Predictive value of procalcitonin, interleukin-6, and C-reactive protein for survival in postoperative patients with severe sepsis

IL-6 Baseline Values and Dynamic Changes in Predicting Sepsis Mortality: A Systematic Review and Meta-Analysis

Sepsis, a life-threatening condition arising from a dysregulated immune response to infection, is a significant health burden globally. Interleukin-6 (IL-6), an inflammatory cytokine produced by immune cells as a response to infection and tissue damage, plays a key role in the pathogenesis of sepsis. This systematic review and meta-analysis aimed to investigate the association of the baseline plasma levels of IL-6, and the dynamic change in these levels over a timespan of 96 h, with short-term mortality. A systematic literature search was conducted across multiple databases. Studies were included if they assessed the independent prognostic value of IL-6 in adult sepsis patients, used well-defined sepsis criteria, and reported at least one IL-6 measurement. Pooled effect estimates for the association between IL-6 and 28-30-day mortality were determined using logistic regression and AUROC analysis. Thirty-one studies, encompassing 4566 patients, were included. While baseline IL-6 levels and 96 h IL-6 clearance were not significantly associated with mortality risk (pooled OR 1.001, 95% CI 0.999-1.003 and 1.019, 95% CI 0.925-1.112, respectively), AUROC analysis indicated moderate-to-good discriminatory power for both baseline (0.701, 95% CI 0.660-0.742) and 96 h IL-6 clearance (0.828, 95% CI 0.736-0.919) in predicting 28-day mortality. While not a strong independent predictor, IL-6 demonstrates some discriminatory ability, suggesting its potential value in conjunction with other biomarkers.

Phellodendrine Exerts Protective Effects on Intra-abdominal Sepsis by Inactivating AKT/NF-kB Signaling

Acute kidney injury (AKI) and acute lung injury (ALI) are major complications of intra-abdominal sepsis, leading to increased mortality. Phellodendrine (PHE) is a characteristic and important active ingredient of Phellodendri Cortex, possessing multiple pharmacological properties. This study intends to explore the effect of PHE on intra-abdominal sepsis-induced AKI and ALI. An intra-abdominal infection-induced rat model of sepsis was established by fecal intraperitoneal injection, followed by the administration of PHE. ELISA was used to determine plasma levels of inflammatory cytokines. Hematoxylin-eosin, Periodic acid Schiff, and Masson trichrome staining were employed for histopathological analysis of rat kidney and lung tissues. Western blotting was used to estimate the AKT/NF-κB signaling-related protein levels. The results showed that PHE improved the survival rate of septic rats and reduced plasma levels of proinflammatory cytokines. PHE administration attenuated pathological lesions in the kidneys and lungs of septic rats. Mechanistically, PHE treatment blocked AKT/NF-κB signaling in septic rats' kidneys and lungs. In conclusion, PHE ameliorates intra-abdominal sepsis-induced kidney and lung injury possibly by inactivating AKT/NF-kB signaling.

Plasma neutrophil extracellular traps in patients with sepsis-induced acute kidney injury serve as a new biomarker to predict 28-day survival outcomes of disease

Background

There is currently no accurate, readily available, or validated biomarker for assessing disease severity and survival outcomes in sepsis-induced acute kidney injury (SAKI), which limits the ability to conduct effective therapeutic interventions. The neutrophil extracellular traps (NETs) may be involved in the pathophysiology of SAKI. The present study investigated the predictive value of plasma NETs for the survival outcome of patients with SAKI.

Methods

This observational study included 136 SAKI patients, all of whom underwent a 28-day follow-up. According to the follow-up records, SAKI patients were divided into two groups: the non-survivor group (60 subjects) and the survivor group (76 subjects). Blood samples were collected after the diagnosis of AKI to measure three NET markers and 12 inflammatory indices. Correlation analysis, logistic regression analysis, receiver operating characteristic curve analysis, and survival analysis were performed.

Results

Compared to survivors, non-survivors among SAKI patients exhibited significantly higher levels of three plasma NET markers (all p < 0.001). Meanwhile, in SAKI patients, plasma levels of NET markers were significantly associated with serum levels of inflammatory indices. Additionally, serum interleukin (IL)-2, IL-8, IL-10, and tumor necrosis factor-alpha showed an interactive effect with plasma NET markers on the survival of SAKI patients. Furthermore, the combination of three plasma NET markers could identify SAKI patients with a poor 28-day survival with better accuracy (area under the curve = 0.857). Finally, plasma NET markers may independently predict the 28-day survival in SAKI patients.

Conclusion

Plasma NET markers were elevated in SAKI patients with poor outcomes and served as biomarkers for predicting 28-day survival in SAKI patients.

Single-cell RNA sequencing reveals cell-cell communication and potential biomarker in sepsis and septic shock patients

BACKGROUND

Sepsis is a disease characterized by infection-induced multiorgan dysfunction, which can progress to septic shock if not promptly treated. Early identification of sepsis is crucial for its treatment. However, there are currently limited specific biomarkers for sepsis or septic shock. This study aims to identify potential biomarkers for sepsis and septic shock.

METHODS

We analyzed single-cell transcriptomic data of peripheral blood mononuclear cells (PBMCs) from healthy individuals, sepsis and septic shock patients, identified differences in gene expression and cell-cell communication between different cell types during disease progression. Moreover, our analyses were further validated with flow cytometry and bulk RNA-seq data.

RESULTS

Our study elucidates the alterations in cellular proportions and cell-cell communication among healthy controls, sepsis, and septic shock patients. We identified a specific augmentation in the Resistin signaling within sepsis monocytes, mediated via RETN-CAP1 ligand-receptor pairs. Additionally, we observed enhanced IL16 signaling within monocytes from septic shock patients, mediated through IL16-CD4 ligand-receptor pairs. Subsequently, we confirmed our findings by validating the increase in CAP-1+ monocytes in sepsis and IL16+ monocytes in septic shock in mouse models. And a significant upregulation of CAP-1 and IL16 was also observed in the bulk RNA-seq data from patients with sepsis and septic shock. Furthermore, we identified four distinct clusters of CD14+ monocytes, highlighting the heterogeneity of monocytes in the progress of sepsis.

CONCLUSIONS

In summary, our work demonstrates changes in cell-cell communication of healthy controls, sepsis and septic shock, confirming that the molecules CAP-1 and IL16 on monocytes may serve as potential diagnostic markers for sepsis and septic shock, respectively. These findings provide new insights for early diagnosis and stratified treatment of the disease.

The value of plasma presepsin as a diagnostic and prognostic biomarker for sepsis in Southern China

BACKGROUND

Presepsin is a soluble CD14 subtype that has been considered as a novel marker for patients with sepsis. This study explored the clinical value of presepsin for sepsis in Southern China, and further established models for diagnosis and prognosis of sepsis through using machine learning (ML), by combining presepsin and other laboratory parameters.

METHODS

269 subjects (105 infected patients, 164 sepsis and septic shock) and 198 healthy controls were enrolled. Laboratory parameters (hematological parameters, coagulation parameters, liver function indices, renal function indices, and inflammatory markers) were collected. Plasma presepsin was tested by chemiluminescence enzyme immunoassay. ML of DxAI™ Research platform was used to establish diagnostic and prognostic models. Sensitivity, specificity, and other performance indicators were used to evaluate the performance of each model.

RESULTS

The level of presepsin was obviously increased in sepsis and sepsis shock, compared with that of infected and healthy group (all P < 0.0001). Presepsin concentration was positively correlated with positive blood culture and 30-day mortality in sepsis and septic shock patients. Through ROC curve analysis, Hb, UREA, APTT, CRP, PCT, and presepsin were incorporated into machine learning to construct diagnosis models. Ada Boost model had the best diagnostic efficiency (AUC: 0.94 (95% CI 0.919-0.968) in the training set and AUC: 0.86 (95% CI 0.813-0.900) in validation set). Furthermore, AST, APTT, UREA, PCT, and presepsin were included in the prognosis ML models, and the Bernoulli NB model had greater predictive ability for 30-day mortality risk of sepsis (AUC: 0.706), which was higher than that of PCT (AUC: 0.617) and presepsin (AUC: 0.634) alone.

CONCLUSION

Machine-learning model based on presepsin and routinely laboratory parameters showed good performance of diagnostic and prognostic ability for sepsis patients.

