OTAVIO TAVARES RANZANI
Projetos de Pesquisa
Unidades Organizacionais
LIM/09 - Laboratório de Pneumologia, Hospital das Clínicas, Faculdade de Medicina
14 resultados
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Agora exibindo 1 - 10 de 14
- 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.
- Prevention of VAP: role of the artificial airway, body position and setting the ventilator(2012) BASSI, G. Li; FERRER, M.; RANZANI, O. T.; MARTI, J-D.; BERRA, L.; FERNANDEZ, L.; TORRES, A.Ventilator associated pneumonia (VAP) is associated with increased morbidity, mortality and burden for the healthcare system. Oropharyngeal secretions, pooled above the endotracheal tube (ETT) cuff, are the primary source of pathogens in this iatrogenic infection. Improvements in the ETT cuff design to achieve tracheal sealing and maintaining the internal cuff pressure within the recommended range (25-30 cmH(2)O) have a pivotal role in the prevention of pulmonary aspiration of colonised oropharyngeal secretions and VAP. Additionally, ETTs coated with antimicrobial agents prevent colonisation of their internal lumen and biofilm formation; however, further evidence is necessary to assess the role of biofilm in the pathogenesis of VAP. The semirecumbent position is universally recommended; yet, laboratory studies challenge the benefits of such a position. Finally, during positive pressure ventilation, the ventilatory parameters that influence the inspiratory flow, i.e. the duty cycle, have a significant effect on retention of mucus and, potentially, on risks of lung infections. Further clinical evidence is necessary to assess benefits and limitations of ventilatory settings on VAP prevention.
- Gravity Predominates Over Ventilatory Pattern in the Prevention of Ventilator-Associated Pneumonia(2014) BASSI, Gianluigi Li; MARTI, Joan Daniel; SAUCEDO, Lina; RIGOL, Montserrat; ROCA, Ignasi; CABANAS, Maria; MUNOZ, Laura; RANZANI, Otavio Tavares; GIUNTA, Valeria; LUQUE, Nestor; ESPERATTI, Mariano; GABARRUS, Albert; FERNANDEZ, Laia; RINAUDO, Mariano; FERRER, Miguel; RAMIREZ, Jose; VILA, Jordi; TORRES, AntoniObjective: In the semirecumbent position, gravity-dependent dissemination of pathogens has been implicated in the pathogenesis of ventilator-associated pneumonia. We compared the preventive effects of a ventilatory strategy, aimed at decreasing pulmonary aspiration and enhancing mucus clearance versus the Trendelenburg position. Design: Prospective randomized animal study. Setting: Animal research facility, University of Barcelona, Spain. Subjects: Twenty-four Large White-Landrace pigs. Interventions: Pigs were intubated and on mechanical ventilation for 72 hours. Following surgical preparation, pigs were randomized to be positioned: 1) in semirecumbent/prone position, ventilated with a duty cycle (TITTOT) of 0.33 and without positive end-expiratory pressure (control); 2) as in the control group, positive end-expiratory pressure of 5 cm H2O and TITTOT to achieve a mean expiratory-inspiratory flow bias of 10 L/min (treatment); 3) in Trendelenburg/prone position and ventilated as in the control group (Trendelenburg). Following randomization, Pseudomonas aeruginosa was instilled into the oropharynx. Measurements and Main Results: Mucus clearance rate was measured through fluoroscopic tracking of tracheal markers. Microspheres were instilled into the subglottic trachea to assess pulmonary aspiration. Ventilator-associated pneumonia was confirmed by histological/microbiological studies. The mean expiratory-inspiratory flow in the treatment, control, and Trendelenburg groups were 10.7 +/- 1.7, 1.8 +/- 3.7 and 4.3 +/- 2.8 L/min, respectively (p < 0.001). Mucus clearance rate was 11.3 +/- 9.9 mm/min in the Trendelenburg group versus 0.1 +/- 1.0 in the control and 0.2 +/- 1.0 in the treatment groups (p = 0.002). In the control group, we recovered 1.35% +/- 1.24% of the instilled microspheres per gram of tracheal secretions, whereas 0.22% +/- 0.25% and 0.97% +/- 1.44% were recovered in the treatment and Trendelenburg groups, respectively (p = 0.031). Ventilator-associated pneumonia developed in 66.67%, 85.71%, and 0% of the animals in the control, treatment, and Trendelenburg groups (p < 0.001). Conclusions: The Trendelenburg position predominates over expiratory flow bias and positive end-expiratory pressure in the prevention of gravity-dependent translocation of oropharyngeal pathogens and development of ventilator-associated pneumonia. These findings further substantiate the primary role of gravity in the pathogenesis of ventilator-associated pneumonia.
- Validation of Predictors of Adverse Outcomes in Hospital-Acquired Pneumonia in the ICU(2013) ESPERATTI, Mariano; FERRER, Miquel; GIUNTA, Valeria; RANZANI, Otavio Tavares; SAUCEDO, Lina Maria; BASSI, Gianluigi Li; BLASI, Francesco; RELLO, Jordi; NIEDERMAN, Michael S.; TORRES, AntoniObjective: To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days. Design: Prospective, observational study. Setting: Six medical and surgical ICUs of a university hospital. Patients: Three hundred thirty-five patients with ICU-acquired pneumonia. Interventions: None. Measurements and Main Results: Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72-96 hours after starting treatment: no improvement of Pao(2)/Fio(2), need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28. One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p < 0.001), and ventilator-free days were lower (median [interquartile range], 0 [0-17] vs 22 [0-28]) for patients with versus patients without predictors of adverse outcomes (p < 0.001). The lack of improvement of Pao(2)/Fio(2) and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01-4.13; p = 0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated. Conclusions: The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the Pao 2 /Fio 2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.
