OTAVIO TAVARES RANZANI
Projetos de Pesquisa
Unidades Organizacionais
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
9 resultados
Resultados de Busca
Agora exibindo 1 - 9 de 9
- A decision-aid tool for ICU admission triage is associated with a reduction in potentially inappropriate intensive care unit admissions(2019) RAMOS, Joao Gabriel Rosa; RANZANI, Otavio T.; PERONDI, Beatriz; DIAS, Roger Daglius; JONES, Daryl; CARVALHO, Carlos Roberto Ribeiro; VELASCO, Irineu Tadeu; FORTE, Daniel NevesPurpose: Intensive care unit (ICU) admission triage occurs frequently and often involves highly subjective decisions that may lead to potentially inappropriate ICU admissions. In this study, we evaluated the effect of implementing a decision-aid tool for ICU triage on ICU admission decisions. Methods: This was a prospective, before-after study. Urgent ICU referrals to ten ICUs in a tertiary hospital in Brazil were assessed before and after the implementation of the decision-aid tool. Our primary outcome was the proportion of potentially inappropriate ICU referrals (defined as priority 4B or 5 referrals, accordingly to the Society of Critical Care Medicine guidelines of 1999 and 2016, respectively) admitted to the ICU within 48 h. We conducted multivariate analyses to adjust for potential confounders and evaluated the interaction between phase and triage priority. Results: Of the 2201 patients analyzed, 1184 (53.8%) patients were admitted to the ICU. After adjustment for confounders, implementation of the decision-aid tool was associated with a reduction in potentially inappropriate ICU admissions using either the 1999 [adjOR (95% CI) = 0.36 (0.13-0.97)] or 2016 [adjOR (95%CI) = 0.35 (0.13-0.96)] definitions. Conclusion: Implementation of a decision-aid tool for ICU triage was associated with a reduction in potentially inappropriate ICU admissions. (C) 2019 Published by Elsevier Inc.
- A Comparison of Mortality From Sepsis in Brazil and England: The Impact of Heterogeneity in General and Sepsis-Specific Patient Characteristics(2019) RANZANI, Otavio T.; SHANKAR-HARI, Manu; HARRISON, David A.; RABELLO, Ligia S.; SALLUH, Jorge I. F.; ROWAN, Kathryn M.; SOARES, MarcioObjectives: To test whether differences in both general and sepsis-specific patient characteristics explain the observed differences in sepsis mortality between countries, using two national critical care (ICU) databases. Design: Cohort study. Setting: We analyzed 62 and 164 ICUs in Brazil and England, respectively. Patients: Twenty-two-thousand four-hundred twenty-six adult ICU admissions from January 2013 to December 2013. Interventions: None. Measurements and Main Results: After harmonizing relevant variables, we merged the first ICU episode of adult medical admissions from Brazil (ORganizational CHaractEeriSTics in cRitical cAre study) and England (Intensive Care National Audit & Research Centre Case Mix Programme). Sepsis-3 definition was used, and the primary outcome was hospital mortality. We used multilevel logistic regression models to evaluate the impact of country (Brazil vs England) on mortality, after adjustment for general (age, sex, comorbidities, functional status, admission source, time to admission) and sepsis-specific (site of infection, organ dysfunction type and number) patient characteristics. Of medical ICU admissions, 13.2% (4,505/34,150) in Brazil and 30.7% (17,921/58,316) in England met the sepsis definition. The Brazil cohort was older, had greater prevalence of severe comorbidities and dependency compared with England. Respiratory was the most common infection site in both countries. The most common organ dysfunction was cardiovascular in Brazil (41.2%) and respiratory in England (85.8%). Crude hospital mortality was similar (Brazil 41.4% vs England 39.3%; odds ratio, 1.12 [0.98-1.30]). After adjusting for general patient characteristics, there was an important change in the point-estimate of the odds ratio (0.88 [0.75-1.02]). However, after adjusting for sepsis-specific patient characteristics, the direction of effect reversed again with Brazil having higher risk-adjusted mortality (odds ratio, 1.22 [1.05-1.43]). Conclusions: Patients with sepsis admitted to ICUs in Brazil and England have important differences in general and sepsis-specific characteristics, from source of admission to organ dysfunctions. We show that comparing crude mortality from sepsis patients admitted to the ICU between countries, as currently performed, is not reliable and that the adjustment for both general and sepsis-specific patient characteristics is essential for valid international comparisons of mortality amongst sepsis patients admitted to critical care units.
