Hospital-related costs of sepsis around the world: A systematic review exploring the economic burden of sepsis

Selective Clearance of Circulating Histones Based on Dodecapeptide-Grafted Copolymer Material for Sepsis Blood Purification

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Research indicates that circulating histones, as pathogenic factors, may represent a therapeutic target for sepsis. However, effectively clearing circulating histones poses a challenge due to their structural similarity to normal blood proteins, their low abundance in the bloodstream, and serious interference from other blood biomacromolecules. Here we design a dodecapeptide-based functional polymer that can selectively adsorb circulating histones from the blood. The peptide, named P1 (HNHHQLALVESY), was discovered through phage display screening and demonstrated a strong affinity for circulating histones while exhibiting negligible affinities for common proteins in the blood, such as human serum albumin (HSA), immunoglobulin G (IgG), and transferrin (TRF). Furthermore, the P1 peptide was incorporated into a functional polymer design, poly(PEGMA-co-P1), which was immobilized onto a silica gel surface through reversible addition-fragmentation chain transfer polymerization. The resulting material was characterized using solid nuclear magnetic resonance, thermogravimetric analysis, and X-ray photoelectron spectroscopy. This material demonstrated the ability to selectively and efficiently capture circulating histones from both model solutions and whole blood samples while also exhibiting satisfactory blood compatibility, good antifouling properties, and resistance to interference. Satisfactory binding affinity and efficient capture capacity toward histone were also observed for the other screened peptide P2 (QMSMDLFGSNFV)-grafted polymer, validating phage display as a reliable ligand screening strategy. These findings present an approach for the specific clearance of circulating histones and hold promise for future clinical applications in blood purification toward sepsis.

Phenanthrenes from Juncus articulatus with Antibacterial and Biofilm Formation Inhibitory Activity

Continuing our search for bioactive compounds in species from the Juncaceae family, Juncus articulatus was investigated. Ten previously undescribed phenanthrenes─articulins A-J (1-10)─and ten known compounds─juncuenin B, dehydrojuncuenin B, juncatrin B, ensifolins E, F, H, I, K, juncuenin D, and luzulin A (11-20)─along with other compounds, have been isolated and identified. The isolated compounds were evaluated for antibacterial activity against Escherichia coli, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus aureus (MSSA), and methicillin-resistant Staphylococcus aureus (MRSA). Compounds 12 and 14 exhibited the most potent activity against planktonic and sessile MSSA and MRSA with minimum inhibitory concentration (MIC) values of 15.1 μM (12 for both bacterial strains) and 15.3 μM (14 for both bacterial strains). Compounds 15, 17, and 18 also exhibited activity against both strains, although to a lower extent, with MIC values ranging from 30.0 to 56.8 μM. The inhibition of biofilm formation of these compounds was observed at 15.1-114.3 μM. This study elucidates the phenanthrene composition of J. articulatus and the antibacterial effect of these compounds.

Can We Improve Mortality Prediction in Patients with Sepsis in the Emergency Department?

Background and Objectives: Sepsis represents a global health challenge and requires advanced diagnostic and prognostic approaches due to its elevated rate of morbidity and fatality. Our study aimed to assess the value of a novel set of six biomarkers combined with severity scores in predicting 28 day mortality among patients presenting with sepsis in the Emergency Department (ED). Materials and Methods: This single-center, observational, prospective cohort included sixty-seven consecutive patients with septic shock and sepsis enrolled from November 2020 to December 2022, categorized into survival and non-survival groups based on outcomes. The following were assessed: procalcitonin (PCT), soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1), the soluble form of the urokinase plasminogen activator receptor (suPAR), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and azurocidin 1 (AZU1), alongside clinical scores such as the Quick Sequential Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS), the Sequential Organ Failure Assessment (SOFA), the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score II and III (SAPS II/III), the National Early Warning Score (NEWS), Mortality in Emergency Department Sepsis (MEDS), the Charlson Comorbidity Index (CCI), and the Glasgow Coma Scale (GCS). The ability of each biomarker and clinical score and their combinations to predict 28 day mortality were evaluated. Results: The overall mortality was 49.25%. Mechanical ventilation was associated with a higher mortality rate. The levels of IL-6 were significantly higher in the non-survival group and had higher AUC values compared to the other biomarkers. The GCS, SOFA, APACHEII, and SAPS II/III showed superior predictive ability. Combining IL-6 with suPAR, AZU1, and clinical scores SOFA, APACHE II, and SAPS II enhanced prediction accuracy compared with individual biomarkers. Conclusion: In our study, IL-6 and SAPS II/III were the most accurate predictors of 28 day mortality for sepsis patients in the ED.

Immunomodulatory Effects and Protection in Sepsis by the Antibiotic Moxifloxacin

Sepsis is a leading cause of death in Intensive Care Units. Despite its prevalence, sepsis remains insufficiently understood, with no substantial qualitative improvements in its treatment in the past decades. Immunomodulatory agents may hold promise, given the significance of TNF-α and IL-1β as sepsis mediators. This study examines the immunomodulatory effects of moxifloxacin, a fluoroquinolone utilized in clinical practice. THP1 cells were treated in vitro with either PBS or moxifloxacin and subsequently challenged with lipopolysaccharide (LPS) or E. coli. C57BL/6 mice received intraperitoneal injections of LPS or underwent cecal ligation and puncture (CLP), followed by treatment with PBS, moxifloxacin, meropenem or epirubicin. Atm-/- mice underwent CLP and were treated with either PBS or moxifloxacin. Cytokine and organ lesion markers were quantified via ELISA, colony-forming units were assessed from mouse blood samples, and DNA damage was evaluated using a comet assay. Moxifloxacin inhibits the secretion of TNF-α and IL-1β in THP1 cells stimulated with LPS or E. coli. Intraperitoneal administration of moxifloxacin significantly increased the survival rate of mice with severe sepsis by 80% (p < 0.001), significantly reducing the plasma levels of cytokines and organ lesion markers. Notably, moxifloxacin exhibited no DNA damage in the comet assay, and Atm-/- mice were similarly protected following CLP, boasting an overall survival rate of 60% compared to their PBS-treated counterparts (p = 0.003). Moxifloxacin is an immunomodulatory agent, reducing TNF-α and IL-1β levels in immune cells stimulated with LPS and E. coli. Furthermore, moxifloxacin is also protective in an animal model of sepsis, leading to a significant reduction in cytokines and organ lesion markers. These effects appear unrelated to its antimicrobial activity or induction of DNA damage.