- 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.
- Association between sepsis at ICU admission and mortality in patients with ICU-acquired pneumonia: An infectious second-hit model(2020) ESPERATTI, Mariano; FUENTES, Nora; FERRER, Miquel; RANZANI, Otavio T.; BASSI, Gianluigi Li; SINGER, Mervyn; GONZALEZ, Maria Eugenia; PERAITA, Georgina; URBANO, Maria Soledad; TORRES, AntoniPurpose: We explore the hypothesis that critically ill patients developing ICU-acquired pneumonia (ICU-AP) have worse outcomes and an altered inflammatory response if their ICU admission was sepsis-related. Methods: Prospective cohort study in two centers. Patients with ICU-AP were evaluated according to their previous exposure to sepsis at ICU-admission. Demographic variables, comorbidities, severity scores at admission and at the time of acquisition of ICU-AP, and serum biomarkers of the inflammatory response were evaluated. Primary outcome: 90-day mortality. Secondary outcomes: ICU and hospital length of stay, mortality at days 28 and 180, in-hospital mortality, ventilator-free days (day-28), and inflammatory response. Propensity scoring weighted the risk of previously-acquired sepsis. Multivariate analysis evaluated the risk of mortality by day-90. Sensitivity analyses evaluated the primary outcome in different subgroups. Results: Of 341 patients enrolled, 147 had sepsis on ICU-admission. Adjusted risk of mortality at 90 days did not differ overall [hazard ratio (HR) = 0.94(0:0.65-137)], nor in subpopulations with a confirmed etiology of pneumonia [HR = 0.93(CI:0.57-1.53)] or sepsis [HR = 0.91(0.54-1.55)], ventilator-associated pneumonia (VAP) [HR = 1.01(CI:0.61-1.68)], nor non-VAP ICU-AP [HR = 0.83(CI:0.40-1.71)]. No differences were found in clinical secondary outcomes, the inflammatory response was similar. Conclusions: Previous sepsis does not appear to predispose to higher mortality nor worse outcomes in patients who develop ICU-acquired pneumonia. (C) 2020 Published by Elsevier Inc.
- 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.
- Rapid identification of antimicrobial resistance patterns allows a faster antibiotic adequacy(2017) CECCATO, Adrian; RANZANI, Otavio T.; TORRES, Antoni
- ICU-Acquired Pneumonia With or Without Etiologic Diagnosis: A Comparison of Outcomes(2013) GIUNTA, Valeria; FERRER, Miquel; ESPERATTI, Mariano; RANZANI, Otavio T.; SAUCEDO, Lina Maria; BASSI, Gianluigi Li; BLASI, Francesco; TORRES, AntoniObjectives: The impact of ICU-acquired pneumonia without etiologic diagnosis on patients' outcomes is largely unknown. We compared the clinical characteristics, inflammatory response, and outcomes between patients with and without microbiologically confirmed ICU-acquired pneumonia. Design: Prospective observational study. Setting: ICUs of a university teaching hospital. Patients: We prospectively collected 270 consecutive patients with ICU-acquired pneumonia. Patients were clustered according to positive or negative microbiologic results. Interventions: None. Measurements and Main Results: We compared the characteristics and outcomes between both groups. Negative microbiology was found in 82 patients (30%). Both groups had similar baseline severity scores. Patients with negative microbiology presented more frequently chronic renal failure (15 [18%] vs 11 [6%]; p = 0.003), chronic heart disorders (35 [43%] vs 55 [29%]; p = 0.044), less frequently previous intubation (44 [54%] vs 135 [72%]; p = 0.006), more severe hypoxemia (Pao(2)/Fio(2) : 165 +/- 73 mm Hg vs 199 +/- 79 mm Hg; p = 0.001), and shorter ICU stay before the onset of pneumonia (5 +/- 5 days vs 7 +/- 9 days; p = 0.001) compared with patients with positive microbiology. The systemic inflammatory response was similar between both groups. Negative microbiology resulted in less changes of empiric treatment (33 [40%] vs 112 [60%]; p = 0.005) and shorter total duration of antimicrobials (13 +/- 6 days vs 17 +/- 12 days; p = 0.006) than positive microbiology. Following adjustment for potential confounders, patients with positive microbiology had higher hospital mortality (adjusted odds ratio 2.96, 95% confidence interval 1.24-7.04, p = 0.014) and lower 90-day survival (adjusted hazard ratio 0.50, 95% confidence interval 0.27-0.94, p = 0.031), with a nonsignificant lower 28-day survival. Conclusions: Although the possible influence of previous intubation in mortality of both groups is not completely discarded, negative microbiologic findings in clinically suspected ICU-acquired pneumonia are associated with less frequent previous intubation, shorter duration of antimicrobial treatment, and better survival. Future studies should corroborate the presence of pneumonia in patients with suspected ICU-acquired pneumonia and negative microbiology.
- Systematic Implementation of Evidence-Based Guidelines in Intensive Care Medicine: Resistance to Change is Human Nature(2013) BASSI, Gianluigi Li; RANZANI, Otavio T.; TORRES, Antoni