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Busani S, Coloretti I, Baciarello M, Bellini V, Sarti M, Biagioni E, Tonelli R, Marchioni A, Clini E, Guaraldi G, Mussini C, Meschiari M, Tonetti T, Pisani L, Nava S, Bignami E, Ranieri MV, Girardis M. Association between respiratory distress time and invasive mechanical ventilation in COVID-19 patients: A multicentre regional cohort study. Pulmonology 2024; 30:282-286. [PMID: 35501277 PMCID: PMC8958102 DOI: 10.1016/j.pulmoe.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/25/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
AIM To determine whether the duration of respiratory distress symptoms in severe COVID-19 pneumonia affects the need for invasive mechanical ventilation and clinical outcomes. MATERIALS AND METHODS An observational multicentre cohort study of patients hospitalised in five COVID-19-designated ICUs of the University Hospitals of Emilia-Romagna Region. Patients included were adults with pneumonia due to SARS-CoV-2 with PaO₂/FiO₂ ratio <300 mmHg, respiratory distress symptoms, and need for mechanical ventilation (invasive or non-invasive). Exclusion criteria were an uncertain time of respiratory distress, end-of-life decision, and mechanical respiratory support before hospital admission. MEASUREMENTS AND MAIN RESULTS We analysed 171 patients stratified into tertiles according to respiratory distress duration (distress time, DT) before application of mechanical ventilation support. The rate of patients requiring invasive mechanical ventilation was significantly different (p < 0.001) among the tertiles: 17/57 patients in the shortest duration, 29/57 in the intermediate duration, and 40/57 in the longest duration. The respiratory distress time significantly increased the risk of invasive ventilation in the univariate analysis (OR 5.5 [CI 2.48-12.35], p = 0.003). Multivariable regression analysis confirmed this association (OR 10.7 [CI 2.89-39.41], p < 0.001). Clinical outcomes (mortality and hospital stay) did not show significant differences between DT tertiles. DISCUSSION Albeit preliminary and retrospective, our data raised the hypothesis that the duration of respiratory distress symptoms may play a role in COVID-19 patients' need for invasive mechanical ventilation. Furthermore, our observations suggested that specific strategies may be directed towards identifying and managing early symptoms of respiratory distress, regardless of the levels of hypoxemia and the severity of the dyspnoea itself.
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Affiliation(s)
- S Busani
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy.
| | - I Coloretti
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - M Baciarello
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - V Bellini
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - M Sarti
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - E Biagioni
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - R Tonelli
- Respiratory Diseases Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - A Marchioni
- Respiratory Diseases Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - E Clini
- Respiratory Diseases Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - G Guaraldi
- Infectious Disease Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - C Mussini
- Infectious Disease Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - M Meschiari
- Infectious Disease Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - T Tonetti
- Anesthesia and Intensive Care Medicine, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - L Pisani
- Pneumology and Respiratory Critical Care, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - S Nava
- Pneumology and Respiratory Critical Care, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - E Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - M V Ranieri
- Anesthesia and Intensive Care Medicine, University Hospital of Bologna Sant'Orsola, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - M Girardis
- Anesthesia and Intensive Care Unit, University Hospital of Modena Policlinico, University of Modena and Reggio Emilia, Modena, Italy
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Girardis M, Coloretti I, Antonelli M, Berlot G, Busani S, Cortegiani A, De Pascale G, De Rosa FG, De Rosa S, Donadello K, Donati A, Forfori F, Giannella M, Grasselli G, Montrucchio G, Oliva A, Pasero D, Piazza O, Romagnoli S, Tascini C, Viaggi B, Tumbarello M, Viale P. Adjunctive immunotherapeutic agents in patients with sepsis and septic shock: a multidisciplinary consensus of 23. J Anesth Analg Crit Care 2024; 4:28. [PMID: 38689337 PMCID: PMC11059820 DOI: 10.1186/s44158-024-00165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND In the last decades, several adjunctive treatments have been proposed to reduce mortality in septic shock patients. Unfortunately, mortality due to sepsis and septic shock remains elevated and NO trials evaluating adjunctive therapies were able to demonstrate any clear benefit. In light of the lack of evidence and conflicting results from previous studies, in this multidisciplinary consensus, the authors considered the rational, recent investigations and potential clinical benefits of targeted adjunctive therapies. METHODS A panel of multidisciplinary experts defined clinical phenotypes, treatments and outcomes of greater interest in the field of adjunctive therapies for sepsis and septic shock. After an extensive systematic literature review, the appropriateness of each treatment for each clinical phenotype was determined using the modified RAND/UCLA appropriateness method. RESULTS The consensus identified two distinct clinical phenotypes: patients with overwhelming shock and patients with immune paralysis. Six different adjunctive treatments were considered the most frequently used and promising: (i) corticosteroids, (ii) blood purification, (iii) immunoglobulins, (iv) granulocyte/monocyte colony-stimulating factor and (v) specific immune therapy (i.e. interferon-gamma, IL7 and AntiPD1). Agreement was achieved in 70% of the 25 clinical questions. CONCLUSIONS Although clinical evidence is lacking, adjunctive therapies are often employed in the treatment of sepsis. To address this gap in knowledge, a panel of national experts has provided a structured consensus on the appropriate use of these treatments in clinical practice.
