Vieri Vannucchi

Cardiovascular Complications and Short-term Mortality Risk in Community-Acquired Pneumonia

Background. Previous reports suggest that community-acquired pneumonia (CAP) is associated with an enhanced risk of cardiovascular complications. However, a contemporary and comprehensive characterization of this association is lacking. Methods. In this multicenter study, 1182 patients hospitalized for CAP were prospectively followed for up to 30 days after their hospitalization for this infection. Study endpoints included myocardial infarction, new or worsening heart failure, atrial fibrillation, stroke, deep venous thrombosis, cardiovascular death, and total mortality. Results. Three hundred eighty (32.2%) patients experienced intrahospital cardiovascular events (CVEs) including 281 (23.8%) with heart failure, 109 (9.2%) with atrial fibrillation, 89 (8%) with myocardial infarction, 11 (0.9%) with ischemic stroke, and 1 (0.1%) with deep venous thrombosis; 28 patients (2.4%) died for cardiovascular causes. Multivariable Cox regression analysis showed that intrahospital Pneumonia Severity Index (PSI) class (hazard ratio [HR], 2.45, P = .027; HR, 4.23, P < .001; HR, 5.96, P < .001, for classes III, IV, and V vs II, respectively), age (HR, 1.02, P = .001), and preexisting heart failure (HR, 1.85, P < .001) independently predicted CVEs. One hundred three (8.7%) patients died by day 30 postadmission. Thirty-day mortality was significantly higher in patients who developed CVEs compared with those who did not (17.6% vs 4.5%, P < .001). Multivariable Cox regression analysis showed that intrahospital CVEs (HR, 5.49, P < .001) independently predicted 30-day mortality (after adjustment for age, PSI score, and preexisting comorbid conditions). Conclusions. CVEs, mainly those confined to the heart, complicate the course of almost one-third of patients hospitalized for CAP. More importantly, the occurrence of CVEs is associated with a 5-fold increase in CAP-associated 30-day mortality.

A case of Candida glabrata severe urinary sepsis successfully treated with micafungin

Candida glabrata is frequently resistant to fluconazole, and in advanced renal failure the safe use of this and other recommended drugs is limited. We report a case of a 56 years-old diabetic woman with renal failure and severe urinary sepsis from C. glabrata successfully treated with micafungin.

Procalcitonin Kinetics in the First 72 Hours Predicts 30-Day Mortality in Severely Ill Septic Patients Admitted to an Intermediate Care Unit

Background Severe sepsis and septic shock are leading causes of morbidity and mortality among critically ill patients, thus the identification of prognostic factors is crucial to determine their outcome. In this study, we explored the value of procalcitonin (PCT) variation in predicting 30-day mortality in patients with sepsis admitted to an intermediate care unit. Methods This prospective observational study enrolled 789 consecutive patients with severe sepsis and septic shock admitted to a medical intermediate care unit between November 2012 and February 2014. Kinetics of PCT expressed as percentage were defined by the variation between admission and 72 hours, and 24 and 72 hours; they were defined as Δ-PCT0-72h and Δ-PCT24-72h, respectively. Results The final study group of 144 patients featured a mean age of 73 ± 14 years, with a high prevalence of comorbidities (Charlson index greater than 6 in 39%). Overall, 30-day mortality was 28.5% (41/144 patients). A receiver-operating-characteristic (ROC) analysis identified a decrease of Δ-PCT0-72h less than 15% (area under the curve: 0.75; 95% confidence interval (CI): 0.67 - 0.82) and a decrease of Δ-PCT24-72h less than 20% (area under the curve: 0.83; 95% CI: 0.74 - 0.92) as the most accurate cut-offs in predicting mortality. Decreases of Δ-PCT0-72h less than 15% (HR: 3.9, 95% CI: 1.6 - 9.5; P < 0.0001) and Δ-PCT24-72h less than 20% (HR: 3.1, 95% CI: 1.2 - 7.9; P < 0.001) were independent predictors of 30-day mortality. Conclusions Evaluation of PCT kinetics over the first 72 hours is a useful tool for predicting 30-day mortality in patients with severe sepsis and septic shock admitted to an intermediate care unit.

Septic shock from community-onset pneumonia: is there a role for aspirin plus macrolides combination?