Sided Stimulation of Endothelial Cells Modulates Neutrophil Trafficking in an In Vitro Sepsis Model

While the role of dysregulated polymorphonuclear leukocyte (PMN) transmigration in septic mediated tissue damage is well documented, strategies to mitigate aberrant transmigration across endothelium have yet to yield viable therapeutics. Recently, microphysiological systems (MPS) have emerged as novel in vitro mimetics that facilitate the development of human models of disease. With this advancement, aspects of endothelial physiology that are difficult to assess with other models can be directly probed. In this study, the role of endothelial cell (EC) apicobasal polarity on leukocyte trafficking response is evaluated with the µSiM-MVM (microphysiological system enabled by a silicon membrane - microvascular mimetic). Here, ECs are stimulated either apically or basally with a cytokine cocktail to model a septic-like challenge before introducing healthy donor PMNs into the device. Basally oriented stimulation generated a stronger PMN transmigratory response versus apical stimulation. Importantly, healthy PMNs are unable to migrate towards a bacterial peptide chemoattractant when ECs are apically stimulated, which mimics the attenuated PMN chemotaxis seen in sepsis. Escalating the apical inflammatory stimulus by a factor of five is necessary to elicit high PMN transmigration levels across endothelium. These results demonstrate that EC apicobasal polarity modulates PMN transmigratory behavior and provides insight into the mechanisms underlying sepsis.

Naringin: A flavanone with a multifaceted target against sepsis-associated organ injuries

BACKGROUND

Sepsis causes multiple organ dysfunctions and raises mortality and morbidity rates through a dysregulated host response to infection. Despite the growing research interest over the last few years, no satisfactory treatment exists. Naringin, a naturally occurring bioflavonoid with vast therapeutic potential in citrus fruits and Chinese herbs, has received much attention for treating sepsis-associated multiple organ dysfunctions.

PURPOSE

The review describes preclinical evidence of naringin from 2011 to 2024, particularly emphasizing the mechanism of action mediated by naringin against sepsis-associated specific injuries. The combination therapy, safety profile, drug interactions, recent advancements in formulation, and future perspectives of naringin are also discussed.

METHODS

In vivo and in vitro studies focusing on the potential role of naringin and its mechanism of action against sepsis-associated organ injuries were identified and summarised in the present manuscript, which includes contributions from 2011 to 2024. All the articles were extracted from the Medline database using PubMed, Science Direct, and Web of Science with relevant keywords.

RESULTS

Research findings revealed that naringin modulates many signaling cascades, such as Rho/ROCK and PPAR/STAT1, PIP3/AKT and KEAP1/Nrf2, and IkB/NF-kB and MAPK/Nrf2/HO-1, to potentially protect against sepsis-induced intestinal, cardiac, and lung injury, respectively. Furthermore, naringin treatment exhibits anti-inflammatory, anti-apoptotic, and antioxidant action against sepsis harm, highlighting naringin's promising effects in septic settings. Naringin could be employed as a treatment against sepsis, based on studies on combination therapy, synergistic effects, and toxicological investigation that show no reported severe side effects.

CONCLUSION

Naringin might be a promising therapeutic approach for preventing sepsis-induced multiple organ failure. Naringin should be used alongside other therapeutic therapies with caution despite its great therapeutic potential and lower toxicity. Nonetheless, clinical studies are required to comprehend the therapeutic benefits of naringin against sepsis.

The Role of Programmed Cell Death 1/Programmed Death Ligand 1 (PD-1/PD-L1) Axis in Sepsis-Induced Apoptosis

Background and Objectives: Sepsis involves a dysregulated host response, characterized by simultaneous immunosuppression and hyperinflammation. Initially, there is the release of pro-inflammatory factors and immune system dysfunction, followed by persistent immune paralysis leading to apoptosis. This study investigates sepsis-induced apoptosis and its pathways, by assessing changes in PD-1 and PD-L1 serum levels, CD4+ and CD8+ T cells, and Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) severity scores. Materials and Methods: This prospective, observational, single-centre study enrolled 87 sepsis patients admitted to the intensive care unit at the County Emergency Clinical Hospital in Târgu Mureș, Romania. We monitored the parameters on day 1 (the day sepsis or septic shock was diagnosed as per the Sepsis-3 Consensus) and day 5. Results: Our study found a statistically significant variation in the SOFA score for the entirety of the patients between the studied days (p = 0.001), as well as for the studied patient groups: sepsis, septic shock, survivors, and non-survivors (p = 0.001, p = 0.003, p = 0.01, p = 0.03). On day 1, we found statistically significant correlations between CD8+ cells and PD-1 (p = 0.02) and PD-L1 (p = 0.04), CD4+ and CD8+ cells (p < 0.0001), SOFA and APACHE II scores (p < 0.0001), and SOFA and APACHE II scores and PD-L1 (p = 0.001 and p = 0.01). On day 5, we found statistically significant correlations between CD4+ and CD8+ cells and PD-L1 (p = 0.03 and p = 0.0099), CD4+ and CD8+ cells (p < 0.0001), and SOFA and APACHE II scores (p < 0.0001). Conclusions: The reduction in Th CD4+ and Tc CD8+ lymphocyte subpopulations were evident from day 1, indicating that apoptosis is a crucial factor in the progression of sepsis and septic shock. The increased expression of the PD-1/PD-L1 axis impairs costimulatory signalling, leading to diminished T cell responses and lymphopenia, thereby increasing the susceptibility to nosocomial infections.