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Affiliation(s)
- Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Antonelli
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Berlot
- Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Gennaro De Pascale
- Dipartimento Di Scienze Biotecnologiche Di Base, Cliniche Intensivologiche E Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Di Scienze Dell'Emergenza, Anestesiologiche E Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Silvia De Rosa
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, and Anesthesia and Intensive Care Unit B, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Francesco Forfori
- Anesthesia and Intensive Care, Anesthesia and Resuscitation Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgia Montrucchio
- Department of Surgical Sciences, Departement of Anesthesia, Resuscitation and Emergency Torino, University of Turin, Turin, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Daniela Pasero
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Ornella Piazza
- University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Stefano Romagnoli
- Department of Health Science, Department of Anesthesia and Intensive Care, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, Udine, Italy
| | - Bruno Viaggi
- Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Mario Tumbarello
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences Infectious Diseases Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Santacroce E, D'Angerio M, Ciobanu AL, Masini L, Lo Tartaro D, Coloretti I, Busani S, Rubio I, Meschiari M, Franceschini E, Mussini C, Girardis M, Gibellini L, Cossarizza A, De Biasi S. Advances and Challenges in Sepsis Management: Modern Tools and Future Directions. Cells 2024; 13:439. [PMID: 38474403 DOI: 10.3390/cells13050439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024] Open
Abstract
Sepsis, a critical condition marked by systemic inflammation, profoundly impacts both innate and adaptive immunity, often resulting in lymphopenia. This immune alteration can spare regulatory T cells (Tregs) but significantly affects other lymphocyte subsets, leading to diminished effector functions, altered cytokine profiles, and metabolic changes. The complexity of sepsis stems not only from its pathophysiology but also from the heterogeneity of patient responses, posing significant challenges in developing universally effective therapies. This review emphasizes the importance of phenotyping in sepsis to enhance patient-specific diagnostic and therapeutic strategies. Phenotyping immune cells, which categorizes patients based on clinical and immunological characteristics, is pivotal for tailoring treatment approaches. Flow cytometry emerges as a crucial tool in this endeavor, offering rapid, low cost and detailed analysis of immune cell populations and their functional states. Indeed, this technology facilitates the understanding of immune dysfunctions in sepsis and contributes to the identification of novel biomarkers. Our review underscores the potential of integrating flow cytometry with omics data, machine learning and clinical observations to refine sepsis management, highlighting the shift towards personalized medicine in critical care. This approach could lead to more precise interventions, improving outcomes in this heterogeneously affected patient population.
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Affiliation(s)
- Elena Santacroce
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Miriam D'Angerio
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Alin Liviu Ciobanu
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Linda Masini
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Domenico Lo Tartaro
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Irene Coloretti
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Stefano Busani
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Ignacio Rubio
- Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care, Jena University Hospital, 07747 Jena, Germany
| | - Marianna Meschiari
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Erica Franceschini
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Cristina Mussini
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Massimo Girardis
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Lara Gibellini
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Sara De Biasi
- Department of Medical and Surgical Sciences for Children & Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
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Coloretti I, Genovese A, Teixeira JP, Cherian A, Ferrer R, Landoni G, Leone M, Girardis M, Nielsen ND. Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review. J Anesth Analg Crit Care 2024; 4:13. [PMID: 38383521 PMCID: PMC10882873 DOI: 10.1186/s44158-024-00150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.
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Affiliation(s)
- Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy.
| | - Andrea Genovese
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Anusha Cherian
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, India
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Giovanni Landoni
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc Leone
- Anesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Caciagli V, Coloretti I, Talamonti M, Farinelli C, Gatto I, Biagioni E, Sarti M, Franceschini E, Meschiari M, Mussini C, Tonelli R, Clini E, Girardis M, Busani S. Association between Pulmonary Aspergillosis and Cytomegalovirus Reactivation in Critically Ill COVID-19 Patients: A Prospective Observational Cohort Study. Viruses 2023; 15:2260. [PMID: 38005936 PMCID: PMC10675747 DOI: 10.3390/v15112260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
COVID-19-associated invasive pulmonary aspergillosis (CAPA) is common and is associated with poor outcomes in critically ill patients. This prospective observational study aimed to explore the association between CAPA development and the incidence and prognosis of cytomegalovirus (CMV) reactivation in critically ill COVID-19 patients. We included all consecutive critically ill adult patients with confirmed COVID-19 infection who were admitted to three COVID-19 intensive care units (ICUs) in an Italian hospital from 25 February 2020 to 8 May 2022. A standardized procedure was employed for early detection of CAPA. Risk factors associated with CAPA and CMV reactivation and the association between CMV recurrence and mortality were estimated using adjusted Cox proportional hazard regression models. CAPA occurred in 96 patients (16.6%) of the 579 patients analyzed. Among the CAPA population, 40 (41.7%) patients developed CMV blood reactivation with a median time of 18 days (IQR 7-27). The CAPA+CMV group did not exhibit a significantly higher 90-day mortality rate (62.5% vs. 48.2%) than the CAPA alone group (p = 0.166). The CAPA+CMV group had a longer ICU stay, fewer ventilation-free days, and a higher rate of secondary bacterial infections than the control group of CAPA alone. In the CAPA population, prior immunosuppression was the only independent risk factor for CMV reactivation (HR 2.33, 95% C.I. 1.21-4.48, p = 0.011). In critically ill COVID-19 patients, CMV reactivation is common in those with a previous CAPA diagnosis. Basal immunosuppression before COVID-19 appeared to be the primary independent variable affecting CMV reactivation in patients with CAPA. Furthermore, the association of CAPA+CMV versus CAPA alone appears to impact ICU length of stay and secondary bacterial infections but not mortality.
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Affiliation(s)
- Valeria Caciagli
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Marta Talamonti
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Carlotta Farinelli
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Ilenia Gatto
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Emanuela Biagioni
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Mario Sarti
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (M.M.)
| | - Marianna Meschiari
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (M.M.)
| | - Cristina Mussini
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (M.M.)
| | - Roberto Tonelli
- Respiratory Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Enrico Clini
- Respiratory Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy (E.B.)
