Efficacy and safety of corticosteroids for septic shock in immunocompromised patients: A cohort study from MIMIC

Effect of methylprednisolone vs hydrocortisone on 30-day mortality in critically ill adults with septic shock: an analysis of the MIMIC-IV database

BACKGROUND

Methylprednisolone is still used to treat adults with septic shock in real-world clinical settings, despite current international guidelines recommending hydrocortisone. The aim of this study was to assess the effect of methylprednisolone vs hydrocortisone on 30-day mortality among critically ill patients with septic shock.

METHODS

We conducted a retrospective cohort study on adults with septic shock using the MIMIC-IV v3.0 database. Patients who received methylprednisolone after diagnosis were matched using propensity score matching (PSM) with those received hydrocortisone, to balance confounding factors between groups. The primary outcome was the 30-day mortality rate. Subgroup and sensitivity analyses were performed to assess the robustness of the conclusions.

RESULTS

A total of 1,607 septic shock patents were enrolled in this study, with an overall 30-day mortality rate of 42.1%. After 1:1 PSM, 376 pairs were successfully matched. The primary outcome occurred in 141 patients (37.5%) and in 131 patients (34.8%) in the methylprednisolone and hydrocortisone groups, respectively (HR = 1.105, 95% CI: 0.871-1.402, P = 0.410). In subgroup analyses based on age, sex, blood culture positivity, pneumonia, and invasive mechanical ventilation (IMV), along with sensitivity analyses for deletion of missing values, findings remained consistent. However, the methylprednisolone group exhibited a longer ICU stay, elevated blood glucose levels, and a shorter maintenance duration for vasopressin compared to the hydrocortisone group.

CONCLUSIONS

Among adults with septic shock, there was no significant difference in 30-day mortality between those administered methylprednisolone and hydrocortisone. It needs to be further verified in prospective, randomized controlled trials.

Antibiotics versus Non-Antibiotic in the treatment of Aspiration Pneumonia: analysis of the MIMIC-IV database

BACKGROUND

Aspiration pneumonia (AP) is a common complication in the intensive care unit (ICU), which is associated with significantly increased morbidity and mortality and has a significant impact on patient prognosis. Antibiotics are commonly used in the clinical treatment of AP. However, the prognostic impact of antibiotics on patients with AP has not been adequately characterized. The purpose of this study is to illustrate the relationship between the use of antibiotics and in-hospital mortality of AP patients, as well as to analyze the effects of different antibiotic treatment regimens on the prognosis of the patients, and to further understand the distribution of pathogens and drug resistance in AP patients, so as to provide guidance information for the rational use of medication for patients in the clinic.

METHODS

Clinical data of AP patients were extracted from the MIMIC-IV database. Statistical methods included multivariate logistic regression, propensity score matching (PSM), and inverse probability weighting (IPW) based on propensity scores to ensure the robustness of the findings. In addition, the characteristics of the medications used by patients with AP were described using statistical graphs and tables.

RESULTS

A total of 4132 patients with AP were included. In-hospital mortality was significantly lower in the group using antibiotics compared to the group not using antibiotics (odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.27- 0.71, P = 0.001). Furthermore, in the group using mechanical ventilation (MV), antibiotics use significantly reduced in-hospital mortality (OR = 0.30, 95% CI 0.15-0.57, P < 0.001). Vancomycin and cephalosporins are the most commonly used antibiotics to treat AP. Specifically, vancomycin in combination with piperacillin-tazobactam was used most frequently with 396 cases. The highest survival rate (97.6\%) was observed in patients treated with levofloxacin combined with metronidazole. Additionally, vancomycin combined with piperacillin-tazobactam had many inflammation related features that differed significantly from those in patients who did not receive medication.

CONCLUSIONS

Antibiotics use is closely associated with lower in-hospital mortality in ICU patients with AP. Moreover, understanding antibiotics use, the composition of pathogenic bacteria, and the rates of drug resistance in patients with AP can aid in disease prevention and prompt infection control.

