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1. Clinical factors associated with death in 3044 COVID-19 patients managed in internal medicine wards in Italy: comment

Author

Bandera, A., Nobili, A., Tettamanti, M., Harari, S., Bosari, S., Mannucci, P. M., Scudeller, L., Fusetti, G., Rusconi, L., Dell'Orto, S., Prati, D., Valenti, L., Giovannelli, S., Manunta, M., Lamorte, G., Ferrari, F., Gori, A., Muscatello, A., Mangioni, D., Alagna, L., Bozzi, G., Lombardi, A., Ungaro, R., Ancona, G., Zuglian, G., Bolis, M., Iannotti, N., Ludovisi, S., Comelli, A., Renisi, G., Biscarini, S., Castelli, V., Palomba, E., Fava, M., Fortina, V., Peri, C. A., Saltini, P., Viero, G., Itri, T., Ferroni, V., Pastore, V., Massafra, R., Liparoti, A., Muheberimana, T., Giommi, A., Bianco, R., De Azevedo, R. M., Chitani, G. E., Peyvandi, F., Gualtierotti, R., Ferrari, B., Rossio, R., Boasi, N., Pagliaro, E., Massimo, C., De Caro, M., Montano, N., Vigone, B., Bellocchi, C., Carandina, A., Fiorelli, E., Melli, V., Tobaldini, E., Blasi, F., Aliberti, S., Spotti, M., Terranova, L., Misuraca, S., D'Adda, A., Della Fiore, S., Di Pasquale, M., Contarini, M. M. M., Ori, M., Morlacchi, L., Rossetti, V., Gramegna, A., Pappalettera, M., Cavallini, M., Buscemi, A., Vicenzi, M., Rota, I., Costantino, G., Solbiati, M., Furlan, L., Mancarella, M., Colombo, G., Fanin, A., Passarella, M., Monzani, V., Canetta, C., Rovellini, A., Barbetta, L., Billi, F., Folli, C., Accordino, S., Maira, D., C. M., Hu, Motta, I., Scaramellini, N., Fracanzani, A. L., Lombardi, R., Cespiati, A., Cesari, M., Lucchi, T., Proietti, M., Calcaterra, L., Mandelli, C., Coppola, C., Cerizza, A., Pesenti, A. M., Grasselli, G., Galazzi, A., Monti, I., Galbussera, A. A., Crisafulli, E., Girelli, D., Maroccia, A., Gabbiani, D., Busti, F., Vianello, A., Biondan, M., Sartori, F., Faverio, P., Pesci, A., Zucchetti, S., Bonfanti, P., Rossi, M., Beretta, I., Spolti, A., Elia, D., Cassandro, R., Caminati, A., Cipollone, F., Guagnano, M. T., D'Ardes, D., Rossi, I., Vezzani, F., Spanevello, A., Cherubino, F., Visca, D., Contoli, M., Papi, A., Morandi, L., Battistini, N., Moreo, G. L., Iannuzzi, P., Fumagalli, D., Leone, S., Bandera, A, Nobili, A, Tettamanti, M, Harari, S, Bosari, S, Mannucci, P, Scudeller, L, Fusetti, G, Rusconi, L, Dell'Orto, S, Prati, D, Valenti, L, Giovannelli, S, Manunta, M, Lamorte, G, Ferrari, F, Gori, A, Muscatello, A, Mangioni, D, Alagna, L, Bozzi, G, Lombardi, A, Ungaro, R, Ancona, G, Zuglian, G, Bolis, M, Iannotti, N, Ludovisi, S, Comelli, A, Renisi, G, Biscarini, S, Castelli, V, Palomba, E, Fava, M, Fortina, V, Peri, C, Saltini, P, Viero, G, Itri, T, Ferroni, V, Pastore, V, Massafra, R, Liparoti, A, Muheberimana, T, Giommi, A, Bianco, R, De Azevedo, R, Chitani, G, Peyvandi, F, Gualtierotti, R, Ferrari, B, Rossio, R, Boasi, N, Pagliaro, E, Massimo, C, De Caro, M, Montano, N, Vigone, B, Bellocchi, C, Carandina, A, Fiorelli, E, Melli, V, Tobaldini, E, Blasi, F, Aliberti, S, Spotti, M, Terranova, L, Misuraca, S, D'Adda, A, Della Fiore, S, Di Pasquale, M, Contarini, M, Ori, M, Morlacchi, L, Rossetti, V, Gramegna, A, Pappalettera, M, Cavallini, M, Buscemi, A, Vicenzi, M, Rota, I, Costantino, G, Solbiati, M, Furlan, L, Mancarella, M, Colombo, G, Fanin, A, Passarella, M, Monzani, V, Canetta, C, Rovellini, A, Barbetta, L, Billi, F, Folli, C, Accordino, S, Maira, D, Hu, C, Motta, I, Scaramellini, N, Fracanzani, A, Lombardi, R, Cespiati, A, Cesari, M, Lucchi, T, Proietti, M, Calcaterra, L, Mandelli, C, Coppola, C, Cerizza, A, Pesenti, A, Grasselli, G, Galazzi, A, Monti, I, Galbussera, A, Crisafulli, E, Girelli, D, Maroccia, A, Gabbiani, D, Busti, F, Vianello, A, Biondan, M, Sartori, F, Faverio, P, Pesci, A, Zucchetti, S, Bonfanti, P, Rossi, M, Beretta, I, Spolti, A, Elia, D, Cassandro, R, Caminati, A, Cipollone, F, Guagnano, M, D'Ardes, D, Rossi, I, Vezzani, F, Spanevello, A, Cherubino, F, Visca, D, Contoli, M, Papi, A, Morandi, L, Battistini, N, Moreo, G, Iannuzzi, P, Fumagalli, D, and Leone, S

