 2020

The War against Bad Bugs: Fighting the Resistance.

J Clin Med 2020 Aug 7;9(8). Epub 2020 Aug 7.

Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), 08036 Barcelona, Spain.

Multidrug-resistant (MDR) microorganisms have become a growing concern, especially in regions with high prevalence [...].
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http://dx.doi.org/10.3390/jcm9082563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465838PMC
August 2020

Aspiration Risk Factors, Microbiology, and Empiric Antibiotics for Patients Hospitalized With Community-Acquired Pneumonia.

Chest 2021 01 17;159(1):58-72. Epub 2020 Jul 17.

Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX. Electronic address:

Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role.

Research Question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP?

Study Design And Methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups.

Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P < .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics.

Interpretation: Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.
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http://dx.doi.org/10.1016/j.chest.2020.06.079DOI Listing
January 2021

Age is a determinant of short-term mortality in patients hospitalized for an acute exacerbation of COPD.

Intern Emerg Med 2021 Mar 7;16(2):401-408. Epub 2020 Jul 7.

Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), Villarroel 170, 08036, Barcelona, Spain.

Several factors worsen the prognosis of hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Little is known about the specific contribution of age. Study aim was to evaluate the impact of age on early mortality (90-days).

Methods: this observational prospective study considered hospitalized AECOPD patients. Three groups were created according to tertiles of age distribution: group 1 (≤ 67 years), group 2 (68-76 years) and group 3 (≥ 77 years). Baseline, clinical, microbiological, gas analysis and laboratory variables were collected at admission. The primary outcome was mortality at 90 days from admission. Multivariate regression models and receiver-operating characteristic (ROC) curves were used to evaluate the predictive power of age versus early mortality and adjusted for gender, comorbidities, staging and disease severity.

Results: we enrolled 449 patients, 33 (7%) of whom died within 90 days from admission. Older patients were predominantly male, with more comorbidities, and higher dyspnoea grade and disease severity. The multivariate logistic regression demonstrated a significant predictive role of age as a continuous variable [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.10; p = 0.046]. The Cox regression analysis found that group 2 [hazard ratio (HR) 6.6; 95% CI 1.5-28.8; p = 0.013], group 3 (HR 7.2; 95% CI 1.6-32.6; p = 0.010) and acute severe hypoxemia at admission (HR 2.7; 95% CI 1.2-6; p = 0.012) were independent significant predictors of mortality. The Kaplan-Meier curves showed a significant role of age in cumulative survival (Gehan-Breslow-Wilcoxon test p = 0.010). ROC curves highlighted 70 years as the best discriminating cut-off.

Conclusions: age is a determinant of worse prognosis among hospitalized patients with AECOPD.
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http://dx.doi.org/10.1007/s11739-020-02420-1DOI Listing
March 2021

Difficult to treat microorganisms in patients aged over 80 years with community-acquired pneumonia: the prevalence of PES pathogens.

Eur Respir J 2020 10 8;56(4). Epub 2020 Oct 8.

Dept of Pulmonology, Hospital Clinic of Barcelona; August Pi i Sunyer Biomedical Research Institute - IDIBAPS, University of Barcelona; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES), Barcelona, Spain.

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http://dx.doi.org/10.1183/13993003.00773-2020DOI Listing
October 2020

Hospital-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) Guidelines. 2019 Update.

Arch Bronconeumol 2020 Mar 1;56 Suppl 1:11-19. Epub 2020 Mar 1.

Centro Cochrane Iberoamericano, Barcelona, España.

Hospital-acquired pneumonia (HAP) is the second leading cause of nosocomial infection, and increases morbidity and mortality. It is currently classified into three groups: HAP not requiring artificial ventilation, HAP requiring artificial ventilation, and HAP acquired during artificial ventilation, also known as ventilator-acquired pneumonia (VAP). The latest guidelines for the management of HAP were published in 2016 (IDSA/ATS) and 2017 (ERS/ESCMID/ESICM and ALAT). The latest Spanish guidelines were published in Archivos de Bronconeumologia in 2011. American guidelines from 2016 and international guidelines from 2017 present their recommendations in a context of significantly increased resistance of both Gram-positive and, in particular, Gram-negative microorganisms to antibacterial agents. In 2019, SEPAR celebrated Pneumonia Year, and we felt that this was an appropriate time to update the guidelines published in 2011. Pulmonologists, intensive care specialists, infectious disease specialists, and methodology experts participated in drawing up this document, and agreed to use the following scheme.
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http://dx.doi.org/10.1016/j.arbres.2020.01.015DOI Listing
March 2020

Ventilator-associated pneumonia: new principles guiding empiric antibiotic therapy.