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Campani S, Talamonti M, Dall’Ara L, Coloretti I, Gatto I, Biagioni E, Tosi M, Meschiari M, Tonelli R, Clini E, Cossarizza A, Guaraldi G, Mussini C, Sarti M, Trenti T, Girardis M. The Association of Procalcitonin and C-Reactive Protein with Bacterial Infections Acquired during Intensive Care Unit Stay in COVID-19 Critically Ill Patients. Antibiotics (Basel) 2023; 12:1536. [PMID: 37887237 PMCID: PMC10604665 DOI: 10.3390/antibiotics12101536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/22/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023] Open
Abstract
In COVID-19 patients, procalcitonin (PCT) and C-reactive protein (CRP) performance in identifying bacterial infections remains unclear. Our study aimed to evaluate the association of PCT and CRP with secondary infections acquired during ICU stay in critically ill COVID-19 patients. This observational study included adult patients admitted to three COVID-19 intensive care units (ICUs) from February 2020 to May 2022 with respiratory failure caused by SARS-CoV-2 infection and ICU stay ≥ 11 days. The values of PCT and CRP collected on the day of infection diagnosis were compared to those collected on day 11 after ICU admission, the median time for infection occurrence, in patients without secondary infection. The receiver operating characteristic curve (ROC) and multivariate logistic model were used to assess PCT and CRP association with secondary infections. Two hundred and seventy-nine patients were included, of whom 169 (60.6%) developed secondary infection after ICU admission. The PCT and CRP values observed on the day of the infection diagnosis were larger (p < 0.001) than those observed on day 11 after ICU admission in patients without secondary infections. The ROC analysis calculated an AUC of 0.744 (95%CI 0.685-0.803) and 0.754 (95%CI 0.695-0.812) for PCT and CRP, respectively. Multivariate logistic models showed that PCT ≥ 0.16 ng/mL and CRP ≥ 1.35 mg/dL were associated (p < 0.001) with infections acquired during ICU stay. Our results indicated that in COVID-19 patients, PCT and CRP values were associated with infections acquired during the ICU stay and can be used to support, together with clinical signs, rather than predict or rule out, the diagnosis of these infections.
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Affiliation(s)
- Simone Campani
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Marta Talamonti
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Lorenzo Dall’Ara
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Irene Coloretti
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Ilenia Gatto
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Emanuela Biagioni
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Martina Tosi
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
| | - Marianna Meschiari
- Infectious Disease Unit, University Hospital of Modena, 41125 Modena, Italy; (M.M.); (G.G.); (C.M.)
| | - Roberto Tonelli
- Respiratory Disease Unit, University Hospital of Modena, 41125 Modena, Italy; (R.T.); (E.C.)
| | - Enrico Clini
- Respiratory Disease Unit, University Hospital of Modena, 41125 Modena, Italy; (R.T.); (E.C.)
| | - Andrea Cossarizza
- Immunology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Giovanni Guaraldi
- Infectious Disease Unit, University Hospital of Modena, 41125 Modena, Italy; (M.M.); (G.G.); (C.M.)
| | - Cristina Mussini
- Infectious Disease Unit, University Hospital of Modena, 41125 Modena, Italy; (M.M.); (G.G.); (C.M.)
| | - Mario Sarti
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, 41125 Modena, Italy;
| | - Tommaso Trenti
- Diagnostic Hematology and Clinical Genomics Laboratory, Department of Laboratory Medicine and Pathology, Local Health Service and University Hospital of Modena, 41124 Modena, Italy;
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, 41125 Modena, Italy; (S.C.); (M.T.); (L.D.); (I.C.); (I.G.); (E.B.); (M.T.)
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Coloretti I, Farinelli C, Biagioni E, Gatto I, Munari E, Dall’Ara L, Busani S, Meschiari M, Tonelli R, Mussini C, Guaraldi G, Cossarizza A, Clini E, Girardis M. Critical COVID-19 patients through first, second, and third wave: retrospective observational study comparing outcomes in intensive care unit. J Thorac Dis 2023; 15:3218-3227. [PMID: 37426115 PMCID: PMC10323587 DOI: 10.21037/jtd-22-764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/02/2022] [Indexed: 07/11/2023]
Abstract
Background The time-course of the coronavirus disease 2019 (COVID-19) pandemic was characterized by subsequent waves identified by peaks of intensive care unit (ICU) admission rates. During these periods, progressive knowledge of the disease led to the development of specific therapeutic strategies. This retrospective study investigates whether this led to improvement in outcomes of COVID-19 patients admitted to ICU. Methods Outcomes were evaluated in consecutive adult COVID-19 patients admitted to our ICU, divided into three waves based on the admission period: the first wave from February 25th, 2020, to July 6th, 2020; the second wave from September 20th, 2020, to February 13th, 2021; the third wave from February 14th, 2021 to April 30th, 2021. Differences were assessed comparing outcomes and by using different multivariable Cox models adjusted for variables related to outcome. Further sensitivity analysis was performed in patients undergoing invasive mechanical ventilation (IMV). Results Overall, 428 patients were included in the analysis: 102, 169, and 157 patients in the first, second, and third wave. The ICU and in-hospital crude mortalities were lower by 7% and 10% in the third wave compared to the other two waves (P>0.05). A higher number of ICU- and hospital-free days at day 90 was found in the third wave when compared to the other two waves (P=0.001). Overall, 62.6% underwent invasive ventilation, with decreasing requirement during the waves (P=0.002). The adjusted Cox model showed no difference in the hazard ratio (HR) for mortality among the waves. In the propensity-matched analysis the hospital mortality rate was reduced by 11% in the third wave (P=0.044). Conclusions With application of best practice as known by the time of the first three waves of the pandemic, our study failed to identify a significant improvement in mortality rate when comparing the different waves of the COVID-19 pandemic, notwithstanding, the sub-analyses showed a trend in mortality reduction in the third wave. Rather, our study identified a possible positive effect of dexamethasone on mortality rate reduction and the increased risk of death related to bacterial infections in the three waves.
