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

Effects of adjunctive milrinone versus placebo on hemodynamics in patients with septic shock: a randomized controlled trial

BACKGROUND

Refractory septic shock can lead to multiorgan failure and death due to myocardial dysfunction-induced inadequate tissue perfusion. Current guidelines advocate inotropic adjuncts to norepinephrine, but the efficacy of milrinone remains understudied in this context. This study aimed to evaluate the hemodynamic changes in septic shock patients treated with adjunctive milrinone compared to those treated with a placebo.

METHODS

This multicenter, double-blind, randomized controlled trial enrolled adults with septic shock, adequate fluid resuscitation, and a mean arterial pressure ≥ 65 mmHg. Eligible patients exhibited poor tissue perfusion or impaired left ventricular systolic function. Participants were randomized 1:1 to milrinone or placebo. Echocardiographic hemodynamic assessments were performed pre- and postintervention. The primary outcome was the change in cardiac output from baseline to 6 h after drug administration. The study was prospectively registered at www.clinicaltrials.gov (NCT05122884).

RESULTS

Among 271 screened patients, 64 were randomized. The baseline characteristics were comparable between the groups. The milrinone group demonstrated a significantly greater change in cardiac output at 6 h (median [IQR] 0.62 L/min [-0.51 to 1.47]) than did the placebo group (0.13 L/min [-0.59 to 0.46]; p = 0.043). The percentage change in the cardiac index was also significantly greater with milrinone (median [IQR] 22.5% [-10.4% to 45.3%]) than with placebo (4.4% [-10.9% to 11.4%]; p = 0.041). There were no significant differences in complication rates between the groups. The 28-day mortality rates of the groups were also statistically nonsignificant and equivalent (16/32 [50.0%] for both; p = 1.000).

CONCLUSIONS

Milrinone administration in septic shock patients improved cardiac output at 6 h, suggesting a potential benefit for patients with persistent tissue hypoperfusion despite norepinephrine.

Norepinephrine Infusion and the Central Venous Waveform in a Porcine Model of Endotoxemic Hypotension with Resuscitation: A Large Animal Study

BACKGROUND

Venous waveform analysis is an emerging technique to estimate intravascular fluid status by fast Fourier transform deconvolution. Fluid status has been shown proportional to f0, the amplitude of the fundamental frequency of the waveform's cardiac wave upon deconvolution. Using a porcine model of distributive shock and fluid resuscitation, we sought to determine the influence of norepinephrine on f0 of the central venous waveform.

METHODS

Eight pigs were anesthetized, catheterized and treated with norepinephrine after precipitation of endotoxemic hypotension, and subsequent fluid resuscitation to mimic sepsis physiology. Hemodynamic parameters and central venous waveforms were continually transduced throughout the protocol for post-hoc analysis. Central venous waveform f0 before, during and after norepinephrine administration were determined using Fourier analysis.

RESULTS

Heart rate increased, while central venous pressure, pulmonary capillary wedge pressure and stroke volume decreased throughout norepinephrine administration (p < 0.05). Mean f0 at pre-norepinephrine, and doses 0.05, 0.10, 0.15, 0.20 and 0.25 mcg/kg/min, were 2.5, 1.4, 1.7, 1.7, 1.6 and 1.4 mmHg2, respectively (repeated measures ANOVA; p < 0.001). On post-hoc comparison to pre-norepinephrine, f0 at 0.05 mcg/kg/min was decreased (p = 0.04).

CONCLUSIONS

As the performance of f0 was previously characterized during fluid administration, these data offer novel insight into the performance of f0 during vasopressor delivery. Central venous waveform f0 is a decreased with norepinephrine, in concordance with pulmonary capillary wedge pressure. This allows contextualization of the novel, venous-derived signal f0 during vasopressor administration, a finding that must be understood prior to clinical translation.

Cannabis use disorder and severe sepsis outcomes in cancer patients: Insights from a national inpatient sample

BACKGROUND

The burden of cannabis use disorder (CUD) in the context of its prevalence and subsequent cardiopulmonary outcomes among cancer patients with severe sepsis is unclear.

AIM

To address this knowledge gap, especially due to rising patterns of cannabis use and its emerging pharmacological role in cancer.

METHODS

By applying relevant International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes to the National Inpatient Sample database between 2016-2020, we identified CUD(+) and CUD(-) arms among adult cancer admissions with severe sepsis. Comparing the two cohorts, we examined baseline demographic characteristics, epidemiological trends, major adverse cardiac and cerebrovascular events, respiratory failure, hospital cost, and length of stay. We used the Pearson χ² d test for categorical variables and the Mann-Whitney U test for continuous, non-normally distributed variables. Multivariable regression analysis was used to control for potential confounders. A P value ≤ 0.05 was considered for statistical significance.

RESULTS

We identified a total of 743520 cancer patients admitted with severe sepsis, of which 4945 had CUD. Demographically, the CUD(+) cohort was more likely to be younger (median age = 58 vs 69, P < 0.001), male (67.9% vs 57.2%, P < 0.001), black (23.7% vs 14.4%, P < 0.001), Medicaid enrollees (35.2% vs 10.7%, P < 0.001), in whom higher rates of substance use and depression were observed. CUD(+) patients also exhibited a higher prevalence of chronic pulmonary disease but lower rates of cardiovascular comorbidities. There was no significant difference in major adverse cardiac and cerebrovascular events between CUD(+) and CUD(-) cohorts on multivariable regression analysis. However, the CUD(+) cohort had lower all-cause mortality (adjusted odds ratio = 0.83, 95% confidence interval: 0.7-0.97, P < 0.001) and respiratory failure (adjusted odds ratio = 0.8, 95% confidence interval: 0.69-0.92, P = 0.002). Both groups had similar median length of stay, though CUD(+) patients were more likely to have higher hospital cost compared to CUD(-) patients (median = 94574 dollars vs 86615 dollars, P < 0.001).

CONCLUSION

CUD(+) cancer patients with severe sepsis, who tended to be younger, black, males with higher rates of substance use and depression had paradoxically significantly lower odds of all-cause in-hospital mortality and respiratory failure. Future research should aim to better elucidate the underlying mechanisms for these observations.

To explore the influencing factors of clinical failure of anti-tumor necrosis factor-α (TNF-α) therapy in sepsis

Sepsis, a condition of significant clinical concern, is characterized by life-threatening organ dysfunction that arises from an infection and is exacerbated by a dysregulated host response. Targeting immune modulation, particularly against tumor necrosis factor-alpha (TNF-α), has emerged as a promising anti-inflammatory therapeutic strategy. However, approaches such as blood purification to eliminate inflammatory mediators or the use of anti-TNF-α therapies have shown limited efficacy in clinical practice. This literature review aims to elucidate the pathogenesis of sepsis and dissect the factors contributing to unfavorable outcomes in TNF-α-targeted treatments. Our analysis highlights several potential reasons for therapeutic failure. Complete blockade of TNF-α may adversely affect both TNFR1 and TNFR2 signaling, thereby reducing the efficacy of TNF-α inhibitors. Additionally, the complex heterogeneity of sepsis, including the etiology of infection, patient-specific factors (e.g., immune responsiveness, body mass index, and obesity), the development of anti-drug antibodies, and treatment duration, significantly influences therapeutic outcomes. Based on these insights, we emphasize the need for precision medicine in sepsis management. This includes stratifying patients into subgroups, using TNFR2 agonists or TNFR1-specific antagonists, refining drug design, implementing multi-target combination therapies, and considering the patient's physiological state at the time of treatment. Collectively, these strategies could enhance the efficacy of sepsis management. This review underscores the multifaceted nature of sepsis treatment and highlights the imperative for personalized, multimodal therapeutic approaches to improve clinical outcomes.

Impact of dysglycemia during the ebb and flow phases of critically ill burn patients: An observational study

BACKGROUND

Critically ill burn patients face severe metabolic stress, divided into early ebb and late flow phases, causing dysglycemia. While detrimental effects of hyper- and hypoglycemia in burn patients have been reported over the entire stay, its impact during the ebb and flow phases remains unexplored. This study is the first to investigate phase-separated dysglycemia for outcome prediction.

METHODS

This retrospective, single-center observational study examined burn ICU patients between 2009 and 2022. Non-severe (ABSI<7) and severe (ABSI≥7) burn patients were investigated separately. Furthermore, the effect of low (<50 %) versus high (≥50 %) dysglycemic rates (<70 or >140 mg/dL) was evaluated within the ebb and flow phases. Dysglycemia was calculated using the time-unified rate, an innovative method representing blood glucose over time. The primary outcome of this study was mortality.

RESULTS

This study included 67 non-severe and 101 severe burn patients. During the flow compared to the ebb phase, non-severe burn patients showed increased hyperglycemic rates (>140 mg/dL, p = 0.027) and mean blood glucose levels (p = 0.003), while severe burn patients showed increased glycemic variability (p < 0.001) and hypoglycemic rates (<70 mg/dL, p = 0.003). Non-severe burn patients with high dysglycemic rates showed increased length of ICU stay (ebb: p = 0.029, flow: p = 0.040) and pneumonia incidence (ebb: p = 0.005, flow: p = 0.002) compared to patients with low dysglycemic rates. High dysglycemic rate was associated with higher mortality in severe burn patients (ebb: p = 0.027, flow: p = 0.008). Multivariate logistic regression revealed that hyper- (OR: 1.034, 95 %-CI: [1.001-1.068], p = 0.045) and hypoglycemic rates (OR: 1.744, 95 %-CI: [1.180-2.577], p = 0.005) during the flow, but not the ebb phase, predicted mortality in severe burn patients.

CONCLUSIONS

This study suggests that increased dysglycemic rate plays a relevant role in both non-severe and severe burn patients, with a varying impact. Over time, the flow phase was characterized by higher glycemic variability as well as hyper- and hypoglycemic rates, with the latter two predicting mortality in severe burn patients. While larger cohorts are needed to confirm these findings, the data indicate that reducing the dysglycemic rate, particularly during the flow phase, could improve outcomes in critically ill burn patients.

Pancreatic Stone Protein as Sepsis Biomarker in Patients Requiring Mechanical Circulatory Support: A Pilot Observational Study

OBJECTIVES

To demonstrate for the first time the performance of the novel biomarker pancreatic stone protein (PSP) in predicting the occurrence of sepsis in cardiogenic shock patients requiring mechanical circulatory support. Many patients with cardiogenic shock develop sepsis and the timely identification and treatment of sepsis remains a key factor to improve outcome and avoid unnecessary antibiotics treatment.