28-day sepsis mortality prediction model from combined serial interleukin-6, lactate, and procalcitonin measurements: a retrospective cohort study

Sepsis is a global medical issue owing to its unacceptably high mortality rate. Therefore, an effective approach to predicting patient outcomes is critically needed. We aimed to search for a novel 28-day sepsis mortality prediction model based on serial interleukin-6 (IL-6), lactate (LAC), and procalcitonin (PCT) measurements. We enrolled 367 septic patients based on Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock). Serum IL-6, LAC, and PCT levels were measured serially. Results collected within 24 and 48-72 h of admission were marked as D1 and D3 (e.g., IL-6D1/D3), respectively; the IL-6, LAC, and PCT clearance (IL-6c, LACc, PCTc) at D3 were calculated. Data were split into training and validation cohorts (7:3). Logistic regression analyses were used to select variables to develop models and choose the best one according to the Akaike information criterion (AIC). Receiver operating characteristic curves (ROC), calibration plots, and decision curve analysis (DCA) were used to test model performance. A nomogram was used to validate the model. There were 314 (85.56%) survivors and 53 (14.44%) non-survivors. Logistic regression analyses showed that IL-6D1, IL-6D3, PCTD1, PCTD3, and LACcD3 could be used to develop the best prediction model. The areas under the curves (AUC) of the training (0.849, 95% CI: 0.787-0.911) and validation cohorts (0.828, 95% CI: 0.727-0.929), calibration plot, and the DCA showed that the model performed well. Thus, the predictive value of the risk nomogram was verified. Combining IL-6D1, IL-6D3, PCTD1, PCTD3, and LACcD3 may create an accurate prediction model for 28-day sepsis mortality. Multiple-center research with a larger quantity of data is necessary to determine its clinical utility.

Blood purification in sepsis and COVID-19: what´s new in cytokine and endotoxin hemoadsorption

Sepsis and COVID-19 are two clinical conditions that can lead to a dysregulated inflammatory state causing multiorgan dysfunction, hypercytokinemia, and a high risk of death. Specific subgroups of critically ill patients with particular characteristics could benefit from rescue treatment with hemoadsorption. There is a lack of adequately designed randomized controlled trials evaluating the potential benefits of cytokine or endotoxin hemoadsorption. Critically ill COVID-19 patients with severe acute respiratory failure poorly responsive to conventional treatment could be candidates to receive cytokine hemoadsorption in the presence of high levels of interleukin 6. This treatment can also be suitable for patients with refractory septic shock and hypercytokinemia. In the context of high endotoxin activity, hemoadsorption with polymyxin B could improve clinical parameters and the prognosis of patients with refractory septic shock. Predictive enrichment, using biomarkers or other individual features, identifies potential responders to cytokine, endotoxin, or sequential hemoadsorption. Besides, recognizing the particular subsets of patients likely to respond to one or both types of hemoadsorption will aid the design of future studies that accurately validate the effectiveness of these therapies.

Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs

The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.

Precision medicine in sepsis and septic shock: From omics to clinical tools

Sepsis is a heterogeneous disease with variable clinical course and several clinical phenotypes. As it is associated with an increased risk of death, patients with this condition are candidates for receipt of a very well-structured and protocolized treatment. All patients should receive the fundamental pillars of sepsis management, which are infection control, initial resuscitation, and multiorgan support. However, specific subgroups of patients may benefit from a personalized approach with interventions targeted towards specific pathophysiological mechanisms. Herein, we will review the framework for identifying subpopulations of patients with sepsis, septic shock, and multiorgan dysfunction who may benefit from specific therapies. Some of these approaches are still in the early stages of research, while others are already in routine use in clinical practice, but together will help in the effective generation and safe implementation of precision medicine in sepsis.

Nephroprotective effect of apilarnil in lipopolysaccharide-induced sepsis through TLR4/NF-κB signaling pathway

AIMS

In this study, we aimed to investigate the protective effect of apilarnil on kidney damage in the sepsis model induced by LPS.

MAIN METHODS

64 Sprague Dawley adult male rats were randomly divided into eight groups; control group, groups in which 0.2, 0.4 and 0.8 g/kg/bw apilarnil (API) was applied by oral gavage method for 10 days, LPS group in which 30 mg/kg/bw lipopolysaccharide (LPS) administered as intraperitoneally, groups in which LPS + 0.2, LPS+ 0.4 and LPS +0,8 API was applied. Six hour after the last administration the rats were anesthetized for euthanasia and kidney tissues were removed for RT-PCR analysis, immunohistochemical analysis and histopathologic analysis.

KEY FINDING

According to the results of RT-PCR expression levels of IL-6, IL-1β, NF-κB, TNF-α and TLR4 were significantly reduced in the LPS + 0,8 API group. Immunoreactivity of TLR4, pNF-κB and TNF-α levels in the LPS + 0.8 apilarnil group were significantly lower than in the LPS and LPS + 0.2 apilarnil groups. Histologically, compared to the LPS group the glomerular damage score tended to decrease in the LPS + 0,4 API and LPS+ 0,8 API groups, while the tubulointerstitial injury score decreased especially in the LPS + 0,8 API group.

SIGNIFICANCE

In the present study, 0,8 g/kg dose of apilarnil promoted potential renoprotective effects which were achieved, at least in part, by the modulation of important markers of the local immune response in the model of LPS-induced sepsis.

C-Reactive Protein at Hospital Discharge and 1-Year Mortality in Acute Infective Endocarditis: A Prospective Observational Study

Background: An accurate biomarker at hospital discharge is needed to identify patients with acute infective endocarditis (IE) who are at high risk of mortality. This prospective observational study evaluated the prognostic value of C-reactive protein (CRP).

Methods: Patients with acute IE (n = 343) and hospitalized at 2 university-affiliated medical centers from January 2014 to December 2019 were enrolled. Patients were categorized as having low or high CRP (n = 217 and 126, respectively) at hospital discharge according to the optimal cutoff (CRP = 6.5 mg/L) determined via receiver-operating characteristic curve analysis. The primary endpoint was all-cause death, from hospital discharge to 1 year. The secondary endpoint was the cumulative rate of rehospitalization or paravalvular abscess at 1 year.

Results: At the 12-month follow-up, the mortality rate of the high-CRP group (21.43%) was significantly higher than that of the low-CRP group (2.76%, log-rank P < 0.0001). The multivariate regression analysis indicated that the high-CRP group had a higher excess mortality hazard risk (HR = 4.182; 95% CI: 2.120, 5.211; P < 0.001). The cumulative 1-year incidence of paravalvular abscess of the high-CRP group (11.90%) was significantly higher than that of the low-CRP (5.07%; P = 0.022). The cumulative rate of heart rehospitalizations of the 2 groups were similar (18.25% cf. 14.29%, P = 0.273).

Conclusion: For hospitalized patients with acute IE, a high CRP at discharge suggests a poor prognosis for 1-year mortality and paravalvular abscess.

Procalcitonin in clinical practice: from diagnosis of sepsis to antibiotic therapy

A diagnostic algorithm that allows for the rapid identification of sepsis and possibly guides the appropriate antimicrobial therapy application is the cornerstone to obtaining effective treatment and better results. The use of emerging surrogate markers could significantly improve clinical practice, but the validity and clinical utility have been proved only for very few of them, and their availability in clinical routine is limited. For this purpose, numerous scientific evidence has indicated procalcitonin as a marker linked to sepsis and its evolution. This review aims to retrace the main evidence relating to the use of procalcitonin in sepsis. We analyzed the primary studies in the literature and the existing meta-analysis evaluating the behavior of procalcitonin as a marker of bacterial sepsis, its prognostic power, and its ability to influence antibiotic therapy. Recent evidence has suggested that procalcitonin could be an efficient marker for diagnosing sepsis and its therapeutic management in many types of patients. The choice of the appropriate timing to initiate and suspend antibiotic therapy, with obvious clinical advantages, the favorable effects could also include reducing health costs, both avoiding the administration of inappropriate antibiotic therapies, and reducing the duration of hospitalization. Moreover, limited studies reported high procalcitonin levels in coronavirus disease 2019 patients with a worse prognosis. Despite the considerable evidence in favor of the potential of procalcitonin as an index for managing septic patients, there are conflicting data that deserve specific and detailed studies.

Predictive Ability of Preoperative PT-INR and Postoperative MCP1 for Post-hepatectomy Liver Failure

BACKGROUND

We sought a diagnostic tool using perioperative variables that might predict post-hepatectomy liver failure (PHLF).

PATIENTS AND METHODS

In 68 patients undergoing major hepatectomy, data on inflammatory markers and coagulation factors were prospectively collected and were compared between patients with International Study Group of Liver Surgery definition grade B/C PHLF (LF group) and those without LF (non-LF group).