Management of the kidney transplant recipient in the intensive care unit

PURPOSE OF REVIEW

Kidney transplantation is the ideal treatment for patients with chronic kidney disease and end stage renal disease. While centers are performing more transplants every year, the need for organ transplantation outpaces the supply of organ donors. Due to a growing population of patients with advanced kidney disease and a scarcity of kidneys from deceased donors, patients face extended wait times. By the time patients approach transplantation they have multiple comorbidities, in particular cardiovascular complications. Their risk of complications is further compounded by exposure to immunosuppression post kidney transplantation. Kidney transplant recipients (KTRs) are medically complex and may require acute management in the intensive care unit (ICU), as a result of cardiovascular complications, infections, and/or respiratory compromise from lung infections and/or acute pulmonary edema. Acute complication of immunosuppression, such as thrombotic microangiopathy and posterior reversible encephalopathy syndrome may also warrant ICU admission. This review will cover assessment of high-risk complications and management strategies following kidney transplantation.

RECENT FINDINGS

For intensivists caring for KTRs, it is imperative to understand anatomical considerations of the transplanted kidney, unique infectious risks faced by this population, and appropriate modulation of immunosuppression.

SUMMARY

Recognizing potential complications and implementing appropriate management strategies for KTRs admitted to the ICU will improve kidney allograft and patient survival outcomes.

Construction and validation of prognostic models in critically Ill patients with sepsis-associated acute kidney injury: interpretable machine learning approach

BACKGROUND

Acute kidney injury (AKI) is a common complication in critically ill patients with sepsis and is often associated with a poor prognosis. We aimed to construct and validate an interpretable prognostic prediction model for patients with sepsis-associated AKI (S-AKI) using machine learning (ML) methods.

METHODS

Data on the training cohort were collected from the Medical Information Mart for Intensive Care IV database version 2.2 to build the model, and data of patients were extracted from Hangzhou First People's Hospital Affiliated to Zhejiang University School of Medicine for external validation of model. Predictors of mortality were identified using Recursive Feature Elimination (RFE). Then, random forest, extreme gradient boosting (XGBoost), multilayer perceptron classifier, support vector classifier, and logistic regression were used to establish a prognosis prediction model for 7, 14, and 28 days after intensive care unit (ICU) admission, respectively. Prediction performance was assessed using the receiver operating characteristic (ROC) curve and decision curve analysis (DCA). SHapley Additive exPlanations (SHAP) were used to interpret the ML models.

RESULTS

In total, 2599 patients with S-AKI were included in the analysis. Forty variables were selected for the model development. According to the areas under the ROC curve (AUC) and DCA results for the training cohort, XGBoost model exhibited excellent performance with F1 Score of 0.847, 0.715, 0.765 and AUC (95% CI) of 0.91 (0.90, 0.92), 0.78 (0.76, 0.80), and 0.83 (0.81, 0.85) in 7 days, 14 days and 28 days group, respectively. It also demonstrated excellent discrimination in the external validation cohort. Its AUC (95% CI) was 0.81 (0.79, 0.83), 0.75 (0.73, 0.77), 0.79 (0.77, 0.81) in 7 days, 14 days and 28 days group, respectively. SHAP-based summary plot and force plot were used to interpret the XGBoost model globally and locally.

CONCLUSIONS

ML is a reliable tool for predicting the prognosis of patients with S-AKI. SHAP methods were used to explain intrinsic information of the XGBoost model, which may prove clinically useful and help clinicians tailor precise management.