DESIGN

Observational study recording PSP values for 5 days or until intensive care unit discharge (whichever came first) to analyze its kinetic and evaluate a potential correlation with sepsis development.

SETTING

Cardiac intensive care unit.

PARTICIPANTS

32 adult patients with cardiogenic shock requiring mechanical circulatory support, 28% women with a median age of 68 years (range, 60-72 years).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The main causes of cardiogenic shock were postcardiotomy (50%) and acute myocardial infarction (25%). Patients were supported with and intra-aortic balloon pump (62.5%), Impella (6.3%), or venoarterial extracorporeal membrane oxygenation (3.1%); 28% of patients had more than 1 support device. Forty percent of patients developed sepsis during their intensive care unit stay. The overall median peak PSP reached was 389.5 ng/mL (interquartile range, 222-601 ng/mL), with a peak on day 2. The peak was higher in patients who developed sepsis (601 ng/mL [interquartile range, 556-601 ng/mL] in patients with sepsis v 257 ng/mL [interquartile range, 207-576 ng/mL] in patients without ). In these patients also daily PSP values from day 2 to 5 were higher.

CONCLUSIONS

Patients supported with mechanical circulatory support who develop sepsis present with significantly higher PSP values than those who do not develop sepsis. PSP values are generally high in this population, even in patients not developing sepsis.

INCREASED CIRCULATORY KREBS CYCLE METABOLITES IN SEPSIS IS ASSOCIATED WITH INCREASED INTERLEUKIN-6 RELEASE AND WORSE SURVIVAL

ABSTRACT

Objective : Recent studies have proposed that Krebs cycle metabolites may serve as potential biomarkers for prognosis in sepsis. However, whether these metabolites are associated with disease severity and can be applied to improve the effectiveness of current prognosis assessment in sepsis remains unclear and is explored in this study. Methods : This prospective multicenter cohort study was conducted in medical intensive care units (ICUs). From December 2019 to September 2022, consecutive patients admitted to medical ICUs for sepsis were screened and recruited. Plasma samples were obtained for measurements of cytokines and Krebs cycle metabolites, including citrate/isocitrate, cis-aconitate, alpha-ketoglutarate, succinate, fumarate, and malate. Results : In total, 97 patients admitted for sepsis were enrolled in the study. The 28-day mortality rate was 17.5%, and nonsurvivors exhibited significantly increased plasma lactate levels and Sequential Organ Failure Assessment (SOFA) scores. Plasma levels of Krebs cycle metabolites were significantly correlated with both plasma lactate and interleukin-6 levels. Except for citrate/isocitrate, all Krebs cycle metabolites were significantly elevated in patients with acute kidney injury. Multivariate Cox proportional hazard models, adjusted for plasma lactate levels and SOFA scores, revealed that plasma levels of alpha-ketoglutarate (adjusted hazard ratio [HR]: 2.404, P = 0.002), fumarate (adjusted HR: 1.904, P = 0.001) and malate (adjusted HR: 1.327, P = 0.019) were associated with increased risk of 28-day mortality. Conclusions : Study findings indicate that Krebs cycle metabolites, particularly alpha-ketoglutarate, fumarate, and malate, when applied with SOFA score, might enhance prognostic assessment in patients with sepsis.

ADJUNCTIVE VASOPRESSORS AND SHORT-TERM MORTALITY IN ADULTS WITH SEPTIC SHOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS

ABSTRACT

Background: Adjunctive vasopressors are added to norepinephrine in one-third of adults with septic shock in the United States. However, effectiveness of this approach is unclear, and treatment recommendations are based on indirect evidence. We sought to synthesize the direct evidence for adjunctive vasopressor administration in adults with septic shock. Methods: We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to June 7, 2023. We included randomized clinical trials of adults with septic shock comparing adjunctive treatment with a vasopressin analogue, angiotensin II, methylene blue, hydroxocobalamin, or catecholamine analog to standard care vasopressors. The primary outcome was short-term mortality (at or before 28-30 days or intensive care discharge). Secondary outcomes included kidney replacement therapy, digital/peripheral ischemia, and venous thromboembolism. Random-effects meta-analyses were conducted to derive risk ratios (RRs) and 95% CIs. The certainty of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Results: Of 6,763 records, 17 trials (3,813 participants) were included. Compared with standard care, adjunctive vasopressor administration may reduce short-term mortality risk (RR, 0.92 [95% CI, 0.85-1.00], low certainty, 17 trials [3618 participants]) and likely reduces kidney replacement therapy receipt (RR, 0.92 [95% CI, 0.84-1.01], moderate certainty, eight trials [2,408 participants]). Adjunctive vasopressor treatment may increase risk of digital/peripheral ischemia (RR, 2.44 [95% CI, 1.17-5.10], low certainty, nine trials [2,981 participants]) and venous thromboembolism (RR, 16.48 [95% CI, 0.96-283.17], low certainty, one trial [321 participants]). There was some evidence that the pooled estimate for short-term mortality was different (interaction P = 0.13) for trials adjudicated as low risk of bias (RR, 0.95 [95% CI, 0.87-1.05]) compared with trials adjudicated as some concerns or high risk of bias (RR, 0.82 [95% CI, 0.69-0.97]). The findings were robust to multiple sensitivity and subgroup analyses. Conclusions: In adults with septic shock, adjunctive vasopressors may lower short-term death risk and likely lower kidney replacement therapy risk, but may increase risk of adverse effects. In the United States, adjunctive vasopressor use prevalence in septic shock is disconnected from the low evidence certainty for a favorable mortality-to-risk profile.

Peripheral Use of Vasopressors in Shock: Clinical Considerations and Recommendations for Use in Obstetrics

This study aimed to evaluate the safety of peripheral administration of vasopressor agents among patients with circulatory shock.We reviewed the published literature evaluating the use of peripheral norepinephrine in patients with shock and proposed a protocol for use in labor and delivery units.Peripheral administration of norepinephrine is a safe and potentially lifesaving intervention for patients in labor and delivery with extremely low complication rates.Adoption of a protocol for peripheral administration of vasopressors in labor and delivery is safe and may prevent life threatening delays in hemodynamic resuscitation. · Administering vasopressors through a peripheral line is safe and helps avoid delays in care.. · An established protocol is essential for the safe peripheral administration of vasopressors.. · Understanding continuous blood pressure monitoring is crucial for managing critically ill patients..

The Association Between Time to Completion of at Least 30 mL/kg and Hospital Outcomes Among Patients With Septic Shock

IMPORTANCE

Sepsis is the leading cause of inpatient mortality in the United States. The optimal timing and volume of fluid resuscitation for septic shock remain a topic of debate.

OBJECTIVES

This study evaluated the effect of time to completion of at least 30 mL/kg of fluid and the impact of smaller fluid volumes on hospital outcomes among patients with septic shock.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study in a large community healthcare system (310,000 annual emergency visits) of all adults (age ≥ 18 yr) admitted from January 2017 to December 2022 with an International Classification of Diseases, 10th Revision diagnosis of sepsis and an initial emergency department (ED) systolic blood pressure (SBP) less than 90 mm Hg, mean arterial blood pressure less than 65 mm Hg, and/or lactate greater than or equal to 4 mmol/L.

MAIN OUTCOMES AND MEASURES

The main outcomes include hospital mortality, ICU admission, mechanical ventilation, and vasopressor use. The relationship between time to completion of 30 mL/kg and the main outcomes was assessed using generalized linear models.

RESULTS

Among the 1602 patients who met inclusion criteria, 1190 (74.3%) received at least 30 mL/kg of fluid after ED arrival. The overall mortality rate was 24.2%, with 28.7% requiring mechanical ventilation and 64.3% requiring vasopressors. Receipt of at least 30 mL/kg between 2 and 3 hours from the time of initial ED SBP (time zero) was associated with lower odds of mortality (odds ratio [OR], 0.61; 95% CI, 0.39-0.97; p = 0.04) and mechanical ventilation use (OR, 0.43; 95% CI, 0.29-0.65; p < 0.01) compared with other intervals. Compared with receiving 30 mL/kg or greater, receiving at least 20 but less than 30 mL/kg within the first hour was associated with the lowest odds of mortality (OR, 0.33; 95% CI, 0.11-0.97; p = 0.04).

CONCLUSIONS AND RELEVANCE

Our findings show that receipt of 30 mL/kg of fluid within 3 hours is associated with reduced mortality and the need for mechanical ventilation among patients with septic shock. These results support the current Surviving Sepsis Campaign fluid recommendations.

Passive leg raising test versus rapid fluid challenge in critically ill medical patients

BACKGROUND

The passive leg raising (PLR) test is a simple test to detect preload responsiveness. However, variable fluid doses and infusion times were used in studies evaluating the effect of PLR. Studies showed that the effect of fluid challenge on hemodynamics dissipates in 10 min. This prospective study aimed to compare PLR and a rapid fluid challenge (RFC) with a 300-ml bolus infused within 5 min in adult patients with a hemodynamic compromise.

MATERIALS AND METHODS

Critically ill medical patients with signs of systemic hypoperfusion were included if volume expansion was considered. Hemodynamic status was assessed with continuous measurements of cardiac output (CO), when possible, and mean arterial pressure (MAP) at baseline, during PLR, and after RFC.

RESULTS

A total of 124 patients with a median age of 65.0 years were included. Their acute physiology and chronic health evaluation (APACHE) II score was 19.7 ± 6.0, with a sequential organ failure assessment (SOFA) score of 9.0 ± 4.4. Sepsis was diagnosed in 73.3%, and 79.8% of the patients were already receiving a norepinephrine infusion. Invasive MAP monitoring was established in all patients, while continuous CO recording was possible in 42 patients (33.9%). Based on CO changes, compared with those with RFC, the false positive and false negative rates with PLR were 21.7 and 36.8%, respectively, with positive and negative predictive values of 70.6 and 72.0%, respectively. Based on MAP changes, compared with those with RFC, the false positive and false negative rates with PLR compared to RFC were 38.2% and 43.3%, respectively, with positive and negative predictive values of 64.4 and 54.0%, respectively.

CONCLUSION

This study demonstrated a moderate agreement between PLR and RFC in hemodynamically compromised medical patients, which should be considered when testing preload responsiveness.

Beyond first-day biomarkers: The critical role of peak cardiac troponin I in sepsis prognosis

BACKGROUND

Sepsis is a global health challenge with high mortality rates. It demands timely risk identification and biomarker-based strategies to optimize ICU management and outcomes.