RESULTS

Preoperatively, the LF group (n=9; 13.2%) had a lower platelet count and a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13) activity and a higher prothrombin time-International Normalized Ratio (PT-INR) than the non-LF group. On postoperative day 1, the LF group had significantly higher serum interleukin 6 (IL6), C-C motif chemokine ligand 2 (CCL2), and IL10 levels than the non-LF group. The logistic regression model that included preoperative PT-INR and CCL2 on postoperative day 1 predicted grade B/C PHLF with 100% sensitivity and 89.8% specificity.

CONCLUSION

Our findings suggest that the combination of preoperative PT-INR and CCL2 on postoperative day 1 can predict PHLF earlier and precisely after major hepatectomy.

Should serial monitoring of procalcitonin be done routinely in critically ill patients of ICU: A systematic review and meta-analysis

Sepsis is a life-threatening condition with dysregulated host response to infection. It is a major determinant of mortality in the intensive care unit (ICU). Procalcitonin (PCT) is widely investigated for prognosis in patients with sepsis. Most of the studies have cited that elevated PCT concentrations and PCT non-clearance are associated with poor outcomes in patients with sepsis and some studies have cited as having no additional benefit. Most of the studies have evaluated single PCT measurement and correlated with prognosis and outcome in septic patients. Limited literature is there about serial PCT levels and its impact on the outcome of patients with sepsis. We searched literature through PubMed, Embase, Web of Knowledge, and the Cochrane Library from 2007 to 2017 and present a systematic review and meta-analysis of studies evaluating the utility of serial measurement of PCT for prognosis in critically ill patients. Articles that assessed PCT non-clearance as a marker of mortality data were included. The primary objective of this meta-analysis was to pool the results of all the available studies on serial PCT non-clearance as a mortality predictor and formulate overall area under receiver operating curve (AUROC). To find out the overall proportion of mortality in PCT non-clearance was our secondary objective. To detect the mortality using PCT non-clearance, ROC curve analysis was done. Area under curve (AUC) of the studies was varying between 0.52 and 0.86. Overall AUC was observed 0.711 (95% confidence interval (CI): 0.662–0.760) under fixed effect model and 0.708 (95% CI: 0.648–0.769) under random effect model. There was moderate variation among the studies, i.e., I² 50.80% (95% CI: 0.00–80.42%). The overall proportion of mortality was 37.54% with much heterogeneity (I² 88.24%) among the studies. PCT non-clearance is a fair predictor of mortality. Further studies are needed to define optimal cut off point for PCT non-clearance in ICU patients with sepsis.

Procalcitonin Levels in Post TACE Infection

Purpose

This study aimed to evaluate the value of serum procalcitonin (PCT) levels in the diagnosis of abscess and sepsis following transarterial chemoembolization (TACE) therapy among patients with hepatocellular carcinoma (HCC).

Patients and Methods

In this study, a retrospective review of patient charts was performed in 2221 patients who suffered from hepatocellular carcinoma and had undergone 8656 TACE procedures from January 2012 to January 2018. According to the diagnosis of infection and abscess after TACE, these participants were divided into infection group (group A, n=48) and abscess group (group B, n=35). Group B included subgroup B1 (suffered from liver abscess but no sepsis, n=16) and subgroup B2 (suffered from liver abscess and sepsis, n=19). The main observational indexes included sociodemographic characteristics and laboratory and clinical parameters.

Results

The results showed that the mean PCT and C-reactive protein (CRP) levels were higher in group B, but receiver-operating characteristic (ROC) analysis showed low sensitivity and specificity. Only the mean PCT level was higher in subgroup B2 than in subgroup B1 (P<0.001); the ROC analysis had high sensitivity and specificity. However, all other data such as NEUT (neutrophil count) and NEUTP (neutrophil percentage) showed no significant differences.

Conclusion

Serum PCT level was a promising inexpensive marker for the diagnosis of liver abscess and sepsis following TACE therapy among patients with primary liver cancer. A cutoff level of 5.1 ng/mL for PCT had high sensitivity and specificity in predicting liver abscess with sepsis.

Multiplexed Plasma Immune Mediator Signatures Can Differentiate Sepsis From NonInfective SIRS: American Surgical Association 2020 Annual Meeting Paper

OBJECTIVES

Sepsis and sterile both release "danger signals' that induce the systemic inflammatory response syndrome (SIRS). So differentiating infection from SIRS can be challenging. Precision diagnostic assays could limit unnecessary antibiotic use, improving outcomes.

METHODS

After surveying human leukocyte cytokine production responses to sterile damage-associated molecular patterns (DAMPs), bacterial pathogen-associated molecular patterns, and bacteria we created a multiplex assay for 31 cytokines. We then studied plasma from patients with bacteremia, septic shock, "severe sepsis," or trauma (ISS ≥15 with circulating DAMPs) as well as controls. Infections were adjudicated based on post-hospitalization review. Plasma was studied in infection and injury using univariate and multivariate means to determine how such multiplex assays could best distinguish infective from noninfective SIRS.

RESULTS

Infected patients had high plasma interleukin (IL)-6, IL-1α, and triggering receptor expressed on myeloid cells-1 (TREM-1) compared to controls [false discovery rates (FDR) <0.01, <0.01, <0.0001]. Conversely, injury suppressed many mediators including MDC (FDR <0.0001), TREM-1 (FDR <0.001), IP-10 (FDR <0.01), MCP-3 (FDR <0.05), FLT3L (FDR <0.05), Tweak, (FDR <0.05), GRO-α (FDR <0.05), and ENA-78 (FDR <0.05). In univariate studies, analyte overlap between clinical groups prevented clinical relevance. Multivariate models discriminated injury and infection much better, with the 2-group random-forest model classifying 11/11 injury and 28/29 infection patients correctly in out-of-bag validation.

CONCLUSIONS

Circulating cytokines in traumatic SIRS differ markedly from those in health or sepsis. Variability limits the accuracy of single-mediator assays but machine learning based on multiplexed plasma assays revealed distinct patterns in sepsis- and injury-related SIRS. Defining biomarker release patterns that distinguish specific SIRS populations might allow decreased antibiotic use in those clinical situations. Large prospective studies are needed to validate and operationalize this approach.

The Use of Serum Procalcitonin in the Setting of Infected Ureteral Stones: A Prospective Observational Study

Introduction: Infected ureteral stones are a urologic emergency and require urgent decompression. We set out to determine whether serum procalcitonin (PCT) could aid in the diagnosis of infected ureteral stones. Methods: All consecutive patients presenting to the emergency room from November 9, 2016, to November 10, 2018, with an obstructing ureteral stone were included. All patients had complete blood count, urinalysis (UA), PCT, and urine culture (UCx). Subgroup analysis was performed in a "clinically equivocal" cohort of afebrile patients defined as a leukocytosis >10⁴/μL and UA with <50 white blood cells (WBCs) per high powered field (hpf). Patients with positive and negative UCx were compared. Results: A total of 231 patients were included, of whom 56 had a positive UCx. Of all covariates, UA WBCs with a cutoff of 9 per hpf performed best at predicting positive UCx with an area under the curve (AUC) of 0.87. PCT did not perform as well with an ideal cutoff of 0.08 ng/mL, having an AUC of 0.77, sensitivity 70.6%, specificity 73.9%, positive predictive value (PPV) 34.3%, and negative predictive value (NPV) 92.9%. When looking at the clinically equivocal cohort, UA WBCs with a cutoff of 6 per hpf appeared to perform best at predicting a positive UCx with an AUC of 0.72. PCT was less predictive in this cohort with an ideal cutoff of 0.3 ng/mL, having an AUC of 0.32, sensitivity 47.1%, specificity 85.2%, PPV 38.1%, and NPV 89.3%. Conclusion: PCT does not appear to be a superior marker for diagnosing urinary tract infection in the setting of obstructing ureterolithiasis when compared with components of the standard work-up.

Biomarkers and newer laboratory investigations in the diagnosis of sepsis

Sepsis is a major cause of death in hospitalised patients accounting for mortality rates as high as 60% and, hence, is called 'a hidden public health disaster'. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis is not a disease but is a clinical syndrome, where the initial features are nonspecific resulting in delayed diagnosis. Lack of specific laboratory tests to diagnose the syndrome adds to the diagnostic confusion. Failure to identify sepsis in the early stages itself delays effective treatment resulting in high morbidity and mortality. Various biomarkers and newer laboratory tests help to address these issues. However, to date there is no ideal test to diagnose sepsis. The most commonly used markers are C-reactive protein (CRP) and procalcitonin (PCT). There are around 180 biomarkers reported to be useful in sepsis. In addition to CRP and PCT, various emerging laboratory markers, such as like serum amyloid A, soluble triggering receptor expressed on myeloid cell-1, mannan and antimannan antibodies, and interferon γ inducible protein-10 etc., have been reviewed and their clinical usefulness discussed in this paper.

