Infections in the Elderly Critically-Ill Patients

Prevalence and Factors with Potentially Inappropriate Prescribing among Older Surgical Outpatients in China: A Nationwide Cross-sectional Study in 100 Hospitals

BACKGROUND

Older outpatients face a heightened risk of potentially inappropriate prescribing (PIP). However, there is a paucity of evidence evaluating PIP in older outpatients attending surgical outpatient departments in China using Chinese-specific criteria. This study aimed to assess the prevalence of PIP and identify associated factors within this population.

METHODS

A cross-sectional design was employed, utilizing prescription data from older surgical outpatients across 100 hospitals in seven Chinese cities between January and December 2021. PIP was assessed based on Chinese criteria, and multivariate logistic regression analysis was performed to identify risk factors. Trends were analyzed using the average annual percent change (AAPC) via joinpoint regression.

RESULTS

A total of 357,135 prescriptions for older surgical outpatients were analyzed. The prevalence of PIP according to Chinese criteria was 13.06%. The five most commonly identified potentially inappropriate medications (PIMs) were doxazosin, clopidogrel, tolterodine, estazolam, and the concurrent use of more than two NSAIDs, which together accounted for 52.73% of all PIMs. From January to December, the prevalence of PIP exhibited a slight decrease, from 13.29 to 13.21% (AAPC: -0.278%). Logistic regression revealed that factors such as tertiary-level hospital status, polypharmacy, pain, sleep disorders, hypertension, benign prostatic hyperplasia, and stone disease were positively associated with PIP in older surgical outpatients.

CONCLUSIONS

The study found that while the prevalence of PIP among older surgical outpatients in China is relatively low, attention is needed to the widespread use of certain PIMs.

Aging-induced Alternation in the Gut Microbiota Impairs Host Antibacterial Defense

Older individuals experience increased susceptibility and mortality to bacterial infections, but the underlying etiology remains unclear. Herein, it is shown that aging-associated reduction of commensal Parabacteroides goldsteinii (P. goldsteinii) in both aged mice and humans critically contributes to worse outcomes of bacterial infection. The colonization of live P. goldsteinii conferred protection against aging-associated bacterial infections. Metabolomic profiling reveals a protective compound, apigenin, generated by P. goldsteinii, antagonizes bacterial clearance defects in aged mice. AMP-binding protein (ampB) is identified as a key gene involved in apigenin synthesis in P. goldsteinii using homologous recombination in bacteria. Mechanistically, apigenin binds directly to the potential sites on Fgr (M341 and D404), preventing its inhibitory role on Vav1 phosphorylation, and therefore promoting the activation of Cdc42/Rac1, Arp2/3 expression and subsequent actin reorganization, which contributes to the enhanced phagocytosis of macrophages to bacteria. Collectively, the findings suggest that dysbiosis of the gut microbiota may impair host defense mechanisms and increase susceptibility to bacterial infections in older adults and highlight the microbiota-apigenin-Fgr axis as a possible route to ameliorate aging-associated antibacterial defects.

Immune-nutritional indicators predict short-term mortality in older patients after emergency gastrointestinal surgery: a retrospective study

BACKGROUND

The aim of this study was to discover immune-nutritional indicators that can preoperatively predict short-term mortality in older patients undergoing emergency gastrointestinal surgery.

METHODS

We retrospectively analyzed older patients older than 65 years of age who underwent various types of emergency gastrointestinal surgery under general anesthesia between January 2012 and December 2023. The immune-nutritional indicators were defined according to previous literature. The primary endpoint of this study was 90-day survival after surgery.

RESULTS

A total of 4120 patients older than 65 years were included in this study. ROC curves and the decision curve analysis for eight factors predicting 90-day postoperative survival were well predicted by the mGPS (0.68, 95% CI: 0.66-0.70), PNI (0.68, 95% CI: 0.66-0.71) and CONUT score (0.68, 95% CI: 0.66-0.70). The models constructed by LASSO Cox and CoxBoost were used to score the risk for each patient, and the high LASSO Cox model risk score group had worse 90-day survival than the low score group, whereas patients in the low CoxBoost model score group had a worse prognosis. The AUC of the CoxBoost model was greater than that of the LASSO Cox model. A nomogram model was constructed using the variables screened by the LASSO Cox model with a C-index of 0.706.

CONCLUSIONS

Immune-nutritional factors could be a favorable predictor for older patients undergoing emergency gastrointestinal surgery.

Rhabdomyolysis in intensive care unit-distinctive clinical indicators and prognosis

BACKGROUND

Rhabdomyolysis is commonly encountered in intensive care unit (ICU), yet its clinical features and prognostic indicators have not been comprehensively defined. This study aims to identify clinical characteristics and outcomes of ICU patients with rhabdomyolysis, and assess if rhabdomyolysis predicts outcomes.

METHODS

This retrospective study investigated patients admitted to the ICU of Shanghai Baoshan District Wusong Central Hospital from 2022 to 2023. Clinical and laboratory indices, along with discharge outcomes, were analyzed.

RESULTS

The study included 151 patients, divided into Control group (CK ≤ 1000 U/L, n = 117) and RML group (CK > 1000 U/L, n = 34) groups. The RML group showed higher proportions of male gender (76.5% vs. 56.4%, p = 0.035), infection (88.2% vs. 68.4%, p = 0.022), muscle weakness (41.2% vs. 13.7%, p = 0.035), and myoglobin > 1000 U/L (55.9% vs. 14.5%, p < 0.001), but lower incidence of malignant tumors (0% vs. 17.9%, p = 0.017). The poor outcome rate (POR, the combined rate of death and cessation of treatment) was significantly higher in the RML group (52.9% vs. 33.3%, p = 0.038). Multivariate logistic regression analysis identified male gender [OR, 1.120-7.147; p = 0.028], sepsis [OR, 1.234-10.949; p = 0.019], and mechanical ventilation [OR, 1.489-8.478; p = 0.004] as independent risk factors for poor outcome in ICU patients. Rhabdomyolysis was not an independent risk factor.

CONCLUSIONS

ICU patients with rhabdomyolysis experienced a significantly higher rate of poor outcomes. Male gender, sepsis, and mechanical ventilation were identified as independent risk factors for poor outcomes, while rhabdomyolysis itself was not found to be an independent risk factor. Prospective research is needed to validate these findings in diverse ICU populations.

Outcomes of Same-sitting bilateral Retrograde IntraRenal Surgery for renal stone in patients aged 70 years and above

OBJECTIVE

To evaluate outcomes of same sitting Bilateral Retrograde IntraRenal Surgery (SSB-RISRS) for kidney stone in patients aged ≥70 years.

METHODS

We retrospectively reviewed patients with bilateral kidney stones who underwent SSB-RISRS in 21 centers (January 2015-June 2022).

INCLUSION CRITERIA

patients aged ≥70 years, bilateral kidney stones diagnosed due to either unilateral or bilateral symptomatic presentation. Patients were divided into 2 groups. Group 1: patients aged 70-74 years, Group 2: patients aged ≥75 years.

RESULTS

There were 86 patients in Group 1 and 60 patients in Group 2. There was no difference between the groups for gender, ASA score, BMI, comorbidities, presenting symptoms, and positive preoperative urine culture. Group 2 had a significantly higher proportion of recurrent stone formers (54.7% vs 35.0%, p=0.03). A higher proportion of bilaterally pre-stented patients were present in group 2 (37.9% vs 18.6%). There was no difference in total operation time and rate of post-operative uni- and bilateral stent positioning. Surgery was discontinued in 15.1% and 18.3% of cases in groups 1 and 2, respectively (p=0.773). Median length of postoperative stay was 2 days in both groups. The most frequent complication was fever requiring antibiotics and prolonged admission (10.5% in group 1 and 11.7% in group 2, p>0.99). Sepsis rate was 2.3% patients in group 1 and none in group 2. 1.2% in group 1 required a blood transfusion due to hematuria. Bilateral SFR was similar (60.0% vs 47.7%, p=0.194).

CONCLUSIONS

SSB-RISRS in elderly patients demonstrated an acceptable safety profile with good bilateral SFR.

Integrated Multi-Organ Ultrasound

Integrated multi-organ ultrasound is increasingly used across various medical specialties. It should be performed in conjunction with history, physical examination, and other investigations in the diagnostic process to enhance the detection of conditions in the lung, heart, and abdomen. Multi-organ ultrasound has been shown to improve diagnostic accuracy in a sizeable portion of patients, potentially altering treatment plans. Specifically, it aids in assessing shock, sepsis, dyspnea, delirium, and in the perioperative setting, contributing to a more comprehensive patient assessment process.