OBJECTIVES

To explore the prognostic value of cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP) in predicting 28-day mortality in septic patients.

METHODS

We analyzed clinical data of septic ICU patients at Shanghai General Hospital. We used Cox models and ROC curves to assess the association between cTnI and BNP levels and 28-day mortality, and their prognostic accuracy.

RESULTS

A total of 333 septic patients were included in this study (mean age [SD], 64.7 [15.2] years; 65.8 % male), of whom 63 (18.9 %) patients died during 28 days. Elevated peak cTnI levels, identified in 233 patients (70.0 %), were independently associated with higher 28-day mortality in septic patients, even after adjusting for SOFA scores, BNP, and other confounding variables. (adjusted HR 2.33, 95 % CI 1.08-5.04, P = 0.03). However, neither first-day cTnI nor BNP levels remained independent predictors of 28-day mortality. Sensitivity analyses for the magnitude of cTnI elevation as a predictive variable also yielded similar results. Compared to first-day cTnI, first-day BNP, and peak BNP, the peak cTnI had the most significant and modest area under the ROC curve (AUC: 0.64 [0.57-0.71]).

CONCLUSION

Elevated peak cTnI or the magnitude of cTnI, rather than first-day, could independently predict the risk of 28-day mortality in septic patients. This finding highlighted the importance of dynamic monitoring cTnI levels for risk stratification identification and management in septic patients.

Early Albumin Administration in Veno-Arterial Extracorporeal Membrane Oxygenation

BACKGROUND

The clinical outcome and fluid balance of patients with veno-arterial extracorporeal membrane oxygenation (VA ECMO) or after extracorporeal cardiopulmonary resuscitation (eCPR) may be improved by addressing the high fluid demand with an early albumin administration.

METHODS

In this prospective observational study, patients supported with VA ECMO or eCPR received early albumin administration (25 g/L) to prime the VA ECMO system. These patients were compared to patients who received a regimen based solely on balanced crystalloids (crystalloid group) or a regimen based on a 1:4 volume mixture of albumin (10 g/L) and balanced crystalloids (albumin group).

RESULTS

660 VA ECMO patients (66.4% eCPR) treated between January 2017 and June 2021 were analyzed, whereby 265 patients received crystalloid fluid therapy, 269 patients received albumin therapy, and 126 patients received early albumin therapy. When compared to the albumin and crystalloid groups, patients in the early albumin treatment group had significantly lower cumulative fluid balances (p < 0.05). However, this effect was only observed in the group of eCPR patients and not in patients with cardiogenic shock. Logistic regression revealed albumin administration as an independent predictor of increased survival (Odds ratio 1.66 (1.11-2.47) [95%-CI], p = 0.013). Yet, only eCPR patients showed a survival benefit from albumin administration compared to the crystalloid group (survival of 29.4% vs. 18.8%, p = 0.024).

CONCLUSION

Early albumin administration in eCPR patients was linked to a significant decline in fluid balance. Moreover, volume therapy with albumin application was an independent predictor for improved survival in eCPR patients.

A National Retrospective Cohort Study Comparing the Effects of Cefepime Versus Piperacillin-Tazobactam on the Development of Severe Acute Kidney Injury in Patients With Septic Shock

BACKGROUND

Cefepime and piperacillin-tazobactam are commonly used broad-spectrum antibiotics used to treat patients with potential gram-negative bacterial sepsis. Piperacillin-tazobactam has been shown to be associated with acute kidney injury (AKI). However, it has not been compared with cefepime in patients with septic shock. We compared the effects of cefepime and piperacillin-tazobactam on the incidence of severe AKI in patients with septic shock.

METHODS

This was a retrospective, multicenter, inverse probability-of-treatment weighted cohort study conducted in 220 geographically diverse community and teaching hospitals across the United States. Adult patients were included if they had septic shock on hospital admission and received cefepime or piperacillin-tazobactam. The proportions of patients in whom stage 3 AKI occurred during hospitalization were compared between groups.

RESULTS

Of the 8427 patients included in the final cohort, 4569 received cefepime and 3858 received piperacillin-tazobactam. Patients had a mean (SD) age of 66.2 (15.2) years, and 45.3% were female; the mean (SD) estimated glomerular filtration rate was 48 (24) mL/min/1.73 m2 on the day of admission. In the weighted cohort, stage 3 AKI occurred in 9.9% receiving cefepime and 9.8% receiving piperacillin-tazobactam (odds ratio, 0.98 [95% confidence interval, .84-1.15]; P = .82). In terms of secondary outcomes, there was no significant difference between cefepime and piperacillin-tazobactam with regard to renal replacement therapy, in-hospital death, major adverse kidney events, stage 1 AKI, stage 2 AKI, maximum recorded serum creatinine, or hospital length of stay.

CONCLUSIONS

Among hospitalized patients with septic shock, there was no difference between cefepime and piperacillin-tazobactam in the occurrence of severe AKI.

Procalcitonin levels in septic and nonseptic subjects with AKI and ESKD prior to and during continuous kidney replacement therapy (CKRT)

BACKGROUND

Procalcitonin is a 14.5 kDa protein used clinically as a marker of sepsis and therapeutic response to antibiotic therapy. However, its utility in critically ill patients with either acute kidney injury (AKI) or end-stage kidney disease (ESKD) who require continuous kidney replacement therapy (CKRT) is unknown. The aim of this study was to determine if plasma levels of procalcitonin could reliably distinguish septic from nonseptic status in patients with AKI or ESKD prior to or during CKRT.

METHODS

Procalcitonin concentrations were measured in plasma of 41 critically ill septic or non-septic subjects with AKI or ESKD prior to CKRT (pre-CKRT) and on days 1, 2, and 3 of CKRT in this retrospective cohort study (n = 111 total plasma measurements). Continuous venovenous hemodialysis was the modality of CKRT in these patients. Sepsis status was stringently defined based on culture results. Effluent procalcitonin levels were ascertained on days 1, 2, and 3 of CKRT to assess the clearance of procalcitonin and effects on plasma levels.

RESULTS

92% (66/72) of the plasma procalcitonin measurements among nonseptic patients with either AKI or ESKD were ≥ 0.5 ng/mL (the diagnostic threshold beyond which bacterial infection is very likely). Prior to CKRT initiation, procalcitonin levels were (median (IQR), ng/mL) 5.6 (1.5-18.9) in nonseptic AKI and 58.1 (6.9-195.5) in septic AKI (P = 0.03) and were 3.3 (1.2-8.3) in nonseptic ESKD and 3.7 (1.4-209.8) in septic ESKD (P = 0.79). However, despite being significantly elevated in septic patients with AKI, substantial overlap among procalcitonin levels was present and ROC curve analysis found no cut point that could reliably separate septic from nonseptic patients. Effluent procalcitonin levels were consistently ~ 20% of plasma levels throughout the course of CKRT (i.e., sieving coefficient was 0.2) suggesting that clearance occurs during therapy. However, plasma procalcitonin levels did not significantly decline during CKRT in either AKI or ESKD.

CONCLUSION

Procalcitonin levels are markedly elevated in nonseptic critically ill patients with either AKI or ESKD and do not effectively distinguish sepsis from nonseptic status prior to or during CKRT. We conclude that procalcitonin testing should be avoided in critically ill patients with kidney failure since results are nonspecific in this population.

Global burden of female infertility attributable to sexually transmitted infections and maternal sepsis: 1990-2021 and projections to 2050

Infectious diseases, such as sexually transmitted infections (STIs) and maternal sepsis, are major contributors to female infertility, creating a substantial burden on women of reproductive age. Based on Global Burden of Disease (GBD) 2021, this study analyzed the global trends and regional disparities in infection-related infertility for women aged 15-49 and projected future burdens. Our result showed that from 1990 to 2021, global age-standardized prevalence rate (ASPR) rose from 839.52 to 982.37 per 100,000 with estimated annual percentage change (EAPC) (0.26 [0.19 to 0.33]), and years lived with disability (YLDs) increasing from 62.81 to 106.69 thousand (EAPC 0.23 [0.16 to 0.31]), and was predicted to continue rising from 2022 to 2050. The disease burden showed significant regional disparities, low socio-demographic index (SDI) regions had the highest ASPR (1247.25 per 100,000 [1085.17 to 1443.57]) but also the fastest decline (EAPC -1.17 [-1.34 to -0.99]), and Western Sub-Saharan Africa (ASPR 1,925.52 [1655.35 to 2241.71] per 100,000) are the regions with highest burden. The disease burden increased with age, peaking at 40-44 years, and was inversely associated with SDI. These findings provide essential insights for policymakers to develop targeted strategies to prevent and control infection-related infertility, particularly in low-SDI regions.

Association Between the Sequence of β-Lactam and Vancomycin Administration and Mortality in Patients With Suspected Sepsis

BACKGROUND

Timely antibiotic initiation is critical to sepsis management, but there are limited data on the impact of giving β-lactams first versus vancomycin first among patients prescribed both agents.

METHODS

We retrospectively analyzed all adults admitted to 5 US hospitals from 2015-2022 with suspected sepsis (blood culture collected, antibiotics administered, and organ dysfunction) treated with vancomycin and a broad-spectrum β-lactam within 24 hours of arrival. We estimated associations between β-lactam- versus vancomycin-first strategies and in-hospital mortality using inverse probability weighting (IPW) to adjust for potential confounders.

RESULTS

Among 25 391 patients with suspected sepsis, 21 449 (84.4%) received β-lactams first and 3942 (15.6%) received vancomycin first. Compared with the β-lactam-first group, patients administered vancomycin first tended to be less severely ill, had more skin/musculoskeletal infections (20.0% vs 7.8%), and received β-lactams a median of 3.5 hours later relative to emergency department arrival. On IPW analysis, the β-lactam-first strategy was associated with lower mortality (adjusted odds ratio [aOR]: .89; 95% CI: .80-.99). Point estimates were directionally similar but nonsignificant in a sensitivity analysis using propensity score matching rather than IPW (aOR: .94; 95% CI: .82-1.07) and in subgroups of patients with positive blood cultures, methicillin-resistant Staphylococcus aureus cultures, and those administered antipseudomonal β-lactams.

CONCLUSIONS

Among patients with suspected sepsis prescribed vancomycin and β-lactam therapy, β-lactam administration before vancomycin was associated with a modest reduction in in-hospital mortality. These findings support prioritizing β-lactam therapy in most patients with sepsis but merit confirmation in randomized trials given the risk of residual confounding in observational analyses.