Resistin as a potential diagnostic biomarker for sepsis: insights from DIA and ELISA analyses

PURPOSE

The primary objective of this investigation is to systematically screen and identify differentially expressed proteins (DEPs) within the plasma of individuals afflicted with sepsis. This endeavor employs both Data-Independent Acquisition (DIA) and enzyme-linked immunosorbent assay (ELISA) methodologies. The overarching goal is to furnish accessible and precise serum biomarkers conducive to the diagnostic discernment of sepsis.

METHOD

The study encompasses 53 sepsis patients admitted to the Affiliated Hospital of Southwest Medical University between January 2019 and December 2020, alongside a control cohort consisting of 16 individuals devoid of sepsis pathology. Subsequently, a subset comprising 10 randomly selected subjects from the control group and 22 from the sepsis group undergoes quantitative proteomic analysis via DIA. The acquired data undergoes Gene Ontology (GO) and Kyoto Encyclopedia of Genes (KEGG) analyses, facilitating the construction of a Protein-Protein Interaction (PPI) network to discern potential markers. Validation of core proteins is then accomplished through ELISA. Comparative analysis between the normal and sepsis groups ensues, characterized by Receiver Operating Characteristic (ROC) curve construction to evaluate diagnostic efficacy.

RESULT

A total of 187 DEPs were identified through bioinformatic methodologies. Examination reveals their predominant involvement in biological processes such as wound healing, coagulation, and blood coagulation. Functional pathway analysis further elucidates their engagement in the complement pathway and malaria. Resistin emerges as a candidate plasma biomarker, subsequently validated through ELISA. Notably, the protein exhibits significantly elevated levels in the serum of sepsis patients compared to the normal control group. ROC curve analysis underscores the robust diagnostic capacity of these biomarkers for sepsis.

CONCLUSION

Data-Independent Acquisition (DIA) and Enzyme-Linked Immunosorbent Assay (ELISA) show increased Resistin levels in sepsis patients, suggesting diagnostic potential, warranting further research.

Recognition and Awareness of Sepsis by First-Aid Providers in Adults With Suspected Infection: A Scoping Review

Sepsis accounts for a significant proportion of preventable deaths worldwide and early treatment has been found to be a mainstay of decreasing mortality. Early identification of sepsis in the first-aid setting is critical as this results in a shorter time to hospital presentation and management with antibiotics and initial resuscitation. Our aim was to explore the existing literature related to either sepsis recognition or awareness of sepsis by first-aid providers who are evaluating an adult suspected of an acute infection. Our scoping review was performed as part of the International Liaison Committee on Resuscitation's (ILCOR) continuous evidence evaluation process to update the 2024 ILCOR Consensus on Science with Treatment Recommendations. We searched Embase, Medline, and Cochrane databases from their inception to January 17, 2023, with updated searches performed on November 21, 2023, and December 2, 2023. The gray literature search was conducted on August 29, 2023. The population included adults presenting with an acute illness exhibiting signs and symptoms of a severe infection. Outcomes included sepsis recognition or awareness of sepsis by a lay first-aid provider. After reviewing 4380 potential sources, four reviews (three systematic reviews and one scoping review), 11 observational studies, and 27 websites met the inclusion criteria. No study directly addressed our PICOST (Population, Intervention, Comparator, Outcomes, Study Design, and Timeframe) question as none were performed in the first-aid setting. Three systematic reviews and nine observational studies that assessed the ability of early warning scores to detect sepsis and predict adverse outcomes secondary to sepsis had inconsistent results, but many found the screening tools to be useful. One scoping review and one observational study found public knowledge and awareness of sepsis to be variable and dependent upon healthcare employment, location, education level, ethnicity, sex, and age. Signs and symptoms associated with sepsis as listed by gray literature sources fell primarily under nine general categories as a means of educating the public on sepsis recognition. Although this scoping review did not identify any studies that directly addressed our outcomes, it highlights the need for future research to better understand the recognition of sepsis in first-aid settings.

Clinical biomarker profiles reveals gender differences and mortality factors in sepsis

Background

Sepsis is a major contributor to global morbidity and mortality, affecting millions each year. Notwithstanding the decline in sepsis incidence and mortality over decades, gender disparities in sepsis outcomes persist, with research suggesting higher mortality rates in males.

Methods

This retrospective study aims to delineate gender-specific clinical biomarker profiles impacting sepsis progression and mortality by examining sepsis cases and related clinical data from the past three years. Propensity score matching was used to select age-matched healthy controls for comparison.

Results

Among 265 sepsis patients, a significantly higher proportion were male (60.8%, P<0.001). While mortality did not significantly differ by gender, deceased patients were significantly older (mean 69 vs 43 years, P=0.003), more likely to have hypertension (54% vs 25%, P=0.019), and had higher SOFA scores (mean ~10 vs 4, P<0.01) compared to survivors. Principal Component Analysis (PCA) showed clear separation between sepsis patients and healthy controls. 48 serum biomarkers were significantly altered in sepsis, with Triiodothyronine, Apolipoprotein A, and Serum cystatin C having the highest diagnostic value by ROC analysis. Gender-stratified comparisons identified male-specific (e.g. AFP, HDLC) and female-specific (e.g. Rheumatoid factor, Interleukin-6) diagnostic biomarkers. Deceased patients significantly differed from survivors, with 22 differentially expressed markers; Antithrombin, Prealbumin, HDL cholesterol, Urea nitrogen and Hydroxybutyrate had the highest diagnostic efficiency for mortality.

Conclusion

These findings enhance our understanding of gender disparities in sepsis and may guide future therapeutic strategies. Further research is warranted to validate these biomarker profiles and investigate the molecular mechanisms underlying these gender differences in sepsis outcomes.