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Affiliation(s)
- Irene Coloretti
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | | | | | - Ilenia Gatto
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elena Munari
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Lorenzo Dall’Ara
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Stefano Busani
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | | | - Roberto Tonelli
- Respiratory Disease Unit, University Hospital of Modena, Modena, Italy
| | - Cristina Mussini
- Infectious Disease Unit, University Hospital of Modena, Modena, Italy
| | - Giovanni Guaraldi
- Infectious Disease Unit, University Hospital of Modena, Modena, Italy
| | - Andrea Cossarizza
- Immunology Laboratory, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Clini
- Respiratory Disease Unit, University Hospital of Modena, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
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Gatto I, Biagioni E, Coloretti I, Viappiani S, Busani S, Girardis M. Difference in PaO2/FiO2 between high-flow nasal cannula and Venturi mask in hypoxemic COVID-19 patients. J Anesth Analg Crit Care 2022. [PMCID: PMC9127475 DOI: 10.1186/s44158-022-00051-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The ratio between arterial blood partial pressure of oxygen and fraction of inspired oxygen (PaO2/FiO2) was largely used for grading and managing the respiratory failure in non-mechanically ventilated COVID-19. In these patients, the assessment of the true FiO2 in the inspired mixture may be difficult with consequent inaccuracies in PaO2/FiO2 assessment. In 30 severe COVID-19 patients, we observed that PaO2/FiO2 values measured immediately before and after the transition from high-flow nasal cannula (HFNC) to one commercially available Venturi mask O2 therapy were similar (bias mean value 0, standard deviation 23 mmHg). In COVID-19 patients recovering from respiratory failure, PaO2/FiO2 is not different whether measured with a commercially available Venturi mask or HFNC.
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9
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Meschiari M, Cozzi-Lepri A, Tonelli R, Bacca E, Menozzi M, Franceschini E, Cuomo G, Bedini A, Volpi S, Milic J, Brugioni L, Romagnoli E, Pietrangelo A, Corradini E, Coloretti I, Biagioni E, Busani S, Girardis M, Cossarizza A, Clini E, Guaraldi G, Mussini C. First and second waves among hospitalised patients with COVID-19 with severe pneumonia: a comparison of 28-day mortality over the 1-year pandemic in a tertiary university hospital in Italy. BMJ Open 2022; 12:e054069. [PMID: 34980623 PMCID: PMC8724593 DOI: 10.1136/bmjopen-2021-054069] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/08/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The first COVID-19-19 epidemic wave was over the period of February-May 2020. Since 1 October 2020, Italy, as many other European countries, faced a second wave. The aim of this analysis was to compare the 28-day mortality between the two waves among COVID-19 hospitalised patients. DESIGN Observational cohort study. Standard survival analysis was performed to compare all-cause mortality within 28 days after hospital admission in the two waves. Kaplan-Meier curves as well as Cox regression model analysis were used. The effect of wave on risk of death was shown by means of HRs with 95% CIs. A sensitivity analysis around the impact of the circulating variant as a potential unmeasured confounder was performed. SETTING University Hospital of Modena, Italy. Patients admitted to the hospital for severe COVID-19 pneumonia during the first (22 February-31 May 2020) and second (1 October-31 December 2020) waves were included. RESULTS During the two study periods, a total of 1472 patients with severe COVID-19 pneumonia were admitted to our hospital, 449 during the first wave and 1023 during the second. Median age was 70 years (IQR 56-80), 37% women, 49% with PaO2/FiO2 <250 mm Hg, 82% with ≥1 comorbidity, median duration of symptoms was 6 days. 28-day mortality rate was 20.0% (95% CI 16.3 to 23.7) during the first wave vs 14.2% (95% CI 12.0 to 16.3) in the second (log-rank test p value=0.03). After including key predictors of death in the multivariable Cox regression model, the data still strongly suggested a lower 28-day mortality rate in the second wave (aHR=0.64, 95% CI 0.45 to 0.90, p value=0.01). CONCLUSIONS In our hospitalised patients with COVID-19 with severe pneumonia, the 28-day mortality appeared to be reduced by 36% during the second as compared with the first wave. Further studies are needed to identify factors that may have contributed to this improved survival.
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Affiliation(s)
- Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | | | - Roberto Tonelli
- Respiratory Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Bacca
- Department of Infectious Diseases, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Menozzi
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Erica Franceschini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Gianluca Cuomo
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Andrea Bedini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Sara Volpi
- Department of Infectious Diseases, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Jovana Milic
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Department of Infectious Diseases, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Brugioni
- Internal Medicine Department, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Elisa Romagnoli
- Internal Medicine Department, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Antonello Pietrangelo
- Department of Medical and Surgical Sciences for Children and Adults, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Elena Corradini
- Department of Medical and Surgical Sciences for Children and Adults, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
| | - Irene Coloretti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera-Universitaria Policlinico di Modena, Modena, Italy
| | - Emanuela Biagioni
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera-Universitaria Policlinico di Modena, Modena, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera-Universitaria Policlinico di Modena, Modena, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera-Universitaria Policlinico di Modena, Modena, Italy
- Anesthesia and Intensive Care, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children and Adults, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Clini
- Respiratory Diseases Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Guaraldi
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
- Department of Infectious Diseases, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena Policlinico di Modena, Modena, Italy
- Department of Infectious Diseases, Faculty of Medicine and Surgery, University of Modena and Reggio Emilia, Modena, Italy
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10
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Gatto I, Biagioni E, Coloretti I, Farinelli C, Avoni C, Caciagli V, Busani S, Sarti M, Pecorari M, Gennari W, Guaraldi G, Franceschini E, Meschiari M, Mussini C, Tonelli R, Clini E, Cossarizza A, Girardis M. Cytomegalovirus blood reactivation in COVID-19 critically ill patients: risk factors and impact on mortality. Intensive Care Med 2022; 48:706-713. [PMID: 35583676 PMCID: PMC9116062 DOI: 10.1007/s00134-022-06716-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/22/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Cytomegalovirus (CMV) reactivation in immunocompetent critically ill patients is common and relates to a worsening outcome. In this large observational study, we evaluated the incidence and the risk factors associated with CMV reactivation and its effects on mortality in a large cohort of patients affected by coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU). METHODS Consecutive patients with confirmed SARS-CoV-2 infection and acute respiratory distress syndrome admitted to three ICUs from February 2020 to July 2021 were included. The patients were screened at ICU admission and once or twice per week for quantitative CMV-DNAemia in the blood. The risk factors associated with CMV blood reactivation and its association with mortality were estimated by adjusted Cox proportional hazards regression models. RESULTS CMV blood reactivation was observed in 88 patients (20.4%) of the 431 patients studied. Simplified Acute Physiology Score (SAPS) II score (HR 1031, 95% CI 1010-1053, p = 0.006), platelet count (HR 0.0996, 95% CI 0.993-0.999, p = 0.004), invasive mechanical ventilation (HR 2611, 95% CI 1223-5571, p = 0.013) and secondary bacterial infection (HR 5041; 95% CI 2852-8911, p < 0.0001) during ICU stay were related to CMV reactivation. Hospital mortality was higher in patients with (67.0%) than in patients without (24.5%) CMV reactivation but the adjusted analysis did not confirm this association (HR 1141, 95% CI 0.757-1721, p = 0.528). CONCLUSION The severity of illness and the occurrence of secondary bacterial infections were associated with an increased risk of CMV blood reactivation, which, however, does not seem to influence the outcome of COVID-19 ICU patients independently.