Subjects
Adult, medicine.medical_specialty, 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Critical Care, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Ce - Letter to the Editor, MEDLINE, Cohort Studies, Hospital, Internal Medicine, Medicine, Humans, Hospital Mortality, Intensive care medicine, Aged, Aged, 80 and over, business.industry, SARS-CoV-2, COVID-19, Middle Aged, Respiration, Artificial, Hospitals, Hospitalization, Survival Rate, Italy, Emergency Medicine, business, Human
Abstract

During the COVID-19 2020 outbreak, a large body of data has been provided on general management and outcomes of hospitalized COVID-19 patients. Yet, relatively little is known on characteristics and outcome of patients managed in Internal Medicine Units (IMU). To address this gap, the Italian Society of Internal Medicine has conducted a nationwide cohort multicentre study on death outcome in adult COVID-19 patients admitted and managed in IMU. This study assessed 3044 COVID-19 patients at 41 referral hospitals across Italy from February 3rd to May 8th 2020. Demographics, comorbidities, organ dysfunction, treatment, and outcomes including death were assessed. During the study period, 697 patients (22.9%) were transferred to intensive care units, and 351 died in IMU (death rate 14.9%). At admission, factors independently associated with in-hospital mortality were age (OR 2.46, p = 0.000), productive cough (OR 2.04, p = 0.000), pre-existing chronic heart failure (OR 1.58, p = 0.017) and chronic obstructive pulmonary disease (OR 1.17, p = 0.048), the number of comorbidities (OR 1.34, p = 0.000) and polypharmacy (OR 1.20, p = 0.000). Of note, up to 40% of elderly patients did not report fever at admission. Decreasing PaO

