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- Medications to Modify Aspiration Risk: Those That Add to Risk and Those That May Reduce RiskPublication . Gonçalves Pereira, João; Mergulhão, Paulo; Froes, FilipeAspiration pneumonia results from the abnormal entry of fluids into the respiratory tract. We present a review of drugs known to affect the risk of aspiration. Drugs that increase the risk of aspiration pneumonia can be broadly divided into those that affect protective reflexes (like cough and swallowing) due to direct or indirect mechanisms, and drugs that facilitate gastric dysbiosis or affect esophageal and intestinal motility. Chief among the first group are benzodiazepines and antipsychotics, while proton pump inhibitors are the most well-studied in the latter group. Pill esophagitis may also exacerbate swallowing dysfunction. On the other hand, some research has also focused on pharmaceutical modulation of the risk of aspiration pneumonia. Angiotensin-converting enzyme inhibitors have been demonstrated to be associated with a decrease in the hazard of aspiration pneumonia in high-risk patients of Chinese or Japanese origin. Drugs like amantadine, nicergoline, or folic acid have shown some promising results in stroke patients, although the available evidence is thus far not enough to allow for anymeaningful conclusions. Importantly, antimicrobial prophylaxis has been proven to be ineffective. Focusing on modifiable risk factors for aspiration pneumonia is relevant since this may help to reduce the incidence of this often severe problem. Among these, several commonly used drug classes have been shown to increase the risk of aspiration pneumonia. These drugs should be withheld in the high-risk population whenever possible, alongside general measures, such as the semirecumbent position during sleep and feeding.
- Molecular antimicrobial susceptibility testing in sepsisPublication . Martin-Loeches, Ignacio; Gonçalves Pereira, João; Teoh, Tee Keat; Barlow, Gavin; Dortet, Laurent; Carrol, Enitan D; Olgemõller, Ulrike; Boyd, Sara E; Textoris, JulienRapidly detecting and identifying pathogens is crucial for appropriate antimicrobial therapy in patients with sepsis. Conventional diagnostic methods have been a great asset to medicine, though they are time consuming and labor intensive. This work will enable healthcare professionals to understand the bacterial community better and enhance their diagnostic capacity by using novel molecular methods that make obtaining quicker, more precise results possible. The authors discuss and critically assess the merits and drawbacks of molecular testing and the added value of these tests, including the shift turnaround time, the implication for clinicians’ decisions, gaps in knowledge, future research directions and novel insights or innovations. The field of antimicrobial molecular testing has seen several novel insights and innovations to improve the diagnosis and management of infectious diseases. Plain language summary: Sepsis is a life-threatening reaction to an infection. This infection is normally caused by a bacteria. Identifying the bacteria that has caused the infection is very important to choosing the best treatment. This is usually done using molecular testing. This article discusses the advantages and disadvantages of molecular testing, which tests are available and the value of these tests in clinical practice, the implication of molecular tests for clinicians’ decisions and the gaps in our knowledge. It also discusses future innovations in molecular testing.
- Posterior Spinal Cord Infarction Complicating a Bronchial Arterial EmbolizationPublication . Mateus, Daniela Barbosa; Dionisio, Antony; Mendes, Tânia F.; Araújo, Ana Margarida; Gonçalves Pereira, JoãoAbstract Massive hemoptysis is a life-threatening condition. Bronchial artery embolization (BAE) is an effective technique for controlling bleeding in cases of severe hemoptysis, with infrequent complications. While rare, spinal cord infarction is a serious potential complication of BAE. Here, we present a case involving a 28-year-old man with idiopathic pulmonary hypertension who underwent BAE after recurrent severe hemoptysis. Following the procedure, he developed urinary retention and progressive sensory deficits, culminating in significant motor impairment. Magnetic resonance imaging (MRI) revealed ischemic lesions in the posterior spinal cord, resulting in a diagnosis of iatrogenic spinal cord ischemia. While BAE is an effective therapeutic option for severe hemoptysis, it carries the risk of serious complications, including spinal cord ischemia. This case underscores the potential for iatrogenic spinal cord injury following BAE and highlights the need for increased awareness in high-risk patients.