Decision analysis model of rapid versus deferred antibiotic initiation in patients with suspected sepsis in the emergency department

PURPOSE

Sepsis remains a major health concern with high associated mortality. Adequate treatment involves the use of antibiotic therapy although the timing of antibiotics is controversial. A decision analysis model of antibiotic initiation was created to determine optimal management of patients with suspected sepsis.

METHODS

Two decision trees were created using data from the published literature. A limited model used mortality as the primary outcome using the impact of antibiotic timing on rates of progression to shock and in-hospital mortality. The primary model included mortality and stewardship-related factors such as antibiotic avoidance and antibiotic-associated adverse events. Rapid initiation of antibiotics was defined as universal antibiotic administration within 3 h of presentation whereas deferred initiation included administration up to 6 h. Sensitivity analyses were performed to evaluate the effectiveness of each option.

RESULTS

When considering only mortality, rapid initiation was the optimal strategy. When considering stewardship-related factors, rapid initiation of antibiotics maximized utility in only 40.6% of model iterations. One-way sensitivity analysis demonstrated rapid initiation of antibiotics was optimal when initiation times were above 1.33 h and the prevalence of infection was above 89.5%. Two-way sensitivity analysis demonstrated that as time to antibiotics increased, rate of true infection above which rapid antibiotics is optimal drops from just under 91% to approximately 88.5%.

CONCLUSION

We constructed decision analysis models to characterize optimal conditions for antibiotic initiation in suspected sepsis. Our model suggests that the prevalence of infection needs to be approximately 90% for rapid initiation of antibiotics to be the optimal strategy.

Respiratory manifestations of rickettsial disease in tropical Australia; clinical course and implications for patient management

BACKGROUND

Rickettsial infections have a global distribution and can cause life-threatening disease. Respiratory symptoms can be a harbinger of a more complicated disease course. However, the clinical associations - and the clinical course - of patients with rickettsial disease and respiratory involvement are incompletely defined.

METHODS

A retrospective study of all patients with a diagnosis of scrub typhus or Queensland tick typhus (QTT) managed at Cairns Hospital in tropical Australia, between 1st January 1997 and 31st October 2023. We determined the demographic, clinical, radiological and laboratory associations of respiratory involvement which was defined as any acute abnormality of lung parenchyma identified on thoracic imaging during their hospitalisation that did not have another more likely explanation. We compared the clinical course of patients with a rickettsial infection who did - and did not - have respiratory involvement.

RESULTS

There were 226 individuals included in the analysis, 51/226 (22%) had respiratory involvement, including 18/59 (31%) with QTT and 33/167 (20%) with scrub typhus, p=0.09. The imaging findings were heterogenous: 33/51 (65%) had predominantly alveolar changes, 18/51 (35%) had interstitial changes and 12/51 (24%) had a pleural effusion. Those with respiratory involvement were older than individuals without respiratory involvement (median (interquartile range (IQR)) age 51 (37-65) years versus 38 (25-51) years (p=0.0001). However, most patients (27/51, 53%) with respiratory involvement had no comorbidity and were younger than 60. Patients with respiratory involvement were more likely to require ICU admission that patients without respiratory involvement (19/51 (38%) versus 6/175 (3%) p<0.001) and 9/51 (18%) with respiratory involvement required mechanical ventilation. Patients with respiratory involvement were also more likely to require vasopressor support (14/51, 27% versus 4/175, 2%, p<0.001) and renal replacement therapy (4/51, 8% versus 1/175, 0.6%, p=0.01) than patients without respiratory involvement. There were 2/226 (1%) individuals who died from their rickettsial infection (1 scrub typhus and 1 QTT) during the study period, both had respiratory involvement.

CONCLUSIONS

Respiratory involvement is common in individuals with rickettsial infection in tropical Australia and is associated with a greater risk of life-threatening disease.

The association between body mass index and ICU 28-day mortality rate in patients with sepsis: A retrospective observational study

OBJECTIVES

Sepsis remains the major cause of mortality among critically ill patients worldwide, indicating the importance of better understanding of its influencing factors for fast recognition and management. Although greater concerns have been raised about the "obesity paradox" and sepsis related mortality, the evidence regarding on overweight or obese septic patients is still controversial. To provide more clinical evidence for the exploration of body mass index (BMI) on sepsis prognostic prediction, we assessed the association of BMI with 28-day mortality of septic patients in intensive care unit (ICU).

METHODS

This was a retrospective observational study with patient data extracted from the eICU Collaborative Research Database. We employed a logistic regression to assess the effect of admission BMI levels on sepsis related mortality risk. Furthermore, the two-piecewise linear model was used to identify BMI mortality thresholds, and BMI-outcome associations were evaluated by interaction tests and subgroup analyses.

RESULTS

Our cohort included a total of 17,454 patients, of whom 1,555 (8.91%) died within 28 days after being admitted to the ICU. The connection between BMI and 28-day mortality in the ICU displayed a U-shaped curve. The threshold effect analysis results in two inflection points of BMI were 23.62kg/m2 and 45.53kg/m2. When the BMI was <23.62kg/m2, the mortality rate decreased by 7% (95%CI 0.91, 0.96, P<0.0001) for every 1 increment in the BMI. When the BMI was ≥45.53kg/m2, the mortality rate increased by 8% (95%CI 1.01,1.15, P=0.0322) for every 1 increment in the BMI. Subgroup analysis showed that neither age nor sex covariates affected the stability of these results (all P for interaction≥0.05).

CONCLUSIONS

In septic ICU patients, the correlation between BMI and 28-day mortality exhibited a U-shaped pattern, indicating that both low and extremely high BMIs were linked to a heightened risk of mortality within 28 days.

Factors associated with delayed order-to-administration time in the emergency department: a retrospective analysis

BACKGROUND

Timely medication administration in the emergency department (ED) is critical for improving patient outcomes. This study aimed to identify predictors of delayed order-to-administration (OTA) time, defined as exceeding 30 min for stat medications.

METHODS

A retrospective analysis was conducted in the ED of a 1,000-bed tertiary hospital. Patients aged 20 years or older who received stat medications between June 1 and August 31, 2020, were included. Only the first stat medication order per patient was analyzed. Data on patient demographics, triage characteristics, environmental factors, prescription details, and OTA times were extracted from the hospital's electronic medical record and nursing information system. Multivariable logistic regression with backward elimination was used to identify predictors of OTA delays.

RESULTS

Among the 11,429 patient visits included, 9.9% experienced OTA delays exceeding 30 min. Predictors of higher odds of delay included older age (adjusted odds ratio [aOR]: 1.01, 95% CI: 1.00-1.01), female sex (aOR: 1.49, 95% CI: 1.31-1.69), limited mobility (aOR: 1.38, 95% CI: 1.17-1.63 for ambulatory with assistance; aOR: 1.24, 95% CI: 1.03-1.48 for non-ambulatory patients), trauma (aOR: 1.35, 95% CI:1.09-1.66), hourly patient visits (aOR: 1.07, 95% CI: 1.05-1.10), concurrent intravenous fluid use (aOR:1.42, 95% CI:1.04-1.93), blood tests (aOR: 1.73, 95% CI: 1.30-2.30), radiography (aOR: 2.22, 95% CI: 1.87-2.64), and computed tomography (aOR: 1.57, 95% CI: 1.37-1.80). Reduced odds of delay were observed among patients with triage level 1 compared to level 3 (aOR 0.25, 95% CI:0.16-0.39), those arriving during night shifts compared to day shifts (aOR: 0.33, 95% CI: 0.18-0.63), and those receiving intramuscular medications compared to intravenous administration (aOR 0.71; 95% CI, 0.55-0.93).

CONCLUSIONS

Several patient, environmental, and diagnostic-related factors were associated with OTA delays in stat medication administration. Understanding these predictors may help inform strategies to optimize ED workflows. Further research is warranted to validate these findings in other ED settings.

CLINICAL TRIAL NUMBER

Not applicable.

Effectiveness of a multi-modal intervention protocol for preventing stress ulcers in critically ill older patients after gastrointestinal surgery

BACKGROUND

Stress ulcers are common complications in critically ill patients, with a higher incidence observed in older patients following gastrointestinal surgery. This study aimed to develop and evaluate the effectiveness of a multi-modal intervention protocol to prevent stress ulcers in this high-risk population.

AIM

To assess the impact of a multi-modal intervention on preventing stress ulcers in older intensive care unit (ICU) patients postoperatively.

METHODS

A randomized controlled trial involving critically ill patients (aged ≥ 65 years) admitted to the ICU after gastrointestinal surgery was conducted. Patients were randomly assigned to either the intervention group, which received a multi-modal stress ulcer prevention protocol, or the control group, which received standard care. The primary outcome measure was the incidence of stress ulcers. The secondary outcomes included ulcer healing time, complication rates, and length of hospital stay.

RESULTS

A total of 200 patients (100 in each group) were included in this study. The intervention group exhibited a significantly lower incidence of stress ulcers than the control group (15% vs 30%, P < 0.01). Additionally, the intervention group demonstrated shorter ulcer healing times (mean 5.2 vs 7.8 days, P < 0.05), lower complication rates (10% vs 22%, P < 0.05), and reduced length of hospital stay (mean 12.3 vs 15.7 days, P < 0.05).

CONCLUSION

This multi-modal intervention protocol significantly reduced the incidence of stress ulcers and improved clinical outcomes in critically ill older patients after gastrointestinal surgery. This comprehensive approach may provide a valuable strategy for managing high-risk populations in intensive care settings.

Novel pulse pressure pattern monitoring in critical care of elderly sepsis patients

OBJECTIVE

Our research aimed to explore the application of pulse pressure (PP) at the bedside of elderly intensive care unit (ICU) patients with sepsis through a large-scale retrospective cohort study.

METHODS

We obtained data from four heterogeneous datasets, which included information on elderly sepsis patients (≥ 65 years). The data were divided into the inference and validation datasets. Thereby enhancing the generalizability of the study. The primary outcome was mortality at 28 days, and piecewise exponential additive mixed model (PAMM) were employed to estimate the strength of the associations over time.

RESULTS

We included 12,525 elderly patients with sepsis in the initial inference dataset. Based on the PAMM's inference results, we identified a specific low PP phenotype from the time-dependent endpoint dataset. The phenotype indicates an imbalance between the patient's cardiac pumping ability and circulatory resistance, contributing to an increased 28-day mortality (hazard ratio, 2.36; 95% CI, 2.12-2.63). The consistency of these results was validated using data from various sources.

