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Nejtek T, Müller M, Moravec M, Průcha M, Zazula R. Bacteremia in Patients with Sepsis in the ICU: Does It Make a Difference? Microorganisms 2023; 11:2357. [PMID: 37764201 PMCID: PMC10534394 DOI: 10.3390/microorganisms11092357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis (and septic shock) is on of the most common causes of death worldwide. Bacteremia often, but not necessarily, occurs in septic patients, but the impact of true bacteremia on a patient's clinical characteristics and outcome remains unclear. The main aim of this study was to compare the characteristics and outcome of a well-defined cohort of 258 septic patients with and without bacteremia treated in the intensive care unit (ICU) of a tertiary center hospital in Prague, Czech Republic. As expected, more frequently, bacteremia was present in patients without previous antibiotic treatment. A higher proportion of bacteremia was observed in patients with infective endocarditis as well as catheter-related and soft tissue infections in contrast to respiratory sepsis. Multivariant analysis showed increased severity of clinical status and higher Charlson comorbidity index (CCI) as variables with significant influence on mortality. Bacteremia appears to be associated with higher mortality rates and length of ICU stay in comparison with nonbacteremic counterparts, but this difference did not reach statistical significance. The presence of bacteremia, apart from previous antibiotic treatment, may be related to the site of infection.
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Affiliation(s)
- Tomáš Nejtek
- Department of Epidemiology, Faculty of Military Science, University of Defence, 500 01 Hradec Králové, Czech Republic;
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and Thomayer University Hospital, 140 59 Prague, Czech Republic; (M.M.); (R.Z.)
| | - Martin Müller
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and Thomayer University Hospital, 140 59 Prague, Czech Republic; (M.M.); (R.Z.)
| | - Michal Moravec
- Department of Epidemiology, Faculty of Military Science, University of Defence, 500 01 Hradec Králové, Czech Republic;
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and Thomayer University Hospital, 140 59 Prague, Czech Republic; (M.M.); (R.Z.)
| | - Miroslav Průcha
- Department of Clinical Biochemistry, Hematology and Immunology, Na Homolce Hospital, 150 00 Prague, Czech Republic;
| | - Roman Zazula
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and Thomayer University Hospital, 140 59 Prague, Czech Republic; (M.M.); (R.Z.)
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Peiris RM, May CN, Booth LC, McAllen RM, McKinley MJ, Hood S, Martelli D, Bellomo R, Lankadeva YR. Splanchnic sympathetic nerve denervation improves bacterial clearance and clinical recovery in established ovine Gram-negative bacteremia. Intensive Care Med Exp 2023; 11:53. [PMID: 37535121 PMCID: PMC10400745 DOI: 10.1186/s40635-023-00530-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/07/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The autonomic nervous system can modulate the innate immune responses to bacterial infections via the splanchnic sympathetic nerves. Here, we aimed to determine the effects of bilateral splanchnic sympathetic nerve denervation on blood pressure, plasma cytokines, blood bacterial counts and the clinical state in sheep with established bacteremia. METHODS Conscious Merino ewes received an intravenous infusion of Escherichia coli for 30 h (1 × 109 colony forming units/mL/h) to induce bacteremia. At 24 h, sheep were randomized to have bilaterally surgically implanted snares pulled to induce splanchnic denervation (N = 10), or not pulled (sham; N = 9). RESULTS Splanchnic denervation did not affect mean arterial pressure (84 ± 3 vs. 84 ± 4 mmHg, mean ± SEM; PGroup = 0.7) compared with sham treatment at 30-h of bacteremia. Splanchnic denervation increased the plasma levels of the pro-inflammatory cytokine interleukin-6 (9.2 ± 2.5 vs. 3.8 ± 0.3 ng/mL, PGroup = 0.031) at 25-h and reduced blood bacterial counts (2.31 ± 0.45 vs. 3.45 ± 0.11 log10 [CFU/mL + 1], PGroup = 0.027) at 26-h compared with sham treatment. Plasma interleukin-6 and blood bacterial counts returned to sham levels by 30-h. There were no differences in the number of bacteria present within the liver (PGroup = 0.3). However, there was a sustained improvement in clinical status, characterized by reduced respiratory rate (PGroup = 0.024) and increased cumulative water consumption (PGroup = 0.008) in splanchnic denervation compared with sham treatment. CONCLUSION In experimental Gram-negative bacteremia, interrupting splanchnic sympathetic nerve activity increased plasma interleukin-6, accelerated bacterial clearance, and improved clinical state without inducing hypotension. These findings suggest that splanchnic neural manipulation is a potential target for pharmacological or non-pharmacological interventions.
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Affiliation(s)
- Rachel M Peiris
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia
| | - Clive N May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Lindsea C Booth
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia
| | - Robin M McAllen
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia
| | - Michael J McKinley
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia
| | - Sally Hood
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia
| | - Davide Martelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Victoria, Australia
- Australian and Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Yugeesh R Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 30 Royal Parade Parkville, Victoria, 3052, Australia.
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia.
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Abbara S, Guillemot D, El Oualydy S, Kos M, Poret C, Breant S, Brun-Buisson C, Watier L. Antimicrobial Resistance and Mortality in Hospitalized Patients with Bacteremia in the Greater Paris Area from 2016 to 2019. Clin Epidemiol 2022; 14:1547-1560. [PMID: 36540898 PMCID: PMC9759973 DOI: 10.2147/clep.s385555] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/12/2022] [Indexed: 08/15/2023] Open
Abstract
PURPOSE Antibiotic-resistant bacteremia is a leading global cause of infectious disease morbidity and mortality. Clinical data warehouses (CDWs) allow for the secure, real-time coupling of diverse data sources from real-world clinical settings, including care-based medical-administrative data and laboratory-based microbiological data. The main purpose of this study was to assess the contribution of CDWs in the epidemiological study of antibiotic resistance by constructing a database of bacteremia patients, BactHub, and describing their main clinico-microbiological features and outcomes. PATIENTS AND METHODS Adult patients with bacteremia hospitalized between January 1, 2016 and December 31, 2019 in 14 acute care university hospitals from the Greater Paris area were identified; their first bacteremia episode was included. Data describing patients, episodes of bacteremia, bacterial isolates, and antimicrobial resistance were structured. RESULTS Among 29,228 patients with bacteremia, 41% of episodes were community-onset (CO) and 59% were hospital-acquired (HA). Thirty-day and ninety-day mortality rates were 15% and 20% in CO episodes, and 18% and 36% in HA episodes. Overall resistance rates were high, including third-generation cephalosporin resistance among Klebsiella pneumoniae (CO 21%, HA 37%) and Escherichia coli (CO 13%, HA 17%), and methicillin resistance among Staphylococcus aureus (CO 11%, HA 14%). Annual incidence rates increased significantly from 2017 to 2019, from 20.0 to 20.9 to 22.1 stays with bacteremia per 1000 stays (p < 0.0001). CONCLUSION The Bacthub database provides accurate clinico-microbiological data describing bacteremia across France's largest hospital group. Data from Bacthub may inform surveillance and the clinical decision-making process for bacteremia patients, including choice of antimicrobial therapy. The database also offers opportunities for research, including analysis of hospital care pathways and significant patient outcomes such as mortality and recurrence of infection.
