Sigrid de Sousa dos Santos

Benefit of antiretroviral therapy on survival of human immunodeficiency virus-infected patients admitted to an intensive care unit

Objective:To evaluate the impact of antiretroviral therapy (ART) and the prognostic factors for in-intensive care unit (ICU) and 6-month mortality in human immunodeficiency virus (HIV)-infected patients. Design:A retrospective cohort study was conducted in patients admitted to the ICU from 1996 through 2006. The follow-up period extended for 6 months after ICU admission. Setting:The ICU of a tertiary-care teaching hospital at the Universidade de São Paulo, Brazil. Participants:A total of 278 HIV-infected patients admitted to the ICU were selected. We excluded ICU readmissions (37), ICU admissions who stayed less than 24 hours (44), and patients with unavailable medical charts (36). Outcome Measure:In-ICU and 6-month mortality. Main Results:Multivariate logistic regression analysis and Cox proportional hazards models demonstrated that the variables associated with in-ICU and 6-month mortality were sepsis as the cause of admission (odds ratio [OR] = 3.16 [95% confidence interval [CI] 1.65–6.06]); hazards ratio [HR] = 1.37 [95% CI 1.01–1.88]), an Acute Physiology and Chronic Health Evaluation II score >19 [OR = 2.81 (95% CI 1.57–5.04); HR = 2.18 (95% CI 1.62–2.94)], mechanical ventilation during the first 24 hours [OR = 3.92 (95% CI 2.20–6.96); HR = 2.25 (95% CI 1.65–3.07)], and year of ICU admission [OR = 0.90 (95% CI 0.81–0.99); HR = 0.92 [95% CI 0.87–0.97)]. CD4 T-cell count <50 cells/mm3 was only associated with ICU mortality [OR = 2.10 (95% CI 1.17–3.76)]. The use of ART in the ICU was negatively predictive of 6-month mortality in the Cox model [HR = 0.50 (95% CI 0.35–0.71)], especially if this therapy was introduced during the first 4 days of admission to the ICU [HR = 0.58 (95% CI 0.41–0.83)]. Regarding HIV-infected patients admitted to ICU without using ART, those who have started this treatment during ICU stay presented a better prognosis when time and potential confounding factors were adjusted for [HR 0.55 (95% CI 0.31–0.98)]. Conclusions:The ICU outcome of HIV-infected patients seems to be dependent not only on acute illness severity, but also on the administration of antiretroviral treatment.

Oral sensorimotor function for feeding in patients with tetanus

Tetanus still remains a significant health problem in developing countries; it is a serious disease with a high mortality rate. The purpose of this study was to characterize the oral sensorimotor function for feeding in patients with tetanus. Thirteen patients clinically diagnosed with tetanus and admitted to an intensive care unit between December of 2005 and May of 2007 underwent a screening tool for dysphagia, involving the assessment of clinical features and 2 swallowing tests. Results indicate that the oral sensorimotor function for feeding in these patients is severely compromised, with the exception for the clinical feature of palate elevation and performance in the saliva swallowing test. The factor analysis indicated that the evaluation of tongue movement change in the oromotor examination is important in predicting alterations of cough/voice in the water swallowing test, thus suggesting that oral feeding might be unsafe. When looking at developing countries, the prolonged intensive medical and nursing care required by many patients with tetanus places extra demands on an already stretched healthcare budget. Intervention by a speech pathologist could mean that time in the ICU would be reduced as well as the number of re-admissions due to complications.

Vitamin E concentrations in adults with HIV/AIDS on highly active antiretroviral therapy.

HIV/AIDS patients are probably more predisposed to vitamin E deficiency, considering that they are more exposed to oxidative stress. Additionally, there are an extensive number of drugs in the highly active antiretroviral therapy (HAART) regimens that may interfere with vitamin E concentrations. The objective of this study was to compare serum concentrations of alpha-tocopherol in 182 HIV/AIDS patients receiving different HAART regimens. The patients were divided into three groups according to regimen: nucleoside analog reverse-transcriptase inhibitors (NRTIs) + non-nucleoside analog reverse-transcriptase inhibitors (NNRTIs); NRTIs + protease inhibitors + ritonavir; NRTIs + other classes. Alpha-tocopherol was assessed by high-performance liquid chromatography. Multiple linear regression analysis was used to evaluate the effects of HAART regimen, time of use, and compliance with the regimen on alpha-tocopherol concentrations. Alpha-tocopherol concentrations were on average 4.12 μmol/L lower for the NRTIs + other classes regimen when compared to the NRTIs + NNRTIs regimen (p = 0.037). A positive association (p < 0.001) was observed between alpha-tocopherol and cholesterol concentrations, a finding due, in part, to the relationship between liposoluble vitamins and lipid profile. This study demonstrated differences in alpha-tocopherol concentrations between patients using different HAART regimens, especially regimens involving the use of new drugs. Long-term prospective cohort studies are needed to monitor vitamin E status in HIV/AIDS patients since the beginning of treatment.

