Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

THE EFFECT OF CATECHOLAMINE VERSUS NONCATECHOLAMINE VASOPRESSORS ON RENAL FUNCTION AND RECOVERY IN VASODILATORY SHOCK: A SYSTEMATIC REVIEW OF PRECLINICAL AND CLINICAL STUDIES

ABSTRACT

Background: Acute kidney injury (AKI) is a common complication of vasodilatory shock. AKI is associated with an increased risk of death, prolonged hospital stays, and subsequent transition to chronic kidney disease. Catecholamines have historically been used as the first-line vasopressors for vasodilatory shock; however, they may adversely affect renal function and recovery. Objectives: To compare the effects of catecholamine and noncatecholamine vasopressors on AKI risk and recovery in preclinical and clinical studies of vasodilatory shock. Methods: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were systematically searched to identify studies reporting renal outcomes associated with catecholamine (norepinephrine, epinephrine, metaraminol, phenylephrine, dopamine) and noncatecholamine vasopressors (vasopressin, angiotensin II), in preclinical models or adult cohorts of vasodilatory shock. Two independent reviewers screened studies and extracted data using a prespecified form for qualitative synthesis and risk of bias assessment. Results: Of 3,504 citations, 90 studies were eligible for inclusion: 41 preclinical studies, 17 nonrandomized clinical studies, 28 randomized clinical studies, and 4 post-hoc analyses. Risk of bias was generally low in preclinical studies and low to moderate in clinical studies. In preclinical studies, catecholamine vasopressors exacerbated medullary hypoxia and intrarenal inflammation compared to noncatecholamine vasopressors. In clinical studies, catecholamines were associated with higher serum creatinine, lower urine output, and increased requirements for renal replacement therapy compared to noncatecholamine vasopressors. In patients on high-dose catecholamines, adjunctive angiotensin II was associated with improved renal replacement therapy liberation. Conclusion: Preclinical and clinical studies suggest that noncatecholamine vasopressors may confer renal benefits compared to catecholamine vasopressors. These hypothesis-generating observations suggest the need for comparative studies focused on renal outcomes. Systematic Review Registration : PROSPERO 2024 CRD42024527773.

Elevated Serum Presepsin Identifies Herpes Simplex Virus-1 Reactivation in COVID-19 Patients

Presepsin, a cleaved peptide of soluble CD14, may become a promising biomarker for assessing disease severity and mortality in coronavirus disease 2019 (COVID-19). Patients with severe COVID-19 frequently develop bacterial and fungal superinfections, as well as herpes simplex virus-1 (HSV-1) reactivation, which may exacerbate disease progression. This study aimed to evaluate the impact of concomitant infections on serum presepsin levels. Serum presepsin levels were measured using an enzyme-linked immunosorbent assay (ELISA) in 63 patients with moderate COVID-19, 60 patients with severe disease, and 49 healthy controls. Correlations with procalcitonin and the presence of superinfections or HSV-1 reactivation were assessed. Consistent with previous studies, serum presepsin levels were the highest in patients with severe COVID-19 (p = 0.002 compared to patients with moderate disease). Within this group, non-survivors exhibited significantly elevated presepsin levels (p = 0.027). A positive correlation between presepsin and procalcitonin was observed in both moderate and severe COVID-19 cases. Patients with bacterial or fungal superinfections showed presepsin levels comparable to those without secondary infections. However, presepsin levels were markedly elevated in patients with HSV-1 reactivation (p = 0.002). After excluding patients with HSV-1 reactivation, presepsin levels no longer differed between moderate and severe COVID-19 cases, though they remained higher than in healthy controls (p < 0.001 for both comparisons). In conclusion, these findings suggest that elevated serum presepsin levels in severe COVID-19 are primarily driven by HSV-1 reactivation rather than bacterial or fungal superinfections.

A review of gut failure as a cause and consequence of critical illness

In critical illness, all elements of gut function are perturbed. Dysbiosis develops as the gut microbial community loses taxonomic diversity and new virulence factors appear. Intestinal permeability increases, allowing for translocation of bacteria and/or bacterial products. Epithelial function is altered at a cellular level and homeostasis of the epithelial monolayer is compromised by increased intestinal epithelial cell death and decreased proliferation. Gut immunity is impaired with simultaneous activation of maladaptive pro- and anti-inflammatory signals leading to both tissue damage and susceptibility to infections. Additionally, splanchnic vasoconstriction leads to decreased blood flow with local ischemic changes. Together, these interrelated elements of gastrointestinal dysfunction drive and then perpetuate multi-organ dysfunction syndrome. Despite the clear importance of maintaining gut homeostasis, there are very few reliable measures of gut function in critical illness. Further, while multiple therapeutic strategies have been proposed, most have not been shown to conclusively demonstrate benefit, and care is still largely supportive. The key role of the gut in critical illness was the subject of the tenth Perioperative Quality Initiative meeting, a conference to summarize the current state of the literature and identify key knowledge gaps for future study. This review is the product of that conference.

Obesity as a Risk Factor in Pediatric Sepsis: A Retrospective Comparative Study Under the Phoenix Definition

Background: The relationship between sepsis outcomes and obesity has attracted significant interest in the medical community. However, this association has not been tested under Phoenix criteria, which represent the new pediatric sepsis definition, defining sepsis as life-threatening organ dysfunction in the setting of infection. Methods: A single-center, observational, retrospective study of pediatric sepsis patients from January 2014 to December 2019. The PICU was located within a tertiary pediatric center in the United States. Children more than one month old, but less than 18 years old, with a diagnosis of sepsis were included. Results: Six hundred and twenty-seven patients with a diagnosis of sepsis based on the Sepsis-2 definition were identified. Within the cohort, 554 patients met the definition of sepsis under the Phoenix criteria. Patients were classified based on the body habitus as underweight, normal, overweight, and obese. Obese patients had significantly higher mortality compared to the normal weight group (p = 0.033). More renal dysfunction was also seen in the obesity group (p = 0.0007). No difference in the frequency of identified Gram-positive, Gram-negative bacterial, viral, or fungal sepsis was observed between normal-weight and obese patients. Conclusions: In our cohort of pediatric sepsis, obesity was significantly associated with a higher degree of organ dysfunction and mortality. However, no difference in the incidence of identified bacterial, fungal, or viral sepsis was observed.

Impact of Short-Acting Beta-Blockers on the Outcomes of Patients With Septic Shock: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the impact of short-acting beta-blocker therapy on outcomes in adult patients with septic shock.

DATA SOURCES

We searched MEDLINE, Embase, and unpublished sources from inception to April 19, 2024.

STUDY SELECTION

We included randomized controlled trials (RCTs) that evaluated short-acting beta-blockers compared with usual care in patients with septic shock.

DATA EXTRACTION

We collected data regarding study and patient characteristics, beta-blocker administration, and clinical, hemodynamic, and biomarker outcomes.

DATA SYNTHESIS

Twelve RCTs proved eligible (n = 1170 patients). Short-acting beta-blockers may reduce 28-day mortality (relative risk [RR], 0.76; 95% CI, 0.62-0.93; low certainty) and probably reduce new-onset tachyarrhythmias (RR, 0.37; 95% CI, 0.18-0.78; moderate certainty) but may increase the duration of vasopressors (mean difference [MD], 1.04 d; 95% CI, 0.37-1.72; low certainty). Furthermore, there is an uncertain effect as to whether short-acting beta blockers impact 90-day mortality (RR, 0.98; 95% CI, 0.73-1.31), ICU length of stay (MD, -0.75 d; 95% CI, -3.43 to 1.93 d), hospital length of stay (MD, 1.03 d; 95% CI, -1.92 to 3.98 d), duration of mechanical ventilation (MD, -0.10 d; 95% CI, -1.25 to 1.05 d) (all very low certainty), bradycardia episodes (RR, 3.14; 95% CI, 0.91-14.01), and hypotension episodes (RR, 4.74; 95% CI, 1.62-14.01) (all very low certainty).

CONCLUSIONS

In patients with septic shock, short-acting beta-blockers may improve survival and reduce new-onset tachyarrhythmias. However, these findings were based on low certainty evidence and given ongoing concerns regarding adverse effects and the increase duration of vasopressor use, we need larger and more rigorous RCTs to evaluate this intervention.

Melatonin Exerts Positive Effects on Sepsis Through Various Beneficial Mechanisms

In recent years, our understanding of sepsis has greatly advanced. However, due to the complex pathological and physiological mechanisms of sepsis, the mechanisms of sepsis are currently not fully elucidated, and it is difficult to translate the research results into specific sepsis treatment methods. Melatonin possesses broad anti-inflammatory, antioxidant, and immune-regulatory properties, making it a promising therapeutic agent for sepsis. In recent years, further research has deepened our understanding of the potential mechanisms and application prospects of melatonin in sepsis. The mechanisms underlying the protective effects of melatonin in sepsis are multifaceted. In this review, based on a substantial body of clinical trials and animal research findings, we first highlighted the significance of melatonin as an important biomarker for disease progression and prognosis in sepsis. We also described the extensive regulatory mechanisms of melatonin in sepsis-induced organ damage. In addition to its broad anti-inflammatory, and anti-oxidant effects, melatonin exerts positive effects by regulating metabolic disorders, hemodynamics, cell autophagy, cellular ion channels, endothelial cell permeability, ferroptosis and other complex pathological mechanisms. Furthermore, as a safe exogenous supplement with low toxicity, melatonin demonstrates positive synergistic effects with other anti-sepsis agents. In the face of the urgent medical challenge of transforming the increasing knowledge of sepsis molecular mechanisms into therapeutic interventions to improve patient prognosis, melatonin seems to be a promising option.

Quality of guidelines for infection management in sepsis: a critical appraisal using the AGREE II instrument

OBJECTIVES

The aim of this study was to systematically assess the methodological quality of current sepsis infection management guidelines and identify gaps in knowledge that limit evidence-based practice.

METHODS

A systematic search was conducted to obtain guidelines for the management of sepsis infections (2012-2021), and three reviewers independently assessed the quality of eligible guidelines using Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. The intraclass correlation coefficients (ICCs) were used to measure the agreement between reviewers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to analyze the strength of recommendation and level of evidence of the guideline, and the number of recommendations, strength of recommendation, and level of evidence were determined.