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Affiliation(s)
- Salam Abbara
- Anti-Infective Evasion and Pharmacoepidemiology Team, Inserm, UVSQ, University Paris-Saclay, CESP, Montigny-Le-Bretonneux, France
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), University Paris Cité, Paris, France
| | - Didier Guillemot
- Anti-Infective Evasion and Pharmacoepidemiology Team, Inserm, UVSQ, University Paris-Saclay, CESP, Montigny-Le-Bretonneux, France
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), University Paris Cité, Paris, France
- Public Health, Medical Information, Clinical Research, AP-HP, University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Salma El Oualydy
- Plateforme des données de santé - Health Data Hub, Paris, France
| | - Maeva Kos
- Plateforme des données de santé - Health Data Hub, Paris, France
| | - Cécile Poret
- AP-HP, Direction des Systèmes d’Information, Pôle Innovation et Données, Paris, France
| | - Stéphane Breant
- AP-HP, Direction des Systèmes d’Information, Pôle Innovation et Données, Paris, France
| | - Christian Brun-Buisson
- Anti-Infective Evasion and Pharmacoepidemiology Team, Inserm, UVSQ, University Paris-Saclay, CESP, Montigny-Le-Bretonneux, France
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), University Paris Cité, Paris, France
| | - Laurence Watier
- Anti-Infective Evasion and Pharmacoepidemiology Team, Inserm, UVSQ, University Paris-Saclay, CESP, Montigny-Le-Bretonneux, France
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), University Paris Cité, Paris, France
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Tsou PY, Yo CH, Hsein YC, Yungtum G, Hsu WT, Chung JY, Su KY, Chang A, Chang IJ, Lee CC. Temporal Trends in the Microbiological Characteristics of Sepsis in the United States: A Population Based Study. J Intensive Care Med 2021; 37:936-945. [PMID: 34787474 DOI: 10.1177/08850666211053778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiologic studies are needed for monitoring population-level trends in sepsis. This study examines sepsis-causing microorganisms from 2006 to 2014 in the United States using data from the Nationwide Inpatient Sample database. METHODS 7 860 686 adults hospitalized with sepsis were identified using a validated ICD-9 coding approach. Associated microorganisms were identified by ICD-9 code and classified by major groups (Gram-positive, Gram-negative, fungi, anaerobes) and specific species for analysis of their incidence and mortality. RESULTS The rate of sepsis incidence has increased for all four major categories of pathogens, while the mortality rate decreased. In 2014, Gram-negative pathogens had a higher incidence than Gram-positives. Anaerobes increased the fastest with an average annual increase of 20.17% (p < 0.001). Fungi had the highest mortality (19.28%) and the slowest annual decrease of mortality (-2.31%, p = 0.006) in 2013, while anaerobic sepsis had the highest hazard of mortality (adjusted HR 1.60, 95% CI 1.53-1.66). CONCLUSIONS Gram-negative pathogens have replaced Gram-positives as the leading cause of sepsis in the United States in 2014 during the study period (2006-2014). The incidence of anaerobic sepsis has an annual increase of 20%, while the mortality of fungal sepsis has not decreased at the same rate as other microorganisms. These findings should inform the diagnosis and management of septic patients, as well as the implementation of public health programs.
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Affiliation(s)
| | - Chia-Hung Yo
- 46608FarEastern Memorial Hospital, New Taipei City, Taiwan
| | - Yenh-Chen Hsein
- 37999National Taiwan University Yunlin Branch, Douliou, Taiwan
| | - Gregory Yungtum
- 12321Warren Alpert Medical School of Brown University, RI, USA
| | - Wan-Ting Hsu
- 1857Harvard Chan School of Public Health, Boston, MA, USA
| | | | - Ke-Ying Su
- 38006National Taiwan University Hospital, Taipei, Taiwan
| | | | - I-Jing Chang
- 63474Taipei Medical University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- 38006National Taiwan University Hospital, Taipei, Taiwan.,Stanford University, Palo Alto, CA, USA.,38006National Taiwan University Hospital, Taiwan
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Alves B, Jouffroy R. [A central role for the home care nurse in the assessment of the severity of sepsis]. SOINS; LA REVUE DE REFERENCE INFIRMIERE 2021; 66:11-13. [PMID: 34187646 DOI: 10.1016/s0038-0814(21)00155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
En 2016, la conférence de consensus Sepsis 3 a mis en avant le score Quick Sepsis-related Organ Failure Assessment en complément du raisonnement clinique paramédical pour évaluer la sévérité et le risque de mortalité du sepsis À l'hôpital, ce score permet de dépister précocement le sepsis à risque d'évolution défavorable Sa mise en œuvre par les infirmiers à domicile devrait permettre de réduire la morbi-mortalité du sepsis, soulignant le rôle essentiel de ces professionnels dans l'activation de la chaîne de survie du sepsis.
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Affiliation(s)
- Barbara Alves
- Service d'anesthésie-réanimation, Samu de Paris, Assistance publique-Hôpitaux de Paris, hôpital Necker-Enfants malades, 149 rue de Sèvres, 75015 Paris, France
| | - Romain Jouffroy
- Service d'anesthésie-réanimation, Samu de Paris, Assistance publique-Hôpitaux de Paris, hôpital Necker-Enfants malades, 149 rue de Sèvres, 75015 Paris, France; Service de médecine intensive réanimation, hôpital Ambroise-Paré, 9 avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France; Centre de recherche en épidémiologie et santé des populations, U1018 Inserm équipe 5, université Paris Saclay, hopital Ambroise-Paré, 9 avenue Charles-de-Gaulle 92100 Boulogne Billancourt, France.
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6
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Nguyen-Hoang N, Bui QTH. Assessing the appropriateness of antimicrobial therapy in patients with sepsis at a Vietnamese national hospital. JAC Antimicrob Resist 2021; 3:dlab048. [PMID: 34223116 PMCID: PMC8210270 DOI: 10.1093/jacamr/dlab048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/15/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives To assess the appropriateness of empirical antimicrobial therapy for sepsis and septic shock and determine factors associated with patient treatment outcomes at a Vietnamese national hospital. Methods A cross-sectional study was conducted on 134 patients diagnosed with sepsis and/or septic shock at Thong-Nhat Hospital, Ho Chi Minh City, Vietnam, from January 2018 to June 2018. Appropriateness of antimicrobial therapy was defined as physician adherence to antimicrobial guidelines using the Sanford Guide to Antimicrobial Therapy and the Vietnam national guidelines. Bayesian model averaging technique was used to identify the related factors associated with patient treatment outcomes. Results The median age of patients was 70 years. Organisms were identified in 54.5% of cases and predominated by Escherichia coli and staphylococci. Appropriate empirical antimicrobial agents were initiated in 56.6% (n = 73) of all cases. Of these patients, 31 cases (42.5%) and 61 cases (83.6%) received the antimicrobials in accordance with recommendations related to dosage and route of administration, respectively, bringing the overall rate of appropriate empirical antimicrobial therapy down to 23.3%. Patients who progressed to septic shock, received inappropriate antimicrobial therapy and required ICU admission were more likely to suffer treatment failure. Conclusions The study findings suggest that clinicians should appropriately adhere to antimicrobial guidelines, especially in patients with septic shock and those who require ICU care, to improve treatment outcomes.