Suppression PCR-Based Selective Enrichment Sequencing for Pathogen and Antimicrobial Resistance Detection on Cell-Free DNA in Sepsis-A Targeted, Blood Culture-Independent Approach for Rapid Pathogen and Resistance Diagnostics in Septic Patients

Sepsis is a life-threatening syndrome triggered by infection and accompanied by high mortality, with antimicrobial resistances (AMRs) further escalating clinical challenges. The rapid and reliable detection of causative pathogens and AMRs are key factors for fast and appropriate treatment, in order to improve outcomes in septic patients. However, current sepsis diagnostics based on blood culture is limited by low sensitivity and specificity while current molecular approaches fail to enter clinical routine. Therefore, we developed a suppression PCR-based selective enrichment sequencing approach (SUPSETS), providing a molecular method combining multiplex suppression PCR with Nanopore sequencing to identify most common sepsis-causative pathogens and AMRs using plasma cell-free DNA. Applying only 1 mL of plasma, we targeted eight pathogens across three kingdoms and ten AMRs in a proof-of-concept study. SUPSETS was successfully tested in an experimental research study on the first ten clinical samples and revealed comparable results to clinical metagenomics while clearly outperforming blood culture. Several clinically relevant AMRs could be additionally detected. Furthermore, SUPSETS provided first pathogen and AMR-specific sequencing reads within minutes of starting sequencing, thereby potentially decreasing time-to-results to 11-13 h and suggesting diagnostic potential in sepsis.

Establishment of a mortality risk nomogram for predicting in-hospital mortality of sepsis: cohort study from a Chinese single center

Objective

To establish a mortality risk nomogram for predicting in-hospital mortality of sepsis patients in the Chinese population.

Methods

Data were obtained from the medical records of sepsis patients enrolled at the Affiliated Huadu Hospital, Southern Medical University, between 2019 and 2021. A total of 696 sepsis patients were initially included in our research, and 582 cases were finally enrolled after screening and divided into the survival group (n = 400) and the non-survival group (n = 182) according to the incidence of mortality during hospitalization. Twenty-eight potential sepsis-related risk factors for mortality were identified. Least absolute shrinkage and selection operator (LASSO) regression was used to optimize variable selection by running cyclic coordinate descent with k-fold (tenfold in this case) cross-validation. We used binary logistic regression to build a model for predicting mortality from the variables based on LASSO regression selection. Binary logistic regression was used to establish a nomogram based on independent mortality risk factors. To validate the prediction accuracy of the nomogram, receiver operating characteristic curve (ROC) analysis, decision curve analysis (DCA) and restricted cubic spline (RCS) analysis were employed. Eventually, the Hosmer-Lemeshow test and calibration curve were used for nomogram calibration.

Results

LASSO regression identified a total of ten factors, namely, chronic heart disease (CHD), lymphocyte count (LYMP), neutrophil-lymphocyte ratio (NLR), red blood cell distribution width (RDW), C reactive protein (CRP), Procalcitonin (PCT), lactic acid, prothrombin time (PT), alanine aminotransferase (ALT), total bilirubin (Tbil), interleukin-6 (IL6), that were incorporated into the multivariable analysis. Finally, a nomogram including CHD, LYMP, NLR, RDW, lactic acid, PT, CRP, PCT, Tbil, ALT, and IL6 was established by multivariable logistic regression. The ROC curves of the nomogram in the training and validation sets were 0.9836 and 0.9502, respectively. DCA showed that the nomogram could be applied clinically if the risk threshold was between 29.52 and 99.61% in the training set and between 31.32 and 98.49% in the testing set. RCS showed that when the value of independent risk factors from the predicted model exceeded the median, the mortality hazard ratio increased sharply. The results of the Hosmer-Lemeshow test (χ2 = 0.1901, df = 2, p = 0.9091) and the calibration curves of the training and validation sets showed good agreement with the actual results, which indicated good stability of the model.

Conclusion

Our nomogram, including CHD, LYMP, NLR, RDW, lactic acid, PT, CRP, PCT, Tbil, ALT, and IL6, exhibits good performance for predicting mortality risk in adult sepsis patients.

Integrating Routine Hematological and Extended Inflammatory Parameters as a Novel Approach for Timely Diagnosis and Prognosis in Sepsis Management

Sepsis is one of the major causes of morbidity and mortality in hospitals, especially in low- and middle-income countries, and represents a challenge to health care providers to carry out early detection, and accurate diagnosis and prognosis with cost-effective diagnostic tools. An observational prospective study was conducted from December 2021 to December 2022 to investigate the extended inflammatory parameters (EIPs) for sepsis management and analyze the survival of septic patients in the emergency unit, intensive care unit (ICU) and inpatient ward. Patients suspected of having sepsis underwent a sequential organ failure assessment (SOFA) evaluation and had blood drawn for complete blood counts (CBCs). Significant changes were observed in various CBC parameters and EIPs, and the sepsis group was followed up with for 30-day mortality. The study highlighted a significant difference yet strong discriminatory power to differentiate sepsis with an AUC of 0.924 against the non-sepsis group and an AUC of 0.991 against the healthy control group using combination of white blood cells and EIPs. Furthermore, the study showed good predictive ability for 30-day mortality with a hazard ratio of 2.311. In summary, this study provides evidence that the utilization of EIPs may be valuable in diagnosing and predicting patient outcomes, and thus will be beneficial for sepsis management in the hospital.

The clinical importance of metagenomic next-generation sequencing in detecting disease-causing microorganisms in cases of sepsis acquired in the community or hospital setting

Objectives

Although metagenomic next-generation sequencing (mNGS) is commonly used for diagnosing infectious diseases, clinicians face limited options due to the high costs that are not covered by basic medical insurance. The goal of this research is to challenge this bias through a thorough examination and evaluation of the clinical importance of mNGS in precisely identifying pathogenic microorganisms in cases of sepsis acquired in the community or in hospitals.

Methods

A retrospective observational study took place at a tertiary teaching hospital in China from January to December 2021. Data on 308 sepsis patients were collected, and the performance of etiological examination was compared between mNGS and traditional culture method.

