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Purpose: Increasing prevalence of candidemia in Internal Medicine wards (IMWs) has been reported in recent years, but risk factors for candida bloodstream infection in patients admitted to IMW may differ from those known in other settings. The aim of this study was to identify risk factors and define a prediction rule for the early recognition of the risk of candidemia in IMW inpatients., Methods: This was a multicentric, retrospective, observational case-control study on non-neutropenic patients with candidemia admitted to IMWs of four large Italian Hospitals. Each eligible patient with candidemia (case) was matched to a control with bacteremia. Stepwise logistic regression analyses were performed., Results: Overall, 300 patients (150 cases and 150 controls) were enrolled. The following factors were associated with an increased risk of candidemia and weighted to build a score: total parenteral nutrition (OR 2.45, p = 0.008; 1 point); central venous catheter (OR 2.19, p = 0.031; 1 point); peripherally inserted central catheter (OR 5.63, p < 0.0001; 3 points), antibiotic treatment prior (OR 2.06; p = 0.059; 1 point) and during hospitalization (OR2.38, p = 0.033; 1 point); neurological disability (OR 2.25, p = 0.01; 1 point); and previous hospitalization within 3 months (OR 1.56, p = 0.163; 1 point). At ROC curve analysis, a final score ≥ 4 showed 84% sensitivity, 76% specificity, and 80% accuracy in predicting the risk of candidemia., Conclusions: The proposed scoring system showed to be a simple and highly performing tool in distinguishing bloodstream infections due to Candida and bacteria in patients admitted to IMW. The proposed rule might help to reduce delay in empirical treatment and improve appropriateness in antifungal prescription in septic patients.

This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management. [ABSTRACT FROM AUTHOR]

Purpose: Candidemia is a highly lethal infection; several scores have been developed to assist the diagnosis process and recently different models have been proposed. Aim of this work was to assess predictive performance of a Random Forest (RF) algorithm for early detection of candidemia in the internal medical wards (IMWs). Methods: A set of 42 potential predictors was acquired in a sample of 295 patients (male: 142, age: 72 ± 15 years; candidemia: 157/295; bacteremia: 138/295). Using tenfold cross-validation, a RF algorithm was compared with a classic stepwise multivariable logistic regression model; discriminative performance was assessed by C-statistics, sensitivity and specificity, while calibration was evaluated by Hosmer–Lemeshow test. Results: The best tuned RF algorithm demonstrated excellent discrimination (C-statistics = 0.874 ± 0.003, sensitivity = 84.24% ± 0.67%, specificity = 91% ± 2.63%) and calibration (Hosmer–Lemeshow statistics = 12.779 ± 1.369, p = 0.120), markedly greater than the ones guaranteed by the classic stepwise logistic regression (C-statistics = 0.829 ± 0.011, sensitivity = 80.21% ± 1.67%, specificity = 84.81% ± 2.68%; Hosmer–Lemeshow statistics = 38.182 ± 15.983, p < 0.001). In addition, RF suggests a major role of in-hospital antibiotic treatment with microbioma highly impacting antimicrobials (MHIA) that are found as a fundamental risk of candidemia, further enhanced by TPN. When in-hospital MHIA therapy is not performed, PICC is the dominant risk factor for candidemia, again enhanced by TPN. When PICC is not used and MHIA therapy is not performed, the risk of candidemia is minimum, slightly increased by in-hospital antibiotic therapy. Conclusion: RF accurately estimates the risk of candidemia in patients admitted to IMWs. Machine learning technique might help to identify patients at high risk of candidemia, reduce the delay in empirical treatment and improve appropriateness in antifungal prescription. [ABSTRACT FROM AUTHOR]

Purpose Infections caused by ESBL-producing Enterobacteriaceae (ESBL-EB) are a major health problem, but data regarding elderly patients is lacking. Methods We performed a retrospective observational study quantifying the effects of antimicrobial treatment and primary infection site on clinical outcomes in an historical case series of 42 patients aged 80.7 ± 10 years admitted to an Internal Medicine ward in Italy for ESBL-EB bloodstream infections (BSI). Results At multivariate risk analysis, we found that urinary tract as primary infection site (RR = 0.181 [0.037–0.886], p = 0.035) and definitive antibiotic therapy (RR = 0.517 [0.147–0.799], p = 0.038) decreased the relative risk of a negative clinical response, while the respiratory tract origin increased the relative risk (RR = 2.788 [1.407–9.228], p = 0.025). Also regarding 30 days mortality, multivariate risk analysis identified that urinary tract as primary infection site (RR = 0.098 [0.011–0.743], p = 0.025) and definitive antibiotic therapy (RR = 0.236 [0.058–0.961], p = 0.044) decreased the relative risk, while the respiratory origin increased the relative risk (RR = 4.241 [1.040–17.295], p = 0.014). We observed similar outcomes in patients definitively treated with carbapenems or with carbapenem-free treatments. Additionally, an initially inappropriate therapy did not correlate with worse outcomes if a switch to an effective definitive treatment was performed promptly. Conclusions Carbapenem-sparing regimens (e.g. piperacillin-tazobactam alone or with an aminoglycoside) could be empirically safely used in elderly patients at high risk of ESBL-EB BSI and for definitive treatment of ascertained cases if the primary site is the urinary tract, leaving early carbapenem use for cases at higher risk of death, such as those with pneumonia. [ABSTRACT FROM AUTHOR]

