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Teresa Cardoso

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University of Oxford

Armando Marques-Guedes

UNL - New University of Lisbon

Birla Institute of Technology, Mesra (Ranchi) India

Sanjaya Shankar Tripathy

Birla Institute of Technology, Mesra (Ranchi) India

Pierfrancesco Lombardo

Università degli Studi "La Sapienza" di Roma

Harvard University

Fazal A Talukdar

National Institute of Technology Silchar

José Sebastião dos Santos

Universidade de São Paulo

Shobha Sundar Ram

Indraprastha Institute of Information Technology(IIIT), Delhi

Pontificia Universidad Catolica de Chile

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Papers by Teresa Cardoso

Community-Acquired Severe Sepsis: A Prospective Cohort Study

Open Journal of Internal Medicine, 2015

Severe sepsis (SS) is one of the principal causes of admission in intensive care units (ICU), wit... more Severe sepsis (SS) is one of the principal causes of admission in intensive care units (ICU), with an associated high morbidity and mortality. This study intends to characterize epidemiology of community-acquired SS (CASS) with special emphasis in the prevalence of multidrug resistant organisms and independent prognostic factors associated with ICU mortality. Methods: A prospective cohort study was conducted over 3.5 years, including all consecutive adult patients with CASS admitted to a mixed ICU, in a 600-bed university-affiliated hospital. Results: 1221 patients were admitted into the ICU, 25% with CASS. The mean age was 59 years and the mean SAPS (simplified acute physiological score) was II 48. Most had septic shock (67%). Respiratory (57%), intra-abdominal (22%) and urinary tract (8%) infections were the main sources of infection. The overall isolation rate was 56%. The most common identified microorganisms were Streptococcus pneumoniae (27%), Escherichia coli (22%), Staphylococcus aureus methicillin sensitive (8%) and Haemophilus influenzae (7%). The median ICU and hospital length of stay were 8 and 16 days, respectively. The ICU mortality rate was 33. Independent risk factors associated with higher mortality were older age, higher SAPS II, septic shock and chronic hepatic disease. Female gender was independently associated with lower mortality. The type of microorganism was not significantly associated with prognosis. Conclusion: CASS was highly prevalent among ICU admissions. Independent risk factors associated with ICU mortality included older age and previous comorbidities, but mainly severity of acute illness reinforcing the need for early recognition and treatment. Multidrug resistant organisms were implicated in considerable proportion of community-acquired sepsis.

Intra-abdominal infections: the role of different classifications on the selection of the best antibiotic treatment

Research Square (Research Square), Sep 26, 2019

Background: Intra-abdominal infections (IAIs) represent a serious cause of morbimortality. A full... more Background: Intra-abdominal infections (IAIs) represent a serious cause of morbimortality. A full classi cation, including all facets of IAIs, does not exist. Two classi cations are used to subdivide IAIs: uncomplicated or complicated, considering infection extent; and community-acquired, healthcareassociated or hospital-acquired, regarding the place of acquisition. Inadequate antibiotic therapy is associated with treatment failure and increased mortality. This study was designed to determine accuracy of different classi cations of IAIs to identify infections by pathogens sensitive to current treatment guidelines helping the selection of the best antibiotic therapy. Methods: A retrospective cohort study including all adult patients discharged from hospital with a diagnosis of IAI between 1st of January and 31st of October 2016. All variables potentially associated with pre-de ned outcomes: infection by a pathogen sensitive to non-pseudomonal cephalosporin or cipro oxacin plus metronidazole (ATB 1, primary outcome), sensitive to piperacillin-tazobactam (ATB 2) and hospital mortality (secondary outcomes) were studied through logistic regression. Accuracy of the models was assessed by area under receiver operating characteristics (AUROC) curve and calibration was tested using the Hosmer-Lemeshow goodness-of-t test. Results: Of 1804 patients screened 154 met inclusion criteria. Sensitivity to ATB 1 was independently associated with male gender (adjusted OR=2.612) and previous invasive procedures in the last year (adjusted OR=0.424) (AUROC curve=0,65). Sensitivity to ATB 2 was independently associated with liver disease (adjusted OR=3.580) and post-operative infections (adjusted OR=2.944) (AUROC curve=0.604). Hospital mortality was independently associated with age≥70 (adjusted OR=4.677), solid tumour (adjusted OR=3.127) and sensitivity to non-pseudomonal cephalosporin or cipro oxacin plus metronidazole (adjusted OR=0.368). The accuracy of pre-existing classi cations to identify infection by a pathogen sensitive to ATB 1 was 0.59 considering place of acquisition, 0.61 infection extent and 0.57 local of infection, for ATB 2 it was 0.66, 0.50 and 0.57, respectively. Conclusion: None of existing classi cations had a good discriminating power to identify IAIs caused by pathogens sensitive to current antibiotic treatment recommendations. A new classi cation, including patients' individual characteristics like those included in the current model, might have a higher potential to distinguish IAIs by resistant pathogens allowing a better choice of empiric antibiotic therapy.