Curr Opin Infect Dis 2020 04;33(2):182-188

Department of Pneumology, Hospital Clinic, Barcelona; August Pi i Sunyer Biomedical Research Institute - IDIBAPS, University of Barcelona; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES).

Purpose Of Review: Ventilator-associated pneumonia (VAP) is a serious event in critically ill patients. We aim to review the most recent evidences about VAP, including its cause, the main differences between the American and European guidelines in the definition of risk factors for multidrug-resistant pathogens, the main principles guiding empirical antibiotic treatment, and the potential role of molecular diagnostic tests.

Recent Findings: The 2016 ATS/IDSA and the 2017 ERS/ESICM/ESCMID/ALAT guidelines provide different approaches for the management of VAP. Both guidelines highlight the need to use local epidemiological data for antibiotic choice; however, they identify different risk factors that can assist with decision making when local data are not available. Nevertheless, validation studies of the American guidelines suggest that empiric antibiotic therapy based on risk factors may lead to an overuse of broad-spectrum antibiotics. Rapid diagnostic tests may allow a faster identification of VAP cause, resulting in more adequate antimicrobial therapy and reduced exposition to broad-spectrum antibiotics.

Summary: Clinical studies should be conducted to evaluate the benefits of implementing guidelines and new approaches such as combinations of clinical data with rapid diagnostic tests; meantime adaptations of guidelines to local settings should be carried out by a local multidisciplinary expert team.
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http://dx.doi.org/10.1097/QCO.0000000000000640DOI Listing
April 2020

Assessment of a Loop-Mediated Isothermal Amplification (LAMP) Assay for the Rapid Detection of Pathogenic Bacteria from Respiratory Samples in Patients with Hospital-Acquired Pneumonia.

Microorganisms 2020 Jan 11;8(1). Epub 2020 Jan 11.

Department of Clinical Microbiology, CDB, Hospital Clínic of Barcelona, University of Barcelona, 08036 Barcelona, Spain.

Rapid identification of the causative agent of hospital-acquired pneumonia (HAP) will allow an earlier administration of a more appropriate antibiotic and could improve the outcome of these patients. The aim of this study was to develop a rapid protocol to identify the main microorganisms involved in HAP by loop-mediated isothermal amplification (LAMP) directly from respiratory samples. First of all, a rapid procedure (<30 min) to extract the DNA from bronchoalveolar lavage (BAL), endotracheal aspirate (EA) or bronchoaspirate (BAS) was set up. A specific LAMP for , , , and was performed with the extracted solution at 65 °C for 30-40 min. Overall, 58 positive BAL and 83 EA/BAS samples were tested. The limits of detection varied according to the microorganism detected. Validation of the LAMP assay with BAL samples showed that the assay was 100% specific and 86.3% sensitive (positive predictive value of 100% and a negative predictive value of 50%) compared with culture. Meanwhile for BAS/EA samples, the assay rendered the following statistical parameters: 100% specificity, 94.6% sensitivity, 100% positive predictive value and 69.2% negative predictive value. The turnaround time including sample preparation and LAMP was circa 1 h. LAMP method may be used to detect the most frequent bacteria causing HAP. It is a simple, cheap, sensitive, specific and rapid assay.
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http://dx.doi.org/10.3390/microorganisms8010103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7022425PMC
January 2020

Effect of Corticosteroids on C-Reactive Protein in Patients with Severe Community-Acquired Pneumonia and High Inflammatory Response: The Effect of Lymphopenia.

J Clin Med 2019 Sep 13;8(9). Epub 2019 Sep 13.

Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York 10065, NY, USA.

Background: Lymphopenic patients with community-acquired pneumonia (CAP) have shown high mortality rates. Corticosteroids have immunomodulatory properties and regulate cytokine storm in CAP. However, it is not known whether their modulatory effect on cytokine secretion differs in lymphopenic and non-lymphopenic patients with CAP. Therefore, we aimed to test whether the presence of lymphopenia may modify the response to corticosteroids (mainly in C reactive protein (CRP)) in patients with severe CAP and high inflammatory status).

Methods: A post hoc analysis of a randomized controlled trial [1] (NCT00908713) which evaluated the effect of corticosteroids in patients with severe CAP and high inflammatory response (CRP > 15 mg/dL). Patients were clustered according to the presence of lymphopenia (lymphocyte count below 1000 cell/mm).