- Follow-up cultures in ventilator-associated pneumonia(2019) DOMINEDO, Cristina; CECCATO, Adrian; FERRER, Miguel; GABARRUS, Albert; CILLONIZ, Catia; RANZANI, Otavio T.; BARBETA, Enric; PASCALE, Gennaro De; ANTONELLI, Massimo; TORRES, Antoni
- Nebulized Amikacin and Fosfomycin for Severe Pseudomonas aeruginosa Pneumonia: An Experimental Study*(2019) BASSI, Gianluigi Li; MOTOS, Ana; FERNANDEZ-BARAT, Laia; XIOL, Eli Aguilera; CHIURAZZI, Chiara; SENUSSI, Tarek; SACO, Maria A.; FUSTER, Carla; CARBONARA, Marco; BOBI, Joaquim; AMARO, Rosanel; ROSA, Francesca De; COMARU, Talitha; YANG, Hua; RANZANI, Otavio T.; MARTI, Joan-Daniel; RINAUDO, Mariano; TRINIDAD, Oscar Comino; RIGOL, Montserrat; BRINGUE, Josep; RAMIREZ, Jose; NICOLAU, David P.; PELOSI, Paolo; ANTONELLI, Massimo; BLASI, Francesco; ARTIGAS, Antonio; MONTGOMERY, A. Bruce; TORRES, AntoniObjectives: Latest trials failed to confirm merits of nebulized amikacin for critically ill patients with nosocomial pneumonia. We studied various nebulized and IV antibiotic regimens in a porcine model of severe Pseudomonas aeruginosa pneumonia, resistant to amikacin, fosfomycin, and susceptible to meropenem. Design: Prospective randomized animal study. Setting: Animal Research, University of Barcelona, Spain. Subjects: Thirty female pigs. Interventions: The animals were randomized to receive nebulized saline solution (CONTROL); nebulized amikacin every 6 hours; nebulized fosfomycin every 6 hours; IV meropenem alone every 8 hours; nebulized amikacin and fosfomycin every 6 hours; amikacin and fosfomycin every 6 hours, with IV meropenem every 8 hours. Nebulization was performed through a vibrating mesh nebulizer. The primary outcome was lung tissue bacterial concentration. Secondary outcomes were tracheal secretions P. aeruginosa concentration, clinical variables, lung histology, and development of meropenem resistance. Measurements and Main Results: We included five animals into each group. Lung P. aeruginosa burden varied among groups (p < 0.001). In particular, IV meropenem and amikacin and fosfomycin + IV meropenem groups presented lower P. aeruginosa concentrations versus amikacin and fosfomycin, amikacin, CONTROL, and fosfomycin groups (p < 0.05), without significant difference between these two groups undergoing IV meropenem treatment. The sole use of nebulized antibiotics resulted in dense P. aeruginosa accumulation at the edges of the interlobular septa. Amikacin, amikacin and fosfomycin, and amikacin and fosfomycin + IV meropenem effectively reduced P. aeruginosa in tracheal secretions (p < 0.001). Pathognomonic clinical variables of respiratory infection did not differ among groups. Resistance to meropenem increased in IV meropenem group versus amikacin and fosfomycin + meropenem (p = 0.004). Conclusions: Our findings corroborate that amikacin and fosfomycin alone efficiently reduced P. aeruginosa in tracheal secretions, with negligible effects in pulmonary tissue. Combination of amikacin and fosfomycin with IV meropenem does not increase antipseudomonal pulmonary tissue activity, but it does reduce development of meropenem-resistant P. aeruginosa, in comparison with the sole use of IV meropenem. Our findings imply potential merits for preemptive use of nebulized antibiotics in order to reduce resistance to IV meropenem.