Published
2022

2. Clinical risk scores for the early prediction of severe outocomes in patients hospitalized for COVID-19: comment

Author

Rossio R., Tettamanti M., Nobili A., Harari S., Mannucci P. M., Bandera A., Peyvandi F., Bosari S., Scudeller L., Fusetti G., Rusconi L., Dell'Orto S., Prati D., Valenti L., Giovannelli S., Manunta M., Lamorte G., Ferrari F., Gori A., Muscatello A., Mangioni D., Alagna L., Bozzi G., Lombardi A., Ungaro R., Ancona G., Zuglian G., Bolis M., Iannotti N., Ludovisi S., Comelli A., Renisi G., Biscarini S., Castelli V., Palomba E., Fava M., Fortina V., Peri C. A., Saltini P., Viero G., Itri T., Ferroni V., Pastore V., Massafra R., Liparoti A., Muheberimana T., Giommi A., Bianco R., De Azevedo R. M., Chitani G. E., Gualtierotti R., Ferrari B., Boasi N., Pagliaro E., Massimo C., De Caro M., Giachi A., Montano N., Vigone B., Bellocchi C., Carandina A., Fiorelli E., Melli V., Tobaldini E., Blasi F., Aliberti S., Spotti M., Terranova L., Misuraca S., D'Adda A., Fiore S. D., Di Pasquale M., Mantero M., Contarini M., Ori M., Morlacchi L., Rossetti V., Gramegna A., Pappalettera M., Cavallini M., Buscemi A., Vicenzi M., Rota I., Costantino G., Solbiati M., Furlan L., Mancarella M., Colombo G., Fanin A., Passarella M., Monzani V., Canetta C., Rovellini A., Barbetta L., Billi F., Folli C., Accordino S., Maira D., Hu C. M., Motta I., Scaramellini N., Fracanzani A. L., Lombardi R., Cespiati A., Cesari M., Lucchi T., Proietti M., Calcaterra L., Mandelli C., Coppola C., Cerizza A., Pesenti A. M., Grasselli G., Galazzi A., Monti I., Galbussera A. A., Crisafulli E., Girelli D., Maroccia A., Gabbiani D., Busti F., Vianello A., Biondan M., Sartori F., Faverio P., Pesci A., Zucchetti S., Bonfanti P., Rossi M., Beretta I., Spolti A., Elia D., Cassandro R., Caminati A., Cipollone F., Guagnano M. T., D'Ardes D., Rossi I., Vezzani F., Spanevello A., Cherubino F., Visca D., Contoli M., Papi A., Morandi L., Battistini N., Moreo G. L., Iannuzzi P., Fumagalli D., Leone S., Rossio, R, Tettamanti, M, Nobili, A, Harari, S, Mannucci, P, Bandera, A, Peyvandi, F, Bosari, S, Scudeller, L, Fusetti, G, Rusconi, L, Dell'Orto, S, Prati, D, Valenti, L, Giovannelli, S, Manunta, M, Lamorte, G, Ferrari, F, Gori, A, Muscatello, A, Mangioni, D, Alagna, L, Bozzi, G, Lombardi, A, Ungaro, R, Ancona, G, Zuglian, G, Bolis, M, Iannotti, N, Ludovisi, S, Comelli, A, Renisi, G, Biscarini, S, Castelli, V, Palomba, E, Fava, M, Fortina, V, Peri, C, Saltini, P, Viero, G, Itri, T, Ferroni, V, Pastore, V, Massafra, R, Liparoti, A, Muheberimana, T, Giommi, A, Bianco, R, De Azevedo, R, Chitani, G, Gualtierotti, R, Ferrari, B, Boasi, N, Pagliaro, E, Massimo, C, De Caro, M, Giachi, A, Montano, N, Vigone, B, Bellocchi, C, Carandina, A, Fiorelli, E, Melli, V, Tobaldini, E, Blasi, F, Aliberti, S, Spotti, M, Terranova, L, Misuraca, S, D'Adda, A, Fiore, S, Di Pasquale, M, Mantero, M, Contarini, M, Ori, M, Morlacchi, L, Rossetti, V, Gramegna, A, Pappalettera, M, Cavallini, M, Buscemi, A, Vicenzi, M, Rota, I, Costantino, G, Solbiati, M, Furlan, L, Mancarella, M, Colombo, G, Fanin, A, Passarella, M, Monzani, V, Canetta, C, Rovellini, A, Barbetta, L, Billi, F, Folli, C, Accordino, S, Maira, D, Hu, C, Motta, I, Scaramellini, N, Fracanzani, A, Lombardi, R, Cespiati, A, Cesari, M, Lucchi, T, Proietti, M, Calcaterra, L, Mandelli, C, Coppola, C, Cerizza, A, Pesenti, A, Grasselli, G, Galazzi, A, Monti, I, Galbussera, A, Crisafulli, E, Girelli, D, Maroccia, A, Gabbiani, D, Busti, F, Vianello, A, Biondan, M, Sartori, F, Faverio, P, Pesci, A, Zucchetti, S, Bonfanti, P, Rossi, M, Beretta, I, Spolti, A, Elia, D, Cassandro, R, Caminati, A, Cipollone, F, Guagnano, M, D'Ardes, D, Rossi, I, Vezzani, F, Spanevello, A, Cherubino, F, Visca, D, Contoli, M, Papi, A, Morandi, L, Battistini, N, Moreo, G, Iannuzzi, P, Fumagalli, D, and Leone, S