Nursing Intervention Based on the Interactive Attainment Model

This study aimed to examine the effectiveness of nursing that was based on the interactive attainment model in alleviating anxiety and pain during colonoscopy. This retrospective study included 213 patients, divided into intervention and control groups. Both groups underwent normal or painless colonoscopy. Anxiety and pain were evaluated using the Self-Rating Anxiety Scale and the Visual Analog Scale (VAS), respectively. The intervention group reported significantly lower anxiety and VAS pain scores compared with the control group. The interactive attainment model of nursing effectively reduces patient anxiety and pain and lowers complication rates in patients undergoing colonoscopy.

Immune aging and infectious diseases

ABSTRACT

The rise in global life expectancy has led to an increase in the older population, presenting significant challenges in managing infectious diseases. Aging affects the innate and adaptive immune systems, resulting in chronic low-grade inflammation (inflammaging) and immune function decline (immunosenescence). These changes would impair defense mechanisms, increase susceptibility to infections and reduce vaccine efficacy in older adults. Cellular senescence exacerbates these issues by releasing pro-inflammatory factors, further perpetuating chronic inflammation. Moreover, comorbidities, such as cardiovascular disease and diabetes, which are common in older adults, amplify immune dysfunction, while immunosuppressive medications further complicate responses to infections. This review explores the molecular and cellular mechanisms driving inflammaging and immunosenescence, focusing on genomic instability, telomere attrition, and mitochondrial dysfunction. Additionally, we discussed how aging-associated immune alterations influence responses to bacterial, viral, and parasitic infections and evaluated emerging antiaging strategies, aimed at mitigating these effects to improve health outcomes in the aging population.

Lipopolysaccharide-Induced Delirium-Like Behavior and Microglial Activation in Mice Correlate With Bispectral Electroencephalography

Delirium is a multifactorial medical condition characterized by impairment across various mental functions and is one of the greatest risk factors for prolonged hospitalization, morbidity, and mortality. Research focused on delirium has proven to be challenging due to a lack of objective measures for diagnosing patients, and few laboratory models have been validated. Our recent studies report the efficacy of bispectral electroencephalography (BSEEG) in diagnosing delirium in patients and predicting patient outcomes. We applied BSEEG to validate a lipopolysaccharide-induced mouse model of delirium. Moreover, we investigated the relationship between BSEEG score, delirium-like behaviors, and microglia activation in hippocampal dentate gyrus and cortex regions in young and aged mice. There was a significant correlation between BSEEG score and impairment of attention in young mice. Additionally, there was a significant correlation between BSEEG score and microglial activation in hippocampal dentate gyrus and cortex regions in young and aged mice. We have successfully validated the BSEEG method by showing its associations with a level of behavioral change and microglial activation in an lipopolysaccharide-induced mouse model of delirium. In addition, the BSEEG method was able to sensitively capture an lipopolysaccharide-induced delirium-like condition that behavioral tests could not capture because of a hypoactive state.

Can cleaning processes based on ozone be used for high-touch surfaces in nursing homes in areas critical for infection control?

In terms of infection control, environmental cleaning is critical in nursing homes, including long term care facilities. According to the statement of the Commission of Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute Berlin on the requirements for disinfectants in these areas, procedures should be used that have been certified by the Association for Applied Hygiene (VAH) for the necessary spectrum of efficacy (or are listed accordingly in the disinfectant list of the Robert Koch Institute). Since ozone is a powerfully oxidizing gas with high inhalation toxicity, the conditions of ap-plication and the measures for occupational safety - including ensuring that the limit value in indoor air is not exceeded when handling and using the product -, must be declared by the manufacturer and observed by the staff to exclude toxic long-term hazard.

Immunosenescence: How Aging Increases Susceptibility to Bacterial Infections and Virulence Factors

The process of aging leads to a progressive decline in the immune system function, known as immunosenescence, which compromises both innate and adaptive responses. This includes impairments in phagocytosis and decreased production, activation, and function of T- and B-lymphocytes, among other effects. Bacteria exploit immunosenescence by using various virulence factors to evade the host's defenses, leading to severe and often life-threatening infections. This manuscript explores the complex relationship between immunosenescence and bacterial virulence, focusing on the underlying mechanisms that increase vulnerability to bacterial infections in the elderly. Additionally, it discusses how machine learning methods can provide accurate modeling of interactions between the weakened immune system and bacterial virulence mechanisms, guiding the development of personalized interventions. The development of vaccines, novel antibiotics, and antivirulence therapies for multidrug-resistant bacteria, as well as the investigation of potential immune-boosting therapies, are promising strategies in this field. Future research should focus on how machine learning approaches can be integrated with immunological, microbiological, and clinical data to develop personalized interventions that improve outcomes for bacterial infections in the growing elderly population.

The emerging links between immunosenescence in innate immune system and neurocryptococcosis

Immunosenescence refers to the age-related progressive decline of immune function contributing to the increased susceptibility to infectious diseases in older people. Neurocryptococcosis, an infectious disease of central nervous system (CNS) caused by Cryptococcus neoformans (C. Neoformans) and C. gattii, has been observed with increased frequency in aged people, as result of the reactivation of a latent infection or community acquisition. These opportunistic microorganisms belonging to kingdom of fungi are capable of surviving and replicating within macrophages. Typically, cryptococcus is expelled by vomocytosis, a non-lytic expulsive mechanism also promoted by interferon (IFN)-I, or by cell lysis. However, whereas in a first phase cryptococcal vomocytosis leads to a latent asymptomatic infection confined to the lung, an enhancement in vomocytosis, promoted by IFN-I overproduction, can be deleterious, leading the fungus to reach the blood stream and invade the CNS. Cryptococcus may not be easy to diagnose in older individuals and, if not timely treated, could be potentially lethal. Therefore, this review aims to elucidate the putative causes of the increased incidence of cryptococcal CNS infection in older people discussing in depth the mechanisms of immunosenscence potentially able to predispose to neurocryptococcosis, laying the foundations for future research. A deepest understanding of this relationship could provide new ways to improve the prevention and recognition of neurocryptococcosis in aged frail people, in order to quickly manage pharmacological interventions and to adopt further preventive measures able to reduce the main risk factors.

A novel clinical prediction model for in-hospital mortality in sepsis patients complicated by ARDS: A MIMIC IV database and external validation study

Background

Sepsis complicated by ARDS significantly increases morbidity and mortality, underscoring the need for robust predictive models to enhance patient management.

Methods

We collected data on 6390 patients with ARDS-complicated sepsis from the MIMIC IV database. Following rigorous data cleaning, including outlier management, handling missing values, and transforming variables, we conducted univariate analysis and logistic multivariate regression. We employed the LASSO machine learning algorithm to identify risk factors closely associated with patient outcomes. These factors were then used to develop a new clinical prediction model. The model underwent preliminary assessment and internal validation, and its performance was further tested through external validation using data from 225 patients at a major tertiary hospital in China. This validation assessed the model's discrimination, calibration, and net clinical benefits.

Results

The model, illustrated by a concise nomogram, demonstrated significant discrimination with an area under the curve (AUC) of 0.711 in the internal validation set and 0.771 in the external validation set, outperforming conventional severity scores such as the SOFA and SAPS II. It also showed good calibration and net clinical benefits.

Conclusions

Our model serves as a valuable tool for identifying sepsis patients with ARDS at high risk of in-hospital mortality. This could enable the implementation of personalized treatment strategies, potentially improving patient outcomes.

Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

Malnutrition and Its Influence on Sepsis Outcomes in Elderly Patients

BACKGROUND

Malnutrition is common among the elderly and has significant implications for hospitalization outcomes. This is particularly true for severe illnesses such as sepsis, given age-related physiological changes and comorbidities.

OBJECTIVE

This study examined how malnutrition affected hospitalization outcomes in older adults admitted for sepsis.

MATERIALS & METHODS

 A prospective cohort study was conducted at Lady Reading Hospital in Peshawar, Pakistan, from January to December 2023, focusing on 390 sepsis patients aged 55 years and older. Data on clinical history, length of stay, mortality rates, comorbidities, and nutritional assessments were collected using standardized forms. After controlling for confounding variables, statistical analysis using SPSS version 23 (IBM Corp., Armonk, NY) examined the relationship between hospitalization outcomes and nutritional status.