Dear Editor, Pneumonia occurring in patients living in the community is the most common infection leading to hospitalization in intensive care units and the first cause of death associated with infectious diseases. The mortality rate due to pneumonia has shown little improvement over time despite advances in antimicrobial therapy and improved intensive care medicine, and severe sepsis and septic shock are associated with a mortality rate as high as 50 % [1]. It has been suggested to use agents that interfere with the pathogenesis of sepsis by modulating inflammation and coagulation. From January 2013 to January 2014, we prospectively observed all patients with community-onset pneumonia needing hospitalization at two teaching hospitals in Italy (Policlinico Umberto I, Rome and University Hospital of Careggi, Florence). We performed a post hoc analysis on patients with pneumonia presenting to the emergency department (ED) with septic shock, to evaluate whether any clinical factor or therapeutic intervention is associated with improved survival in this setting of patients. Adult patients fulfilling criteria for community-acquired pneumonia and healthcare-associated pneumonia were included in the study. Septic shock was defined according to Surviving Sepsis Campaign criteria. The effect of clinical and therapeutics variables on the primary end-point was assessed by means of a logistic regression model. In order to correct for possible bias arising from the observational nature of the experiment, we corrected all relevant effect estimates and p values with the propensity score analysis. Overall, 188 patients with pneumonia and septic shock were included in the analysis. The 30-day mortality rate was 42.5 %. No difference in the term of median age was detected between survivors and non-survivors. Patients who died had a higher mean sequential organ failure assessment (SOFA) score, presented more frequently with delirium, had a more frequent PaO2/FiO2 ratio\300, needed more frequent mechanical ventilation, non-invasive ventilation, and continuous renal replacement therapy. Survivors were more likely to receive macrolide therapy and a combination of aspirin plus a macrolide (see supplementary material). All patients taking aspirin were on chronic aspirin therapy at a dosage of 100 mg/day. At Cox regression analysis SOFA score[3 [hazard ratio (HR) 1.13, 95 % confidence interval (CI) 1.06–1.20, p\ 0.001], delirium (HR 1.56, 95 %CI 1.14–3.23, p = 0.01), and PaO2/FiO2 ratio\300 (HR 2.42, 95 % CI 1.28–3.56, p\ 0.001) were independently associated with death, while receipt of aspirin plus a macrolide (HR 0.24, 95 % CI 0.08–0.79, p = 0.01) was associated with survival. This latter finding was confirmed by the propensity score adjusted estimates (see Table 1). The use of macrolides has been previously associated with lower mortality in patients with severe pneumonia, and the administration of clarithromycin has been associated with restoration of the balance between pro-inflammatory versus anti-inflammatory mediators in patients with Gram-negative sepsis and ventilator-associated pneumonia (VAP). A further double-blind, randomized, multicenter trial found that clarithromycin accelerates resolution of VAP, and favors weaning from mechanical ventilation [2]. As regards to aspirin, a propensity-adjusted analysis by Chen and coworkers revealed that the pre-hospital use of aspirin was associated with a decreased risk of developing an acute respiratory distress syndrome (ARDS) [3]. Furthermore, we recently reported a beneficial activity of aspirin in patients with community-onset pneumonia, with a

Chagas disease as a cause of heart failure and ventricular arrhythmias in patients long removed from endemic areas: an emerging problem in Europe.

Chagas disease is a parasitic disease caused by the protozoan Trypanosoma cruzi. In endemic areas (South and Central America), Chagas disease represents a relevant public health issue, and is the most frequent cause of cardiomyopathy. In nonendemic areas, such as Europe, Chagas disease represents an emerging problem following the establishment of sizeable communities from Brazil and Bolivia. Chagas cardiomyopathy represents the most frequent and serious complication of chronic Chagas disease, affecting about 20–30% of patients, potentially leading to heart failure, arrhythmias, thromboembolism, stroke and sudden death. Because late complications of Chagas disease may develop several years or even decades after the acute infection, it may be extremely challenging to reach the correct diagnosis in patients long removed from the countries of origin. We report two examples of Chagas cardiomyopathy in South American women permanently residing in Italy for more than 20 years, presenting with cardiac manifestations ranging from left ventricular dysfunction and heart failure to isolated ventricular arrhythmias. The present review emphasizes that Chagas disease should be considered as a potential diagnosis in patients from endemic areas presenting with ‘idiopathic’ cardiac manifestations, even when long removed from their country of origin, with potential implications for treatment and control of Chagas disease transmission.

Trends in length of hospital stay in acute pulmonary embolism over the years. What is changing in the era of direct oral anticoagulants

Letter to the EditorThe optimal management of acute pulmonary embolism remains a compelling challenge. In recent years, with the improvement of prognostic stratification, it has become clear that entire home treatment or early hospital discharge could be a possible option for managing pulmonary embo

Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non-Vitamin-K Oral Anticoagulants (RAF-NOACs) Study

