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Güleç T, Yılmaz S, Ak R, Tatlıparmak AC, Karcıoğlu Ö. Can we recognize severe community-acquired pneumonia without pneumonia severity index? Use of modified qSOFA with procalcitonin. Heliyon 2023; 9:e19937. [PMID: 37809503 PMCID: PMC10559344 DOI: 10.1016/j.heliyon.2023.e19937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Objective The aim of this study is to analyze the diagnostic value of Quick Sequential Organ Failure Assessment (qSOFA), modified qSOFA, National Early Warning Score (NEWS) and NEWS + Lactate (NEWS + L) scores in the detection of severe community-acquired pneumonia (CAP). Methods This research is a retrospective cohort study. Patients admitted to the Emergency Department (ED) with the diagnosis of CAP were divided into severe and mild pneumonia regarding their Pneumonia Severity Index (PSI) scores. The accuracies of lactate, procalcitonin (PCT) values, NEWS and qSOFA scores, as well as score combinations (NEWS + L and qSOFA + PCT) in predicting patients with severe CAP were analyzed. Results Median qSOFA value in the severe CAP group (0 [IQR 0-1]) was found to be higher than median qSOFA value (0 [IQR 0-0]) in the mild CAP group (p < 0.001). The rate of qSOFA positivity (qSOFA ≥ 2) was significantly higher in the severe CAP group (17.1%, n = 21) compared to the mild CAP group (1.3%, n = 1) (p < 0.001). Median qSOFA + PCT for the severe CAP group (2 [IQR 1-2]) was higher than the mild CAP group (1 [IQR 0-1]) (p < 0.001). Mean NEWS score for severe CAP (4.95 ± 3.09) was found to be 1.69 (95% CI 0.92-2.46) higher than mean NEWS score of the mild CAP group (3.26 ± 2.39) (p < 0.001). The severe CAP NEWS + L score (6.97 ± 3.71) was higher than the mild CAP NEWS + L score (4.94 ± 2.48) (p < 0.001). Blood lactate level was not significant in the evaluation of severe CAP (p = 0.221). PCT (AUROC = 0.685 [95% CI 0.610-0.760]; p = 0.038), NEWS score (AUROC = 0.658 95% CI [0.582-0.733]; p < 0.001), qSOFA (AUROC = 0.686) were calculated to have adequate accuracy for the detection of severe CAP. [95% CI 0.613-0.759]; p = 0.037), NEWS + L score (AUROC = 0.665 [95% CI 0.589-0.740]; p = 0.038). The qSOFA + PCT score (AUROC = 0.758 [95% 0.691-0.825]; p = 0.034) was also found to be a highly accurate predictor of severe CAP. Conclusion In this study, we found a combination of qSOFA and PCT to be the most reliable method of detecting severe CAP.
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Affiliation(s)
- Tolgahan Güleç
- University of Health Sciences, Dept. of Emergency Medicine, Adiyaman Education and Research Hospital, Adiyaman, Turkey
| | - Sarper Yılmaz
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Rohat Ak
- Kartal Dr. Lütfi Kırdar City Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | | | - Özgür Karcıoğlu
- University of Health Sciences, Dept. of Emergency Medicine, Istanbul Education and Research Hospital, Istanbul, Turkey
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2
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Kichloo A, El-Amir Z, Dahiya DS, Singh J, Solanki D, Wani F, Shaka H. Impact of coexisting pneumonia in the patients admitted with Clostridium difficile infection: a retrospective study from a national inpatient database. J Investig Med 2021; 69:976-982. [PMID: 33785548 DOI: 10.1136/jim-2021-001820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/04/2022]
Abstract
Clostridium difficile is a gram-positive anaerobic spore forming bacillus that can cause infection in a setting of antibiotic use. Pneumonia is a major cause of morbidity and mortality in an inpatient setting and is frequently associated with significant antibiotic administration. This study aims to compare the outcomes of C. difficile infection (CDI) with and without pneumonia to determine the impact of pneumonia in hospitalized patients with CDI. This population-based retrospective observational propensity matched analysis study uses data from the National Inpatient Sample database for the years 2016 and 2017. The primary outcomes were in-hospital mortality, total hospital charges, and mean length of stay. Secondary outcomes were the rates of sepsis, septic shock, non-ST elevation myocardial infarction (NSTEMI), acute renal failure, deep vein thrombosis, and pulmonary embolism. In-hospital mortality was noted to be higher in patients with pneumonia than those without (6.5% vs 1.2%, adjusted OR (aOR) 3.85; 95% CI 2.90 to 5.11, p<0.001). The following outcomes were more prevalent in patients with pneumonia compared with those without pneumonia: sepsis (9.8% vs 1.8%, aOR 4.69, 95% CI 3.73 to 5.87, p<0.001), septic shock (4.0% vs 0.5%, aOR 6.32, 95% CI 4.43 to 9.03, p<0.001), NSTEMI (1.9% vs 0.5%, aOR 2.95, 95% CI 1.85 to 4.71, p<0.001), and acute renal failure (31.5% vs 23.1%, aOR 1.23, 95% CI 1.07 to 1.40, p=0.003). In conclusion, patients with pneumonia were associated with significantly higher rates of system-based complications and higher in-hospital mortality rates.
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Affiliation(s)
- Asim Kichloo
- Department of Medicine, Samaritan Medical Center, Watertown, New York, USA .,Department of Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Zain El-Amir
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Jagmeet Singh
- Department of Internal Medicine, Guthrie Healthcare System, Sayre, Pennsylvania, USA.,Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Dhanshree Solanki
- Department of Public Health, Rutgers University System, New Brunswick, New Jersey, USA
| | - Farah Wani
- Department of Medicine, Samaritan Medical Center, Watertown, New York, USA
| | - Hafeez Shaka
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
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3
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Hypercoagulability and coronavirus disease 2019-associated hypoxemic respiratory failure: Mechanisms and emerging management paradigms. J Trauma Acute Care Surg 2020; 89:e177-e181. [PMID: 32890338 PMCID: PMC7687878 DOI: 10.1097/ta.0000000000002938] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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4
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Vlaeminck J, Raafat D, Surmann K, Timbermont L, Normann N, Sellman B, van Wamel WJB, Malhotra-Kumar S. Exploring Virulence Factors and Alternative Therapies against Staphylococcus aureus Pneumonia. Toxins (Basel) 2020; 12:toxins12110721. [PMID: 33218049 PMCID: PMC7698915 DOI: 10.3390/toxins12110721] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/12/2020] [Accepted: 11/15/2020] [Indexed: 12/13/2022] Open
Abstract
Pneumonia is an acute pulmonary infection associated with high mortality and an immense financial burden on healthcare systems. Staphylococcus aureus is an opportunistic pathogen capable of inducing S. aureus pneumonia (SAP), with some lineages also showing multidrug resistance. Given the high level of antibiotic resistance, much research has been focused on targeting S. aureus virulence factors, including toxins and biofilm-associated proteins, in an attempt to develop effective SAP therapeutics. Despite several promising leads, many hurdles still remain for S. aureus vaccine research. Here, we review the state-of-the-art SAP therapeutics, highlight their pitfalls, and discuss alternative approaches of potential significance and future perspectives.
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Affiliation(s)
- Jelle Vlaeminck
- Laboratory of Medical Microbiology, Vaccine and Infectious Diseases Institute, University of Antwerp, 2610 Antwerp, Belgium; (J.V.); (L.T.)
| | - Dina Raafat
- Department of Immunology, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (D.R.); (N.N.)
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria 21521, Egypt
| | - Kristin Surmann
- Department of Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Leen Timbermont
- Laboratory of Medical Microbiology, Vaccine and Infectious Diseases Institute, University of Antwerp, 2610 Antwerp, Belgium; (J.V.); (L.T.)
| | - Nicole Normann
- Department of Immunology, Institute of Immunology and Transfusion Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (D.R.); (N.N.)
| | - Bret Sellman
- Microbiome Discovery, Microbial Sciences, BioPharmaceuticals R & D, AstraZeneca, Gaithersburg, MD 20878, USA;
| | - Willem J. B. van Wamel
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center Rotterdam, 3015 Rotterdam, The Netherlands;
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine and Infectious Diseases Institute, University of Antwerp, 2610 Antwerp, Belgium; (J.V.); (L.T.)
- Correspondence: ; Tel.: +32-3-265-27-52
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5
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José RJ, Williams A, Manuel A, Brown JS, Chambers RC. Targeting coagulation activation in severe COVID-19 pneumonia: lessons from bacterial pneumonia and sepsis. Eur Respir Rev 2020; 29:29/157/200240. [PMID: 33004529 PMCID: PMC7537941 DOI: 10.1183/16000617.0240-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 08/20/2020] [Indexed: 12/15/2022] Open
Abstract
Novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has rapidly spread throughout the world, resulting in a pandemic with high mortality. There are no effective treatments for the management of severe COVID-19 and current therapeutic trials are focused on antiviral therapy and attenuation of hyper-inflammation with anti-cytokine therapy. Severe COVID-19 pneumonia shares some pathological similarities with severe bacterial pneumonia and sepsis. In particular, it disrupts the haemostatic balance, which results in a procoagulant state locally in the lungs and systemically. This culminates in the formation of microthrombi, disseminated intravascular coagulation and multi-organ failure. The deleterious effects of exaggerated inflammatory responses and activation of coagulation have been investigated in bacterial pneumonia and sepsis and there is recognition that although these pathways are important for the host immune response to pathogens, they can lead to bystander tissue injury and are negatively associated with survival. In the past two decades, evidence from preclinical studies has led to the emergence of potential anticoagulant therapeutic strategies for the treatment of patients with pneumonia, sepsis and acute respiratory distress syndrome, and some of these anticoagulant approaches have been trialled in humans. Here, we review the evidence from preclinical studies and clinical trials of anticoagulant treatment strategies in bacterial pneumonia and sepsis, and discuss the importance of these findings in the context of COVID-19.