Monkeypox (mpox) in immunosuppressed patients

The World Health Organization (WHO) proclaimed a public health emergency in July 2022 due to the emergence of Mpox (formerly monkeypox) while the globe was still dealing with the COVID-19 epidemic. The characteristics of mpox in immunocompetent individuals are well-characterized, despite difficulties in diagnostics, immunization, and access to treatment that persist in low-income countries. Patients with weakened immune systems are more likely to spread an illness and die from it than healthy people because they cannot mount a protective immune response against it, such as a neutralizing IgG and poxvirus-specific Th1 response. A health warning on severe mpox in people who are immunocompromised due to Human Immunodeficiency virus (HIV) and other illnesses was released by the U.S. Centers for Disease Control and Prevention (CDC) on September 29, 2022. The advice does not specifically include primary immunodeficiency, but it does define other immunocompromising disorders as "having autoimmune disease with immunodeficiency as a clinical component". Both those with healthy immune systems and those with weakened immune systems, such as those who are immunosuppressed, older people, children, etc., have encountered serious health issues, but the latter group is more likely to do so. According to the advisory, "of the people with severe mpox manifestations for whom CDC has been consulted, the majority have had HIV with CD4 counts 200 cells/ml, indicating substantial immunosuppression". However, new cases are still expected to be discovered, especially in low-income countries with limited access to diagnosis, treatment, and prevention, and where a large percentage of the mpox-infected population also has advanced HIV infection. Thus, further research is always needed to determine the best way to treat mpox in immunocompromised people. In this context, we discussed /reviewed the mpox clinical presentation, available treatment options and current preventive guidelines in immunocompromised patients.

Monkeypox (mpox) in immunosuppressed patients

The World Health Organization (WHO) proclaimed a public health emergency in July 2022 due to the emergence of Mpox (formerly monkeypox) while the globe was still dealing with the COVID-19 epidemic. The characteristics of mpox in immunocompetent individuals are well-characterized, despite difficulties in diagnostics, immunization, and access to treatment that persist in low-income countries. Patients with weakened immune systems are more likely to spread an illness and die from it than healthy people because they cannot mount a protective immune response against it, such as a neutralizing IgG and poxvirus-specific Th1 response. A health warning on severe mpox in people who are immunocompromised due to Human Immunodeficiency virus (HIV) and other illnesses was released by the U.S. Centers for Disease Control and Prevention (CDC) on September 29, 2022. The advice does not specifically include primary immunodeficiency, but it does define other immunocompromising disorders as "having autoimmune disease with immunodeficiency as a clinical component". Both those with healthy immune systems and those with weakened immune systems, such as those who are immunosuppressed, older people, children, etc., have encountered serious health issues, but the latter group is more likely to do so. According to the advisory, "of the people with severe mpox manifestations for whom CDC has been consulted, the majority have had HIV with CD4 counts 200 cells/ml, indicating substantial immunosuppression". However, new cases are still expected to be discovered, especially in low-income countries with limited access to diagnosis, treatment, and prevention, and where a large percentage of the mpox-infected population also has advanced HIV infection. Thus, further research is always needed to determine the best way to treat mpox in immunocompromised people. In this context, we discussed /reviewed the mpox clinical presentation, available treatment options and current preventive guidelines in immunocompromised patients.

Association between blood urea nitrogen to serum albumin ratio and in-hospital mortality of patients with sepsis in intensive care: A retrospective analysis of the fourth-generation Medical Information Mart for Intensive Care database

BACKGROUND

This study aimed to investigate the relationship between the blood urea nitrogen to serum albumin ratio (BAR) and in-hospital mortality in patients with sepsis.

MATERIALS AND METHODS

This is a retrospective cohort study. All septic patient data for the study were obtained from the intensive care unit of Beth Israel Deaconess Medical Center. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using multivariable Cox regression analyses. Survival curves were plotted and subgroup analyses were stratified by relevant covariates.

RESULTS

Among 23,901 patients, 13,464 with sepsis were included. The overall in-hospital mortality rate was 18.9% (2550/13464). After adjustment for confounding factors, patients in the highest BAR quartile had an increased risk of sepsis death than those in the lowest BAR quartile (HR: 1.42, 95% CI: 1.3-1.55), using BAR as a categorical variable. When BAR was presented as a continuous variable, the prevalence of in-hospital sepsis-related death increased by 8% (adjusted HR: 1.08, 95% CI: 1.07-1.1, P < 0.001) for each 5-unit increase in BAR, irrespective of confounders. Stratified analyses indicated age interactions (P < 0.001), and the correlation between BAR and the probability of dying due to sepsis was stable.

CONCLUSION

BAR was significantly associated with in-hospital mortality in intensive care patients with sepsis. A higher BAR in patients with sepsis is associated with a worse prognosis in the ICU in the USA. However, further research is required to confirm this finding.

