Coexisting cytomegalovirus infection in immunocompetent patients with Clostridium difficile colitis

AbstractCytomegalovirus (CMV) colitis usually occurs in immunocompromised patients with human immunodeficiency virus infection, organ transplantation, and malignancy receiving chemotherapy or ulcerative colitis receiving immunosuppressive agents. However, CMV colitis is increasingly recognized in immunocompetent hosts. Notably, CMV colitis coexisting with Clostridium difficile infection (CDI) in apparently healthy individuals has been published in recent years, which could result in high morbidity and mortality. CMV colitis is a rare but possible differential diagnosis in immunocompetent patients with abdominal pain, watery, or especially bloody diarrhea, which could be refractory to standard treatment for CDI. As a characteristic of CDI, however, pseudomembranous colitis may be only caused by CMV infection. Real-time CMV-polymerase chain reaction (PCR) for blood and stool samples may be a useful and noninvasive diagnostic strategy to identify CMV infection when treatment of CDI eventually fails to show significant benefits. Quantitative CMV-PCR in mucosal biopsies may increase the diagnostic yield of traditional histopathology. CMV colitis is potentially life-threatening if severe complications occur, such as sepsis secondary to colitis, massive colorectal bleeding, toxic megacolon, and colonic perforation, so that may necessitate pre-emptive antiviral treatment for those who are positive for CMV-PCR in blood and/or stool samples while pending histological diagnosis

Age May Not Influence the Outcome of Patients with Severe Sepsis in Intensive Care Units

Background: This study attempted to determine the association between age and outcome for severe sepsis patients in the intensive care unit (ICU). Methods: From May 2004 through April 2005, we conducted a prospective study of patients with severe sepsis in eight ICUs of Chi-Mei Medical Center. Demographic and clinical information, laboratory results, comorbidities, severity scores, mortality, and lengths of stays for both ICU and hospital were analyzed for older (age ≥ 65 years) and younger adult (age < 65 years) patients. We analyzed the association between age and outcome and the predictors of hospital mortality. Results: Of the 254 patients included, 63.8% were aged ≥65 years. ICU and hospital mortality rates were 50.4% and 55.1%, respectively, for older and younger adult patients. Both groups had similar baseline data, except that the older group had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, different comorbidities (less active cancer and alcoholism, but higher percentage of cerebral vascular accident) and more neurologic organ failure. Older patients also had higher ICU (54.3% vs. 43.5%, p = 0.097) and hospital mortality (58.0% vs. 50.0%, p = 0.216). Multivariate analyses showed the following predictors of hospital mortality: being female, active cancer, septic shock, acute respiratory distress syndrome, hematological failure, APACHE II scores >25, and inadequate drainage of infection site. Age was not a significant predictor for mortality after adjusting for other factors. Conclusion: In this cohort, age was not an important predictor of mortality in ICU patients with severe sepsis. Physicians should consider other risk factors to improve outcomes in these critically ill aged patients

COVID-19 Associated with Cryptococcosis: A New Challenge during the Pandemic

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a great threat to global health. In addition to SARS-CoV-2 itself, clinicians should be alert to the possible occurrence of co-infection or secondary infection among patients with COVID-19. The possible co-pathogens include bacteria, viruses, and fungi, but COVID-19-associated cryptococcosis is rarely reported. This review provided updated and comprehensive information about this rare clinical entity of COVID-19-associated cryptococcosis. Through an updated literature search till 23 August 2022, we identified a total of 18 culture-confirmed case reports with detailed information. Half (n = 9) of them were elderly. Fifteen (83.3%) of them had severe COVID-19 and ever received systemic corticosteroid. Disseminated infection with cryptococcemia was the most common type of cryptococcosis, followed by pulmonary and meningitis. Except one case of C. laurentii, all other cases are by C. neoformans. Liposomal amphotericin B and fluconazole were the most commonly used antifungal agents. The overall mortality was 61.1% (11/18) and four of them did not receive antifungal agents before death. Improving the poor outcome requires a physician&rsquo;s high suspicion, early diagnosis, and prompt treatment

Aspergillosis related to severe influenza: A worldwide phenomenon?