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Affiliation(s)
- Nam Nguyen-Hoang
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Quynh Thi Huong Bui
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,Department of Pharmacy, Thong-Nhat Hospital, Ho Chi Minh City, Vietnam
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Quantifying risk of disease due to extended-spectrum β-lactamase producing Enterobacteriaceae in patients who are colonized at ICU admission. J Infect 2020; 80:504-510. [PMID: 32142931 DOI: 10.1016/j.jinf.2020.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has globally increased and spread to the community. No clinical score is available to select carriers in whom these organisms can be empirically targeted at ICU admission. METHODS We prospectively assessed between 2009 and 2017 the prevalence of ESBL-PE infection in carriers at ICU admission. A logistic regression was used to determine independent risk factors associated with ESBL-PE infection, and to build a clinical risk score. RESULTS Of the 8,061 admissions over the study 7-year period, 745 (9%) patients were ESBL-PE carriers at admission, of whom 395 had infections at ICU admission including 59 (15%) who had culture-proven ESBL-PE related infection. By multivariable analysis, age >60 years, cirrhosis, being on broad-spectrum antibiotics within the past three months, urinary or intra-abdominal source of infection, and the absence of chronic pulmonary disease, were the five independent factors associated with ESBL-PE infection in carriers. A clinical risk score ranging from 0 to 7 was built based on these variables, with an area under the receiver operating characteristic curve (ROC) of 0.82 (95% CI 0.78-0.86); p <0.001. The prevalence of ESBL-PE infection for clinical risk scores of 0-1, 2-3, 4-5, or 6-7 was 0%, 4%, 26%, and 49%, respectively. The negative predictive value when Mondor ESBL risk score is <4 was 97%. CONCLUSION ESBL-PE related infection was not common in carriers at ICU admission. A clinical risk score may spare ESBL-PE carriers with lower risk of ESBL-PE infection at ICU admission unnecessary empiric carbapenem therapy.
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Epidemiology of Sepsis-3 in a sub-district of Beijing: secondary analysis of a population-based database. Chin Med J (Engl) 2020; 132:2039-2045. [PMID: 31425273 PMCID: PMC6793784 DOI: 10.1097/cm9.0000000000000392] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: With the publication of Sepsis-3 definition, epidemiological data based on Sepsis-3 definition from middle-income countries including China are scarce, which prohibits understanding of the disease burden of this newly defined syndrome in these settings. The purpose of this study was to describe incidence and outcome of Sepsis-3 in Yuetan sub-district of Beijing and to estimate the incidence rate of Sepsis-3 in China. Methods: The medical records of all adult residents hospitalized from July 1, 2012 to June 30, 2014 in Yuetan sub-district of Beijing were reviewed. Patients with sepsis-3 and severe sepsis/septic shock were identified. The incidence rates and mortality rate of sepsis-3 and sepsis/septic shock were calculated, incidence rates and in-hospital mortality rates were normalized to the population distribution in the 2010 National Census. Population incidence rate and case fatality rate between sexes were compared with the Z test, as the data conformed to Poisson distribution. Results: Of the 21,191 hospitalized patients, 935 patients were diagnosed with Sepsis-3, and 498 cases met severe sepsis/septic shock criteria. The crude annual incidence rate of Sepsis-3 in Yuetan sub-district was 363 cases per 100,000 population, corresponding to standardized incidence rates of 236 cases per 100,000 population per year, respectively. The overall case fatality rate of Sepsis-3 was 32.0%, the crude population mortality rates of Sepsis-3 was 116 cases per 100,000 population per year, the standardized mortality rate was 67 cases per 100,000 population per year, corresponding to a speculative extrapolation of 700,437 deaths in China. The incidence rate and mortality rate of Sepsis-3 were significantly higher in males, elderly people, and patients with more comorbidities. The 62.1% of patients with Sepsis-3 had community-acquired infections, compared with 75.3% of infected patients without Sepsis-3 (P < 0.001). The most common infection in patients with Sepsis-3 was lower respiratory tract infection. When compared with patients with Sepsis-3, patients diagnosed as severe sepsis/septic shock were more likely to have higher case fatality rate (53.4% vs. 32.0%, P < 0.001) Conclusions: This study found the standardized incidence rate of 236 cases per 100,000 person-year for Sepsis-3, which was more common in males and elderly population. This corresponded to about 2.5 million new cases of Sepsis-3 per year, resulting in more than 700,000 deaths in China. Clinical trial registration: NCT02285257, https://clinicaltrials.gov/ct2/show/record/NCT02285257.
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Yee CR, Narain NR, Akmaev VR, Vemulapalli V. A Data-Driven Approach to Predicting Septic Shock in the Intensive Care Unit. BIOMEDICAL INFORMATICS INSIGHTS 2019; 11:1178222619885147. [PMID: 31700248 PMCID: PMC6829643 DOI: 10.1177/1178222619885147] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 12/29/2022]
Abstract
Early diagnosis of sepsis and septic shock has been unambiguously linked to lower
mortality and better patient outcomes. Despite this, there is a strong unmet
need for a reliable clinical tool that can be used for large-scale automated
screening to identify high-risk patients. We addressed the following questions:
Can a novel algorithm to identify patients at high risk of septic shock 24 hours
before diagnosis be discovered using available clinical data? What are
performance characteristics of this predictive algorithm? Can current metrics
for evaluation of sepsis be improved using novel algorithm? Publicly available
data from the intensive care unit setting was used to build septic shock and
control patient cohorts. Using Bayesian networks, causal relationships between
diagnosis groups, procedure groups, laboratory results, and demographic data
were inferred. Predictive model for septic shock 24 hours prior to digital
diagnosis was built based on inferred causal networks. Sepsis risk scores were
augmented by de novo inferred model and performance was evaluated. A novel
predictive model to identify high-risk patients 24 hours ahead of time, with
area under curve of 0.81, negative predictive value of 0.87, and a positive
predictive value as high as 0.65 was built. The specificity of quick sequential
organ failure assessment, systemic inflammatory response syndrome, and modified
early warning score was improved when augmented with the novel model, whereas no
improvements were made to the sequential organ failure assessment score. We used
a data-driven, expert knowledge agnostic method to build a screening algorithm
for early detection of septic shock. The model demonstrates strong performance
in the data set used and provides a basis for expanding this work toward
building an algorithm that is used to screen patients based on electronic
medical record data in real time.
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Huang AH, Liu Y, Hsien YC, Hsu TC, Yen D, Hsu WT, Lin HY, Chen SC, Lee CC. Survival Impact and Clinical Predictors of Acute Gastrointestinal Bleeding in Patients With Bloodstream Infection. J Intensive Care Med 2019; 36:63-69. [PMID: 31684828 DOI: 10.1177/0885066619884896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The impact of gastrointestinal bleeding (GIB) on outcomes of patients with bloodstream infection (BSI) has not been studied. We aim to evaluate the risk factors and survival impact of GIB on the outcome of BSI. MATERIALS AND METHODS This study was conducted prospectively at National Taiwan University Hospital Yunlin Branch between January 1, 2015, and December 31, 2016. Patients aged ≥18 years for who BSI was confirmed by blood cultures were enrolled and followed for 90 days. Risk factors of GIB were identified by univariable and multivariable logistic regression models. The survival impact of GIB on BSI was evaluated with the Cox proportional hazards model with inverse probability of treatment weighting. RESULTS Of the 1034 patients with BSI, 79 (7.64%) developed acute GIB. We identified 5 independent predictors of GIB. Patients with BSI complicated with GIB had an increased 90-day mortality compared to patients without GIB (hazard ratio 1.74, 95% confidence interval: 1.14, 2.65). CONCLUSIONS Gastrointestinal bleeding had an adverse impact on the short-term survival in patients with BSI. The clinical predictors may help identify patients who may benefit from active prevention and treatment of GIB.