Cytokine Levels in Critically Ill Children With Severe Sepsis and Their Relation With the Severity of Illness and Mortality

OBJECTIVE

To study the baseline cytokine levels and their relation with the severity of illness and mortality in critically ill children with severe sepsis.

DESIGN

Subgroup analysis of a randomized, double-blind, placebo-controlled trial.

SETTING

Pediatric intensive care unit of a tertiary level teaching hospital in India.

PATIENTS

Fifty children with severe sepsis aged 3 months to 12 years.

MATERIAL AND METHODS

Blood was collected at admission for estimation of pro-inflammatory (interleukin 6 [IL-6], IL-12p70, IL-17, and tumor necrotic factor α [TNF-α]) and anti-inflammatory (IL-10 and transforming growth factor β1 [TGF-β1]) cytokines.

PRIMARY OUTCOME

To find out correlation between cytokine levels and severity of illness scores (Pediatric Risk of Mortality [PRISM] III score, Sequential Organ Failure Assessment [SOFA], and Vasoactive-Inotropic Score [VIS]).

SECONDARY OUTCOMES

To compare cytokine levels among survivors and nonsurvivors.

RESULTS

Baseline pro-inflammatory cytokine levels (median [interquartile range]) were IL-6: 189 (35-285) pg/mL, IL-12p: 48 (28-98) pg/mL, IL-17: 240 (133-345) pg/mL, and TNF-α: 296 (198-430) pg/mL; anti-inflammatory cytokine levels were IL-10: 185 (62-395) pg/mL and TGF-β1: 204 (92-290) ng/mL. Pro-inflammatory cytokines showed positive correlation with PRISM III score: IL-6 (Spearman correlation coefficient, ρ = 0.273, P = .06), IL-12 (ρ = 0.367, P = .01), IL-17 (ρ = 0.197, P = .17), and TNF-α (ρ = 0.284, P = .05), and anti-inflammatory cytokines showed negative correlation: IL-10 (ρ = -0.257, P = .09) and TGF-β (ρ = -0.238, P = .11). Both SOFA and VIS also showed weak positive correlation with IL-12 (ρ = 0.32, P = .03 and ρ = 0.31, P = .03, respectively). Among nonsurvivors (n = 5), the levels of all the measured pro-inflammatory cytokines were significantly higher as compared to survivors, IL-6: 359 (251-499) pg/mL versus 157 (97-223) pg/mL, P < .0001, IL-12p70: 167 (133-196) pg/mL versus 66 (30-100) pg/mL, P < .0001, IL-17: 400 (333-563) pg/mL versus 237 (122-318) pg/mL, P = .009, and TNF-α: 409 (355-503) pg/mL versus 330 (198-415) pg/mL, P = .002, respectively.

CONCLUSION

In critically ill children with severe sepsis, pro-inflammatory cytokines (especially IL-12p70) showed a weak positive correlation with severity of illness and were significantly higher among nonsurvivors.

The utility of fibrinogen level as a predictor of complications after laparoscopic gynecologic surgery: a prospective observational study

Background

Complications after laparoscopic gynecological surgery may increase patients’ morbidity and mortality; therefore, their timely diagnosis and early treatment would help clinicians to avoid life-threatening situations. We aimed to evaluate the predictive role of fibrinogen for diagnosing complications after laparoscopic gynecologic surgery for benign and malignant conditions.

Patients and methods

All patients who underwent elective laparoscopic gynecologic surgery between June 2013 and December 2017 at the Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, Cagliari, were prospectively included. Post-operative complications were assessed and graded according to the Clavien-Dindo classification. Fibrinogen and white blood cell level were determined preoperatively, on the first post-operative day and at the appearance of symptoms indicative of an irregular post-operative course or at the time of re-hospitalization for persistent symptoms. The postoperative changes (calculated from the first postoperative day) were correlated with the occurrence and severity of complications and their predictive role was assessed.

Results

We enrolled 1016 patients: 36% underwent surgery for benign pathologies (mainly voluminous fibromatous uteri and severe deep endometriosis) and 64% for gynecologic malignancies. The overall complication rate was of 3.45%, the rate of major postoperative complications was 2.85%. A postoperative fibrinogen increase ≥ 20% had a high diagnostic accuracy to identify postoperative complications early (AUC 0.931, sensitivity 89%, and specificity 99%). The magnitude of postoperative fibrinogen change was associated with complication severity.

Conclusions

Our findings demonstrated that fibrinogen increase can enable the early detection of postoperative complications after laparoscopic gynecological surgery. Further prospective and multi-center studies are warranted to confirm these results.

The Pathogenesis of Sepsis and Potential Therapeutic Targets

Sepsis is defined as “a life-threatening organ dysfunction caused by a host’s dysfunctional response to infection”. Although the treatment of sepsis has developed rapidly in the past few years, sepsis incidence and mortality in clinical treatment is still climbing. Moreover, because of the diverse manifestations of sepsis, clinicians continue to face severe challenges in the diagnosis, treatment, and management of patients with sepsis. Here, we review the recent development in our understanding regarding the cellular pathogenesis and the target of clinical diagnosis of sepsis, with the goal of enhancing the current understanding of sepsis. The present state of research on targeted therapeutic drugs is also elaborated upon to provide information for the treatment of sepsis.

Neutrophil-lymphocyte ratio and plasma lactate predict 28-day mortality in patients with sepsis

OBJECTIVE

The predictive potential of the neutrophil-to-lymphocyte ratio (NLR) and plasma lactate was investigated in regard to the prognosis of patients with sepsis.

METHODS

Sixty-three nonsurgical and nontrauma adult patients with sepsis admitted to the intensive care unit (ICU) from September 2016 to October 2018 were consecutively included in the study. In addition, healthy subjects were assigned to a control group. Neutrophil and lymphocyte counts were evaluated via a complete blood count. Plasma lactate, procalcitonin (PCT), and C-reactive protein (CRP) levels were measured. The main outcome was 28-day mortality.

RESULTS

Neutrophil-to-lymphocyte ratio and plasma lactate levels of the patients were significantly higher than those of control subjects: 19.44 (14.3-34.53) vs 14.09 (8.17-28.99), P = 0.049; and 3.7 (3-6.6) vs 2.72 (2.13-4.3) ng/mL, P = 0.008, respectively. There were no statistical differences in the concentrations of PCT and CRP between nonsurvivors and survivors: 6.1 (3.43-33.59) vs 9.43 (4.24-37.68) ng/mL, P = 0.44; and 108 (77.8-153) vs 114.5 (71.43-162) ng/mL, P = 0.672, respectively. With an optimal cutoff of 14.08, the sensitivity and specificity of NLR for prediction of 28-day mortality were 78.3% and 50%, respectively. And the sensitivity and specificity of plasma lactate level to predict 28-day mortality, at an optimal cutoff value of 2.99 mmol/L, were 82.6% and 55%, respectively.

CONCLUSIONS

Neutrophil-to-lymphocyte ratio and plasma lactate were associated with poor outcomes in patients with sepsis and predicted mortality.

Association between Tumor Necrosis Factor-α Promoter -308 G/A Polymorphism and Early Onset Sepsis in Preterm Infants

Early-onset neonatal sepsis (EOS) is diagnosed during the first 7 days of neonatal life and is the major cause of morbidity and mortality among preterm infants. Genetic predisposition may have an impact on EOS susceptibility and outcome. The aim of our study was to explore the association between TNF-α -308 G/A or IL-6 -174 G/C gene polymorphism and the susceptibility and outcome of EOS in preterm infants. The study included 471 preterm infants: 282 with EOS (151 with culture proven sepsis and 131 with clinical sepsis) and 189 without infection (control group). TNF-α -308 G/A and IL-6 -174 G/C were genotyped using Real-time RCR method. We observed significantly higher frequency of A allele of TNF-α -308 G/A polymorphism in blood culture proven EOS (p = 0.017) or clinical EOS (p = 0.025) compared with the control group. Logistic regression confirmed significant association between TNF-α -308 GA+AA genotypes and development of culture proven EOS (B = -0.718, p = 0.013) or clinical EOS (B = -0.602, p = 0.027). No significant differences in IL6 -174G/C alleles or genotypes distribution have been observed between culture proven EOS group, clinical EOS group and the control group. An association between TNF-α -308 G/A or IL-6 -174 G/C genotypes and EOS lethal outcome was not observed (p = 0.652 and p = 0.384, respectively). According to our analysis of large cohort of preterm infants with clearly defined EOS groups, the TNF-α -308 A allele may be a risk factor for the EOS occurrence.