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Affiliation(s)
- Ricardo J José
- Centre for Inflammation and Tissue Repair, University College London, London, UK .,Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Andrew Williams
- Centre for Inflammation and Tissue Repair, University College London, London, UK
| | - Ari Manuel
- University Hospital Aintree, Liverpool, UK
| | - Jeremy S Brown
- Centre for Inflammation and Tissue Repair, University College London, London, UK.,Dept of Thoracic Medicine, University College London Hospital, London, UK
| | - Rachel C Chambers
- Centre for Inflammation and Tissue Repair, University College London, London, UK
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6
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Semler MW, Bernard GR, Aaron SD, Angus DC, Biros MH, Brower RG, Calfee CS, Colantuoni EA, Ferguson ND, Gong MN, Hopkins RO, Hough CL, Iwashyna TJ, Levy BD, Martin TR, Matthay MA, Mizgerd JP, Moss M, Needham DM, Self WH, Seymour CW, Stapleton RD, Thompson BT, Wunderink RG, Aggarwal NR, Reineck LA. Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care: NHLBI Working Group Report. Am J Respir Crit Care Med 2020; 202:511-523. [PMID: 32150460 DOI: 10.1164/rccm.201908-1595ws] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Preventing, treating, and promoting recovery from critical illness due to pulmonary disease are foundational goals of the critical care community and the National Heart, Lung, and Blood Institute. Decades of clinical research in acute respiratory distress syndrome, acute respiratory failure, pneumonia, and sepsis have yielded improvements in supportive care, which have translated into improved patient outcomes. Novel therapeutics have largely failed to translate from promising pre-clinical findings into improved patient outcomes in late-phase clinical trials. Recent advances in personalized medicine, "big data", causal inference using observational data, novel clinical trial designs, pre-clinical disease modeling, and understanding recovery from acute illness promise to transform the methods of pulmonary and critical care clinical research. To assess the current state, research priorities, and future directions for adult pulmonary and critical care research, the NHLBI assembled a multidisciplinary working group of investigators. This working group identified recommendations for future research, including: (1) focusing on understanding the clinical, physiological, and biological underpinnings of heterogeneity in syndromes, diseases, and treatment-response with the goal of developing targeted, personalized interventions; (2) optimizing pre-clinical models by incorporating comorbidities, co-interventions, and organ support; (3) developing and applying novel clinical trial designs; and (4) advancing mechanistic understanding of injury and recovery in order to develop and test interventions targeted at achieving long-term improvements in the lives of patients and families. Specific areas of research are highlighted as especially promising for making advances in pneumonia, acute hypoxemic respiratory failure, and acute respiratory distress syndrome.
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Affiliation(s)
- Matthew W Semler
- Vanderbilt University Medical Center, 12328, Department of Allergy, Pulmonary, and Critical Care Medicine, Nashville, Tennessee, United States
| | - Gordon R Bernard
- Vanderbilt University Medical Center, 12328, Department of Allergy, Pulmonary, and Critical Care Medicine, Nashville, Tennessee, United States
| | - Shawn D Aaron
- Ottawa Health Research Institute, Ottawa, Ontario, Canada
| | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Michelle H Biros
- University of Minnesota, 5635, Department of Emergency Medicine, Minneapolis, Minnesota, United States
| | - Roy G Brower
- School of Medicine, Johns Hopkins University, Pulmonary and Critical Care, Baltimore, Maryland, United States
| | | | | | - Niall D Ferguson
- University Health Network, Department of Medicine, Division of Respirology, Toronto, Ontario, Canada.,University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Michelle N Gong
- Montefiore Medical Center, Division of Critical Care Med, Bronx, New York, United States
| | - Ramona O Hopkins
- Brigham Young University, Psychology, Provo, Utah, United States.,Intermountain Medical Center, Critical Care Medicine, Murray, Utah, United States
| | - Catherine L Hough
- University of Washington, Pulmonary and Critical Care Medicine, Seattle, Washington, United States
| | - Theodore J Iwashyna
- University of Michigan, Division of Pulmonary and Critical Care Medicine, Ann Arbor, Michigan, United States
| | - Bruce D Levy
- Brigham and Women's Hospital Biomedical Research Institute, 278479, Pulmonary and Critical Care Medicine, Boston, Massachusetts, United States
| | - Thomas R Martin
- University of Washington, 7284, Medicine, Seattle, Washington, United States
| | - Michael A Matthay
- Cardiovascular Research Institute (CVRI), University of San Francisco, Medicine and Anesthesia, San Francisco, California, United States
| | - Joseph P Mizgerd
- BU School of Medicine, Pulmonary Center, Boston, Massachusetts, United States
| | - Marc Moss
- University of Colorado/ Emory University, Division of Pulmonary Sciences and Critical Care Medicine, Denver, Colorado, United States
| | - Dale M Needham
- Johns Hopkins University, Pulmonary & Critical Care Medicine, Baltimore, Maryland, United States
| | - Wesley H Self
- Vanderbilt University Medical Center, 12328, Department of Emergency Medicine, Nashville, Tennessee, United States
| | | | - Renee D Stapleton
- University of Vermont College of Medicine, 12352, Division of Pulmonary Disease and Critical Care Medicine, Burlington, Vermont, United States
| | - B Taylor Thompson
- Massachusetts General Hospital, Harvard School of Medicine,, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston, Massachusetts, United States
| | | | - Neil R Aggarwal
- National Heart Lung and Blood Institute Division of Lung Diseases, 377197, Bethesda, Maryland, United States
| | - Lora A Reineck
- NHLBI, 35035, Division of Lung Diseases, Bethesda, Maryland, United States;
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7
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Abstract
Few guidelines have greater acceptance than that for management of community-acquired pneumonia (CAP). Despite this, areas remain controversial, and new challenges continue to emerge. Current guidelines differ from those of northern European countries predominantly in need for macrolide combination with β-lactams for hospitalized, non-intensive care unit patients. A preponderance of evidence favors combination therapy. Challenges for current and future CAP guidelines include new antibiotic classes, emergence of viruses as major causes for CAP, new diagnostic modalities, alternative risk stratification for pathogens resistant to usual CAP antibiotics, and evidence-based management of severe CAP, including immunomodulatory therapy such as corticosteroids.
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Affiliation(s)
- Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, 240 East Huron Street, McGaw M-336, Chicago, IL 60611, USA.
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8
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Berger S, Goekeri C, Gupta SK, Vera J, Dietert K, Behrendt U, Lienau J, Wienhold SM, Gruber AD, Suttorp N, Witzenrath M, Nouailles G. Delay in antibiotic therapy results in fatal disease outcome in murine pneumococcal pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:287. [PMID: 30382866 PMCID: PMC6211394 DOI: 10.1186/s13054-018-2224-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) remains a major cause of death worldwide. Mechanisms underlying the detrimental outcome despite adequate antibiotic therapy and comorbidity management are still not fully understood. METHODS To model timely versus delayed antibiotic therapy in patients, mice with pneumococcal pneumonia received ampicillin twice a day starting early (24 h) or late (48 h) after infection. Clinical readouts and local and systemic inflammatory mediators after early and late antibiotic intervention were examined. RESULTS Early antibiotic intervention rescued mice, limited clinical symptoms and restored fitness, whereas delayed therapy resulted in high mortality rates. Recruitment of innate immune cells remained unaffected by antibiotic therapy. However, both early and late antibiotic intervention dampened local levels of inflammatory mediators in the alveolar spaces. Early treatment protected from barrier breakdown, and reduced levels of vascular endothelial growth factor (VEGF) and perivascular and alveolar edema formation. In contrast, at 48 h post infection, increased pulmonary leakage was apparent and not reversed by late antibiotic treatment. Concurrently, levels of VEGF remained high and no beneficial effect on edema formation was evident despite therapy. Moreover, early but not late treatment protected mice from a vast systemic inflammatory response. CONCLUSIONS Our data show that only early antibiotic therapy, administered prior to breakdown of the alveolar-capillary barrier and systemic inflammation, led to restored fitness and rescued mice from fatal streptococcal pneumonia. The findings highlight the importance of identifying CAP patients prior to lung barrier failure and systemic inflammation and of handling CAP as a medical emergency.
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Affiliation(s)
- Sarah Berger
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Cengiz Goekeri
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Shishir K Gupta
- Department of Dermatology, Laboratory of Systems Tumor Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Julio Vera
- Department of Dermatology, Laboratory of Systems Tumor Immunology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Kristina Dietert
- Department of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany
| | - Ulrike Behrendt
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Jasmin Lienau
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Sandra-Maria Wienhold
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Achim D Gruber
- Department of Veterinary Pathology, Freie Universität Berlin, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Martin Witzenrath
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
| | - Geraldine Nouailles
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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9
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Tao RJ, Luo XL, Xu W, Mao B, Dai RX, Li CW, Yu L, Gu F, Liang S, Lu HW, Chen KB, Bai JW, Ji XB, Gu SY, Sun XL, Dai FH, Jiang P, Cao WJ, Xu JF. Viral infection in community acquired pneumonia patients with fever: a prospective observational study. J Thorac Dis 2018; 10:4387-4395. [PMID: 30174887 DOI: 10.21037/jtd.2018.06.33] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Patients with community acquired pneumonia (CAP) caused by viruses can develop severe complications, which result in hospitalization and death. The purpose of this study was to analyse the aetiology, incidence, clinical characteristics, and outcomes of CAP patients with fever during non-pandemics, and then to provide theoretical basis for accurate diagnosis and treatment in CAP patients. Methods An enrolment system was established for monitoring the CAP patients with fever. Multiplex polymerase chain reaction (mPCR) kits were used to detect 10 viruses [influenza A and B, adenovirus (ADV), respiratory syncytial virus (RSV) A and B, picornavirus, parainfluenza virus (PIV), coronavirus, human metapneumovirus (HMPV), and bocavirus]. Data on age, gender, underlying diseases, complications, laboratory indexes, and outcomes were collected by physicians. Results This prospective study included 320 patients with fever. Among them, 23.4% were viral-positive by mPCR, with influenza virus most prominent followed by picornavirus. Strong variation in seasonal distribution was shown in viral infections, with peak months from December to February. Patients with influenza infection were likely to be taken to emergency rooms and have respiratory failure with higher creatinine kinase levels and lower white blood cell counts. Streptococcus pneumoniae followed by haemophilus influenzae were the most common bacteria in viral co-infections, which accounted for one third of virus-positive patients. Viral CAP and mixed CAP were not independent factors for death. In addition, lactate dehydrogenase (LDH) >246 IU/L [odds ratio (OR) =7.06, 95% confidence interval (CI): 2.15-23.2, P=0.001], and serum calcium <2.18 mmol/L (OR =6.67, 95% CI: 1.42-31.3, P=0.016) were associated with death. Conclusions Viruses play an important role in CAP patients with fever, a systematic clinical, radiological and biological analysis of these patients can contribute to effective therapy that may prevent the development of CAP and improve the outcomes. The present work showed an elaborate analysis evidence of viral infection among fever CAP inpatients.