Results

Two hundred twenty-nine cases were observed in the community-acquired sepsis (CAS) group and 79 cases in the hospital-acquired sepsis (HAS) group. In comparison with conventional culture, mNGS showed a significantly higher rate of positivity in both the CAS group (88.21% vs. 25.76%, adj.P < 0.001) and the HAS group (87.34% vs. 44.30%, adj.P < 0.001), particularly across various infection sites and specimens, which were not influenced by factors like antibiotic exposure or the timing and frequency of mNGS technology. Sepsis pathogens detected by mNGS were broad, especially viruses, Mycobacterium tuberculosis, and atypical pathogens, with mixed pathogens being common, particularly bacterial-viral co-detection. Based on the optimization of antimicrobial therapy using mNGS, 58 patients underwent antibiotic de-escalation, two patients were switched to antiviral therapy, and 14 patients initiated treatment for tuberculosis, resulting in a reduction in antibiotic overuse but without significant impact on sepsis prognosis. The HAS group exhibited a critical condition, poor prognosis, high medical expenses, and variations in etiology, yet the mNGS results did not result in increased medical costs for either group.

Conclusions

mNGS demonstrates efficacy in identifying multiple pathogens responsible for sepsis, with mixed pathogens of bacteria and viruses being prevalent. Variability in microbiological profiles among different infection setting underscores the importance of clinical vigilance. Therefore, the adoption of mNGS for microbiological diagnosis of sepsis warrants acknowledgment and promotion.

Methodological quality of systematic reviews on sepsis treatments: A cross-sectional study

OBJECTIVE

Systematic reviews (SRs) offer updated evidence to support decision-making on sepsis treatments. However, the rigour of SRs may vary, and methodological flaws may limit their validity in guiding clinical practice. This cross-sectional study appraised the methodological quality of SRs on sepsis treatments.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Database for eligible SRs on randomised controlled trials on sepsis treatments with at least one meta-analysis published between 2018 and 2023. We extracted SRs' bibliographical characteristics with a pre-designed form and appraised their methodological quality using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. We applied logistic regressions to explore associations between bibliographical characteristics and methodological quality ratings.

RESULTS

Among the 102 SRs, two (2.0%) had high overall quality, while respectively four (3.9%), seven (6.9%) and 89 (87.3%) were of moderate, low, and critically low quality. Performance in several critical methodological domains was poor, with only 32 (31.4%) considering the risk of bias in primary studies in result interpretation, 22 (21.6%) explaining excluded primary studies, and 16 (15.7%) applying comprehensive searching strategies. SRs published in higher impact factor journals (adjusted odds ratio: 1.19; 95% confidence interval: 1.05 to 1.36) was associated with higher methodological quality.

CONCLUSIONS

The methodological quality of recent SRs on sepsis treatments is unsatisfactory. Future reviewers should address the above critical methodological aspects. More resources should also be allocated to support continuous training in critical appraisal among healthcare professionals and other evidence users.

Assessment of Sepsis Risk at Admission to the Emergency Department: Clinical Interpretable Prediction Model

This study aims to develop an interpretable prediction model based on explainable artificial intelligence to predict bacterial sepsis and discover important biomarkers. A total of 1572 adult patients, 560 of whom were sepsis positive and 1012 of whom were negative, who were admitted to the emergency department with suspicion of sepsis, were examined. We investigated the performance characteristics of sepsis biomarkers alone and in combination for confirmed sepsis diagnosis using Sepsis-3 criteria. Three different tree-based algorithms-Extreme Gradient Boosting (XGBoost), Light Gradient Boosting Machine (LightGBM), Adaptive Boosting (AdaBoost)-were used for sepsis prediction, and after examining comprehensive performance metrics, descriptions of the optimal model were obtained with the SHAP method. The XGBoost model achieved accuracy of 0.898 (0.868-0.929) and area under the ROC curve (AUC) of 0.940 (0.898-0.980) with a 95% confidence interval. The five biomarkers for predicting sepsis were age, respiratory rate, oxygen saturation, procalcitonin, and positive blood culture. SHAP results revealed that older age, higher respiratory rate, procalcitonin, neutrophil-lymphocyte count ratio, C-reactive protein, plaque, leukocyte particle concentration, as well as lower oxygen saturation, systolic blood pressure, and hemoglobin levels increased the risk of sepsis. As a result, the Explainable Artificial Intelligence (XAI)-based prediction model can guide clinicians in the early diagnosis and treatment of sepsis, providing more effective sepsis management and potentially reducing mortality rates and medical costs.

The Impact of Pathogens on Sepsis Prevalence and Outcome

Sepsis, a severe global healthcare challenge, is characterized by significant morbidity and mortality. The 2016 redefinition by the Third International Consensus Definitions Task Force emphasizes its complexity as a "life-threatening organ dysfunction caused by a dysregulated host response to infection". Bacterial pathogens, historically dominant, exhibit geographic variations, influencing healthcare strategies. The intricate dynamics of bacterial immunity involve recognizing pathogen-associated molecular patterns, triggering innate immune responses and inflammatory cascades. Dysregulation leads to immunothrombosis, disseminated intravascular coagulation, and mitochondrial dysfunction, contributing to the septic state. Viral sepsis, historically less prevalent, saw a paradigm shift during the COVID-19 pandemic, underscoring the need to understand the immunological response. Retinoic acid-inducible gene I-like receptors and Toll-like receptors play pivotal roles, and the cytokine storm in COVID-19 differs from bacterial sepsis. Latent viruses like human cytomegalovirus impact sepsis by reactivating during the immunosuppressive phases. Challenges in sepsis management include rapid pathogen identification, antibiotic resistance monitoring, and balancing therapy beyond antibiotics. This review highlights the evolving sepsis landscape, emphasizing the need for pathogen-specific therapeutic developments in a dynamic and heterogeneous clinical setting.

Potential impact of a new sepsis prediction model for the primary care setting: early health economic evaluation using an observational cohort

OBJECTIVES

To estimate the potential referral rate and cost impact at different cut-off points of a recently developed sepsis prediction model for general practitioners (GPs).

DESIGN

Prospective observational study with decision tree modelling.

SETTING

Four out-of-hours GP services in the Netherlands.

PARTICIPANTS

357 acutely ill adult patients assessed during home visits.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is the cost per patient from a healthcare perspective in four scenarios based on different cut-off points for referral of the sepsis prediction model. Second, the number of hospital referrals for the different scenarios is estimated. The potential impact of referral of patients with sepsis on mortality and hospital admission was estimated by an expert panel. Using these study data, a decision tree with a time horizon of 1 month was built to estimate the referral rate and cost impact in case the model would be implemented.