RESULTS

The research included 390 elderly sepsis patients and showed significant variations in the demographics, comorbidities, and severity of disease between the well-nourished and malnourished groups. Malnourished patients had higher rates of ICU admission (52.82% vs. 29.23%), mechanical ventilation (45.13% vs. 16.41%), mortality (27.18% vs. 14.87%), and 30-day readmission (28.21% vs. 12.82%) as compared to the well-nourished group. They also had longer hospital stays (18.1 days vs. 12.6 days). Malnutrition significantly influenced outcomes, with multivariate analysis indicating it as a predictor of longer stays (β = 2.8, p < 0.001) and increased mortality risk (OR = 3.2, 95% CI: 1.9-5.4, p < 0.001).

CONCLUSION

Malnutrition significantly worsens outcomes for elderly sepsis patients, increasing ICU admissions, ventilation needs, mortality rates, and readmissions, emphasizing the need for proactive nutritional interventions.

Comprehensive analysis of multiple cytokines to stratify uropathogenic Escherichia coli pathogenesis in mouse model of urinary tract infection

PURPOSE

Urinary tract infection (UTI) is one of the most common human bacterial infections primarily caused by uropathogenic E. coli (UPEC). Empiric treatment in UTI cause emergence of multidrug resistance and limit treatment options. Understanding UTI at the molecular level with respect to the causative pathogen as well as subsequent host response pose an absolute necessity towards appropriate clinical management. This study aimed to investigate host cytokine response in mouse UTI model with respect to bacterial colonization and associated virulence gene expression upon infection.

METHOD

Mouse UTI model was established with two clinical UPEC isolates E. coli NP105 and E. coli P025. UPEC colonization in bladder and kidney was evaluated by bacterial culture (CFU/ml). Histopathology of the tissues were examined by hematoxylin and eosin staining. PCR and real time PCR were used to detect the incidence and expression of respective bacterial genes. Cytokine concentrations in tissues and sera were evaluated using ELISA. GraphPad prism version 8.0.2 was used for statistical interpretation.

RESULT

Highest bacterial colonization was observed on 7th and 9th day post infection (p.i). in bladder and kidney of mouse infected with E. coli P025 and E. coli NP105 respectively with a distinct difference in relative expression of fimH and papC adhesin genes in vivo. IL-1β level in tissues and sera of E. coli NP105 and E. coli P025 infected mouse was significantly different but the IL-17A, GCSF, TGF-β levels were comparable.

CONCLUSION

These findings show a role of IL1β to stratify pathogenicity of UPEC in mouse UTI model.

Nomogram predictive model for in-hospital mortality risk in elderly ICU patients with urosepsis

BACKGROUND

Urinary tract infection (UTI) is a common cause of sepsis. Elderly patients with urosepsis in intensive care unit (ICU) have more severe conditions and higher mortality rates owing to factors such as advanced age, immunosenescence, and persistent host inflammatory responses. However, comprehensive studies on nomograms to predict the in-hospital mortality risk in elderly patients with urosepsis are lacking. This study aimed to construct a nomogram predictive model to accurately assess the prognosis of elderly patients with urosepsis and provide therapeutic recommendations.

METHODS

Data of elderly patients with urosepsis were extracted from the Medical Information Mart for Intensive Care (MIMIC) IV 2.2 database. Patients were randomly divided into training and validation cohorts. A predictive nomogram model was constructed from the training set using logistic regression analysis, followed by internal validation and sensitivity analysis.

RESULTS

This study included 1,251 patients. LASSO regression analysis revealed that the Glasgow Coma Scale (GCS) score, red cell distribution width (RDW), white blood count (WBC), and invasive ventilation were independent risk factors identified from a total of 43 variables studied. We then created and verified a nomogram. The area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA) of the nomogram were superior to those of the traditional SAPS-II, APACHE-II, and SOFA scoring systems. The Hosmer-Lemeshow test results and calibration curves suggested good nomogram calibration. The IDI and NRI values showed that our nomogram scoring tool performed better than the other scoring systems. The DCA curves showed good clinical applicability of the nomogram.

CONCLUSIONS

The nomogram constructed in this study is a convenient tool for accurately predicting in-hospital mortality in elderly patients with urosepsis in ICU. Improving the treatment strategies for factors related to the model could improve the in-hospital survival rates of these patients.

Feeding Drosophila gut microbiomes from young and old flies modifies the microbiome

It is becoming increasingly evident that the myriad of microbes in the gut, within cells and attached to body parts (or roots of plants), play crucial roles for the host. Although this has been known for decades, recent developments in molecular biology allow for expanded insight into the abundance and function of these microbes. Here we used the vinegar fly, Drosophila melanogaster, to investigate fitness measures across the lifetime of flies fed a suspension of gut microbes harvested from young or old flies, respectively. Our hypothesis was that flies constitutively enriched with a 'Young microbiome' would live longer and be more agile at old age (i.e. have increased healthspan) compared to flies enriched with an 'Old microbiome'. Three major take home messages came out of our study: (1) the gut microbiomes of young and old flies differ markedly; (2) feeding flies with Young and Old microbiomes altered the microbiome of recipient flies and (3) the two different microbial diets did not have any effect on locomotor activity nor lifespan of the recipient flies, contradicting our working hypothesis. Combined, these results provide novel insight into the interplay between hosts and their microbiomes and clearly highlight that the phenotypic effects of gut transplants and probiotics can be complex and unpredictable.

Prediction of Th17/Treg cell balance on length of stay in intensive care units of patients with sepsis

Background

Prolonged length of stay (LOS) of sepsis can drain a hospital's material and human resources. This study investigated the correlations between T helper type 17 (Th17) and regulatory T (Treg) balance with LOS in sepsis.

Methods

A prospective clinical observational study was designed in Changhai Hospital affiliated to Naval Medical University in Shanghai, China, from January to October 2020. The patients diagnosed with sepsis and who met the inclusion and exclusion criteria were recruited and whether the levels of cytokines, procalcitonin, subtypes, and biomarkers of T cells in the peripheral blood were detected. We analyzed the correlation between these and LOS.

Results

Sixty septic patients were classified into two groups according to whether their intensive care unit (ICU) stay exceeded 14 days. The patients with LOS ≥14 days were older ([72.6±7.5] years vs. [63.3±10.4] years, P=0.015) and had higher Sequential Organ Failure Assessment (SOFA) (median [interquartile range]: 6.5 [5.0-11.0] vs. 4.0 [3.0-6.0], P=0.001) and higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (16.0 [13.0-21.0] vs. 8.5 [7.0-14.0], P=0.001). There was no difference in other demographic characteristics and cytokines, interleukin-6, tumor necrosis factor-α, and interleukin-10 between the two groups. The Th17/Treg ratio of sepsis with LOS <14 days was considerably lower (0.48 [0.38-0.56] vs. 0.69 [0.51-0.98], P=0.001). For patients with LOS ≥14 days, the area under the receiver operating characteristic curve for the Th17/Treg ratio was 0.766. It improved to 0.840 and 0.850 when combined with the SOFA and APACHE II scores, respectively.

Conclusions

The Th17/Treg ratio was proportional to septic severity and can be used as a potential predictor of ICU stay in sepsis, presenting a new option for ICU practitioners to better care for patients with sepsis.

Antimicrobial resistance prevalence in bloodstream infection in 29 European countries by age and sex: An observational study

BACKGROUND

Antibiotic usage, contact with high transmission healthcare settings as well as changes in immune system function all vary by a patient's age and sex. Yet, most analyses of antimicrobial resistance (AMR) ignore demographic indicators and provide only country-level resistance prevalence values. This study aimed to address this knowledge gap by quantifying how resistance prevalence and incidence of bloodstream infection (BSI) varied by age and sex across bacteria and antibiotics in Europe.