CONCLUSION

Low PP phenotype (PP < 45 mmHg 72 h after intensive care unit admission and lasting for > 3h) may provide an early dynamic warning of the therapeutic effects of resuscitation interventions in long-hospitalized elderly patients with sepsis.

IMPLICATIONS FOR CLINICAL PRACTICE

The results demonstrate acceptable consistency across heterogeneous datasets and hold promise for further development and integration into bedside monitoring systems for elderly sepsis patients.

The Efficacy of Hydrocortisone Combined With Norepinephrine in the Treatment of Severe Septic Shock and Its Effect on Immunoinflammatory Indexes

Aims/Background Severe septic shock (SS) is a life-threatening condition characterized by systemic inflammation and organ dysfunction. Hydrocortisone is used to reduce inflammation, while norepinephrine raises blood pressure and supports vasoconstriction, helping to maintain organ perfusion. This study aims to investigate the efficacy of hydrocortisone combined with norepinephrine in the treatment of SS and its effect on immunoinflammatory indexes. Methods A total of 126 patients with severe SS admitted to Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University from December 2020 to December 2023 were retrospectively selected as the study subjects. Patients were divided into control group (n = 67) and observation group (n = 59) according to the treatment given. The control group was treated with norepinephrine, whereas the observation group was treated with hydrocortisone combined with norepinephrine. The clinical efficacy of the treatment given between the two groups was compared. The serum levels of interleukin 6 (IL-6), C-reactive protein (CRP), procalcitonin (PCT) and serum amyloid A (SAA) were compared between the two groups before and after treatment. The occurrence of adverse reactions was compared between the two groups. The clinical prognostic indexes of the two groups were analyzed. Results The total efficacy rate of observation group (93.22%) was significantly higher than that of control group (74.63%) (p = 0.005). After treatment, the levels of CRP, PCT, IL-6 and SAA in both groups were significantly decreased, with the observation group exhibiting significantly lower levels of these inflammatory indexes than the control group (p < 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (p > 0.05). After 7 days of treatment, compared with the control group, the observation group showed significantly lower Acute Physiology and Chronic Health Evaluation (APACHE) II score and Sepsis-related Organ Failure Assessment (SOFA) score, required shorter mechanical ventilation time and total emergency intensive care unit (EICU) treatment time, and had lower mortality within 4 weeks (p < 0.05). Conclusion Hydrocortisone combined with norepinephrine holds high degree of efficacy in the treatment of severe SS by alleviating inflammation, improving prognosis and reducing mortality, while maintaining a good safety profile.

[Specialty-specific knowledge as prerequisite for effective treatment of critically ill patients]

Since the last meeting of the German Medical Association in May 2024, there has been a discussion in Germany about the shortening of primary specialty training and a transfer of the contents of additional supra-specialty training to the existing primary specialty training. This also affects intensive care medicine, with the prospect of creating a subspecialty for subspecialties in intensive care medicine (e.g., a specialty in surgical intensive care medicine). We consider the associated reduction of general specialty-specific contents to be inappropriate for several reasons. Knowledge of the specialty-specific trigger factors (foci) of a critical illness (organ dysfunction) as well as knowledge of the respective trigger factor-specific symptoms, diagnostics and pathways for initiating a causal treatment, are decisive for the prognosis. Recent evidence suggests that in the case of septic foci a time span between making the diagnosis and treatment of the focus should not exceed ca. 6h in order to avoid a worsening of the prognosis. To ensure that the time between symptom onset and effective treatment of the causal factors is not too long, an in-depth expertise in the primary specialty is required throughout the process. This expertise is independent of training in intensive care medicine and can only be acquired through adequate training in the specialty, followed by additional training in intensive care medicine. Expertise in the primary specialty is a prerequisite for the effective treatment of critically ill patients. Maintaining the training specific to the primary specialty and the associated acquisition of specific knowledge in the respective specialty also enables a wider deployment of specialists in clinical practice and a more economical use of diagnostic and therapeutic resources. The additional training in intensive care medicine (supraspecialty) should not be at the expense of content specific to the primary specialty and must remain accessible to all surgical specialties in the field of surgery in the next revision of the training regulations. Due to the unavoidable extent, the additional training in intensive care medicine can itself only be provided on a full-time basis.

The role of telehealth in sepsis care in rural emergency departments: A qualitative study of emergency department sepsis telehealth user perspectives

PURPOSE

Sepsis is a leading cause of hospitalization and death in the United States, and rural patients are at particularly high risk. Telehealth has been proposed as one strategy to narrow rural-urban disparities. The objective of this study was to understand why rural emergency department (ED) staff use provider-to-provider telehealth (tele-ED) and how tele-ED care changes the care for rural patients with sepsis.

METHODS

We conducted a qualitative interview study between February 15, 2022, and May 22, 2023, with participants from upper Midwest rural EDs and tele-ED hub physicians in a single tele-ED network that delivers provider-to-provider consultation for sepsis patients. One interviewer conducted individual telephone interviews, then we used standard qualitative methods based on modified grounded theory to identify themes and domains.

FINDINGS

We interviewed 27 participants, and from the interviews we identified nine themes within three domains. Participants largely felt tele-ED for sepsis was valuable in their practice. We identified that telehealth was consulted to facilitate interhospital transfer, provide surge capacity for small teams, to adhere with provider scope-of-practice policies, for inexperienced providers, and for patients with increased severity of illness or complex comorbidities. Barriers to tele-ED use and impact included increased sepsis care standardization, provider reluctance, and sepsis diagnostic uncertainty. Additionally, we identified that real-time education and training were important secondary benefits identified from tele-ED use.

CONCLUSIONS

Tele-ED care was used by rural providers for sepsis treatment, but many barriers existed that may have limited potential benefits to its use.

Effectiveness of a multi-model teaching strategy to train emergency medicine residents to use point-of-care ultrasound (POCUS) for assessment of shock

OBJECTIVE

To evaluate the effectiveness and feasibility of a multimodal teaching method to train emergency residents to use point-of-care ultrasound (POCUS) in the assessment of shock.

METHODS

The study subjects were Emergency Medicine residents at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine between January 2023 and December 2023. These residents volunteered for the study and were randomly divided into either the teaching reform (TR) group or the traditional teaching (TT) group. The assessment outcomes of the study included the residents' scores on theoretical tests and practical tests and the residents' satisfaction with and evaluation of the teaching method.

RESULTS

A total of 100 residents participated in this study in either the TR or TT groups. Compared with the TT group, the TR group achieved higher scores on both the theoretical test and the practical assessment (p < 0.05). Similarly, analysis of the questionnaire indicated that the TR group was more satisfied with their training and evaluated it higher than the TT group (p < 0.05).

CONCLUSION

Integrating point-of-care ultrasound with a multimodal teaching method in standardized training for emergency medicine residents could effectively improve the teaching effect and quality, which may provide important value in the emergency teaching of residents.

Use of procalcitonin in therapeutic decisions in the pediatric intensive care unit

Procalcitonin (PCT) is frequently used by clinicians in children with suspected bacterial infections and sepsis. However interpretation in the critically ill child may be challenging due to the complexity of underlying conditions and its impact on PCT values. Herein, we propose a guidance for the use of procalcitonin in critically ill children, supported by a comprehensive analysis of the literature, to help the clinician for interpreting PCT in the various clinical conditions encountered in pediatric intensive care units. We describe the importance of the clinical context, timing of measurement and evidence on PCT values in diagnosing sepsis and to guide antibiotic therapy in critically ill children.

The ACTH test fails to diagnose adrenal insufficiency and augments cytokine production in sepsis

The adrenocorticotropic hormone (ACTH) test diagnoses relative adrenal insufficiency (RAI) or critical illness-related corticosteroid insufficiency (CIRCI). Initially, guidelines recommended corticosteroid/glucocorticoid (GC) therapy for septic patients with RAI, but later trials did not show a survival benefit, leading to updated guidelines that abandon targeting RAI or CIRCI. Recent studies with an RAI mouse model showed a clear survival benefit from GC therapy in mice with RAI, suggesting that inconclusive GC clinical trials might be due to issues with the ACTH test rather than targeting RAI. To investigate, we performed the ACTH test in septic mice. Interestingly, the ACTH test identified most mice as having adrenal insufficiency in early and middle stages of sepsis, even those with a normal adrenal stress response. Surprisingly, the ACTH test increased inflammatory cytokines to lethal levels, moderately increasing mortality in septic mice. This study revealed significant flaws in the ACTH test for diagnosing RAI/CIRCI. It not only fails to correctly identify these conditions, leading to misguided use of GCs, but also induces a lethal inflammatory response in sepsis. These findings suggest that inconclusive GC therapy trials may be due to the problematic nature of the ACTH test rather than ineffectiveness of targeting RAI/CIRCI.

Antimicrobial Dosing During Continuous Venovenous Hemodiafiltration in Septic Shock Patients: A Prospective, Multicenter Study Protocol

Background: Sepsis is a major global health issue and the leading cause of death in critically ill patients, with rising incidence and associated healthcare costs. Early administration of antibiotic therapy is crucial, but increasing antibiotic resistance poses a threat. Beta-lactam antibiotics, commonly used as a first-line therapy option against sepsis, often demonstrate unpredictable concentrations due to pharmacokinetic and pharmacodynamic changes in critically ill patients. Acute kidney injury (AKI) affects a significant portion of septic patients, and continuous renal replacement therapy can further complicate treatment by reducing antibiotic levels and, consequently, increasing antibiotic resistance risk. Objectives: To develop pharmacokinetic/pharmacodynamic models for beta-lactam antibiotics in septic shock patients undergoing continuous renal replacement therapy (CRRT), with the goal of optimizing antibiotic dosing and then improving treatment outcomes. Methods: Septic shock Caucasian adult patients treated with beta-lactams and who have undergone major surgery in AKI failure that requires CRRT will be eligible with previous informed written consent. CRRT will be performed exclusively using Continuous Venovenous Hemodiafiltration (CVVHDF) modality. Antimicrobial determination analyses will be carried out with LC-MS/MS. Further calculation of pharmacokinetic parameters and determination of PK/PD breakpoints will be made using Monte Carlo simulation. Conclusions: The expected results from this study will lead to a better understanding of the pharmacokinetics of beta-lactam antibiotics in critically ill patients with AKI and septic shock undergoing CVVHDF, allowing for improved therapeutic strategies.