RESULTS

Eleven guidelines for the management of sepsis infection were identified. An overall high agreement among the evaluators for each domain was observed (ICC ranged from 0.850 to 0.959). The overall scores of the included guidelines were all over 60% (range, 62.3-89.90%), which were worthy of recommendation for clinical use; among them, 4 guidelines had an overall score of over 80%, which were high-quality guideline articles. In terms of the quality domains of the guidelines, the scope and purpose domain and the clarity of expression domain had the highest average scores, which were 93.6% (range, 79.6-98.1%) and 91.4% (range, 64.8-98.1%), respectively, while the applicability domain had the lowest average score, which was 64.8% (range, 51.4-76.4%). The strength of the recommendations of the guideline recommendations was mainly weak, accounting for 73.4%; the level of evidence cited was mainly very low quality (60.2%) and low quality (28.1%).

CONCLUSIONS

The quality of sepsis infection management guidelines varies, but the overall quality level is satisfactory. Improving the low-quality areas of sepsis guidelines, attempting to resolve existing problems and controversies, and improving the quality of research evidence will be effective ways for developers to upgrade sepsis guidelines.

Lactated Ringer's or Normal Saline for Initial Fluid Resuscitation in Sepsis-Induced Hypotension

OBJECTIVES

To assess whether initial fluid resuscitation with lactated Ringer's solution compared with 0.9% saline is associated with improved clinical outcomes in patients with sepsis-induced hypotension.

DESIGN

Secondary analysis of the randomized controlled Crystalloid Liberal or Vasopressors Early Resuscitation in Sepsis (CLOVERS) trial.

SETTING

ICUs and emergency departments in 60 U.S. centers from March 2018 to January 2022.

PATIENTS

Participants from the CLOVERS trial. Adult patients with a suspected or confirmed infection and hypotension caused by sepsis.

INTERVENTIONS

Participants received 1-3 L of crystalloid fluid for initial fluid resuscitation before randomization. In this analysis, participants were categorized into a lactated Ringer's group and a 0.9% saline group based on the fluid type predominantly used for the initial fluid resuscitation (i.e., ≥ 95% of pre-randomization fluid).

MEASUREMENTS AND MAIN RESULTS

Of 1563 participants with sepsis-induced hypotension included in the CLOVERS trial, 622 (39.8%) received lactated Ringer's solution and 690 (44.1%) received 0.9% saline as solution for the initial fluid bolus. Death before discharge home by day 90 occurred in 76 of 622 participants (12.2%) in the lactated Ringer's group and in 110 of 690 participants (15.9%) in the 0.9% saline group, resulting in an adjusted hazard ratio of 0.71 (95% CI, 0.51-0.99; p = 0.043). Patients receiving lactated Ringer's solution had more hospital-free days at 28 days than those receiving 0.9% saline (16.6 ± 10.8 vs. 15.4 ± 11.4, respectively; adjusted mean difference, 1.6 d [95% CI, 0.4-2.8 d; p = 0.009]). Treatment with 0.9% saline was associated with higher levels of serum chloride and decreased levels of serum bicarbonate.

CONCLUSIONS

Initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, might be associated with improved survival in patients with sepsis-induced hypotension.

An index of the initial blood pressure response to angiotensin II treatment and its association with clinical outcomes in vasodilatory shock

BACKGROUND

No standardized index exists to assess cardiovascular responsiveness to angiotensin-II. We hypothesized that a standardized index of initial blood pressure response to angiotensin-II treatment would be associated with clinical outcomes.

METHODS

Using data from the Angiotensin Therapy for High Output Shock (ATHOS-3) trial, we developed an Angiotensin-II Initial MAP Response Index of Treatment Effect (AIMRITE) defined as (MAP at hr1 - MAP at baseline)/study drug dose. We assessed AIMRITE continuously and, based on observed distributions, we additionally categorized patients as "responsive" or "resistant", with responsiveness defined by an AIMRITE ≥ 0.90 mmHg/ng/kg/min. The primary clinical outcome was 28-day mortality. Secondary outcomes included days alive and vasopressor- or ventilator- or renal replacement therapy-free at day-7. Biological outcomes included baseline renin, angiotensin-II, and renin/angiotensin-II ratio, and their change at hr3.

RESULTS

Of 158 placebo patients, as expected, 157 (99%) had AIMRITE < 0.90 mmHg/ng/kg/min (median AIMRITE 0.02; IQR - 0.03-0.10). In contrast, 163 patients assigned to angiotensin-II had a median AIMRITE of 1.43 mmHg/ng/kg/min (IQR 0.35-2.83). Of these, 97 (60%) were responsive (median AIMRITE 2.55; IQR 1.66-4.12) and 66 (40%) were resistant (median AIMRITE 0.24; IQR 0.10-0.52). Each 1.0-unit increase in AIMRITE was associated with a 16% lower hazard of death (HR: 0.84 per-mmHg/ng/kg/min [95% CI 0.74-0.95], p = 0.0062). Responsive patients had half the mortality hazard than resistant patients (HR: 0.50 [95% CI 0.32-0.78], p = 0.0026) and placebo patients (HR 0.58 [95% CI 0.40-0.86], p = 0.0064). Resistant patients had a similar mortality hazard to placebo (HR 1.17 [95% CI 0.80-1.72], p = 0.41). Compared to resistant patients, responsive patients had lower baseline renin and renin/angiotensin-II ratio, but a greater decrease in both at hr3. When stratified by baseline renin level, mortality was highest in placebo patients with high renin (69%) and angiotensin-II resistant patients with low renin (61%).

CONCLUSIONS

Among patients with catecholamine-refractory vasodilatory shock treated with angiotensin-II, the AIMRITE was associated with mortality at day-28. Responsive angiotensin-II patients had higher survival versus both angiotensin-II resistant patients and those treated with placebo plus standard vasopressors. This index may serve as a prognostic indicator and early identifier of patients most likely to benefit from angiotensin-II.

Effect of restrictive fluid resuscitation on severe acute kidney injury in septic shock: a systematic review and meta-analysis

OBJECTIVES

Sepsis-associated hypotension or shock is a critical stage of sepsis, and a current clinical emergency that has high mortality and multiple complications. A new restrictive fluid resuscitation therapy has been applied, and its influence on patients' renal function remains unclear. The purpose of this study is to evaluate the influence of restrictive fluid resuscitation on incidence of severe acute kidney injury (AKI) in adult patients with sepsis hypotension and shock compared with usual care.

DESIGN

Systematic review and meta-analysis using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

PubMed, Embase, Web of Science and Cochrane Library were searched through 1 November 2024.

ELIGIBILITY CRITERIA

We included randomised controlled trials that compared restrictive fluid resuscitation with liberal fluid therapy on patients with sepsis-associated hypotension and shock, to find out their effect on the incidence of severe AKI. Severe AKI was defined as the AKI network score 2-3 or Kidney Disease Improving Global Outcomes stages 2 and 3.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included trials. Risk of bias was assessed using the Cochrane Systematic Review Handbook for randomised clinical trials. Meta-analysis was conducted using random effects models. Sensitivity and subgroup analyses, trial sequential analysis (TSA), Egger's test and the trim-and-fill method were performed. Findings were summarised in GRADE evidence profiles and synthesised qualitatively.

RESULTS

Nine trials (3718 participants) were included in this research and the analysis was conducted in random effects model. There was a significant difference in the incidence of severe AKI (risk ratio 0.87, 95% CI 0.79 to 0.96, p=0.006; I2=0%) and the duration of mechanical ventilation (mean difference -41.14, 95% CI -68.80 to -13.48; p=0.004; I2=74%) between patients receiving restrictive fluid resuscitation and patients receiving liberal fluid resuscitation. TSA showed that the cumulative amount of participants met the required information size, the positive conclusion had been confirmed. The GRADE assessment results demonstrated moderate confidence in the incidence of severe AKI, as well as the results of all second outcomes except the Intensive Care Unit length of stay (ICU LOS), which received limited confidence. The result of incidence of worse AKI was rated as of high certainty.

CONCLUSIONS

It is conclusive that fluid restriction strategy is superior to usual care when it comes to reducing the incidence of severe AKI in sepsis-associated hypotension and shock. Shorter duration of ventilation is concerned with fluid restriction as well, but the heterogeneity is substantial. GRADE assessments confirmed moderate and above certainty. Traditional fluid resuscitation therapy has the potential to be further explored for improvements to be more precise and appropriate for a better prognosis.

PROSPERO REGISTRATION NUMBER

CRD42023449239.

Use of Primary Prophylaxis with G-CSF in Acute Myeloid Leukemia Patients Undergoing Intensive Chemotherapy Does Not Affect Quality of Response

Background/Objectives: The objective of our study was to evaluate the safety and efficacy of granulocyte colony-stimulating factor (G-CSF) as primary prophylaxis in adult patients with acute myeloid leukemia (AML) undergoing intensive chemotherapy. Methods: We retrospectively analyzed 112 AML patients treated with intensive chemotherapy at Fondazione Policlinico Tor Vergata in Rome between January 2014 and March 2024. Patients were divided into G-CSF and non-G-CSF (nG-CSF) groups. We assessed the incidence of neutropenia, its severity and duration; duration of hospitalization and its costs; incidence of febrile neutropenia (FN) and septic shock; duration of antibiotic therapy (ABT) and antifungal therapy (AFT); complete remission (CR) rates; measurable residual disease (MRD) status; relapse rates; and outcomes. Results: G-CSF administration significantly reduced the duration of neutropenia (median 14 vs. 18 days, p < 0.05) and length of hospitalization (median 28 vs. 35 days, p < 0.05), in both induction and consolidation therapy. There were no significant differences in CR rates (73% vs. 67%, p = 0.64), MRD negativity achievement (52% vs. 48%, p = 0.68), leukemia relapse rates (43% vs. 62%, p = 0.14), or overall survival (OS) (median 16.7 vs. 12.3 months, p = 0.3) between G-CSF and nG-CSF groups. Thanks to a shorter hospitalization, the use of G-CSF led to €300,000 in savings over the last 4 years. Conclusions: Our findings support the safety of G-CSF in AML patients, demonstrating no adverse impact on treatment response. G-CSF abbreviated the duration of neutropenia and hospitalization, highlighting its potential clinical and cost-effective role in AML treatment.