Results: At day 1, 35 patients (59%) in the placebo group presented with lymphopenia, compared to 44 patients (73%) in the corticosteroid group. The adjusted mean changes from day 1 showed an increase of 1.19 natural logarithm (ln) cell/mm in the corticosteroid group and an increase of 0.67 ln cell/mm in the placebo group (LS mean difference of the changes in ln (methylprednisolone minus placebo) 0.51, 95%CI (0.02 to 1.01), = 0.043). A significant effect was also found for the interaction ( = 0.043) between corticosteroids and lymphopenia in CRP values at day 3, with lower values in patients without lymphopenia receiving corticosteroids after adjustments for potential confounders.

Conclusion: In this exploratory post hoc analysis from ramdomized controlled trial (RCT) data, the response to corticosteroids, measured by CRP, may differ according to lymphocyte count. Further larger studies are needed to confirm this data.
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http://dx.doi.org/10.3390/jcm8091461DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780068PMC
September 2019

Response.

Chest 2019 08;156(2):415

Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), Ciber de Enfermedades Respiratorias (CIBERES) Villarroel 170 (08036), Barcelona, Spain. Electronic address:

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http://dx.doi.org/10.1016/j.chest.2019.05.001DOI Listing
August 2019

Comparative efficacy of linezolid and vancomycin for endotracheal tube MRSA biofilms from ICU patients.

Crit Care 2019 07 10;23(1):251. Epub 2019 Jul 10.

Cellex Laboratory, CibeRes ((Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, C/ Casanova 143, 08036, Cellex laboratory, Barcelona, Spain.

Purpose: To compare the efficacy of systemic treatment with linezolid (LNZ) versus vancomycin (VAN) on methicillin-resistant Staphylococcus aureus (MRSA) burden and eradication in endotracheal tube (ETT) biofilm and ETT cuff from orotracheally intubated patients with MRSA respiratory infection.

Methods: Prospective observational clinical study was carried out at four European tertiary hospitals. Plasma and endotracheal aspirate (ETA) levels of LNZ and VAN were determined 72 h after treatment initiation through high-performance liquid chromatography or bioassay. LNZ or VAN concentration in the ETT biofilm and MRSA burden and eradication was determined upon extubation. The minimum inhibitory concentration (MIC) for LNZ and VAN was assessed by E-test strips (Biomerieux®). Scanning electron microscopy images were obtained, and ETT biofilm thickness was compared between groups.

Results: Twenty-five patients, 15 treated with LNZ and 10 with VAN, were included in the study. LNZ presented a significantly higher concentration (μg/mL) than VAN in ETT biofilm (72.8 [1.3-127.1] vs 0.4 [0.4-1.3], p < 0.001), although both drugs achieved therapeutic plasma levels 72 h after treatment initiation. Systemic treatment with LNZ achieved lower ETT cuff MRSA burdens than systemic treatment with VAN. Indeed, LNZ increased the MRSA eradication rate in ETT cuff compared with VAN (LNZ 75%, VAN 20%, p = 0.031).

Conclusions: In ICU patients with MRSA respiratory infection intubated for long periods, systemic treatment with LNZ obtains a greater beneficial effect than VAN in limiting MRSA burden in ETT cuff.
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http://dx.doi.org/10.1186/s13054-019-2523-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617612PMC
July 2019

Lymphocytopenia as a Predictor of Mortality in Patients with ICU-Acquired Pneumonia.

J Clin Med 2019 Jun 13;8(6). Epub 2019 Jun 13.

Pneumology Department, Respiratory Institute (ICR), Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) - University of Barcelona, Ciber de Enfermedades Respiratorias (CIBERES), ICREA Academia, 08036 Barcelona, Spain.

Background: Intensive care unit-acquired pneumonia (ICU-AP) is a severe complication in patients admitted to the ICU. Lymphocytopenia is a marker of poor prognosis in patients with community-acquired pneumonia, but its impact on ICU-AP prognosis is unknown. We aimed to evaluate whether lymphocytopenia is an independent risk factor for mortality in non-immunocompromised patients with ICU-AP.

Methods: Prospective observational cohort study of patients from six ICUs of an 800-bed tertiary teaching hospital (2005 to 2016).

