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Predictors of mortality among adult, old and the oldest old patients with bloodstream infections: An age comparison

  • Francesca Giovannenze
    Correspondence
    Corresponding author.
    Affiliations
    Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy
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  • Rita Murri
    Affiliations
    Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy

    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
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  • Claudia Palazzolo
    Affiliations
    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy

    Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, IRCCS, Rome, Italy
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  • Francesco Taccari
    Affiliations
    Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy

    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
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  • Marta Camici
    Affiliations
    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy

    Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, IRCCS, Rome, Italy
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  • Teresa Spanu
    Affiliations
    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy

    Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica S. Cuore, Rome, Italy
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  • Brunella Posteraro
    Affiliations
    Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica S. Cuore, Rome, Italy

    Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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  • Maurizio Sanguinetti
    Affiliations
    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy

    Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica S. Cuore, Rome, Italy
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  • Roberto Cauda
    Affiliations
    Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy

    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
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  • Graziano Onder
    Affiliations
    Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
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  • Massimo Fantoni
    Affiliations
    Dipartimento di Sicurezza e Bioetica, Sezione Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy

    Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
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Published:January 04, 2021DOI:https://doi.org/10.1016/j.ejim.2020.12.017

      Highlights

      • Mortality due to bloodstream infections is increased in geriatric patients.
      • Elderly and oldest old show different susceptibility to distinct pathogens.
      • MRSA and Enterococcus spp strongly affect survival in oldest old patients.

      Abstract

      Background

      Bloodstream infections (BSIs) are a major cause of mortality in elderly. Objective of the study is to identify factors predictive of mortality in old and oldest old patients.

      Methods

      This is a single centre retrospective observational study, including all patients admitted to Fondazione Policlinico A. Gemelli university hospital and diagnosed with BSI. Patients were stratified into three groups according to age: adult (A), younger than 65; old (O), aged between 65 and 80; oldest old (OO), older than 80. Primary outcome was 30-day in-hospital mortality. Secondary outcomes were duration of antimicrobial therapy (DOT) and length of hospital stay (LOS).

      Results

      Of the 1034 patients included in the study, 346 were in group A, 447 in group O and 241 in group OO. The rate of 30-day mortality raised from 6.9% (24/346) in group A to 10.8% (84/447) in group O and 33.2% (80/241) in group OO (p<0.01), while DOT and LOS significantly decreased moving from adults to oldest old (p<0.01). Methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus spp were both independently correlated to an increased 30-day mortality risk selectively in patients older than 80 (MRSA: HR 2.37, p=0.03; Enterococcus spp: HR 2.44, p=0.01).

      Conclusions

      BSIs have a high impact on survival in old and oldest old patients. BSIs by gram-positive pathogens, in particular MRSA and Enterococcus spp, should be a wake-up call for physicians, who should focus efforts on adequate and prompt antibiotic and support treatment.

      Keywords

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      References

        • Goto M.
        • Al-Hasan M.N.
        Overall burden of bloodstream infection and nosocomial bloodstream infection in North America and Europe.
        Clin Microbiol Infect. 2013; 19: 501-509https://doi.org/10.1111/1469-0691.12195
        • Skogberg K.
        • Lyytikäinen O.
        • Ollgren J.
        • Nuorti J.P.
        • Ruutu P.
        Population-based burden of bloodstream infections in Finland.
        Clin Microbiol Infect. 2012; 18https://doi.org/10.1111/j.1469-0691.2012.03845.x
        • Yahav D.
        • Eliakim-Raz N.
        • Leibovici L.
        • Paul M.
        Bloodstream infections in older patients.
        Virulence. 2016; 7: 341-352https://doi.org/10.1080/21505594.2015.1132142
        • Mehl A.
        • Åsvold B.O.
        • Lydersen S.
        • Paulsen J.
        • Solligård E.
        • Damås J.K.
        • Harthug S.
        • Edna T.H.
        Burden of bloodstream infection in an area of Mid-Norway 2002-2013: A prospective population-based observational study.
        BMC Infect Dis. 2017; 17: 1-14https://doi.org/10.1186/s12879-017-2291-2
      1. C.C. Lee, S.Y. Chen, I.J. Chang, S.C. Chen, S.C. Wu, Erratum: Comparison of clinical manifestations and outcome of community-acquired bloodstream infections among the oldest old, elderly, and adult patients (Medicine (United States) (2007) 86 (138-144)), Med. (United States). 92 (2013) 216. 10.1097/MD.0b013e31806a754c.