Treatment of nosocomial pneumonia: an experience with meropenem

This study aimed at evaluating the efficacy and safety of meropenem as first choice treatment for nosocomial pneumonia (NP) in intensive care units (ICU) in Hospital das Clínicas (HC) - University of São Paulo; a hospital with high incidence of antimicrobial resistance. Prospective, open, and non-comparative trial with meropenem were done in patients with ventilator-associated or aspiration NP in 2 ICUs at HC - University of São Paulo. Etiologic investigation was done through bronchoalveolar lavage and blood cultures prior to study entry. Twenty-five (25) critically ill patients with NP were enrolled (mean age 40 years). Ventilator-acquired pneumonia was responsible for 76% of cases and aspiration NP for 24%. Specific etiologic agents were identified and considered to be clinically and temporally responsible for NP in 11 (44%) patients. A. baumanii was responsible for 6 cases (55%), P. aeruginosa for 3 (27%), and S. aureus for 2 (18%). At completion of treatment, 19 patients (76%) showed either cure (48%) or improvement (28%) after use of meropenem therapy. Mortality was 12% at the end of therapy (8% after excluding 1 non-evaluable patient). After 4 to 6 weeks of follow-up, 12 (48%) patients had improved or been totally cured, and overall mortality was 24%. Clinical complications were observed in 11 patients (44%), with none of them definitely related to the study drug. Meropenem as monotherapy was effective and well-tolerated in most NP patients in our ICU. The low mortality rate in this study might have been due to first choice use of this drug. Controlled, drug comparative clinical trials are needed to support this preliminary observation.

Letalidade e complicações osteomusculares e cardiovasculares no tétano

OBJECTIVE: Despite the decline in the incidence of tetanus, this disease is still neglected in the developing world and remains a major cause of morbidity and mortality. With improvements in intensive care, it is important to better understand the complications of this serious condition. We aim to evaluate 1) the lethality and osteomuscular and cardiovascular complications of patients with tetanus who are admitted to the intensive care unit (ICU) and 2) the risk factors associated with a poor prognosis. METHODS: This was a retrospective study that analyzed the medical records of all of the patients diagnosed with tetanus who were admitted to an infectious diseases ICU between January 2000 and December 2001. A standardized form that included demographic, clinical and laboratory data was completed. The clinical variables that were related to lethality and osteomuscular and cardiovascular complications were described. RESULTS: A total of 22 tetanus patients were admitted (81.8% male, mean age of 47.8 years).The tetanus infection was associated with professional activities in 54.5% of cases. The majority of patients (20 patients) presented with the generalized form of disease. Eighty-one percent of the patients had never received a tetanus vaccine or were unaware of their vaccine status. Following the injury, none had received appropriated passive prophylaxis, only two patients had received surgical debridement of wound and six patients received antibiotic therapy. Eleven patients (52.4%) experienced some cardiovascular complication. A pressure ulcer was the most frequent cardiovascular complication (38.1%), followed by arrhythmias (28.6%). Two of the patients developed bone fractures secondary to tetanus spasms, corresponding to 9.6% of sample. The tetanus lethality rate was 9.1%. Higher APACHE II severity scores and very severe status based on the Veronesi tetanus classification were significantly associated with the risk of death (p=0.04 and 0.03, respectively). The Veronesi classification was also associated with the risk of cardiovascular complications (p=0.013) and the length of the ICU stay (p=0.009). CONCLUSION: The present study demonstrates the failure of primary medical care in vaccination and post-traumatic tetanus prophylaxis. Despite improvements in intensive care support, cardiovascular complications are still frequent in these patients. Individuals exhibiting high APACHE II scores and severe clinical forms of tetanus should be monitored closely due to a risk of death and cardiovascular complications.