Immunometabolic chaos in septic shock

Septic shock is associated with over 40% mortality. The immune response in septic shock is tightly regulated by cellular metabolism and transitions from early hyper-inflammation to later hypo-inflammation. Patients are susceptible to secondary infections during hypo-inflammation. The magnitude of the metabolic dysregulation and the effect of plasma metabolites on the circulating immune cells in septic shock are not reported. We hypothesized that the accumulated plasma metabolites affect the immune response in septic shock during hypo-inflammation. Our study took a unique approach. Using peripheral blood from adult septic shock patients and healthy controls, we studied: (i) Whole blood stimulation ± E. Coli lipopolysaccharide (LPS: endotoxin) to analyze plasma TNF protein, and (ii). Plasma metabolomic profile by Metabolon. Inc. (iii) We exposed peripheral blood mononuclear cells (PBMCs) from healthy controls to commercially available carbohydrate, amino acid, and fatty acid metabolites and studied the response to LPS. We report that: (i) The whole blood stimulation of the healthy control group showed a significantly upregulated TNF protein, while the septic shock group remained endotoxin tolerant, a biomarker for hypo-inflammation. (ii) A significant accumulation of carbohydrate, amino acid, fatty acid, ceramide, sphingomyelin, and TCA cycle pathway metabolites in septic shock plasma. (iii) In vitro exposure to 5 metabolites repressed while 2 metabolites upregulated the inflammatory response of PBMCs to LPS. We conclude that the endotoxin-tolerant phenotype of septic shock is associated with a simultaneous accumulation of plasma metabolites from multiple metabolic pathways, and these metabolites fundamentally influence the immune response profile of circulating cells.

Effects of Hyperoxia on Pulmonary Inflammation and organ injury in a human in vivo model (HIPI): study protocol of a randomised, double-blind, placebo-controlled trial

INTRODUCTION

Liberal administration of supplemental oxygen (O2) is ubiquitous across numerous healthcare settings. However, appropriate O2 titration targets remain controversial and despite numerous large-scale randomised trials, there is an ongoing lack of consensus regarding optimal oxygenation strategies and the absence of high-quality mechanistic data pertaining to the potential proinflammatory effects of hyperoxia.

METHODS AND ANALYSIS

We hypothesise that (1) short-term exposure to hyperoxia will induce mild pulmonary inflammation and cellular injury and that (2) hyperoxia will accentuate pulmonary inflammation and cellular injury in the setting of inhaled lipopolysaccharide challenge. To test our hypotheses, we will conduct a randomised, double-blind, placebo-controlled study of hyperoxia administered via a high-flow nasal O2 delivery system (fractional inspired oxygen 1.0, 60 L/min flow rate) compared with synthetic medical air. Blocked randomisation will be undertaken by an independent clinical trials statistician. Healthy non-smoking adult volunteers (<45 years of age), taking no regular medications will be recruited. Bronchoalveolar lavage (BAL) will be performed at 6 hours. The study outcome measures will include BAL markers of inflammation and injury (including but not limited to interleukin (IL)-8, IL-6, tumour necrosis factor alpha), BAL differential cell counts, BAL markers of oxidative stress (superoxide dismutase and glutathione), alveolar epithelial cell injury (SP-D, vWF, RAGE) and markers of systemic inflammation (neutrophils and plasma C-reactive protein).

ETHICS AND DISSEMINATION

Dissemination of the research findings will be achieved in the following ways: (1) Our findings will be presented at national and international meetings with open-access abstracts online and (2) in accordance with the open-access policies proposed by the leading research funding bodies we aim to publish the findings in high quality peer-reviewed open-access journals.

TRIAL REGISTRATION NUMBER

NCT05414370.

Thrombocytopenia in Sepsis

Platelets, traditionally known for their role in hemostasis, have emerged as key players in immune response and inflammation. Sepsis, a life-threatening condition characterized by systemic inflammation, often presents with thrombocytopenia, which at times, can be significant. Platelets contribute to the inflammatory response by interacting with leukocytes, endothelial cells, and the innate immune system. However, excessive platelet activation and consumption can lead to thrombocytopenia and exacerbate the severity of sepsis. Understanding the multifaceted roles of platelets in sepsis is crucial for developing effective therapeutic strategies. Targeting platelet-mediated inflammatory responses and promoting platelet production may offer potential avenues for improving outcomes in septic patients with thrombocytopenia. Future research should focus on elucidating the mechanisms underlying platelet dysfunction in sepsis and exploring novel therapeutic approaches to optimize platelet function and mitigate inflammation. This review explores the intricate relationship between platelets, inflammation, and thrombosis in the context of sepsis.

Genetic analysis of diagnostic and therapeutic potential for ferroptosis in postoperative sepsis

BACKGROUND

Ferroptosis is a new form of iron-dependent cell death that is closely associated with sepsis. However, few studies have investigated the diagnostic and therapeutic potential for ferroptosis-related genes (FRGs) among postoperative sepsis.

METHODS

The GSE131761 dataset was used to identify differentially expressed FRGs (DE-FRGs). KEGG and GO analyses were subsequently performed. LASSO and SVM-RFE methods were applied for identifying genetic biomarkers for sepsis. Gene set enrichment analysis (GSEA) and gene set variation analysis (GSVA) were applied for exploring the biological properties of the DEGs. CIBERSORT was applied to analyse immune cell infiltration. DGldb was employed for predicting potential target drugs for the DEGs. Competing endogenous RNA (ceRNA) networks were constructed to analyse the regulatory patterns of the DEGs. The expression of hub genes was validated based on GSE26440 dataset. The bioinformatics analysis was carried out with R software (version 4.1.2). Blood from sepsis patients and healthy controls was collected and the expression of hub genes was experimentally verified by real-time quantitative polymerase chain reaction (RT-qPCR).

RESULTS

38 sepsis-associated DE-FRGs were assessed via Gene Expression Omnibus (GEO) and Ferroptosis database (FerrDb), and the gene function analysis showed that they were closely related to inflammatory response and autophagy regulation. Subsequently, SVM-RFE and LASSO methods determined 7 marker genes. GSEA suggested that these marker genes may be involved in regulating several biological pathways. Furthermore, 52 gene-targeted drugs were identified in this study, the vast majority of which were associated with MAPK14. CIBERSORT analysis suggested that SLC38A1, MGST1, and MAPK14 may be involved in immune microenvironment alterations. We revealed the potential complex regulatory relationship by constructing a ceRNA network based on marker genes. Finally, 6 genes were validated in the validation set, with 5 of them further confirmed through RT-qPCR.

CONCLUSION

Seven genes associated with ferroptosis are screened from postoperative sepsis samples. The expression of these genes has high diagnostic validity for sepsis and may serve as potential diagnostic biomarkers. This study gives an entrance point to uncover the underlying mechanisms of sepsis.

Interdisciplinary Team Pilot to Reduce Time to Administration of Piperacillin/Tazobactam in the Emergency Department at a Veterans Affairs Medical Center

Background

Sepsis is a condition of life-threatening organ dysfunction caused by a dysregulated host response to an infection. Adults with suspected sepsis or possible septic shock should receive antimicrobials within 1 hour. Early administration of antibiotics to patients with sepsis has been shown to decrease in-hospital mortality. Factors that affect antibiotic administration time include the antibiotic dispensary location, best practice alerts in electronic medical records, and staff "huddles" to continuously reinforce the importance of antibiotics.

Methods

At our Veterans Affairs Medical Center, we moved piperacillin/tazobactam from the central pharmacy to the emergency department automated dispensing cabinet. We implemented an interdisciplinary sepsis team comprised of emergency medicine (EM) nurses, pharmacists, and physicians. This was a retrospective chart review to assess whether our change in practice affected the time to administration of piperacillin/tazobactam in the emergency department. We assessed whether the change in practice had an effect on mortality in our population.

Results

Patients were reviewed 6 months pre- and post-implantation of the practice changes. There were 139 veterans in the pre-implementation group and 128 in the post-implementation group. The two groups were similar in age, sex, and African-American race. There was a statistically significant reduction in the average time from EM pharmacist verification to nurse administration when comparing the groups (46.5±49.8 vs 30.6±28.7 minutes, p=0.004). There were statistically significant reductions in the time from EM physician recognition to pharmacist order verification (54.37±50.22 vs 40.52±31.26 minutes, p=0.009). Eight patients died in the pre-pilot group compared to five in the post-pilot group. The relative risk of mortality was reduced between the two groups by 32%.

Conclusion

When piperacillin/tazobactam was stocked in the emergency department and we implemented an interdisciplinary sepsis team, there was a significant reduction in the time to administration in patients with sepsis.

Effect of the hour-1 bundle on clinical outcomes in patients with sepsis and septic shock: A protocol for systematic review and meta-analysis

BACKGROUND

According to the 2018 bundle guidelines of the Surviving Sepsis Campaign, many emergency departments and intensive care units currently adopt the hour-1 bundle as a standard practice for sepsis management. However, recent studies on the hour-1 bundle for sepsis treatment have yielded inconsistent results, raising questions and challenges about its clinical efficacy.

AIM

This study will conduct a systematic review and meta-analysis to compare the impact of the hour-1 bundle and non-hour-1 bundle on the clinical outcomes in patients with sepsis and septic shock.

METHODS

The protocol was prepared according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol (PRISMA-P) statement. The systematic review will be carried out in line with the statement of PRISMA. The following electronic databases will be searched: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science. All clinical studies comparing the impact of the hour-1 bundle and non-hour-1 bundle on clinical outcomes in patients with sepsis and septic shock will be included. All stages of the literature search, study selection, data extraction, and quality assessment will be conducted independently by two reviewers. Any disagreements between the two reviewers will be resolved by discussion or arbitration by a third reviewer. The primary outcome will be short-term mortality, which involves in-hospital, 28-day, 30-day, and 90-day mortality corresponding to the definition used in each study. For quality assessment, the risk of bias specified by the Cochrane Collaboration and the methodological index for non-randomized studies will be used for randomized control trials (RCTs) and non-RCTs, respectively. Data synthesis will be performed via Review Manager 5.1.0.

EXPECTED RESULTS

This systematic review will integrate all relevant studies to quantitatively estimate the effect size and clarify the role of the hour-1 bundle in sepsis management, contributing new evidence-based guidance to the field.

SYSTEMATIC REVIEW REGISTRATION

Protocol registration and reporting: PROSPERO CRD42024579314.

Transcriptomic analysis of key genes and signaling pathways in sepsis-associated intestinal mucosal barrier damage

OBJECTIVES

The aim is to analyze differentially expressed genes (DEGs) in mice with sepsis-related intestinal mucosal barrier damage and to explore the diagnostic and protective mechanisms of this condition at the transcriptome level.

METHODS

Small intestinal tissues from healthy male C57BL/6J mice subjected to Cecal ligation and puncture (CLP) and sham operation were collected. High-throughput sequencing was performed using the paired-end sequencing mode of the Illumina HiSeq platform. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were conducted on the differentially expressed genes (DEGs). A protein-protein interaction (PPI) network was constructed using the STRING database, and hub genes were identified with Cytoscape. These hub genes were then validated using quantitative real-time polymerase chain reaction (RT-qPCR).