Subjects
Male, Outcome Assessment, Disease, 030204 cardiovascular system & hematology, Respiratory failure, 0302 clinical medicine, Risk Factors, Epidemiology, Early prediction, Outcome Assessment, Health Care, 030212 general & internal medicine, Framingham Risk Score, Respiration, Area under the curve, Middle Aged, Hospitalization, Survival Rate, Italy, Artificial, Emergency Medicine, Female, Clinical risk factor, 2019-20 coronavirus outbreak, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Ce - Letter to the Editor, MEDLINE, Risk Assessment, 03 medical and health sciences, Predictive Value of Tests, Internal medicine, Internal Medicine, medicine, Intubation, Intratracheal, Humans, In patient, Derivation, COVID-19, Risk prediction model, SARS-CoV 2, Selection (genetic algorithm), Aged, Retrospective Studies, SARS-CoV-2, business.industry, Retrospective cohort study, Respiration, Artificial, Im - Original, Health Care, Intratracheal, ROC Curve, Intubation, business
Abstract

Coronavirus disease of 2019 (COVID-19) is associated with severe acute respiratory failure. Early identification of high-risk COVID-19 patients is crucial. We aimed to derive and validate a simple score for the prediction of severe outcomes. A retrospective cohort study of patients hospitalized for COVID-19 was carried out by the Italian Society of Internal Medicine. Epidemiological, clinical, laboratory, and treatment variables were collected at hospital admission at five hospitals. Three algorithm selection models were used to construct a predictive risk score: backward Selection, Least Absolute Shrinkage and Selection Operator (LASSO), and Random Forest. Severe outcome was defined as the composite of need for non-invasive ventilation, need for orotracheal intubation, or death. A total of 610 patients were included in the analysis, 313 had a severe outcome. The subset for the derivation analysis included 335 patients, the subset for the validation analysis 275 patients. The LASSO selection identified 6 variables (age, history of coronary heart disease, CRP, AST, D-dimer, and neutrophil/lymphocyte ratio) and resulted in the best performing score with an area under the curve of 0.79 in the derivation cohort and 0.80 in the validation cohort. Using a cut-off of 7 out of 13 points, sensitivity was 0.93, specificity 0.34, positive predictive value 0.59, and negative predictive value 0.82. The proposed score can identify patients at low risk for severe outcome who can be safely managed in a low-intensity setting after hospital admission for COVID-19.

Published
2021

3. Development of a Risk Prediction Model for Carbapenem-resistant Enterobacteriaceae Infection after Liver Transplantation: A Multinational Cohort Study

Author

Giannella, M., Freire, M., Rinaldi, M., Abdala, E., Rubin, A., Mularoni, A., Gruttadauria, S., Grossi, P., Shbaklo, N., Tandoi, F., Ferrarese, A., Burra, P., Fernandes, R., Aranha Camargo, L. F., Asensio, A., Alagna, L., Bandera, A., Simkins, J., Abbo, L., Halpern, M., Santana Girao, E., Valerio, M., Munoz, P., Fernandez Yunquera, A., Statlender, L., Yahav, D., Franceschini, E., Graziano, E., Morelli, M. C., Cescon, M., Viale, P., Lewis, R., Bartoletti, M., Pascale, R., Campoli, C., Coladonato, S., Cristini, F., Tumietto, F., Siniscalchi, A., Laici, C., Ambretti, S., Romagnoli, R., De Rosa, F. G., Muscatello, A., Mangioni, D., Gori, A., Antonelli, B., Dondossola, D., Rossi, G., Invernizzi, F., Peghin, M., Cillo, U., Mussini, C., Benedetto, F. D., Terrabuio, D. R. B., Bittante, C. D., Toniolo, A. D. R., Balbi, E., Garcia, J. H. P., Morras, I., Ramos, A., Cruz, A. F., Salcedo, M., Giannella M., Freire M., Rinaldi M., Abdala E., Rubin A., Mularoni A., Gruttadauria S., Grossi P., Shbaklo N., Tandoi F., Ferrarese A., Burra P., Fernandes R., Aranha Camargo L.F., Asensio A., Alagna L., Bandera A., Simkins J., Abbo L., Halpern M., Santana Girao E., Valerio M., Munoz P., Fernandez Yunquera A., Statlender L., Yahav D., Franceschini E., Graziano E., Morelli M.C., Cescon M., Viale P., Lewis R., Bartoletti M., Pascale R., Campoli C., Coladonato S., Cristini F., Tumietto F., Siniscalchi A., Laici C., Ambretti S., Romagnoli R., De Rosa F.G., Muscatello A., Mangioni D., Gori A., Antonelli B., Dondossola D., Rossi G., Invernizzi F., Peghin M., Cillo U., Mussini C., Benedetto F.D., Terrabuio D.R.B., Bittante C.D., Toniolo A.D.R., Balbi E., Garcia J.H.P., Morras I., Ramos A., Cruz A.F., and Salcedo M.