Impact of cancer on mortality rates in patients with sepsis: A meta-analysis and meta-regression of current studies

BACKGROUND

Research suggests that approximately 6% of adult patients admitted to hospitals in the United States present with sepsis and there has been a minimal change in the incidence of this condition in the last decade. Furthermore, patients with cancer generally have a higher incidence of sepsis due to immunosuppression caused by cancer or its treatment.

AIM

To assess if cancer increases the mortality rates in sepsis patients by pooling evidence from contemporary studies.

METHODS

PubMed, Embase, and Google Scholar databases were searched from January 1, 2001 to December 15, 2021 for studies comparing outcomes of sepsis patients based on the presence of active cancer. Mortality data were pooled using a random-effects model, with the odds ratio (OR) and 95% confidence interval (CI) calculated. Meta-regression was conducted to assess the influence of confounders on mortality rates.

RESULTS

Nine studies were included. The meta-analysis demonstrated a non-significant tendency towards increased risk of early mortality (OR = 2.77, 95%CI: 0.88-8.66, I² = 99%) and a statistically significantly increased risk of late mortality amongst sepsis patients with cancer as compared to non-cancer sepsis patients (OR = 2.46, 95%CI: 1.42-4.25, I² = 99%). Overall, cancer was found to significantly increase the risk of mortality in sepsis patients (OR = 2.7, 95%CI: 1.07-6.84, I² = 99%). Meta-analysis indicated a statistically significantly increased risk of mortality in patients with solid tumors as well as hematological malignancies. Meta-regression indicated that an increase in the prevalence of comorbid pulmonary and renal diseases increased the risk of mortality in cancer patients with sepsis. Mortality rates increased with an increase in the percentage of patients with urinary tract infections while an inverse relationship was seen for infections of cutaneous origin.

CONCLUSION

Contemporary evidence indicates that the presence of any cancer in sepsis patients significantly increases the risk of mortality. Scarce data suggest that mortality is equally increased for both solid and hematological cancers. Current evidence is limited by high heterogeneity and there is a need for further studies taking into account several confounding variables to present better evidence.

The Use of Antibiotics for Ventilator-Associated Pneumonia in the MIMIC-IV Database

Purpose: By analyzing the clinical characteristics, etiological characteristics and commonly used antibiotics of patients with ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in the intensive care database. This study aims to provide guidance information for the clinical rational use of drugs for patients with VAP. Method: Patients with VAP information were collected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, including their sociodemographic characteristics, vital signs, laboratory measurements, complications, microbiology, and antibiotic use. After data processing, the characteristics of the medications used by patients with VAP in ICUs were described using statistical graphs and tables, and experiences were summarized and the reasons were analyzed. Results: This study included 2,068 patients with VAP. Forty-eight patient characteristics, including demographic indicators, vital signs, biochemical indicators, scores, and comorbidities, were compared between the survival and death groups of VAP patients. Cephalosporins and vancomycin were the most commonly used. Among them, fourth-generation cephalosporin (ForGC) combined with vancomycin was used the most, by 540 patients. First-generati49n cephalosporin (FirGC) combined with vancomycin was associated with the highest survival rate (86.7%). More than 55% of patients were infected with Gram-negative bacteria. However, patients with VAP had fewer resistant strains (<25%). FirGC or ForGC combined with vancomycin had many inflammation-related features that differed significantly from those in patients who did not receive medication. Conclusion: Understanding antibiotic use, pathogenic bacteria compositions, and the drug resistance rates of patients with VAP can help prevent the occurrence of diseases, contain infections as soon as possible, and promote the recovery of patients.

Association of Blood Glucose Level and Glycemic Variability With Mortality in Sepsis Patients During ICU Hospitalization

Background

There was considerable debate regarding the effect of mean blood glucose (MBG) and glycemic variability (GV) on the mortality of septic patients. This retrospective cohort study aimed to assess the association between MBG and GV with ICU mortality of sepsis patients and to explore the optimal MBG range.