Evaluation of antibiotic de-escalation based on the DASON criteria by pharmacist-led post-prescription review and feedback: A retrospective study in a medium-sized Japanese hospital

INTRODUCTION

Among antimicrobial stewardship team (AST) activities, de-escalation, which is aimed at optimizing antibiotic use, lacks a standardized evaluation method. The Duke Antimicrobial Stewardship Outreach Network (DASON) criteria provide a framework for assessing de-escalation; however, their applicability in small to medium-sized hospitals in Japan has remained unclear. We aimed to evaluate the effectiveness of AST pharmacist-led post-prescription review and feedback (PPRF) using multiple indicators, including de-escalation based on the DASON criteria, to determine whether these indicators are also applicable in medium-sized hospitals.

METHODS

A retrospective study was conducted at a 330-bed hospital, comparing pre-PPRF (April 2021 to March 2022) and post-PPRF (April 2022 to March 2023) periods. The effectiveness of AST pharmacist-led PPRF was evaluated using the de-escalation rate determined by the DASON criteria, inappropriate antibiotic use in definitive therapy, days of therapy (DOT), and days of antibiotic spectrum coverage (DASC) per DOT.

RESULTS

The de-escalation rate significantly increased from 20 % to 45 % (P < 0.01), and inappropriate antibiotic use in definitive therapy decreased from 7 % to 0 % after AST pharmacist-led PPRF. While DOT significantly increased from 11 days to 13 days (P = 0.02), no significant change was observed in the DASC/DOT ratio.

CONCLUSION

This study suggests that de-escalation based on the DASON criteria can be an effective quantitative indicator for evaluating AST pharmacist-led PPRF in medium-sized hospitals. The findings also suggest that incorporating multiple indicators tailored to each hospital's conditions can provide a more comprehensive framework for evaluating AST pharmacist-led PPRF.

Effect of host-protein test (TRAIL/IP-10/CRP) on antibiotic prescription and emergency department or urgent care center return visits: The JUNO pilot randomized controlled trial

OBJECTIVES

Determining etiology for adults with symptoms of lower respiratory tract infection (LRTI) is challenging. MeMed BV (MMBV), an FDA-cleared blood test, computationally integrates the levels of three host proteins to differentiate bacterial and viral infections. We evaluated MMBV's impact on safe antibiotic prescribing at emergency department/urgent care centers (ED/UC).

METHODS

The JUNO randomized controlled trial (RCT; NCT05762302) was a prespecified pilot phase of the JUPITER RCT. JUNO enrolled adult ED/UC patients with LRTI symptoms and clinician's consideration for antibiotic treatment. Inclusion criteria were fever within 7 days and one of cough, sputum production, dyspnea, or auscultation abnormality. Exclusion criteria were prior antibiotic use or immunosuppression. Patients were randomized to standard care (SC) or SC plus MMBV arms. JUNO's primary objective was to assess antibiotic prescription rate in the SC arm; the secondary objective was to assess JUPITER's study design.

RESULTS

Eleven centers randomized 260 patients, with 214 included (106 SC, 108 MMBV). Median (IQR) age was 40 (28-55.8) years, 57% were female, and 78.5% were enrolled at ED. Common symptoms were cough (93.0%) and chills (70.0%). Overall, antibiotic prescription rates were 30% (95% CI 22% to 40%) and 24% (95% CI 17% to 33%) in the SC arm versus the MMBV (absolute difference of -6% [95% CI -18% to 6%]). More antibiotics were given with bacterial MMBV scores (41% vs. 78%, absolute difference 37%, 95% CI 6% to 61%; n = 40) and less with viral MMBV scores (25% vs. 12%, absolute difference -13%, 95% CI -25% to 0%; n = 144) in the SC versus MMBV arms. There was no increase in ED/UC return visits (8% vs. 3%, difference -6%, 95% CI -12% to 1%) or hospitalizations (3% vs. 0%, difference -3%, 95% CI -7% to 1%) in the SC arm versus the MMBV arm.

CONCLUSIONS

JUNO demonstrated that JUPITER's design results in 30% antibiotic prescription rate in the SC arm. JUNO supports that MMBV optimizes antibiotic prescriptions without increasing return ED/UC visits or hospitalizations.

Norepinephrine Versus Dopamine for Septic Shock in Neonates: A Randomized Controlled Trial

OBJECTIVE

To assess the effect of norepinephrine (NE) versus dopamine (DA) as first-line vasoactive agent in neonates with fluid refractory septic shock.

STUDY DESIGN

In this randomized controlled trial, 80 neonates with fluid refractory septic shock were allocated to receive either NE (n=41) or DA (n=39) as the first-line vasoactive drug. NE and DA were initiated at a dose of 0.2 and 10 μg/kg/min and escalated to a maximum dose of 0.3 and 15 μg/kg/min, respectively. The primary outcome was the proportion of neonates with shock reversal at 30 minutes of initiation of vasoactive support. Other outcomes included time to shock reversal, requirement of additional vasoactive drugs and steroids, changes in cerebral tissue oxygen saturation (CrSO2), and acid-base parameters and lactate levels at 6-8 and 24 hours. Incidence of mortality, hyperglycemia, tachycardia, and other morbidities were recorded.

RESULTS

Baselines characteristics were comparable between the two groups. The proportion of neonates with shock reversal at 30 minutes was 32% (13/41) and 46% (18/39) in NE and DA groups, respectively (relative risk 0.69, 95% CI 0.39 to 1.20, p=0.19). Time to reversal of shock, need for additional vasoactive drugs and steroids, lactate levels, hyperglycemia, mortality, and other morbidities were comparable. However, neonates in the DA group had a higher incidence of tachycardia, lower CrSO2, and lower pH at 24 hours of recruitment.

CONCLUSION

In neonates with septic shock, NE and DA had comparable efficacy as a first-line vasoactive agent.

Nitric oxide biomarkers and circulatory failure in critical illness: A cohort study

PURPOSE

Arterial hypotension is frequently observed in critically ill patients. Nitric oxide (NO) is pivotal in vasodilation. We investigated the associations between NO-biomarkers (asymmetrical dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), arginine, and homoarginine) and treatment with norepinephrine and plasma lactate on ICU days 1-3.

MATERIALS AND METHODS

A prospective cohort study of 527 adult ICU patients with NO-biomarkers at admission. Associations with norepinephrine treatment were analyzed in logistic regressions on the first three days of ICU admission. Associations with the highest daily plasma lactate were analyzed with linear mixed models.

RESULTS

Increasing ADMA and arginine were associated with decreased norepinephrine treatment (ICU day 1: OR 0.36 pr 1 μmol/L ADMA, 95 % CI 0.17-0.78; p = 0.009, and OR 0.85 pr 10 μmol/L arginine; 95 % CI 0.79-0.92; p < 0.001). An increase in homoarginine of 1 μmol/L was associated with an increase in plasma lactate of 6 % (95 % CI -2 % to 15 %) from ICU days 1-2 and 4 % (95 % CI -4 % to 13 %) from ICU days 2-3. SDMA was not associated with either outcome.

CONCLUSIONS

Increased ADMA and arginine at admission are associated with decreased norepinephrine treatment on the first three days of ICU admission. Increased homoarginine concentrations are associated with increasing plasma lactate.

Efficacy of adjuvant use of midodrine in patients with septic shock: An open label randomized controlled trial

BACKGROUND

Midodrine has been primarily studied as an adjunctive oral therapy to reduce the need for vasopressors in intensive care units (ICU). Nonetheless, the available results evaluating midodrine as an adjuvant therapy in the treatment of septic shock are limited and inconclusive. This study aims to evaluate the efficacy of midodrine, specifically focusing on its effect on mortality outcomes in patients with septic shock.

METHODS

This was an open-label randomized controlled trial. Patients with septic shock (n = 100) were randomized to either the control group, who received intravenous norepinephrine, or the midodrine group, who received intravenous norepinephrine and midodrine 10 mg every 8 h. The primary outcome was the 28-day in-hospital mortality. Secondary outcomes were 7-day ICU mortality, average dose of norepinephrine, duration of intravenous norepinephrine, ICU length of stay (LOS), and in-hospital LOS.

RESULTS

The 28-day mortality rate was 68% in the control group compared to 54% in the midodrine group (risk difference -14% (95% confidence interval (CI)) -32.9% to 4.9%). Similarly, the 7-day ICU mortality rate was 56% in the control group and 42% in the midodrine group (risk difference -14% (95% CI -33.4% to 5.4%)). The average intravenous norepinephrine dose in the midodrine group was significantly lower compared to the control group (mean difference 0.06 (95% CI 0.01-0.11), p = 0.002). However, midodrine did not have a significant impact on the duration of intravenous norepinephrine use (mean difference 0.66 (95% CI -0.56 to 1.88)). Midodrine did not significantly shorten the course of hospitalization. There was no significant difference in median ICU LOS between the control group and the midodrine group (4 vs. 5 days, respectively).

CONCLUSION

The findings did not demonstrate a significant reduction in mortality with adjuvant midodrine use in the treatment of septic shock. Midodrine appears to reduce the need for vasopressors. However, our findings did not support that midodrine shortens the duration of vasopressor use nor the course of hospitalization for patients with septic shock.

Piperacillin/tazobactam versus carbapenems for 30-day mortality in patients with ESBL-producing Enterobacterales bloodstream infections: a retrospective, multicenter, non-inferiority, cohort study

PURPOSE

Antimicrobial resistance increases with the use of broad-spectrum antibiotics. Studies evaluating antibiotic stewardship are in high demand. Is piperacillin/tazobactam non-inferior to carbapenems regarding 30-day mortality among patients with bloodstream infections caused by extended-spectrum beta-lactamase-producing Enterobacterales?

METHODS

This retrospective, multicenter, non-inferiority, cohort study assessed adult patients with bloodstream infections caused by extended-spectrum beta-lactamase-producing Enterobacterales in southern Sweden from 2013 to 2022. Patients were categorized according to the first therapy they received two consecutive doses of (piperacillin/tazobactam or a carbapenem). The primary outcome was 30-day all-cause mortality, measured from when the positive blood cultures were taken. The absolute risk difference for this outcome was calculated for all patients, and two propensity score matched cohorts (empirical and effective), with two different delta limits (5% and 2%). Secondary outcomes included intensive care unit admission, early clinical response, superinfections, relapsed infection and one-year mortality.

RESULTS

A total of 644 patients were included. In the piperacillin/tazobactam group, 26/309 patients met the primary outcome, compared to 27/335 patients in the carbapenem group. The absolute risk difference (-0.4%) was statistically significant in the propensity score matched empirical cohort [1-sided 97.5% confidence interval]: -∞ to 4.0, p = 0.008). Piperacillin/tazobactam was non-inferior to carbapenems for all the secondary outcomes in the same cohort, except for the early clinical response.