METHODS AND FINDINGS

We used patient-level data collected as part of routine surveillance between 2015 and 2019 on BSIs in 29 European countries from the European Antimicrobial Resistance Surveillance Network (EARS-Net). A total of 6,862,577 susceptibility results from isolates with age, sex, and spatial information from 944,520 individuals were used to characterise resistance prevalence patterns for 38 different bacterial species and antibiotic combinations, and 47% of these susceptibility results were from females, with a similar age distribution in both sexes (mean of 66 years old). A total of 349,448 isolates from 2019 with age and sex metadata were used to calculate incidence. We fit Bayesian multilevel regression models by country, laboratory code, sex, age, and year of sample to quantify resistant prevalence and provide estimates of country-, bacteria-, and drug-family effect variation. We explore our results in greater depths for 2 of the most clinically important bacteria-antibiotic combinations (aminopenicillin resistance in Escherichia coli and methicillin resistance in Staphylococcus aureus) and present a simplifying indicative index of the difference in predicted resistance between old (aged 100) and young (aged 1). At the European level, we find distinct patterns in resistance prevalence by age. Trends often vary more within an antibiotic family, such as fluroquinolones, than within a bacterial species, such as Pseudomonas aeruginosa. Clear resistance increases by age for methicillin-resistant Staphylococcus aureus (MRSA) contrast with a peak in resistance to several antibiotics at approximately 30 years of age for P. aeruginosa. For most bacterial species, there was a u-shaped pattern of infection incidence with age, which was higher in males. An important exception was E. coli, for which there was an elevated incidence in females between the ages of 15 and 40. At the country-level, subnational differences account for a large amount of resistance variation (approximately 38%), and there are a range of functional forms for the associations between age and resistance prevalence. For MRSA, age trends were mostly positive, with 72% (n = 21) of countries seeing an increased resistance between males aged 1 and 100 years and a greater change in resistance in males. This compares to age trends for aminopenicillin resistance in E. coli which were mostly negative (males: 93% (n = 27) of countries see decreased resistance between those aged 1 and 100 years) with a smaller change in resistance in females. A change in resistance prevalence between those aged 1 and 100 years ranged up to 0.51 (median, 95% quantile of model simulated prevalence using posterior parameter ranges 0.48, 0.55 in males) for MRSA in one country but varied between 0.16 (95% quantile 0.12, 0.21 in females) to -0.27 (95% quantile -0.4, -0.15 in males) across individual countries for aminopenicillin resistance in E. coli. Limitations include potential bias due to the nature of routine surveillance and dependency of results on model structure.

CONCLUSIONS

In this study, we found that the prevalence of resistance in BSIs in Europe varies substantially by bacteria and antibiotic over the age and sex of the patient shedding new light on gaps in our understanding of AMR epidemiology. Future work is needed to determine the drivers of these associations in order to more effectively target transmission and antibiotic stewardship interventions.

Biosynthetic potential of the gut microbiome in longevous populations

Gut microbiome plays a pivotal role in combating diseases and facilitating healthy aging, and natural products derived from biosynthetic gene clusters (BGCs) of the human microbiome exhibit significant biological activities. However, the natural products of the gut microbiome in long-lived populations remain poorly understood. Here, we integrated six cohorts of long-lived populations, encompassing a total of 1029 fecal metagenomic samples, and employed the metagenomic single sample assembled BGCs (MSSA-BGCs) analysis pipeline to investigate the natural products and their associated species. Our findings reveal that the BGC composition of the extremely long-lived group differed significantly from that of younger elderly and young individuals across five cohorts. Terpene and Type I PKS BGCs were enriched in the extremely long-lived, whereas cyclic-lactone-autoinducer BGCs were more prevalent in the young. Association analysis indicated that terpene BGCs were strongly associated with the abundance of Akkermansia muciniphila, which was also more abundant in the long-lived elderly across at least three cohorts. We assembled 18 A. muciniphila draft genomes using metagenomic data from the extremely long-lived group across six cohorts and discovered that they all harbor two classes of terpene BGCs, which aligns with the 97 complete genomes of A. muciniphila strains retrieved from the NCBI database. The core domains of these two BGC classes are squalene/phytoene synthases involved in the biosynthesis of tri- and tetraterpenes. Furthermore, the abundance of fecal A. muciniphila was significantly associated with eight types of triterpenoids. Targeted terpenoid metabolomic analysis revealed that two triterpenoids, Holstinone C and colubrinic acid, were enriched in the A. muciniphila culture solution compared to the medium, thereby confirming the production of triterpenoids by A. muciniphila. The natural products derived from the gut of long-lived populations provide intriguing indications of their potential beneficial roles in regulating health.

Current State of Knowledge on the Definition, Pathophysiology, Etiology, Outcomes, and Management of Fever in the Intensive Care Unit

Fever-an elevated body temperature-is a prominent feature of a wide range of disease conditions and is a common finding in intensive care, affecting up to 70% of patients in the intensive care unit (ICU). The causes of fever in the ICU are multifactorial, and it can be due to a number of infective and noninfective etiologies. The production of fever represents a complex physiological, adaptive host response that is beneficial for host defense and survival but can be maladaptive and harmful if left unabated. Despite any cause, fever is associated with a wide range of cellular, local, and systemic effects, including multiorgan dysfunction, systemic inflammation, poor neurological recovery, and an increased risk of mortality. This narrative review presents the current state-of-the-art knowledge on the definition, pathophysiology, etiology, and outcomes of fever in the ICU and highlights evidence-based findings regarding the management of fever in the intensive care setting.

Biofilm and Hospital-Acquired Infections in Older Adults

Biofilm infections are a serious threat to public health, resistant to traditional treatments and host immune defenses. Biofilm infections are often polymicrobial, related to chronic wounds, medical devices (eg, knee replacements, catheters, tubes, contact lenses, or prosthetic valves) and chronic recurring diseases. Biofilms are more complex than nonadhered planktonic bacteria and produce a structure that prevents damage to the bacteria within the biofilm structure. The structure provides a hidden route to feed and nurture the bacteria allowing for ongoing spread of the bacteria.

The Association Between Malignant Otitis Externa and Diabetes Mellitus in Africa: A Systematic Review

Diabetes mellitus is one of the risk factors for malignant otitis externa. There are very few studies on the disease in Africa and there is a need to pool the prior studies to highlight the characteristics of the disease. The study type is a systematic review and the PRISMA guidelines were followed. Using the appropriate terms, relevant medical databases were systematically searched. Thirty-two studies met the eligibility criteria with a total sample size of 848, who were mainly elderly. Diabetes mellitus was present in 94% of the participants. Average duration of diabetes diagnosis in the participants was 12.4 years. The pooled HbA1c was 9.8%. The most common symptoms were otalgia (96.1%), otorrhoea (75.8%) and hearing loss (56.1%). Pseudomonas was the most common isolate (72%). Fluoroquinolones and the 3rd-generation cephalosporins were the preferred antibiotics. The pooled cure rate from antimicrobial usage was 76.2%. In addition to medications, 24.6% of the affected individuals required debridement. About 1.6% of the participants died from malignant otitis externa. Malignant otitis externa is associated with poorly controlled diabetes. Pseudomonas is the most common cause and a significant proportion gets cured with prolonged antibiotherapy.

What Are the Causes of Death among Patients Admitted to a Contemporary Tertiary-Level Cardiology Department? An Analysis of 10 Years of Morbidity and Mortality Meetings

Despite the efforts to deliver the best evidence-based care, in-hospital death is an inevitable event among some patients hospitalized in cardiology departments. We conducted a retrospective evaluation of mortality events from inpatient admissions to the cardiology department between 2010 and 2019. Data were collected from morbidity and mortality meeting presentations that evaluated comorbidities, medical history, treatments, and causes of death for the overall cohort and according to age group and sex. There were 1182 registered deaths. The most common causes of death among patients were acute myocardial infarction (AMI, 53.0%), heart failure (HF, 11.7%), cardiac arrest (CA, 6.6%), HF with complication/defined cardiomyopathy (6.3%), and sepsis (4.4%). We observed a decline in deaths from AMI from 61.9% in 2010 to 46.7% in 2019, while there was a clear increase in deaths from HF (11.1% in 2010 to 25.9% in 2019). Compared to patients ≥65 years, younger patients were more likely to have died from CA (15.7% vs. 4.3%, p < 0.001) and other cardiac reasons (3.0% vs. 0.4%, p < 0.001). The majority of deaths were due to AMI, HF, and CA. We observed a significant declining trend in the proportion of deaths due to AMI in recent years, with an increase in deaths due to HF.

Microbial Community Characterization and Molecular Resistance Monitoring in Geriatric Intensive Care Units in China Using mNGS

Background

Surface pathogens in the ICU pose a global public health threat, especially to elderly patients who are immunocompromised. To detect these pathogens, unbiased methods such as metagenomic next-generation sequencing (mNGS) are increasingly utilized for environmental microbiological surveillance.

Methods

In a six-month study from January to July 2022, we investigated microbial communities in Chinese geriatric ICUs by regularly monitoring multiple surfaces at three-month intervals. Using mNGS sequencing, we analyzed microorganisms present at eight specific locations within the ICU. Additionally, we compared pathogen profiles and drug resistance genes between patient cultures and environmental samples collected during the same period.