Role of red blood cell distribution width in predicting the prognosis of patients with sepsis

Background:

Sepsis is a dangerous disease with rapid development and high mortality rate, which is an important cause of death for critically ill patients. Therefore, timely and accurate assessment of patients’ condition is beneficial to improve prognosis and reduce mortality.

Objective:

This study was designed to investigate the potential correlation between red blood cell distribution width and 28-day prognosis of patients with sepsis.

Methods:

A prospective observational study enrolling 236 patients with sepsis or septic shock was performed at our hospital. All cases were divided into survival versus non-survival group on 28th day after diagnosis. The two groups were compared for general condition, underlying diseases, quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II score, C-reactive protein, procalcitonin, and red blood cell distribution width at admission.

Results:

The red blood cell distribution width level in non-survivors was higher than that in survivors (16.3 ± 2.8 vs 15.2 ± 1.7, p = 0.013). Cox regression analysis indicated that red blood cell distribution width was an independent predictor for 28-day mortality (hazard ratio: 1.311, 95% confidence interval: 1.119–3.011, p = 0.018). The red blood cell distribution width cutoff value of red blood cell distribution width for 28-day mortality was 16.1%, while patients with lower red blood cell distribution width levels had a better prognosis as demonstrated by Kaplan–Meier survival curves (log-rank = 7.398, p = 0.007). Unlike the septic shock group, in the sepsis group, the red blood cell distribution width level was higher in the non-survival group compared to the survival group (15.82% ± 0.93% vs 15.01% ± 0.89%, p < 0.001).

Conclusion:

Increased red blood cell distribution width may be an important predictor of disease progression and prognosis in patients with sepsis and septic shock. In the sepsis group, higher red blood cell distribution width levels predict poor prognosis.

Evaluation of a novel prognostic score based on thrombosis and inflammation in patients with sepsis: a retrospective cohort study

BACKGROUND

Inflammation and thrombosis are involved in the development and progression of sepsis. A novel thrombo-inflammatory prognostic score (TIPS), based on both an inflammatory and a thrombus biomarker, was assessed for its ability to predict adverse outcomes of sepsis patients in the emergency department (ED).

METHODS

This was a retrospective cohort study of sepsis patients. TIPS (range: 0-2) was predictive of adverse outcomes. Multivariable logistic regression analyses were performed to investigate the associations between TIPS and 28-day adverse outcomes. The study end points were mortality, mechanical ventilation (MV), consciousness disorder (CD) and admission to the intensive care unit (AICU).

RESULTS

In total, 821 sepsis patients were enrolled; 173 patients died within the 28-day follow-up period. Procalcitonin and D-dimer values were used to calculate TIPS because they had the best performance in the prediction of 28-day mortality by receiver operating characteristic curves. The 28-day mortality and the incidence of MV, CD and AICU were significantly higher in patients with higher TIPS. Multivariable logistic regression analysis indicated TIPS was an independent predictor of 28-day mortality, MV and AICU. TIPS performed better than other prognostic scores, including quick sequential organ failure assessment, Modified Early Warning Score and Mortality in Emergency Department Sepsis Score for predicting 28-day mortality, and similar to the Acute Physiology and Chronic Health Evaluation II, but inferior to sequential organ failure assessment.

CONCLUSIONS

TIPS is useful for stratifying the risk of adverse clinical outcomes in sepsis patients shortly after admission to the ED.

Is Interleukin-6 a better predictor of successful antibiotic therapy than procalcitonin and C-reactive protein? A single center study in critically ill adults

Background

The aim of this study was to evaluate whether Interleukin-6 (IL-6) could be a faster indicator of treatment success in adults with severe sepsis and septic shock compared to procalcitonin (PCT) and C-reactive protein (CRP).

Methods

Data from adult patients with severe sepsis and septic shock managed at the medical intensive care unit (ICU) of the University Hospital Leipzig between September 2009 and January 2012 were analyzed retrospectively. Values for CRP, PCT and IL-6 on admission as well as after 24 and 48–72 h were collected. Antibiotic therapy was defined as clinically successful if the patient survived ICU stay.

Results

A total of 328 patients with severe sepsis and septic shock with adequate data quality were included. After 48–72 h, the median IL-6 was significantly lower in survivors than in non-survivors (114.2 pg/ml vs. 746.6 pg/ml; p < 0.001), while there was no significant difference for PCT (5.6 vs. 4.9 ng/ml; p = 0.586) and CRP (158.5 mg/l vs. 172.4 mg/l; p = 0.988).

Conclusions

The results of this study suggest that IL-6 is better than PCT and CRP in predicting the treatment success in predominantly non-surgical sepsis in the first 48–72 h.

APRIL and sTACI could be predictors of multiorgan dysfunction syndrome in sepsis

Although the role of B cells in sepsis immunoregulation has become an interesting topic, there is lack of data on the role of B cell function regulators in prediction of multiorgan dysfunction syndrome (MODS). The aim of this study was to evaluate the prognostic value of A Proliferation Inducing Ligand (APRIL) and soluble Transmembrane Activator and CAML Interactor Protein (sTACI), the main B cell function regulators, in prediction of MODS development within the first 48 h after admission to intensive care unit, among septic patients. We included 112 patients with sepsis, treated at Clinic for Infectious Diseases and Emergency Center, Clinical Center of Vojvodina, Novi Sad, Serbia. Plasma concentrations of APRIL and sTACI were determined at the admission and potential development of MODS was confirmed in the first 48 h. Concentrations of APRIL (p = 0.003) and sTACI (p<0.001) were higher in patients who developed MODS (n = 30). ROC curve analysis showed that AUC for sTACI (AUC = 0.764) was greater than that for procalcitonin (AUC = 0.719) and APRIL (AUC = 0.673) in MODS development prediction. Multivariate regression analysis showed that sTACI, as an anti-inflammatory biomarker stimulating the apoptosis of B cells, was the only independent predictor of MODS, beside SOFA score. Elevated level of sTACI could be the alarm for the increased B cell apoptosis and development of immune paralysis. Including these biomarkers into predictive scores specific for septic patients may potentially improve their sensitivity and specificity. Measurement of their concentrations dynamics could contribute to better assessment of sepsis evolution and timely introduction of immunomodulatory therapy.

Recent advances in biosensors for diagnosis and detection of sepsis: A comprehensive review

Sepsis is one of the leading causes of mortality among critically ill patients globally. According to WHO report 2018, it is estimated to affect beyond 30 million people worldwide every year. It causes loss of human lives, which arise from infection and inflammation and long term stay in intensive care unit (ICU) in hospitals. Despite the availability of satisfactory prognostic markers contributing to the diagnosis of sepsis, millions of people die even after admission to the hospitals. Correct and early diagnosis of sepsis leads to rapid administration of appropriate antibiotics can thus potentially avert the attainment to critical stages of sepsis, thereby saving human lives. Conventional diagnostic practices are costly, time consuming and they lack adequate sensitivity and selectivity, provoking an urgent need for developing alternate sepsis diagnosis systems. Nevertheless, biosensors have the much-treasured scope for reasonable sepsis diagnosis. Advancement in nano-biotechnology has provided new paradigm for biosensor platforms with upgraded features. Here, we provide an overview of the recent advances in biosensors with a brief introduction to sepsis, followed by the conventional methods of diagnosis and bio-sensing. To conclude, a proactive role and an outlook on technologically advanced biosensor platforms are discoursed with possible biomedical applications.

Impact of human sepsis on CCCTC-binding factor associated monocyte transcriptional response of Major Histocompatibility Complex II components

Background

Antigen presentation on monocyte surface to T-cells by Major Histocompatibility Complex, Class II (MHC-II) molecules is fundamental for pathogen recognition and efficient host response. Accordingly, loss of Major Histocompatibility Complex, Class II, DR (HLA-DR) surface expression indicates impaired monocyte functionality in patients suffering from sepsis-induced immunosuppression. Besides the impact of Class II Major Histocompatibility Complex Transactivator (CIITA) on MHC-II gene expression, X box-like (XL) sequences have been proposed as further regulatory elements. These elements are bound by the DNA-binding protein CCCTC-Binding Factor (CTCF), a superordinate modulator of gene transcription. Here, we hypothesized a differential interaction of CTCF with the MHC-II locus contributing to an altered monocyte response in immunocompromised septic patients.

