Factors associated with non-invasive positive pressure ventilation failure in a COVID-19 intermediate care unit

BACKGROUND

The use of non-invasive positive pressure ventilation (NIPPV) in COVID-19 patients with hypoxaemia is still under debate. The aim was to evaluate the efficacy of NIPPV (CPAP, HELMET-CPAP or NIV) in COVID-19 patients treated in the dedicated COVID-19 Intermediate Care Unit of Coimbra Hospital and University Centre, Portugal, and to assess factors associated with NIPPV failure.

METHODS

Patients admitted from December 1st 2020 to February 28th 2021, treated with NIPPV due to COVID-19 were included. Failure was defined as orotracheal intubation (OTI) or death during hospital stay. Factors associated with NIPPV failure were included in a univariate binary logistic regression analysis; those with a significance level of p < 0.001 entered a multivariate logistic regression model.

RESULTS

A total of 163 patients were included, 64.4% were males (n = 105). The median age was 66 years (IQR 56-75). NIPPV failure was observed in 66 (40.5%) patients, 26 (39.4%) were intubated and 40 (60.6%) died during their hospital stay. The highest CRP (OR 1.164; 95%CI 1.036-1.308) and morphine use (OR 24.771; 95%CI 1.809-339.241) were identified as predictors of failure after applying multivariate logistic regression. Adherence to prone positioning (OR 0.109; 95%CI 0.017-0.700) and a higher value of the lowest platelet count during hospital stay (OR 0.977; 95%CI 0.960-0.994) were associated with a favorable outcome.

CONCLUSIONS

NIPPV was successful in over half of patients. Highest CRP during hospital stay and morphine use were predictors of failure. Adherence to prone positioning and a higher value of the lowest platelet count during hospital stay were associated with a favourable outcome.

Brucella vertebral osteomyelitis misidentified as an Ochrobactrum anthropi infection

Ochrobactrum anthropi is a Gram-negative bacillus widely distributed in nature. It is a low virulence and low pathogenic microorganism and human infection by this agent is considered rare. This microorganism can cause bacteremia and in some cases can lead to osteomyelitis and endocarditis. Included in Brucellaceae family, this bacterium is phenotypically and genetically closely related to the Brucella genus and may be misidentified by rapid identification systems. The authors describe a patient admitted to the Infectious Diseases Department with vertebral osteomyelitis initially identified as Ochrobactrum anthropi. Despite appropriate antimicrobial therapy, the blood cultures remained positive and there were no signs of clinical improvement. This raised suspicion of a possible misidentification. It was decided to initiate antimicrobial therapy to include the Brucella genus, with slow but progressive clinical improvement. Samples were sent to Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA) for genotyping, confirming the initial suspicion of misidentification and identifying Brucella melitensis as the causal agent. Timely diagnosis of brucellosis is essential for the correct management and prevention of its consequences for the patient and for safe handling of the laboratory samples, preventing laboratory-acquired infection.

Miliary tuberculosis with cerebral, liver, prostate and retroesophageal involvement

Miliary tuberculosis results from the lymphohematogenous spread of Mycobacterium tuberculosis and it is a rare form of this disease. The most affected places are the lymph nodes, pleura, and osteoarticular system, but any organ can be involved. Currently the disease is still endemic in developing countries by its close association with poor living conditions and malnutrition. Other comorbidities, particularly infection by human immunodeficiency virus (HIV), diabetes mellitus, smoking and alcoholism are of great importance in the epidemiology of this disease. The authors describe the case of an adult man from Guinea-Bissau that has been residing in Portugal for the last few months, admitted with complaints of headache. He was submitted to a computerized tomography (CT) scan of the brain which showed multiple lesions. This led to further study and the diagnosis of a disseminated tuberculosis with cerebral, liver, prostate and retroesophageal involvement. He was started on anti-tuberculosis therapy, achieving good results.