Objectives: Among critically ill patients, there is usually impairment of the hypothalamic-pituitary- adrenal axis, leading to a condition known as critical illness-related corticosteroid insufficiency (CIRCI). The aims of this investigation are to determine the incidence of and characterize CIRCI among patients with COVID-19 as well as to analyze the outcomes of these critically ill patients. Methodology: This is a single-center, retrospective, cohort study that investigated the occurrence of CIRCI among critically ill patients infected with COVID-19. Results: In this cohort, there were 145 COVID-19 positive patients with refractory shock included, which reflects that 22.94% of the COVID-19 admissions have probable CIRCI. Patients who were given corticosteroids were found to have statistically significant longer median days on ventilator (p= 0.001). However, those on the corticosteroid arm were at higher risk of morbidity and mortality and a greater proportion of patients with organ dysfunction. Multivariable logistic regression analysis revealed that SOFA score was a significant predictor of mortality in CIRCI (p=0.013). Conclusion CIRCI has a unique presentation among COVID-19 patients because of the presence of a high level of inflammation in this life-threatening infection. It possibly is a harbinger of markedly increased risk of mortality in these patients.
adrenal insufficiency ; COVID-19 ; critical illness ; shock

Objectives: The diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) remains a challenge. This initiative aimed to develop a protocol for the diagnosis and management of CIRCI which will facilitate informed decision-making among clinicians through consensus-building among a multi-disciplinary team. Methodology: This was a single-center, qualitative study which utilized the modified Delphi method, consisting of a sequential iterative process with two rounds of voting. A cut-off value of 70% was set as the threshold for reaching consensus. Results: The protocol on the diagnosis and management of CIRCI was approved after two rounds of voting, with all the components reaching 83.3%-100% agreement. This protocol on CIRCI provided a framework for the clinical approach to refractory shock. It was advocated that all cases of probable CIRCI should immediately be started on hydrocortisone at 200 mg/day. The definitive diagnosis of CIRCI is established through a random serum cortisol <10 mcg/dL or increase in cortisol of <9 mcg/dL at 60 minutes after a 250 mcg ACTH stimulation test in patients with indeterminate random cortisol levels Conclusion The presence of refractory shock unresponsive to fluid resuscitation and vasopressors should warrant the clinical suspicion for the existence of CIRCI and should trigger a cascade of management strategies.
Shock ; Adrenal Cortex Hormones ; Hydrocortisone

Introduction. A significant number of critically ill patients, as high as 60% among patients with septic shock, suffer from critical illness-related corticosteroid insufficiency (CIRCI), which refers to an inadequate corticosteroid response to the level of stress.

Objectives. This study aimed to determine the strategies employed in managing patients with critical illness-related corticosteroid insufficiency and the outcomes of these patients at a tertiary hospital.

Methods. This was a single-center, mixed-methods study which consisted of a review of charts of patients 19 years old and above admitted for shock or developed refractory hypotension from January 2017-December 2019, and key informant interviews and focus group discussion among clinicians who have experience in managing CIRCI.

Results. A total number of 362 patient charts reviewed showed a relatively low rate of initiation of corticosteroids for patients with refractory shock, at just 28.57% of the entire population. After corticosteroids were initiated, patients were in shock for a median of just one day and the median blood pressure improved to 100/60 mm Hg. In this cohort, patients who were started on steroids had more severe illness, as measured by the Mortality Probability Model (MPM) score, which had a median of 43.65% for the group on steroids and just 25.0% for the non-steroid group (p ? 0.0001). Patients who were started on steroids had a statistically significant longer median days on a ventilator, 5 days vs. 3 days for the non-steroid group (p = 0.0297); longer median length of intensive care unit (ICU) stay, 8 days vs. 5 days for the non-steroid group (p = 0.0410), and a higher morbidity and mortality rate. The need for steroids, the presence of septic shock, and a higher MPM score were significant predictors of mortality.

Discussions among clinicians revealed significant variability in practices in the management of CIRCI.

Conclusion. The presence of clinical features of CIRCI is a poor prognostic factor. Timely recognition, work-up, and interventions to address CIRCI are paramount in critical care.

BACKGROUND: The worldwide incidence of osteomyelitis is approximately 21.8 cases per 100,000 person-years. The cornerstone of treatment is prolonged (4-6 weeks) intravenous antibiotic administration. This entails additional cost, inconvenience, and added manpower from the healthcare system. Thus, studies have explored the possible use of oral antibiotics as alternatives to improve patient compliance and reduce costs. Our meta-analysis aimed to compare the efficacy of oral versus intravenous antibiotics in treating adult patients with osteomyelitis. MATERIALS AND METHODS: Electronic databases (PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Research Gate) from 1966 to April 2020 were searched using the terms “oral antibiotics”, “osteomyelitis”, “randomized controlled trial”. Only studies that directly compared oral versus intravenous antibiotics and confirmed osteomyelitis through biopsy and/or imaging were included. Primary outcome is remission (resolution of symptoms with no relapse and bacteriologic eradication); secondary outcomes, (a) relapse (persistence of the pathogen after treatment) and (b) adverse events. The validity of included studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We performed a random-effects model in Review Manager Version 5.3 with 95% confidence interval. The I 2 test was used to assess heterogeneity. RESULTS: Seven of 89 trials comprised of 1,282 patients were included in the final analysis. All studies included patients with osteomyelitis of the lower extremities. Oral antibiotics used were Ciprofloxacin, Ofloxacin, and Co-trimoxazole; intravenous antibiotics used were deemed appropriate by the infectious disease specialist. Patients were only given either oral or intravenous antibiotics. Results showed an 8% increase in remission rates [RR 1.08 (0.81 to 1.44, 95% CI, Z = 0.52, p=0.60)] with no heterogeneity (I2 = 0%) in the intravenous antibiotics group. However, this was not statistically significant. Furthermore, there was a 62% decrease in relapse rates in the intravenous antibiotics group [RR 1.62 (0.85 to 3.07, 95% CI, Z = 1.47, p = 0.14)] with no heterogeneity (I2 = 0%) but was not statistically significant. CONCLUSION: Oral are comparable to intravenous antibiotics in treating osteomyelitis in terms of remission and relapse rates. However, larger and double-blinded trials should be done to generate more robust data to validate these claims.
Osteomyelitis ; Administration, Intravenous ' ; Parenteral Nutrition