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Affiliation(s)
- Ilenia Gatto
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Emanuela Biagioni
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlotta Farinelli
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Camilla Avoni
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Valeria Caciagli
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mario Sarti
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy
| | - Monica Pecorari
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy
| | - William Gennari
- Virology and Molecular Microbiology Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Guaraldi
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Tonelli
- Respiratory Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Clini
- Respiratory Diseases Unit, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cossarizza
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy ,Intensive Care Department, University Hospital of Modena, L.go del Pozzo 71, 41125 Modena, Italy
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11
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Franceschini E, Cozzi-Lepri A, Santoro A, Bacca E, Lancellotti G, Menozzi M, Gennari W, Meschiari M, Bedini A, Orlando G, Puzzolante C, Digaetano M, Milic J, Codeluppi M, Pecorari M, Carli F, Cuomo G, Alfano G, Corradi L, Tonelli R, De Maria N, Busani S, Biagioni E, Coloretti I, Guaraldi G, Sarti M, Luppi M, Clini E, Girardis M, Gyssens IC, Mussini C. Herpes Simplex Virus Re-Activation in Patients with SARS-CoV-2 Pneumonia: A Prospective, Observational Study. Microorganisms 2021; 9:microorganisms9091896. [PMID: 34576791 PMCID: PMC8465957 DOI: 10.3390/microorganisms9091896] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Herpes simplex 1 co-infections in patients with COVID-19 are considered relatively uncommon; some reports on re-activations in patients in intensive-care units were published. The aim of the study was to analyze herpetic re-activations and their clinical manifestations in hospitalized COVID-19 patients, performing HSV-1 PCR on plasma twice a week. Methods: we conducted a prospective, observational, single-center study involving 70 consecutive patients with severe/critical SARS-CoV-2 pneumonia tested for HSV-1 hospitalized at Azienda Ospedaliero-Universitaria of Modena. Results: of these 70 patients, 21 (30.0%) showed detectable viremia and 13 (62%) had clinically relevant manifestations of HSV-1 infection corresponding to 15 events (4 pneumonia, 5 herpes labialis, 3 gingivostomatitis, one encephalitis and two hepatitis). HSV-1 positive patients were more frequently treated with steroids than HSV-1 negative patients (76.2% vs. 49.0%, p = 0.036) and more often underwent mechanical ventilation (IMV) (57.1% vs. 22.4%, p = 0.005). In the unadjusted logistic regression analysis, steroid treatment, IMV, and higher LDH were significantly associated with an increased risk of HSV1 re-activation (odds ratio 3.33, 4.61, and 16.9, respectively). The association with the use of steroids was even stronger after controlling for previous use of both tocilizumab and IMV (OR = 5.13, 95% CI:1.36–19.32, p = 0.016). The effect size was larger when restricting to participants who were treated with high doses of steroids while there was no evidence to support an association with the use of tocilizumab Conclusions: our study shows a high incidence of HSV-1 re-activation both virologically and clinically in patients with SARS-CoV-2 severe pneumonia, especially in those treated with steroids.
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Affiliation(s)
- Erica Franceschini
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
- Correspondence: (E.F.); (C.M.)
| | - Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation, Institute for Global Health, University College London, London NW3 2PF, UK;
| | - Antonella Santoro
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Erica Bacca
- Department of Infectious Diseases, University of Modena and Reggio Emilia, 41124 Modena, Italy; (E.B.); (G.L.); (J.M.); (G.G.)
| | - Guido Lancellotti
- Department of Infectious Diseases, University of Modena and Reggio Emilia, 41124 Modena, Italy; (E.B.); (G.L.); (J.M.); (G.G.)
| | - Marianna Menozzi
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - William Gennari
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (W.G.); (M.P.); (M.S.)
| | - Marianna Meschiari
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Andrea Bedini
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Gabriella Orlando
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Cinzia Puzzolante
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Margherita Digaetano
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Jovana Milic
- Department of Infectious Diseases, University of Modena and Reggio Emilia, 41124 Modena, Italy; (E.B.); (G.L.); (J.M.); (G.G.)
| | - Mauro Codeluppi
- Infectious Diseases Unit, G. da Saliceto Hospital, 29121 Piacenza, Italy;
| | - Monica Pecorari
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (W.G.); (M.P.); (M.S.)
| | - Federica Carli
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Gianluca Cuomo
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Gaetano Alfano
- Nephrology, Dialysis and Transplant Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy;
| | - Luca Corradi
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
| | - Roberto Tonelli
- Respiratory Diseases Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (R.T.); (E.C.)
| | - Nicola De Maria
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy;
| | - Stefano Busani
- Intensive Care Unit, Department of Anaesthesia, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (S.B.); (E.B.); (I.C.); (M.G.)
| | - Emanuela Biagioni
- Intensive Care Unit, Department of Anaesthesia, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (S.B.); (E.B.); (I.C.); (M.G.)
| | - Irene Coloretti
- Intensive Care Unit, Department of Anaesthesia, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (S.B.); (E.B.); (I.C.); (M.G.)