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Affiliation(s)
- Ru-Jia Tao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Xiao-Li Luo
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Wen Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Bei Mao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Ruo-Xuan Dai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Cheng-Wei Li
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Li Yu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Fen Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Shuo Liang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Hai-Wen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Ke-Bin Chen
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jiu-Wu Bai
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Xiao-Bin Ji
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Shu-Yi Gu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Xiao-Li Sun
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Fa-Hui Dai
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201058, China
| | - Ping Jiang
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Wei-Jun Cao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
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10
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11
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Wu WF, Fang Q, He GJ. Efficacy of corticosteroid treatment for severe community-acquired pneumonia: A meta-analysis. Am J Emerg Med 2018; 36:179-184. [DOI: 10.1016/j.ajem.2017.07.050] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 02/08/2023] Open
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12
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van ’t Veer C, Roelofs J, Gerlitz B, Grinnell B, Levi M, der Poll T, Schouten M. Recombinant activated protein C attenuates coagulopathy and inflammation when administered early in murine pneumococcal pneumonia. Thromb Haemost 2017; 106:1189-96. [DOI: 10.1160/th11-06-0438] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 08/17/2011] [Indexed: 02/04/2023]
Abstract
SummaryRecombinant human activated protein C (APC), which has both anticoagulant and anti-inflammatory properties, improves survival of patients with severe sepsis. This beneficial effect is especially apparent in patients with pneumococcal pneumonia. Earlier treatment with APC in sepsis has been associated with a better therapeutic response as compared to later treatment. In a mouse model it was recently confirmed that recombinant murine (rm-)APC decreases coagulation activation and improves survival in pneumococcal pneumonia; however, APC did not impact on the inflammatory response. The aim of this study was to determine the effect of APC treatment instigated early in infection on activation of coagulation and inflammation after induction of pneumococcal pneumonia. Mice were infected intranasally with viable S. pneumoniae. Mice were treated with rm-APC (125 μg) or vehicle intraperitoneally 12 hours after infection and were sacrificed after 20 hours, after which blood and organs were harvested for determination of bacterial outgrowth, coagulation activation and inflammatory markers. In this early treatment model, rm-APC treatment inhibited pulmonary and systemic activation of coagulation as reflected by lower levels of throm-bin-antithrombin complexes and D-dimer. Moreover, rm-APC reduced the levels of a large number of cytokines and chemokines in the lung. When administered early in pneumococcal pneumonia, rm-APC inhibits systemic and pulmonary activation of coagulation and moreover exerts various anti-inflammatory effects in the lung.
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Voiriot G, Visseaux B, Cohen J, Nguyen LBL, Neuville M, Morbieu C, Burdet C, Radjou A, Lescure FX, Smonig R, Armand-Lefèvre L, Mourvillier B, Yazdanpanah Y, Soubirou JF, Ruckly S, Houhou-Fidouh N, Timsit JF. Viral-bacterial coinfection affects the presentation and alters the prognosis of severe community-acquired pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:375. [PMID: 27852281 PMCID: PMC5112669 DOI: 10.1186/s13054-016-1517-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/29/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multiplex polymerase chain reaction (mPCR) enables recovery of viruses from airways of patients with community-acquired pneumonia (CAP), although their clinical impact remains uncertain. METHODS Among consecutive adult patients who had undergone a mPCR within 72 hours following their admission to one intensive care unit (ICU), we retrospectively included those with a final diagnosis of CAP. Four etiology groups were clustered: bacterial, viral, mixed (viral-bacterial) and no etiology. A composite criterion of complicated course (hospital death or mechanical ventilation > 7 days) was used. A subgroup analysis compared patients with bacterial and viral-bacterial CAP matched on the bacterial pathogens. RESULTS Among 174 patients (132 men [76 %], age 63 [53-75] years, SAPSII 38 [27;55], median PSI score 106 [78;130]), bacterial, viral, mixed and no etiology groups gathered 46 (26 %), 53 (31 %), 45 (26 %) and 30 (17 %) patients, respectively. Virus-infected patients displayed a high creatine kinase serum level, a low platelet count, and a trend toward more frequent alveolar-interstitial infiltrates. A complicated course was more frequent in the mixed group (31/45, 69 %), as compared to bacterial (18/46, 39 %), viral (15/53, 28 %) and no etiology (12/30, 40 %) groups (p < 0.01). In multivariate analysis, the mixed (viral-bacterial) infection was independently associated with complicated course (reference: bacterial pneumonia; OR, 3.58; CI 95 %, 1.16-11; p = 0.03). The subgroup analysis of bacteria-matched patients confirmed these findings. CONCLUSIONS Viral-bacterial coinfection during severe CAP in adults is associated with an impaired presentation and a complicated course.
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Affiliation(s)
- Guillaume Voiriot
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France. .,Hôpital Bichat Claude Bernard, 46 rue Henri Huchard, Paris, 75018, France.
| | - Benoit Visseaux
- Service de Virologie, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Johana Cohen
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Liem Binh Luong Nguyen
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Mathilde Neuville
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Caroline Morbieu
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Charles Burdet
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Aguila Radjou
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - François-Xavier Lescure
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Roland Smonig
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Laurence Armand-Lefèvre
- Service de Microbiologie, Hôpital Bichat Claude Bernard, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Bruno Mourvillier
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Yazdan Yazdanpanah
- Service de Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France.,Université Paris Diderot-Paris VII, Paris, France
| | - Jean-Francois Soubirou
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Stephane Ruckly
- Université de Grenoble 1, Center U823 Epidemioloy of Cancers and Severe Diseases, La Tronche, France
| | - Nadhira Houhou-Fidouh
- Service de Virologie, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean-François Timsit
- Service de Réanimation Médicale et Infectieuse, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France.,Université Paris Diderot-Paris VII, Paris, France
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Peñaloza HF, Schultz BM, Nieto PA, Salazar GA, Suazo I, Gonzalez PA, Riedel CA, Alvarez-Lobos MM, Kalergis AM, Bueno SM. Opposing roles of IL-10 in acute bacterial infection. Cytokine Growth Factor Rev 2016; 32:17-30. [PMID: 27522641 DOI: 10.1016/j.cytogfr.2016.07.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 07/14/2016] [Indexed: 12/16/2022]
Abstract
Interleukin-10 (IL-10) is recognized as an anti-inflammatory cytokine that downmodulates inflammatory immune responses at multiple levels. In innate cells, production of this cytokine is usually triggered after pathogen recognition receptor (PRR) engagement by pathogen-associated molecular patterns (PAMPs) or damage-associated molecular patters (DAMPs), as well as by other soluble factors. Importantly, IL-10 is frequently secreted during acute bacterial infections and has been described to play a key role in infection resolution, although its effects can significantly vary depending on the infecting bacterium. While the production of IL-10 might favor host survival in some cases, it may also result harmful for the host in other circumstances, as it can prevent appropriate bacterial clearance. In this review we discuss the role of IL-10 in bacterial clearance and propose that this cytokine is required to recover from infection caused by extracellular or highly pro-inflammatory bacteria. Altogether, we propose that IL-10 drives excessive suppression of the immune response upon infection with intracellular bacteria or in non-inflammatory bacterial infections, which ultimately favors bacterial persistence and dissemination within the host. Thus, the nature of the bacterium causing infection is an important factor that needs to be taken into account when considering new immunotherapies that consist on the modulation of inflammation, such as IL-10. Indeed, induction of this cytokine may significantly improve the host's immune response to certain bacteria when antibiotics are not completely effective.
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Affiliation(s)
- Hernán F Peñaloza
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile
| | - Barbara M Schultz
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile
| | - Pamela A Nieto
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile
| | - Geraldyne A Salazar
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile
| | - Isidora Suazo
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile
| | - Pablo A Gonzalez
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile
| | - Claudia A Riedel
- Millennium Institute on Immunology and Immunotherapy, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas y Facultad de Medicina, Universidad Andrés Bello, Chile
| | - Manuel M Alvarez-Lobos
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Alexis M Kalergis
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile; Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile; INSERM U1064, Nantes, France
| | - Susan M Bueno
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Pontificia Universidad Católica de Chile, Chile; INSERM U1064, Nantes, France.
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Abdel Aziz AO, Abdel Fattah MT, Mohamed AH, Abdel Aziz MO, Mohammed MS. Mortality predictors in patients with severe community-acquired pneumonia requiring ICU admission. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2016. [DOI: 10.4103/1687-8426.184373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Liapikou A, Torres A. The clinical management of lower respiratory tract infections. Expert Rev Respir Med 2016; 10:441-452. [PMID: 26894943 DOI: 10.1586/17476348.2016.1156537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The 2010 Global Burden of Disease Study reported that lower respiratory tract infections, including pneumonia, are the fourth most common cause of death globally. The etiology of acute bronchitis and asthma exacerbations is mostly viral and the therapy is symptomatic. Management decisions in community acquired pneumonia regarding site of care, extent of assessment, and level of treatment are based primarily on disease severity (outpatient, inpatient, ICU admission). Antibiotics are the main choice of treatment for patients with pneumonia, acute exacerbations (AE) of COPD (including increased sputum purulence and worsening shortness of breath) and AE of non-CF bronchiectasis. Inhaled antibiotics may represent a more optimal approach for the treatment and prevention of AE of non-CF bronchiectasis. Approved strategies for the prevention of exacerbations include smoking cessation and rehabilitation programs, drug therapy and vaccination.
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Affiliation(s)
| | - Antoni Torres
- b Department of Pneumology, Institut Clinic del Tórax, Institut d'investigacions Biomèdiques August Pi i Sunyer - IDIBAPS , University of Barcelona - UB - Ciber de Enfermedades Respiratorias - CIBERES, Hospital Clinic , Barcelona , Spain
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17
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Marti C, Grosgurin O, Harbarth S, Combescure C, Abbas M, Rutschmann O, Perrier A, Garin N. Adjunctive Corticotherapy for Community Acquired Pneumonia: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0144032. [PMID: 26641253 PMCID: PMC4671611 DOI: 10.1371/journal.pone.0144032] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 11/12/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) induces lung and systemic inflammation, leading to high morbidity and mortality. We systematically reviewed the risks and benefits of adjunctive corticotherapy in the management of patients with CAP. METHODS We systematically searched Pubmed, Embase and the Cochrane Library for randomized controlled trials comparing adjunctive corticotherapy and antimicrobial therapy with antimicrobial therapy alone in patients with CAP. The primary outcome was 30-day mortality. Secondary outcomes were length of hospital stay, time to clinical stability and severe complications. RESULTS 14 trials (2077 patients) were included. The reported 30-day mortality was 7.9% (80/1018) among patients treated with adjunctive corticotherapy versus 8.3% (85/1028) among patients treated with antimicrobial therapy alone (RR 0.84; 95%CI 0.55 to1.29). Adjunctive corticotherapy was associated with a reduction of severe complications (RR 0.36; 95%CI 0.23 to 0.56), a shorter length of stay (9.0 days; 95%CI 7.6 to 10.7 vs 10.6 days; 95%CI 7.4 to 15.3) and a shorter time to clinical stability (3.3 days; 95% CI 2.8 to 4.1 vs 4.3 days; 95%CI 3.6 to 5.1). The risk of hyperglycemia was higher among patients treated with adjunctive corticotherapy (RR 1.59; 95%CI 1.06 to 2.38), whereas the risk of gastro-intestinal bleeding was similar (RR 0.83; 95%CI 0.35 to 1.93). In the subgroup analysis based on CAP severity, a survival benefit was found among patients with severe CAP (RR 0.47; 95%CI 0.23 to 0.96). CONCLUSION Adjunctive corticotherapy is associated with a reduction of length of stay, time to clinical stability, and severe complications among patients with CAP, but the effect on mortality remains uncertain.