        • Leibovici L.
        • Samra Z.
        • Konigsberger H.
        • Drucker M.
        • Ashkenazi S.
        • Pitlik S.D.
        Long-term Survival Following Bacteremia or Fungemia.
        JAMA J Am Med Assoc. 1995; 274: 807-812https://doi.org/10.1001/jama.1995.03530100047033
        • Ouchi Y.
        • Rakugi H.
        • Arai H.
        • Akishita M.
        • Ito H.
        • Toba K.
        • Kai I.
        Redefining the elderly as aged 75 years and older: Proposal from the Joint Committee of Japan Gerontological Society and the Japan Geriatrics Society.
        Geriatr Gerontol Int. 2017; 17: 1045-1047https://doi.org/10.1111/ggi.13118
      2. The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters, version 10.0, 2020”, http://www.eucast.org/clinical_breakpoints/.

        • Wester A.L.
        • Dunlop O.
        • Melby K.K.
        • Dahle U.R.
        • Wyller T.B.
        Age-related differences in symptoms, diagnosis and prognosis of bacteremia.
        BMC Infect Dis. 2013; 13: 1https://doi.org/10.1186/1471- 2334-13-346
        • Søgaard M.
        • Schønheyder H.C.
        • Riis A.
        • Sørensen H.T.
        • Nørgaard M.
        Short-term mortality in relation to age and comorbidity in older adults with community-acquired bacteremia: a population-based cohort study.
        J Am Geriatr Soc. 2008; 56: 1593-1600https://doi.org/10.1111/j.1532- 5415.2008.01855.x
        • Martin-Loeches I.
        • Guia M.C.
        • Vallecoccia M.S.
        • Suarez D.
        • Ibarz M.
        • Irazabal M.
        • Ferrer R.
        • Artigas A.
        Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study.
        Ann Intens Care. 2019; 9https://doi.org/10.1186/s13613-019-0495-x
        • Retamar P.
        • López-Prieto M.D.
        • Rodríguez-López F.
        • de Cueto M.
        • García M.V.
        • González-Galan V.
        • del Arco A.
        • Pérez-Santos M.J.
        • Téllez-Pérez F.
        • Becerril-Carral B.
        • Martín-Aspas A.
        • Arroyo A.
        • Pérez- Cortés S.
        • Acosta F.
        • Florez C.
        • León-Ruiz L.
        • Muñoz-Medina L.
        • Rodríguez-Baño J.
        • Natera C.
        • Nuño E.
        • Herrero M.
        • Fernández-Sánchez F.
        • Muñoz A.
        • Sánchez-Porto A.
        • Torres-Tortosa M.
        • García-Tapia A.
        • Carazo I.
        • Alados J.C.
        • Moya R.
        • Corzo J.E.
        • Navas P.
        • Escobar Lara T.
        Predictors of early mortality in very elderly patients with bacteremia: a prospective multicenter cohort.
        Int J Infect Dis. 2014; 26: 83-87https://doi.org/10.1016/j.ijid.2014.04.029
        • Ayau P.
        • Bardossy A.C.
        • Sanchez G.
        • Ortiz R.
        • Moreno D.
        • Hartman P.
        • Rizvi K.
        • Prentiss T.C.
        • Perri M.B.
        • Mahan M.
        • Huang V.
        • Reyes K.
        • Zervos M.J.
        Risk Factors for 30-Day Mortality in Patients with Methicillin-Resistant Staphylococcus aureus Bloodstream Infections.
        Int J Infect Dis. 2017; 61: 3-6https://doi.org/10.1016/j.ijid.2017.05.010
        • Simor A.E.
        • Pelude L.
        • Golding G.
        • Fernandes R.
        • Bryce E.
        • Frenette C.
        • Gravel D.
        • Katz K.
        • Mcgeer A.
        • Mulvey M.R.
        • Smith S.
        • Weiss K.
        Determinants of outcome in hospitalized patients with methicillin- resistant staphylococcus aureus bloodstream infection: Results From National Surveillance in Canada, 2008-2012.
        Infect Control Hosp Epidemiol. 2016; 37: 390-397https://doi.org/10.1017/ice.2015.323
        • Suppli M.
        • Aabenhus R.
        • Harboe Z.B.
        • Andersen L.P.
        • Tvede M.
        • Jensen J.U.S.
        Mortality in enterococcal bloodstream infections increases with inappropriate antimicrobial therapy.