Methods

We collected blood from six patients diagnosed with sepsis and six healthy controls. Flow cytometric analysis was used to identify sepsis-induced immune suppression, while inflammatory cytokine levels in blood were determined via ELISA. Isolation of CD14⁺⁺ CD16^—monocytes was followed by (i) RNA extraction for gene expression analysis and (ii) chromatin immunoprecipitation to assess the distribution of CTCF and chromatin modifications in selected MHC-II regions.

Results

Compared to healthy controls, CD14⁺⁺ CD16^—monocytes from septic patients with immune suppression displayed an increased binding of CTCF within the MHC-II locus combined with decreased transcription of CIITA gene. In detail, enhanced CTCF enrichment was detected on the intergenic sequence XL9 separating two subregions coding for MHC-II genes. Depending on the relative localisation to XL9, gene expression of both regions was differentially affected in patients with sepsis.

Conclusion

Our experiments demonstrate for the first time that differential CTCF binding at XL9 is accompanied by uncoupled MHC-II expression as well as transcriptional and epigenetic alterations of the MHC-II regulator CIITA in septic patients. Overall, our findings indicate a sepsis-induced enhancer blockade mediated by variation of CTCF at the intergenic sequence XL9 in altered monocytes during immunosuppression.

Streptococcal M1 protein induces hyporesponsiveness and cytokine release from human arteries in a fibrinogen-dependent manner: a translational study

BACKGROUND

Streptococcus pyogenes is a Gram positive bacterial species commonly involved in sepsis. Invasive strains express virulence factors such as the M1 protein. M1 protein forms complexes with fibrinogen leading to a cytokine storm in plasma contributing to the development of septic shock and organ failure. In experimental animals M1 protein causes vascular nitric oxide production and hyporesponsiveness to pressors, but it is not known whether it affects the human vascular wall.

METHODS

Human omental arteries obtained during surgery were incubated in vitro with M1 protein or lipopolysaccharide (LPS) as positive control, with or without plasma. After 48 h, contractile response to noradrenaline was measured, and levels of nitrite/nitrate and the cytokines interleukin (IL)-1β, IL-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α in the incubation medium were measured. A second set of arteries were incubated with or without main components of plasma (immunoglobulin G, albumin or fibrinogen), in the presence of M1 protein followed by cytokine measurement.

RESULTS

Artery segments incubated with M1 protein and plasma contracted weaker in response to noradrenaline, and levels of IL-6 and IL-8 were significantly higher compared to after incubation with M1 protein alone. Incubation with M1 protein and fibrinogen resulted in elevated levels of IL-6 and IL-8, while incubation with M1 protein and albumin or immunoglobulin G did not affect the levels. Neither any of the other cytokines nor nitrite/nitrate was detected in the medium in any of the incubation conditions.

CONCLUSIONS

The study shows that M1 protein of Streptococcus pyogenes has a direct effect on the human vascular wall in the presence of plasma, demonstrated both as a diminished contractile response to noradrenaline and increased cytokine production. The effect of plasma was attributed to fibrinogen. The findings suggest that M1 protein contributes to the development of septic shock through impairment of the contractility of the vascular wall.

Outcomes of Infant Cardiac Surgery for Congenital Heart Disease Concomitant With Persistent Pneumonia: A Retrospective Cohort Study

OBJECTIVES

There is still controversy about whether an infant should have cardiac surgery concomitant with ongoing persistent pneumonia. This study analyzes the outcome of surgical treatment for infants with left-to-right shunt congenital heart disease accompanied with persistent pneumonia and discusses the perioperative management strategies for these cases.

DESIGN

This is a retrospective cohort study.

SETTING

This study was conducted in an academic hospital and is a single-center study.

PARTICIPANTS

In this study, the authors analyzed the data of 94 infants admitted to our hospital from January 2014 to May 2016 who underwent surgical correction for left-to-right shunt congenital heart disease.

INTERVENTIONS

Fifty cases without pneumonia were included as a control group, and 44 cases with unresolved persistent pneumonia were included as a study group. The clinical characteristics between the 2 groups were compared, and the perioperative safety and short-term prognosis were evaluated.

MEASUREMENTS AND MAIN RESULTS

There was no significant difference in sex composition between the 2 groups. Infants in the pneumonia group were younger and had a lower body weight (p < 0.001). There was a significant difference in types of congenital heart disease between the 2 groups (p < 0.001). Preoperative body temperature and heart rate of infants in the pneumonia group were higher than those in the control group (p < 0.001). The cardiopulmonary bypass time in the pneumonia group was significantly longer than that of the control group (p = 0.001). Perioperative major complications were not significantly different between the 2 groups. The postoperative ventilator-assisted time, duration of intensive care unit stay, and length of hospital stay were longer in the pneumonia group (p < 0.001). Only 1 patient in the control group died of severe low cardiac output syndrome.

CONCLUSION

The authors conclude that in the presented cases, no mortality or major morbidity was observed related to the practice of performing surgery in infants with signs of persistent pneumonia. The authors conclude that it is likely to be safe and effective for infants to receive cardiac surgery for left-to-right shunt congenital heart disease in the presence of persistent pneumonia.

A Sustained Reduction in Serum Cholinesterase Enzyme Activity Predicts Patient Outcome following Sepsis

Early sepsis identification is of paramount importance for an effective therapy and the patient outcome; however, a suitable prognostic biomarker is lacking. Anti-inflammatory nonneuronal cholinergic signaling modulates the magnitude of an immune response. Serum cholinesterase (BChE), an enzyme that hydrolyzes acetylcholine, plays an important role during inflammatory response and serves as an accurate index of cholinergic activity. BChE activity was measured in septic patients using a point-of-care system, and levels of conventional inflammatory markers and the disease severity scores were obtained. We observed a strong, sustained reduction in BChE activity in patients who died within a 90-day observation period, as compared to survivors. Reduced BChE activity when measured at the ICU admission effectively differentiated between the 90-day survivor and the nonsurvivor patient groups. We estimated a critical BChE level of 1.661 kU/L (CI 0.5–0.8, 94% sensitivity, 48% specificity, AUC 0.7) to best predict patient outcome providing a benchmark criterion for early detection of potentially fatal sepsis measured at the admission. This finding suggests that the BChE activity, used in combination with the laboratory tests, clinical examination, and the disease severity scoring, could serve to identify high-risk patients at the ICU admission, the most critical time point in the sepsis treatment.

Predictive utilities of neutrophil gelatinase-associated lipocalin (NGAL) in severe sepsis

BACKGROUND

We aim to investigate the predictive value of plasma neutrophil gelatinase-associated lipocalin (pNGAL) in patients with severe sepsis.

METHODS

A total of 124 patients were enrolled in this observational study. Blood samples were obtained at admission, on day 2 and day 7. Receiver operating characteristic (ROC) curves were generated to assess the utility of pNGAL in prediction of 28-day mortality and need for CRRT. Cox regression curves were built with and without pNGAL for 28-day mortality prediction to determine NGAL's contributive predictive value.

RESULTS

Plasma NGAL was significantly increased in non-survivors group on day 2 and 7 and predicted 28-day mortality with AuROC values of 0.675 (95% CI 0.570-0.780) and 0.752 (95% CI 0.619-0.885). Addition of day 2 NGAL to the clinical model resulted in a net reclassification index (NRI) increment of 0.40 (95% CI 0.06-0.75, P = 0.028) for prediction of 28-day mortality. The AuROC of NGAL at admission and day 2 was greater than creatinine in prediction of the need for CRRT.

CONCLUSION

Plasma NGAL discriminated 28-day survivors from non-survivors on day 2 and 7 and was a relatively robust predictor of 28-day mortality prediction. Plasma NGAL possibly outperformed creatinine in the prediction of need for CRRT.

Interleukin-6 Levels Act as a Diagnostic Marker for Infection and a Prognostic Marker in Patients with Organ Dysfunction in Intensive Care Units

INTRODUCTION

There are significant unmet requirements for rapid differential diagnosis of infection in patients admitted to intensive care units. Serum levels of interleukin-6 (IL-6), procalcitonin (PCT), presepsin, and C-reactive protein (CRP) are measured in clinical practice; however, their clinical utility in patients with organ dysfunction has not been tested adequately. Thus, we investigated the diagnostic and prognostic value of IL-6, PCT, presepsin, and CRP in critically ill patients who had organ dysfunction with suspicion of infection.

METHODS

In 100 consecutive critically ill patients with organ dysfunction and suspected infection, serum levels of IL-6, PCT, presepsin, and CRP were measured upon suspicion of infection and serially every other day up to 7 days (cohort 1). The primary outcome variable was the presence of infections. The diagnostic value of IL-6 was further tested in cohort 2 (n = 72, case-control matched). The secondary outcome variables were the sequential organ failure assessment (SOFA) score, serum creatinine levels, and 28-day mortality.