The Accuracy of Saps Ii and Sofa Score to Predict Mortality in Immunosuppressed Patients Admitted in Intensive Care

Intensive Care Medicine Experimental, Oct 1, 2015

Immunossupressed patients admitted into intensive care with infection: risk factors for infection by multidrug resistant pathogens and hospital mortality

Intensive Care Medicine Experimental, Oct 1, 2015

Epidemiology of community-acquired bacteremia patients admitted to the intensive care unit

Critical Care, 2007

Background The pathogenesis of endotoxemic tubular dysfunction with failure in urine concentratio... more Background The pathogenesis of endotoxemic tubular dysfunction with failure in urine concentration is poorly understood. Urea plays an important role in the urinary concentrating mechanism and expression of the urea transporters UT-A1, UT-A2, UT-A3, UT-A4 and UT-B is essential for tubular urea reabsorption. The present study attempts to assess the regulation of renal urea transporters during severe inflammation in vivo. Materials and methods By agreement of the animal protection committee C57BL/6J, mice were injected with lipopolysaccharides (LPS, 10 mg/kg) or proinflammatory cytokines. Hemodynamic, renal parameters and the expression of renal urea transporters were investigated. To clarify the role of cytokines and renal ischemia in the regulation of renal urea transporters, experiments S2

Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

Annals of Intensive Care, 2021

Background Stratifying patients with sepsis was the basis of the predisposition, infection, respo... more Background Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important. Methods Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included. Results There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24%...

Donor-derived fatal hyperinfection strongyloidiasis in renal transplant recipient

IDCases, 2020

Strongyloides stercoralis is a nematode, endemic in tropical and subtropical areas. Strongyloidia... more Strongyloides stercoralis is a nematode, endemic in tropical and subtropical areas. Strongyloidiasis has been reported in recipients of hematopoietic stem cells, kidney, liver, heart, intestine, and pancreas, eventually presenting as disseminated strongyloidiasis and hyperinfection syndrome (SHS) which is associated with high mortality. We report one case of a recent renal transplant recipient, who presented with gastrointestinal and respiratory symptoms, evolving into shock. The identification of Strongyloides stercoralis in the bronchoalveolar lavage (BAL) lead us to the diagnosis of SHS. Treatment with subcutaneous ivermectin was started, however the patient did not survive. Retrospective serum donor analysis allowed us to identify the donor as the source of infection.

Reply to: Long-term psychological outcome after discharge from intensive care

Revista Brasileira de Terapia Intensiva, 2019

We have read the letter sent by Dr. Fernanda Lima-Setta el al. (1) with great interest and very c... more We have read the letter sent by Dr. Fernanda Lima-Setta el al. (1) with great interest and very carefully, and we thank you in advance for your consideration. We agree that the importance of posthospitalization syndrome in intensive care is undeniable and that the article "Long-term psychological outcomes after discharge from intensive care" represents a pilot study, which will be further developed in the future and in which we intend to increase the sample size and draw solid conclusions. (2) Considering the previously described limitations of this study, we do not intend to lead professionals to change their decisions or to interfere with clinical practice. Our intent is to draw the attention of the community working in intensive care medicine to the relevance of this topic and to its consequences. Fortunately, medicine has evolved to recognize the patient at risk and prevent disease, and it is also important to follow this path with regard to this syndrome. The chosen methodology included the study of the probability of developing cognitive deficit, whether or not each of the chosen variables was present, by simple logistic regression; thus, the odds ratio in table 3 (3) is crude and not adjusted. As Lima-Setta et al. (1) have emphasized, considering the limited number of patients, progression of the study with multivariate logistic regression would not be adequate. Limitations of the study were clearly described in the article, drawing attention to the limited number of patients included and to the absence of evaluation of the functional, cognitive and psychological status prior to admission and discharge from the intensive care unit, which would allow assessing the impact of hospitalization in a more objective manner. Loss to follow-up is a limitation that was partially overcome by the lack of significant differences between the two groups with regard to demographic and clinical data. As mentioned in the discussion, the association found between hypoxia and a lower cognitive impact contradicted the known pathophysiology. The possible explanation is that patients who suffered more hypoxia belonged to a younger group, with lower comorbidities. Being young and having lower comorbidities are protective factors against cognitive decline, not hypoxia, and these two factors explain the difference found. The most relevant result of our study was the finding that throughout the five years after discharge from the intensive care unit, there was a progressive Resposta para: Desfechos psicológicos em longo prazo após alta da terapia intensiva

Microbiology of healthcare-associated infections and the definition accuracy to predict infection by potentially drug resistant pathogens: a systematic review

BMC Infectious Diseases, 2015

Background: Healthcare-associated infections (HCAI) represent up to 50 % of all infections among ... more Background: Healthcare-associated infections (HCAI) represent up to 50 % of all infections among patients admitted from the community. The current review intends to provide a systematic review on the microbiological profile involved in HCAI, to compare it with community-acquired (CAI) and hospital-acquired infections (HAI) and to evaluate the definition accuracy to predict infection by potentially drug resistant pathogens. Methods: We search for HCAI in MEDLINE, SCOPUS and ISI Web of Knowledge with no limitations in regards to publication language, date of publication, study design or study quality. Only studies using the definition by Friedman et al. were included. This review was registered at PROSPERO Systematic Review Registration with the Number CRD42014013648. Results: A total of 21 eligible studies with 12,096 infected patients were reviewed; of these 3497 had HCAI, 2723 were microbiologically documented. Twelve studies were on pneumonia involving 1051 patients with microbiological documented HCAI, the application of the current guidelines for this group of patients would result in an appropriate antibiotic therapy in 95 % of cases at the expense of overtreatment in 73 %; the application of community-acquired pneumonia guidelines would be adequate in only 73-76 % of the cases; an alternative regimen with piperacillin-tazobactam or aztreonam plus azithromycin would increase antibiotic adequacy rate to 90 %. Few studies were found on additional focus of infection: endocarditis, urinary, intra-abdominal and bloodstream infections. All studies included in this review showed an association of the HCAI definition with infection by PDR pathogens when compared to CAI [odds ratio (OR) 4.05, 95 % confidence interval (95 % CI) 2.60-6.31)]. The sensitivity of HCAI to predict infection by a PDR pathogen was 0.69 (0.65-0.72), specificity was 0.67 (0.66-0.68), positive likelihood ratio was 1.9 and the area under the summary ROC curve was 0.71. Conclusions: This systematic review provides evidence that HCAI represents a separate group of infections in terms of the microbiology profile, including a significant association with infection by PDR pathogens, for the main focus of infection. The results provided can help clinician in the selection of empiric antibiotic therapy and international societies in the development of specific treatment recommendations.