        Clin Microbiol Infect. 2011; 17: 1078-1083https://doi.org/10.1111/j.1469-0691.2010.03394.x
        • Hernández C.
        • Fehér C.
        • Soriano A.
        • Marco F.
        • Almela M.
        • Cobos-Trigueros N.
        • De La Calle C.
        • Morata L.
        • Mensa J.
        • Martínez J.A.
        Clinical characteristics and outcome of elderly patients with community-onset bacteremia.
        J Infect. 2015; 70: 135-143https://doi.org/10.1016/j.jinf.2014.09.002
        • Bassetti M.
        • Righi E.
        • Del Giacomo P.
        • Sartor A.
        • Ansaldi F.
        • Trucchi C.
        • Alicino C.
        • Trecarichi E.M.
        • Spanu T.
        • Paganino C.
        • Tumbarello M.
        • Carnelutti A.
        Predictors of mortality with staphylococcus aureus bacteremia in elderly adults.
        J Am Geriatr Soc. 2018; 66: 1284-1289https://doi.org/10.1111/jgs.15391
        • Tacconelli E.
        • Pop-Vicas A.E.
        • D'Agata E.M.C.
        Increased mortality among elderly patients with meticillin-resistant Staphylococcus aureus bacteraemia.
        J Hosp Infect. 2006; 64: 251-256https://doi.org/10.1016/j.jhin.2006.07.001
        • Cuervo G.
        • Gasch O.
        • Shaw E.
        • Camoez M.
        • Domínguez M.Á.
        • Padilla B.
        • Pintado V.
        • Benito N.
        • Lepe J.A.
        • López-Medrano F.
        • Ruiz de Gopegui E.
        • Martínez J.A.
        • Montejo J.M.
        • Perez-Nadales E.
        • Arnáiz A.
        • Goenaga M.Á.
        • Horcajada J.P.
        • Rodríguez-Baño J.
        • Pujol M.
        • Jover A.
        • Barcenilla F.
        • Garcia M.
        • Domínguez M.A.
        • Dueñas C.
        • Ojeda E.
        • Martinez J.A.
        • Marco F.
        • Chaves F.
        • Lagarde M.
        • Bereciartua E.
        • Hernández J.L.
        • Von Wichmann M.A.
        • Goenaga M.A.
        • García-Arenzana J.M.
        • Padilla C.
        • Cercenado E.
        • García-Pardo G.
        • Tapiol J.
        • Montero M.
        • Salvado M.
        • Fernandez C.
        • Calbo E.
        • Xercavins M.
        • Granados A.
        • Fontanals D.
        • Loza E.
        • Torre-Cisneros J.
        • Lara R.
        • Rodríguez-López F.
        • Rodríguez M.
        • Natera C.
        • Gracia-Ahufinger I.
        • Blanco J.R.
        • Olarte I.
        • Benito N.
        • Mirelis B.
        • Murillas J.
        • Espejo E.
        • Morera M.A.
        • López- Cortés L.E.
        • Pascual A.
        • Martín C.
        • Lepe J.A.
        • Molina J.
        • Sordé R.
        • Larrosa N.
        Clinical characteristics, treatment and outcomes of MRSA bacteraemia in the elderly.
        J Infect. 2016; 72: 309-316https://doi.org/10.1016/j.jinf.2015.12.009
        • Reunes S.
        • Rombaut V.
        • Vogelaers D.
        • Brusselaers N.
        • Lizy C.
        • Cankurtaran M.
        • Labeau S.
        • Petrovic M.
        • Blot S.
        Risk factors and mortality for nosocomial bloodstream infections in elderly patients.
        Eur J Intern Med. 2011; 22: e39-e44https://doi.org/10.1016/j.ejim.2011.02.004
        • Pop-Vicas A.
        • Tacconelli E.
        • Gravenstein S.
        • Lu B.
        • D'Agata E.M.C.
        Influx of multidrug-resistant, gram-negative bacteria in the hospital setting and the role of elderly patients with bacterial bloodstream infection.
        Infect Control Hosp Epidemiol. 2009; 30: 325-331https://doi.org/10.1086/596608
        • Falcone M.
        • Tiseo G.
        • Dentali F.
        • La Regina M.
        • Foglia E.
        • Gambacorta M.
        • Garagiola E.
        • Bonardi G.
        • Clerici P.
        • Colombo F.
        • Farcomeni A.
        • Concia E.
        • Corrao S.
        • Campanini M.