RESULTS

A total of 239 DEGs were identified, with 49 upregulated and 130 downregulated genes. KEGG enrichment analysis showed that these DEGs were primarily involved in cytokine-cytokine receptor interaction, Th1 and Th2 cell differentiation, viral protein interactions with cytokines and their receptors, and the IL-17 signaling pathway. The top 10 hub genes were selected using the cytoHubba plugin. Experimental validation confirmed that the expression levels of TBX21, CSF3, IL-6, CXCR3, and CXCL9 matched the sequencing results.

CONCLUSION

TBX21, CSF3, IL-6,CXCR3, and CXCL9 may be potential biological markers for the diagnosis and treatment the sepsis-associated intestinal mucosal barrier.

Erbin Regulates Tissue Factors Through Ras/Raf Pathway in Coagulation Disorders in Sepsis

Background

Sepsis, as a clinically critical disease, usually induces coagulation disorders. It has been reported that ERBB2 Interacting Protein (Erbin) is involved in the development of various inflammatory diseases, and macrophages are involved in the regulation of coagulation disorders in sepsis. However, the role of Erbin in coagulation disorders in sepsis and the relationship between Erbin and macrophage regulation of coagulation function are still unclear.

Methods

At the cellular level, macrophages were treated with lipopolysaccharide (LPS) or MEK inhibitor (PD98059), protein expression levels were detected by Western blot, co-immunoprecipitation (Co-IP), and immunofluorescence, mRNA expression levels were detected by quantitative real-time polymerase chain reaction (qPCR), and the concentration of tissue factor (TF) in cell supernatant was detected by enzyme linked immunosorbent assay (ELISA). At the animal level, the cecal ligation and perforation (CLP) model was constructed in mice, and the inflammatory response and coagulation disorder of mice were observed by hematoxylin-eosin (HE) staining, immunohistochemistry, ELISA, and automatic hemagglutination analyzer. The protein and mRNA expression level were detected by Western blot and qPCR. Pearson linear correlation analysis was used to analyze the correlation between the inflammation index and the coagulation function index.

Results

We confirmed that the Erbin is involved in the regulation of coagulation function by macrophages and plays a role in the coagulation disorder of sepsis. In vivo studies have shown that mice with Erbin deletion have more obvious enhanced coagulation function, and in vitro studies have shown that Erbin knockout mediated macrophage secretion of TF by activating the Ras/Raf pathway.

Conclusion

Erbin reduces the coagulation activation by inhibiting TF release from macrophages.

Genetically predicted basal metabolic rate and infectious diseases: a Mendelian randomization study

BACKGROUND

The causal relationship between basal metabolic rate (BMR) and infectious diseases remains elusive. This study aims to clarify this association.

METHODS

This study analyzed genome-wide association studies (GWASs) data from the UK Biobank and FinnGen cohorts to investigate the association between BMR and infectious diseases in European populations. Mendelian randomization (MR) analysis was initially employed, followed by multivariable Mendelian randomization (MVMR) to account for potential confounders. Mediation analysis further confirmed significant relationships. Sensitivity analyses were conducted to validate the study findings.

RESULTS

Using two sample MR, genetically predicted BMR was positively linked to skin and soft tissue infections (SSTIs) (OR: 1.31, 95% CI: 1.18-1.47, P < .001), osteomyelitis (OR: 1.95, 95% CI: 1.36-2.80, P < .001) (1.36 ± 2.80), all-cause infections (OR: 1.36, 95% CI: 1.26-1.48, P < .001) and sepsis (OR: 1.36, 95% CI: 1.23-1.51, P < .001). MVMR analysis confirmed BMR's direct causal effect on SSTIs, osteomyelitis, all-cause infections, and sepsis, except for BMI and other factors affecting osteomyelitis. Mediation analysis revealed VAT as a mediator in the linkage between BMR and SSTIs and all-cause infections. HbA1c mediated the path from BMR to osteomyelitis, while CRP and BMI exhibited mediation effects in the BMR-all-cause infections relationship.

CONCLUSION

The study revealed a significant link between increased BMR and elevated risks of SSTIs, osteomyelitis, and bacterial infections, highlighting the intricate BMR-immune connection and its implications for disease control. Key message What is already known on this topic:  High BMR is positively correlated with COVID-19 and associated with proinflammatory and immunological activation, but the relationship between BMR and other infectious diseases remains largely unexplored. What this study adds:  Higher BMR significantly raises the risk of SSTIs, osteomyelitis, all-cause infections, and sepsis. VAT, HbA1c, CRP, and BMI may mediate the BMR-infection relationship. How this study might affect research, practice, or policy:  A higher BMR may be a valuable indicator associated with an increased risk for SSTIs, osteomyelitis, and sepsis. Modulating BMR might hold promise as a clinically relevant intervention to prevent specific infectious diseases.

Development of an Electronic Clinical Surveillance Measure for Unnecessary Rapid Antibiotic Administration in Suspected Sepsis

BACKGROUND

Substantial efforts focus on monitoring and reducing delays in antibiotic treatment for sepsis, but little has been done to characterize the balancing measure of sepsis overtreatment. We aimed to establish preliminary validity and usefulness of electronic health record (EHR) data-derived criteria for sepsis overtreatment surveillance (SEP-OS).

METHODS

We evaluated adults with potential sepsis (≥2 Systemic Inflammatory Response Syndrome criteria within 6 hours of arrival) presenting to the emergency department of 12 hospitals, excluding patients with shock. We defined SEP-OS as the proportion of patients receiving rapid IV antibiotics (≤3 hours) who did not ultimately meet the Centers for Disease Control Adult Sepsis Event "true sepsis" definition. We evaluated the frequency and characteristics of patients meeting overtreatment criteria and outcomes associated with sepsis overtreatment.

RESULTS

Of 113 764 eligible patients, the prevalence of sepsis overtreatment was 22.5%. The measure met prespecified criteria for reliability, content, construct, and criterion validity. Patients classified by the SEP-OS overtreatment criteria had higher median antibiotic days (4 days [IQR, 2-5] vs 1 day [1-2]; P < .01), longer median length of stay (4 days [2-6] vs 3 days [2-5]; P < .01), higher hospital mortality (2.4% vs 2.1%; P = .01), and higher frequency of Clostridioides difficile infection within 6 months of hospital discharge (P < .01) compared with "true negative" cases.

CONCLUSIONS

We developed a novel, valid EHR metric for clinical surveillance of sepsis overtreatment. Applying this metric to a large cohort of potential sepsis patients revealed a high rate of overtreatment and provides a useful tool to inform sepsis quality-improvement targets.

Dynamic changes and prognosis value of plasma syndecan-1 and different microcirculatory parameters in sepsis: A prospective observational study

BACKGROUND

Glycocalyx degradation is implicated in endothelial damage and microcirculatory dysfunction in sepsis, whereas the effectiveness of plasma syndecan-1 levels and sublingual microcirculatory parameters in evaluating sepsis's prognosis has not yet been determined. This study aims to track their dynamic changes and investigate the prognostic utility of these indexes in sepsis.

METHODS

In this prospective study conducted at the First Affiliated Hospital of Sun Yat-sen University, blood samples were collected from adult surgical septic patients within 2 days after intensive care unit admission measuring plasma syndecan-1 concentrations. Relevant sublingual microcirculatory parameters were also obtained simultaneously. Additionally, capillary refill time and serum lactate levels were recorded. The primary outcome was 30-day mortality.

RESULTS

Of the 74 patients enrolled, the 30-day mortality rate was 35.1%. Significantly, higher syndecan-1 levels were observed in nonsurvivors at baseline, day 1, and day 2 (62.43 [37.37 and 103.16] vs. 97.24 [52.95 and 186.40] ng/mL and p = 0.035; 62.22 [41.50 and 87.52] vs. 96.71 [60.82 and 176.00] ng/mL and p = 0.009; and 56.03 [39.16 and 94.48] vs. 87.69 [72.52 and 159.70] ng/mL and p = 0.005, respectively). High syndecan-1 levels (≥121 ng/mL) were associated with lower survival rates (p = 0.001) and an increase exceeding 8 ng/mL within 2 days indicated a higher mortality risk (p = 0.0075). Syndecan-1 levels displayed satisfactory prognostic capability (AUC: 0.7056), whereas combining syndecan-1 and blood lactate demonstrated the highest predictive ability for 30-day survival (AUC: 0.7726).

CONCLUSIONS

Plasma syndecan-1 levels effectively predict sepsis prognosis, with higher baseline levels or increasing trends indicating worse outcomes. Combining syndecan-1 with blood lactate enhances predictive accuracy for 30-day mortality in sepsis.

TRIAL REGISTRATION

This study registered in China on December 31, 2021 at Chinese Clinical Trial Registry (ChiCTR2100055066).

Machine learning and clinician predictions of antibiotic resistance in Enterobacterales bloodstream infections

BACKGROUND

Patients with Gram-negative bloodstream infections are at risk of serious adverse outcomes without active treatment, but identifying who has antimicrobial resistance (AMR) to target empirical treatment is challenging.

METHODS

We used XGBoost machine learning models to predict antimicrobial resistance to seven antibiotics in patients with Enterobacterales bloodstream infection. Models were trained using hospital and community data from Oxfordshire, UK, for patients with positive blood cultures between 01-January-2017 and 31-December-2021. Model performance was evaluated by comparing predictions to final microbiology results in test datasets from 01-January-2022 to 31-December-2023 and to clinicians' prescribing.

FINDINGS

4709 infection episodes were used for model training and evaluation; antibiotic resistance rates ranged from 7-67%. In held-out test data, resistance prediction performance was similar for the seven antibiotics (AUCs 0.680 [95%CI 0.641-0.720] to 0.737 [0.674-0.797]). Performance improved for most antibiotics when species identifications (available ∼24 h later) were included as model inputs (AUCs 0.723 [0.652-0.791] to 0.827 [0.797-0.857]). In patients treated with a beta-lactam, clinician prescribing led to 70% receiving an active beta-lactam: 44% were over-treated (broader spectrum treatment than needed), 26% optimally-treated (narrowest spectrum active agent), and 30% under-treated (inactive beta-lactam). Model predictions without species data could have led to 79% of patients receiving an active beta-lactam: 45% over-treated, 34% optimally-treated, and 21% under-treated.