Adult intensive-care patients with 2009 pandemic influenza A(H1N1) infection

Epidemiology and Infection, 2010

SUMMARYIn France, the surveillance of hospitalized cases of pandemic influenza was implemented in... more SUMMARYIn France, the surveillance of hospitalized cases of pandemic influenza was implemented in July 2009 and restricted to intensive-care unit (ICU) patients in November. We described the characteristics of the 1065 adult patients admitted to ICUs and analysed risk factors for severe outcome (mechanical ventilation or death). Eighty-seven percent of cases were aged 15–64 years. The case-fatality ratio was 20%. The risk for severe outcome increased with age and obesity while this association was negative for chronic respiratory disease. Late antiviral therapy was associated with a severe outcome in ICU patients with risk factors (adjusted OR 2·0, 95% CI 1·4–3·0). This study confirms the considerable contribution of young adults to A(H1N1) 2009 mortality. It shows the role of obesity as an independent risk factor for severe disease, and of early antiviral therapy as a protective factor, at least in patients with risk factors.

Predisposition, Insult/Infection, Response and Organ Dysfunction (PIRO): A Pilot Clinical Staging System for Hospital Mortality in Patients with Infection

PLOS ONE, Jul 24, 2013

Purpose: To develop a clinical staging system based on the PIRO concept (Predisposition, Infectio... more Purpose: To develop a clinical staging system based on the PIRO concept (Predisposition, Infection, Response and Organ dysfunction) for hospitalized patients with infection. Methods: One year prospective cohort study of all hospitalized patients with infection (n = 1035), admitted into a large tertiary care, university hospital. Variables associated with hospital mortality were selected using logistic regressions. Based on the regression coefficients, a score for each PIRO component was developed and a classification tree was used to stratify patients into four stages of increased risk of hospital mortality. The final clinical staging system was then validated using an independent cohort (n = 186). Results: Factors significantly associated with hospital mortality were N for Predisposition: age, sex, previous antibiotic therapy, chronic hepatic disease, chronic hematologic disease, cancer, atherosclerosis and a Karnofsky index,70; N for Insult/Infection: type of infection N for Response: abnormal temperature, tachypnea, hyperglycemia and severity of infection and N for Organ dysfunction: hypotension and SOFA score$1. The area under the ROC curve (CI 95%) for the combined PIRO model as a predictor for mortality was 0.85 (0.82-0.88). Based on the scores for each of the PIRO components and on the cutoffs estimated from the classification tree, patients were stratified into four stages of increased mortality rates: stage I: #5%, stage II: 6-20%, stage III: 21-50% and stage IV: .50%. Finally, this new clinical staging system was studied in a validation cohort, which provided similar results (0%, 9%, 31% and 67%, in each stage, respectively). Conclusions: Based on the PIRO concept, a new clinical staging system was developed for hospitalized patients with infection, allowing stratification into four stages of increased mortality, using the different scores obtained in Predisposition, Response, Infection and Organ dysfunction. The proposed system will likely help to define inclusion criteria in clinical trials as well as tailoring individual management plans for patients with infection.

A model to identify patients from the community with infection by pathogens not covered by the guidelines

Intra-abdominal infections: the role of different classifications on the selection of the best antibiotic treatment

Background Intra-abdominal infections (IAIs) represent a most frequent gastrointestinal emergency... more Background Intra-abdominal infections (IAIs) represent a most frequent gastrointestinal emergency and serious cause of morbimortality. A full classification including all facets of IAIs does not exist. Two classifications are used to subdivide IAIs: uncomplicated or complicated, considering infection extent; and community-acquired, healthcare-associated or hospital-acquired, regarding place of acquisition. Adequacy of initial empirical antibiotic therapy prescribed is an essential need. Inadequate antibiotic therapy is associated with treatment failure and increased mortality. This study was designed to determine accuracy of different classifications of IAIs to identify infections by pathogens sensitive to current treatment guidelines helping in selection of best antibiotic therapy. Methods Retrospective cohort study including all adult patients discharged from hospital with diagnosis of IAI between 1st of January and 31st of October, 2016. All variables potentially associated with ...

Anaphylactic Reactions in the Emergency Department of a Portuguese Tertiary Hospital: Clinical Characterization and Disease Notification

Acta Médica Portuguesa

Introduction: Anaphylaxis is significantly underdiagnosed, and the medical community’s knowledge ... more Introduction: Anaphylaxis is significantly underdiagnosed, and the medical community’s knowledge about it is precarious. The aim of this study is to characterize the patient population and the Emergency Department approach of anaphylaxis.Material and Methods: Retrospective study of adult patients attending the Emergency Department of a tertiary care Portuguese hospital, over a year, with anaphylaxis. Data were obtained from each patient’s clinical records and anonymized. A questionnaire evaluating knowledge about the notification of anaphylaxis was applied to Emergency Department physicians.Results: The study included 69 patients. Cutaneous (97%) and respiratory features (80%) were most prevalent; 22% of patients presented with shock or related symptoms. There were no reported biphasic reactions or deaths. The likely allergen was identified in 73%, most commonly food; 12% of reactions were related to a previously known allergen. Epinephrine was administered to 15%. Referral to an Im...

