OTAVIO TAVARES RANZANI
Projetos de Pesquisa
Unidades Organizacionais
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
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conferenceObject Intensive care unit acquired pneumonia with or without etiologic diagnosis: A comparison of outcomes(2012) GIUNTA, Valeria; FERRER, Miguel; ESPERATTI, Mariano; RANZANI, Otavio Tavares; SAUCEDO, Lina Maria; BASSI, Gianluigi Li; BLASI, Francesco; TORRES, Antoni- Validation of a Prediction Score for Drug-Resistant Microorganisms in Community-acquired Pneumonia(2021) CECCATO, Adrian; MENDEZ, Raul; EWIG, Santiago; TORRE, Mari C. de la; CILLONIZ, Catia; GABARRUS, Albert; PRINA, Elena; RANZANI, Otavio T.; FERRER, Miquel; ALMIRALL, Jordi; MENENDEZ, Rosario; TORRES, AntoniRationale: Recommended initial empiric antimicrobial treatment covers the most common bacterial pathogens; however, community-acquired pneumonia (CAP) may be caused by microorganisms not targeted by this treatment. Developed in 2015, the PES (Pseudonzonas aeruginosa, extended-spectrum beta-lactamase-producing Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus) score was developed in 2015 to predict the microbiological etiology of CAP caused by PES microorganisms. Objective: To validate the usefulness of the PES score for predicting PES microorganisms in two cohorts of patients with CAP from Valencia and Mataro. Methods: We analyzed two prospective observational cohorts of patients with CAP from Valencia and Mataro. Patients in the Mataro cohort were all admitted to an intensive care unit (ICU). Results: Of the 1,024 patients in the Valencia cohort, 505 (51%) had a microbiological etiology and 31 (6%) had a PES microorganism isolated. The area under the receiver operating characteristic curve was 0.81 (95% confidence interval [95% CI], 0.74-0.88). For a PES score >= 5, sensitivity, specificity, the negative and positive predictive values as well as the negative and positive likelihood ratios were 72%, 74%, 98%, 14%, 0.38, and 2.75, respectively. Of the 299 patients in the Mataro cohort, 213 (71%) had a microbiological etiology and 11 (5%) had a PES microorganism isolated. The area under the receiver operating characteristic curve was 0.73 (95% CI 0.61-0.86). For a PES score >= 5, sensitivity, specificity, the negative and positive predictive values, and the negative and positive likelihood ratios were 36%, 83%, 96%, 11%, 0.77, and 2.09, respectively. The best cutoff for patients admitted to the ICU was 4 points, which improved sensitivity to 86%. The hypothetical application of the PPS score showed high rates of overtreatment in both cohorts (26% and 35%, respectively) and similar rates of undertreatment. Conclusions: The PES score showed good accuracy in predicting the risk for microorganisms that required different empirical therapy; however, its use as a single strategy for detecting noncore pathogens could lead to high rates of overtreatment. Given its high negative predictive value, the PES score may be used as a first step of a wider strategy that includes subsequent advanced diagnostic tests.
- Randomized, multicenter trial of lateral Trendelenburg versus semirecumbent body position for the prevention of ventilator-associated pneumonia(2017) BASSI, Gianluigi Li; PANIGADA, Mauro; RANZANI, Otavio T.; ZANELLA, Alberto; BERRA, Lorenzo; CRESSONI, Massimo; PARRINI, Vieri; KANDIL, Hassan; SALATI, Giovanni; SELVAGGI, Paola; AMATU, Alessandro; SANZ-MONCOSI, Miquel; BIAGIONI, Emanuela; TAGLIAFERRI, Fernanda; FURIA, Mirella; MERCURIO, Giovanna; COSTA, Antonietta; MANCA, Tullio; LINDAU, Simone; BABEL, Jaksa; CAVANA, Marco; CHIURAZZI, Chiara; MARTI, Joan-Daniel; CONSONNI, Dario; GATTINONI, Luciano; PESENTI, Antonio; WIENER-KRONISH, Janine; BRUSCHI, Cecilia; BALLOTTA, Andrea; SALSI, Pierpaolo; LIVIGNI, Sergio; IOTTI, Giorgio; FERNANDEZ, Javier; GIRARDIS, Massimo; BARBAGALLO, Maria; MOISE, Gabriella; ANTONELLI, Massimo; CASPANI, Maria Luisa; VEZZANI, Antonella; MEYBOHM, Patrick; GASPAROVIC, Vladimir; GEAT, Edoardo; AMATO, Marcelo; NIEDERMAN, Michael; KOLOBOW, Theodor; TORRES, AntoniPurpose: The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). Methods: This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two pre-planned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. Results: At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). Conclusions: The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure.