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Affiliation(s)
- Christophe Marti
- Division of General Internal Medicine, Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Olivier Grosgurin
- Division of General Internal Medicine, Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Stephan Harbarth
- Division of Infectious Diseases, Department of Medical Specialties, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Christophe Combescure
- Department of Health and Community Medicine, University Hospitals of Geneva and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Mohamed Abbas
- Division of Infectious Diseases, Department of Medical Specialties, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Olivier Rutschmann
- Division of Emergency Medicine, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Arnaud Perrier
- Division of General Internal Medicine, Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Garin
- Division of General Internal Medicine, Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Geneva, Switzerland
- Division of Internal Medicine, Hôpital Riviera-Chablais, Monthey, Switzerland
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18
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Kim JW, Kim JJ, Yang HJ, Lim YS, Cho JS, Hwang IC, Han SH. The Prognostic Factors of Pneumonia with Septic Shock in Patients Presenting to the Emergency Department. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.4.258] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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19
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Hifumi T, Fujishima S, Abe T, Kiriu N, Inoue J, Kato H, Koido Y, Kawakita K, Kuroda Y, Sasaki J, Hori S. Prognostic factors of Streptococcus pneumoniae infection in adults. Am J Emerg Med 2015; 34:202-6. [PMID: 26508390 DOI: 10.1016/j.ajem.2015.10.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/10/2015] [Accepted: 10/13/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The mortality of severe sepsis has markedly decreased since the implementation of the Surviving Sepsis Campaign guidelines. The next logical step is to examine the necessity of individualized management guidelines for targeted therapy against specific bacteria. Streptococcus pneumoniae is the leading cause of community-acquired severe sepsis; however, little is known regarding the prognostic factors in adult patients with S pneumoniae sepsis. We aimed to identify prognostic factors in patients with S pneumoniae sepsis and to explore a subgroup of patients at high risk for death with detailed Sequential Organ Failure Assessment (SOFA) score analysis. METHODS We retrospectively reviewed the records of patients with S pneumoniae infection treated between 1st January 2006 and 31st July 2012. We identified prognostic factors for 28-day mortality using univariate and multivariate logistic regression models. RESULTS Of 171 patients (median age, 72 years) with S pneumoniae infection who were included in this study, the 28-day mortality was 17% (29/171). The SOFA score (odds ratio, 2.25; 95% confidence interval, 1.60-3.18; P < .001) and bacteremia (odds ratio, 19.0; 95% confidence interval, 4.06-90.20; P < .001) were identified as prognostic factors for the 28-day mortality. In a subgroup analysis with a cutoff value of the SOFA score determined by receiver operating characteristic analysis, patients with bacteremia and a SOFA score of at least 7 had a significantly higher mortality than did patients without bacteremia and a SOFA score lower than 7 (84% vs 0%, respectively). CONCLUSIONS Bacteremia and a SOFA score at least 7 were independent prognostic factors of poor outcome in S pneumoniae sepsis.
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Affiliation(s)
- Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan.
| | - Seitaro Fujishima
- Center for General Internal Medicine and Education, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Takayuki Abe
- Center for Clinical Research, Department of Preventive Medicine and Public Health, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nobuaki Kiriu
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Junichi Inoue
- Division of Critical Care Medicine and Trauma, Yamanashi Prefectural Central Hospital, Kofu, Yamanashi, Japan
| | - Hiroshi Kato
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Yuichi Koido
- Division of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tachikawa, Tokyo, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Miki, Kita, Kagawa, Japan
| | - Junichi Sasaki
- Department of Emergency Medicine and Critical Care Medicine, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
| | - Shingo Hori
- Department of Emergency Medicine and Critical Care Medicine, Keio University Hospital, Shinjuku-ku, Tokyo, Japan
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Welte T, Dellinger RP, Ebelt H, Ferrer M, Opal SM, Schliephake DE, Wartenberg-Demand A, Werdan K, Löffler K, Torres A. Concept for a study design in patients with severe community-acquired pneumonia: A randomised controlled trial with a novel IGM-enriched immunoglobulin preparation – The CIGMA study. Respir Med 2015; 109:758-67. [DOI: 10.1016/j.rmed.2015.03.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 02/11/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
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22
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Schouten M, van ‘t Veer C, Poulussen N, Meijers JC, Levi M, Esmon CT, van der Poll T. The cytoprotective effects of endogenous activated protein C reduce activation of coagulation during murine pneumococcal pneumonia and sepsis. Thromb Res 2015; 135:537-43. [DOI: 10.1016/j.thromres.2014.12.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/04/2014] [Accepted: 12/23/2014] [Indexed: 11/28/2022]
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Impellizzeri D, Bruschetta G, Esposito E, Cuzzocrea S. Emerging drugs for acute lung injury. Expert Opin Emerg Drugs 2015; 20:75-89. [PMID: 25560706 DOI: 10.1517/14728214.2015.1000299] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Acute respiratory distress syndromes (ARDS) are devastating disorders of overwhelming pulmonary inflammation and hypoxemia, resulting in high morbidity and mortality. AREAS COVERED The main pharmacological treatment strategies have focused on the attempted inhibition of excessive inflammation or the manipulation of the resulting physiological derangement causing respiratory failure. Additionally, such interventions may allow reduced occurence mechanical ventilation injury. Despite promising preclinical and small clinical studies, almost all therapies have been shown to be unsuccessful in large-scale randomized controlled trials. The evidence for pharmacological treatment for ARDS is reviewed. Potential future treatments are also presented. EXPERT OPINION We suggest for future clinical trials addressing prevention and early intervention to attenuate lung injury and progression to respiratory failure.
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Affiliation(s)
- Daniela Impellizzeri
- University of Messina, Department of Biological and Environmental Sciences , Viale Ferdinando Stagno D'Alcontres n°31 98166 Messina , Italy
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Rautanen A, Mills TC, Gordon AC, Hutton P, Steffens M, Nuamah R, Chiche JD, Parks T, Chapman SJ, Davenport EE, Elliott KS, Bion J, Lichtner P, Meitinger T, Wienker TF, Caulfield MJ, Mein C, Bloos F, Bobek I, Cotogni P, Sramek V, Sarapuu S, Kobilay M, Ranieri VM, Rello J, Sirgo G, Weiss YG, Russwurm S, Schneider EM, Reinhart K, Holloway PAH, Knight JC, Garrard CS, Russell JA, Walley KR, Stüber F, Hill AVS, Hinds CJ. Genome-wide association study of survival from sepsis due to pneumonia: an observational cohort study. THE LANCET. RESPIRATORY MEDICINE 2015; 3:53-60. [PMID: 25533491 PMCID: PMC4314768 DOI: 10.1016/s2213-2600(14)70290-5] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sepsis continues to be a major cause of death, disability, and health-care expenditure worldwide. Despite evidence suggesting that host genetics can influence sepsis outcomes, no specific loci have yet been convincingly replicated. The aim of this study was to identify genetic variants that influence sepsis survival. METHODS We did a genome-wide association study in three independent cohorts of white adult patients admitted to intensive care units with sepsis, severe sepsis, or septic shock (as defined by the International Consensus Criteria) due to pneumonia or intra-abdominal infection (cohorts 1-3, n=2534 patients). The primary outcome was 28 day survival. Results for the cohort of patients with sepsis due to pneumonia were combined in a meta-analysis of 1553 patients from all three cohorts, of whom 359 died within 28 days of admission to the intensive-care unit. The most significantly associated single nucleotide polymorphisms (SNPs) were genotyped in a further 538 white patients with sepsis due to pneumonia (cohort 4), of whom 106 died. FINDINGS In the genome-wide meta-analysis of three independent pneumonia cohorts (cohorts 1-3), common variants in the FER gene were strongly associated with survival (p=9·7 × 10(-8)). Further genotyping of the top associated SNP (rs4957796) in the additional cohort (cohort 4) resulted in a combined p value of 5·6 × 10(-8) (odds ratio 0·56, 95% CI 0·45-0·69). In a time-to-event analysis, each allele reduced the mortality over 28 days by 44% (hazard ratio for death 0·56, 95% CI 0·45-0·69; likelihood ratio test p=3·4 × 10(-9), after adjustment for age and stratification by cohort). Mortality was 9·5% in patients carrying the CC genotype, 15·2% in those carrying the TC genotype, and 25·3% in those carrying the TT genotype. No significant genetic associations were identified when patients with sepsis due to pneumonia and intra-abdominal infection were combined. INTERPRETATION We have identified common variants in the FER gene that associate with a reduced risk of death from sepsis due to pneumonia. The FER gene and associated molecular pathways are potential novel targets for therapy or prevention and candidates for the development of biomarkers for risk stratification. FUNDING European Commission and the Wellcome Trust.
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Affiliation(s)
- Anna Rautanen
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK.