        • Mazzone A.
        Predicting resistant etiology in hospitalized patients with blood cultures positive for Gram-negative bacilli.
        Eur J Intern Med. 2018; 53: 21-28https://doi.org/10.1016/j.ejim.2018.01.029
        • Leal H.F.
        • Azevedo J.
        • Silva G.E.O.
        • Amorim A.M.L.
        • De Roma L.R.C.
        • Arraes A.C.P.
        • Gouveia E.L.
        • Reis M.G.
        • Mendes A.V.
        • De Oliveira Silva M.
        • Barberino M.G.
        • Martins I.S.
        • Reis J.N.
        Bloodstream infections caused by multidrug-resistant gram-negative bacteria: Epidemiological, clinical and microbiological features.
        BMC Infect Dis. 2019; 19: 1-11https://doi.org/10.1186/s12879-019- 4265-z
        • Fülöp T.
        • Fóris G.
        • Wórum I.
        • Leövey A.
        Age-dependent alterations of Fc gamma receptor-mediated effector functions of human polymorphonuclear leucocytes.
        Clin Exp Immunol. 1985; 61: 425-42532
        • Butcher S.
        • Chahel H.
        • Lord J.M.
        Ageing and the neutrophil: No appetite for killing?.
        Immunology. 2000; 100: 411-416https://doi.org/10.1046/j.1365-2567.2000.00079.x
        • Mermel Leonard A.
        • Allon Michael
        • Bouza Emilio
        • Craven Donald E.
        • Flynn Patricia
        • O'Grady Naomi P.
        • Raad Issam I.
        • Rijnders Bart J.A.
        • Sherertz Robert J.
        • Warren David K.
        Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the infectious diseases society of America.
        Clin Infect Dis. Jul 1 2009; 49: 1-45https://doi.org/10.1086/599376
        • Marín M.
        • Gudiol C.
        • Garcia-Vidal C.
        • Ardanuy C.
        • Carratalà J.
        Bloodstream infections in patients with solid tumors: Epidemiology, antibiotic therapy, and outcomes in 528 episodes in a single cancer center.
        Med. (United States). 2014; 93: 143-149https://doi.org/10.1097/MD.0000000000000026
        • Islas-Muñoz B.
        • Volkow-Fernández P.
        • Ibanes-Gutiérrez C.
        • Villamar-Ramírez A.
        • Vilar-Compte D.
        • Cornejo-Juárez P.
        Bloodstream infections in cancer patients. Risk factors associated with mortality.
        Int J Infect Dis. 2018; 71: 59-64https://doi.org/10.1016/j.ijid.2018.03.022
        • Kullberg B.J.
        • Arendrup M.C.
        Invasive candidiasis.
        N Engl J Med. 2015; 373: 1445-1456https://doi.org/10.1056/NEJMra1315399
        • Barchiesi F.
        • Orsetti E.
        • Mazzanti S.
        • Trave F.
        • Salvi A.
        • Nitti C.
        • Manso E.
        Candidemia in the elderly: What does it change?.
        PLoS One. 2017; 12: 1-14https://doi.org/10.1371/journal.pone.0176576
      3. A. Ramos-Martínez, N. Vicente-López, I. Sánchez-Romero, B. Padilla, P. Merino-Amador, J. Garnacho- Montero, I. Ruiz-Camps, M. Montejo, M. Salavert, J. Mensa, M. Cuenca-Estrella, P. Muñoz, J. Guinea, J.R. Paño Pardo, J. García-Rodríguez, C.G. Cerrada, J. Fortún, P. Martín, E. Gómez, P. Ryan, C. Campelo, I. de los Santos Gil, V. Buendía, B.P. Gorricho, M. Alonso, F.S. Sanz, J.M. Aguado, F.G. Romo, M. Gorgolas, I. Gadea, J.E. Losa, A. Delgado-Iribarren, Y. Romero, O. Zaragoza, J. Rodriguez- Baño, A.I. Suarez, A. Loza, A.I. Aller García, E. Martín-Mazuelos, M.R. Pérez de Pipaón, C. Ortiz, M. Chávez, F.L. Maroto, M. Salavert, J. Pemán, J. Blanquer, D. Navarro, J.J. Camarena, R. Zaragoza, V. Abril, C. Gimeno, S. Hernáez, G. Ezpeleta, E. Bereciartua, J.L. Hernández Almaraz, M. Montejo, R.A. Rivas, R. Ayarza, A.M. Planes, B. Almirante, M. Almela, M. Gurgui, F. Sánchez-Reus, J. Martinez- Montauti, M. Sierra, J.P. Horcajada, L. Sorli, J. Gómez, A. Gené, M. Urrea, M. Valerio, A. Díaz-Martín, F. Puchades, A. Mularoni, Epidemiology and prognosis of candidaemia in elderly patients, Mycoses. 60 (2017) 808–817. 10.1111/myc.12677.