The incidence and prevalence associated with the growing age of population have made heart failure (HF) a new epidemic. In Italy most of HF patients are admitted to Internal Medicine Departments (IMD). We conducted a 30-day cross-sectional study involving patients with HF admitted to IMD of Tuscany. The aim of the study was to provide an updated snapshot of in-hospital management of HF in Tuscany and to analyze the differences in relation to the most recent guidelines. We have recruited 770 patients (M=45.4%) with a mean age of 82.5±8.9 years. Only 16.1% had a de novo HF. Most of them were re-admitted for decompensated HF. Hypertension and ischemic disease are the prevailing etiologies. HF alone was in less than 2%. 71.5% of patients had more than two comorbidities and 40.6% more than three concomitant diseases. The mean hospital stay (overall 8.6±5.5 days) correlated with the number of comorbidity. About 25% of patients had a creatinine clearance <30 mL/min. Nearly 50% of patients had atrial fibrillation but only the half was anti-coagulated. b-blockers, angiotensin converting enzyme-inhibitors (ACE-I) or angiotensin receptor blockers (ARB) were prescribed in about two-thirds of the subjects. Echocardiography was performed in 64.1% of patients. BNP or NT-pro BNP was tested in 67% at the hospital admission and in 18.3% at the discharge. At the discharge 50.1% of patients had loss of autonomy, 57% a polypharmacy prescription (≥8 classes of medicines) and 21.2% needed domiciliary oxygen therapy, but despite these critical points only 8% of the patients were transferred to long-term/intermediate care settings. In conclusion, the main characteristics of patients with HF admitted to IMD in Tuscany are the advanced age (the patients are old and very old) and the presence of multiple comorbidities (HF alone is a rarity indeed). The use of echocardiography and the pharmacological therapy with ACE-I, ARB, β-blocker and anti-aldosterone agents is wider than previous surveys, but some diagnostic, therapeutic and prognostic aspects are not similar to that recommended by the most recent HF guidelines. This survey underscores again some differences between HF trials world and HF real world, where the management is probably also driven by a clinical holistic approach. [ABSTRACT FROM AUTHOR]

Summary: Introduction: Critical limb ischemia (CLI) is a clinical entity that is not well known to patients or the mass media, and it often receives inadequate attention by medical specialists as well. In most cases, patients with CLI already have advanced disease when they are first seen by physicians, and they frequently arrive on internal medicine wards without having received appropriate treatment. The numerous comorbidities that characterize these cases really require multidisciplinary management. Materials and methods: We sent multiple-choice questionnaires to 26 internal medicine units in hospitals located in the Tuscany region of Italy to learn more about the true incidence and impact of CLI. Results: As expected, in most wards, there is no specific, structured clinical protocols for effective management of CLI patients. Discussion: We analyze the current situation and propose a multidisciplinary network for structured, integrated management of CLI. The network would operate throughout the region and be composed of internist-angiologists and vascular surgeons with greater awareness of CLI and experience in its management. This initiative, if effectively implemented, will help increase awareness of this condition and the fact that CLI patients are suffering from what is unacceptably an “orphan” illness. [Copyright &y& Elsevier]

Few data are available on the validity of "Sepsis-3" criteria in identifying patients with sepsis in internal medicine wards (IMWs). Real-life data about this topic and on the prevalence of sepsis in IMWs could be useful for improving hospital organization. To assess the validity of "Sepsis-3" criteria in identifying patients with community-onset sepsis in IMWs. Secondary objectives: to evaluate the prevalence of these patients in IMWs and to compare "Sepsis-3" and "Sepsis-1" criteria. Multicenter, prospective, observational, cohort study, carried out in 22 IMWs of Tuscany (Italy). All patients admitted to each of the study centers over a period of 21-31 days were evaluated within 48 hours; those with clinical signs of infection were enrolled. The main outcome was in-hospital mortality. 2,839 patients were evaluated and 938 (33%) met the inclusion criteria. Patients with sepsis diagnosed according to "Sepsis-3" were 522, representing 55.6% of patients with infection and 18.4% of all patients hospitalized; they were older than those without sepsis (79.4±12.5 vs 74.6±15.2 years, p<0.001). In-hospital mortality was significantly higher in patients with sepsis compared to others (13.8% vs 4.6%; p<0.001). "Sepsis-3" criteria showed greater predictive validity for in-hospital mortality than "Sepsis-1" criteria (AUROC=0.71; 95%CI, 0.66-0.77 vs 0.60; 95%CI 0.54-0.66; p=0.0038). "Sepsis-3" criteria are able to identify patients with community-onset sepsis in IMWs, whose prevalence and in-hospital mortality are remarkably high. Medical departments should adapt their organization to the needs for care of these complex patients. [ABSTRACT FROM AUTHOR]