RESULTS

Referral rates at a low cut-off (score 2 or 3 on a scale from 0 to 6) of the prediction model were higher than observed for patients with sepsis (99% and 91%, respectively, compared with 88% observed). However, referral was also substantially higher for patients who did not need hospital assessment. As a consequence, cost-savings due to referral of patients with sepsis were offset by increased costs due to unnecessary referral for all cut-offs of the prediction model.

CONCLUSIONS

Guidance for referral of adult patients with suspected sepsis in the primary care setting using any cut-off point of the sepsis prediction model is not likely to save costs. The model should only be incorporated in sepsis guidelines for GPs if improvement of care can be demonstrated in an implementation study.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (NTR 7026).

Knowledge and Associated Factors Towards Sepsis Management Among Nurses Working in the Emergency Department of Public Hospitals in Addis Ababa

Background

Sepsis is a major cause of mortality worldwide and an important public health problem. The quality of patient care is negatively impacted when nurses lack adequate knowledge regarding the management of sepsis. On the other hand, little is known regarding Ethiopian nurses' knowledge of sepsis management.

Objective

To assess the level of knowledge and the associated factors towards sepsis management among nurses working in emergency departments in public hospitals in Addis Ababa, Ethiopia.

Method

From March 18 to April 18, 2022, a health facility-based cross-sectional study was conducted. A simple sampling technique (lottery method) was used to select the hospitals. The data was analyzed using SPSS version 25. The study employed logistic regression analysis to examine the association between the independent variables and the level of knowledge. Variables were significantly associated with a level of knowledge if they had a p-value of less than 0.05 and a 95% confidence interval.

Result

Of the 127 participants, more than half (56.7%) had poor knowledge. Nurses' knowledge of managing sepsis was significantly associated with not having regular training, a low level of education, and working experience of less than five years. The findings of the multivariable regression analysis revealed that the following variables were associated with a nurse's knowledge of sepsis management: low level of education (AOR = 3.2 (95% CI, 1.16-8.77), lack of training adjusted odd ratio (AOR = 2.5 (95% CI, 1.07-5.93), and less than five years of work experience (AOR = 3.6 (95% CI, 1. 29-9.830).

Conclusion

The majority of nurses had inadequate knowledge of managing sepsis. On the other hand, the majority of nurses had a favourable attitude toward sepsis management. Lack of prior training, a low level of education, and less than five years of work experience were all significantly associated with nurses' poor knowledge regarding sepsis management. This study recommends that hospital managers should provide on-the-job and long-term training for nurses working in the emergency department to enhance the level of nurses' knowledge towards sepsis management at their institutions.

Antibiotic failure: Beyond antimicrobial resistance

Despite significant progress in antibiotic discovery, millions of lives are lost annually to infections. Surprisingly, the failure of antimicrobial treatments to effectively eliminate pathogens frequently cannot be attributed to genetically-encoded antibiotic resistance. This review aims to shed light on the fundamental mechanisms contributing to clinical scenarios where antimicrobial therapies are ineffective (i.e., antibiotic failure), emphasizing critical factors impacting this under-recognized issue. Explored aspects include biofilm formation and sepsis, as well as the underlying microbiome. Therapeutic strategies beyond antibiotics, are examined to address the dimensions and resolution of antibiotic failure, actively contributing to this persistent but escalating crisis. We discuss the clinical relevance of antibiotic failure beyond resistance, limited availability of therapies, potential of new antibiotics to be ineffective, and the urgent need for novel anti-infectives or host-directed therapies directly addressing antibiotic failure. Particularly noteworthy is multidrug adaptive resistance in biofilms that represent 65 % of infections, due to the lack of approved therapies. Sepsis, responsible for 19.7 % of all deaths (as well as severe COVID-19 deaths), is a further manifestation of this issue, since antibiotics are the primary frontline therapy, and yet 23 % of patients succumb to this condition.

Targeting Toll-like receptor-driven systemic inflammation by engineering an innate structural fold into drugs

There is a clinical need for conceptually new treatments that target the excessive activation of inflammatory pathways during systemic infection. Thrombin-derived C-terminal peptides (TCPs) are endogenous anti-infective immunomodulators interfering with CD14-mediated TLR-dependent immune responses. Here we describe the development of a peptide-based compound for systemic use, sHVF18, expressing the evolutionarily conserved innate structural fold of natural TCPs. Using a combination of structure- and in silico-based design, nuclear magnetic resonance spectroscopy, biophysics, mass spectrometry, cellular, and in vivo studies, we here elucidate the structure, CD14 interactions, protease stability, transcriptome profiling, and therapeutic efficacy of sHVF18. The designed peptide displays a conformationally stabilized, protease resistant active innate fold and targets the LPS-binding groove of CD14. In vivo, it shows therapeutic efficacy in experimental models of endotoxin shock in mice and pigs and increases survival in mouse models of systemic polymicrobial infection. The results provide a drug class based on Nature´s own anti-infective principles.

Causal pathway from telomere length to occurrence and 28-day mortality of sepsis: an observational and mendelian randomization study

BACKGROUND

Telomeres are considered to be a physiological marker of aging. Elucidating relationship between telomere length and sepsis is an essential step towards understanding the biological processes involved in sepsis and its salvation. Mendelian randomization studies based on SNPs have given us new insights into genetic susceptibility to disease.

OBJECTIVES

To explore the causal pathway from telomere length to occurrence and 28-day mortality of sepsis.

METHODS

Leveraging genetic information resource of UK Biobank, we captured three groups of large-scale GWAS data: leukocyte telomere length (LTL), sepsis and all-cause death of 28-day. Study design consisted of three parts: forward analysis, reverse analysis and one-way analysis. Genetic instrumental variables were selected for different analyses under the premise that three MR core assumptions were satisfied. Causality was determined by means of IVW.