CONCLUSION

Our findings indicate that piperacillin/tazobactam is non-inferior to carbapenems for treating extended-spectrum beta-lactamase-producing Enterobacterales bloodstream infections, with an acceptable 5% increase in 30-day mortality. We suggest that piperacillin/tazobactam should be used more frequently to decrease antimicrobial resistance.

Frequency of Antibiotic Overtreatment and Associated Harms in Patients Presenting With Suspected Sepsis to the Emergency Department: A Retrospective Cohort Study

BACKGROUND

Treatment guidelines recommend rapidly treating all patients with suspected sepsis with broad-spectrum antibiotics. This may contribute to antibiotic overuse. We quantified the incidence of antibiotic overtreatment and possible antibiotic-associated harms among patients with suspected sepsis.

METHODS

We reviewed the medical records of 600 adults treated for suspected sepsis with anti-methicillin-resistant Staphylococcus aureus and/or antipseudomonal β-lactam antibiotics in the emergency departments of 7 hospitals, 2019-2022, to assess their post hoc likelihood of infection, whether narrower antibiotics would have sufficed in retrospect, and possible antibiotic-associated complications. We used generalized estimating equations to assess associations between likelihood of infection and hospital mortality.

RESULTS

Of 600 patients, 411 (68.5%) had definite (48.0%) or probable (20.5%) bacterial infection and 189 (31.5%) had possible but less likely (18.3%) or definitely no (13.2%) bacterial infection. Among patients with definite/probable bacterial infection, 325 of 411 (79.1%) received antibiotics that were overly broad in retrospect. Potential antibiotic-associated complications developed in 104 of 600 (17.3%) patients within 90 days, most commonly new infection or colonization with organisms resistant to first-line agents (48/600 [8.0%]). Mortality was higher for patients with less likely/definitely no bacterial infection versus definite/probable bacterial infections (9.0% vs 4.9%; adjusted odds ratio [aOR], 2.25 [95% confidence interval{CI}, 1.70-2.98]), but antibiotic-associated complication rates were similar (14.8% vs 18.5%; aOR, 0.79 [95% CI, .60-1.05]).

CONCLUSIONS

Among 600 patients treated with broad-spectrum antibiotics for possible sepsis, 1 in 3 most likely did not have a bacterial infection, 4 in 5 of those with bacterial infections were treated with regimens that were broader than necessary in retrospect, and 1 in 6 developed antibiotic-associated complications.

CMTM4 promotes PD-L1-mediated macrophage apoptosis by enhancing STAT2 phosphorylation in sepsis

BACKGROUND

Macrophage apoptosis is a key contributor to the elimination of immune cells and increased susceptibility during sepsis. CKLF like MARVEL transmembrane domain containing 4 (CMTM4) is a membrane protein with four transmembrane domains. It has recently been implicated in the regulation of immune cell biological functions. However, its role in regulating macrophage apoptosis during sepsis has not been extensively studied.

METHODS

Clinical samples were analyzed to determine CMTM4 expression levels and their correlation with clinical examination results. An in vitro model was developed using C57BL/6 mice and the THP-1 cell line. An immunofluorescence analysis was used to assess protein expression levels, apoptosis, and protein co-localization. Western blotting (WB) was used to measure protein expression levels, while flow cytometry was used to detect cell apoptosis. Transcriptomic sequencing was conducted to identify differentially expressed genes and to perform a functional enrichment analysis. Transcription factors were screened using databases. Chromatin immunoprecipitation, followed by quantitative PCR (ChIP-qPCR), was conducted to analyze protein-DNA interactions, and co-immunoprecipitation (Co-IP) was used to examine protein-protein interactions.

RESULTS

CMTM4 expression in macrophages was upregulated in sepsis. The inhibition of CMTM4 expression reduced macrophage apoptosis. PD-L1 was identified as a key molecule regulated by CMTM4 in macrophage apoptosis. CMTM4 regulates PD-L1 by promoting the phosphorylation of its transcription factor, STAT2, rather than directly binding to PD-L1.

CONCLUSION

In sepsis, CMTM4 facilitates PD-L1-dependent macrophage apoptosis by enhancing STAT2 phosphorylation. This discovery offers new insights for the diagnosis and treatment of sepsis.

Protein C in adult patients with sepsis: from pathophysiology to monitoring and supplementation

Protein C (PC) plays a crucial role in modulating inflammation and coagulation in sepsis. Its anticoagulant and cytoprotective properties are critical in mitigating sepsis-induced coagulopathy, which is associated with high mortality rates. In sepsis, low levels of PC are associated with an elevated risk of multiple organ dysfunction and increased mortality. Routine monitoring of PC levels is not widely implemented but appears relevant in selected populations, such as patients with purpura fulminans, sepsis-induced coagulopathy (SIC), disseminated intravascular coagulopathy (DIC) or hyperinflammatory septic shock phenotypes. Treatment with PC has been limited to PC concentrate approved for paediatric use in congenital PC deficiencies and purpura fulminans, while the efficacy of PC supplementation in sepsis remains a subject of debate. Considering the physiological significance of PC and its role in sepsis pathophysiology, additional studies are necessary to fully elucidate its therapeutic efficacy in specific clinical settings.

Staircase strategy, tier-three therapies, and effects on outcome in traumatic brain injured patients: the Triple-T TBI study

PURPOSE

To evaluate the clinical practice and timing of use of tier-three therapies (TTT) after traumatic brain injury (TBI), and to explore their association with intensive care unit (ICU) mortality and 3 months neurological outcome.

METHODS

International multicenter, retrospective, observational, cohort study performed in 16 ICUs including 408 adult TBI patients requiring at least one of the TTT [i.e. metabolic suppression with barbiturates, secondary decompressive craniectomy (DC), and mild hypothermia] for the control of intracranial hypertension during the ICU stay.

RESULTS

Among 408 adult TBI patients, secondary DC was the most frequent TTT utilized (n = 297, 72.8%), and was associated with reduced ICU mortality [Odds Ratio, OR 0.34 (95% Confidence Interval, CI 0.14-0.78) p = 0.012] and better neurological outcome (p = 0.047), whereas barbiturates were associated with increased ICU mortality [OR: 3.05 (95% CI 1.43-6.49); p = 0.004) and worse neurological outcome (p = 0.032). Two hundred and twenty-four (55%) patients received interventions in adherence to guidelines, which was associated with a non-significant trend towards better outcomes.

CONCLUSIONS

The staircase approach before the use of TTT was not often utilized after severe TBI. Secondary DC was performed more often than other treatments and its use was associated with improved mortality and neurological outcome. The benefits of adherence to guidelines before TTT prescription should be further evaluated.

Prehospital Sepsis Recognition and Antibiotic Administration: A Retrospective Analysis

OBJECTIVES

Although earlier antibiotics are known to be beneficial in sepsis, very few emergency medical services (EMS) agencies have protocols for prehospital antibiotics for sepsis. Therefore, we sought to assess how well a large EMS agency that uses prehospital antibiotics for sepsis adheres to its sepsis protocol (when initiated), and to determine how soon antibiotics are typically given.

METHODS

We conducted a retrospective chart review of patients identified as "sepsis alerts" by EMS clinicians from a single EMS system in Florida, USA. The prehospital sepsis protocol dictated that EMS clinicians initiate a "sepsis alert" if the patient had a suspected infection and at least 2 of the following 3 criteria based on the sequential (sepsis-related) organ failure assessment (qSOFA) score: altered mental status, respiratory rate > 22 breaths per minute or end-tidal CO2 < 25 mmHg, or systolic blood pressure < 100 mmHg. Per protocol, patients meeting sepsis criteria were supposed to receive intravenous ceftriaxone and intramuscular gentamicin. We reviewed the charts of sepsis alert patients to determine demographic information, clinical characteristics, sepsis protocol compliance, and when patients received antibiotics.

RESULTS

Between June 1, 2023, and June 30, 2024, there were 1308 patients for whom a prehospital sepsis alert was initiated. Median age was 80.0 years (IQR: 72-87.5), and 48.5% had hypotension (systolic blood pressure < 100 mmHg). Of the 1308 sepsis alert patients, review of documentation confirmed that 1301 (99.5%) had a suspected infection with at least 2 sepsis alert criteria. In total, 1264 (96.6%) received at least 1 antibiotic (either ceftriaxone or gentamicin) prior to hospital arrival. The median time from 9-1-1 call to first antibiotic administration was 26 min (IQR: 21-31 min). The first antibiotic was given a median of 11 min (IQR: 7-16 min) prior to hospital arrival.

CONCLUSIONS

For patients in whom a sepsis alert was initiated, EMS clinicians adhered to the sepsis protocol and administered antibiotics prior to hospital arrival in 97% of cases. Patients received their first antibiotic a median of approximately 26 min after 9-1-1 call and 11 min prior to hospital arrival.

Diagnostic safety and quality optimization in sepsis study protocol

BACKGROUND

Sepsis ranks among the "Big Three" conditions most prone to harmful diagnostic errors. Despite its high prevalence and severity, health systems lack effective and contextually tailored strategies to optimize diagnostic accuracy for sepsis.

OBJECTIVES

The purpose of this study is to understand factors related to high sepsis diagnostic accuracy using principles and tools of safety and implementation science.

METHODS

This is a multi-site study involving 20 hospitals across four states in the United States. The primary objectives are to (1) describe hospital-level variability and understand barriers and facilitators to sepsis diagnostic accuracy and (2) apply cross-case and coincidence analysis to determine minimally sufficient and necessary conditions for optimal sepsis diagnosis that minimizes under- and overtreatment. To identify barriers and facilitators of acute sepsis diagnosis, we will conduct electronic surveys and in-depth interviews with key informants from each hospital. We will use data from electronic health records (EHR) and data warehouses to operationalize sepsis diagnostic accuracy.

RESULTS

We have enrolled 20 hospitals and begum data collection. The findings of this study will be used to develop a context-specific toolkit that guides the selection of feasible and important strategies to promote optimal sepsis diagnosis in diverse hospitals settings.

CONCLUSIONS

The study uses tools and principles from safety and implementation science to generate first-of-its-kind evidence to improve diagnostic excellence in sepsis.