Results: Of the 473 patients included, 277 (59%) had ventilator-associated pneumonia (VAP). Receiver operating characteristic (ROC) analysis of the lymphocyte counts at diagnosis showed that 595 cells/mm was the best cut-off for discriminating two groups of patients at risk: lymphocytopenic group (lymphocyte count <595 cells/mm, 141 patients (30%)) and non-lymphocytopenic group (lymphocyte count ≥595 cells/mm, 332 patients (70%)). Patients with lymphocytopenia presented more comorbidities and a higher sequential organ failure assessment (SOFA) score at the moment of pneumonia diagnosis. Also, 28-day mortality and 90-day mortality were higher in patients with lymphocytopenia (28-day: 38 (27%) versus 59 (18%), 90-day: 74 (53%) versus 111 (34%)). In the multivariable model, <595 cells/mm resulted to be an independent predictor for 90-day mortality (Hazard Ratio 1.41; 95% Confidence Interval 1.02 to 1.94).

Conclusion: Lymphocytopenia is an independent predictor of 90-day mortality in non-immunocompromised patients with ICU-AP.
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http://dx.doi.org/10.3390/jcm8060843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617552PMC
June 2019

Score for Differentiating Pleural Tuberculosis from Malignant Effusion.

Med Sci (Basel) 2019 Feb 26;7(3). Epub 2019 Feb 26.

Pneumonology, Hospital de Clínicas, Buenos Aires 1120, Argentina.

Differential diagnosis of lymphocytic pleural effusions between tuberculous (TBE) and malignant (ME) effusion is usually difficult in daily practice. Our aim was to develop a score to differentiate TBE from ME effusions. A cohort of 138 consecutive patients with pleural effusion was prospectively studied from May 2014 through June 2017. Glucose, lactate dehydrogenase (LDH), proteins, white cell count, lactic acid, and pH in the pleural fluid were measured. Pleural effusions other than lymphocytic, patients with a final diagnosis other than tuberculosis or malignancy, and patients who met Light's criteria for transudate were excluded. Eighty-two samples (47 TBE and 35 ME) were included in the analysis. Using logistic regression analysis and Wald test, we developed a score including age, glucose, proteins, and lactic acid. The receiver operating characteristic curve (ROC) for the score was determined, and the area under the curve (AUC) was calculated. A cutoff of eight points was required to achieve 93.5% sensitivity, 78% specificity, and a likelihood ratio of 4.26 to distinguish tuberculosis from malignant pleural effusion. The AUC of the score was 0.915 (95% CI = 0.82⁻0.96).
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http://dx.doi.org/10.3390/medsci7030036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6473504PMC
February 2019

Invasive and non-invasive diagnostic approaches for microbiological diagnosis of hospital-acquired pneumonia.

Crit Care 2019 Feb 18;23(1):51. Epub 2019 Feb 18.

Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB), ICREA Academia award, Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Barcelona, Spain.

Background: Data on the methods used for microbiological diagnosis of hospital-acquired pneumonia (HAP) are mainly extrapolated from ventilator-associated pneumonia. HAP poses additional challenges for respiratory sampling, and the utility of sputum or distal sampling in HAP has not been comprehensively evaluated, particularly in HAP admitted to the ICU.

Methods: We analyzed 200 patients with HAP from six ICUs in a teaching hospital in Barcelona, Spain. The respiratory sampling methods used were divided into non-invasive [sputum and endotracheal aspirate (EAT)] and invasive [fiberoptic-bronchoscopy aspirate (FBAS), and bronchoalveolar lavage (BAL)].

Results: A median of three diagnostic methods were applied [range 2-4]. At least one respiratory sampling method was applied in 93% of patients, and two or more were applied in 40%. Microbiological diagnosis was achieved in 99 (50%) patients, 69 (70%) by only one method (42% FBAS, 23% EAT, 15% sputum, 9% BAL, 7% blood culture, and 4% urinary antigen). Seventy-eight (39%) patients underwent a fiberoptic-bronchoscopy when not receiving mechanical ventilation. Higher rates of microbiological diagnosis were observed in the invasive group (56 vs. 39%, p = 0.018). Patients with microbiological diagnosis more frequently presented changes in their empirical antibiotic scheme, mainly de-escalation.

Conclusions: A comprehensive approach might be undertaken for microbiological diagnosis in critically ill nonventilated HAP. Sputum sampling determined one third of microbiological diagnosis in HAP patients who were not subsequently intubated. Invasive methods were associated with higher rates of microbiological diagnosis.
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http://dx.doi.org/10.1186/s13054-019-2348-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379979PMC
February 2019
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