RESULTS

In forward analysis, we did not observe a significant causal pathway from sepsis to LTL under IVW model: β (SE) was -0.0051 (0.0075) with a p-value of 0.499. In reverse analysis, based on the IVW model, the OR (95% CI) was 0.89 (0.80-0.99) and the p-values was 0.043; based on the results of leave out method and single SNP analysis, we obtained seven key SNPs. There were results of IVW model in the one-way analysis: β (SE) was -0.0287(0.1261).

CONCLUSIONS

Short LTL increases susceptibility to sepsis, but sepsis does not shorten telomere length. LTL does not affect sepsis 28-day all-cause mortality and does not serve as a causal intermediate in gene regulation during the progression of sepsis to 28-day death.

Analysis of Calprotectin as an Early Marker of Infections Is Economically Advantageous in Intensive Care-Treated Patients

Calprotectin is released from neutrophil granulocytes upon activation. Several studies have indicated that plasma calprotectin is an early determinant of bacterial infections, which may serve as a diagnostic tool facilitating decision making on antibiotic treatment. The study objective was to explore the health and economic implications of calprotectin as a predictive tool to initiate antimicrobial therapy in a cohort of critically ill patients. Thus, data obtained from a previously published study on calprotectin as a hypothetical early biomarker of bacterial infections in critically ill patients were evaluated regarding the potential cost-effective impact of early analysis of calprotectin on an earlier start of antibiotic treatment. Under the assumption that calprotectin is used predictively and comparators (white blood cells, procalcitonin, and C-reactive protein) are used diagnostically, a cost-effective impact of EUR 11,000-12,000 per patient would be obtained. If calprotectin would be used predictively and comparators would be used predictively for 50% of patients, it is hypothesized that cost-effectiveness would be between EUR 6000 and 7000 per patient, based on reduced stay in the ICU and general ward, respectively. Furthermore, predictive use of calprotectin seems to reduce both mortality and the length of hospital stay. This health economic analysis on the predictive use of plasma calprotectin, which facilitates clinical decision making in cases of suspected sepsis, indicates that such determination has a cost-saving and life-saving impact on the healthcare system.

Is patients' rurality associated with in-hospital sepsis death in US hospitals?

Background

The focus of this study was to explore the association of patients' rurality and other patient and hospital-related factors with in-hospital sepsis mortality to identify possible health disparities across United States hospitals.

Methods

The National Inpatient Sample was used to identify nationwide sepsis patients (n = 1,977,537, weighted n = 9,887,682) from 2016 to 2019. We used multivariate survey logistic regression models to identify predictors for how patients' rurality is associated with in-hospital death.

Findings

During the study periods, in-hospital death rates among sepsis inpatients continuously decreased (11.3% in 2016 to 9.9% in 2019) for all rurality levels. Rao-Schott Chi-Square tests demonstrated that certain patient and hospital factors had varied in-hospital death rates. Multivariate survey logistic regressions suggested that rural areas, minorities, females, older adults, low-income, and uninsured patients have higher odds of in-hospital mortality. Further, specific census divisions like New England, Middle Atlantic, and East North Central had greater in-hospital sepsis death odds.

Conclusion

Rurality was associated with increased in-hospital sepsis death across multiple patient populations and locations. Further, rurality in New England, Middle Atlantic, and East North Central locations is exceptionally high odds. In addition, minority races in rural areas also have an increased odds of in-hospital death. Therefore, rural healthcare requires a more significant influx of resources and should also include assessing patient-related factors.

Identification of featured necroptosis-related genes and imbalanced immune infiltration in sepsis via machine learning

Background: The precise diagnostic and prognostic biological markers were needed in immunotherapy for sepsis. Considering the role of necroptosis and immune cell infiltration in sepsis, differentially expressed necroptosis-related genes (DE-NRGs) were identified, and the relationship between DE-NRGs and the immune microenvironment in sepsis was analyzed.

Methods: Machine learning algorithms were applied for screening hub genes related to necroptosis in the training cohort. CIBERSORT algorithms were employed for immune infiltration landscape analysis. Then, the diagnostic value of these hub genes was verified by the receiver operating characteristic (ROC) curve and nomogram. In addition, consensus clustering was applied to divide the septic patients into different subgroups, and quantitative real-time PCR was used to detect the mRNA levels of the hub genes between septic patients (SP) (n = 30) and healthy controls (HC) (n = 15). Finally, a multivariate prediction model based on heart rate, temperature, white blood count and 4 hub genes was established.

Results: A total of 47 DE-NRGs were identified between SP and HC and 4 hub genes (BACH2, GATA3, LEF1, and BCL2) relevant to necroptosis were screened out via multiple machine learning algorithms. The high diagnostic value of these hub genes was validated by the ROC curve and Nomogram model. Besides, the immune scores, correlation analysis and immune cell infiltrations suggested an immunosuppressive microenvironment in sepsis. Septic patients were divided into 2 clusters based on the expressions of hub genes using consensus clustering, and the immune microenvironment landscapes and immune function between the 2 clusters were significantly different. The mRNA levels of the 4 hub genes significantly decreased in SP as compared with HC. The area under the curve (AUC) was better in the multivariate prediction model than in other indicators.

Conclusion: This study indicated that these necroptosis hub genes might have great potential in prognosis prediction and personalized immunotherapy for sepsis.

The NUTRIC Score as a Tool to Predict Mortality and Increased Resource Utilization in Intensive Care Patients with Sepsis

The Nutrition Risk in Critically Ill score (NUTRIC) is an important nutritional risk assessment instrument for patients in the intensive care unit (ICU). The purpose of this study was to evaluate the power of the score to predict mortality in patients treated for sepsis and to forecast increased resource utilization and nursing workload in the ICU. The NUTRIC score predicted mortality (AUC 0.833, p < 0.001) with the optimal cut-off value of 6 points. Among patients with a score ≥ 6 on ICU admission, the 28-day mortality was 61%, and 10% with a score < 6 (p < 0.001). In addition, a NUTRIC score of ≥6 was associated with a more intense use of ICU resources, as evidenced by a higher proportion of patients requiring vasopressor infusion (98 vs. 82%), mechanical ventilation (99 vs. 87%), renal replacement therapy (54 vs. 26%), steroids (68 vs. 31%), and blood products (60 vs. 43%); the nursing workload was also significantly higher in this group. In conclusion, the NUTRIC score obtained at admission to the ICU provided a good discriminative value for mortality and makes it possible to identify patients who will ultimately require intense use of ICU resources and an associated increase in the nursing workload during treatment.