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The Implementation of Sepsis Bundles on the Outcome of Patients with Severe Sepsis or Septic Shock in Intensive Care Units

SummaryBackgroundThe goal of the study was to implement sepsis bundles and examine the effect on patients with severe sepsis or septic shock in intensive care units (ICUs).MethodsAll patients with severe sepsis or septic shock admitted to the 13-bed ICU were included. Sepsis bundles were implemented within 24 hours after admission. The implementation of sepsis bundles was categorized into preintervention (January to April 2010), education (July to October 2010), operational (November to December 2010), and postintervention (January to April 2011) phases. Comparison of bundle compliance and outcome between each phase were examined. We also found mortality predictors between preintervention and postintervention phases.ResultsThere were 164 patients included in the study. Compared with the preintervention phase, the bundle compliance of each phase (education, operation, and postintervention separately) was higher (43.3%, 84.6%, and 79.2%, respectively, vs. 20.0%, p < 0.05), the hospital mortality was lower (10.0%, 23.1%, and 24.5%, respectively, vs. 43.6%, p < 0.05). Under multivariate analyses, the predictors for mortality between the preintervention and postintervention phases were: lactate at ICU (odds ratio [OR] 2.212), urinary tract infection (OR 0.026), and postintervention (OR 0.239).ConclusionImplementation of modified sepsis bundles was successful in changing sepsis treatment behavior and was associated with a substantial reduction in hospital mortality and trends of decreased hospital expenditure. Factors improved hospital mortality, as lower lactate levels at ICU, urinary tract infection, and postintervention. The proposed intervention is generally applicable to achieve similar improvements

Epidemiological Correlation of Pulmonary Aspergillus Infections with Ambient Pollutions and Influenza A (H1N1) in Southern Taiwan

An increase in fungal spores in ambient air is reported during a spike in particulate matter (PM2.5 and PM10) aerosols generated during dust or smog events. However, little is known about the impact of ambient bioaerosols on fungal infections in humans. To identify the correlation between the incidence of pulmonary aspergillosis and PM-associated bioaerosols (PM2.5 and PM10), we retrospectively analyzed data between 2015 and 2018 (first stage) and prospectively analyzed data in 2019 (second stage). Patient data were collected from patients in three medical institutions in Tainan, a city with a population of 1.88 million, located in southern Taiwan. PM data were obtained from the Taiwan Air Quality Monitoring Network. Overall, 544 non-repeated aspergillosis patients (first stage, n = 340; second stage, n = 204) were identified and enrolled for analysis. The trend of aspergillosis significantly increased from 2015 to 2019. Influenza A (H1N1) and ambient PMs (PM2.5 and PM10) levels had significant effects on aspergillosis from 2015 to 2018. However, ambient PMs and influenza A (H1N1) in Tainan were correlated with the occurrence of aspergillosis in 2018 and 2019, respectively. Overall (2015–2019), aspergillosis was significantly correlated with influenza (p = 0.002), influenza A (H1N1) (p &lt; 0.001), and PM2.5 (p = 0.040) in Tainan City. Using a stepwise regression model, influenza A (H1N1) (p &lt; 0.0001) and Tainan PM10 (p = 0.016) could significantly predict the occurrence of aspergillosis in Tainan. PM-related bioaerosols and influenza A (H1N1) contribute to the incidence of pulmonary aspergillosis

Outcomes and Cost Analysis of Patients With Successful In-Hospital Cardiopulmonary Resuscitation