RESULTS

Among the four biomarkers, serum IL-6 levels had the highest area under the curve (AUC) value of 0.824 (95% confidence interval [CI] 0.735-0.913) for diagnosing infection in critically ill patients with organ dysfunction and suspected infection in cohort 1 (AUC [95% CI] for the other biomarkers: PCT, 0.813 [0.714-0.911]; CRP, 0.764 [0.645-0.883]; presepsin, 0.681 [0.513-0.849]). In cohort 2, the sensitivity and specificity of IL-6 for diagnosing infection were 0.861 and 0.806, respectively. The presepsin levels were significantly correlated with the SOFA score and serum creatinine levels upon suspicion of infection (r > 0.5), especially serum creatinine levels in the patients without infection (r = 0.789). Serum IL-6 levels were significant predictors of 28-day mortality. The AUC value of serum IL-6 levels for 28-day mortality increased over time; the serum IL-6 levels on Day 7 had the highest AUC value of 0.883 (95% CI, 0.788-0.978) for 28-day mortality.

CONCLUSION

Among serum IL-6, PCT, presepsin, and CRP levels, serum IL-6 levels had the highest diagnostic value for infection. They were also significant predictors of 28-day mortality. Hence, they may improve diagnosis of infection and prediction of 28-day mortality in critically ill patients with organ dysfunction.

[Postoperative C-reactive protein is a reliable marker to detect complications after radical cystectomy]

PURPOSE

Postoperative serum C-reactive protein (CRP) can be measured after major abdominal surgery to predict of complications at postoperative day (POD) 4. However, in urology, no studies have been conduced to analyze the role of CRP after radical cystectomy. The present study aims to analyze the relationship between a high postoperative level of CRP and the presence of complications after radical cystectomy for cancer.

MATERIALS AND METHODS

This multicenter retrospective study included 313 patients treated with radical cystectomy for cancer between January 2013 and July 2016. Among the patients, 57.5% of patients received urinary diversion using a Bricker ileal conduit, 30.5% an orthotropic ileal neobladder, and 11.5% had an ureterocutaneostomy.

RESULTS

Three hundred and thirteen patients were included (mean age 68.1±9.2 years). Among the patients, 26.5% had grade≥2 complications, according to the Clavien-Dindo classification. In multivariate analysis, only CRP level at POD 4 predicted the risk of a complication (P<0.001). CRP>150mg/L at POD 4 was strongly associated with a risk of a postoperative complication after a cystectomy (OR=81.42, 95% CI [25.6-258.3], P<0.001). CRP assessed on POD4 was reliable at ruling out the existence of an infectious complications with a negative predictive value of 0.94. The main limitation of our study was it observational design.

CONCLUSIONS

CRP at POD4 with a threshold of 150mg/L would reliably predict the risk of postoperative complications after cystectomy. Monitoring postoperative CRP could help adapt rehabilitation protocols after radical cystectomy and also the early management of complications.

B-Type Natriuretic Peptide: A Predictor for Mortality, Intensive Care Unit Length of Stay, and Hospital Length of Stay in Patients With Resolving Sepsis

Background

B-type natriuretic peptide (BNP) is a hormone secreted by cardiomyocytes in response to myocardial ischemia, increased ventricular wall tension, and overload. BNP is utilized as a diagnostic and prognostic marker in congested heart failure (CHF). Its prognostic value in sepsis is unknown. The aim of this study is to determine if BNP correlates with increased in-hospital mortality for septic patients.

Methods

This was a retrospective study of 505 patients admitted for sepsis or severe sepsis or septic shock during the period of January 2013 and August 2014. Patients that received > 3 L of intravenous fluids on presentation were included. Intensive care unit length of stay (ICULOS), hospital length of stay (HLOS) and in-hospital mortality were measured. Mean BNP level was calculated and compared to ICULOS and HLOS and in-hospital mortality. Controlled variables included ejection fraction (measured by echocardiogram within 6 months of presentation), glomerular filtration rate (calculated by Cockroft-Gault equation), patient demographics, and lactic acid trends. Exclusion criteria were no echocardiogram within 6 months of admission, no BNP levels on admission, and no repeat lactate or rising lactate levels within 24 h to indicate worsening sepsis.

Results

Patients’ mean BNP with in-hospital mortality was 908 pg/mL as compared to mean BNP of 678 pg/mL in survivors. T-test comparisons were statistically significant (P = 0.0375). The Kaplan-Meier curve for BNP as a predictor for in-hospital mortality showed that for the first 25 days, patients with BNP higher than 500 pg/mL had a higher mortality than patients with BNP lower than 500 pg/mL. When comparing HLOS, there is a statistically significant correlation (P = 0.0046). A similar scatter plot was prepared for ICULOS which showed there was a weak positive correlation (r = 0.199).

Conclusion

Septic patients with in-hospital mortality had an average BNP of 908 pg/mL and statistically significant higher HLOS.

Curcumin suppresses inflammatory cytokines and heat shock protein 70 release and improves metabolic parameters during experimental sepsis

CONTEXT

Curcumin has been reported to have anti-inflammatory, antioxidant and hypoglycaemic properties, besides reducing mortality in sepsis.

OBJECTIVE

This study evaluates the biological activities of a curcumin dispersion formulated by spray-drying in experimental sepsis.

MATERIALS AND METHODS

Male Wistar rats were subjected to sepsis by caecal ligation and puncture (CLP), controls were sham operated. The animals were treated with curcumin dispersion (100 mg/kg, p.o.) or water for 7 days prior to CLP and at 2 h after surgery. One group was used to analyze curcumin absorption through HPLC; another had the survival rate assessed during 48 h; and from a third group, blood was collected by decapitation to analyze metabolic and inflammatory parameters.

RESULTS

The plasma curcumin levels reached 2.5 ng/mL at 4 h, dropped significantly (p < 0.001) at 6 h (1.2 ng/mL), and were undetectable at 24 h in both groups. Curcumin temporarily increased the survival rate of the septic rats by 20%. Moreover, it attenuated glycaemia (p < 0.05) and volemia (p < 0.05) alterations typically observed during sepsis, and decreased the levels of the proinflammatory cytokines IL-1β and IL-6 in plasma (p < 0.001) and peritoneal lavage fluid (p < 0.05) of septic rats. Serum HSP70 levels were decreased (p < 0.01) at 24 h after CLP.

DISCUSSION AND CONCLUSION

Our results show that the curcumin dispersion dose employed was not detrimental to the septic rats. In fact, it temporarily increased their survival rate, improved important metabolic parameters, reduced proinflammatory cytokines and HSP70 production.

The risk stratification and prognostic evaluation of soluble programmed death-1 on patients with sepsis in emergency department

OBJECTIVE

To evaluate the efficacy of soluble programmed death-1 (sPD-1) for risk stratification and prediction of 28-day mortality in patients with sepsis, we compared serum sPD-1 with procalcitonin (PCT), C-reactive protein (CRP), and the Mortality in Emergency Department Sepsis (MEDS) score.

METHODS

A total of 60 healthy volunteers and 595 emergency department (ED) patients were recruited for this prospective cohort study. According to the severity of their condition on ED arrival, the patients were allocated to the systemic inflammatory response syndrome group (130 cases), sepsis group (276 cases), severe sepsis group (121 cases), and septic shock group (68 cases). In addition, all patients with sepsis were also divided into the survivor group (349 cases) and nonsurvivor group (116 cases) according to the 28-day outcomes.

RESULTS

When the severity of sepsis increased, the levels of sPD-1 gradually increased. The levels of sPD-1, PCT, CRP and the MEDS score were also higher in the nonsurvivor group compared to the survivor group. Logistic regression suggested that sPD-1, PCT, and the MEDS score were independent risk factors for 28-day mortality of patients with sepsis. Area under the curve (AUC) of sPD-1, PCT and the MEDS score for 28-day mortality was 0.725, 0.693, and 0.767, respectively, and the AUC was improved when all 3 factors were combined (0.843).

CONCLUSION

Serum sPD-1 is positively correlated with the severity of sepsis, and it is valuable for risk stratification of patients and prediction of 28-day mortality. Combining sPD-1 with PCT and the MEDS score improves the prognostic evaluation.

Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference

This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.

C-Reactive Protein Was an Early Predictor of Postoperative Infectious Complications After Pancreaticoduodenectomy for Pancreatic Cancer

Objective

The study objective was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications (PICs) after pancreaticoduodenectomy.