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Affiliation(s)
| | - Ye Liu
- Department of Health Care Organization and Policy, 48653University of Alabama at Birmingham School of Public Health, AL, USA
| | - Yenh-Chen Hsien
- Department of Laboratory Medicine, 37999National Taiwan University Hospital Yunlin Branch, Douliu
| | - Tzu-Chun Hsu
- Department of Emergency Medicine, 38006National Taiwan University Hospital, Taipei
| | - Debra Yen
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Wan-Ting Hsu
- Department of Epidemiology, 1857Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hsin-Yang Lin
- Department of Emergency Medicine, 38024Kaohsiung Veterans General Hospital, Kaohsiung
| | - Shyr-Chyr Chen
- Department of Emergency Medicine, 38006National Taiwan University Hospital, Taipei
| | - Chien-Chang Lee
- Department of Emergency Medicine, 38006National Taiwan University Hospital, Taipei
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İlce Z, Bekdemir FO, Pandır D. Acute toxic effect of lipopolysaccharides to blood tissue in rats and responses to vitamin E and sodium selenite. J Food Biochem 2019; 43:e13060. [PMID: 31576601 DOI: 10.1111/jfbc.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/18/2019] [Accepted: 09/11/2019] [Indexed: 11/29/2022]
Abstract
This work has been prepared to find out changes in the biochemicals with DNA damage, micronucleus, and apoptosis to lipopolysaccharides (LPS) alone or vitamin E (VE) and sodium selenite (SS) in rats' blood tissue. Rats were divided into eight groups according to the treatment into control vitamin E (VE) treatment group (200 mg/kg bw), sodium selenite (SS) treatment (0.35 mg/kg bw) group, VE + SS treatment group (200 + 0.35 mg/kg bw), LPS treatment group (10 mg/kg bw), LPS + VE (10 + 200 mg/kg bw), LPS + SS treatment (10 + 0.35 mg/kg bw), and LPS + SS+VE treatment (10 + 0.35 + 200 mg/kg bw) group for 6 hr. LPS increased malondialdehyde (MDA) level and decreased antioxidant enzymes' activities in rat erythrocytes and leukocytes. DNA damage of leukocytes with comet assay and RAPD-PCR was detected in LPS treatment group. The levels of micronucleus and apoptosis percentage were increased significantly at the end of 6 hr. VE and/or SS protected the LPS-induced erythrocytes and leukocytes against damage as they have caused amelioration of rats by altering the results. As a result, the co-administration of VE and/or SS against LPS-induced damage provides protection. VE and/or SS in patients and animal models with sepsis must be taken in the diet because they are protective against the cellular degradation caused by oxidative damage. PRACTICAL APPLICATIONS: LPS obtained from E. coli is used more frequently in experimental sepsis studies. When LPS is administered to experimental animals, interstitial pneumonia, adult respiratory fatal syndrome, acute tubular necrosis, and fatal effects such as coagulopathy and hypoglycemia may be seen in these animals. The co-treatment of VE and SS may be more effective than using them alone against LPS.
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Affiliation(s)
- Zehra İlce
- Graduate School of Natural and Applied Sciences, Department of Biology, Bozok University, Yozgat, Turkey
| | - Fatih Oğuz Bekdemir
- Graduate School of Natural and Applied Sciences, Department of Biology, Bozok University, Yozgat, Turkey
| | - Dilek Pandır
- Faculty of Arts and Science, Department of Biology, Bozok University, Yozgat, Turkey
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12
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Basmaci I, Sefik E. A novel use of attenuation value (Hounsfield unit) in non-contrast CT: diagnosis of pyonephrosis in obstructed systems. Int Urol Nephrol 2019; 52:9-14. [PMID: 31541403 DOI: 10.1007/s11255-019-02283-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/14/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the predictive value of attenuation value (HU) in renal pelvis urine for detecting renal pelvis urine culture (RPUC) positivity in obstructed urinary systems. METHODS The study group consisted of patients who had nephrostomy insertion performed because of obstructed system and suspicion of pyonephrosis and percutaneous nephrolithotomy (PCNL) patients who had obstructed calculi. Group 1 consisted of RPUC positive 28 patients during nephrostomy insertion or needle access in PCNL and group 2 consisted of 23 patients with negative RPUC. RPUC results and non-contrast computed tomography measurements [Hounsfield unit (HU)] were compared between group 1 and group 2. A cut-off value was determined for HU. All patients were grouped according to whether they were above or below this value. RESULTS The median HU calculated from the renal pelvis was - 8.5 (range - 29/- 1) and 10 (range- 4/+ 17) (p < 0.001) in group 1 and group 2, respectively. The cut-off value of HU that predicted positive RPUC was 0. Sensitivity and specificity of HU when considering this cut-off value were 100% and 96%, respectively (p < 0.001). Whereas RPUC positivity was found in 96.6% (28/29) of patients with HU < 0, there were no patients with HU > 0 where RPUC positivity was detected (p < 0.001). CONCLUSION In this cohort, we found that HU of the urine in the renal pelvis can be used to predict RPUC positivity.
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Affiliation(s)
- Ismail Basmaci
- Department of Urology, HSU Izmir Bozyaka Training and Research Hospital, Saim Cikrikci Str. No. 59, Bozyaka, Izmir, Turkey.
| | - Ertugrul Sefik
- Department of Urology, HSU Izmir Bozyaka Training and Research Hospital, Saim Cikrikci Str. No. 59, Bozyaka, Izmir, Turkey
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13
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Giménez-Llort L, Ramírez-Boix P, de la Fuente M. Mortality of septic old and adult male mice correlates with individual differences in premorbid behavioral phenotype and acute-phase sickness behavior. Exp Gerontol 2019; 127:110717. [PMID: 31479727 DOI: 10.1016/j.exger.2019.110717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/08/2019] [Accepted: 08/30/2019] [Indexed: 11/18/2022]
Abstract
Individual differences in premorbid behaviors and in those exhibited in the course of an infection disease may be useful to explain the individual susceptibility to infections, the underlying neuroimmunological mechanisms and be helpful to design patient oriented treatments with better prediction of pharmacological reactivity/outcome. Age (old) and gender (male) are also considered vulnerability factors. In the present study, the motor, emotional, anxious-like and social phenotypes of adult (6-month-old) and old (18-month-old) male C57BL/6 × 129Sv mice were determined using both a transversal and longitudinal designs prior to the analysis of LPS (150 mg/kg, i.p.)-induced sickness behavior and mortality. The results show: i) Individual premorbid behavioral phenotype had short- and long-term predictive value of hours of survival; ii) Persistence of behavioral traits from adulthood to old age and predictive value on hours of survival; iii) First signs of sickness behavior were also predicting mortality, mostly in old animals; iv) LPS-sickness behavior was the same at both ages but adult animals were able to show attempts of motor recovery; v) The mortality rate over 96 h was 100% in both ages, but old animals showed shorter survival times. In summary, these results confirm the relevance of age/aging but also individual behavioral differences in the premorbid phenotype and the morbidity response to the LPS-induced-sepsis that correlate with the individual's mortality. Thus, this work supports the translational scenarios to study personalized evaluation of risks factors and psycho-neuro-immunological mechanisms relevant for better interventions and prognosis in the critically ill young but specially aged patient population.