Long-term psychological outcome after discharge from intensive care

Revista Brasileira de terapia intensiva, 2018

To investigate the longterm psychological outcome in survivors of critical illness after intensiv... more To investigate the longterm psychological outcome in survivors of critical illness after intensive care unit discharge. A prospective cohort of survivors admitted to a mixed intensive care unit between January and September 2010 was evaluated six months and five years after hospital discharge. The Dementia Rating Scale-2, the Hospital Anxiety and Depression Scale, the Posttraumatic stress syndrome 14-questions inventory, the Euro Quality of Life 5 Dimensions (EQ-5-D), and the Visual Analogue Scale (EQ VAS) were assessed at both follow-up periods. Of 267 patients, 25 patients were evaluated at 6 months after discharge (62 ± 16 years); 12 (48%) presented cognitive impairment, 6 (24%) anxiety, 4 (16%) depression, and 4 (16%) post-traumatic stress disorder. Among those re-evaluated five years after discharge (n = 17; 65 ± 15 years), the frequency of cognitive impairment dropped from 8 (47%) to 3 (18%) (p = 0.063), due to improvement in these patients over time, and other patients did no...

Which algorithm diagnoses invasive pulmonary aspergillosis best in ICU patients with COPD?

The European respiratory journal, Sep 1, 2017

Which algorithm diagnoses invasive pulmonary aspergillosis best in ICU patients with COPD? To the... more Which algorithm diagnoses invasive pulmonary aspergillosis best in ICU patients with COPD? To the Editor: Invasive pulmonary aspergillosis (IPA) is a potentially lethal opportunistic infection, mainly affecting immunocompromised patients, particularly those with prolonged neutropenia [1]. Several reports have shown that Aspergillus spp. can also cause IPA in patients with a priori less severe immune dysfunction, such as those in intensive care units (ICUs) [2-5] or with chronic obstructive pulmonary disease (COPD) [5-8]. In these patients, diagnosis of IPA remains a challenge, because the reference diagnostic criteria (defined by the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG)) were developed for research in high-risk patients and not specifically for patients in the ICU or patients with COPD [9]. Two alternative algorithms have been proposed for this setting: the COPD algorithm for patients with COPD [6] and the Clinical algorithm for patients in the ICU [10]. We compared the three algorithms to evaluate which of them is the most accurate for classifying critically ill patients with COPD and Aspergillus-positive cultures. This study was part of the AspICU project [11], focusing on patients with COPD and Aspergillus-positive lower airway cultures. Collected data included demographics, clinical features, cultures, radiological findings (suggestive of IPA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage [12]. Using the COPD [6], Clinical [10] and EORTC/MSG [9] algorithms, patients were classified as having proven IPA, putative/probable IPA or colonisation. None of the patients could be classified as having "possible" IPA (as defined by the COPD and EORTC/MSG algorithms) because this requires negative cultures and all the patients in AspICU had at least one positive culture.

Predicting hospital mortality: comparing accuracy of SAPS II score and clinical staff prognosis

F1000posters, May 2, 2012

Purpura: an unusual presentation of HAV infection

Journal of Clinical Gastroenterology, May 1, 1994

Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... An abstract is unavailable. This article is ...

Medical Emergency Team: How do we play when we stay? Characterization of MET actions at the scene

Scandinavian journal of trauma, resuscitation and emergency medicine, Jan 22, 2016

The creation, implementation and effectiveness of a medical emergency team (MET) in every hospita... more The creation, implementation and effectiveness of a medical emergency team (MET) in every hospital is encourage and supported by international bodies of quality certification. Issues such as what is the best composition of the team or the interventions performed by the MET at the scene and the immediate outcomes of the patients after MET intervention have not yet been sufficiently explored. The purpose of the study is to characterize MET actions at the scene and the immediate patient outcome. Retrospective cohort study, at a tertiary care, university-affiliated, 600-bed hospital, in the north of Portugal, over two years. There were 511 MET activations: 389 (76 %) were for inpatients. MET activation rate was 8.6/1,000 inpatients. The main criteria for activation were airway threatening in 143 (36.8 %), concern of medical staff in 121 (31.1 %) and decrease in GCS > 2 in 98 (25.2 %) patients; MET calls for cardiac arrest occurred in 68 patients (17.5 %). The median (IQR) time the te...