Results

The microbial composition remained relatively stable over time, but significant differences in alpha diversities were observed among various surfaces such as floors, hands, pumps, trolleys, and ventilator inlets/outlets. Surfaces with high contact frequency for healthcare workers, including workstations, ventilator panels, trolleys, pumps, and beds, harbored pathogenic microorganisms such as Acinetobacter baumannii, Cutibacterium acnes, Staphylococcus haemolyticus, Pseudomonas aeruginosa, and Enterococcus faecium. Acinetobacter baumannii, particularly the carbapenem-resistant strain (CRAB), was the most frequently identified pathogen in geriatric ICU patients regardless of testing method used. The mNGS approach enabled detection of viruses, fungi, and parasites that are challenging to culture. Additionally, an abundance of drug resistance genes was found in almost all environmental samples.

Conclusion

The microbial composition and abundance in the ICU remained relatively constant over time. The floor exhibited the highest microbial diversity and abundance in the ICU environment. Drug-resistant genes in the ICU environment may migrate between patients. Overall, mNGS is an emerging and powerful tool for microbiological monitoring of the hospital environment.

Resistance pattern of isolated microorganisms from 783 clinical specimen cultures in patients admitted to Yasuj Educational Hospitals, Iran

BACKGROUND

Infectious diseases are still one of the leading causes of morbidity and mortality in resource-limited settings. Serious infection caused mostly by gram-negative pathogens causes significant morbidity. According to the Centers for Disease Control and Prevention, antimicrobial resistance kills over 700,000 people worldwide. Antibiotic resistance is on the rise, and as a consequence, serious public health issues are arising. The present study investigated isolated clinical samples from Yasuj teaching hospitals to determine the antimicrobial resistance profile to various antibiotics.

MATERIALS AND METHODS

Microbial isolates regarding cultures from urine, blood, wound, abdominal tap, throat, stool, cerebrospinal fluid, endotracheal tube, sputum, skin lesion, nasal, and mouth secretion were collected from patients admitted to hospitals affiliated with Yasuj teaching hospitals. Antibiotic susceptibility profiles were determined by using the Kirby-Bauer disc diffusion method. Data were tabulated and analyzed with SPSS version 26.0.

RESULTS

A total of 783 samples were evaluated in our study, with an average of 30.6 years and 54.5% female patients. Most of the bacterial isolates were gram-negative (64.2%). The majority of cultures were Escherichia coli (49.9%), mainly among urine samples (64.2%). The frequency distribution of norfloxacin antibiotic resistance was more common in internal medicine (66.7%), infectious (63.6%), and emergency wards (58.8%). The frequency distribution of penicillin antibiotic resistance was statistically significant in different wards. All cases of oxacillin were resistant.

CONCLUSION

Our data showed a high level of antibiotic resistance among bacterial isolates in our center. Considering widespread empirical antibiotic therapy in Iran, the rate of increasing resistance to common antibiotics prescribed for ambulatory and hospitalized patients is concerning. We recommend providing more strict guidelines and policies to control the overuse and overprescription of antimicrobials by health policy-making organizations.

Back to the Basics: Usefulness of Naturally Aged Mouse Models and Immunohistochemical and Quantitative Morphologic Methods in Studying Mechanisms of Lung Aging and Associated Diseases

Aging-related molecular and cellular alterations in the lung contribute to an increased susceptibility of the elderly to devastating diseases. Although the study of the aging process in the lung may benefit from the use of genetically modified mouse models and omics techniques, these approaches are still not available to most researchers and produce complex results. In this article, we review works that used naturally aged mouse models, together with immunohistochemistry (IHC) and quantitative morphologic (QM) methods in the study of the mechanisms of the aging process in the lung and its most commonly associated disorders: cancer, chronic obstructive pulmonary disease (COPD), and infectious diseases. The advantage of using naturally aged mice is that they present characteristics similar to those observed in human aging. The advantage of using IHC and QM methods lies in their simplicity, economic accessibility, and easy interpretation, in addition to the fact that they provide extremely important information. The study of the aging process in the lung and its associated diseases could allow the design of appropriate therapeutic strategies, which is extremely important considering that life expectancy and the number of elderly people continue to increase considerably worldwide.

Challenges in the Vaccination of the Elderly and Strategies for Improvement

In recent years, the elderly has become a rapidly growing proportion of the world's population as life expectancy is extending. Immunosenescence and inflammaging contribute to the increased risk of chronic non-communicable and acute infectious diseases. Frailty is highly prevalent in the elderly and is associated with an impaired immune response, a higher propensity to infection, and a lower response to vaccines. Additionally, the presence of uncontrolled comorbid diseases in the elderly also contributes to sarcopenia and frailty. Vaccine-preventable diseases that threaten the elderly include influenza, pneumococcal infection, herpes zoster, and COVID-19, which contribute to significant disability-adjusted life years lost. Previous studies had shown that conventional vaccines only yielded suboptimal protection that wanes rapidly in a shorter time. This article reviews published papers on several vaccination strategies that were developed for the elderly to solve these problems: more immunogenic vaccine formulations using larger doses of antigen, stronger vaccine adjuvants, recombinant subunit or protein conjugated vaccines, newly developed mRNA vaccines, giving booster shots, and exploring alternative routes of administration. Included also are several publications on senolytic medications under investigation to boost the immune system and vaccine response in the elderly. With all those in regard, the currently recommended vaccines for the elderly are presented.

Unlocking the potential of phages: Innovative approaches to harnessing bacteriophages as diagnostic tools for human diseases

Phages, viruses that infect bacteria, have been explored as promising tools for the detection of human disease. By leveraging the specificity of phages for their bacterial hosts, phage-based diagnostic tools can rapidly and accurately detect bacterial infections in clinical samples. In recent years, advances in genetic engineering and biotechnology have enabled the development of more sophisticated phage-based diagnostic tools, including those that express reporter genes or enzymes, or target specific virulence factors or antibiotic resistance genes. However, despite these advancements, there are still challenges and limitations to the use of phage-based diagnostic tools, including concerns over phage safety and efficacy. This review aims to provide a comprehensive overview of the current state of phage-based diagnostic tools, including their advantages, limitations, and potential for future development. By addressing these issues, we hope to contribute to the ongoing efforts to develop safe and effective phage-based diagnostic tools for the detection of human disease.

Evaluation of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia: Epidemiology, clinical characteristics, and outcomes in the older patients in a tertiary teaching hospital in Malaysia

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is a major concern in the global healthcare system. However, data from Asian regions dealing with the singularity of this infection in older persons is lacking. We aimed to identify the differences in the clinical characteristics and outcomes of MRSA bacteremia between adults aged 18-64 and ≥ 65 years.

METHODS

A retrospective study cohort was conducted at the University Malaya Medical Centre (UMMC) on cases of MRSA bacteremia from 2012 to 2016. Patient demographic and clinical data were collected for risk factors analyses.

RESULTS

New cases of MRSA bacteremia showed a trend of increase from 0.12 to 100 admissions in 2012 to 0.17 per 100 admissions in 2016 but a drop was observed in 2014 (0.07 per 100 admissions). Out of the 275 patients with MRSA bacteremia, 139 (50.5%) patients were aged ≥ 65 years old. Co-morbidities and severity at presentation were significantly higher among older adults, including diabetes mellitus (p = 0.035), hypertension (p = 0.001), and ischemic heart disease (p < 0.001), as well as higher Charlson Comorbidity Index (p < 0.001) and Pitt bacteremia scores (p = 0.016). Central line-associated bloodstream infections were more common among younger patients (37.5% vs. 17.3% in older patients, p < 0.001), while skin and soft tissue infections are more frequent among older adults (20.9% vs. 10.3% in younger patients, p = 0.016). All-cause mortality and in-hospital mortality were significantly higher in older patients (82.7% and 56.1% vs. 63.2% and 28.7% in younger patients, p < 0.001). Multivariate analysis revealed age ≥ 65 years (adjusted odds ratio: 3.36; 95% confidence interval: 1.24-9.13), Pitt score ≥ 3 (2.15; 1.54-3.01), hospital (6.12; 1.81-20.72) and healthcare (3.19; 1.30-7.81) acquisition of MRSA, indwelling urinary catheters (5.43; 1.39-21.23), inappropriate targeted treatment (8.08; 1.15-56.86), lack of infectious disease team consultation (2.90; 1.04-8.11) and hypoalbuminemia (3.31; 1.25-8.79), were significant risk factors for 30-day mortality.

CONCLUSION

Older patients' risk of mortality from MRSA bacteremia was three times higher than younger patients. Our data will contribute to developing and validating a robust scoring system for risk-stratifying patients to achieve better management and improved clinical outcomes.