| | - Tara C Mills
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | | | | | - Michael Steffens
- Institute for Medical Biometry, Informatics and Epidemiology (IMBIE) of the University of Bonn, Bonn, Germany
| | - Rosamond Nuamah
- William Harvey Research Institute, Barts and The London School of Medicine Queen Mary University of London, London, UK
| | | | - Tom Parks
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Stephen J Chapman
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Emma E Davenport
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | | | - Julian Bion
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Peter Lichtner
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Thomas Meitinger
- Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany; Technische Universität München, Institute of Human Genetics, Munich, Germany
| | - Thomas F Wienker
- Institute for Medical Biometry, Informatics and Epidemiology (IMBIE) of the University of Bonn, Bonn, Germany
| | - Mark J Caulfield
- William Harvey Research Institute, Barts and The London School of Medicine Queen Mary University of London, London, UK
| | - Charles Mein
- William Harvey Research Institute, Barts and The London School of Medicine Queen Mary University of London, London, UK
| | - Frank Bloos
- Jena University Hospital and Center for Sepsis Control and Care, Jena, Germany
| | - Ilona Bobek
- National Health Service Centre, Budapest, Hungary
| | | | | | | | | | | | - Jordi Rello
- CIBERES, Vall d'Hebron Institute of Research, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Gonzalo Sirgo
- Joan XXIII University Hospital, Pere Virgili Health Institute, University Rovirai Virgili, Tarragona, Spain
| | | | | | - E Marion Schneider
- Section of Experimental Anesthesiology, University Hospital, Ulm, Germany
| | - Konrad Reinhart
- Jena University Hospital and Center for Sepsis Control and Care, Jena, Germany
| | | | - Julian C Knight
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | | | | | | | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, and University of Bern, Switzerland
| | - Adrian V S Hill
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Charles J Hinds
- William Harvey Research Institute, Barts and The London School of Medicine Queen Mary University of London, London, UK
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de Boer JD, Kager LM, Roelofs JJTH, Meijers JCM, de Boer OJ, Weiler H, Isermann B, van 't Veer C, van der Poll T. Overexpression of activated protein C hampers bacterial dissemination during pneumococcal pneumonia. BMC Infect Dis 2014; 14:559. [PMID: 25366058 PMCID: PMC4228088 DOI: 10.1186/s12879-014-0559-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/14/2014] [Indexed: 12/27/2022] Open
Abstract
Background During pneumonia, inflammation and coagulation are activated as part of anti-bacterial host defense. Activated protein C (APC) has anticoagulant and anti-inflammatory properties and until recently was a registered drug for the treatment of severe sepsis. Streptococcus (S.) pneumoniae is the most common causative pathogen in community-acquired pneumonia. Methods We aimed to investigate the effect of high APC levels during experimental pneumococcal pneumonia. Wild type (WT) and APC overexpressing (APChigh)-mice were intranasally infected with S. pneumoniae and sacrificed after 6, 24 or 48 hours, or followed in a survival study. Results In comparison to WT mice, APChigh-mice showed decreased bacterial dissemination to liver and spleen, while no differences in bacterial loads were detected at the primary site of infection. Although no differences in the extent of lung histopathology were seen, APChigh-mice showed a significantly decreased recruitment of neutrophils into lung tissue and bronchoalveolar lavage fluid. Activation of coagulation was not altered in APChigh-mice. No differences in survival were observed between WT and APChigh-mice (P =0.06). Conclusion APC overexpression improves host defense during experimental pneumococcal pneumonia. This knowledge may add to a better understanding of the regulation of the inflammatory and procoagulant responses during severe Gram-positive pneumonia. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0559-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes Daan de Boer
- Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, Amsterdam, The Netherlands. .,Center for Experimental and Molecular Medicine (CEMM), Academic Medical Center, Amsterdam, The Netherlands.
| | - Liesbeth M Kager
- Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, Amsterdam, The Netherlands. .,Center for Experimental and Molecular Medicine (CEMM), Academic Medical Center, Amsterdam, The Netherlands. .,Center for Experimental and Molecular Medicine (CEMM), Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105 AZ, Amsterdam, The Netherlands.
| | - Joris J T H Roelofs
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Joost C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands. .,Department Plasma Proteins, Sanquin, Amsterdam, The Netherlands.
| | - Onno J de Boer
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Hartmut Weiler
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA.
| | - Berend Isermann
- Department of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke University, Magdeburg, Germany.
| | - Cornelis van 't Veer
- Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, Amsterdam, The Netherlands. .,Center for Experimental and Molecular Medicine (CEMM), Academic Medical Center, Amsterdam, The Netherlands.
| | - Tom van der Poll
- Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, Amsterdam, The Netherlands. .,Center for Experimental and Molecular Medicine (CEMM), Academic Medical Center, Amsterdam, The Netherlands. .,Division of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.
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Salluh JI, Lisboa T, Bozza FA, Soares M, Póvoa P. Management of severe community-acquired pneumonia: A survey on the attitudes of 468 physicians in Iberia and South America. J Crit Care 2014; 29:743-7. [DOI: 10.1016/j.jcrc.2014.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/26/2014] [Accepted: 05/14/2014] [Indexed: 10/25/2022]
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27
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Achouiti A, Vogl T, Endeman H, Mortensen BL, Laterre PF, Wittebole X, van Zoelen MAD, Zhang Y, Hoogerwerf JJ, Florquin S, Schultz MJ, Grutters JC, Biesma DH, Roth J, Skaar EP, van 't Veer C, de Vos AF, van der Poll T. Myeloid-related protein-8/14 facilitates bacterial growth during pneumococcal pneumonia. Thorax 2014; 69:1034-42. [PMID: 25179663 DOI: 10.1136/thoraxjnl-2014-205668] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Streptococcus pneumoniae is the most commonly identified pathogen in community-acquired pneumonia (CAP). Myeloid-related protein (MRP) 8/14 is a major component of neutrophils that is released upon infection or injury. MRP8/14 is essential for protective immunity during infection by a variety of micro-organisms through its capacity to chelate manganese and zinc. Here, we aimed to determine the role of MRP8/14 in pneumococcal pneumonia. METHODS MRP8/14 was determined in bronchoalveolar lavage fluid (BALF) and serum of CAP patients, in lung tissue of patients who had succumbed to pneumococcal pneumonia, and in BALF of healthy subjects challenged with lipoteichoic acid (a component of the gram-positive bacterial cell wall) via the airways. Pneumonia was induced in MRP14 deficient and normal wildtype mice. The effect of MRP8/14 on S. pneumoniae growth was studied in vitro. RESULTS CAP patients displayed high MRP8/14 levels in BALF, lung tissue and serum. Healthy subjects challenged with lipoteichoic acid demonstrated elevated MRP8/14 in BALF. Likewise, mice with pneumococcal pneumonia had high MRP8/14 levels in lungs and the circulation. MRP14 deficiency, however, was associated with reduced bacterial growth and lethality, in the absence of notable effects on the inflammatory response. High zinc levels strongly inhibited growth of S. pneumoniae in vitro, which was partially reversed by MRP8/14. CONCLUSIONS In sharp contrast to its previously reported host-protective role in several infections, the present results reveal that in a model of CAP, MRP8/14 is misused by S. pneumoniae, facilitating bacterial growth by attenuating zinc toxicity toward the pathogen.
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Affiliation(s)
- Ahmed Achouiti
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas Vogl
- Institute of Immunology, University of Muenster, Muenster, Germany
| | - Henrik Endeman
- Intensive Care Department, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Brittany L Mortensen
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Pierre-Francois Laterre
- Department of Critical Care Medicine, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Xavier Wittebole
- Department of Critical Care Medicine, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Marieke A D van Zoelen
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yaofang Zhang
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jacobien J Hoogerwerf
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, University of Amsterdam, Amsterdam, The Netherlands Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan C Grutters
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands Division of Heart & Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Douwe H Biesma
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes Roth
- Institute of Immunology, University of Muenster, Muenster, Germany
| | - Eric P Skaar
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Cornelis van 't Veer
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alex F de Vos
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, University of Amsterdam, Amsterdam, The Netherlands Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, The Netherlands
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Violi F, Cangemi R, Calvieri C. Pneumonia, thrombosis and vascular disease. J Thromb Haemost 2014; 12:1391-400. [PMID: 24954194 DOI: 10.1111/jth.12646] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Indexed: 02/06/2023]
Abstract
SUMMARY An enhanced risk of cardiovascular mortality has been observed after pneumonia. Epidemiological studies have shown that respiratory tract infections are associated with an increased risk of thrombotic-related vascular disease such as myocardial infarction, ischemic stroke and venous thrombosis. Myocardial infarction and stroke have been detected essentially in the early phase of the disease (i.e. within 48 h from hospital admission), with an incidence ranging from as low as 1% to as high as 11%. Age, previous cardiovascular events and high pneumonia severity index were independent predictors of myocardial infarction; clinical predictors of stroke were not identified. Deep venous thrombosis and pulmonary embolism may also occur after pneumonia but incidence and clinical predictors must be defined. The biological plausibility of such an association may be deduced by experimental and clinical studies, showing that lung infection is complicated by platelet aggregation and clotting system activation, as documented by up-regulation of tissue factor and down-regulation of activated protein C. The effect of antithrombotic drugs has been examined in experimental and clinical studies but results are still inconclusive.
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Affiliation(s)
- F Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Plovsing RR, Berg RMG, Evans KA, Konge L, Iversen M, Garred P, Møller K. Transcompartmental inflammatory responses in humans: IV versus endobronchial administration of endotoxin*. Crit Care Med 2014; 42:1658-65. [PMID: 24732241 DOI: 10.1097/ccm.0000000000000320] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Transcompartmental signaling during early inflammation may lead to propagation of disease to other organs. The time course and the mechanisms involved are still poorly understood. We aimed at comparing acute transcompartmental inflammatory responses in humans following lipopolysaccharide-induced pulmonary and systemic inflammation. DESIGN Randomized, double-blind, placebo-controlled, crossover study. SETTING ICU SUBJECTS Healthy male volunteers. INTERVENTIONS Fifteen volunteers (mean age, 23; SD, 2 yr) received Escherichia coli endotoxin (lipopolysaccharide, 4 ng/kg) IV or endobronchially on two different study days. Groups were evaluated by bronchoalveolar lavage at baseline (0 hr) and 2, 4, 6, 8, or 24 hours postchallenge. Cardiorespiratory variables were continuously recorded throughout the study day, and plasma and bronchoalveolar lavage fluid markers of inflammation were measured. MEASUREMENTS AND MAIN RESULTS IV endotoxin elicited a systemic inflammatory response with a time-dependent increase and peak in tumor necrosis factor-α, interleukin-6, and leukocyte counts (all p < 0.001). Furthermore, a delayed (6-8 hr) increase in bronchoalveolar lavage fluid interleukin-6 concentration (p < 0.001) and alveolar leukocyte count (p = 0.03) and a minor increase in bronchoalveolar lavage fluid tumor necrosis factor-α were observed (p = 0.06). Endobronchial endotoxin was followed by progressive alveolar neutrocytosis and increased bronchoalveolar lavage fluid tumor necrosis factor-α, interleukin-6, and albumin (all p < 0.001); a systemic inflammatory response was observed after 2-4 hours, with no change in plasma tumor necrosis factor-α. CONCLUSIONS Acute lung or systemic inflammation in humans is followed by a transcompartmental proinflammatory response, the degree and differential kinetics of which suggests that the propagation of inflammation may depend on the primary site of injury.