P0753 Septic Shock in a Hiv Patient with Infection by Mycobacterium Tuberculosis

Eur J Intern Med, 2009

89,7% received antifungical therapy, as in the other cases diagnosis was done post-mortem. 66,7% ... more 89,7% received antifungical therapy, as in the other cases diagnosis was done post-mortem. 66,7% of those treated receives anfotericine, 23,9% voriconazole, 35,9% caspofungine, 23,1% itraconazole and 46,2% a combination of antifungicals. Medium time rate passed from the clinical onset to the diagnosis was 11,88± 24,99 days and therapy had a medium time rate of 16,31±16,31 days. Mortality was 84,6% and there was no difference in epidemiological and clinical factors or therapy used but in those who received combinated antifungical treatment, illness developed slowlier. Conclusions: Recognising those factors commonly associated to IPA should help us to prevent this increasing illness and to starting therapy as quick as possible as this is the most effective attitude to treat this disease. Voriconazol is nowadays the election for treatment but as mortality is still high, an antifungical combinated treatment could have interesting achieves as first line therapy

Community-Acquired Severe Sepsis: A Prospective Cohort Study

Open Journal of Internal Medicine, 2015

Severe sepsis (SS) is one of the principal causes of admission in intensive care units (ICU), wit... more Severe sepsis (SS) is one of the principal causes of admission in intensive care units (ICU), with an associated high morbidity and mortality. This study intends to characterize epidemiology of community-acquired SS (CASS) with special emphasis in the prevalence of multidrug resistant organisms and independent prognostic factors associated with ICU mortality. Methods: A prospective cohort study was conducted over 3.5 years, including all consecutive adult patients with CASS admitted to a mixed ICU, in a 600-bed university-affiliated hospital. Results: 1221 patients were admitted into the ICU, 25% with CASS. The mean age was 59 years and the mean SAPS (simplified acute physiological score) was II 48. Most had septic shock (67%). Respiratory (57%), intra-abdominal (22%) and urinary tract (8%) infections were the main sources of infection. The overall isolation rate was 56%. The most common identified microorganisms were Streptococcus pneumoniae (27%), Escherichia coli (22%), Staphylococcus aureus methicillin sensitive (8%) and Haemophilus influenzae (7%). The median ICU and hospital length of stay were 8 and 16 days, respectively. The ICU mortality rate was 33. Independent risk factors associated with higher mortality were older age, higher SAPS II, septic shock and chronic hepatic disease. Female gender was independently associated with lower mortality. The type of microorganism was not significantly associated with prognosis. Conclusion: CASS was highly prevalent among ICU admissions. Independent risk factors associated with ICU mortality included older age and previous comorbidities, but mainly severity of acute illness reinforcing the need for early recognition and treatment. Multidrug resistant organisms were implicated in considerable proportion of community-acquired sepsis.

Intra-abdominal infections: the role of different classifications on the selection of the best antibiotic treatment

Research Square (Research Square), Sep 26, 2019

Background: Intra-abdominal infections (IAIs) represent a serious cause of morbimortality. A full... more Background: Intra-abdominal infections (IAIs) represent a serious cause of morbimortality. A full classi cation, including all facets of IAIs, does not exist. Two classi cations are used to subdivide IAIs: uncomplicated or complicated, considering infection extent; and community-acquired, healthcareassociated or hospital-acquired, regarding the place of acquisition. Inadequate antibiotic therapy is associated with treatment failure and increased mortality. This study was designed to determine accuracy of different classi cations of IAIs to identify infections by pathogens sensitive to current treatment guidelines helping the selection of the best antibiotic therapy. Methods: A retrospective cohort study including all adult patients discharged from hospital with a diagnosis of IAI between 1st of January and 31st of October 2016. All variables potentially associated with pre-de ned outcomes: infection by a pathogen sensitive to non-pseudomonal cephalosporin or cipro oxacin plus metronidazole (ATB 1, primary outcome), sensitive to piperacillin-tazobactam (ATB 2) and hospital mortality (secondary outcomes) were studied through logistic regression. Accuracy of the models was assessed by area under receiver operating characteristics (AUROC) curve and calibration was tested using the Hosmer-Lemeshow goodness-of-t test. Results: Of 1804 patients screened 154 met inclusion criteria. Sensitivity to ATB 1 was independently associated with male gender (adjusted OR=2.612) and previous invasive procedures in the last year (adjusted OR=0.424) (AUROC curve=0,65). Sensitivity to ATB 2 was independently associated with liver disease (adjusted OR=3.580) and post-operative infections (adjusted OR=2.944) (AUROC curve=0.604). Hospital mortality was independently associated with age≥70 (adjusted OR=4.677), solid tumour (adjusted OR=3.127) and sensitivity to non-pseudomonal cephalosporin or cipro oxacin plus metronidazole (adjusted OR=0.368). The accuracy of pre-existing classi cations to identify infection by a pathogen sensitive to ATB 1 was 0.59 considering place of acquisition, 0.61 infection extent and 0.57 local of infection, for ATB 2 it was 0.66, 0.50 and 0.57, respectively. Conclusion: None of existing classi cations had a good discriminating power to identify IAIs caused by pathogens sensitive to current antibiotic treatment recommendations. A new classi cation, including patients' individual characteristics like those included in the current model, might have a higher potential to distinguish IAIs by resistant pathogens allowing a better choice of empiric antibiotic therapy.

The Accuracy of Saps Ii and Sofa Score to Predict Mortality in Immunosuppressed Patients Admitted in Intensive Care

Intensive Care Medicine Experimental, Oct 1, 2015

Immunossupressed patients admitted into intensive care with infection: risk factors for infection by multidrug resistant pathogens and hospital mortality

Intensive Care Medicine Experimental, Oct 1, 2015

Epidemiology of community-acquired bacteremia patients admitted to the intensive care unit

Critical Care, 2007

Background The pathogenesis of endotoxemic tubular dysfunction with failure in urine concentratio... more Background The pathogenesis of endotoxemic tubular dysfunction with failure in urine concentration is poorly understood. Urea plays an important role in the urinary concentrating mechanism and expression of the urea transporters UT-A1, UT-A2, UT-A3, UT-A4 and UT-B is essential for tubular urea reabsorption. The present study attempts to assess the regulation of renal urea transporters during severe inflammation in vivo. Materials and methods By agreement of the animal protection committee C57BL/6J, mice were injected with lipopolysaccharides (LPS, 10 mg/kg) or proinflammatory cytokines. Hemodynamic, renal parameters and the expression of renal urea transporters were investigated. To clarify the role of cytokines and renal ischemia in the regulation of renal urea transporters, experiments S2

Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

Annals of Intensive Care, 2021

Background Stratifying patients with sepsis was the basis of the predisposition, infection, respo... more Background Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important. Methods Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included. Results There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24%...