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Affiliation(s)
- L Giménez-Llort
- Medical Psychology Unit, Department of Psychiatry and Forensic Medicine, Institute of Neuroscience, School of Medicine, Campus Bellaterra, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Barcelona, Spain.
| | - P Ramírez-Boix
- Medical Psychology Unit, Department of Psychiatry and Forensic Medicine, Institute of Neuroscience, School of Medicine, Campus Bellaterra, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Barcelona, Spain
| | - M de la Fuente
- Department of Animal Physiology II, Universidad Complutense de Madrid, Madrid, Spain
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14
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Linder A, Fjell CD, Inghammar M, Hsu J, Walley KR, Boyd JH, Russell JA. The Specific Organism: Not Bacterial Gram Type: Drives the Inflammatory Response in Septic Shock. J Innate Immun 2019; 12:182-190. [PMID: 31242491 DOI: 10.1159/000500418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 04/08/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND HYPOTHESIS The inflammatory response was targeted by unsuccessful therapies but ignored pathogen. We hypothesized that the inflammatory response differs according to organism in human septic shock. MATERIALS AND METHODS We measured 39 cytokines at baseline and 24 h in patients (n = 363) in the Vasopressin and Septic Shock Trial (VASST). We compared cytokine profiles (cytokine functional class) at baseline and at 24 h by organism and used hierarchical clustering to classify cytokines according to 28-day outcomes. RESULTS In 363 patients, 88 and 176 patients had at least 1 species isolated from blood and other sites, respectively. Cytokine levels differed significantly according to organism: Neisseria meningitidis and Streptococcus pneumoniae had the highest (baseline and at 24 h), while Enterococcus faecalis (blood) had the lowest mean cytokine levels. N. meningitidis and Klebsiella pneumoniae had significantly higher cytokine levels at baseline versus 24 h (p = 0.01 and 0.02, respectively); E. faecalis had significantly higher cytokine levels at 24 h versus baseline. Hierarchical clustering heat maps showed that pathogens elicited similar cytokine responses not related to the functional cytokine class. CONCLUSION The organism type induces different cytokine profiles in septic shock. Specific gram-positive and gram-negative pathogens stimulated similar plasma cytokine-level patterns.
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Affiliation(s)
- Adam Linder
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Chris D Fjell
- Centre for Heart Lung Innovation and Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Malin Inghammar
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Joseph Hsu
- Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Keith R Walley
- Centre for Heart Lung Innovation and Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John H Boyd
- Centre for Heart Lung Innovation and Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - James A Russell
- Centre for Heart Lung Innovation and Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Abe T, Ogura H, Kushimoto S, Shiraishi A, Sugiyama T, Deshpande GA, Uchida M, Nagata I, Saitoh D, Fujishima S, Mayumi T, Hifumi T, Shiino Y, Nakada TA, Tarui T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Takuma K, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Fujimi S, Gando S. Variations in infection sites and mortality rates among patients in intensive care units with severe sepsis and septic shock in Japan. J Intensive Care 2019; 7:28. [PMID: 31073407 PMCID: PMC6500015 DOI: 10.1186/s40560-019-0383-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background Accurate and early identification of infection sites might help to drive crucial decisions regarding the treatment of sepsis. We aimed to determine the clinical and etiological features of infection according to sites among patients with severe sepsis in Japan. Methods This secondary analysis of a multicenter, prospective cohort study included 59 intensive care units (ICU) and proceeded between January 2016 and March 2017. The study cohort comprised 1184 adults (≥ 16 years) who were admitted to an ICU with severe sepsis and septic shock diagnosed according to the sepsis-2 criteria. Sites of infection diagnosed by physicians in charge at the time of arrival comprised the lung, abdomen, urinary tract, soft tissue, bloodstream, central nervous system (CNS), and undifferentiated infections. The primary outcome was in-hospital mortality. Results The most common sites of infection were the lungs (31.0%), followed by intra-abdominal sites (26.3%), the urinary tract (18.4%), and soft tissue (10.9%). The characteristics of the patients with severe sepsis across seven major suspected infection sites were heterogeneous. Septic shock was more frequent among patients with intra-abdominal (72.2%) and urinary tract (70.2%) infections than other sites. The in-hospital mortality rate due to severe sepsis and septic shock of a pooled sample was 23.4% (range, 11.9% [urinary tract infection] to 47.6% [CNS infection]). After adjusting for clinical background, sepsis severity, and stratification according to the presence or absence of shock, variations in hospital mortality across seven major sites of infection remained essentially unchanged from those for crude in-hospital mortality; adjusted in-hospital mortality rates ranged from 7.7% (95%CI, − 0.3 to 15.8) for urinary tract infection without shock to 58.3% (95%CI, 21.0–95.7) for CNS infection with shock in a generalized estimating equation model. Intra-abdominal and urinary tract infections were statistically associated with less in-hospital mortality than pneumonia. Infections of the CNS were statistically associated with higher in-hospital mortality rates than pneumonia in a logistic regression model, but not in the generalized estimating equation model. Conclusions In-hospital mortality and clinical features of patients with severe sepsis and septic shock were heterogeneous according to sites of infection. Electronic supplementary material The online version of this article (10.1186/s40560-019-0383-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Toshikazu Abe
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan.,2Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,30Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiroshi Ogura
- 3Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shigeki Kushimoto
- 4Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Shiraishi
- 5Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Japan
| | - Takehiro Sugiyama
- 2Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,6Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,30Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Gautam A Deshpande
- 1Department of General Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Masatoshi Uchida
- 2Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Isao Nagata
- 2Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Daizoh Saitoh
- 7Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Seitaro Fujishima
- 8Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- 9Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toru Hifumi
- 10Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasukazu Shiino
- 11Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Taka-Aki Nakada
- 12Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takehiko Tarui
- 13Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yasuhiro Otomo
- 14Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- 3Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Joji Kotani
- 16Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- 17Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- 18Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- 20Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- 21Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- 24Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- 25Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- 26Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- 27Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- 28Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Gando
- 29Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,31Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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16
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Stoclin A, Rotolo F, Hicheri Y, Mons M, Chachaty E, Gachot B, Pignon JP, Wartelle M, Blot F. Ventilator-associated pneumonia and bloodstream infections in intensive care unit cancer patients: a retrospective 12-year study on 3388 prospectively monitored patients. Support Care Cancer 2019; 28:193-200. [PMID: 31001694 PMCID: PMC7224052 DOI: 10.1007/s00520-019-04800-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 04/03/2019] [Indexed: 01/03/2023]
Abstract
Purpose Some publications suggest high rates of healthcare-associated infections (HAIs) and of nosocomial pneumonia portending a poor prognosis in ICU cancer patients. A better understanding of the epidemiology of HAIs in these patients is needed. Methods A retrospective analysis of all the patients hospitalized for ≥ 48 h during a 12-year period in the 12-bed ICU of the Gustave Roussy hospital, monitored prospectively for ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) and for use of medical devices. Results During 3388 first stays in the ICU, 198 cases of VAP and 103 primary, 213 secondary, and 77 catheter-related BSIs were recorded. The VAP rate was 24.5/1000 ventilator days (95% confidence interval [CI] 21.2–28.0); the catheter-related BSI rate was 2.3/1000 catheter days (95% CI 1.8–2.8). The cumulative incidence during the first 25 days of exposure was 58.8% (95% CI 49.1–66.6%) for VAP, 8.9% (95% CI, 6.2–11.5%) for primary, 15.1% (95% CI 11.6–18.5%) for secondary and 5.0% (95% CI 3.2–6.8%) for catheter-related BSIs. VAP or BSIs were not associated with a higher risk of ICU mortality. Conclusions This is the first study to report HAI rates in a large cohort of critically ill cancer patients. Although both the incidence of VAP and the rate of BSI are higher than in general ICU populations, this does not impact patient outcomes. The occurrence of device-associated infections is essentially due to severe medical conditions in patients and to the characteristics of malignancy. Electronic supplementary material The online version of this article (10.1007/s00520-019-04800-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Stoclin
- Service de Médecine Intensive Réanimation, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France. .,Service de Réanimation Médico-Chirurgicale, Gustave Roussy, 114, rue Edouard Vaillant, 94805, Villejuif, France.