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Affiliation(s)
- Ronni R Plovsing
- 1Department of Intensive Care, University Hospital Rigshospitalet, Copenhagen Ø, Denmark. 2Centre of Inflammation and Metabolism, Department of Infectious Diseases M7641, University Hospital Rigshospitalet, Copenhagen Ø, Denmark. 3Neurovascular Research Laboratory, Faculty of Health, Science and Sport, University of Glamorgan, South Wales, United Kingdom. 4Centre for Clinical Education, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark. 5The Heart Centre, Department of Lung Transplantation, University Hospital Rigshospitalet, Copenhagen Ø, Denmark. 6Laboratory of Molecular Medicine, Department of Clinical Immunology M7631, University Hospital Rigshospitalet, Copenhagen Ø, Denmark. 7Neurointensive Care Unit 2093, Department of Neuroanesthesiology, University Hospital Rigshospitalet, Copenhagen Ø, Denmark
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Recombinant human activated protein C in the treatment of acute respiratory distress syndrome: a randomized clinical trial. PLoS One 2014; 9:e90983. [PMID: 24632673 PMCID: PMC3954619 DOI: 10.1371/journal.pone.0090983] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 02/04/2014] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Pulmonary coagulopathy may play a pathogenetic role in acute respiratory distress syndrome (ARDS), by contributing to alveolocapillary inflammation and increased permeability. Recombinant human activated protein C (rh-APC) may inhibit this process and thereby improve patient outcome. METHODS A prospective randomized, saline-controlled, single-blinded clinical trial was performed in the intensive care units of two university hospitals, and patients with ARDS were included within 24 h after meeting inclusion criteria. INTERVENTION A 4-day course of intravenous rh-APC (24 mcg/kg/h) (n = 33) versus saline (n = 38). OUTCOMES The primary outcome parameter was the pulmonary leak index (PLI) of 67Gallium-transferrin as a measure of alveolocapillary permeability and secondary outcomes were disease severity scores and ventilator-free days, among others. RESULTS Baseline characteristics were similar; in 87% of patients the PLI was above normal and in 90% mechanical or non-invasive ventilation was instituted at a median lung injury score of 2.5. There was no evidence that Rh-APC treatment affected the PLI or attenuated lung injury and sequential organ failure assessment scores. Mean ventilator-free days amounted to 14 (rh-APC) and 12 days (saline, P = 0.35). 28-day mortality was 6% in rh-APC- and 18% in saline-treated patients (P = 0.12). There was no difference in bleeding events. The study was prematurely discontinued because rh-APC was withdrawn from the market. CONCLUSION There is no evidence that treatment with intravenous rh-APC during 4 days for infectious or inflammatory ARDS ameliorates increased alveolocapillary permeability or the clinical course of ARDS patients. We cannot exclude underpowering. TRIAL REGISTRATION Nederlands Trial Register ISRCTN 52566874.
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31
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Schouten M, de Boer JD, Kager LM, Roelofs JJTH, Meijers JCM, Esmon CT, Levi M, van 't Veer C, van der Poll T. The endothelial protein C receptor impairs the antibacterial response in murine pneumococcal pneumonia and sepsis. Thromb Haemost 2014; 111:970-80. [PMID: 24401906 DOI: 10.1160/th13-10-0859] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 12/10/2013] [Indexed: 11/05/2022]
Abstract
Pneumococcal pneumonia is a frequent cause of gram-positive sepsis and has a high mortality. The endothelial protein C receptor (EPCR) has been implicated in both the activation of protein C (PC) and the anti-inflammatory actions of activated (A)PC. The aim of this study was to determine the role of the EPCR in murine pneumococcal pneumonia and sepsis. Wild-type (WT), EPCR knockout (KO) and Tie2-EPCR mice, which overexpress EPCR on the endothelium, were infected intranasally (pneumonia) or intravenously (sepsis) with viable Streptococcus pneumoniae and euthanised at 24 or 48 hours after initiation of the infection for analyses. Pneumonia did not alter constitutive EPCR expression on pulmonary endothelium but was associated with an influx of EPCR positive neutrophils into lung tissue. In pneumococcal pneumonia EPCR KO mice demonstrated diminished bacterial growth in the lungs and dissemination to spleen and liver, reduced neutrophil recruitment to the lungs and a mitigated inflammatory response. Moreover, EPCR KO mice displayed enhanced activation of coagulation in the early phase of disease. Correspondingly, in pneumococcal sepsis EPCR KO mice showed reduced bacterial growth in lung and liver and attenuated cytokine release. Conversely, EPCR-overexpressing mice displayed higher bacterial outgrowth in lung, blood, spleen and liver in pneumococcal sepsis. In conclusion, EPCR impairs antibacterial defense in both pneumococcal pneumonia and sepsis, which is associated with an enhanced pro-inflammatory response.
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Affiliation(s)
- Marcel Schouten
- Marcel Schouten, MD, Center for Experimental and Molecular Medicine (CEMM), Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105 AZ Amsterdam, The Netherlands, Tel.: +31 20 566 5910, Fax: +31 20 697 7192, E-mail:
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Birkhamshaw E, Waitt CJ, Innes M, Waitt PI. Severity assessment of lower respiratory tract infection in Malawi: derivation of a novel index (SWAT-Bp) which outperforms CRB-65. PLoS One 2013; 8:e82178. [PMID: 24324763 PMCID: PMC3855704 DOI: 10.1371/journal.pone.0082178] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 10/22/2013] [Indexed: 01/20/2023] Open
Abstract
Objective To assess the validity of CRB-65 (Confusion, Respiratory rate >30 breaths/min, BP<90/60 mmHg, age >65 years) as a pneumonia severity index in a Malawian hospital population, and determine whether an alternative score has greater accuracy in this setting. Design Forty three variables were prospectively recorded during the first 48 hours of admission in all patients admitted to Queen Elizabeth Central Hospital, Malawi, for management of lower respiratory tract infection over a two month period (N = 240). Calculation of sensitivity and specificity for CRB-65 in predicting mortality was followed by multivariate modeling to create a score with superior performance in this population. Results Median age 37, HIV prevalence 79.9%, overall mortality 18.3%. CRB-65 predicted mortality poorly, indicated by the area under the ROC curve of 0.649. Independent predictors of death were: Male sex, “S” (AOR 2.6); Wasting, “W” (AOR 6.6); non-ambulatory, “A” (AOR 2.5); Temp >38°C or <35°C, “T” (AOR 3.2); BP<100/60, “Bp” (AOR 3.7). Combining these factors to form a severity index (SWAT-Bp) predicted mortality with high sensitivity and specificity (AUC: 0.867). Mortality for scores 0–5 was 0%, 3.3%, 7.4%, 29.2%, 61.5% and 87.5% respectively. A score ≥3 was 84% sensitive and 77% specific for mortality prediction, with a negative predictive value of 95.8%. Conclusion CRB-65 performs poorly in this population. The SWAT-Bp score can accurately stratify patients; ≤2 indicates non-severe infection (mortality 4.4%) and ≥3 severe illness (mortality 45%).
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Affiliation(s)
- Edmund Birkhamshaw
- Birmingham College of Medicine, Birmingham University, Birmingham, United Kingdom
- * E-mail: (EB); (CW)
| | - Catriona J. Waitt
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
- * E-mail: (EB); (CW)
| | - Michael Innes
- Department of Primary Care, Birmingham University, Birmingham, United Kingdom
| | - Peter I. Waitt
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Achouiti A, de Vos AF, de Beer R, Florquin S, van 't Veer C, van der Poll T. Limited role of the receptor for advanced glycation end products during Streptococcus pneumoniae bacteremia. J Innate Immun 2013; 5:603-12. [PMID: 23774862 DOI: 10.1159/000348739] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 02/07/2013] [Indexed: 12/22/2022] Open
Abstract
Streptococcus pneumoniae is one of the most common causes of sepsis. Sepsis is associated with the release of 'damage-associated molecular patterns' (DAMPs). The receptor for advanced glycation end products (RAGE) is a multiligand receptor, abundantly expressed in the lungs, that recognizes several of these DAMPs. Triggering of RAGE leads to activation of the NF-κB pathway and perpetuation of inflammation. Earlier investigations have shown that the absence of RAGE reduces inflammation and bacterial dissemination and increases survival in sepsis caused by S. pneumoniae pneumonia. We hypothesized that the detrimental role of RAGE depends on the level of RAGE expression in the primary organ of infection. By directly injecting S. pneumoniae intravenously, thereby circumventing the extensive RAGE-expressing lung, we here determined whether RAGE contributes to an adverse outcome of bacteremia or whether its role is restricted to primary lung infection. During late-stage infection (48 h), rage(-/-) mice had an attenuated systemic inflammatory response, as reflected by lower plasma levels of proinflammatory cytokines, reduced endothelial cell activation (as measured by E-selectin levels) and less neutrophil accumulation in lung tissue. However, RAGE deficiency did not influence bacterial loads or survival in this model. In accordance, plasma markers for cell injury were similar in both mouse strains. These results demonstrate that while RAGE plays a harmful part in S. pneumoniae sepsis originating from the respiratory tract, this receptor has a limited role in the outcome of primary bloodstream infection by this pathogen.
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Affiliation(s)
- Ahmed Achouiti
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Cornet AD, Hofstra JJ, Vlaar AP, Tuinman PR, Levi M, Girbes AR, Schultz MJ, Groeneveld AB, Beishuizen A. Activated protein C attenuates pulmonary coagulopathy in patients with acute respiratory distress syndrome. J Thromb Haemost 2013; 11:894-901. [PMID: 23433188 PMCID: PMC9906436 DOI: 10.1111/jth.12179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) frequently complicates critical illness. We hypothesized that an infusion of recombinant human activated protein C (rh-APC), a natural anticoagulant, would attenuate pulmonary coagulopathy and injury. METHODS In this sub study of a multicenter open-label randomized controlled trial of patients with ARDS, we compared an intravenous (i.v.) infusion of rh-APC (24 mcg kg(-1) h(-1) for 96 h) with placebo. Patients with sepsis or septic shock were excluded. RESULTS In 27 patients serial non-directed bronchoalveolar lavage fluid (NBLF) samples were obtained: 16 patients were treated with rh-APC and 11 patients with placebo. The rh-APC infusion was associated with higher APC levels in plasma during the infusion period of 4 days (P = 0.001), as well as higher APC levels in NBLF up to day 5 after the start of the infusion (P = 0.028). An infusion of rh-APC was associated with lower levels of thrombin-antithrombin complexes (P = 0.009) and soluble tissue factor (P = 0.011) in NBLF, compared with treatment with placebo. An infusion of rh-APC affected fibrinolysis, as plasminogen activator activity levels in NBLF were higher in the patients treated with rh-APC (P = 0.01), presumably as a result of lower NBLF levels of plasminogen activator inhibitor 1, (P = 0.01). The rh-APC infusion decreased the lung injury score (P = 0.005) and simplified the acute physiology score (P = 0.013) on day 5, when compared with baseline. The rh-APC infusion was not associated with bleeding complications. CONCLUSION An infusion of rh-APC in patients with ARDS attenuates pulmonary coagulopathy and injury.