Donor-derived fatal hyperinfection strongyloidiasis in renal transplant recipient

IDCases, 2020

Strongyloides stercoralis is a nematode, endemic in tropical and subtropical areas. Strongyloidia... more Strongyloides stercoralis is a nematode, endemic in tropical and subtropical areas. Strongyloidiasis has been reported in recipients of hematopoietic stem cells, kidney, liver, heart, intestine, and pancreas, eventually presenting as disseminated strongyloidiasis and hyperinfection syndrome (SHS) which is associated with high mortality. We report one case of a recent renal transplant recipient, who presented with gastrointestinal and respiratory symptoms, evolving into shock. The identification of Strongyloides stercoralis in the bronchoalveolar lavage (BAL) lead us to the diagnosis of SHS. Treatment with subcutaneous ivermectin was started, however the patient did not survive. Retrospective serum donor analysis allowed us to identify the donor as the source of infection.

Reply to: Long-term psychological outcome after discharge from intensive care

Revista Brasileira de Terapia Intensiva, 2019

We have read the letter sent by Dr. Fernanda Lima-Setta el al. (1) with great interest and very c... more We have read the letter sent by Dr. Fernanda Lima-Setta el al. (1) with great interest and very carefully, and we thank you in advance for your consideration. We agree that the importance of posthospitalization syndrome in intensive care is undeniable and that the article "Long-term psychological outcomes after discharge from intensive care" represents a pilot study, which will be further developed in the future and in which we intend to increase the sample size and draw solid conclusions. (2) Considering the previously described limitations of this study, we do not intend to lead professionals to change their decisions or to interfere with clinical practice. Our intent is to draw the attention of the community working in intensive care medicine to the relevance of this topic and to its consequences. Fortunately, medicine has evolved to recognize the patient at risk and prevent disease, and it is also important to follow this path with regard to this syndrome. The chosen methodology included the study of the probability of developing cognitive deficit, whether or not each of the chosen variables was present, by simple logistic regression; thus, the odds ratio in table 3 (3) is crude and not adjusted. As Lima-Setta et al. (1) have emphasized, considering the limited number of patients, progression of the study with multivariate logistic regression would not be adequate. Limitations of the study were clearly described in the article, drawing attention to the limited number of patients included and to the absence of evaluation of the functional, cognitive and psychological status prior to admission and discharge from the intensive care unit, which would allow assessing the impact of hospitalization in a more objective manner. Loss to follow-up is a limitation that was partially overcome by the lack of significant differences between the two groups with regard to demographic and clinical data. As mentioned in the discussion, the association found between hypoxia and a lower cognitive impact contradicted the known pathophysiology. The possible explanation is that patients who suffered more hypoxia belonged to a younger group, with lower comorbidities. Being young and having lower comorbidities are protective factors against cognitive decline, not hypoxia, and these two factors explain the difference found. The most relevant result of our study was the finding that throughout the five years after discharge from the intensive care unit, there was a progressive Resposta para: Desfechos psicológicos em longo prazo após alta da terapia intensiva

Microbiology of healthcare-associated infections and the definition accuracy to predict infection by potentially drug resistant pathogens: a systematic review

BMC Infectious Diseases, 2015

Background: Healthcare-associated infections (HCAI) represent up to 50 % of all infections among ... more Background: Healthcare-associated infections (HCAI) represent up to 50 % of all infections among patients admitted from the community. The current review intends to provide a systematic review on the microbiological profile involved in HCAI, to compare it with community-acquired (CAI) and hospital-acquired infections (HAI) and to evaluate the definition accuracy to predict infection by potentially drug resistant pathogens. Methods: We search for HCAI in MEDLINE, SCOPUS and ISI Web of Knowledge with no limitations in regards to publication language, date of publication, study design or study quality. Only studies using the definition by Friedman et al. were included. This review was registered at PROSPERO Systematic Review Registration with the Number CRD42014013648. Results: A total of 21 eligible studies with 12,096 infected patients were reviewed; of these 3497 had HCAI, 2723 were microbiologically documented. Twelve studies were on pneumonia involving 1051 patients with microbiological documented HCAI, the application of the current guidelines for this group of patients would result in an appropriate antibiotic therapy in 95 % of cases at the expense of overtreatment in 73 %; the application of community-acquired pneumonia guidelines would be adequate in only 73-76 % of the cases; an alternative regimen with piperacillin-tazobactam or aztreonam plus azithromycin would increase antibiotic adequacy rate to 90 %. Few studies were found on additional focus of infection: endocarditis, urinary, intra-abdominal and bloodstream infections. All studies included in this review showed an association of the HCAI definition with infection by PDR pathogens when compared to CAI [odds ratio (OR) 4.05, 95 % confidence interval (95 % CI) 2.60-6.31)]. The sensitivity of HCAI to predict infection by a PDR pathogen was 0.69 (0.65-0.72), specificity was 0.67 (0.66-0.68), positive likelihood ratio was 1.9 and the area under the summary ROC curve was 0.71. Conclusions: This systematic review provides evidence that HCAI represents a separate group of infections in terms of the microbiology profile, including a significant association with infection by PDR pathogens, for the main focus of infection. The results provided can help clinician in the selection of empiric antibiotic therapy and international societies in the development of specific treatment recommendations.