Background The optimal timing to administer non–vitamin K oral anticoagulants (NOACs) in patients with acute ischemic stroke and atrial fibrillation is unclear. This prospective observational multicenter study evaluated the rates of early recurrence and major bleeding (within 90 days) and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOACs for secondary prevention. Methods and Results Recurrence was defined as the composite of ischemic stroke, transient ischemic attack, and symptomatic systemic embolism, and major bleeding was defined as symptomatic cerebral and major extracranial bleeding. For the analysis, 1127 patients were eligible: 381 (33.8%) were treated with dabigatran, 366 (32.5%) with rivaroxaban, and 380 (33.7%) with apixaban. Patients who received dabigatran were younger and had lower admission National Institutes of Health Stroke Scale score and less commonly had a CHA 2 DS 2‐VASc score >4 and less reduced renal function. Thirty‐two patients (2.8%) had early recurrence, and 27 (2.4%) had major bleeding. The rates of early recurrence and major bleeding were, respectively, 1.8% and 0.5% in patients receiving dabigatran, 1.6% and 2.5% in those receiving rivaroxaban, and 4.0% and 2.9% in those receiving apixaban. Patients who initiated NOACs within 2 days after acute stroke had a composite rate of recurrence and major bleeding of 12.4%; composite rates were 2.1% for those who initiated NOACs between 3 and 14 days and 9.1% for those who initiated >14 days after acute stroke. Conclusions In patients with acute ischemic stroke and atrial fibrillation, treatment with NOACs was associated with a combined 5% rate of ischemic embolic recurrence and severe bleeding within 90 days.

Direct oral anticoagulants in the early phase of non-valvular atrial fibrillation-related ischemic stroke in very old patients undergoing systemic thrombolysis and/or mechanical thrombectomy: Letters to the Editor

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Early recurrence in paroxysmal versus sustained atrial fibrillation in patients with acute ischaemic stroke

Background The relationship between different patterns of atrial fibrillation and early recurrence after an acute ischaemic stroke is unclear. Purpose In a prospective cohort study, we evaluated the rates of early ischaemic recurrence after an acute ischaemic stroke in patients with paroxysmal atrial fibrillation or sustained atrial fibrillation which included persistent and permanent atrial fibrillation. Methods In patients with acute ischaemic stroke, atrial fibrillation was categorised as paroxysmal atrial fibrillation or sustained atrial fibrillation. Ischaemic recurrences were the composite of ischaemic stroke, transient ischaemic attack and symptomatic systemic embolism occurring within 90 days from acute index stroke. Results A total of 2150 patients (1155 females, 53.7%) were enrolled: 930 (43.3%) had paroxysmal atrial fibrillation and 1220 (56.7%) sustained atrial fibrillation. During the 90-day follow-up, 111 ischaemic recurrences were observed in 107 patients: 31 in patients with paroxysmal atrial fibrillation (3.3%) and 76 with sustained atrial fibrillation (6.2%) (hazard ratio (HR) 1.86 (95% CI 1.24–2.81)). Patients with sustained atrial fibrillation were on average older, more likely to have diabetes mellitus, hypertension, history of stroke/ transient ischaemic attack, congestive heart failure, atrial enlargement, high baseline NIHSS-score and implanted pacemaker. After adjustment by Cox proportional hazard model, sustained atrial fibrillation was not associated with early ischaemic recurrences (adjusted HR 1.23 (95% CI 0.74–2.04)). Conclusions After acute ischaemic stroke, patients with sustained atrial fibrillation had a higher rate of early ischaemic recurrence than patients with paroxysmal atrial fibrillation. After adjustment for relevant risk factors, sustained atrial fibrillation was not associated with a significantly higher risk of recurrence, thus suggesting that the risk profile associated with atrial fibrillation, rather than its pattern, is determinant for recurrence.

Trends of Spontaneous Intracerebral Hemorrhage in Florence District Along Fifteen Years: A Brief Report

Spontaneous intracerebral hemorrhage (ICH) represents the most feared stroke subtype. Real world epidemiological data about trends in incident cases and in-hospital mortality lack. Therefore we performed this study aimed to answer this concern. International Classification of Diseases, 9th revision, Clinical Modification (ICD-9 th CM) database referred to patients discharged from six Hospitals of Florence district, Tuscany, Italy in a period fifteen years long (2001-2015)was analyzed. We searched for code 431 as primary or secondary diagnosis at hospital discharge. Overall, 7452 patients were discharged with ICH as primary or secondary diagnosis. Of them, 3695 (49.5%) were females and 4363 (59.1%) were 75-years old and over. Cases of ICH increased from 461 in 2001 to 568 in 2015. The greatest increase was observed in patients 75 years old and over (216 cases in 2001, 339 cases in 2015). Overall, 2273 patients died during hospital stay, in-hospital mortality being 30.5%. In-hospital mortality increased according to age, being 18% in under 65 years and 35.9% in 75-years old and over. In-hospital mortality decreased from 30.8% in 2001 to 25.1% in 2015. The decrease in in-hospital mortality was observed irrespective of age. In Florence district, cases of ICH increased over the years, especially in very old people, whereas in-hospital mortality decreased irrespective of age.