Year in Review 2024: Noteworthy Literature in Cardiothoracic Critical Care

This article reviews noteworthy additions to the literature for the management of critically ill cardiothoracic surgical patients published in 2024. We reviewed 8100 articles to identify 10 publications that provided new or updated information across a diverse range of topics including extracorporeal membrane oxygenation (ECMO), sepsis and shock, and acute hypoxemic respiratory failure (AHRF). Additional topics within these publications included prophylaxis guidelines and evidence for prevention of common complications in the intensive care unit, such as bleeding, thrombosis, and acute kidney injury (AKI).

Predictive factors of mortality in very old patients visited in Emergency Department and admitted for infection

OBJECTIVE

To describe mortality predictive factors in patients 80years or older with infection who were visited at the emergency department and were admitted to hospital.

METHODS

Retrospective observational study. Patients ≥80years old who visited the emergency department (January 1st to December 31st, 2022), whose main diagnosis was infection and required admission, were included. Factors associated with mortality at the end of the episode were determined.

RESULTS

987 patients were included (mean age 87years, 53% women). Mortality at the end of the episode was 13% (n=127). Median survival of the series was 52days (95%CI: 44-60). The independent factors related to mortality were: age (HR: 1.07; 95%CI: 1.03-1.11; P<.001), frailty (Clinical Frailty Scale [CFS]) (HR: 1.51; 95%CI: 1.15-1.97; P=.003), qSOFA (HR: 1.35; 95%CI: 1.07-1.70; P=.01), SOFA (HR: 1.23; 95%CI: 1.15-1.38; P<.001), leukocyte count (HR: 1.04; 95%CI: 1.02-1.06; P<.001) and criteria for sepsis and/or septic shock (HR: 2.52; 95%CI: 1.63-3.87; P<.001). On the contrary, any type of microbiological isolation was associated with lower mortality (HR: 0.44; 95%CI: 0.29-0.64; P<.001).

CONCLUSIONS

qSOFA and SOFA scores, the sepsis and septic shock criteria, as well as frailty are predictive factors of poor prognosis in very elderly patients who come to the emergency room due to infection. Knowing frailty would allow us to adapt the treatment and therapeutic effort to the patient's characteristics.

Large Language Models in Action: Supporting Clinical Evaluation in an Infectious Disease Unit

Background/Objectives: Healthcare-associated infections (HAIs), including sepsis, represent a major challenge in clinical practice owing to their impact on patient outcomes and healthcare systems. Large language models (LLMs) offer a potential solution by analyzing clinical documentation and providing guideline-based recommendations for infection management. This study aimed to evaluate the performance of LLMs in extracting and assessing clinical data for appropriateness in infection prevention and management practices of patients admitted to an infectious disease ward. Methods: This retrospective proof-of-concept study analyzed the clinical documentation of seven patients diagnosed with sepsis and admitted to the Infectious Disease Unit of San Bortolo Hospital, ULSS 8, in the Veneto region (Italy). The following five domains were assessed: antibiotic therapy, isolation measures, urinary catheter management, infusion line management, and pressure ulcer care. The records, written in Italian, were anonymized and paired with international guidelines to evaluate the ability of LLMs (ChatGPT-4o) to extract relevant data and determine appropriateness. Results: The model demonstrated strengths in antibiotic therapy, urinary catheter management, the accurate identification of indications, de-escalation timing, and removal protocols. However, errors occurred in isolation measures, with incorrect recommendations for contact precautions, and in pressure ulcer management, where non-existent lesions were identified. Conclusions: The findings underscore the potential of LLMs not merely as computational tools but also as valuable allies in advancing evidence-based practice and supporting healthcare professionals in delivering high-quality care.

Association between alactic base excess on mortality in sepsis patients: a retrospective observational study

BACKGROUND

Sepsis is a life-threatening condition often associated with metabolic and acid-base imbalances. Alactic base excess (ABE) has emerged as a novel biomarker to assess metabolic disturbances in critically ill sepsis patients, but its prognostic value remains underexplored. We aimed to investigate the relationship between ABE and 30-day/90-day ICU all-cause mortality in a large sepsis cohort in the intensive care unit (ICU) setting.

METHODS

This study utilised data from a large US ICU sepsis cohort. ABE was calculated as the sum of lactate and base excess (BE) values from the first day of ICU admission. Patients were divided into quartiles based on ABE values. Kaplan-Meier survival analysis, Cox proportional hazards models, and restricted cubic spline analyses were used to examine the associations between ABE and mortality outcomes. The predictive performance of ABE combined with the SOFA score was assessed using the area under the curve, Net Reclassification Improvement, and Integrated Discrimination Improvement.

RESULTS

17,099 patients with sepsis were included in this analysis, with median (IQR) age of 67.82 (56.80, 78.04) years and 59.7% males. Our analysis revealed a U-shaped association between ABE and 30-day and 90-day ICU all-cause mortality. Both the lowest (Q1) and highest (Q4) quartiles of ABE were linked to increased mortality risks, with 30-day mortality showing HRs of 1.27 (95% CI 1.13-1.44) for Q1 and 1.17 (95% CI 1.06-1.31) for Q4, while 90-day mortality showed HRs of 1.28 (95% CI 1.16-1.44) for Q1, 1.12 (95% CI 1.02-1.23) for Q2, and 1.22 (95% CI 1.11-1.34) for Q4. ABE demonstrated superior predictive performance for mortality compared to BE and lactate. Incorporating ABE into the SOFA score improved predictive performance, emphasizing ABE's value in better risk stratification. The identified thresholds (2.5 mmol/L for 30-day mortality and 2.2 mmol/L for 90-day mortality) indicate optimal ABE levels that may be associated with improved survival outcomes.

CONCLUSIONS

ABE demonstrated a U-shaped association with 30-day and 90-day ICU all-cause mortality in critically ill sepsis patients, suggesting its superiority over BE and lactate as a predictive biomarker. Incorporating ABE with the SOFA score may further enhance prognostic predictions. Further studies are needed to determine whether ABE should serve solely as a biomarker for monitoring the clinical course or could also be considered a potential therapeutic target.

Risk Factors for Recurrent Episodes of Suspected Pneumonia

Background: Pneumonia remains the most common intensive care unit (ICU)-acquired infection with patients often suffering multiple episodes. The diagnosis remains difficult as many non-infectious causes can masquerade as pneumonia. The purpose of this study is to identify risk factors for potential recurrent pneumonia from a recent randomized trial. Methods: We performed a retrospective analysis of the recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter trial of antibiotic initiation strategies. Demographics, comorbidities, and outcomes were reviewed. Standard uni-variable statistical analysis was performed. Results: TARPP enrolled 186 patients with 47 patients (25.3%) having at least one additional episode of suspected pneumonia. Patients with recurrent episodes of suspected pneumonia were more likely to identify as Hispanic or Latino or to speak Spanish as their primary language. Patients with recurrent suspected episodes had longer ICU length of stay, total days of antibiotic agents, and longer ventilator days. Patients with recurrent episodes had a greater overall of culture positivity, but no difference in the rate of infection because of non-fermenting gram-negatives. Patients with recurrent episodes had lower mortality rates overall compared with those with a single infectious episode. Conclusions: This retrospective analysis suggests that ethnicity and language barriers may be associated with recurrent suspected pneumonia. Although greater rate of culture positivity was associated potential recurrence, the lower mortality rates in this group suggest a survivorship bias. More work is needed to evaluate the risks for recurrent pneumonia in the ICU.

Improving Outcomes in Survivors of Sepsis-The Transition from Secondary to Primary Care, and the Role of Primary Care: A Narrative Review

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. The number of patients with sepsis requiring critical care admission is increasing. At the same time, overall mortality from sepsis is declining. With increasing survival to hospital discharge, there are an increasing number of sepsis survivors whose care needs shift from the acute to chronic care settings. Recently, the phrase "post-sepsis syndrome" has emerged to encompass the myriad of complications in patients recovering from sepsis. The aim of this narrative review is to provide a contemporary summary of the available literature on post-sepsis care and highlight areas of ongoing research. There are many incentives for improving the quality of survivorship following sepsis, including individual health-related outcomes (e.g., increased survival, enhanced physical and psychological health) and wider socio-economic benefits (e.g., reduced economic burden on the healthcare systems, reduced physical and psychological burden on carers, ability for individuals (and carers) to return to workforce). Modifiable factors influencing long-term outcomes can be in-hospital or after discharge, when primary care physicians play a pivotal role. Despite national and international guidance being available, this area has been under-recognised historically, despite its profoundly negative impact on both patients and their families or caregivers. Contributing factors likely include the lack of a formally recognised "disease" or pathology, the presence of challenging-to-treat symptoms such as fatigue, weakness and cognitive impairment, and the prevailing assumption that ongoing rehabilitation merely requires time. Our review will focus on the following areas: screening for new cognitive and physical impairments; optimisation of pre-existing comorbidities; transition to primary care; and palliative care. Primary care physicians may have a crucial role to play in improving outcomes in sepsis survivors, and candidate interventions include education on common complications of post-sepsis syndrome.

A narrative review of the pathophysiology of sepsis in sub-Saharan Africa: Exploring the potential for corticosteroid therapy

Sepsis remains a significant global health threat with a disproportionate burden in low-income countries including those in sub-Saharan Africa where case fatality rates are as high as 30% to 50%. Defined as a severe systemic response to infection, sepsis leads to widespread immune dysregulation and organ dysfunction, including adrenal insufficiency. Critical illness-related corticosteroid insufficiency (CIRCI) arises from dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids, all of which can occur during sepsis. Clinical trials of corticosteroids for the treatment of patients with sepsis and septic shock have shown improvements in shock reversal, and in some studies, patient survival; however, their role in the treatment of sepsis in sub-Saharan Africa is unknown. The incidence of sepsis in sub-Saharan Africa is compounded by high rates of human immunodeficiency virus (HIV) and co-infections, including tuberculosis (TB), which is the leading cause of sepsis. Both HIV and TB can cause immune dysregulation and adrenal insufficiency, which may exacerbate CIRCI and prolong shock. Existing sepsis research has been predominantly conducted in high-income countries and has largely excluded people living with HIV or TB. Therefore, there is a need to better understand sepsis and CIRCI pathophysiology in the context of specific regional host and pathogen characteristics. In this narrative review, we explored the pathophysiology of sepsis in sub-Saharan Africa including the existing literature on the immune response to sepsis and the prevalence of adrenal insufficiency in patients with HIV and TB, with a focus on the implications for corticosteroid management. We found a compelling need to further evaluate corticosteroids for the treatment of sepsis in Africa.