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 exaggerates multiple organ injury, inflammation, and immune cell imbalance by activating the NF-κB pathway in sepsis

Objective

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) modulates the inflammatory immune response and organ dysfunction, which are closely implicated in sepsis pathogenesis and progression. This study aimed to explore the role of MALT1 in sepsis-induced organ injury, immune cell dysregulation, and inflammatory storms.

Methods

Septic mice were constructed by intraperitoneal injection of lipopolysaccharide, followed by overexpression or knockdown of MALT1 by tail vein injection of the corresponding lentivirus. Mouse naïve CD4⁺ T cells and bone marrow-derived macrophages were treated with MALT1 overexpression/knockdown lentivirus plus lipopolysaccharide.

Results

In the lungs, livers, and kidneys of septic mice, MALT1 overexpression exaggerated their injuries, as shown by hematoxylin and eosin staining (all p < 0.05), elevated cell apoptosis, as reflected by the TUNEL assay and cleaved caspase-3 expression (p < 0.05 in the lungs and kidneys), and promoted macrophage infiltration, as illustrated by CD68 immunofluorescence (p < 0.05 in the lungs and kidneys). Meanwhile, in the blood, MALT1 overexpression reduced T-helper (Th)1/Th2 cells, increased Th17/regulatory T-cell ratios (both p < 0.05), promoted systematic inflammation, as revealed by tumor necrosis factor-α, interleukin-6, interleukin-1β, and C-reactive protein (all p < 0.05), elevated oxidative stress, as shown by nitric oxide (p < 0.05), superoxide dismutase, and malondialdehyde (p < 0.05), and enhanced liver and kidney dysfunction, as revealed by an automatic animal biochemistry analyzer (all p < 0.05 except for aspartate aminotransferase). However, MALT1 knockdown exerted the opposite effect as MALT1 overexpression. Ex vivo experiments revealed that MALT1 overexpression promoted the polarization of M1 macrophages and naïve CD4⁺ T cells toward Th2 and Th17 cells (all p < 0.05), while MALT1 knockdown attenuated these effects (all p < 0.05). Mechanistically, MALT1 positively regulated the nuclear factor-κB (NF-κB) pathway both in vivo and ex vivo (p < 0.05).

Conclusion

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 amplifies multiple organ injury, inflammation, oxidative stress, and imbalance of macrophages and CD4⁺ T cells by activating the NF-κB pathway in sepsis.

IV Vitamin C in Sepsis: A Latest Systematic Review and Meta-Analysis

Sepsis is a high-incidence disease and demands intensive care. Finding effective treatment is the key to cure sepsis. Studies have shown a lower level of vitamin C in patients with sepsis. Therefore, vitamin C supplementation has become one of the measures to treat sepsis. However, the clinical studies of vitamin C in the treatment of sepsis have been controversial. We performed a meta-analysis to evaluate vitamin C's efficacy and safety in the treatment of sepsis. We searched four electronic databases: PubMed, Embase, Web of Science, and the Cochrane Library, and two researchers independently screened 24 eligible RCTs published in English. Our review demonstrates that intravenous (IV) vitamin C might improve short-term mortality (RR, 0.82; 95% CI, 0.65-1.02; P=0.07; and I ² = 45%) and overall mortality (RR, 0.86; 95% CI, 0.74-1.01; P=0.06; and I ² = 51%) of patients with sepsis. Moreover, the SOFA score of patients with sepsis improved significantly after treatment with vitamin C for over 72 hours (RR, 0.26; 95% CI, 0.09-0.42; P=0.002; and I ² = 0%). The main results of our study were moderate-quality evidence. More high-quality, multicenter RCTs are needed to provide more substantial evidence on the efficacy and safety of IV vitamin C for sepsis.

Defining Exposure Predictors of Meropenem That Are Associated with Improved Survival for Severe Bacterial Infection: A Preclinical PK/PD Study in Sepsis Rat Model

Background: The pharmacokinetic/pharmacodynamic (PK/PD) index of carbapenems that best correlates with in vivo antimicrobial activity is percent time of dosing interval in which free drug concentration remains above MIC (%fT > MIC), while the magnitudes of the PK/PD index of carbapenems remains undefined in critically ill sepsis patients. Methods: A sepsis rat model was first developed by comparing the survival outcomes after intraperitoneal injection of different inoculum size (1−10 × 107 CFU) of Pseudomonas aeruginosa ATCC9027 (MIC = 0.125 mg/L) in neutropenic rats. The PK characteristics of the model drug meropenem in the developed sepsis rat model was then evaluated, and PK modeling and simulation was applied to design meropenem dosing regimens attaining various PD targets (40%fT > MIC, 100%fT > MIC, and 100%fT > 4 × MIC). The microbiological response and survival outcomes for different meropenem treatment regimens were investigated in the rat sepsis model (n = 12 for each group). Results: The optimal inoculum for the rat sepsis model was 1 × 107 CFU of Pseudomonas aeruginosa ATCC9027. A one-compartment model with first-order absorption best described the PK of meropenem in sepsis rats. Pronounced survival prolongation and lower hazard risk were observed in the treatment groups of 50 or 75 mg/kg/q2.4h (100%fT > MIC) and 75 mg/kg/q2h (100%fT > 4 × MIC) compared to the 75 mg/kg/q6h (40%fT > MIC) group, while meropenem groups with PD targets of 100%fT > MIC and 100%fT > 4 × MIC showed comparable survival curves. Microbiological response for different PD targets is inconclusive due to irregular bacterial counts in blood samples. Conclusions: The PD target of 40%fT > MIC is suboptimal for sepsis rats, and the aggressive 100%fT > 4 × MIC target does not provide a survival benefit against the target of 100%fT > MIC.