CONCLUSIONS

Predicting AMR in bloodstream infections is challenging for both clinicians and models. Despite modest performance, machine learning models could still increase the proportion of patients receiving active empirical treatment by up to 9% over current clinical practice in an environment prioritising antimicrobial stewardship.

Dilated common bile duct diameter as an indicator of bacteremia in patients with symptomatic common bile duct stones

BACKGROUND

The optimal timing and selection for blood culture collection in patients with acute cholangitis remains unclear. The relationship between common bile duct (CBD) diameter and the incidence of bacteremia in patients with CBD stones was elucidated.

METHODS

This single-center retrospective observational study included patients with symptomatic CBD stones who presented to the emergency department between January 2019 and December 2021. The primary endpoint was the incidence of bacteremia. The patients were divided into two groups based on bacteremia complications. The patient characteristics and CBD diameters were compared between the two groups to identify factors associated with bacteremia.

RESULTS

In total, 270 patients were analyzed, with bacteremia identified in 134 patients (50 %), and the median CBD diameter was 10.7 mm (IQR, 8.7-13.7). The CBD diameter was significantly larger in patients with bacteremia (median 12.4 mm [IQR, 9.9-15.7] vs. 9.7 mm [IQR, 8.2-11.7], P < 0.001) in univariate analysis. Multivariable analysis revealed that the CBD diameter was significantly associated with bacteremia (OR: 1.25, 95 % CI: 1.14-1.38, P < 0.010). The area under the ROC curves, representing the diagnostic accuracy of CBD diameter for indicating bacteremia, was 0.72 (95 % CI, 0.66-0.78) with a cut-off value of 11.2 mm.

CONCLUSION

CBD dilation in patients with symptomatic CBD stones is significantly correlated with bacteremia. The CBD diameter cannot be assessed as the sole tool for detecting bacteremia; however, CBD dilation could be an indicator of bacteremia, assisting in the treatment strategy, regardless of the initial severity of cholangitis.

Development and validation of a screening tool for sepsis without laboratory results in the emergency department: a machine learning study

Background

Sepsis is a significant health burden on a global scale. Timely identification and treatment of sepsis can greatly improve patient outcomes, including survival rates. However, time-consuming laboratory results are often needed for screening sepsis. We aimed to develop a quick sepsis screening tool (qSepsis) based on patients' non-laboratory clinical data at the emergency department (ED) using machine learning (ML), and compare its performance with established clinical scores.

Methods

This retrospective study included patients admitted to the ED of Zhongnan Hospital of Wuhan University (Wuhan, China) from 1/1/2015 to 5/31/2022. Patients who were under 18 years of age, had cardiopulmonary arrest upon arrival at the ED, or had missing and abnormal medical record data were excluded. The qSepsis was derived by three ML algorithms, including logistic regression (LR), random forest (RF), and extreme gradient boosting (XGB). To benchmark the existing clinical tools for assessing the risk of sepsis in the ED, qSepsis was compared with the Systemic Inflammatory Response Syndrome (SIRS), the Quick Sepsis-Related Organ Failure Assessment (qSOFA), and the Modified Early Warning Score (MEWS). The external validation was performed with the Medical Information Mart for Intensive Care IV ED database (United States), and adopted the same inclusion and exclusion criteria. The predictive power of qSepsis and other clinical scores was measured using the area under the receiver operating characteristic curve (AUROC). The primary outcome of the study was the diagnosis of sepsis in the ED based on the Sepsis 3.0 criteria, which served as the basis for developing the qSepsis tool.

Findings

A total of 414,864 patients were finally included in the cohort (median ([IQR]) patient age, 43 (29, 60) years; 202,730 (48.87%) females, 212,134 (51.13%) males), and 200,089 in the external testing cohort (median (SD) patient age, 57 (39, 71) years; 107,427 (53.69%) females, 92,663 (46.31%) males). For internal testing, LR outperformed RF and XGB with an AUROC of 0.862 (95% CI, 0.855-0.869). In external testing, the AUROC decreased to 0.766 (95% CI, 0.758-0.774) for LR, 0.725 (95% CI, 0.717-0.733) for RF, and 0.735 (95% CI, 0.728-0.742) for XGB. In addition, the AUROC for the qSOFA, MEWS, and SIRS scores in external validation cohort were 0.579 (95% CI, 0.563-0.596), 0.600 (95% CI, 0.578-0.622), and 0.704 (95% CI, 0.683-0.725), respectively. The area under the precision-recall curve (AUPRC) for the qSepsis model was 0.213 (95% CI: 0.204-0.222). The AUPRC values for the other scores were as follows: SIRS, 0.071 (95% CI: 0.013-0.099); qSOFA, 0.096 (95% CI: 0.003-0.186); and MEWS, 0.083 (95% CI: 0.063-0.111).

Interpretation

This retrospective study demonstrated that qSepsis had better predictive performance in terms of AUROC and area under the precision-recall curve (AUPRC) compared to existing assessment scores. It has the potential to be used in pre-hospital settings with limited access to laboratory tests and in the ED for quick screening of patients with sepsis. However, due to its low positive predictive value (PPV), the false alarms may increase in actual clinical practice.

Funding

Transformation of Scientific and Technological Achievements Fund Project of Zhongnan Hospital of Wuhan University.

Characteristics and Readmission Risks Following Sepsis Discharges to Home

OBJECTIVE

To examine the characteristics and risk factors associated with 30-day readmissions, including the impact of home health care (HHC), among older sepsis survivors transitioning from hospital to home.

RESEARCH DESIGN

Retrospective cohort study of the Medical Information Mart for Intensive Care (MIMIC)-IV data (2008-2019), using generalized estimating equations (GEE) models adjusting for patient sociodemographic and clinical characteristics.

SUBJECTS

Sepsis admission episodes with in-hospital stays, aged over 65, and discharged home with or without HHC were included.

MEASURES

The outcome was all-cause hospital readmission within 30 days following sepsis hospitalization. Covariates, including the primary predictor (HHC vs. Home discharges), were collected during hospital stays.

RESULTS

Among 9115 sepsis admissions involving 6822 patients discharged home (66.8% HHC, 33.2% Home), HHC patients, compared with those discharged without services, were older, had more comorbidities, longer hospital stays, more prior hospitalizations, more intensive care unit admissions, and higher rates of septic shock diagnoses. Despite higher illness severity in the HHC discharges, both groups had high 30-day readmission rates (30.2% HHC, 25.2% Home). GEE analyses revealed 14% higher odds of 30-day readmission for HHC discharges after adjusting for risk factors (aOR: 1.14; 95% CI: 1.02-1.27; P=0.02).

CONCLUSIONS

HHC discharges experienced higher 30-day readmission rates than those without, indicating the need for specialized care in HHC settings for sepsis survivors due to their complex health care needs. Attention to sepsis survivors, regardless of HHC receipt, is crucial given the high readmission rates in both groups. Further research is needed to optimize postacute care/interventions for older sepsis survivors.

A Screening Tool to Predict Sepsis in Patients With Suspected Infection in the Emergency Department

Background and objective Sepsis is a life-threatening condition associated with high morbidity and mortality, and hence early recognition and treatment are crucial. The 2016 Sepsis-3 guidelines introduced the quick Sequential Organ Failure Assessment (qSOFA), but its low sensitivity limits early detection. The 2021 Surviving Sepsis Campaign Guidelines (SSCG) discourage relying solely on qSOFA and recommend additional tools such as the systemic inflammatory response syndrome (SIRS) score, the National Early Warning Score (NEWS), and the Modified Early Warning Score (MEWS) along with lactate measurement. This study assessed whether combining qSOFA with quantitative capillary refill time (Q-CRT) or lactate levels enhances early sepsis diagnosis in emergency departments. Methods This retrospective, multi-facility observational study was conducted at two hospitals in Yokohama, Japan. Patients with suspected infections who underwent Q-CRT measurement were included. Q-CRT was measured using a pulse oximeter-based device that records the time taken for blood flow to return to 90% after compression. Receiver operating characteristic (ROC) curves determined the area under the curve (AUC), sensitivity, and specificity. Statistical significance was set at p<0.05. Results Of the 357 patients who underwent Q-CRT measurement, 75 (21%) were suspected of having an infection, with 48 (64%) classified as having sepsis with organ dysfunction. Patients in the sepsis group had higher age, heart rate, lactate level, creatinine level, NEWS, MEWS, and Sequential Organ Failure Assessment (SOFA) scores compared to those without organ dysfunction. Among individual tools, the qSOFA, NEWS, and MEWS scores showed high AUCs (>0.8), while Q-CRT and lactate levels demonstrated moderate predictive accuracy with AUCs exceeding 0.7. The SIRS score had the lowest predictive ability, with an AUC of approximately 0.6. Combining qSOFA with Q-CRT or lactate levels significantly improved sensitivity and specificity. The qSOFA+Q-CRT combination resulted in an AUC of 0.821, sensitivity of 83.3%, and specificity of 81.4%, while the qSOFA+lactate combination yielded an AUC of 0.844, sensitivity of 87.5%, and specificity of 81.4%. These combinations exceeded 80% in both sensitivity and specificity, unlike the SIRS-based combinations, which showed limited improvement and specificity below 40%. While the qSOFA score alone demonstrated limited sensitivity, combining it with Q-CRT or lactate levels enhanced its predictive performance for early sepsis detection. This approach improved sensitivity without compromising specificity. The increase in sensitivity and specificity is likely due to Q-CRT and lactate identifying sepsis cases not detected by qSOFA, thereby making the combined approach more reliable for clinical use. Lactate levels are well-established markers associated with sepsis severity, and Q-CRT offers a non-invasive means of assessing peripheral perfusion. Conclusions Combining qSOFA with Q-CRT or lactate levels significantly improves early sepsis detection by enhancing both sensitivity and specificity. These combinations offer superior diagnostic accuracy compared to standalone tools, supporting their potential integration into clinical protocols for better patient outcomes. Further prospective studies are needed to validate these findings across diverse clinical settings.

The smell of sepsis: Electronic nose measurements improve early recognition of sepsis in the ED

OBJECTIVE

Early recognition of sepsis is essential for timely initiation of adequate care. However, this is challenging as signs and symptoms may be absent or nonspecific. The cascade of events leading to organ failure in sepsis is characterized by immune-metabolic alterations. Volatile organic compounds (VOCs) are metabolic byproducts released in expired air. We hypothesize that measuring the VOC profile using electronic nose technology (eNose) could improve early recognition of sepsis.