        • Flaatten H.
        • De Lange D.W.
        • Morandi A.
        • Andersen F.H.
        • Artigas A.
        • Bertolini G.
        • Boumendil A.
        • Cecconi M.
        • Christensen S.
        • Faraldi L.
        • Fjølner J.
        • Jung C.
        • Marsh B.
        • Moreno R.
        • Oeyen S.
        • Öhman C.A.
        • Pinto B.B.
        • Soliman I.W.
        • Szczeklik W.
        • Valentin A.
        • Watson X.
        • Zaferidis T.
        • Guidet B.
        • Schmutz R.
        • Wimmer F.
        • Eller P.
        • Zotter K.
        • Swinnen W.
        • De Buysscher P.
        • De Neve N.
        • Abraham P.
        • Fleury Y.
        • Schefold J.C.
        • Biskup E.
        • Taliadoros I.
        • Piza P.
        • Lauten A.
        • Sacher A.L.
        • Brenner T.
        • Franz M.
        • Bloos F.
        • Ebelt H.
        • Schaller S.J.
        • Fuest K.
        • Rabe C.
        • Dieck T.
        • Steiner S.
        • Graf T.
        • Nia A.M.
        • Janosi R.A.
        • Meybohm P.
        • Simon P.
        • Utzolino S.
        • Rahmel T.
        • Barth E.
        • Schuster M.
        • Dey N.
        • Sølling C.
        • Rasmussen B.S.
        • Rodriguez E.
        • Rebollo S.
        • Aguilar G.
        • Masdeu G.
        • Jaimes M.I.
        • Mira Á.Prado
        • Bodi M.A.
        • Barea Mendoza J.A.
        • López-Cuenca S.
        • Homez Guzman M.
        • Rico-Feijoo J.
        • Ibarz M.
        • Trenado-Alvarez J.
        • Forceville X.
        • Besch G.
        • Mentec H.
        • Michel P.
        • Mateu P.
        • Vettoretti L.
        • Bourenne J.
        • Marin N.
        • Guillot M.
        • Aissaoui N.
        • Goulenok C.
        • Thieulot-Rolin N.
        • Messika J.
        • Lamhaut L.
        • Charron C.
        • Dempsey G.
        • Mathew S.J.
        • Raj A.S.
        • Grecu I.
        • Cupitt J.
        • Lawton T.
        • Clark R.
        • Popescu M.
        • Spittle N.
        • Faulkner M.
        • Cowton A.
        • Elloway E.
        • Williams P.
        • Reay M.
        • Chukkambotla S.
        • Kumar R.
        • Al-Subaie N.
        • Kent L.
        • Tamm T.
        • Kajtor I.
        • Burns K.
        • Pugh R.
        • Ostermann M.
        • Kam E.
        • Bowyer H.
        • Smith N.
        • Templeton M.
        • Henning J.
        • Goffin K.
        • Kapoor R.
        • Laha S.
        • Chilton P.
        • Khaliq W.
        • Crayford A.
        • Coetzee S.
        • Tait M.
        • Boultoukas E.
        • Stoker W.
        • Gimenez M.
        • Pope A.
        • Camsooksai J.
        • Pogson D.
        • Quigley K.
        • Ritzema J.
        • Hormis A.
        • Boulanger C.
        • Balasubramaniam M.
        • Vamplew L.
        • Burt K.
        • Martin D.
        • Craig J.
        • Prowle J.
        • Doyle N.
        • Shelton J.
        • Scott C.
        • Donnison P.
        • Shelton S.
        • Frey C.
        • Ryan C.
        • Spray D.
        • Barnes V.
        • Barnes K.
        • Furneval J.
        • Ridgway S.
        • Saha R.
        • Clark T.
        • Wood J.
        • Bolger C.
        • Bassford C.
        • Lewandowski john
        • Zhao X.
        • Humphreys S.
        • Dowling S.
        • Richardson N.
        • Burtenshaw A.
        • Stevenson C.
        • Wilcock D.
        • Aidoni Z.