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Affiliation(s)
- A D Cornet
- Department of Intensive Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
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Islam MA, Pröll M, Hölker M, Tholen E, Tesfaye D, Looft C, Schellander K, Cinar MU. Alveolar macrophage phagocytic activity is enhanced with LPS priming, and combined stimulation of LPS and lipoteichoic acid synergistically induce pro-inflammatory cytokines in pigs. Innate Immun 2013; 19:631-43. [PMID: 23608822 DOI: 10.1177/1753425913477166] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The objective of the present study was to investigate LPS and lipoteichoic acid (LTA)-induced TLRs, associated signaling molecules and inflammatory mediators, as well as to compare their combined effect in porcine alveolar macrophages. Macrophages were incubated for 24 h with various concentrations of LPS, LTA, LPS + LTA or control. Multiple concentrations of LPS elicited marked up-regulation in mRNA for TLR2 and TLR4, CD14, MD2, MyD88, IRAK-4 and TRAF6 compared with the control. LTA had no effect on TLR4 and MD2; only higher doses up-regulated TLR2, CD14, MyD88, IRAK-4 and TRAF6 mRNA. LPS-activated cells released IL1-β, IL12-β, TNF-α, IL-6, IL-8, IFN-γ and IL-10 in a dose-dependent manner, while LTA had no effect on IL-1β, IL-6 and IFN-γ. Higher doses of LTA induced IL-12β, TNF-α, IL-8 and IL-10. Combined stimulation augmented TLR2, CD14 and MyD88 mRNA, and subsequently produced elevated levels of IL-6, TNF-α and IL-8 when compared with LPS and LTA alone. Additionally, phagocytosis of macrophages was significantly increased following low concentration of LPS treatment. Only low levels of NO (nitric oxide) were detected in the LPS group. Overall, compared with LPS, LTA was a relatively weak inducer, and co-stimulation accelerated gene and cytokine production associated with pulmonary innate immune function.
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Confalonieri M, Annane D, Antonaglia C, Santagiuliana M, Borriello EM, Meduri GU. Is prolonged low-dose glucocorticoid treatment beneficial in community-acquired pneumonia? Curr Infect Dis Rep 2013; 15:158-66. [PMID: 23371407 DOI: 10.1007/s11908-013-0322-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Community-acquired pneumonia (CAP) has a significant impact on public health in terms of short-term and long-term morbidity and mortality. Irrespective of microbiological etiology, the host's inability to fully downregulate systemic inflammation is the dominant pathogenetic process contributing to acute and long-term morbidity and mortality in CAP. Glucocorticoids are the natural regulators of inflammation, and their production increases during infection. There is consistent evidence that downregulation of systemic inflammation with prolonged low-dose glucocorticoid treatment in patients with severe sepsis and acute respiratory distress syndrome improves cardiovascular and pulmonary organ physiology. A recent meta-analysis of pooled controlled small trials (n = 970) of patients admitted with CAP found improved short-term mortality in the subgroup with severe CAP and/or receiving >5 days of glucocorticoid treatment. We have expanded on this meta-analysis by including patients with CAP recruited in trials investigating prolonged low-dose glucocorticoid treatment in septic shock and/or early acute respiratory distress syndrome (n = 1,206). Our findings confirm a survival advantage for severe CAP (RR 0.66, 95% confidence interval 0.51-0.84; p = .001). A large randomized trial is in progress to confirm the aggregate findings of these small trials and to evaluate the long-term effect of this low-cost treatment.
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Affiliation(s)
- Marco Confalonieri
- Department of Pneumology & Respiratory Intensive Care Unit, University Hospital of Cattinara, Trieste, Italy,
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Cornet AD, van Nieuw Amerongen GP, Beishuizen A, Schultz MJ, Girbes AR, Groeneveld AJ. Activated protein C in the treatment of acute lung injury and acute respiratory distress syndrome. Expert Opin Drug Discov 2013; 4:219-27. [PMID: 23489122 DOI: 10.1517/17460440902721204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) frequently necessitate mechanical ventilation in the intensive care unit. The syndromes have a high mortality rate and there is at present no treatment specifically directed at the underlying pathogenesis. Central in the pathophysiology of ALI/ARDS is alveolocapillary inflammation leading to permeability edema. As a result of the crosstalk between inflammation and coagulation, activation of proinflammatory and procoagulant/antifibrinolytic pathways contributes to disruption of the endothelial barrier. Protein C (PC) plays a central role in maintaining the equilibrium between coagulation and inflammation. Additionally, natural anticoagulants, such as PC, are depleted, both in blood as well as in the lung. Therefore, the PC system is of interest as a therapeutic target in patients with ALI/ARDS. METHOD This review is based on a Medline search of relevant basic and clinical studies. OBJECTIVE It discusses the potential role of activated PC in modulating the proinflammatory/procoagulant state for enhancing endothelial barrier function in animal models and human ALI/ARDS.
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Affiliation(s)
- Alexander D Cornet
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands +31 20 4443933 ; +31 20 4442392 ;
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Sibila O, Restrepo MI, Anzueto A. What is the Best Antimicrobial Treatment for Severe Community-Acquired Pneumonia (Including the Role of Steroids and Statins and Other Immunomodulatory Agents). Infect Dis Clin North Am 2013; 27:133-47. [DOI: 10.1016/j.idc.2012.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Schouten M, van't Veer C, Roelofs JJTH, Levi M, van der Poll T. Protease-activated receptor-1 impairs host defense in murine pneumococcal pneumonia: a controlled laboratory study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R238. [PMID: 23270594 PMCID: PMC3672627 DOI: 10.1186/cc11910] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 12/14/2012] [Indexed: 01/21/2023]
Abstract
Introduction Streptococcus pneumoniae is the most common causative pathogen in community-acquired pneumonia. Protease-activated receptor-1 (PAR-1) is expressed by multiple cell types present in the lungs and can be activated by various proteases generated during acute inflammation. The cellular effect of PAR-1 activation partially depends on the specific protease involved. We here determined the role of PAR-1 in the host response during murine pneumococcal pneumonia. Methods Wild-type (WT) and PAR-1 knockout (KO) mice were infected intranasally with viable S. pneumoniae and observed in a survival study or euthanized at 6, 24 or 48 hours of infection. Results PAR-1 KO mice had a better survival early after infection compared to WT mice. Moreover, PAR-1 KO mice had lower bacterial loads in lungs and blood at 24 hours and in spleen and liver at 48 hours after infection. This favorable response was accompanied by lower lung histopathology scores and less neutrophil influx in PAR-1 KO mice. Conclusion PAR-1 impairs host defense during murine pneumococcal pneumonia.
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Tuinman PR, Dixon B, Levi M, Juffermans NP, Schultz MJ. Nebulized anticoagulants for acute lung injury - a systematic review of preclinical and clinical investigations. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R70. [PMID: 22546487 PMCID: PMC3681399 DOI: 10.1186/cc11325] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 04/02/2012] [Accepted: 04/30/2012] [Indexed: 12/16/2022]
Abstract
Background Data from interventional trials of systemic anticoagulation for sepsis inconsistently suggest beneficial effects in case of acute lung injury (ALI). Severe systemic bleeding due to anticoagulation may have offset the possible positive effects. Nebulization of anticoagulants may allow for improved local biological availability and as such may improve efficacy in the lungs and lower the risk of systemic bleeding complications. Method We performed a systematic review of preclinical studies and clinical trials investigating the efficacy and safety of nebulized anticoagulants in the setting of lung injury in animals and ALI in humans. Results The efficacy of nebulized activated protein C, antithrombin, heparin and danaparoid has been tested in diverse animal models of direct (for example, pneumonia-, intra-pulmonary lipopolysaccharide (LPS)-, and smoke inhalation-induced lung injury) and indirect lung injury (for example, intravenous LPS- and trauma-induced lung injury). Nebulized anticoagulants were found to have the potential to attenuate pulmonary coagulopathy and frequently also inflammation. Notably, nebulized danaparoid and heparin but not activated protein C and antithrombin, were found to have an effect on systemic coagulation. Clinical trials of nebulized anticoagulants are very limited. Nebulized heparin was found to improve survival of patients with smoke inhalation-induced ALI. In a trial of critically ill patients who needed mechanical ventilation for longer than two days, nebulized heparin was associated with a higher number of ventilator-free days. In line with results from preclinical studies, nebulization of heparin was found to have an effect on systemic coagulation, but without causing systemic bleedings. Conclusion Local anticoagulant therapy through nebulization of anticoagulants attenuates pulmonary coagulopathy and frequently also inflammation in preclinical studies of lung injury. Recent human trials suggest nebulized heparin for ALI to be beneficial and safe, but data are very limited.
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Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
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Martí-Carvajal AJ, Solà I, Gluud C, Lathyris D, Cardona AF. Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients. Cochrane Database Syst Rev 2012; 12:CD004388. [PMID: 23235609 PMCID: PMC6464614 DOI: 10.1002/14651858.cd004388.pub6] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been introduced to reduce the high risk of death associated with severe sepsis or septic shock. This systematic review is an update of a Cochrane review originally published in 2007. OBJECTIVES We assessed the benefits and harms of APC for patients with severe sepsis or septic shock. SEARCH METHODS We searched CENTRAL (The Cochrane Library 2012, Issue 6); MEDLINE (2010 to June 2012); EMBASE (2010 to June 2012); BIOSIS (1965 to June 2012); CINAHL (1982 to June 2012) and LILACS (1982 to June 2012). There was no language restriction. SELECTION CRITERIA We included randomized clinical trials assessing the effects of APC for severe sepsis or septic shock in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28 and at the end of study follow up, and hospital mortality as the primary outcomes. DATA COLLECTION AND ANALYSIS We independently performed trial selection, risk of bias assessment, and data extraction in duplicate. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model. MAIN RESULTS We identified one new randomized clinical trial in this update which includes six randomized clinical trials involving 6781 participants in total, five randomized clinical trials in adult (N = 6307) and one randomized clinical trial in paediatric (N = 474) participants. All trials had high risk of bias and were sponsored by the pharmaceutical industry. APC compared with placebo did not significantly affect all-cause mortality at day 28 compared with placebo (780/3435 (22.7%) versus 767/3346 (22.9%); RR 1.00, 95% confidence interval (CI) 0.86 to 1.16; I(2) = 56%). APC did not significantly affect in-hospital mortality (393/1767 (22.2%) versus 379/1710 (22.1%); RR 1.01, 95% CI 0.87 to 1.16; I(2) = 20%). APC was associated with an increased risk of serious bleeding (113/3424 (3.3%) versus 74/3343 (2.2%); RR 1.45, 95% CI 1.08 to 1.94; I(2) = 0%). APC did not significantly affect serious adverse events (463/3334 (13.9%) versus 439/3302 (13.2%); RR 1.04, 95% CI 0.92 to 1.18; I(2) = 0%). Trial sequential analyses showed that more trials do not seem to be needed for reliable conclusions regarding these outcomes. AUTHORS' CONCLUSIONS This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. APC seems to be associated with a higher risk of bleeding. The drug company behind APC, Eli Lilly, has announced the discontinuation of all ongoing clinical trials using this drug for treating patients with severe sepsis or septic shock. APC should not be used for sepsis or septic shock outside randomized clinical trials.
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Affiliation(s)
- Arturo J Martí-Carvajal
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad Tecnológica Equinoccial, Quito, Ecuador.