MATERIAL AND METHODS

In this cohort study, bedside eNose measurements were collected prospectively from ED patients with suspected infections. Sepsis diagnosis was retrospectively defined based on Sepsis-3 criteria. eNose sensor data were used in a discriminant analysis to evaluate the predictive performance for early sepsis recognition. The dataset was randomly split into training (67 %) and validation (33 %) subsets. The derived discriminant function from the training subset was then applied to classify new observations in the validation subset. Model performance was evaluated using receiver operating characteristic (ROC) curves and predictive values.

RESULTS

We analyzed a total of 160 eNose measurements. The eNose measurements had an area under the ROC (AUROC) of 0.78 (95 % CI: 0.69-0.87) for diagnosing sepsis, with a sensitivity of 72 %, specificity of 73 %, and an overall accuracy of 73 %. The validation model showed an AUC of 0.83 (95 % CI: 0.71-0.94), sensitivity of 71 %, specificity of 83 %, and an accuracy of 80 %.

CONCLUSION

eNose measurements can identify sepsis among patients with a suspected infection at the ED.

CLINICAL TRIAL REGISTRATION

The study is embedded in the Acutelines data-biobank (www.acutelines.nl), registered in Clinicaltrials.gov (NCT04615065).

Optical Bionanosensors for Sepsis Diagnostics

Sepsis is a global health challenge, characterized by a dysregulated immune response, leading to organ dysfunction and death. Despite advances in medical care, sepsis continues to claim a significant toll on human lives, with mortality rates from 10-25% for sepsis and 30-50% for septic shock, making it a leading cause of death worldwide. Current diagnostic methods rely on clinical signs, laboratory parameters, or microbial cultures and suffer from delays and inaccuracies. Therefore, there is a pressing need for novel diagnostic tools that can rapidly and accurately identify sepsis. This review highlights advances in biosensor development that could ultimately lead to faster and more accurate sepsis diagnostics. The focus is on nanomaterial-based optical approaches that promise rapid diagnostics without the need for large equipment or trained personnel. An overview of sepsis is provided, highlighting potential molecular targets and the challenges they present for assay development. The requirements for an ideal point-of-care test (POC) are discussed, including speed, simplicity, and cost-effectiveness. Different nanomaterials suitable for various optical detection methods are reviewed and innovative nanosensors are discussed for sepsis diagnostics, focusing on chemical design and approaches to increase selectivity by multiplexing.

Short-term mortality and readmission rate prediction by the sequential organ failure assessment score in acute decompensated heart failure

Background

Data on the use of sequential organ failure assessment (SOFA) in patients with cardiovascular disease are increasing. Several studies demonstrated that the SOFA score can identify short-term mortality in patients with acute decompensated heart failure (ADHF). This study was conducted to determine the prognostic value of the admission SOFA score in patients hospitalized for ADHF and to assess its ability in predicting the 30-day readmission rate.

Materials and methods

This study was conducted from July 2022 to August 2023 at our institution. A total of 216 patients were included in the study, and the SOFA score was calculated for all patients.

Results

The average SOFA score is 3.14 ± 2.67, of which SOFA scores of ≤1, 2-3, and ≥4 account for 34.3%, 27.8%, and 37.9% of the total score, respectively. During the 30-day follow-up period, there were 22 cases of death from all causes (10.2%), of which in-hospital mortality accounted for 9.7%. Patients with all-cause mortality had higher SOFA scores than the survivors (7.32 ± 2.93 and 2.66 ± 2.12, respectively). The area under the receiver operating characteristic curve (AUC) for the SOFA score is 0.897 [95% confidence interval (CI) = 0.830-0.964] for 30-day mortality. The SOFA score was also compared with other validated risk scores, namely, the Get With the Guidelines-Heart Failure (GWTG-HF) risk score and the Acute Decompensated Heart Failure National Registry (ADHERE) score. In this study cohort, the SOFA score demonstrates superior predictive accuracy to the GWTG-HF and ADHERE scores [the AUCs when predicting 30-day mortality are 0.769 (95% CI = 0.676-0.862) and 0.789 (95% CI = 0.705-0.873), respectively].

Conclusion

The SOFA score might be used to screen high-risk patients for optimization strategy in the treatment of ADHF.

[Position paper of DGKL and DIVI on requirements for laboratory services in intensive care and emergency medicine]

BACKGROUND AND OBJECTIVES

The timely determination and evaluation of laboratory parameters in patients with acute life- or organ-threatening diseases and disease states in the emergency room or intensive care units can be essential for diagnosis, initiation of therapy, and outcome. The aim of the position paper is to define the time requirements for the provision of laboratory results in emergency and intensive care medicine. Requirements for point-of-care testing (POCT) and the (central) laboratory can be derived from the urgency.

METHODS

Expert groups from the DGKL (Deutsche Gesellschaft für Klinische Chemie und Laboratoriumsmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) developed a classification about the urgency for the determination of laboratory parameters as well as recommendations on the necessary organizational framework and quality assurance measures using national and international guidelines, review articles, and original papers.

RESULTS

Three levels of urgency are defined, based on the turnaround time of the most common laboratory parameters: emergency 1, with a turnaround time of no more than 15 min; emergency 2, with a turnaround time of a maximum of 60 min; urgent case, with a turnaround time within 4 h. In addition, a recommendation is made when to provide the results for the main ward rounds in the intensive care unit and the emergency department.

CONCLUSIONS

The recommendations allow the organizational and technical regulations for each hospital to be aligned with the urgency of the provision of the test results to the medical team based on the medical requirements.

Screening and Identification of Neutrophil Extracellular Trap-related Diagnostic Biomarkers for Pediatric Sepsis by Machine Learning

Neutrophil extracellular trap (NET) is released by neutrophils to trap invading pathogens and can lead to dysregulation of immune responses and disease pathogenesis. However, systematic evaluation of NET-related genes (NETRGs) for the diagnosis of pediatric sepsis is still lacking. Three datasets were taken from the Gene Expression Omnibus (GEO) database: GSE13904, GSE26378, and GSE26440. After NETRGs and differentially expressed genes (DEGs) were identified in the GSE26378 dataset, crucial genes were identified by using LASSO regression analysis and random forest analysis on the genes that overlapped in both DEGs and NETRGs. These crucial genes were then employed to build a diagnostic model. The diagnostic model's effectiveness in identifying pediatric sepsis across the three datasets was confirmed through receiver operating characteristic curve (ROC) analysis. In addition, clinical pediatric sepsis samples were collected to measure the expression levels of important genes and evaluate the diagnostic model's performance using qRT-PCR in identifying pediatric sepsis in actual clinical samples. Next, using the CIBERSORT database, the relationship between invading immune cells and diagnostic markers was investigated in more detail. Lastly, to evaluate NET formation, we measured myeloperoxidase (MPO)-DNA complex levels using ELISA. A group of five important genes (MME, BST1, S100A12, FCAR, and ALPL) were found among the 13 DEGs associated with NET formation and used to create a diagnostic model for pediatric sepsis. Across all three cohorts, the sepsis group had consistently elevated expression levels of these five critical genes as compared to the normal group. Area under the curve (AUC) values of 1, 0.932, and 0.966 indicate that the diagnostic model performed exceptionally well in terms of diagnosis. Notably, when applied to the clinical samples, the diagnostic model also showed good diagnostic capacity with an AUC of 0.898, outperforming the effectiveness of traditional inflammatory markers such as PCT, CRP, WBC, and NEU%. Lastly, we discovered that children with high ratings for sepsis also had higher MPO-DNA complex levels. In conclusion, the creation and verification of a five-NETRGs diagnostic model for pediatric sepsis performs better than established markers of inflammation.

Defining Fulminant Clostridioides difficile Infections: Assessing the Utility of Hypotension as a Diagnostic Criterion

Background

Fulminant Clostridioides difficile infection (FCDI) is associated with a 30%-40% mortality rate. Guideline definitions for FCDI severity classification include ileus, megacolon, shock, or hypotension. However, no hypotension definition is provided, making application of the definition challenging. The objective of this study was to assess optimal hypotension definitions for FCDI severity criteria.

Methods

This was a multicenter cohort study involving 1172 hospitalized patients diagnosed with C difficile infection (CDI) from 2015 to 2022 (Houston cohort). Patients were assessed for a composite endpoint of colectomy or mortality within 30 days of diagnosis. The ability of the CDI severity criteria to predict the composite endpoint was assessed using 2 definitions of hypotension (systolic blood pressure [SBP] ≤90 mm Hg and mean arterial pressure [MAP] ≤65 mm Hg) through multivariable regression models. A separate CDI cohort of 494 hospitalized patients validated the results (Midwest cohort).

Results

The composite endpoint was similar in the Houston cohort (98 patients [8.4%]) and the Midwest cohort (26 patients [5.3%]). Using either a MAP ≤65 mm Hg or SPB ≤90 mm Hg as criteria for hypotension was the best-performing model in both the development and validation cohorts. Removal of hypotension was the worst-performing model in both cohorts.

Conclusions

Inclusion of hypotension, defined as SBP ≤90 mm Hg or MAP ≤65 mm Hg, was an important component of FCDI severity criteria, significantly improving the predictive ability to identify FCDI patients at risk for poor outcomes.

SOMANZ position statement for the investigation and management of sepsis in pregnancy 2023

BACKGROUND

The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static.

AIMS

To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis.

MATERIALS AND METHODS

A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement.

RESULTS

This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes.

CONCLUSION

Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.

The Diagnostic Utility of Host RNA Biosignatures in Adult Patients With Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVES

Sepsis is a life-threatening medical emergency, with a profound healthcare burden globally. Its pathophysiology is complex, heterogeneous and temporally dynamic, making diagnosis challenging. Medical management is predicated on early diagnosis and timely intervention. Transcriptomics is one of the novel "-omics" technologies being evaluated for recognition of sepsis. Our objective was to evaluate the performance of host gene expression biosignatures for the diagnosis of all-cause sepsis in adults.

DATA SOURCES

PubMed/Ovid Medline, Ovid Embase, and Cochrane databases from inception to June 2023.

STUDY SELECTION

We included studies evaluating the performance of host gene expression biosignatures in adults who were diagnosed with sepsis using existing clinical definitions. Controls where applicable were patients without clinical sepsis.

DATA EXTRACTION

Data including population demographics, sample size, study design, tissue specimen, type of transcriptome, health status of comparator group, and performance of transcriptomic biomarkers were independently extracted by at least two reviewers.