        • Aloizos S.
        • Tasioudis P.
        • Lampiri K.
        • Zisopoulou V.
        • Ifigenia R.
        • Eymorfia P.
        • Angela A.
        • Katsoulas T.A.
        • Kyparissi A.
        • Aikaterini K.
        • Marinakis G.
        • Tsimpoukas F.
        • Spyropoulou A.
        • Zygoulis P.
        • Hayes I.
        • Kelly Y.
        • Westbrook A.
        • Fitzpatrick G.
        • Maheshwari D.
        • Motherway C.
        • Gupta M.
        • Gurjar M.
        • Maji I.M.
        • Negri G.
        • Spadaro S.
        • Nattino G.
        • Pedeferri M.
        • Boscolo A.
        • Rossi S.
        • Rossi M.
        • Calicchio G.
        • Cubattoli L.
        • Di Lascio G.
        • Barbagallo M.
        • Berruto F.
        • Codazzi D.
        • Bottazzi A.
        • Fumagalli P.
        • Negro G.
        • Lupi G.
        • Savelli F.
        • Vulcano G.A.
        • Fumagalli R.
        • Marudi A.
        • Lefons U.
        • Lembo R.
        • Babini M.
        • Paggioro A.
        • Parrini V.
        • Zaccaria M.
        • Clementi S.
        • Gigliuto C.
        • Facondini F.
        • Pastorini S.
        • Munaron S.
        • Calamai I.
        • Bocchi A.
        • Brizio E.
        • Adorni A.
        • Bocci M.G.
        • Cortegiani A.
        • Casalicchio T.
        • Mellea S.
        • Graziani E.
        • Barattini M.
        • van Dijk I.
        • van Lelyveld-Haas L.E.M.
        • Ramnarain D.
        • Jansen T.
        • Nooteboom F.
        • van der Voort P.H.J.
        • Dieperink W.
        • de Waard M.C.
        • Bormans L.
        • Hahn M.
        • Kemmerer N.
        • Strietzel H.F.
        • Fehrle L.
        • Dybwik K.
        • Legernaes T.
        • Klepstad P.
        • Olaussen E.B.
        • Olsen K.I.
        • Børresen O.M.
        • Bjørsvik G.
        • Maini S.
        • Czuczwar M.
        • Krawczyk P.
        • Ziętkiewicz M.
        • Nowak Ł.R.
        • Kotfis K.
        • Cwyl K.
        • Gajdosz R.
        • Biernawska J.
        • Grudzień P.
        • Nasiłowski P.
        • Popek N.
        • Cyrankiewicz W.
        • Wnuk M.
        • Maciejewski D.
        • Studzińska D.
        • Zukowski M.
        • Bernas S.
        • Serwa M.
        • Stefaniak J.
        • Pawel M.
        • Szymkowiak M.
        • Adamik B.
        • Catorze N.
        • Castelo Branco M.
        • Barros I.
        • Barros N.
        • Krystopchuk A.
        • Honrado T.
        • Sousa C.
        • Munoz F.
        • Rebelo M.
        • Gomes R.
        • Nunes J.
        • Dias C.
        • Fernandes A.M.
        • Petrisor C.
        • Constantin B.
        • Belskiy V.
        • Boskholov B.
        • Kawati R.
        • Sivik J.
        • Nauska J.
        • Smole D.
        • Parenmark F.
        • Lyrén J.
        • Rockstroh K.
        • Rydén S.
        • Spångfors M.
        • Strinnholm M.
        • Walther S.
        • De Geer L.
        • Nordlund P.
        • Pålsson S.
        • Zetterquist H.
        • Nilsson A.
        • Thiringer K.
        • Jungner M.
        • Bark B.
        • Nordling B.
        • Sköld H.
        • Brorsson C.
        • Persson S.
        • Bergström A.
        • Berkius J.
        • Holmström J.
        • Yapici N.
        The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years).
        Intens. Care Med. 2017; 43: 1820-1828https://doi.org/10.1007/s00134-017-4940-8