Backgrounds: This study evaluated the outcomes of patients after in-hospital cardiac arrest who were admitted to the intensive care unit (ICU) with successful cardiopulmonary resuscitation (CPR). Methods: Data were extracted from a prospectively maintained database of intubation and mechanical ventilation in a tertiary hospital. Adult patients (age ≥ 18 years) with successful CPR and admitted to the ICU were included for analysis. The characteristics of the patients and the outcomes were analyzed. Results: A total of 313 patients were included from January 1, 2004, to December 31, 2004, with 114 (36.4%) admitted from the emergency department and 199 (63.6%) from the ward. The in-hospital mortality was high (209, 66.8%), with 130 (62.2%) of the patients dying within 24 hours. The nonsurvivors had a significantly higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Therapeutic Intervention Scoring System (TISS) score but a lower Glasgow Coma Scale (GCS), a shorter ICU and hospital stay, shorter mechanical ventilation (MV) hours, and fewer expenses. Patients with early mortality (< 24 hours) had a significantly higher APACHE II score and a greater portion were admitted from the ward. Only 73 (23.3%) were discharged home and 31 (9.9%) were transferred to a chronic care center. Patients who were discharged to chronic care centers were older, had a higher APACHE II score, higher medical expenses, more MV hours, longer ICU and hospital stays, but a lower GCS than those who were discharged home. The mean expense for survivors was about threefold that of nonsurvivors, and patients who were discharged to a chronic care center had the highest mean hospital expense, which was about sixfold of the patients with early mortality. Although survivors comprised 33.3% of the in-hospital cardiac arrest patients with return of spontaneous circulation, they have consumed 60% of the total hospital expenses. Conclusions: Given the fact that less than one quarter of the successfully resuscitated patients have a favorable outcome, two-thirds of the mortality cases died within 24 hours, which is a high cost for successful resuscitation, and one-third of the survivors had to stay on chronic respiratory care center. A better prognostic tool to predict outcomes should be developed to avoid futile resuscitation

Age is an Important Predictor of Failed Unplanned Extubation

Background: Unplanned extubation (UE) is a frequent complication following endotracheal intubation and can increase intensive care unit (ICU) stay and hospital expenditure. We investigated the incidence, outcome, and predictive factors of patients with failed UE (reintubation within 48 hours) in the adult ICU of a medical center in Taiwan. Methods: We reviewed the medical records of patients with UE in ICUs from January 2004 through December 2007. The primary endpoint was factors predicting failed UE, especially in older patients (age ≥ 65 years). The second endpoint was the outcomes by age. Results: There were 539 UEs, representing a rate of 3.6% for all mechanically ventilated patients, a failed UE rate of 48.2% (260/539) and a hospital mortality rate of 16.9% (91/539). In multivariate analyses, the factors predicting failed UE were: not being on a weaning trial (odds ratio, OR, 2.694), accidental extubation (OR, 2.232), older age (OR, 2.028), pulmonary cause of intubation (OR, 1.958), longer intubation time (OR, 1.002), and lower mean arterial pressure (OR, 0.980). Older patients had significant longer ICU and hospital stays than younger ones (15.5 vs. 12.1 days and 37.4 vs. 30.2 days, respectively, both p < 0.05), higher hospital mortality (17.7% vs. 15.8%), and higher hospital costs ($375,700 vs.$337,200 New Taiwan Dollars). Conclusion: Older patients with failed UE had significantly longer ICU and hospital stays and tended to have higher hospital mortality and costs. Many factors predicted failed UE, including age. Physicians should consider age a risk factor for failed UE and adverse events

The Impacts of Aspergillosis on Outcome, Burden and Risks for Mortality in Influenza Patients with Critical Illness

Previous studies have revealed higher mortality rates in patients with severe influenza who are coinfected with invasive pulmonary aspergillosis (IPA) than in those without IPA coinfection; nonetheless, the clinical impact of IPA on economic burden and risk factors for mortality in critically ill influenza patients remains undefined. The study was retrospectively conducted in three institutes. From 2016 through 2018, all adult patients with severe influenza admitted to an intensive care unit (ICU) were identified. All patients were classified as group 1, patients with concomitant severe influenza and IPA; group 2, severe influenza patients without IPA; and group 3, severe influenza patients without testing for IPA. Overall, there were 201 patients enrolled, including group 1 (n = 40), group 2 (n = 50), and group 3 (n = 111). Group 1 patients had a significantly higher mortality rate (20/40, 50%) than that of group 2 (6/50, 12%) and group 3 (18/11, 16.2%), p &lt; 0.001. The risk factors for IPA occurrence were solid cancer and prolonged corticosteroid use in ICU of &gt;5 days. Group 1 patients had significantly longer hospital stay and higher medical expenditure than the other two groups. The risk factors for mortality in group 1 patients included patients’ Charlson comorbidity index, presenting APACHE II score, and complication of severe acute respiratory distress syndrome. Overall, IPA has a significant adverse impact on the outcome and economic burden of severe influenza patients, who should be promptly managed based on risk host factors for IPA occurrence and mortality risk factors for coinfection with both diseases