DATA SYNTHESIS

Meta-analysis to describe the performance of host gene expression biosignatures for the diagnosis of sepsis in adult patients was performed using the random-effects model. Risk of bias was assessed according to the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A total of 117 studies (n = 17,469), comprising 132 separate patient datasets, were included in our final analysis. Performance of transcriptomics for the diagnosis of sepsis against pooled controls showed area under the receiver operating characteristic curve (AUC, 0.86; 95% CI, 0.84-0.88). Studies using healthy controls showed AUC 0.87 (95% CI, 0.84-0.89), while studies using controls with systemic inflammatory response syndrome (SIRS) had AUC 0.84 (95% CI, 0.78-0.90). Transcripts with excellent discrimination against SIRS controls include UrSepsisModel, a 210 differentially expressed genes biosignature, microRNA-143, and Septicyte laboratory.

CONCLUSIONS

Transcriptomics is a promising approach for the accurate diagnosis of sepsis in adults and demonstrates good discriminatory ability against both healthy and SIRS control subjects.

Predictors of mortality of Pseudomonas aeruginosa bacteraemia and the role of infectious diseases consultation and source control; a retrospective cohort study

PURPOSE

To determine predictors of mortality among patients with Pseudomonas aeruginosa bacteraemia.

METHODS

Retrospective study.

SETTING

This study conducted at the Lausanne University Hospital, Switzerland included adult patients with P. aeruginosa bacteraemia from 2015 to 2021.

RESULTS

During the study period, 278 episodes of P. aeruginosa bacteraemia were included. Twenty (7%) isolates were multidrug-resistant. The most common type of infection was low respiratory tract infection (58 episodes; 21%). Sepsis was present in the majority of episodes (152; 55%). Infectious diseases consultation within 48 h of bacteraemia onset was performed in 203 (73%) episodes. Appropriate antimicrobial treatment was administered within 48 h in 257 (92%) episodes. For most episodes (145; 52%), source control was considered necessary, with 93 (64%) of them undergoing such interventions within 48 h. The 14-day mortality was 15% (42 episodes). The Cox multivariable regression model showed that 14-day mortality was associated with sepsis (P 0.002; aHR 6.58, CI 1.95-22.16), and lower respiratory tract infection (P < 0.001; aHR 4.63, CI 1.78-12.06). Conversely, interventions performed within 48 h of bacteraemia onset, such as infectious diseases consultation (P 0.036; HR 0.51, CI 0.27-0.96), and source control (P 0.009; aHR 0.17, CI 0.47-0.64) were associated with improved outcome.

CONCLUSION

Our findings underscore the pivotal role of early infectious diseases consultation in recommending source control interventions and guiding antimicrobial treatment for patients with P. aeruginosa bacteraemia.

H3K14la drives endothelial dysfunction in sepsis-induced ARDS by promoting SLC40A1/transferrin-mediated ferroptosis

Pulmonary endothelial cell (EC) activation is a key factor in acute respiratory distress syndrome (ARDS). In sepsis, increased glycolysis leads to lactate buildup, which induces lysine lactylation (Kla) on histones and other proteins. However, the role of protein lactylation in EC dysfunction during sepsis-induced ARDS remains unclear. Integrative lactylome and proteome analyses were performed to identify the global lactylome profile in the lung tissues of septic mice. Cut&Tag analysis was used to identify the transcriptional targets of histone H3 lysine 14 lactylation (H3K14la) in ECs. Septic mice presented elevated levels of lactate and H3K14la in lung tissues, particularly in pulmonary ECs. Suppressing glycolysis reduced both H3K14la and EC activation, suggesting a link between glycolysis and lactylation. Moreover, H3K14la was enriched at promoter regions of ferroptosis-related genes such as transferrin receptor (TFRC) and solute carrier family 40 member 1 (SLC40A1), which contributed to EC activation and lung injury under septic conditions. For the first time, we reported the role of lactate-dependent H3K14 lactylation in regulating EC ferroptosis to promote vascular dysfunction during sepsis-induced lung injury. Our findings suggest that manipulation of the glycolysis/H3K14la/ferroptosis axis may provide novel therapeutic approaches for sepsis-associated ARDS.

The effect of percentage of time spent above different glucose levels on 90 days mortality of critically ill patients - A retrospective cohort study

INTRODUCTION

Glycemic control is a major concern during critical illness. Several prospective studies have yielded conflicting results regarding its mortality effect. Current recommendations are to initiate insulin therapy for all patients when glucose levels are higher than 180 mg/dL. Some suggest decreasing this threshold for non-diabetic patients to 140 mg/dL. These thresholds haven't been compared to each other or to other glucose thresholds. This study aimed to find out whether different glucose levels are associated with 90-d mortality.

METHODS

A retrospective cohort study. Critically ill patients who were admitted from 2019 to 2022 to a mixed medical-surgical intensive care unit for more than 48 h were included. Collected data included baseline characteristics, and all glucose levels recorded (time-indexed to the admission time). Glucose levels were considered constant until the following glucose level. The percentage of time above several chosen glucose cutoff levels was calculated and analyzed for mortality adjusted to other baseline covariates.

RESULTS

45,512 glucose measurements of 1429 patients were included in the study; 21.76 % of the patients had diabetes. Mean glucose level and glucose variability were higher in diabetic patients (165.86 mg/dL vs 135.47 mg/dL, p < 0.0001, and 30.81 % vs 20.86 %, p < 0.0001, respectively), along with a higher incidence of hypoglycemia (40.84 % vs 24.89 %, p < 0.001). 90-d mortality was higher in diabetic patietns (42.12 % vs 32.41 %, p = 0.0014) and was found associated with age, acute physiology and chronic health evaluation 2 score, medical or surgical admission reasons. Percentage of time above cutoffs ≥150 mg/dL was associated with 90-d mortality only in non-diabetic patients.

CONCLUSIONS

In non-diabetic patients, hyperglycemia greater than 150 mg/dL, was associated with increased 90-day mortality.

Effectiveness of a Pharmacist-Led Intervention to Reduce Acid Suppression Therapy for Stress Ulcer Prophylaxis in ICUs in China: A Multicenter, Stepped-Wedge, Cluster-Randomized Controlled Trial

OBJECTIVES

This study aimed to evaluate the effectiveness of a pharmacist-led intervention in decreasing the overuse of stress ulcer prophylaxis (SUP) compared with the usual care for adult patients in Chinese ICUs.

DESIGN

Pragmatic, multicenter, stepped-wedge, cluster-randomized controlled trial.

SETTING

Twenty-six ICUs in China from October 2022 to March 2023.

PATIENTS

We enrolled 2199 patients 18 years old or older who were newly admitted to the participating ICUs.

INTERVENTIONS

Using the Medical Research Council framework for developing and evaluating complex intervention measures, a multidisciplinary team (Scenarios, Improving and Refining Interventions, Constructing, Refining and Testing Research Theories, Incorporating Stakeholders, Identifying Important Uncertainties, and Economics Considerations) designed a multifaceted intervention.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes were the proportion of patients receiving SUP and that with overt gastrointestinal bleeding. We conducted intention-to-treat analyses using generalized linear mixed models to adjust for potential confounders (age, sex, and acute physiology and chronic health evaluation II score) with random effects for the site. The proportion of patients receiving SUP in the intervention group was lower than that in the control group (45.5% vs. 49.5%; odds ratio [OR], 0.81; 95% CI, 0.68-0.96; p = 0.017). The proportion of patients with overt gastrointestinal bleeding was similar (3.7% vs. 4.0%; OR, 1.05; 95% CI, 0.65-2.85; p = 0.81).

CONCLUSIONS

The pharmacist-led intervention reduced the proportion of patients receiving SUP in the ICUs, without significantly affecting the proportion of patients with overt gastrointestinal bleeding. These findings will help guide ICU medical decision-making.

A program to improve sepsis management in the Emergency Department: a multicenter prospective study in France

Implementation of a regional sepsis program to improve compliance with sepsis care bundles and optimize septic patient management and outcomes in the Emergency Department (ED). The program included a multifaceted intervention in 8 EDs: creation of a regional sepsis team, meetings, education (yearly 6-h course and site visits) and sepsis alert. Clinical practice was evaluated in each ED during 1 month every year over 3 years. The primary outcome was the initiation of all criteria of the Surviving Sepsis Campaign (SSC) bundle within 3 h after triage. Secondary outcomes were the initiation of the 3-h bundle in patients with hypotension (SBP ≤ 100 mmHg), admission related to infection or not, proportion of organ supports, subsequent intensive care unit (ICU) admission, and early mortality (day 7). During the 3-month study period, 739 patients were identified with a sepsis including 8% with septic shock. Compliance with the SSC bundle improved during the three periods (P1: 28/176 (16%), P2: 42/272 (15%), P3:69/291 (24%), p = 0.023). In patients with hypotension (n = 142, 19%), no improvement was observed (P1:12/38 (32%), P2:18/46 (39%), P3: 28/58 (48%), p = 0.255). Mortality on day 7 was also similar (10% vs 11% vs 9%, p = 0.621). In multivariate analysis, age (OR = 1.03; 95% CI 1.01-1.05, p = 0.003) and confusion (OR = 2.37; 95% CI 1.37-4.14, p = 0.002) were independently associated with D7 mortality. Patients referred to ED for infection had a better prognosis compared to those with a non-specific reason (OR = 0.56; 95% CI 0.32-0.97, p = 0.038). A regional sepsis educational program appears to improve compliance with the SSC bundle. Pre-hospital identification of sepsis appears to improve further management.

Current Concepts in Fluid Resuscitation and Vasopressor Use in Cirrhosis

Critically ill patients with cirrhosis and liver failure do not uncommonly have hypotension due to multifactorial reasons, which include a hyperdynamic state with increased cardiac index (CI), low systemic vascular resistance (SVR) due to portal hypertension, following the use of beta-blocker or diuretic therapy, and severe sepsis. These changes are mediated by microvascular alterations in the liver, systemic inflammation, activation of renin-angiotensin-aldosterone system, and vasodilatation due to endothelial dysfunction. Haemodynamic assessment includes measuring inferior vena cava indices, cardiac output (CO), and SVR using point-of-care ultrasound (POCUS), arterial waveform analysis, pulmonary artery pressures, and lactate clearance to guide fluid resuscitation. Fluid responsiveness reflects the ability of fluid bolus to increase the CO and is assessed effectively by POCUS, passive leg raises manoeuvre, and dynamic tests such as pulse pressure and stroke volume variation in spontaneously breathing and mechanically ventilated patients. Albumin has pleiotropic benefits through anti-inflammatory properties besides its standard action on oncotic pressure and volume expansion in patients with cirrhosis but has the potential for precipitating pulmonary oedema. In conclusion, fluid therapy in critically ill patients with liver disease is a complex and dynamic process that requires individualized management protocols to optimize patient outcomes.