Subjects
Microbiology (medical), Adult, medicine.medical_specialty, medicine.medical_treatment, Carbapenem-resistant enterobacteriaceae, Liver transplantation, CRE carriage, CRE infection, SOT, liver transplantation, Anti-Bacterial Agents, Carbapenems, Cohort Studies, Humans, Risk Factors, Carbapenem-Resistant Enterobacteriaceae, Enterobacteriaceae Infections, Liver Transplantation, 03 medical and health sciences, 0302 clinical medicine, Interquartile range, Internal medicine, Anti-Bacterial Agent, Medicine, 030212 general & internal medicine, Carbapenem, Univariate analysis, business.industry, Risk Factor, Area under the curve, Nomogram, Enterobacteriaceae Infection, Transplantation, Infectious Diseases, 030211 gastroenterology & hepatology, Cohort Studie, business, Human, Cohort study
Abstract

BackgroundPatients colonized with carbapenem-resistant Enterobacteriaceae (CRE) are at higher risk of developing CRE infection after liver transplantation (LT), with associated high morbidity and mortality. Prediction model for CRE infection after LT among carriers could be useful to target preventive strategies.MethodsMultinational multicenter cohort study of consecutive adult patients underwent LT and colonized with CRE before or after LT, from January 2010 to December 2017. Risk factors for CRE infection were analyzed by univariate analysis and by Fine-Gray subdistribution hazard model, with death as competing event. A nomogram to predict 30- and 60-day CRE infection risk was created.ResultsA total of 840 LT recipients found to be colonized with CRE before (n = 203) or after (n = 637) LT were enrolled. CRE infection was diagnosed in 250 (29.7%) patients within 19 (interquartile range [IQR], 9–42) days after LT. Pre- and post-LT colonization, multisite post-LT colonization, prolonged mechanical ventilation, acute renal injury, and surgical reintervention were retained in the prediction model. Median 30- and 60-day predicted risk was 15% (IQR, 11–24) and 21% (IQR, 15–33), respectively. Discrimination and prediction accuracy for CRE infection was acceptable on derivation (area under the curve [AUC], 74.6; Brier index, 16.3) and bootstrapped validation dataset (AUC, 73.9; Brier index, 16.6). Decision-curve analysis suggested net benefit of model-directed intervention over default strategies (treat all, treat none) when CRE infection probability exceeded 10%. The risk prediction model is freely available as mobile application at https://idbologna.shinyapps.io/CREPostOLTPredictionModel/.ConclusionsOur clinical prediction tool could enable better targeting interventions for CRE infection after transplant.