Development and first results of a national databank on care and treatment outcome after traumatic brain injury

PURPOSE

In absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries.

METHODS

From 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months.

RESULTS

For this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home.

CONCLUSION

Within five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany.

Clinical impact of carbapenems in critically ill patients with valproic acid therapy: A propensity-matched analysis

Background

Valproic acid (VPA) is one of the most widely used broad-spectrum antiepileptic drugs, and carbapenems (CBPs) remain the drug of choice for severe infection caused by multidrug-resistant bacteria in critically ill patients. The interaction between VPA and CBPs can lead to a rapid depletion of serum VPA level. This may then cause status epilepticus (SE), which is associated with significant mortality. However, the prognostic impact of drug interactions in critically ill patients remains an under-investigated issue.

Objective

The aim of this study was to compare the prognosis of critically ill patients treated with VPA and concomitant CBPs or other broad-spectrum antibiotics.

Methods

Adult patients admitted to a medical center intensive care unit between January 2007 and December 2017 who concomitantly received VPA and antibiotics were enrolled. The risk of reduced VPA serum concentration, seizures and SE, mortality rate, length of hospital stay (LOS), and healthcare expenditure after concomitant administration were analyzed after propensity score matching.

Results

A total of 1,277 patients were included in the study, of whom 264 (20.7%) concomitantly received VPA and CBPs. After matching, the patients who received CBPs were associated with lower VPA serum concentration (15.8 vs. 60.8 mg/L; p &lt; 0.0001), a higher risk of seizures (51.2 vs. 32.4%; adjusted odds ratio [aOR], 2.19; 95% CI, 1.48–3.24; p &lt; 0.0001), higher risk of SE (13.6 vs. 4.7%; aOR, 3.20; 95% CI, 1.51–6.74; p = 0.0014), higher in-hospital mortality rate (33.8 vs. 24.9%; aOR, 1.57; 95% CI, 1.03–2.20; p = 0.036), longer LOS after concomitant therapy (41 vs. 30 days; p &lt; 0.001), and increased healthcare expenditure (US$20,970 vs. US$12,848; p &lt; 0.0001) than those who received other broad-spectrum antibiotics.

Conclusion

The administration of CBPs in epileptic patients under VPA therapy was associated with lower VAP serum concentration, a higher risk of seizures and SE, mortality, longer LOS, and significant utilization of healthcare resources. Healthcare professionals should pay attention to the concomitant use of VPA and CBPs when treating patients with epilepsy. Further studies are warranted to investigate the reason for the poor outcomes and whether avoiding the co-administration of VPA and CBP can improve the outcomes of epileptic patients.

Risk of Infection in Elderly Patients with Inflammatory Bowel Disease under biologics: A Prospective, Multicenter, Observational, One-Year follow-up comparative study

OBJECTIVES

The emergence of biologics has improved the course of inflammatory bowel diseases (IBD) in the elderly population despite a potential higher risk of infections. We conducted a one-year, prospective, multicenter, observational study to determine the frequency of occurrence of at least one infectious event in elderly IBD patients under anti-TNF therapy compared with that in elderly patients under vedolizumab or ustekinumab therapies .

METHODS

All IBD patients over 65 years exposed to anti-TNF, vedolizumab or ustekinumab therapies were included. The primary endpoint was the prevalence of at least one infection during the whole one year follow-up.

RESULTS

Among the 207 consecutive elderly IBD patients prospectively enrolled, 113 were treated with anti-TNF and 94 with vedolizumab (n=63) or ustekinumab (n=31) (median age 71 years, 112 Crohn's disease). The Charlson index was similar between patients under anti-TNF and those under vedolizumab or ustekinumab as well as the proportion of patients under combination therapy and under concomitant steroid therapy did not differ between both both groups. The prevalence of infections was similar in patients under anti-TNF and in those under vedolizumab or ustekinumab (29% versus 28%, respectively; p=0.81). There was no difference in terms of type and severity of infection and of infection-related hospitalization rate. In multivariate regression analysis, only the Charlson comorbidity index (≥ 1) was identified as a significant and independent risk factor of infection (p=0.03).

CONCLUSION

Around 30 % of elderly patients with IBD under biologics experienced at least one infection during the one-year study follow-up period. The risk of occurrence of infection does not differ between anti-TNF and vedolizumab or ustekinumab therapies, and only the associated comorbidity was linked with the risk of infection.

Health Care-Associated Infections in Older Adults: Epidemiology and Prevention

Health care-associated infections (HAIs) are a global public health threat, which disproportionately impact older adults. Host factors including aging-related changes, comorbidities, and geriatric syndromes, such as dementia and frailty, predispose older individuals to infection. The HAI risks from medical interventions such as device use, antibiotic use, and lapses in infection control follow older adults as they transfer among a network of interrelated acute and long-term care facilities. Long-term care facilities are caring for patients with increasingly complex needs, and the home-like communal environment of long-term care facilities creates distinct infection prevention challenges.

The cutoff value of presepsin for diagnosing sepsis increases with kidney dysfunction, a cross-sectional observational study

As presepsin levels increase with kidney dysfunction (KD), our aim was to establish cutoff points for presepsin adapted to the level of KD in order to avoid bacterial infection overdiagnosis, antibiotic overprescription, and risk of bacterial resistance. This is a unicenter retrospective study, which included all patients admitted on an emergency basis to 2 departments of a teaching hospital during a 2-year interval to whom presepsin level was determined at the emergency department prior to admission. Serum creatinine (sCrt) was employed to estimate the severity of KD using 3 thresholds (1.5, 2, and 4 mg/dL) resulting in 4 degrees of severity: KD_1, KD_2, KD_3, KD_4. There is an ascending exponential relationship between presepsin and sCrt: presepsin = 600.03e0.212sCrt. Presepsin levels are significantly different between the patients with KD_1, KD_2, KD_3, and KD_4. In the receiver operating characteristic curves exploring the usefulness of presepsin in sepsis diagnosis, the area under the curve was satisfactory for KD_1 (0.78), KD_2 (0.78), and KD_3 (0.82), but unacceptably low for KD_4 (0.59), while the optimal cutoff points were (depending on the computational method) 700/ 982, 588/ 1125, 1065, and 2260 pg/mL for KD_1, KD_2, KD_3, and KD_4 respectively. The threshold for abnormal presepsin should be about 600, 1000, and 1300 pg/mL in patients with KD_1, KD_2, and KD_3, respectively. In patients with KD_4, presepsin has a poor discriminating power for sepsis diagnosis. If, notwithstanding, it is used for this purpose, the cutoff point should be at least at 2200.

Role of antiseptics in the prevention and treatment of infections in nursing homes

Inadequate infection control, wound care, and oral hygiene protocols in nursing homes pose challenges to residents' quality of life. Based on the outcomes from a focus group meeting and a literature search, this narrative review evaluates the current and potential roles of antiseptics within nursing home infection management procedures. We examine contemporary strategies and concerns within the management of meticillin-resistant Staphylococcus aureus (MRSA; including decolonization regimes), chronic wound care, and oral hygiene, and review the available data for the use of antiseptics, with a focus on povidone-iodine. Compared with chlorhexidine, polyhexanide, and silver, povidone-iodine has a broader spectrum of antimicrobial activity, with rapid and potent activity against MRSA and other microbes found in chronic wounds, including biofilms. As no reports of bacterial resistance or cross-resistance following exposure to povidone-iodine exist, it may be preferable for MRSA decolonization compared with mupirocin and chlorhexidine, which can lead to resistant MRSA strains. Povidone-iodine oral products have greater efficacy against oral pathogens compared with other antiseptics such as chlorhexidine mouthwash, highlighting the clinical benefit of povidone-iodine in oral care. Additionally, povidone-iodine-based products, including mouthwash, have demonstrated rapid in-vitro virucidal activity against SARS-CoV-2 and may help reduce its transmission if incorporated into nursing home coronavirus 2019 control protocols. Importantly, povidone-iodine activity is not adversely affected by organic material, such as that found in chronic wounds and the oral cavity. Povidone-iodine is a promising antiseptic agent for the management of infections in the nursing home setting, including MRSA decolonization procedures, chronic wound management, and oral care.