| | - F Rotolo
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France.,INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Y Hicheri
- Service de Médecine Intensive Réanimation, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France
| | - M Mons
- Service d'Information Médicale, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France
| | - E Chachaty
- Service de Microbiologie Médicale, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France
| | - B Gachot
- Service de Médecine Intensive Réanimation, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France
| | - J-P Pignon
- Service de Biostatistique et d'Epidémiologie, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France.,INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - M Wartelle
- Direction du Système d'Information, Gustave Roussy, 114 Rue Edouard Vaillant, Villejuif, 94805, France
| | - F Blot
- Service de Médecine Intensive Réanimation, Gustave Roussy, 114, rue Edouard Vaillant, Villejuif, 94805, France
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17
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Gasté M, Monteils É, Alves B, Meyer B, Jouffroy R. [Screening for sepsis, the central role of the nurse]. SOINS; LA REVUE DE REFERENCE INFIRMIERE 2018; 63:18-21. [PMID: 30213308 DOI: 10.1016/j.soin.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In 2016, the International Consensus Conference 'Sepsis-3' highlighted the value of Sequential Organ Failure Assessment (SOFA) and Quick Sequential Organ Failure Assessment (qSOFA) scores in addition to medical and paramedical clinical reasoning to assess severity and the risk of mortality. The option of using qSOFA scores in healthcare services underlines the important role of nurses in the early detection of sepsis with a risk of unfavourable outcome, raising hopes of reducing the associated mortality.
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Affiliation(s)
- Marine Gasté
- Service d'anesthésie réanimation, Samu de Paris, AP-HP, hôpital Necker-Enfants Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Éric Monteils
- Service d'anesthésie réanimation, Samu de Paris, AP-HP, hôpital Necker-Enfants Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Barbara Alves
- Service d'anesthésie réanimation, Samu de Paris, AP-HP, hôpital Necker-Enfants Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Bruno Meyer
- Service d'anesthésie réanimation, Samu de Paris, AP-HP, hôpital Necker-Enfants Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Romain Jouffroy
- Service d'anesthésie réanimation, Samu de Paris, AP-HP, hôpital Necker-Enfants Malades, 149, rue de Sèvres, 75015 Paris, France.
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18
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Gonçalves MC, Horewicz VV, Lückemeyer DD, Prudente AS, Assreuy J. Experimental Sepsis Severity Score Associated to Mortality and Bacterial Spreading is Related to Bacterial Load and Inflammatory Profile of Different Tissues. Inflammation 2018; 40:1553-1565. [PMID: 28567497 DOI: 10.1007/s10753-017-0596-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pneumonia-induced sepsis is responsible for about 50% of cases in the world. Patients who develop severe sepsis and septic shock present organ dysfunction and elevated plasma cytokine levels, which may lead to death. Clinical scores are important to evaluate the framework of septic patients and are used to predict the syndrome progress, prognostics, and mortality. The objective of the present study was to verify the applicability of a murine clinical score system to experimental sepsis (pneumonia-induced sepsis in male mice) and to correlate it with mortality and bacterial dissemination in different organs. Results demonstrated that animals which present higher clinical scores (>3) are more likely to die. Animals presenting high clinical scores exhibited transient bacteremia and displayed bacterial spreading to different organs such as heart, kidney, liver, and brain. There is a correlation between clinical score and bacterial dissemination and consequently greater risk of death. In addition, animals which showed bacterial dissemination in more than three organs and high clinical scores presented high levels of cytokines (TNF-α, MCP-1, IL-6, and IL-10) in plasma, lung, heart, liver, kidney, and brain. Therefore, our study suggests that (1) severity scores have predictive power in experimental models of sepsis and (2) high concentrations of tissue cytokines may contribute to localized inflammation and be one of the factors responsible for the systemic inflammatory syndrome of sepsis.
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Affiliation(s)
- Muryel Carvalho Gonçalves
- Department of Pharmacology, Center of Biological Sciences, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Verônica Vargas Horewicz
- Department of Pharmacology, Center of Biological Sciences, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Débora Denardin Lückemeyer
- Department of Pharmacology, Center of Biological Sciences, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Arthur Silveira Prudente
- Department of Pharmacology, Center of Biological Sciences, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Jamil Assreuy
- Department of Pharmacology, Center of Biological Sciences, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. .,Department of Pharmacology, Block D/CCB, Universidade Federal de Santa Catarina, Florianópolis, SC, 88040-900, Brazil.
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19
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Faria MMP, Winston BW, Surette MG, Conly JM. Bacterial DNA patterns identified using paired-end Illumina sequencing of 16S rRNA genes from whole blood samples of septic patients in the emergency room and intensive care unit. BMC Microbiol 2018; 18:79. [PMID: 30045694 PMCID: PMC6060528 DOI: 10.1186/s12866-018-1211-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 06/27/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sepsis refers to clinical presentations ranging from mild body dysfunction to multiple organ failure. These clinical symptoms result from a systemic inflammatory response to pathogenic or potentially pathogenic microorganisms present systemically in the bloodstream. Current clinical diagnostics rely on culture enrichment techniques to identify bloodstream infections. However, a positive result is obtained in a minority of cases thereby limiting our knowledge of sepsis microbiology. Previously, a method of saponin treatment of human whole blood combined with a comprehensive bacterial DNA extraction protocol was developed. The results indicated that viable bacteria could be recovered down to 10 CFU/ml using this method. Paired-end Illumina sequencing of the 16S rRNA gene also indicated that the bacterial DNA extraction method enabled recovery of bacterial DNA from spiked blood. This manuscript outlines the application of this method to whole blood samples collected from patients with the clinical presentation of sepsis. RESULTS Blood samples from clinically septic patients were obtained with informed consent. Application of the paired-end Illumina 16S rRNA sequencing to saponin treated blood from intensive care unit (ICU) and emergency department (ED) patients indicated that bacterial DNA was present in whole blood. There were three clusters of bacterial DNA profiles which were distinguished based on the distribution of Streptococcus, Staphylococcus, and Gram-negative DNA. The profiles were examined alongside the patient's clinical data and indicated molecular profiling patterns from blood samples had good concordance with the primary source of infection. CONCLUSIONS Overall this study identified common bacterial DNA profiles in the blood of septic patients which were often associated with the patients' primary source of infection. These results indicated molecular bacterial DNA profiling could be further developed as a tool for clinical diagnostics for bloodstream infections.