- Effect of Combined beta-Lactam/Macrolide Therapy on Mortality According to the Microbial Etiology and Inflammatory Status of Patients With Community-Acquired Pneumonia(2019) CECCATO, Adrian; CILLONIZ, Catia; MARTIN-LOECHES, Ignacio; RANZANI, Otavio T.; GABARRUS, Albert; BUENA, Leticia; GARCIA-VIDAL, Carolina; FERRER, Miguel; NIEDERMAN, Michael S.; TORRES, AntoniBACKGROUND: Antibiotic combinations that include macrolides have shown lower mortality rates than beta-lactams in monotherapy or combined with fluoroquinolones in patients with community-acquired pneumonia (CAP). However, this effect has not been studied according to the levels of C-reactive protein in CAP with identified microbial cause. In patients with CAP and known microbial cause we aimed to evaluate 30-day mortality of a beta-lactam plus macrolide (BL + M) compared with a fluoroquinolone alone or with a beta-lactam (FQ +/- BL). METHODS: We analyzed a prospective observational cohort of patients with CAP admitted to the Hospital Clinic of Barcelona between 1996 and 2016. We included only patients with known microbial cause. RESULTS: Of 1,715 patients (29%) with known etiology, a total of 932 patients (54%) received BL + M. Despite lower crude mortality in the BL thorn M group in the overall population (BL thorn M, 5% vs FQ +/- BL, 8%; P = .015), after adjustment by a propensity score and baseline characteristics, the combination of BL thorn M had a protective effect on mortality only in patients with high inflammatory response (C-reactive protein, > 15 mg/dL) and pneumococcal CAP (adjusted OR, 0.28; 95% CI, 0.09-0.93). No benefits on mortality were observed for the population without high inflammatory response and pneumococcal CAP or with other etiologies. CONCLUSIONS: The combination of a beta-lactam with a macrolide was associated with decreased mortality in patients with pneumococcal CAP and in patients with high systemic inflammatory response. When both factors occurred together, BL thorn M was protective for mortality in the multivariate analysis.
- Lymphocytopenia as a Predictor of Mortality in Patients with ICU-Acquired Pneumonia(2019) CECCATO, Adrian; PANAGIOTARAKOU, Meropi; RANZANI, Otavio T.; MARTIN-FERNANDEZ, Marta; ALMANSA-MORA, Raquel; GABARRUS, Albert; BUENO, Leticia; CILLONIZ, Catia; LIAPIKOU, Adamantia; FERRER, Miquel; BERMEJO-MARTIN, Jesus E.; TORRES, AntoniBackground: Intensive care unit-acquired pneumonia (ICU-AP) is a severe complication in patients admitted to the ICU. Lymphocytopenia is a marker of poor prognosis in patients with community-acquired pneumonia, but its impact on ICU-AP prognosis is unknown. We aimed to evaluate whether lymphocytopenia is an independent risk factor for mortality in non-immunocompromised patients with ICU-AP. Methods: Prospective observational cohort study of patients from six ICUs of an 800-bed tertiary teaching hospital (2005 to 2016). Results: Of the 473 patients included, 277 (59%) had ventilator-associated pneumonia (VAP). Receiver operating characteristic (ROC) analysis of the lymphocyte counts at diagnosis showed that 595 cells/mm(3) was the best cut-off for discriminating two groups of patients at risk: lymphocytopenic group (lymphocyte count <595 cells/mm(3), 141 patients (30%)) and non-lymphocytopenic group (lymphocyte count >= 595 cells/mm(3), 332 patients (70%)). Patients with lymphocytopenia presented more comorbidities and a higher sequential organ failure assessment (SOFA) score at the moment of pneumonia diagnosis. Also, 28-day mortality and 90-day mortality were higher in patients with lymphocytopenia (28-day: 38 (27%) versus 59 (18%), 90-day: 74 (53%) versus 111 (34%)). In the multivariable model, <595 cells/mm(3) resulted to be an independent predictor for 90-day mortality (Hazard Ratio 1.41; 95% Confidence Interval 1.02 to 1.94). Conclusion: Lymphocytopenia is an independent predictor of 90-day mortality in non-immunocompromised patients with ICU-AP.