Predictors of Survival Among the Oldest Old Following Acute Hospital Admission: Insights From Clinical and Biochemical Factors

Understanding the factors influencing survival in oldest old population is crucial for providing appropriate care and improving outcomes. This prospective observational study aimed to investigate the determinants of survival in acutely ill oldest old patients during acute hospitalization and 1-month follow-up. Various geriatric domains and biochemical markers were assessed. Among the 70 included patients with a median age of 87 (Inter quartile range: 85-90), the presence of diabetes, delirium, tachypnea, and high sirtuin-5 levels were associated with reduced in-hospital survival. Non-survivors had raised levels of Sirtuin 1 and Sirtuin 5, with an increase of 43% and 70%, respectively. At 1 month, delirium and diabetes were still associated with reduced survival. These findings suggest that type-2 diabetes, delirium, tachypnea, and high sirtuin-5 levels could serve as predictors of reduced survival in acutely ill, hospitalized oldest old patients.

Aging and macrophages: Not standing the test of time?

The underlying mechanism of immunosenescence and compromised responses to environmental stressors in alveolar macrophages is a result of epigenetic dysregulation, rather than loss of subtypes.

Katater İlişkili Üriner Sistem Enfeksiyonlarında Mortalite ile İlişkili Faktörlerin Değerlendirilmesi, 5 Yıllık Retrosepektif Çalışma

Amaç: Bu çalışmanın amacı, kateter ilişkili üriner sistem enfeksiyonlarında (Kİ-ÜSİ) mortalite ile epidemiyolojik faktörler, komorbid durumlar, antibiyotik direnci, ampirik antimikrobiyal tedavi ve laboratuvar parametreleri arasındaki ilişkiyi değerlendirmektir. Gereç ve yöntemler: Yoğun bakıma 1 Ocak 2015 ile 1 Ocak 2020 arasında kabul edilen 18 yaş ve üzeri hastalarda retrospektif bir kohort çalışması tasarlanmıştır. Birincil sonlanım noktası hastanın kabulünün ilk 28 günü içinde ölüm, ikincil son nokta ise 28 günden sonra sağkalımdı. p< 0.05 değeri anlamlı kabul edildi. Bulgular: Çalışmaya medyan yaşı 78, 198'i (%52,8) kadın olan toplam 375 hasta alındı. En sık saptanan mikroorganizmalar Escherichia coli (%50.9) ve Enterococcus faecalis (%16.8) idi. Gram negatif bakterilerin 3. kuşak sefalosporinlere, siprofloksasine ve meropenem'e direnci sırasıyla %41,3, %40 ve %8,6 saptandı. Gram pozitif bakterilerin %0,3'ünde vankomisin direnci tespit edildi. Mortalite oranı %58,1 idi. Artmış mortalite riski ile ilişkili faktörler ≥ 65 yaş, malignite varlığı, mekanik ventilasyon, APACHE II skoru ≥ 20 ve septik şok tanısıydı. Daha düşük ölüm riski ile ilişkili tek faktör kültürde E. coli'nin saptanmasıydı. Sonuç: Epidemiyolojik faktörlerin, eşlik eden hastalıkların, klinik skorlama sistemlerinin ve mikrobiyolojik sonuçların mortalite üzerine etkisi olduğu belirlendi. Bu çalışmanın sonuçları, kılavuzlarda yer alan enfeksiyon kontrol önlemleri ve tedavi önerileri ile birlikte değerlendirildiğinde, Kİ-ÜSİ'ye bağlı mortalitenin azaltılabileceğini düşünmekteyiz.

Hospital admissions due to infectious and parasitic diseases in England and Wales between 1999 and 2019: an ecological study

Background

Infectious diseases continue to account for considerable illness and death worldwide, and emerging infectious diseases (EIDs) are a significant burden on global economies and public health. This study aimed to investigate the trends in infectious and parasitic disease (IPD) hospital admissions (HA) in England and Wales between 1999 and 2019.

Methods

This is an ecological study using publicly available data taken from the Hospital Episode Statistics database in England and the Patient Episode Database for Wales. Hospital admission data were collected for the period between April 1999 to March 2019. IPDHA were identified using the tenth version of the International Statistical Classification of Diseases system, diagnostic codes (A00–B99). The trend in hospital admissions was assessed using a Poisson model.

Results

The overall annual number for IPD hospital admissions for various causes increased by 412.9%, from 151,336 in 1999 to 776,215 in 2019, representing an increase in hospital admission rate of 349.9% from 290.25 (95% CI 288.79–291.71) in 1999 to 1305.88 (95% CI 1303.00–1308.77) in 2019 per 100,000 persons: trend test, p < 0.01. The most common causes of infectious and parasitic disease hospital admissions were intestinal infectious diseases, other bacterial diseases, and other viral diseases, which accounted for 33.6, 27.5, and 23.8%, respectively. Patients aged 15 years and below accounted for 34.2% of the entire number of IPD hospital admissions, followed by the age group 15–59 years with 27.9%, the age group 75 years and above with 22.7%, and then the age group 60–74 years with 15.2%.

Conclusion

There was an increase in the hospital admission rate due to infectious diseases in the UK from 1999 to 2019. The most common causes of infectious and parasitic disease hospital admissions were intestinal infectious diseases, other bacterial diseases, and other viral diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07388-1.

Functional, transcriptional, and microbial shifts associated with healthy pulmonary aging in rhesus macaques

Older individuals are at increased risk of developing severe respiratory infections. However, our understanding of the impact of aging on the respiratory tract remains limited as samples from healthy humans are challenging to obtain and results can be confounded by variables such as smoking and diet. Here, we carry out a comprehensive cross-sectional study (n = 34 adult, n = 49 aged) to define the consequences of aging on the lung using the rhesus macaque model. Pulmonary function testing establishes similar age and sex differences as humans. Additionally, we report increased abundance of alveolar and infiltrating macrophages and a concomitant decrease in T cells were in aged animals. scRNAseq reveals shifts from GRZMB to IFN expressing CD8⁺ T cells in the lungs. These data provide insight into age-related changes in the lungs’ functional, microbial, and immunological landscape that explain increased prevalence and severity of respiratory diseases in the elderly.

Rhoades et al. describe age-associated functional, microbial, and immunological changes in the lung using the rhesus macaque model. These data will support further studies aimed at designing and testing interventions to mitigate the impact of age-associated shifts in the lung environment to reduce age-related pulmonary disease in the elderly.

Clinical symptoms, diagnosis, treatment, and outcome of COVID-19-associated encephalitis: A systematic review of case reports and case series

Introduction

Since COVID‐19 outbreak, various studies mentioned the occurrence of neurological disorders. Of these, encephalitis is known as a critical neurological complication in COVID‐19 patients. Numerous case reports and case series have found encephalitis in relation to COVID‐19, which have not been systematically reviewed. This study aims to evaluate the clinical symptoms, diagnosis, treatment, and outcome of COVID‐19‐associated encephalitis.

Methods

We used the Pubmed/Medline, Embase, and Web of Science databases to search for reports on COVID‐19‐associated encephalitis from January 1, 2019, to March 7, 2021. The irrelevant studies were excluded based on screening and further evaluation. Then, the information relating diagnosis, treatment, clinical manifestations, comorbidities, and outcome was extracted and evaluated.

Results

From 4455 initial studies, 45 articles met our criteria and were selected for further evaluation. Included publications reported an overall number of 53 COVID‐19‐related encephalitis cases. MRI showed hyperintensity of brain regions including white matter (44.68%), temporal lobe (17.02%), and thalamus (12.76%). Also, brain CT scan revealed the hypodensity of the white matter (17.14%) and cerebral hemorrhages/hemorrhagic foci (11.42%) as the most frequent findings. The IV methylprednisolone/oral prednisone (36.11%), IV immunoglobulin (27.77%), and acyclovir (16.66%) were more preferred for COVID‐19 patients with encephalitis. From the 46 patients, 13 (28.26%) patients were died in the hospital.

Conclusion

In this systematic review, characteristics of COVID‐19‐associated encephalitis including clinical symptoms, diagnosis, treatment, and outcome were described. COVID‐19‐associated encephalitis can accompany with other neurological symptoms and involve different brain. Although majority of encephalitis condition are reversible, but it can lead to life‐threatening status. Therefore, further investigation of COVID‐19‐associated encephalitis is required.

Antimicrobial-associated organ injury among the elderly: a systematic review and meta-analysis protocol

INTRODUCTION

Older adults (aged 65 years and above) constitute the fastest growing population cohort in the western world. There is increasing evidence that the burden of infections disproportionately affects this cohort of older adults and hence this vulnerable population is frequently exposed to antimicrobials. There is currently no systematic review summarising the evidence for risk of organ injury following antimicrobial exposure among older adults. This protocol will outline how we will conduct a systematic review and meta-analyses to examine the relationship between antimicrobial exposure and organ injury in older adults.