- Pulmonary infections complicating ARDS(2020) LUYT, Charles-Edouard; BOUADMA, Lila; MORRIS, Andrew Conway; DHANANI, Jayesh A.; KOLLEF, Marin; LIPMAN, Jeffrey; MARTIN-LOECHES, Ignacio; NSEIR, Saad; RANZANI, Otavio T.; ROQUILLY, Antoine; SCHMIDT, Matthieu; TORRES, Antoni; TIMSIT, Jean-FrancoisPulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.
- Nebulized antibiotics for ventilator-associated pneumonia: a systematic review and meta-analysis(2015) ZAMPIERI, Fernando G.; NASSAR JR., Antonio P.; GUSMAO-FLORES, Dimitri; TANIGUCHI, Leandro U.; TORRES, Antoni; RANZANI, Otavio T.Introduction: Nebulized antibiotics are a promising new treatment option for ventilator-associated pneumonia. However, more evidence of the benefit of this therapy is required. Methods: The Medline, Scopus, EMBASE, Biological Abstracts, CAB Abstracts, Food Science and Technology Abstracts, CENTRAL, Scielo and Lilacs databases were searched to identify randomized controlled trials or matched observational studies that compared nebulized antibiotics with or without intravenous antibiotics to intravenous antibiotics alone for ventilator-associated pneumonia treatment. Two reviewers independently collected data and assessed outcomes and risk of bias. The primary outcome was clinical cure. Secondary outcomes were microbiological cure, ICU and hospital mortality, duration of mechanical ventilation, ICU length of stay and adverse events. A mixed-effect model meta-analysis was performed. Trial sequential analysis was used for the main outcome of interest. Results: Twelve studies were analyzed, including six randomized controlled trials. For the main outcome analysis, 812 patients were included. Nebulized antibiotics were associated with higher rates of clinical cure (risk ratio (RR) = 1.23; 95% confidence interval (CI), 1.05 to 1.43; I-2 = 34%; D-2 = 45%). Nebulized antibiotics were not associated with microbiological cure (RR = 1.24; 95% CI, 0.95 to 1.62; I-2 = 62.5), mortality (RR = 0.90; CI 95%, 0.76 to 1.08; I-2 = 0%), duration of mechanical ventilation (standardized mean difference = -0.10 days; 95% CI, -1.22 to 1.00; I-2 = 96.5%), ICU length of stay (standardized mean difference = 0.14 days; 95% CI, -0.46 to 0.73; I-2 = 89.2%) or renal toxicity (RR = 1.05; 95% CI, 0.70 to 1.57; I-2 = 15.6%). Regarding the primary outcome, the number of patients included was below the information size required for a definitive conclusion by trial sequential analysis; therefore, our results regarding this parameter are inconclusive. Conclusions: Nebulized antibiotics seem to be associated with higher rates of clinical cure in the treatment of ventilator-associated pneumonia. However, the apparent benefit in the clinical cure rate observed by traditional meta-analysis does not persist after trial sequential analysis. Additional high-quality studies on this subject are highly warranted.