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Affiliation(s)
- Monica Martins Pereira Faria
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB T2N 4N1 Canada
| | - Brent Warren Winston
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Department of Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB T2N 4N1 Canada
- Foothills Medical Centre, Alberta Health Services, Room AGW5, 1403 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Michael Gordon Surette
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4K1 Canada
- Department of Medicine and Biochemistry, Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4K1 Canada
- Department of Biomedical Sciences, Faculty of Health Science, McMaster University, Hamilton, ON L8S 4K1 Canada
| | - John Maynard Conly
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1 Canada
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB T2N 4N1 Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 4N1 Canada
- Foothills Medical Centre, Alberta Health Services, Room AGW5, 1403 29th Street NW, Calgary, AB T2N 2T9 Canada
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20
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Meißner A, Hasenclever D, Brosteanu O, Chaberny IF. EFFECT of daily antiseptic body wash with octenidine on nosocomial primary bacteraemia and nosocomial multidrug-resistant organisms in intensive care units: design of a multicentre, cluster-randomised, double-blind, cross-over study. BMJ Open 2017; 7:e016251. [PMID: 29122787 PMCID: PMC5695441 DOI: 10.1136/bmjopen-2017-016251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Nosocomial infections are serious complications that increase morbidity, mortality and costs and could potentially be avoidable. Antiseptic body wash is an approach to reduce dermal micro-organisms as potential pathogens on the skin. Large-scale trials with chlorhexidine as the antiseptic agent suggest a reduction of nosocomial infection rates. Octenidine is a promising alternative agent which could be more effective against Gram-negative organisms. We hypothesise that daily antiseptic body wash with octenidine reduces the risk of intensive care unit (ICU)-acquired primary bacteraemia and ICU-acquired multidrug-resistant organisms (MDRO) in a standard care setting. METHODS AND ANALYSIS EFFECT is a controlled, cluster-randomised, double-blind study. The experimental intervention consists in using octenidine-impregnated wash mitts for the daily routine washing procedure of the patients. This will be compared with using placebo wash mitts. Replacing existing washing methods is the only interference into clinical routine.Participating ICUs are randomised in an AB/BA cross-over design. There are two 15-month periods, each consisting of a 3-month wash-out period followed by a 12-month intervention and observation period. Randomisation determines only the sequence in which octenidine-impregnated or placebo wash mitts are used. ICUs are left unaware of what mitts packages they are using.The two coprimary endpoints are ICU-acquired primary bacteraemia and ICU-acquired MDRO. Endpoints are defined based on individual ward-movement history and microbiological test results taken from the hospital information systems without need for extra documentation. Data on clinical symptoms of infection are not collected. EFFECT aims at recruiting about 45 ICUs with about 225 000 patient-days per year. ETHICS AND DISSEMINATION The study was approved by the ethics committee of the University of Leipzig (number 340/16-ek) in November 2016. Findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER DRKS-ID: DRKS00011282.
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Affiliation(s)
- Anne Meißner
- Institute of Hygiene/Hospital Epidemiology, Medical Faculty of the University of Leipzig, Leipzig, Saxony, Germany
| | - Dirk Hasenclever
- Institute for Medical Informatics, Statistics and Epidemiology, Medical Faculty of the University of Leipzig, Leipzig, Saxony, Germany
| | - Oana Brosteanu
- Clinical Trial Centre Leipzig, Medical Faculty of the University of Leipzig, Leipzig, SAxony, Germany
| | - Iris Freya Chaberny
- Institute of Hygiene/Hospital Epidemiology, Medical Faculty of the University of Leipzig, Leipzig, Saxony, Germany
- Institute of Hygiene/Hospital Epidemiology, Leipzig University Hospital, Leipzig, Saxony, Germany
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Fogarty CB, Mikkelsen ME, Gaieski DF, Small DS. Discrete Optimization for Interpretable Study Populations and Randomization Inference in an Observational Study of Severe Sepsis Mortality. J Am Stat Assoc 2016. [DOI: 10.1080/01621459.2015.1112802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Goto T, Yoshida K, Tsugawa Y, Filbin MR, Camargo CA, Hasegawa K. Mortality trends in U.S. adults with septic shock, 2005-2011: a serial cross-sectional analysis of nationally-representative data. BMC Infect Dis 2016; 16:294. [PMID: 27301657 PMCID: PMC4908776 DOI: 10.1186/s12879-016-1620-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 06/04/2016] [Indexed: 12/28/2022] Open
Abstract
Background We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use. Methods We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality. Results From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; Ptrend = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96–1.00; P < 0.001). In stratified analysis, the mortality trend was not significant in the subgroup with vasopressor use (from 42 % in 2005 to 40 % in 2011; Ptrend =0.57); similarly, the adjusted mortality did not change significantly (OR, 1.01; 95 % CI, 0.97–1.05; P =0.62). By contrast, there was a downward trend in mortality in the subgroup without vasopressor use (from 47 % in 2005 to 43 % in 2011; Ptrend =0.002); likewise, the adjusted mortality decreased significantly (OR, 0.97; 95 % CI, 0.95–0.99; P =0.002) Conclusions From 2005 to 2011, we found a modest decrease in in-hospital mortality among patients identified with septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1620-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tadahiro Goto
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan. .,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Kazuki Yoshida
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Yusuke Tsugawa
- Harvard Interfaculty Initiative in Health Policy, Harvard University, Boston, MA, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carlos A Camargo
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Bloodstream infections (BSIs) are both common and fatal in older patients. We describe data from studies evaluating older patients hospitalized with BSIs. Most older patients with BSIs present "typically" with either fever or leukocytosis. The most common source of BSI in older patients is the urinary tract, and accordingly, Gram-negative organisms predominate. A significant part of these BSIs may thus be preventable by removal of unnecessary urinary catheters. Increased long term mortality is reported following BSIs in older patients, however, data on other long-term outcomes, including functional capacity, cognitive decline and others are lacking. Management of BSIs may include less invasive procedures due to the fragility of older patients. This approach may delay the diagnosis and treatment in some cases. Older patients are probably under-represented in clinical trials assessing treatment of bacteremia. Physicians treating older patients should consider the relevance of these studies' outcomes.
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Affiliation(s)
- Dafna Yahav
- a Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital , Petah-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel
| | - Noa Eliakim-Raz
- a Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital , Petah-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel
| | - Leonard Leibovici
- b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel.,c Department of Medicine E , Rabin Medical Center, Beilinson Hospital , Petah-Tikva , Israel
| | - Mical Paul
- b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel.,d Unit of Infectious Diseases, Rambam Hospital , Haifa , Israel
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Neither Single nor a Combination of Routine Laboratory Parameters can Discriminate between Gram-positive and Gram-negative Bacteremia. Sci Rep 2015; 5:16008. [PMID: 26522966 PMCID: PMC4629184 DOI: 10.1038/srep16008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 10/05/2015] [Indexed: 12/18/2022] Open
Abstract
Adequate early empiric antibiotic therapy is pivotal for the outcome of patients with bloodstream infections. In clinical practice the use of surrogate laboratory parameters is frequently proposed to predict underlying bacterial pathogens; however there is no clear evidence for this assumption. In this study, we investigated the discriminatory capacity of predictive models consisting of routinely available laboratory parameters to predict the presence of Gram-positive or Gram-negative bacteremia. Major machine learning algorithms were screened for their capacity to maximize the area under the receiver operating characteristic curve (ROC-AUC) for discriminating between Gram-positive and Gram-negative cases. Data from 23,765 patients with clinically suspected bacteremia were screened and 1,180 bacteremic patients were included in the study. A relative predominance of Gram-negative bacteremia (54.0%), which was more pronounced in females (59.1%), was observed. The final model achieved 0.675 ROC-AUC resulting in 44.57% sensitivity and 79.75% specificity. Various parameters presented a significant difference between both genders. In gender-specific models, the discriminatory potency was slightly improved. The results of this study do not support the use of surrogate laboratory parameters for predicting classes of causative pathogens. In this patient cohort, gender-specific differences in various laboratory parameters were observed, indicating differences in the host response between genders.