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An after action report of drotrecogin α (activated) and lessons for the future*. Pediatr Crit Care Med 2012; 13:692-4. [PMID: 23128590 DOI: 10.1097/pcc.0b013e31825b827e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Långström S, Peltola V, Petäjä J, Ruuskanen O, Heikinheimo M. Enhanced thrombin generation and depressed anticoagulant function in children with pneumonia. Acta Paediatr 2012; 101:919-23. [PMID: 22646857 DOI: 10.1111/j.1651-2227.2012.02746.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS To clarify the status of the coagulation system in children with community-acquired pneumonia. METHODS Coagulation activation markers (prothrombin fragment F1 + 2, thrombin-antithrombin complexes, D-dimer), the natural anticoagulants (antithrombin, protein C and S) and tissue factor were measured in 28 consecutive children with pneumonia on admission to the hospital. Patients were divided into those with either bacterial-type pneumonia (at least two of the following three criteria: plasma C-reactive protein (CRP) >80 mg/L, white blood cell count >15 × 10(9) /L and alveolar infiltrates on the chest radiograph) or viral-type pneumonia. RESULTS The majority of the patients (79%) showed elevation of at least one of the three coagulation activation markers. Plasma CRP concentration correlated with F1 + 2 (R = 0.44, p < 0.05) and D-dimer (R = 0.71, p < 0.0001). Patients with bacterial-type pneumonia (n = 17) had higher D-dimer levels (p < 0.05) and lower levels of antithrombin (p = 0.005) and protein C (p = 0.08) than the patients with viral-type pneumonia. CONCLUSIONS Children with community-acquired bacterial-type pneumonia show distinctive changes in their coagulation system. The finding of coagulation system activation and depressed function of natural anticoagulants in uncomplicated pneumonia helps to understand the rapid and unpredictable changes observed in the coagulation status in patients with more severe forms of disease.
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Mongardon N, Max A, Bouglé A, Pène F, Lemiale V, Charpentier J, Cariou A, Chiche JD, Bedos JP, Mira JP. Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive care unit: a multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R155. [PMID: 22894879 PMCID: PMC3580745 DOI: 10.1186/cc11471] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/15/2012] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) account for a high proportion of ICU admissions, with Streptococcus pneumoniae being the main pathogen responsible for these infections. However, little is known on the clinical features and outcomes of ICU patients with pneumococcal pneumonia. The aims of this study were to provide epidemiological data and to determine risk factors of mortality in patients admitted to ICU for severe S. pneumoniae CAP. METHODS We performed a retrospective review of two prospectively-acquired multicentre ICU databases (2001-2008). Patients admitted for management of severe pneumococcal CAP were enrolled if they met the 2001 American Thoracic Society criteria for severe pneumonia, had life-threatening organ failure and had a positive microbiological sample for S. pneumoniae. Patients with bronchitis, aspiration pneumonia or with non-pulmonary pneumococcal infections were excluded. RESULTS Two hundred and twenty two patients were included, with a median SAPS II score reaching 47 [36-64]. Acute respiratory failure (n = 154) and septic shock (n = 54) were their most frequent causes of ICU admission. Septic shock occurred in 170 patients (77%) and mechanical ventilation was required in 186 patients (84%); renal replacement therapy was initiated in 70 patients (32%). Bacteraemia was diagnosed in 101 patients. The prevalence of S. pneumoniae strains with decreased susceptibility to penicillin was 39.7%. Although antibiotherapy was adequate in 92.3% of cases, hospital mortality reached 28.8%. In multivariate analysis, independent risk factors for mortality were age (OR 1.05 (95% CI: 1.02-1.08)), male sex (OR 2.83 (95% CI: 1.16-6.91)) and renal replacement therapy (OR 3.78 (95% CI: 1.71-8.36)). Co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not influence outcome. CONCLUSIONS In ICU, mortality of pneumococcal CAP remains high despite adequate antimicrobial treatment. Baseline demographic data and renal replacement therapy have a major impact on adverse outcome.
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Design, conduct, and analysis of a multicenter, pharmacogenomic, biomarker study in matched patients with severe sepsis treated with or without drotrecogin Alfa (activated). Ann Intensive Care 2012; 2:15. [PMID: 22694772 PMCID: PMC3403963 DOI: 10.1186/2110-5820-2-15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 06/13/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A genomic biomarker identifying patients likely to benefit from drotrecogin alfa (activated) (DAA) may be clinically useful as a companion diagnostic. This trial was designed to validate biomarkers (improved response polymorphisms (IRPs)). Each IRP (A and B) contains two single nucleotide polymorphisms that were associated with a differential DAA treatment effect. METHODS DAA is typically given to younger patients with greater disease severity; therefore, a well-matched control group is critical to this multicenter, retrospective, controlled, outcome-blinded, genotype-blinded trial. Within each center, DAA-treated patients will be matched to controls treated within 24 months of each other taking into account age, APACHE II, cardiovascular, respiratory, renal, and hematologic dysfunction, mechanical ventilation status, medical/surgical status, and infection site. A propensity score will estimate the probability that a patient would have received DAA given their baseline characteristics. Two-phase data transfer will ensure unbiased selection of matched controls. The first transfer will be for eligibility and matching data and the second transfer for outcomes and genotypic data. The primary analysis will compare the effect of DAA in IRP + and IRP - groups on in-hospital mortality through day 28. DISCUSSION A design-based approach matching DAA-free to DAA-treated patients in a multicenter study of patients who have severe sepsis and high risk of death will directly compare control to DAA-treated groups for mortality by genotype. Results, which should be available in 2012, may help to identify the group of patients who would benefit from DAA and may provide a model for future investigation of sepsis therapies.
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Martí-Carvajal AJ, Solà I, Lathyris D, Cardona AF. Human recombinant activated protein C for severe sepsis. Cochrane Database Syst Rev 2012:CD004388. [PMID: 22419295 DOI: 10.1002/14651858.cd004388.pub5] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been used to reduce the high rate of death by severe sepsis or septic shock. This is an update of a Cochrane review (originally published in 2007 and updated in 2008). OBJECTIVES We assessed the clinical effectiveness and safety of APC for the treatment of patients with severe sepsis or septic shock. SEARCH METHODS For this updated review we searched CENTRAL (The Cochrane Library 2010, Issue 6); MEDLINE (1966 to June 2010); EMBASE (1980 to July 1, 2010); BIOSIS (1965 to July 1, 2010); CINAHL (1982 to 16 June 2010) and LILACS (1982 to 16 June 2010). There was no language restriction. SELECTION CRITERIA We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28, at the end of study follow up, and hospital mortality as the primary outcomes. DATA COLLECTION AND ANALYSIS We independently performed study selection, risk of bias assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model. MAIN RESULTS We identified one new RCT in this update. We included a total of five RCTs involving 5101 participants. For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.97, 95% confidence interval (CI) 0.78 to 1.22; P = 0.82, I(2) = 68%). APC use was associated with an increased risk of bleeding (RR 1.47, 95% CI 1.09 to 2.00; P = 0.01, I(2) = 0%). In paediatric patients, APC did not reduce the risk of death (RR 0.98, 95% CI 0.66 to 1.46; P = 0.93). Although the included trials had no major limitations most of them modified their original completion or recruitment protocols. AUTHORS' CONCLUSIONS This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC is associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.Warning: On October 25th 2011, the European Medicines Agency issued a press release on the worldwide withdrawal of Xigris (activated protein C / drotrecogin alfa) from the market by Eli Lilly due to lack of beneficial effect on 28-day mortality in the PROWESS-SHOCK study. Furthermore, Eli Lily has announced the discontinuation of all other ongoing clinical trials. The final results of the PROWESS-SHOCK study are expected to be published in 2012. This systematic review will be updated when results of the PROWESS-SHOCK or other trials are published.
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Affiliation(s)
- Arturo J Martí-Carvajal
- Universidad de Carabobo and Iberoamerican Cochrane Network, Valencia, Edo. Carabobo,Venezuela.
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Aslami H, Haitsma JJ, Hofstra JJ, Florquin S, Dos Santos C, Streutker C, Zhang H, Levi M, Slutsky AS, Schultz MJ. Plasma-derived human antithrombin attenuates ventilator-induced coagulopathy but not inflammation in a Streptococcus pneumoniae pneumonia model in rats. J Thromb Haemost 2012; 10:399-410. [PMID: 22236057 DOI: 10.1111/j.1538-7836.2012.04622.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Mechanical ventilation exaggerates pneumonia-associated pulmonary coagulopathy and inflammation. We hypothesized that the administration of plasma-derived human antithrombin (AT), one of the natural inhibitors of coagulation, prevents ventilator-induced pulmonary coagulopathy, inflammation and bacterial outgrowth in a Streptococcus pneumoniae pneumonia model in rats. METHODS Forty-eight hours after induction of S. pneumoniae pneumonia rats were subjected to mechanical ventilation (tidal volume 12 mL kg(-1), positive end-expiratory pressure 0 cmH(2)O and inspired oxygen fraction 40%). Rats were randomized to systemic treatment with AT (250 IU administered intravenously (i.v.) before the start of mechanical ventilation) or placebo (saline). Non-ventilated, non-infected rats and non-ventilated rats with pneumonia served as controls. The primary endpoints were pulmonary coagulation and inflammation in bronchoalveolar lavage fluid (BALF). RESULTS Pneumonia was characterized by local activation of coagulation and inhibition of fibrinolysis, resulting in increased levels of fibrin degradation products and fibrin deposition in the lung. Mechanical ventilation exaggerated pulmonary coagulopathy and inflammation. Systemic administration of AT led to supra-normal BALF levels of AT and decreased ventilator-associated activation of coagulation. AT neither affected pulmonary inflammation nor bacterial outgrowth from the lungs or blood. CONCLUSIONS Plasma-derived human AT attenuates ventilator-induced coagulopathy, but not inflammation and bacterial outgrowth in a S. pneumoniae pneumonia model in rats.
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Affiliation(s)
- H Aslami
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Combined Recombinant Human Activated Protein C and Ceftazidime Prevent the Onset of Acute Respiratory Distress Syndrome in Severe Sepsis. Shock 2012; 37:170-6. [DOI: 10.1097/shk.0b013e31823ca8ee] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effective Antibiotic Treatment Prescribed by Emergency Physicians in Patients Admitted to the Intensive Care Unit with Severe Sepsis or Septic Shock: Where is the Gap? J Emerg Med 2011; 41:573-80. [DOI: 10.1016/j.jemermed.2010.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 08/30/2010] [Accepted: 10/31/2010] [Indexed: 11/21/2022]
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Severe community-acquired pneumonia: The search for the diagnostic holy grail continues*. Crit Care Med 2011; 39:2354-5. [DOI: 10.1097/ccm.0b013e31822a5847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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