- Guillain-Barré Syndrome After a SARS-CoV-2 VaccinePublication . Oliveira, Ana Maria; Ramos, Patrícia Varela; Durão-Carvalho, Gonçalo; Almeida, Vânia; Gonçalves Pereira, JoãoAbstract The worldwide mass vaccination campaign against COVID-19 has been the largest one ever undertaken. Although the short-term safety profile of the different vaccines has been well established, neuroinflammatory complications have been described, including rare cases of acute demyelinating inflammatory polyneuropathy. We report a 63-year-old man who presented to the emergency department with proximal muscle weakness and paresthesia. He had received the first dose of the AZD1222 SARS-CoV-2 vaccine (Oxford, AstraZeneca) two weeks before presentation. The diagnosis of Guillain-Barré syndrome (GBS) was confirmed by clinical features, cerebrospinal fluid analysis, and electromyography. On the second hospital day, progression to flaccid tetraplegia, cranial nerve involvement, and respiratory failure, requiring invasive mechanical ventilation, were noted, and he was admitted to the intensive care unit. Despite the prompt diagnosis and immunosuppressive treatment initiation, the patient was left with severe disability. Although the COVID-19 vaccination was generally safe and socially beneficial, individual adverse reactions, including neuroinflammatory severe complications, may occur.
- Infection on Frail Patients in the Intensive Care Unit: Insights From the PalMuSIC StudyPublication . Correia, Iuri; Fernandes, Susana; Bernardino, Mariana; Gonçalves Pereira, JoãoAbstract Background: Along with population aging, frailty is also increasingly common in the intensive care unit (ICU). However, the impact of frailty on the infection incidence, the risk of multidrug-resistant (MDR) microorganisms, and the potential benefits of broad-spectrum antibiotics are still poorly studied. Methods: This is a multicentric, prospective, observational study collecting data for 15 consecutive days of all consecutive adult patients admitted in each participating ICU. Exclusion criteria included admission for less than 24 hours or failure to obtain informed consent. The Clinical Frailty Score (CFS) was calculated both by the doctor and by the nurse in charge, and the patient's next of kin. Patients were considered frail if the mean of the three measured scores was ≥5. This is a post hoc analysis of the PALliative MUlticenter Study in Intensive Care (PalMuSIC) study. The Hospital de Vila Franca de Xira Ethics Committee approved the study (approval number: 63). Results: A total of 335 patients from 23 Portuguese ICUs were included. Frailty was diagnosed in 20.9%. More than 60% of the patients had a diagnosis of infection during their ICU stay, either present on admission or hospital-acquired. This included 25 (35.7%) frail and 75 (28.3%) non-frail (p=0.23) patients diagnosed with infection. In 34 patients, MDR microorganisms were isolated, which were more common in frail patients (odds ratio (OR): 2.65, 95% confidence interval (CI): 1.3-5.6, p=0.018). Carbapenems were started in 37 (18.1%) patients, but after adjusting for frailty and severity, no clear mortality benefit of this strategy was noted (odds ratio for ICU mortality: 1.61, 95% confidence interval: 0.49-5.31, p=0.43; odds ratio for hospital mortality: 1.61, 95% confidence interval: 0.61-4.21, p=0.33). Conclusion: Frail patients had similar rates of infection to non-frail patients but were more prone to have MDR microorganisms as causative pathogens. The use of empirical therapy with large-spectrum antibiotics should be based on microbiological risk factors and not simply on the host characteristics.
- Hospital Context Determinants of Variability in Healthcare-Associated Infection Prevalence: Multi-Level AnalysisPublication . Malheiro, Rui; Gomes, André Amaral; Fernnades, Carlos; Fareleira, Ana; Lebre, Ana; Pascoalinho, Dulce; Gonçalves Pereira, João; Paiva, José Artur; Sá-Machado, RitaAbstract: Healthcare-associated infections (HAIs) represent a major challenge in patient safety that affects services disproportionally. This paper aimed to assess how the HAI prevalence varies between hospital services and what contextual characteristics may explain such variance. A cross sectional study was conducted on adult patients in Portuguese hospitals, using data from the European point prevalence survey of HAI prevalence. The study variables included patient, structural, and process variables, tested as risk factors, with patients clustered in hospitals. Variables with a p-value ≤ 0.2 in univariate analyses were retested in a multivariable model. A total of 18,261 patients from 119 hospitals were included: 736 from 56 intensive care units (ICUs), 3160 from 72 surgical departments, and 8081 from 90 medical departments. The HAI prevalence was 7.9%, 5.9%, and 1.7%, respectively. In ICUs, only the number of devices was associated with the HAI prevalence. In surgical departments, age, comorbidities, being a specialized hospital, and a higher ratio of infection prevention and control (IPC) personnel were associated with higher SSI. The safety climate was associated with lower SSI. In medical departments, age and devices were positively associated, whereas a larger ratio of IPC nurses was negatively associated. These results may help implement targeted interventions to achieve optimal results in each department.