METHODS AND ANALYSIS

We will search for PsycINFO, PubMed and EMBASE databases for relevant articles using MeSH terms where applicable. After removing duplicates, articles will be screened for inclusion into or exclusion from the study by two reviewers. Title and abstract screening will be done first, followed by full-text screening. The Newcastle-Ottawa scale will be used to assess the risk of bias for cohort and case control studies, and the Cochrane collaboration's risk of bias tool will be used for randomised control trials. We will explore the potential sources of heterogeneity and bias using funnel and forest plots of the included studies.

ETHICS AND DISSEMINATION

During the conduct of the review, ethical principles will be observed to ensure integrity. Any potential conflicts of interests will be declared, all contributors acknowledged and no plagiarised material will be included in the review.The systematic review and meta-analysis will be submitted for publication in a peer-reviewed journal in geriatrics. The findings will also be presented at international conferences in geriatrics or pharmacoepidemiology. The results will be communicated to patient and public engagement networks supported by the NHS Research and Development.

PROSPERO REGISTRATION NUMBER

This protocol is registered in the PROSPERO database (registration number CRD42020152621).

Risk Factors for Infections, Antibiotic Therapy, and Its Impact on Cancer Therapy Outcomes for Patients with Solid Tumors

Infections represent a significant cause of morbidity and mortality in cancer patients. Multiple factors related to the patient, tumor, and cancer therapy can affect the risk of infection in patients with solid tumors. A thorough understanding of such factors can aid in the identification of patients with substantial risk of infection, allowing medical practitioners to tailor therapy and apply prophylactic measures to avoid serious complications. The use of novel treatment modalities, including targeted therapy and immunotherapy, brings diagnostic and therapeutic challenges into the management of infections in cancer patients. A growing body of evidence suggests that antibiotic therapy can modulate both toxicity and antitumor response induced by chemotherapy, radiotherapy, and especially immunotherapy. This article provides a comprehensive review of potential risk factors for infections and therapeutic approaches for the most prevalent infections in patients with solid tumors, and discusses the potential effect of antibiotic therapy on toxicity and efficacy of cancer therapy.

Implementation of Nurse-Led, Goal-Directed Lung Physiotherapy for Older Patients With Sepsis and Pneumonia in the ICU

Objectives: This study aimed to investigate the effect of nurse-led, goal-directed lung physiotherapy (GDLPT) on the prognosis of older patients with sepsis caused by pneumonia in the intensive care unit. Methods: We conducted a prospective, two-phase (before-and-after) study over 3 years called the GDLPT study. All patients received standard lung therapy for sepsis caused by pneumonia and patients in phase 2 also received GDLPT. In this study, 253 older patients (age ≥ 65 years) with sepsis and pneumonia were retrospectively analyzed. The main outcome was 28 day mortality. Results: Among 742 patients with sepsis, 253 older patients with pneumonia were divided into the control group and the treatment group. Patients in the treatment group had a significantly shorter duration of mechanical ventilation [5 (4, 6) vs. 5 (4, 8) days; P = 0.045], and a lower risk of intensive care unit (ICU) mortality [14.5% (24/166) vs. 28.7% (25/87); P = 0.008] and 28 day mortality [15.1% (25/166) vs. 31% (27/87); P = 0.005] compared with those in the control group. GDLPT was an independent risk factor for 28 day mortality [odds ratio (OR), 0.379; 95% confidence interval (CI), 0.187-0.766; P = 0.007]. Conclusions: Nurse-led GDLPT shortens the duration of mechanical ventilation, decreases ICU and 28-day mortality, and improves the prognosis of older patients with sepsis and pneumonia in the ICU.

Long-term cardiovascular complications following sepsis: is senescence the missing link?

Among the long-term consequences of sepsis (also termed “post-sepsis syndrome”) the increased risk of unexplained cardiovascular complications, such as myocardial infarction, acute heart failure or stroke, is one of the emerging specific health concerns. The vascular accelerated ageing also named premature senescence is a potential mechanism contributing to atherothrombosis, consequently leading to cardiovascular events. Indeed, vascular senescence-associated major adverse cardiovascular events (MACE) are a potential feature in sepsis survivors and of the elderly at cardiovascular risk. In these patients, accelerated vascular senescence could be one of the potential facilitating mechanisms. This review will focus on premature senescence in sepsis regardless of age. It will highlight and refine the potential relationships between sepsis and accelerated vascular senescence. In particular, key cellular mechanisms contributing to cardiovascular events in post-sepsis syndrome will be highlighted, and potential therapeutic strategies to reduce the cardiovascular risk will be further discussed.

With improved management of patients, sepsis survivors are increasing each year.

Early cardiovascular complications, of yet undeciphered mechanisms, are an emerging health issue in post-sepsis syndrome.

Premature senescence of endothelium and vascular tissue is proven an accelerated process of atherogenesis in young septic rats.

An increasing body of clinical evidence point at endothelial senescence in the initiation and development of atherosclerosis.

Prevention of premature senescence by senotherapy and cardiological follow-up could improve long-term septic patients’ outcomes.

Risk of antimicrobial-associated organ injury among the older adults: a systematic review and meta-analysis

Background

Older adults (aged 65 years and above) constitute the fastest growing population cohort in the western world. There is increasing evidence that the burden of infections disproportionately affects older adults, and hence this vulnerable population is frequently exposed to antimicrobials. There is currently no systematic review summarising the evidence for organ injury risk among older adults following antimicrobial exposure. This systematic review and meta-analysis examined the relationship between antimicrobial exposure and organ injury in older adults.

Methodology

We searched for original research articles in PubMed, Embase.com, Web of Science core collection, Web of Science BIOSIS citation index, Scopus, Cochrane Central Register of Controlled Trials, ProQuest, and PsycINFO databases, using key words in titles and abstracts, and using MeSH terms. We searched for all available articles up to 31 May 2021. After removing duplicates, articles were screened for inclusion into or exclusion from the study by two reviewers. The Newcastle-Ottawa scale was used to assess the risk of bias for cohort and case-control studies. We explored the heterogeneity of the included studies using the Q test and I² test and the publication bias using the funnel plot and Egger’s test. The meta-analyses were performed using the OpenMetaAnalyst software.

Results

The overall absolute risks of acute kidney injury among older adults prescribed aminoglycosides, glycopeptides, and macrolides were 15.1% (95% CI: 12.8–17.3), 19.1% (95% CI: 15.4–22.7), and 0.3% (95% CI: 0.3–0.3), respectively. Only 3 studies reported antimicrobial associated drug-induced liver injury. Studies reporting on the association of organ injury and antimicrobial exposure by age or duration of treatment were too few to meta-analyse. The funnel plot and Egger’s tests did not indicate evidence of publication bias.

Conclusion

Older adults have a significantly higher risk of sustaining acute kidney injury when compared to the general adult population. Older adults prescribed aminoglycosides have a similar risk of acute kidney injury to the general adult population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02512-3.

Encephalitis as a neurological complication of COVID-19: A systematic review and meta-analysis of incidence, outcomes, and predictors

BACKGROUND AND PURPOSE

Although COVID-19 predominantly affects the respiratory system, recent studies have reported the occurrence of neurological disorders such as stroke in relation to COVID-19 infection. Encephalitis is an inflammatory condition of the brain that has been described as a severe neurological complication of COVID-19. Despite a growing number of reported cases, encephalitis related to COVID-19 infection has not been adequately characterised. To address this gap, this systematic review and meta-analysis aims to describe the incidence, clinical course, and outcomes of patients who suffer from encephalitis as a complication of COVID-19.

METHODS

All studies published between 1 November 2019 and 24 October 2020 that reported on patients who developed encephalitis as a complication of COVID-19 were included. Only cases with radiological and/or biochemical evidence of encephalitis were included.

RESULTS

In this study, 610 studies were screened and 23 studies reporting findings from 129,008 patients, including 138 with encephalitis, were included. The average time from diagnosis of COVID-19 to onset of encephalitis was 14.5 days (range = 10.8-18.2 days). The average incidence of encephalitis as a complication of COVID-19 was 0.215% (95% confidence interval [CI] = 0.056%-0.441%). The average mortality rate of encephalitis in COVID-19 patients was 13.4% (95% CI = 3.8%-25.9%). These patients also had deranged clinical parameters, including raised serum inflammatory markers and cerebrospinal fluid pleocytosis.

CONCLUSIONS

Although encephalitis is an uncommon complication of COVID-19, when present, it results in significant morbidity and mortality. Severely ill COVID-19 patients are at higher risk of suffering from encephalitis as a complication of the infection.