Opportunity for early de-escalation of antibiotics in Enterobacterales bacteremia with multiplex PCR rapid diagnostic technology

Gram-negative bacteremia and antimicrobial resistance cause significant morbidity and mortality. Strategies are needed to optimize rapid and effective antimicrobial therapy with early de-escalation. In this brief, we describe the utilization of multiplex polymerase chain reaction rapid diagnostic technology for the early de-escalation of broad-spectrum antimicrobials in patients with Enterobacterales bacteremia.

Integration of Mendelian Randomization to explore the genetic influences of pediatric sepsis: a focus on RGL4, ATP9A, MAP3K7CL, and DDX11L2

OBJECTIVE

This study aims to explore the genetic characteristics of pediatric sepsis through a combined analysis of multiple methods, including Mendelian Randomization (MR), differential gene expression analysis, and immune cell infiltration assessment. It explores their potential as biomarkers for sepsis risk and their involvement in immune-related pathways.

METHODS

Differential expression analysis was performed using public datasets to identify genes with significant expression changes between pediatric sepsis patients and healthy controls. MR analysis utilized genome-wide significant SNPs as instrumental variables to assess causal relationships between gene expression and sepsis risk. Bi-directional MR was conducted to assess both forward and reverse causality. FDR correction was applied to adjust for multiple comparisons in MR results. Immune cell infiltration analysis was performed to investigate the genes' roles in immune responses, and findings were validated with independent datasets. ROC curves were constructed to assess predictive performance.

RESULTS

Differential expression analysis identified significant changes in RGL4,ATP9A,MAP3K7CL, and DDX11L2. MR analysis revealed causal associations between these genes and sepsis risk, with RGL4 and ATP9A upregulated (inflammatory roles), and MAP3K7CL and DDX11L2 downregulated (protective roles). Bi-directional MR found no significant reverse causality. Immune cell analysis showed associations with key immune cell types, and ROC analysis demonstrated strong predictive potential.

CONCLUSION

RGL4,ATP9A,MAP3K7CL, and DDX11L2 play important roles in pediatric sepsis risk and immune response regulation, offering insights into genetic and immune mechanisms that may inform future sepsis research and treatment.

AI-Driven Innovations for Early Sepsis Detection by Combining Predictive Accuracy With Blood Count Analysis in an Emergency Setting: Retrospective Study

BACKGROUND

Sepsis, a critical global health challenge, accounted for approximately 20% of worldwide deaths in 2017. Although the Sequential Organ Failure Assessment (SOFA) score standardizes the diagnosis of organ dysfunction, early sepsis detection remains challenging due to its insidious symptoms. Current diagnostic methods, including clinical assessments and laboratory tests, frequently lack the speed and specificity needed for timely intervention, particularly in vulnerable populations such as older adults, intensive care unit (ICU) patients, and those with compromised immune systems. While bacterial cultures remain vital, their time-consuming nature and susceptibility to false negatives limit their effectiveness. Even promising existing machine learning approaches are restricted by reliance on complex clinical factors that could delay results, underscoring the need for faster, simpler, and more reliable diagnostic strategies.

OBJECTIVE

This study introduces innovative machine learning models using complete blood count with differential (CBC+DIFF) data-a routine, minimally invasive test that assesses immune response through blood cell measurements, critical for sepsis identification. The primary objective was to implement this model within an artificial intelligence-clinical decision support system (AI-CDSS) to enhance early sepsis detection and management in critical care settings.

METHODS

This retrospective study at Tri-Service General Hospital (September to December 2023) analyzed 746 ICU patients with suspected pneumonia-induced sepsis (supported by radiographic evidence and a SOFA score increase of ≥2 points), alongside 746 stable outpatients as controls. Sepsis infection sources were confirmed through positive sputum, blood cultures, or FilmArray results. The dataset incorporated both basic hematological factors and advanced neutrophil characteristics (side scatter light intensity, cytoplasmic complexity, and neutrophil-to-lymphocyte ratio), with data from September to November used for training and data from December used for validation. Machine learning models, including light gradient boosting machine (LGBM), random forest classifier, and gradient boosting classifier, were developed using CBC+DIFF data and were assessed using metrics such as area under the curve, sensitivity, and specificity. The best-performing model was integrated into the AI-CDSS, with its implementation supported through workshops and training sessions.

RESULTS

Pathogen identification in ICU patients found 243 FilmArray-positive, 411 culture-positive, and 92 undetected cases, yielding a final dataset of 654 (43.8%) sepsis cases out of 1492 total cases. The machine learning models demonstrated high predictive accuracy, with LGBM achieving the highest area under the curve (0.90), followed by the random forest classifier (0.89) and gradient boosting classifier (0.88). The best-performing LGBM model was selected and integrated as the core of our AI-CDSS, which was built on a web interface to facilitate rapid sepsis risk assessment using CBC+DIFF data.

CONCLUSIONS

This study demonstrates that by providing streamlined predictions using CBC+DIFF data without requiring extensive clinical parameters, the AI-CDSS can be seamlessly integrated into clinical workflows, enhancing rapid, accurate identification of sepsis and improving patient care and treatment timeliness.

Intervention With Concentrated Albumin for Undifferentiated Sepsis in the Emergency Department (ICARUS-ED): A Pilot Randomized Controlled Trial

STUDY OBJECTIVES

Concentrated albumin early in sepsis resuscitation remains largely unexplored. Objectives were to determine 1) feasibility of early intervention with concentrated albumin in emergency department (ED) patients with suspected infection and hypoperfusion and 2) whether early albumin therapy improves outcomes.

METHODS

ED patients with suspected infection and hypoperfusion (systolic blood pressure [SBP]<90 mmHg or lactate ≥4.0 mmol/L) were randomized to receive either 400 mL 20% albumin over 4 hours or no albumin. All patients were treated with crystalloids, antibiotics, and other therapies at the treating team's discretion. Primary outcome was SBP at 24 hours; secondary outcomes included SBP at 6 hours, fluid and organ support requirements, organ dysfunction, and mortality. Quantile and logistic regressions were used to calculate differences (and 95% CI) between study groups.

RESULTS

Compliance with study protocol was more than 95%, and infection was confirmed in 95% of the 464 study patients enrolled. SBP at 24 hours did not differ between intervention (110.5 mmHg) and standard care arms (110 mmHg). In patients treated with albumin, SBP was higher at 6 hours, less total fluid was infused at 72 hours, fewer patients required vasopressor therapy at 24 and 72 hours, and organ function was improved. Mortality was not significantly different.

CONCLUSIONS

Early identification, trial enrollment, and intervention in ED patients with sepsis is feasible. In this pilot study, concentrated albumin given early in resuscitation did not improve SBP at 24 hours. Albumin was associated with less total fluid and vasopressor requirements and improved organ dysfunction. A multicenter study is indicated.

Hypoglycemia and hospital mortality in critically ill patients

Prior research has indicated that adopting strict glycemic control measures might elevate the risk of hypoglycemia and result in higher mortality rates among critically ill patients. However, there is a lack of studies investigating the incidence of hypoglycemia and its consequential outcomes in real-world clinical settings. This retrospective cohort study was conducted at Taichung Veterans General Hospital, utilizing critical care databases covering the period from 2015 to 2020. The objective was to examine the outcomes and identify risk factors associated with hypoglycemia in critically ill patients. Out of the total of 16,699 patients admitted to the intensive care units (ICUs), 2,115(12.7%) experienced at least one episode of hypoglycemia were included in the analysis. Critically ill patients who developed hypoglycemia had a significantly higher hospital mortality rate compared to those who did not experience hypoglycemia. (48.9% vs. 15.9%, p < 0.001). Moreover, patients with more severe hypoglycemia exhibited a higher mortality rate (moderate hypoglycemia: hazard ratio [HR] 1.477, 95% confidence interval [C.I.] 1.351-1.614, p < 0.001; severe hypoglycemia: HR 1.847, 95% C.I. 1.607-2.123, p < 0.001) compared to those without hypoglycemia. Additionally, patients with greater frequency of hypoglycemic episodes also showed a higher mortality rate (one episode HR 1.504, 95% C.I. 1.366-1.657, p < 0.001; multiple episodes HR 1.613, 95% C.I. 1.444-1.801, p < 0.001) compared to those without hypoglycemia. Patient who experienced spontaneous hypoglycemia (53.9% vs. 42.4%, p < 0.001) and those without a prior diagnosis of diabetes (60.2% vs. 37.0%, p < 0.001) had higher mortality rate. Hypoglycemia frequently occurs and serves as an independent risk factor for mortality among critically ill individuals, particularly in cases of severe and recurrent episodes. Patients experiencing spontaneous hypoglycemia, as well as those lacking a diabetes diagnosis, demonstrated elevated mortality rates.

Effect of Treatment With Balanced Crystalloids Versus Normal Saline on the Mortality of Critically Ill Patients With and Without Traumatic Brain Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Some studies suggest that balanced solutions may improve outcomes in critical care patients. However, in patients with traumatic brain injury (TBI) existing data indicate that normal saline may be preferred. We hypothesized that mortality in critically ill patients with and without TBI would differ with the use of balanced salt solutions versus normal saline.

METHODS

We conducted a systematic review and meta-analysis to investigate the impact of balanced crystalloids versus normal saline on 90-day mortality in adult critical care patients with and without TBI. Secondary outcomes included length of hospital stay, renal complications, need for vasopressors or mechanical ventilation, and mortality in critically ill patients with sepsis. We followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) statement and estimated the odds ratio (OR) and 95% confidence interval (CI) with a random-effects model.

RESULTS

We included 15 clinical trials involving 35,207 patients. The OR of mortality with balanced solutions versus saline in patients without TBI was 0.93 (95% CI, 0.87-0.98; P = .01; I2 = 0%), while the OR for mortality in patients with TBI was 1.31 (95% CI, 1.03-1.65; P = .03; I2 = 0%). We found no differences in secondary outcomes due to fluid choice although data were unavailable to calculate pooled estimates for some of the secondary outcomes for TBI patients. In patients with sepsis, the OR of mortality with balanced solutions was 0.92 (95% CI, 0.83-1.02; I2 = 0%).

CONCLUSIONS

In comparison to normal saline, balanced solutions were associated with a reduction in mortality in critical care patients without TBI. However, balanced solutions were associated with an increase in mortality in patients with TBI. These findings suggest that the effect of fluid choice on intensive care unit (ICU) outcomes may depend partially on the type of critical illness and in particular in patients with TBI.