- Infectious Foci, Comorbidities and Its Influence on the Outcomes of Septic Critically Ill PatientsPublication . Oliveira, Ana Maria; Oliveira, André; Vidal, Raquel; Gonçalves Pereira, JoãoAbstract: Sepsis is among the most frequent diagnoses on admission to the intensive care unit (ICU). A systemic inflammatory response, activated by uncontrolled infection, fosters hypoperfusion and multiorgan failure and often leads to septic shock and mortality. These infections arise from a specific anatomic source, and how the infection foci influence the outcomes is unknown. All patients admitted to the ICU of Hospital de Vila Franca de Xira, between 1 January 2017 and 31 June 2023, were screened for sepsis and categorized according to their infection foci. During the study period, 1296 patients (32.2%) had sepsis on admission. Their mean age was 67.5 ± 15.3 and 58.1% were male; 73.0% had community-acquired infections. The lung was the main focus of infection. Septic shock was present in 37.9% of the patients and was associated with hospital mortality. Severe imbalances were noted in its incidence, and there was lower mortality in lung infections. The hospital-acquired infections had a slightly higher mortality but, after adjustment, this difference was non-significant. Patients with secondary bacteremia had a worse prognosis (one-year adjusted hazard ratio of 1.36, 95% confidence interval 1.06–1.74, p = 0.015), especially those with an isolated non-fermenting Gram negative infection. Lung, skin, and skin structure infections and peritonitis had a worse prognosis, whilst urinary, biliary tract, and other intra-abdominal infections had a better one-year outcome
- Frailty influences clinical outcomes in critical patients: a post hoc analysis of the PalMuSIC studyPublication . Mestre, Ana; Afonso, Rodrigo; Simões, André Ferreira; Correia, Iuri; Gonçalves Pereira, JoãoObjective: Frailty is a multidimensional syndrome characterized by diminished physiological reserve, increasing the risk of adverse outcomes, particularly in intensive care unit patients. The Clinical Frailty Scale, ranging from 1 (nonfrail) to 9 (terminally ill), is widely used to quantify frailty. This post hoc analysis of the Palliative Multicenter Study in Intensive Care (PalMuSIC) assesses the impact of frailty and clinical severity on short- and long-term outcomes. Methods: This subanalysis involved 23 Portuguese intensive care units and 335 patients. Patients admitted between March 1 and May 15, 2019, aged ≥ 18 years, and hospitalized for > 24 hours in the intensive care unit were eligible. The severity of illness was assessed using SAPS II, and frailty was assessed using the clinical frailty scale, which was recorded by a nurse and a doctor in charge. Patients were classified as frail (clinical frailty scale score ≥ 5), prefrail (clinical frailty scale score = 4), or nonfrail (clinical frailty scale score < 4). The outcomes measured included intensive care unit and hospital LOS (length of stay), need for organ support, infections, mortality at hospital discharge and mortality at 6 months post discharge. We divided the population in half according to the length of their intensive care unit stay to evaluate a possible interaction between intensive care unit length of stay and frailty. Results: The mean age was 63.2 years, and 66% were male. The mean SAPS II score was 41.8. Frailty was observed in 23.0% of the patients. Frail patients had higher hospital mortality (39.0% frail patients versus 28.2% prefrail patients versus 11.8% nonfrail patients) and 6-month mortality (frail 49.4% frail patients versus 30.6% prefrail patients versus 15.6% nonfrail patients). Patients with longer intensive care unit stays had higher 6-month mortality rates than did those with shorter intensive care unit stays did, which resulted in more frail patients: odds ratio (95% confidence interval) 3.1 (1.2 - 7.8) versus odds ratio 1.8 (0.9 - 4.0) in nonfrail patients. Conclusion: Frailty may significantly impact hospital and 6-month mortality. In our cohort, a longer intensive care unit length of stay was associated with worse long-term outcomes, especially in frail patients.