| | - Giovanni Guaraldi
- Department of Infectious Diseases, University of Modena and Reggio Emilia, 41124 Modena, Italy; (E.B.); (G.L.); (J.M.); (G.G.)
| | - Mario Sarti
- Microbiology and Virology Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (W.G.); (M.P.); (M.S.)
| | - Mario Luppi
- Hematology Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy;
| | - Enrico Clini
- Respiratory Diseases Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (R.T.); (E.C.)
| | - Massimo Girardis
- Intensive Care Unit, Department of Anaesthesia, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (S.B.); (E.B.); (I.C.); (M.G.)
| | - Inge C. Gyssens
- Radboud Center for Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
- Faculty of Medicine and Life Sciences, Hasselt University, 3500 Hasselt, Belgium
| | - Cristina Mussini
- Infectious Diseases Unit, Azienda Ospedaliero-Universitaria Policlinico, 41124 Modena, Italy; (A.S.); (M.M.); (M.M.); (A.B.); (G.O.); (C.P.); (M.D.); (F.C.); (G.C.); (L.C.)
- Department of Infectious Diseases, University of Modena and Reggio Emilia, 41124 Modena, Italy; (E.B.); (G.L.); (J.M.); (G.G.)
- Correspondence: (E.F.); (C.M.)
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Coloretti I, Berlot G, Busani S, De Rosa FG, Donati A, Forfori F, Grasselli G, Mirabella L, Tascini C, Viale P, Girardis M. Rationale for Polyclonal Intravenous Immunoglobulin Adjunctive Therapy in COVID-19 Patients: Report of a Structured Multidisciplinary Consensus. J Clin Med 2021; 10:jcm10163500. [PMID: 34441796 PMCID: PMC8396919 DOI: 10.3390/jcm10163500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction: Adjunctive therapy with polyclonal intravenous immunoglobins (IVIg) is currently used for preventing or managing infections and sepsis, especially in immunocompromised patients. The pathobiology of COVID-19 and the mechanisms of action of Ig led to the consideration of this adjunctive therapy, including in patients with respiratory failure due to the SARS-CoV-2 infection. This manuscript reports the rationale, the available data and the results of a structured consensus on intravenous Ig therapy in patients with severe COVID-19. Methods: A panel of multidisciplinary experts defined the clinical phenotypes of COVID-19 patients with severe respiratory failure and, after literature review, voted for the agreement on the rationale and the potential role of IVIg therapy for each phenotype. Due to the scarce evidence available, a modified RAND/UCLA appropriateness method was used. Results: Three different phenotypes of COVID-19 patients with severe respiratory failure were identified: patients with an abrupt and dysregulated hyperinflammatory response (early phase), patients with suspected immune paralysis (late phase) and patients with sepsis due to a hospital-acquired superinfection (sepsis by bacterial superinfection). The rationale for intravenous Ig therapy in the early phase was considered uncertain whereas the panelists considered its use in the late phase and patients with sepsis/septic shock by bacterial superinfection appropriate. Conclusion: As with other immunotherapies, IVIg adjunctive therapy may have a potential role in the management of COVID-19 patients. The ongoing trials will clarify the appropriate target population and the true effectiveness.
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Affiliation(s)
- Irene Coloretti
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
| | - Giorgio Berlot
- Anestesia and Intensive Care Department, University Hospital of Trieste, 34127 Trieste, Italy;
| | - Stefano Busani
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
| | | | - Abele Donati
- Anaesthesia and Intensive Care Department, University Hospital of Ancona, 60127 Ancona, Italy;
| | - Francesco Forfori
- Anaesthesia and Intensive Care Department, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Giacomo Grasselli
- Anaesthesia and Intensive Care Department, University Hospital of Milan, 20122 Milano, Italy;
| | - Lucia Mirabella
- Anaesthesia and Intensive Care Department, University Hospital of Foggia, 71122 Foggia, Italy;
| | - Carlo Tascini
- Infectious Disease Department, University Hospital of Udine, 33100 Udine, Italy;
| | - Pierluigi Viale
- Infectious Disease Department, University Hospital of Bologna, 40126 Bologna, Italy;
| | - Massimo Girardis
- Anaesthesia and Intensive Care Department, University Hospital of Modena, 41124 Modena, Italy; (I.C.); (S.B.)
- Correspondence:
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13
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Alfano G, Ferrari A, Fontana F, Mori G, Magistroni R, Meschiari M, Franceschini E, Menozzi M, Cuomo G, Orlando G, Santoro A, Digaetano M, Puzzolante C, Carli F, Bedini A, Milic J, Coloretti I, Raggi P, Mussini C, Girardis M, Cappelli G, Guaraldi G. Incidence, risk factors and outcome of acute kidney injury (AKI) in patients with COVID-19. Clin Exp Nephrol 2021; 25:1203-1214. [PMID: 34196877 PMCID: PMC8245663 DOI: 10.1007/s10157-021-02092-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/07/2021] [Indexed: 01/08/2023]
Abstract
Background Acute kidney injury (AKI) is a severe complication of coronavirus disease-2019 (COVID-19). This study aims to evaluate incidence, risk factors and case-fatality rate of AKI in patients with COVID-19. Methods We reviewed the health medical records of 307 consecutive patients with COVID-19 hospitalized at the University Hospital of Modena, Italy. Results AKI was diagnosed in 69 out of 307 (22.4%) COVID-19 patients. Stages 1, 2, or 3 AKI accounted for 57.9%, 24.6% and 17.3%, respectively. AKI patients had a mean age of 74.7 ± 9.9 years. These patients showed higher serum levels of the main markers of inflammation and higher rate of severe pneumonia than non-AKI patients. Kidney injury was associated with a higher rate of urinary abnormalities including proteinuria (0.44 ± 0.85 vs 0.18 ± 0.29 mg/mg; P = < 0.0001) and microscopic hematuria (P = 0.032) compared to non-AKI patients. Hemodialysis was performed in 7.2% of the subjects and 33.3% of the survivors did not recover kidney function after AKI. Risk factors for kidney injury were age, male sex, CKD and higher non-renal SOFA score. Patients with AKI had a mortality rate of 56.5%. Adjusted Cox regression analysis revealed that COVID-19-associated AKI was independently associated with in-hospital death (hazard ratio [HR] = 4.82; CI 95%, 1.36–17.08) compared to non-AKI patients. Conclusion AKI was a common and harmful consequence of COVID-19. It manifested with urinary abnormalities (proteinuria, microscopic hematuria) and conferred an increased risk for death. Given the well-known short-term sequelae of AKI, prevention of kidney injury is imperative in this vulnerable cohort of patients. Supplementary Information The online version contains supplementary material available at 10.1007/s10157-021-02092-x.