Adult intensive-care patients with 2009 pandemic influenza A(H1N1) infection

Epidemiology and Infection, 2010

SUMMARYIn France, the surveillance of hospitalized cases of pandemic influenza was implemented in... more SUMMARYIn France, the surveillance of hospitalized cases of pandemic influenza was implemented in July 2009 and restricted to intensive-care unit (ICU) patients in November. We described the characteristics of the 1065 adult patients admitted to ICUs and analysed risk factors for severe outcome (mechanical ventilation or death). Eighty-seven percent of cases were aged 15–64 years. The case-fatality ratio was 20%. The risk for severe outcome increased with age and obesity while this association was negative for chronic respiratory disease. Late antiviral therapy was associated with a severe outcome in ICU patients with risk factors (adjusted OR 2·0, 95% CI 1·4–3·0). This study confirms the considerable contribution of young adults to A(H1N1) 2009 mortality. It shows the role of obesity as an independent risk factor for severe disease, and of early antiviral therapy as a protective factor, at least in patients with risk factors.

Predisposition, Insult/Infection, Response and Organ Dysfunction (PIRO): A Pilot Clinical Staging System for Hospital Mortality in Patients with Infection

PLOS ONE, Jul 24, 2013

Purpose: To develop a clinical staging system based on the PIRO concept (Predisposition, Infectio... more Purpose: To develop a clinical staging system based on the PIRO concept (Predisposition, Infection, Response and Organ dysfunction) for hospitalized patients with infection. Methods: One year prospective cohort study of all hospitalized patients with infection (n = 1035), admitted into a large tertiary care, university hospital. Variables associated with hospital mortality were selected using logistic regressions. Based on the regression coefficients, a score for each PIRO component was developed and a classification tree was used to stratify patients into four stages of increased risk of hospital mortality. The final clinical staging system was then validated using an independent cohort (n = 186). Results: Factors significantly associated with hospital mortality were N for Predisposition: age, sex, previous antibiotic therapy, chronic hepatic disease, chronic hematologic disease, cancer, atherosclerosis and a Karnofsky index,70; N for Insult/Infection: type of infection N for Response: abnormal temperature, tachypnea, hyperglycemia and severity of infection and N for Organ dysfunction: hypotension and SOFA score$1. The area under the ROC curve (CI 95%) for the combined PIRO model as a predictor for mortality was 0.85 (0.82-0.88). Based on the scores for each of the PIRO components and on the cutoffs estimated from the classification tree, patients were stratified into four stages of increased mortality rates: stage I: #5%, stage II: 6-20%, stage III: 21-50% and stage IV: .50%. Finally, this new clinical staging system was studied in a validation cohort, which provided similar results (0%, 9%, 31% and 67%, in each stage, respectively). Conclusions: Based on the PIRO concept, a new clinical staging system was developed for hospitalized patients with infection, allowing stratification into four stages of increased mortality, using the different scores obtained in Predisposition, Response, Infection and Organ dysfunction. The proposed system will likely help to define inclusion criteria in clinical trials as well as tailoring individual management plans for patients with infection.

A model to identify patients from the community with infection by pathogens not covered by the guidelines

Intra-abdominal infections: the role of different classifications on the selection of the best antibiotic treatment

Background Intra-abdominal infections (IAIs) represent a most frequent gastrointestinal emergency... more Background Intra-abdominal infections (IAIs) represent a most frequent gastrointestinal emergency and serious cause of morbimortality. A full classification including all facets of IAIs does not exist. Two classifications are used to subdivide IAIs: uncomplicated or complicated, considering infection extent; and community-acquired, healthcare-associated or hospital-acquired, regarding place of acquisition. Adequacy of initial empirical antibiotic therapy prescribed is an essential need. Inadequate antibiotic therapy is associated with treatment failure and increased mortality. This study was designed to determine accuracy of different classifications of IAIs to identify infections by pathogens sensitive to current treatment guidelines helping in selection of best antibiotic therapy. Methods Retrospective cohort study including all adult patients discharged from hospital with diagnosis of IAI between 1st of January and 31st of October, 2016. All variables potentially associated with ...

Anaphylactic Reactions in the Emergency Department of a Portuguese Tertiary Hospital: Clinical Characterization and Disease Notification

Acta Médica Portuguesa

Introduction: Anaphylaxis is significantly underdiagnosed, and the medical community’s knowledge ... more Introduction: Anaphylaxis is significantly underdiagnosed, and the medical community’s knowledge about it is precarious. The aim of this study is to characterize the patient population and the Emergency Department approach of anaphylaxis.Material and Methods: Retrospective study of adult patients attending the Emergency Department of a tertiary care Portuguese hospital, over a year, with anaphylaxis. Data were obtained from each patient’s clinical records and anonymized. A questionnaire evaluating knowledge about the notification of anaphylaxis was applied to Emergency Department physicians.Results: The study included 69 patients. Cutaneous (97%) and respiratory features (80%) were most prevalent; 22% of patients presented with shock or related symptoms. There were no reported biphasic reactions or deaths. The likely allergen was identified in 73%, most commonly food; 12% of reactions were related to a previously known allergen. Epinephrine was administered to 15%. Referral to an Im...