Published
2021

4. Hospital-Acquired Infections in Critically Ill Patients With COVID-19

Author

Antonio Muscatello, Giacomo Bellani, Paolo Bonfanti, Gabriele Fior, Sara Linguadoca, Antonio Pesenti, Alessandra Bandera, Massimiliano Greco, Michele Bartoletti, Massimo Girardis, Irene Coloretti, Paola Morelli, N Bottino, Mario Carlo Raviglione, Gennaro De Pascale, Marianna Meschiari, Marco Ranieri, Giacomo Grasselli, Roberto Fumagalli, Luigia Scudeller, Giuseppe Foti, Daniela Ferlicca, Andrea Forastieri, Antonio Messina, Emanuela Biagioni, Flavia Stefanini, Pierluigi Viale, Marco Franzetti, Maurizio Cecconi, Tommaso Tonetti, Andrea Gori, Massimo Antonelli, Laura Alagna, Vittorio Scaravilli, Amedeo Guzzardella, SL Cutuli, Simone Redaelli, Davide Mangioni, Gianpaola Monti, Grasselli G., Scaravilli V., Mangioni D., Scudeller L., Alagna L., Bartoletti M., Bellani G., Biagioni E., Bonfanti P., Bottino N., Coloretti I., Cutuli S.L., De Pascale G., Ferlicca D., Fior G., Forastieri A., Franzetti M., Greco M., Guzzardella A., Linguadoca S., Meschiari M., Messina A., Monti G., Morelli P., Muscatello A., Redaelli S., Stefanini F., Tonetti T., Antonelli M., Cecconi M., Foti G., Fumagalli R., Girardis M., Ranieri M., Viale P., Raviglione M., Pesenti A., Gori A., Bandera A., Grasselli, G, Scaravilli, V, Mangioni, D, Scudeller, L, Alagna, L, Bartoletti, M, Bellani, G, Biagioni, E, Bonfanti, P, Bottino, N, Coloretti, I, Cutuli, S, De Pascale, G, Ferlicca, D, Fior, G, Forastieri, A, Franzetti, M, Greco, M, Guzzardella, A, Linguadoca, S, Meschiari, M, Messina, A, Monti, G, Morelli, P, Muscatello, A, Redaelli, S, Stefanini, F, Tonetti, T, Antonelli, M, Cecconi, M, Foti, G, Fumagalli, R, Girardis, M, Ranieri, M, Viale, P, Raviglione, M, Pesenti, A, Gori, A, and Bandera, A

Subjects
Pulmonary and Respiratory Medicine, Male, medicine.medical_specialty, COVID-19, SARS-CoV-2, critical care, hospital-acquired infections, medicine.medical_treatment, Critical Illness, Critical Care and Intensive Care Medicine, Aged, Cross Infection, Female, Humans, Middle Aged, Pneumonia, Ventilator-Associated, Retrospective Studies, Sepsis, Interquartile range, Internal medicine, Settore MED/41 - ANESTESIOLOGIA, Hospital-acquired infection, Correspondence, medicine, Mechanical ventilation, hospital-acquired infection, Septic shock, business.industry, Incidence (epidemiology), Mortality rate, Ventilator-associated pneumonia, Pneumonia, medicine.disease, Ventilator-Associated, Cardiology and Cardiovascular Medicine, business
Abstract

Background: Few small studies have described hospital-acquired infections (HAIs) occurring in patients with COVID-19. Research Question: What characteristics in critically ill patients with COVID-19 are associated with HAIs and how are HAIs associated with outcomes in these patients? Study Design and Methods: Multicenter retrospective analysis of prospectively collected data including adult patients with severe COVID-19 admitted to eight Italian hub hospitals from February 20, 2020, through May 20, 2020. Descriptive statistics and univariate and multivariate Weibull regression models were used to assess incidence, microbial cause, resistance patterns, risk factors (ie, demographics, comorbidities, exposure to medication), and impact on outcomes (ie, ICU discharge, length of ICU and hospital stays, and duration of mechanical ventilation) of microbiologically confirmed HAIs. Results: Of the 774 included patients, 359 patients (46%) demonstrated 759 HAIs (44.7 infections/1,000 ICU patient-days; 35% multidrug-resistant [MDR] bacteria). Ventilator-associated pneumonia (VAP; n = 389 [50%]), bloodstream infections (BSIs; n = 183 [34%]), and catheter-related BSIs (n = 74 [10%]) were the most frequent HAIs, with 26.0 (95% CI, 23.6-28.8) VAPs per 1,000 intubation-days, 11.7 (95% CI, 10.1-13.5) BSIs per 1,000 ICU patient-days, and 4.7 (95% CI, 3.8-5.9) catheter-related BSIs per 1,000 ICU patient-days. Gram-negative bacteria (especially Enterobacterales) and Staphylococcus aureus caused 64% and 28% of cases of VAP, respectively. Variables independently associated with infection were age, positive end expiratory pressure, and treatment with broad-spectrum antibiotics at admission. Two hundred thirty-four patients (30%) died in the ICU (15.3 deaths/1,000 ICU patient-days). Patients with HAIs complicated by septic shock showed an almost doubled mortality rate (52% vs 29%), whereas noncomplicated infections did not affect mortality. HAIs prolonged mechanical ventilation (median, 24 days [interquartile range (IQR), 14-39 days] vs 9 days [IQR, 5-13 days]; P < .001), ICU stay (24 days [IQR, 16-41 days] vs 9 days [IQR, 6-14 days]; P = .003), and hospital stay (42 days [IQR, 25-59 days] vs 23 days [IQR, 13-34 days]; P < .001). Interpretation: Critically ill patients with COVID-19 are at high risk for HAIs, especially VAPs and BSIs resulting from MDR organisms. HAIs prolong mechanical ventilation and hospitalization, and HAIs complicated by septic shock almost double mortality. Trial Registry: ClinicalTrials.gov; No.: NCT04388670; URL: www.clinicaltrials.gov