- Invasive and non-invasive diagnostic approaches for microbiological diagnosis of hospital-acquired pneumonia(2019) RANZANI, Otavio T.; SENUSSI, Tarek; IDONE, Francesco; CECCATO, Adrian; BASSI, Gianluigi Li; FERRER, Miquel; TORRES, AntoniBackgroundData on the methods used for microbiological diagnosis of hospital-acquired pneumonia (HAP) are mainly extrapolated from ventilator-associated pneumonia. HAP poses additional challenges for respiratory sampling, and the utility of sputum or distal sampling in HAP has not been comprehensively evaluated, particularly in HAP admitted to the ICU.MethodsWe analyzed 200 patients with HAP from six ICUs in a teaching hospital in Barcelona, Spain. The respiratory sampling methods used were divided into non-invasive [sputum and endotracheal aspirate (EAT)] and invasive [fiberoptic-bronchoscopy aspirate (FBAS), and bronchoalveolar lavage (BAL)].ResultsA median of three diagnostic methods were applied [range 2-4]. At least one respiratory sampling method was applied in 93% of patients, and two or more were applied in 40%. Microbiological diagnosis was achieved in 99 (50%) patients, 69 (70%) by only one method (42% FBAS, 23% EAT, 15% sputum, 9% BAL, 7% blood culture, and 4% urinary antigen). Seventy-eight (39%) patients underwent a fiberoptic-bronchoscopy when not receiving mechanical ventilation. Higher rates of microbiological diagnosis were observed in the invasive group (56 vs. 39%, p=0.018). Patients with microbiological diagnosis more frequently presented changes in their empirical antibiotic scheme, mainly de-escalation.ConclusionsA comprehensive approach might be undertaken for microbiological diagnosis in critically ill nonventilated HAP. Sputum sampling determined one third of microbiological diagnosis in HAP patients who were not subsequently intubated. Invasive methods were associated with higher rates of microbiological diagnosis.
- Biomarkers in community-acquired pneumonia: can we do better by using them correctly?(2019) RANZANI, Otavio Tavares; COELHO, Luis; TORRES, Antoni
- Zoonotic Tuberculosis in Humans: Control, Surveillance, and the One Health Approach(2019) COUTO, Rodrigo de Macedo; RANZANI, Otavio T.; WALDMAN, Eliseu AlvesZoonotic tuberculosis is a reemerging infectious disease in high-income countries and a neglected one in low- and middle-income countries. Despite major advances in its control as a result of milk pasteurization, its global burden is unknown, especially due the lack of surveillance data. Additionally, very little is known about control strategies. The purpose of this review was to contextualize the current knowledge about the epidemiology of zoonotic tuberculosis and to describe the available evidence regarding surveillance and control strategies in high-, middle-, and low-income countries. We conducted this review enriched by a One Health perspective, encompassing its inherent multifaceted characteristics. We found that the burden of zoonotic tuberculosis is likely to be underreported worldwide, with higher incidence in low-income countries, where the surveillance systems are even more fragile. Together with the lack of specific political commitment, surveillance data is affected by lack of a case definition and limitations of diagnostic methods. Control measures were dependent on risk factors and varied greatly between countries. This review supports the claim that a One Health approach is the most valuable concept to build capable surveillance systems, resulting in effective control measures. The disease characteristics and suggestions to implement surveillance and control programs are discussed.