Long-term psychological outcome after discharge from intensive care

Revista Brasileira de terapia intensiva, 2018

To investigate the longterm psychological outcome in survivors of critical illness after intensiv... more To investigate the longterm psychological outcome in survivors of critical illness after intensive care unit discharge. A prospective cohort of survivors admitted to a mixed intensive care unit between January and September 2010 was evaluated six months and five years after hospital discharge. The Dementia Rating Scale-2, the Hospital Anxiety and Depression Scale, the Posttraumatic stress syndrome 14-questions inventory, the Euro Quality of Life 5 Dimensions (EQ-5-D), and the Visual Analogue Scale (EQ VAS) were assessed at both follow-up periods. Of 267 patients, 25 patients were evaluated at 6 months after discharge (62 ± 16 years); 12 (48%) presented cognitive impairment, 6 (24%) anxiety, 4 (16%) depression, and 4 (16%) post-traumatic stress disorder. Among those re-evaluated five years after discharge (n = 17; 65 ± 15 years), the frequency of cognitive impairment dropped from 8 (47%) to 3 (18%) (p = 0.063), due to improvement in these patients over time, and other patients did no...

Which algorithm diagnoses invasive pulmonary aspergillosis best in ICU patients with COPD?

The European respiratory journal, Sep 1, 2017

Which algorithm diagnoses invasive pulmonary aspergillosis best in ICU patients with COPD? To the... more Which algorithm diagnoses invasive pulmonary aspergillosis best in ICU patients with COPD? To the Editor: Invasive pulmonary aspergillosis (IPA) is a potentially lethal opportunistic infection, mainly affecting immunocompromised patients, particularly those with prolonged neutropenia [1]. Several reports have shown that Aspergillus spp. can also cause IPA in patients with a priori less severe immune dysfunction, such as those in intensive care units (ICUs) [2-5] or with chronic obstructive pulmonary disease (COPD) [5-8]. In these patients, diagnosis of IPA remains a challenge, because the reference diagnostic criteria (defined by the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG)) were developed for research in high-risk patients and not specifically for patients in the ICU or patients with COPD [9]. Two alternative algorithms have been proposed for this setting: the COPD algorithm for patients with COPD [6] and the Clinical algorithm for patients in the ICU [10]. We compared the three algorithms to evaluate which of them is the most accurate for classifying critically ill patients with COPD and Aspergillus-positive cultures. This study was part of the AspICU project [11], focusing on patients with COPD and Aspergillus-positive lower airway cultures. Collected data included demographics, clinical features, cultures, radiological findings (suggestive of IPA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage [12]. Using the COPD [6], Clinical [10] and EORTC/MSG [9] algorithms, patients were classified as having proven IPA, putative/probable IPA or colonisation. None of the patients could be classified as having "possible" IPA (as defined by the COPD and EORTC/MSG algorithms) because this requires negative cultures and all the patients in AspICU had at least one positive culture.

Predicting hospital mortality: comparing accuracy of SAPS II score and clinical staff prognosis

F1000posters, May 2, 2012

Purpura: an unusual presentation of HAV infection

Journal of Clinical Gastroenterology, May 1, 1994

Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... An abstract is unavailable. This article is ...

Medical Emergency Team: How do we play when we stay? Characterization of MET actions at the scene

Scandinavian journal of trauma, resuscitation and emergency medicine, Jan 22, 2016

The creation, implementation and effectiveness of a medical emergency team (MET) in every hospita... more The creation, implementation and effectiveness of a medical emergency team (MET) in every hospital is encourage and supported by international bodies of quality certification. Issues such as what is the best composition of the team or the interventions performed by the MET at the scene and the immediate outcomes of the patients after MET intervention have not yet been sufficiently explored. The purpose of the study is to characterize MET actions at the scene and the immediate patient outcome. Retrospective cohort study, at a tertiary care, university-affiliated, 600-bed hospital, in the north of Portugal, over two years. There were 511 MET activations: 389 (76 %) were for inpatients. MET activation rate was 8.6/1,000 inpatients. The main criteria for activation were airway threatening in 143 (36.8 %), concern of medical staff in 121 (31.1 %) and decrease in GCS > 2 in 98 (25.2 %) patients; MET calls for cardiac arrest occurred in 68 patients (17.5 %). The median (IQR) time the te...

P0753 Septic Shock in a Hiv Patient with Infection by Mycobacterium Tuberculosis

Eur J Intern Med, 2009

89,7% received antifungical therapy, as in the other cases diagnosis was done post-mortem. 66,7% ... more 89,7% received antifungical therapy, as in the other cases diagnosis was done post-mortem. 66,7% of those treated receives anfotericine, 23,9% voriconazole, 35,9% caspofungine, 23,1% itraconazole and 46,2% a combination of antifungicals. Medium time rate passed from the clinical onset to the diagnosis was 11,88± 24,99 days and therapy had a medium time rate of 16,31±16,31 days. Mortality was 84,6% and there was no difference in epidemiological and clinical factors or therapy used but in those who received combinated antifungical treatment, illness developed slowlier. Conclusions: Recognising those factors commonly associated to IPA should help us to prevent this increasing illness and to starting therapy as quick as possible as this is the most effective attitude to treat this disease. Voriconazol is nowadays the election for treatment but as mortality is still high, an antifungical combinated treatment could have interesting achieves as first line therapy