Methods

Sepsis patients were enrolled from the Medical Information Mart for Intensive Care IV database (MIMIC-IV). MBG and glycemic coefficient of variation (GluCV) were, respectively, calculated to represent the overall glycemic status and GV during ICU stay. The associations between MBG, GluCV, and ICU mortality of the septic patients were assessed by using multivariate logistic regression in different subgroups and the severity of sepsis. Restricted cubic splines evaluated the optimal MBG target.

Results

A total of 7,104 adult sepsis patients were included. The multivariate logistic regression results showed that increased MBG and GluCV were significantly correlated with ICU mortality. The adjusted odds ratios were 1.14 (95% CI 1.09-1.20) and 1.05 (95% CI 1.00-1.12). However, there was no association between hyperglycemia and ICU mortality among diabetes, liver disease, immunosuppression, and hypoglycemia patients. And the impact of high GluCV on ICU mortality was not observed in those with diabetes, immunosuppression, liver disease, and non-septic shock. The ICU mortality risk of severe hyperglycemia (≧200 mg/dl) and high GluCV (>31.429%), respectively, elevated 2.30, 3.15, 3.06, and 2.37, 2.79, 3.14-folds in mild (SOFA ≦ 3), middle (SOFA 3-7), and severe group (SOFA ≧ 7). The MBG level was associated with the lowest risk of ICU mortality and hypoglycemia between 120 and 140 mg/dl in the subgroup without diabetes. For the diabetic subset, the incidence of hypoglycemia was significantly reduced when the MBG was 140-190 mg/dl, but a glycemic control target effectively reducing ICU mortality was not observed.

Conclusion

MBG and GluCV during the ICU stay were associated with all-cause ICU mortality in sepsis patients; however, their harms are not apparent in some particular subgroups. The impact of hyperglycemia and high GV on death increased with the severity of sepsis. The risk of ICU mortality and hypoglycemia in those with no pre-existing diabetes was lower when maintaining the MBG in the range of 120-140 mg/dl.

The Interplay between Host Defense, Infection, and Clinical Status in Septic Patients: A Narrative Review

Sepsis is a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs. Despite significant morbidity and mortality throughout the world, its pathogenesis and mechanisms are not clearly understood. In this narrative review, we aimed to summarize the recent developments in our understanding of the hallmarks of sepsis pathogenesis (immune and adaptive immune response, the complement system, the endothelial disfunction, and autophagy) and highlight novel laboratory diagnostic approaches. Clinical management is also discussed with pivotal consideration for antimicrobic therapy management in particular settings, such as intensive care unit, altered renal function, obesity, and burn patients.

A Nomogram Based on Comorbidities and Infection Location to Predict 30 Days Mortality of Immunocompromised Patients in ICU: A Retrospective Cohort Study

Background

The existing comorbidity indexes, like Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI), do not take infection factors into account for critically ill patients with immunocompromise, bringing about a decrease of prediction accuracy. Therefore, we attempted to incorporate infection location into the analysis to construct a rapid comorbidity scoring system independent of laboratory tests.

Methods

Data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database. A total of 3904 critically ill patients with immunocompromise admitted to ICU were enrolled and assigned into training or validation sets according to the date of ICU admission. The predictive nomogram was constructed in the training set based on logistic regression analysis and then undergone validation in the validation set in comparison with SOFA, CCI and ECI.

Results

Factors eligible for the nomogram included patient’s age, gender, ethnicity, underlying disease of immunocompromise like metastatic cancer and leukemia, possible infection on admission including pulmonary infection, urinary tract infection and blood infection, and one comorbidity, coagulopathy. The nomogram we developed exhibited better discrimination than SOFA, CCI and ECI with an area under the receiver operating characteristic curve (AUC) of 0.739 (95% CI 0.707–0.771) and 0.746 (95% CI 0.713–0.779) in the training and validation sets, respectively. Combining the nomogram and SOFA could bring a new prediction model with a superior predictive effect in both sets (training set AUC = 0.803 95% CI 0.777–0.828, validation set AUC = 0.818 95% CI 0.783–0.854). The calibration curve exhibited coherence between the nomogram and ideal observation for two cohorts (p>0.05). Decision curve analysis revealed the clinical usefulness of the nomogram in both sets.