Summary of Background Data

The incidence of PICs after pancreaticoduodenectomy still remains high and a clinically relevant problem, despite improvements in the surgical procedure.

Methods

We examined 110 consecutive patients who underwent pancreaticoduodenectomy for primary pancreatic cancer between 2006 and 2014. The predictive value was assessed by estimating the area under the receiver operating characteristic curve (AUC). Clinical and laboratory data, including CRP, were analyzed with univariate and multivariate logistic regression analyses to identify predictors of PICs of grade III or higher according to the Clavien-Dindo classification.

Results

PICs of grade III or higher occurred in 13 patients [11.8%; 95% confidence interval (CI), 6.45%–19.36%]. CRP level on postoperative day 3 (POD 3) was a good predictor of PICs (AUC, 0.815; 95% CI, 0.651–0.980), showing the highest accuracy among clinical and laboratory data. A cutoff value of 13.2 mg/dL yielded a sensitivity of 0.846 and a specificity of 0.794. On multivariate analysis, a POD 3 CRP level of 13.2 mg/dL or higher (odds ratio, 20.0; 95% CI, 4.07–97.9; P = 0.002) was a significant predictor of PICs after pancreaticoduodenectomy.

Conclusions

CRP elevation above 13.2 mg/dL on POD 3 is a significant predictive factor for PICs and should prompt an intense clinical search and therapeutic approach for PICs.

Sepsis and septic shock: Pathogenesis and treatment perspectives

The majority of bacteremias do not develop to sepsis: bacteria are cleared from the bloodstream. Oxygen released from erythrocytes and humoral immunity kill bacteria in the bloodstream. Sepsis develops if bacteria are resistant to oxidation and proliferate in erythrocytes. Bacteria provoke oxygen release from erythrocytes to arterial blood. Abundant release of oxygen to the plasma triggers a cascade of events that cause: 1. oxygen delivery failure to cells; 2. oxidation of plasma components that impairs humoral regulation and inactivates immune complexes; 3. disseminated intravascular coagulation and multiple organs' failure. Bacterial reservoir inside erythrocytes provides the long-term survival of bacteria and is the cause of ineffectiveness of antibiotics and host immune reactions. Treatment perspectives that include different aspects of sepsis development are discussed.

IL-6 rs1800795 polymorphism is associated with septic shock-related death in patients who underwent major surgery: a preliminary retrospective study

Background

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, being the primary cause of death from infection, especially if not recognized and treated promptly. The aim of this study was to analyze whether IL-6 rs1800795 polymorphism is associated with septic shock-related death in European white patients who underwent major surgery.

Methods

We performed a retrospective study on 202 septic shock patients who underwent major cardiac or abdominal surgery. The septic shock was established according to the international septic shock definition. The primary outcome variable was the death within 90 days after diagnosis of septic shock. The IL-6 rs1800795 polymorphism was genotyped by Sequenom’s MassARRAY platform.

Results

The median age of the patients was 73 years, 63.4% were male, and more than 40% of patients had heart disease and hypertension. Overall, the survival analysis showed that 111 (55%) patients died with a survival median of 39 days (95% CI 30.7; 47.2). The genetic analysis association with survival was performed under a recessive genetic model (CC vs. GG/CG). Patients with IL-6 rs1800795 CC genotype had higher mortality rate than the IL-6 rs1800795 GG/CG genotype at days 7 [31.6% (6/19) vs. 10.4% (19/183); log-rank test (p = 0.005)] and 28 [57.9% (11/19) vs. 33.3% (61/183); log-rank test (p = 0.009)], and 90 [68.4% (13/19) vs. 53.5% (98/183); log-rank test (p = 0.006)]. The IL-6 rs1800795 CC genotype was associated with higher risk of septic shock-related death during the first 7 days [adjusted hazard ratio (aHR 4.65; p = 0.002), 28 days (aHR 2.50; p = 0.006), and 90 days (aHR 2.28; p = 0.006)] with septic shock. When patients were stratified by type of surgery, those with IL-6 rs1800795 CC genotype who underwent cardiac surgery had higher risk of death during the first 7 days (aHR 18.39; p = 0.001) and 28 days (aHR 6.1; p = 0.025) than IL-6 rs1800795 GG/GC carrier, whereas patients with IL-6 rs1800795 CC genotype who underwent abdominal surgery had higher risk of death during all follow-up (aHR 1.98; p = 0.050) than IL-6 rs1800795 GG/GC carrier.

Conclusions

The presence of IL-6 rs1800795 CC genotype was associated with higher risk of septic shock-related death in patients who underwent major cardiac or abdominal surgery. These findings need robust validation in bigger independent cohorts.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0247-8) contains supplementary material, which is available to authorized users.

The Relevance of Coding Gene Polymorphysms of Cytokines and Cellular Receptors in Sepsis

Sepsis is an injurious systemic host response to infection, which can often lead to septic shock and death. Recently, the immune-pathogenesis and genomics of sepsis have become a research topic focusing on the establishment of diagnostic and prognostic biomarkers. As yet, none have been identified as having the necessary specificity to be used independently of other factors in this respect. However the accumulation of current evidence regarding genetic variations, especially the single nucleotide polymorphisms (SNPs) of cytokines and other innate immunity determinants, partially explains the susceptibility and individual differences of patients with regard to the evolution of sepsis. This article outlines the role of genetic variation of some serum proteins which have the potential to be used as biomarker values in evaluating sepsis susceptibility and the progression of the condition.

Immature platelet fraction in septic patients: clinical relevance of immature platelet fraction is limited to the sensitive and accurate discrimination of septic patients from non-septic patients, not to the discrimination of sepsis severity

Background

The immature platelet fraction (IPF) reflects the degree of reticulated platelets. We evaluated performances of IPF as a biomarker for the discrimination of septic patients from non-septic patients and sepsis severity.

Methods

Total 312 patients admitted between March and July 2013 were enrolled and samples were obtained at admission. Lactate (LA), procalcitonin (PCT), C-reactive protein (CRP), immature granulocyte fraction (IG), immature reticulocyte fraction (IRF), and IPF were analyzed as sepsis biomarkers and their performances were compared.

Results

The performance of IPF (area under the curve [AUC]=0.868) in the discrimination of septic patients from non-septic patients was comparable to PCT/CRP/LA/IG (AUC=0.923/0.940/0.781/0.812, P=0.233/0.106/0.186/0.353, respectively), and was significantly better than the IRF (AUC=0.658, P=0.007). Sensitivity (89.8%, 95% confidence interval [CI] 84.9-99.8%) and accuracy (83.2%, 95% CI 78.8-90.0%) of IPF were the best among all biomarkers. The performance of IPF in discriminating septic patients from non-septic patients with local infection showed similar results. However, the IPF could not efficiently discriminate sepsis severity (AUC=0.599), similar to other biomarkers (AUC=0.519-0.752).

Conclusions

The IPF possessed high sensitivity/accuracy in discriminating septic patients from non-septic patients, regardless of local infection status. However, the IPF did not efficiently discriminate sepsis severity. The clinical relevance of IPF as a sepsis biomarker is, therefore, limited to sensitive and accurate discrimination of septic patients from non-septic patients, not discrimination of sepsis severity.

Association between Interleukin-6 Promoter Polymorphism (-174 G/C), Serum Interleukin-6 Levels and Mortality in Severe Septic Patients

The association between interleukin (IL)-6 promoter polymorphism (-174 G/C), circulating IL-6 levels and mortality in septic patients has scarcely been addressed, and then only in studies of small sample size, and a direct association among them has not been previously reported. Therefore, the purpose of our study was to determine whether this association exists. An observational, prospective and multicenter study including severe septic patients was undertaken and serum IL-6 levels at severe sepsis diagnosis and IL-6 promoter polymorphism (-174 G/C) were determined. The end-point of the study was 30-day mortality. The study included 263 patients with the following genotypes of IL-6 promoter polymorphism (-174 G/C): 123 (46.8%) GG, 110 (41.8%) GC and 30 (11.4%) CC. CC homozygous patients showed lower sepsis-related organ failure assessment (SOFA) score, serum IL-6 levels and mortality at 30 days compared to those with other genotypes (GC or GG). On regression analysis, CC homozygous patients showed lower 30-day mortality than those with genotype GG (odds ratio = 0.21; 95% CI = 0.053−0.838; p = 0.03) or GC (hazard ratio = 0.28; 95% CI = 0.074−1.037; p = 0.06). The most important results of our study were that CC might be a favorable genotype in septic patients showing lower serum IL-6 levels and lower risk of death within 30 days.