Published
2020

5. Microbiota in ICU, not only a gut problem

Author

Antonio Muscatello, Andrea Gori, Alessandra Bandera, Laura Alagna, Giuseppe Citerio, A. Patruno, Alagna, L, Bandera, A, Patruno, A, Muscatello, A, Citerio, G, and Gori, A

Subjects
medicine.medical_specialty, business.industry, Microbiota, Pain medicine, Gastrointestinal Microbiome, MEDLINE, Critical Care and Intensive Care Medicine, Hospitalization, Intensive Care Units, Anesthesiology, medicine, Humans, Intensive care medicine, business
Published
2019
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6. Nosocomial infections during extracorporeal membrane oxygenation: Incidence, etiology, and impact on patients' outcome

Author

Antonio Pesenti, Andrea Gori, Stefano Biffi, Michela Bombino, Luca Bisi, Vittorio Scaravilli, Nicolò Patroniti, Stefano Di Bella, Giacomo Grasselli, Laura Alagna, Anna Maria Peri, Grasselli, G., Scaravilli, V., Di Bella, S., Biffi, S., Bombino, M., Patroniti, N., Bisi, L., Peri, A. M., Pesenti, A., Gori, A., and Alagna, L.

Subjects
Male, medicine.medical_treatment, retrospective study, Drug Resistance, Bacteremia, 030204 cardiovascular system & hematology, Critical Care and Intensive Care Medicine, intensive care unit, law.invention, 0302 clinical medicine, Retrospective Studie, law, Risk Factors, Drug Resistance, Multiple, Bacterial, Age Factor, health care-associated infection, Child, Cross Infection, Incidence (epidemiology), Incidence, Age Factors, Bacterial, Pneumonia, Ventilator-Associated, Middle Aged, Intensive care unit, Intensive Care Units, Ventilator-Associated, Italy, extracorporeal membrane oxygenation, multidrug resistance, Adolescent, Adult, Catheter-Related Infections, Child, Preschool, Extracorporeal Membrane Oxygenation, Female, Humans, Length of Stay, Retrospective Studies, Urinary Tract Infections, Young Adult, Multiple, Human, medicine.medical_specialty, Intensive Care Unit, Extracorporeal, 03 medical and health sciences, medicine, Extracorporeal membrane oxygenation, Intensive care medicine, Preschool, Catheter-Related Infection, business.industry, Risk Factor, 030208 emergency & critical care medicine, Retrospective cohort study, Pneumonia, medicine.disease, Urinary Tract Infection, Emergency medicine, Etiology, business
Abstract