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Affiliation(s)
- Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy.
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Annachiara Ferrari
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Giacomo Mori
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Riccardo Magistroni
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Erica Franceschini
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Marianna Menozzi
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Gianluca Cuomo
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Gabriella Orlando
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Antonella Santoro
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | | | - Cinzia Puzzolante
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Federica Carli
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Andrea Bedini
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Jovana Milic
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Department of Anesthesia and Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Paolo Raggi
- Department of Medicine, Division of Cardiology, Mazankowski Alberta Heart Institute, Alberta, Canada
| | - Cristina Mussini
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Gianni Cappelli
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Guaraldi
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
- Department of Infectious Diseases, University Hospital of Modena, Modena, Italy
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14
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Grasselli G, Scaravilli V, Mangioni D, Scudeller L, Alagna L, Bartoletti M, Bellani G, Biagioni E, Bonfanti P, Bottino N, Coloretti I, Cutuli SL, De Pascale G, Ferlicca D, Fior G, Forastieri A, Franzetti M, Greco M, Guzzardella A, Linguadoca S, Meschiari M, Messina A, Monti G, Morelli P, Muscatello A, Redaelli S, Stefanini F, Tonetti T, Antonelli M, Cecconi M, Foti G, Fumagalli R, Girardis M, Ranieri M, Viale P, Raviglione M, Pesenti A, Gori A, Bandera A. Hospital-Acquired Infections in Critically Ill Patients With COVID-19. Chest 2021; 160:454-465. [PMID: 33857475 PMCID: PMC8056844 DOI: 10.1016/j.chest.2021.04.002] [Citation(s) in RCA: 202] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/23/2021] [Accepted: 04/01/2021] [Indexed: 12/23/2022] Open
Abstract
Background Few small studies have described hospital-acquired infections (HAIs) occurring in patients with COVID-19. Research Question What characteristics in critically ill patients with COVID-19 are associated with HAIs and how are HAIs associated with outcomes in these patients? Study Design and Methods Multicenter retrospective analysis of prospectively collected data including adult patients with severe COVID-19 admitted to eight Italian hub hospitals from February 20, 2020, through May 20, 2020. Descriptive statistics and univariate and multivariate Weibull regression models were used to assess incidence, microbial cause, resistance patterns, risk factors (ie, demographics, comorbidities, exposure to medication), and impact on outcomes (ie, ICU discharge, length of ICU and hospital stays, and duration of mechanical ventilation) of microbiologically confirmed HAIs. Results Of the 774 included patients, 359 patients (46%) demonstrated 759 HAIs (44.7 infections/1,000 ICU patient-days; 35% multidrug-resistant [MDR] bacteria). Ventilator-associated pneumonia (VAP; n = 389 [50%]), bloodstream infections (BSIs; n = 183 [34%]), and catheter-related BSIs (n = 74 [10%]) were the most frequent HAIs, with 26.0 (95% CI, 23.6-28.8) VAPs per 1,000 intubation-days, 11.7 (95% CI, 10.1-13.5) BSIs per 1,000 ICU patient-days, and 4.7 (95% CI, 3.8-5.9) catheter-related BSIs per 1,000 ICU patient-days. Gram-negative bacteria (especially Enterobacterales) and Staphylococcus aureus caused 64% and 28% of cases of VAP, respectively. Variables independently associated with infection were age, positive end expiratory pressure, and treatment with broad-spectrum antibiotics at admission. Two hundred thirty-four patients (30%) died in the ICU (15.3 deaths/1,000 ICU patient-days). Patients with HAIs complicated by septic shock showed an almost doubled mortality rate (52% vs 29%), whereas noncomplicated infections did not affect mortality. HAIs prolonged mechanical ventilation (median, 24 days [interquartile range (IQR), 14-39 days] vs 9 days [IQR, 5-13 days]; P < .001), ICU stay (24 days [IQR, 16-41 days] vs 9 days [IQR, 6-14 days]; P = .003), and hospital stay (42 days [IQR, 25-59 days] vs 23 days [IQR, 13-34 days]; P < .001). Interpretation Critically ill patients with COVID-19 are at high risk for HAIs, especially VAPs and BSIs resulting from MDR organisms. HAIs prolong mechanical ventilation and hospitalization, and HAIs complicated by septic shock almost double mortality. Trial Registry ClinicalTrials.gov; No.: NCT04388670; URL: www.clinicaltrials.gov
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Affiliation(s)
- Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vittorio Scaravilli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Mangioni
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luigia Scudeller
- Direzione Scientifica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Alagna
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Giacomo Bellani
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Emanuela Biagioni
- Department of Anesthesia and Intensive Care Unit, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Bonfanti
- Infectious Diseases Unit, San Gerardo Hospital ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Nicola Bottino
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Coloretti
- Department of Anesthesia and Intensive Care Unit, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Salvatore Lucio Cutuli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Sacred Heart Catholic University, Rome, Italy
| | - Gennaro De Pascale
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Sacred Heart Catholic University, Rome, Italy
| | - Daniela Ferlicca
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital ASST Monza, Monza, Italy
| | - Gabriele Fior
- Dipartimento di Anestesia e Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Forastieri
- Department of Anesthesia and Intensive Care, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Marco Franzetti
- Infectious Diseases Unit, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Massimiliano Greco
- Department of Anaesthesia and Intensive Care, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Sara Linguadoca
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marianna Meschiari
- Infectious Diseases Clinics, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Messina
- Department of Anaesthesia and Intensive Care, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Gianpaola Monti
- Dipartimento di Anestesia e Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paola Morelli
- Infectious Disease Unit, Hospital Health Direction, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simone Redaelli