- Epidemiology and Burden of Ventilator-Associated Pneumonia among Adult Intensive Care Unit Patients: A Portuguese, Multicenter, Retrospective Study (eVAP-PT Study)Publication . Mergulhão, Paulo; Gonçalves Pereira, João; Fernandes, Antero Vale; Krystopchuk, Andriy; Ribeiro, João Miguel; Miranda, Daniel; Castro, Heloísa; Eira, Carla; Morais, Juvenal; Lameirão, Cristina; Gomes, Sara; Leal, Dina; Duarte, Joana; Pássaro, Leonor; Froes, Filipe; Martin-Loeches, IgnacioAbstract: Ventilator-associated pneumonia (VAP) is a prevailing nosocomial infection in critically ill patients requiring invasive mechanical ventilation (iMV). The impact of VAP is profound, adversely affecting patient outcomes and placing a significant burden on healthcare resources. This study assessed for the first time the contemporary VAP epidemiology in Portugal and its burden on the healthcare system and clinical outcomes. Additionally, resource consumption (duration of iMV, intensive care unit (ICU), hospital length of stay (LOS)) and empirical antimicrobial therapy were also evaluated. This multicenter, retrospective study included patients admitted to the hospital between July 2016 and December 2017 in a participating ICU, who underwent iMV for at least 48 h. Patients with a VAP diagnosis were segregated for further analysis (n = 197). Control patients, ventilated for >48 h but without a VAP diagnosis, were also included in a 1:1 ratio. Cumulative VAP incidence was computed. All-cause mortality was assessed at 28, 90, and 365 days after ICU admission. Cumulative VAP incidence was 9.2% (95% CI 8.0–10.5). The all-cause mortality rate in VAP patients was 24.9%, 34.0%, and 40.6%, respectively, and these values were similar to those observed in patients without VAP diagnosis. Further, patients with VAP had significantly longer ICU (27.5 vs. 11.0 days, p < 0.001) and hospital LOS (61 vs. 35.9 days, p < 0.001), more time under iMV (20.7 vs. 8.0 days, p < 0.001) and were more often subjected to tracheostomy (36.5 vs. 14.2%; p < 0.001). Patients with VAP who received inappropriate empirical antimicrobials had higher 28-day mortality, 34.3% vs. 19.5% (odds ratio 2.16, 95% CI 1.10–4.23), although the same was not independently associated with 1-year all-cause mortality (p = 0.107). This study described the VAP impact and burden on the Portuguese healthcare system, with approximately 9% of patients undergoing iMV for >48 h developing VAP, leading to increased resource consumption (longer ICU and hospital LOS). An unexpectedly high incidence of inappropriate, empirical antimicrobial therapy was also noted, being positively associated with a higher mortality risk of these patients. Knowledge of the Portuguese epidemiology characterization of VAP and its multidimensional impact is essential for efficient treatment and optimized long-term health outcomes of these patients.
- Phenotypic Characterization of Intensive Care Patients With Infections: A Pilot Study of Host and Pathogen-Based Cluster AnalysisPublication . Oliveira, André; Fernandes, Ana Rita; Mendes, Tânia F.; Gonçalves Pereira, JoãoAbstract Introduction: Sepsis is a prevalent, albeit complex, disorder among critically ill patients and a “one-size fits-all” approach does not seem applicable. Host intrinsic characteristics and microorganisms’ particularities may influence response to therapy and outcomes. Attempting to group patients and microorganism characteristics may be an important step in developing and facilitating personalized infection treatment plans. This work intends to identify infected patients’ clusters using clinical data that includes infection determinants: the isolated pathogen and the site of infection. Methods: In this retrospective analysis, we included patients with a microbiologically documented infection and non-infected controls. Patients admitted between January 2015 and December 2019 in the intensive care unit (ICU) were included (aged 17-95 years). Those with isolated microorganisms during their ICU stay were further analyzed using cluster analysis (hierarchical clustering and K-means; SPSS version 25.0). Four primary outcomes were addressed: ICU and hospital mortality rate and ICU and hospital length of stay (LOS). Results: This study included 1,923 patients, of whom 721 (37.5%) had at least one microbiological isolate during their ICU stay. Patients with at least one isolate identification were older (mean age 67.7 years vs. 65 years; p < 0.001) and had a higher ICU and hospital mortality (20.3% vs. 24.3%, p = 0.041; 26.9% vs. 38.4%, p < 0.001), as well as a longer LOS (median hospital LOS 8 vs. 18 days; p < 0.001) than patients without microorganisms identified. Patients with at least one isolated microorganism were divided into five different clusters. Notable differences were found in their ICU and hospital trajectories between clusters. Conclusion: The cluster analysis approach provided valuable insights into the complex interplay between bacterial virulence, infection site, and patient outcomes in critical care medicine. Patients infected with bacteraemia by Gram-positive bacteria (cluster 2) or Enterobacteriaceae (Cluster 5) and fungal isolation in respiratory samples (Cluster 3) should prompt more aggressive clinical interventions, as these patients are more prone to die in the hospital.