OBJECTIVE: To study incidence, type, etiology, risk factors, and impact on outcome of nosocomial infections during extracorporeal membrane oxygenation. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Italian tertiary referral center medical-surgical ICU. PATIENTS: One hundred five consecutive patients who were treated with extracorporeal membrane oxygenation from January 2010 to November 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ninety-two patients were included in the analysis (48.5 [37-56] years old, simplified acute physiology score II 37 [32-47]) who underwent peripheral extracorporeal membrane oxygenation (87% veno-venous) for medical indications (78% acute respiratory distress syndrome). Fifty-two patients (55%) were infected (50.4 infections/1,000 person-days of extracorporeal membrane oxygenation). We identified 32 ventilator-associated pneumonia, eight urinary tract infections, five blood stream infections, three catheter-related blood stream infections, two colitis, one extracorporeal membrane oxygenation cannula infection, and one pulmonary-catheter infection. G+ infections (35%) occurred earlier compared with G- (48%) (4 [2-10] vs. 13 [7-23] days from extracorporeal membrane oxygenation initiation; p < 0.001). Multidrug-resistant organisms caused 56% of bacterial infections. Younger age (2-35 years old) was independently associated with higher risk for nosocomial infections. Twenty-nine patients (31.5%) died (13.0 deaths/1,000 person-days of extracorporeal membrane oxygenation). Infected patients had higher risk for death (18 vs. 8 deaths/1,000 person-days of extracorporeal membrane oxygenation; p = 0.037) and longer ICU stay (32.5 [19.5-78] vs. 19 [10.5-27.5] days; p = 0.003), mechanical ventilation (36.5 [20-80.5] vs. 16.5 [9-25.5] days; p < 0.001), and extracorporeal membrane oxygenation (25.5 [10.75-54] vs. 10 [5-13] days; p < 0.001). Older age (> 50 years old), reason for connection different from acute respiratory distress syndrome, higher simplified acute physiology score II, diagnosis of ventilator-associated pneumonia, and infection by multidrug-resistant bacteria were independently associated to increased death rate. CONCLUSIONS: Infections (especially ventilator-associated pneumonia) during extracorporeal membrane oxygenation therapy are common and frequently involve multidrug-resistant organisms. In addition, they have a negative impact on patients' outcomes.

Published
2017

7. Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention

Author

Andrea Gori, Antonio Pesenti, Vittorio Scaravilli, Laura Alagna, Anna Maria Peri, Giacomo Grasselli, Stefano Di Bella, Stefano Biffi, Biffi, S, DI BELLA, S, Scaravilli, V, Peri, Am, Grasselli, G, Alagna, L, Pesenti, A, and Gori, A

Subjects
Microbiology (medical), medicine.medical_specialty, medicine.medical_treatment, 030204 cardiovascular system & hematology, law.invention, 03 medical and health sciences, 0302 clinical medicine, Extracorporeal Membrane Oxygenation, law, Risk Factors, Epidemiology, Hospital-acquired infection, Severity of illness, ECMO, infections, epidemiology, medicine, Extracorporeal membrane oxygenation, Prevalence, Humans, Pharmacology (medical), Risk factor, Intensive care medicine, Infection Control, business.industry, Mortality rate, 030208 emergency & critical care medicine, General Medicine, Bacterial Infections, medicine.disease, Intensive care unit, infection, Pneumonia, surgical procedures, operative, Infectious Diseases, Mycoses, business
Abstract

Extracorporeal membrane oxygenation (ECMO) is a life support technique used in patients with respiratory and/or cardiac failure. The ECMO circuit consists of vascular cannulae, a pump and an artificial lung. Infections are among the most common complications associated with ECMO and have a significant impact on the mortality rate. Here we present a narrative literature review regarding the epidemiology, risk factors, pathogenesis and prevention of infectious complications during ECMO support. The prevalence of hospital-acquired infections during ECMO is 10-12% and their occurrence is likely to be more frequent compared with other critically ill patients. Coagulase-negative staphylococci, Candida spp., Enterobacteriaceae and Pseudomonas aeruginosa are the most frequently involved pathogens. A high incidence of ventilator-associated pneumonia was reported (24.4 cases/1000 ECMO days), with a major role unexpectedly played by Enterobacteriaceae. The infectious risk was shown to increase along the duration of the ECMO run, which represents the most important risk factor for the development of infections. Other ECMO-specific factors predisposing to infections include the severity of illness in ECMO patients, the high risk of bacterial translocation from the gut, and ECMO-related impairment of the immune system. Another important issue could be microbial colonisation of catheters, ECMO cannulae and the oxygenator, which is consistent with most commonly observed aetiologies.

Published
2016

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