conferenceObject Validation Of Predictors Of Adverse Outcomes In Hospital-Acquired Pneumonia In The Intensive Care Unit(2013) ESPERATTI, M.; FERRER, M.; GIUNTA, V.; TAVARES, O.; SAUCEDO, L. M.; BASSI, G. Li; BLASI, F.; RELLO, J.; NIEDERMAN, M. S.; TORRES, A.- New Sepsis Definition (Sepsis-3) and Community-acquired Pneumonia Mortality A Validation and Clinical Decision-Making Study(2017) RANZANI, Otavio T.; PRINA, Elena; MENENDEZ, Rosario; CECCATO, Adrian; CILLONIZ, Catia; MENDEZ, Raul; GABARRUS, Albert; BARBETA, Enric; BASSI, Gianluigi Li; FERRER, Miquel; TORRES, AntoniRationale: The Sepsis-3 Task Force updated the clinical criteria for sepsis, excluding the need for systemic inflammatory response syndrome (SIRS) criteria. The clinical implications of the proposed flowchart including the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and SOFA scores are unknown. Objectives: To perform a clinical decision-making analysis of Sepsis-3 in patients with community-acquired pneumonia. Methods: This was a cohort study including adult patients with community-acquired pneumonia from two Spanish university hospitals. SIRS, qSOFA, the Confusion, Respiratory Rate and Blood Pressure (CRB) score, modified SOFA (mSOFA), the Confusion, Urea, Respiratory Rate, Blood Pressure and Age (CURB-65) score, and Pneumonia Severity Index (PSI) were calculated with data from the emergency department. We used decision-curve analysis to evaluate the clinical usefulness of each score and the primary outcome was in-hospital mortality. Measurements and Main Results: Of 6,874 patients, 442 (6.4%) died in-hospital. SIRS presented the worst discrimination, followed by qSOFA, CRB, mSOFA, CURB-65, and PSI. Overall, overestimation of in-hospital mortality and miscalibration was more evident for qSOFA and mSOFA. SIRS had lower net benefit than qSOFA and CRB, significantly increasing the risk of over-treatment and being comparable with the ""treat-all"" strategy. PSI had higher net benefit than mSOFA and CURB-65 for mortality, whereas mSOFA seemed more applicable when considering mortality/intensive care unit admission. Sepsis-3 flowchart resulted in better identification of patients at high risk of mortality. Conclusions: qSOFA and CRB outperformed SIRS and presented better clinical usefulness as prompt tools for patients with community-acquired pneumonia in the emergency department. Among the tools for a comprehensive patient assessment, PSI had the best decision-aid tool profile.
- Sepsis-3 in Community-acquired Pneumonia: How Reliable Is It? Reply(2018) RANZANI, Otavio T.; TORRES, Antoni
- Diagnostic accuracy of Gram staining when predicting staphylococcal hospital-acquired pneumonia and ventilator-associated pneumonia: a systematic review and meta-analysis(2020) RANZANI, Otavio T.; MOTOS, Ana; CHIURAZZI, Chiara; CECCATO, Adrian; RINAUDO, Mariano; BASSI, Gianluigi Li; FERRER, Miquel; TORRES, AntoniBackground: There is no clear guidance on empirical antibiotic coverage against Staphylococcus aureus for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Objective: To evaluate whether the presence of clusters of Gram-positive cocci in Gram staining of res-piratory samples predicts S. aureus as HAP/VAP pathogen. Methods: Data sources were MEDLINE, PubMed, Embase, Scielo, CINAHL and Scopus, from inception to 15/07/2017 (update on 31/10/2019), and original data from a single-centre database (PROSPERO: CRD42017072138). We included studies reporting the diagnostic accuracy of a Gram-staining evaluation suggestive of Staphylococcus compared with a positive culture for S. aureus in any type of lower respiratory tract sample. Participants were adult patients with HAP/VAP. The index test was morphological evaluation of Gram staining of respiratory samples. We followed PRISMA guidelines and assessed risk of bias and applicability with the QUADAS-2 tool. We conducted a meta-analysis using a bivariate random effects model. Results: We selected five studies that included only VAP and data from a single-centre database including VAP and HAP. We pooled six studies for VAP and analysed 1665 respiratory samples. Pooled sensitivity was 68% (95%CI 49-83 and specificity 95% (95%CI 86-98). The pooled positive likelihood ratio was 12.7 (95%CI 5.1-31.6), negative likelihood ratio 0.34 (95%CI 0.20-0.57), diagnostic odds ratio 38 (95% CI 13-106) and area under the summary receiver operating curve (SROC) 0.91 (95%CI 0.88-0.93). There was great heterogeneity between sensitivity and specificity. In scenarios in which the prevalence of S. aureus was between 5% and 20%, the positive and negative predictive values were 62% (95%CI 47-77) and 95% (95%CI 82-100), respectively. Conclusions: Detection of Gram-positive cocci in clusters in respiratory samples of patients with VAP has the potential to guide risk assessments of S. aureus for more personalized antibiotic coverage. Randomized clinical trials with patient-centred outcomes are needed for strong clinical recommendations.
conferenceObject Follow-Up Cultures in Ventilator-Associated Pneumonia(2021) CECCATO, A.; DOMINEDO, C.; MONREAL, M. Ferrer; IGNACIO, M.; BARBETA, E. R.; ALBERT, G.; CILLONIZ, C.; RANZANI, O. T.; PASCALE, G. De; STEFANO, N.; GIANNATALE, P. Di; ANTONELLI, M.; TORRES, A.