- Department of Anesthesia and Intensive Care, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Flavia Stefanini
- Dipartimento di Anestesia e Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Tommaso Tonetti
- Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Sacred Heart Catholic University, Rome, Italy
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- Dipartimento di Anestesia e Rianimazione, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care Unit, AOU Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Ranieri
- Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Mario Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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15
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Busani S, Roat E, Tosi M, Biagioni E, Coloretti I, Meschiari M, Gelmini R, Brugioni L, De Biasi S, Girardis M. Adjunctive Immunotherapy With Polyclonal Ig-M Enriched Immunoglobulins for Septic Shock: From Bench to Bedside. The Rationale for a Personalized Treatment Protocol. Front Med (Lausanne) 2021; 8:616511. [PMID: 33681248 PMCID: PMC7930614 DOI: 10.3389/fmed.2021.616511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 01/19/2023] Open
Abstract
Septic shock still has a high mortality rate which has not hinted at decreasing in recent years. Unfortunately, randomized trials failed mainly because the septic patient was considered as a homogeneous entity. All this creates a sort of therapeutic impotence in everyday clinical practice in treating patients with septic shock. The need to customize therapy on each patient with sepsis has now become an established necessity. In this scenario, adjuvant therapies can help if interpreted as modulators of the immune system. Indeed, the host's immune response differs from patient to patient based on the virulence of the pathogen, comorbidity, infection site, and prolonged hospitalization. In this review, we summarize the rationale for using immunoglobulins as an adjunctive treatment. Furthermore, we would like to suggest a possible protocol to personalize treatment in the different clinical scenarios of the host's response to serious infectious events.
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Affiliation(s)
- Stefano Busani
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Erika Roat
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martina Tosi
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Emanuela Biagioni
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Gelmini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Brugioni
- Internal Medicine Department, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Sara De Biasi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
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16
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Coloretti I, Busani S, Biagioni E, Venturelli S, Munari E, Sita M, DallAra L, Tosi M, Clini E, Tonelli R, Fantini R, Mussini C, Meschiari M, Guaraldi G, Cossarizza A, Alfano G, Girardis M. Effects of cytokine blocking agents on hospital mortality in patients admitted to ICU with acute respiratory distress syndrome by SARS-CoV-2 infection: retrospective cohort study. Multidiscip Respir Med 2021; 16:737. [PMID: 34040779 PMCID: PMC8139121 DOI: 10.4081/mrm.2021.737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/19/2021] [Indexed: 01/08/2023] Open
Abstract
Background The use of cytokine-blocking agents has been proposed to modulate the inflammatory response in patients with COVID-19. Tocilizumab and anakinra were included in the local protocol as an optional treatment in critically ill patients with acute respiratory distress syndrome (ARDS) by SARS-CoV-2 infection. This cohort study evaluated the effects of therapy with cytokine blocking agents on in-hospital mortality in COVID-19 patients requiring mechanical ventilation and admitted to intensive care unit. Methods The association between therapy with tocilizumab or anakinra and in-hospital mortality was assessed in consecutive adult COVID-19 patients admitted to our ICU with moderate to severe ARDS. The association was evaluated by comparing patients who received to those who did not receive tocilizumab or anakinra and by using different multivariable Cox models adjusted for variables related to poor outcome, for the propensity to be treated with tocilizumab or anakinra and after patient matching. Results Sixty-six patients who received immunotherapy (49 tocilizumab, 17 anakinra) and 28 patients who did not receive immunotherapy were included. The in-hospital crude mortality was 30,3% in treated patients and 50% in nontreated (OR 0.77, 95% CI 0.56-1.05, p=0.069). The adjusted Cox model showed an association between therapy with immunotherapy and in-hospital mortality (HR 0.40, 95% CI 0.19-0.83, p=0.015). This protective effect was further confirmed in the analysis adjusted for propensity score, in the propensity-matched cohort and in the cohort of patients with invasive mechanical ventilation within 2 hours after ICU admission. Conclusions Although important limitations, our study showed that cytokine-blocking agents seem to be safe and to improve survival in COVID-19 patients admitted to ICU with ARDS and the need for mechanical ventilation.
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Affiliation(s)
| | | | | | | | - Elena Munari
- Intensive Care Unit, University Hospital of Modena
| | - Marco Sita
- Intensive Care Unit, University Hospital of Modena
| | | | - Martina Tosi
- Intensive Care Unit, University Hospital of Modena
| | - Enrico Clini
- Respiratory Disease Unit, University Hospital of Modena
| | | | | | | | | | | | | | - Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena.,Respiratory Disease Unit, University Hospital of Modena.,Infectious Disease Unit, University Hospital of Modena.,Immunology Laboratory, University of Modena and Reggio Emilia.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Italy
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17
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Coloretti I, Biagioni E, Venturelli S, Munari E, Tosi M, Roat E, Brugioni L, Gelmini R, Venturelli C, Girardis M. Adjunctive therapy with vitamin c and thiamine in patients treated with steroids for refractory septic shock: A propensity matched before-after, case-control study. J Crit Care 2020; 59:37-41. [DOI: 10.1016/j.jcrc.2020.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
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18
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Coloretti I, Tosi M, Biagioni E, Girardis M. Oxygen: a powerful drug to handle with care. J Thorac Dis 2019; 11:S226-S229. [DOI: 10.21037/jtd.2019.01.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Tosi M, Roat E, De Biasi S, Munari E, Venturelli S, Coloretti I, Biagioni E, Cossarizza A, Girardis M. Multidrug resistant bacteria in critically ill patients: a step further antibiotic therapy. ACTA ACUST UNITED AC 2018. [DOI: 10.21037/jeccm.2018.11.08] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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