Conclusion

We established a nomogram that could provide an accurate assessment of 30 days ICU mortality in critically ill patients with immunocompromise, which can be employed to evaluate the short-term prognosis of those patients and bring more clinical benefits without dependence on laboratory tests.

Efficacy and safety of corticosteroids in immunocompetent patients with septic shock

BACKGROUND

The use of corticosteroids in septic shock has been studied for many decades but yielded conflicting results. We conducted a systematic review to evaluate the efficacy and the safety of corticosteroids in immunocompetent patients with septic shock.

METHODS

Medline via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, and EMBASE were searched from inception to March 2020. Two reviewers independently identified randomized controlled trials (RCTs) comparing corticosteroids with a control group for immunocompetent patients with septic shock. Data were abstracted and reported following the Cochrane Handbook for Systematic Review of Intervention and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The efficacy outcome included mortality and shock reversal. The safety outcomes were infection, gastrointestinal bleeding, and hyperglycemia.

RESULTS

Nine RCTs with a total of 1,298 patients were included. Compared with the control group, corticosteroid group did not lower the short-term (28 or 30 days) mortality (risk ratio [RR] 0.95, 95% confidence interval (CI) 0.85 to 1.06, inconsistency [I ²]=0%, trial sequential analysis [TSA]-adjusted CI 0.83 to 1.09, moderate-certainty evidence). Corticosteroids significantly shortened the time to shock reversal compared with the control group (mean difference [MD] -21.56 hours; 95% CI -32.95 to -10.16, I ²=0%; TSA-adjusted CI -33.33 to -9.78, moderate-certainty evidence). The corticosteroid treatment was associated with an increased risk of hyperglycemia but not the infection or gastrointestinal bleeding.

CONCLUSIONS

The corticosteroid treatment is not associated with lower short- or long- term mortality compared with placebo in immunocompetent patients with septic shock. However, corticosteroids significantly shorten the time to shock reversal without increasing the risk of infection. The patient's immune status should also be considered during clinical treatment and clinical trials in future.

Prognosis of Patients with Sepsis and Non-Hepatic Hyperammonemia: A Cohort Study

Background

Hyperammonemia has been reported in some critically ill patients with sepsis who do not have hepatic failure. A significant proportion of patients with non-hepatic hyperammonemia have underlying sepsis, but the association between non-hepatic hyperammonemia and prognosis is unclear.

Material/Methods

Information about patients with sepsis and non-hepatic hyperammonemia was retrieved from the Medical Information Mart for Intensive Care-III database. Survival rates were analyzed using the Kaplan-Meier method. Multivariate logistic regression models were employed to identify prognostic factors. Receiver operating characteristic (ROC) curve analysis was used to measure the predictive ability of ammonia in terms of patient mortality.

Results

A total of 265 patients with sepsis were enrolled in this study. Compared with the non-hyperammonemia group, the patients with hyperammonemia had significantly higher rates of hospital (59.8% vs. 43.0%, P=0.007), 30-day (47.7% vs. 34.8%, P=0.036), 90-day (61.7% vs. 43.7%, P=0.004), and 1-year mortality (67.3% vs. 49.4%, P=0.004). In the survival analysis, hyperammonemia was associated with these outcomes. Serum ammonia level was an independent predictor of hospital mortality. The area under the ROC curve for the ammonia levels had poor discriminative capacity. The hyperammonemia group also had significantly lower Glasgow Coma Scale scores (P=0.020) and higher incidences of delirium (15.9% vs. 8.2%, P=0.034) and encephalopathy (37.4% vs. 19.6%, P=0.001). Intestinal infection and urinary tract infection with organisms such as Escherichia coli may be risk factors for hyperammonemia in patients who have sepsis.

Conclusions

Higher ammonia levels are associated with poorer prognosis in patients with sepsis. Ammonia also may be associated with sepsis-associated encephalopathy. Therefore, we recommend that serum ammonia levels be measured in patients who are suspected of having sepsis.