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Faria MMP, Conly JM, Surette MG. The development and application of a molecular community profiling strategy to identify polymicrobial bacterial DNA in the whole blood of septic patients. BMC Microbiol 2015; 15:215. [PMID: 26474751 PMCID: PMC4609058 DOI: 10.1186/s12866-015-0557-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/08/2015] [Indexed: 02/08/2023] Open
Abstract
Background The application of molecular based diagnostics in sepsis has had limited success to date. Molecular community profiling methods have indicated that polymicrobial infections are more common than suggested by standard clinical culture. A molecular profiling approach was developed to investigate the propensity for polymicrobial infections in patients predicted to have bacterial sepsis. Results Disruption of blood cells with saponin and hypotonic shock enabled the recovery of microbial cells with no significant changes in microbial growth when compared to CFU/ml values immediately prior to the addition of saponin. DNA extraction included a cell-wall digestion step with both lysozyme and mutanolysin, which increased the recovery of terminal restriction fragments by 2.4 fold from diverse organisms. Efficiencies of recovery and limits of detection using Illumina sequencing of the 16S rRNA V3 region were determined for both viable cells and DNA using mock bacterial communities inoculated into whole blood. Bacteria from pre-defined communities could be recovered following lysis and removal of host cells with > 97 % recovery of total DNA present. Applying the molecular profiling methodology to three septic patients in the intensive care unit revealed microbial DNA from blood had consistent alignment with cultured organisms from the primary infection site providing evidence for a bloodstream infection in the absence of a clinical lab positive blood culture result in two of the three cases. In addition, the molecular profiling indicated greater diversity was present in the primary infection sample when compared to clinical diagnostic culture. Conclusions A method for analyzing bacterial DNA from whole blood was developed in order to characterize the bacterial DNA profile of sepsis infections. Preliminary results indicated that sepsis infections were polymicrobial in nature with the bacterial DNA recovered suggesting a more complex etiology when compared to blood culture data.
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Affiliation(s)
- M M P Faria
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Department of Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Farncombe Family Digestive Health Research Institute, Departments of Medicine and Biochemistry and Biomedical Sciences, Faculty of Health Sciences, McMaster University, 1280 Main Street, HSC 3 N 8 F, Hamilton, ON, L8S 4 K1, Canada.
| | - J M Conly
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Department of Medicine, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Department of Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, T2N 4 N1, Canada.
| | - M G Surette
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Department of Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, T2N 4 N1, Canada. .,Farncombe Family Digestive Health Research Institute, Departments of Medicine and Biochemistry and Biomedical Sciences, Faculty of Health Sciences, McMaster University, 1280 Main Street, HSC 3 N 8 F, Hamilton, ON, L8S 4 K1, Canada. .,Department of Medicine, McMaster University, Hamilton, ON, L8S 4 K1, Canada. .,Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, L8S 4 K1, Canada.
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Flukes S, Hayne D, Kuan M, Wallace M, McMillan K, Rukin NJ. Retrograde ureteric stent insertion in the management of infected obstructed kidneys. BJU Int 2015; 115 Suppl 5:31-4. [PMID: 25174441 DOI: 10.1111/bju.12918] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To quantify the outcomes of retrograde ureteric stenting in the setting of infected hydronephrosis secondary to ureteric calculi. PATIENTS AND METHODS Prospective analysis of all patients over a 15-month period admitted with infected obstructed kidneys secondary to ureteric calculi. Inclusion criteria were based on clinical evidence of systemic inflammatory response syndrome (SIRS) and radiological evidence of obstructing ureteric calculi. Outcome measures included success of procedure, admission to intensive care unit (ICU), length of hospital stay, morbidity, and all-cause mortality during hospital admission. RESULTS In all, 52 patients were included. Success of retrograde ureteric stenting was 98%. In all, 17% of patients required an ICU admission, with a post ureteric instrumentation ICU admissions rate of 6%. The mean white cell count and serum creatinine improved significantly after the procedure. Major complication rate included septic shock 6%, but there were no episodes of major haemorrhage and no deaths. CONCLUSION Retrograde ureteric stenting is safe and effective in infected obstructed kidneys with results comparable to percutaneous nephrostomy tube insertion. Post instrumentation ICU admissions occur in 6% of retrograde stentings.
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Affiliation(s)
- Stephanie Flukes
- Department of Urological Surgery, Fremantle Hospital, Perth, Australia
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Quenot JP, Pavon A, Fournel I, Barbar SD, Bruyère R. Le choc septique de l’adulte en France : vingt ans de données épidémiologiques. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1062-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Ebihara I, Hirayama K, Nagai M, Koda M, Gunji M, Okubo Y, Katayama T, Sato C, Usui J, Yamagata K, Kobayashi M. Soluble vascular endothelial-cadherin levels in patients with sepsis treated with direct hemoperfusion with a polymyxin B-immobilized fiber column. Ther Apher Dial 2015; 18:272-8. [PMID: 24965294 DOI: 10.1111/1744-9987.12215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Capillary permeability is a tightly regulated feature of microcirculation in all organ beds; however, in sepsis this feature is fundamentally altered. Several molecules are investigated as associated factors with capillary permeability and vascular endothelial (VE)-cadherin internalization by vascular endothelial growth factor (VEGF)-induced signaling through VEGF receptors leads to increased vascular endothelial cell detachment and trans-endothelial permeability. We investigated serum soluble VE-cadherin levels in septic patients. An enzyme-linked immunoassay was used to measure serum soluble VE-cadherin levels in 47 septic patients treated by direct hemoperfusion with a polymyxin B-immobilized fiber column (DHP-PMX). The serum soluble VE-cadherin level of septic patients before PMX-DHP was 3424.1 ± 2033.0 ng/mL, which was significantly lower than that of the controls (5862.0 ± 1521.2 ng/mL; P < 0.0001). The time course of serum soluble VE-cadherin levels remained unchanged during PMX-DHP therapy. There was no significant difference in serum soluble VE-cadherin levels before PMX-DHP therapy between survivors and non-survivors, and there was no significant difference in those levels between the groups at any time after the initiation of PMX-DHP therapy. There was no correlation between soluble VE-cadherin levels and clinical data, except white blood cell count (r = -0.277, P = 0.0009). There was no correlation between soluble VE-cadherin levels and the levels of angiopoietin 1 and 2. In summary, the relationship between VE-cadherin and capillary permeability in sepsis could not be demonstrated. Soluble VE-cadherins are not reflected in the balance between intercellular junction plasticity and integrity, but VE-cadherin stabilization by its phosphorylation or internalization may be associated with capillary permeability.
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Affiliation(s)
- Itaru Ebihara
- Department of Nephrology, Mito Saiseikai General Hospital, Mito, Japan
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Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1795-815. [PMID: 25392034 PMCID: PMC4239778 DOI: 10.1007/s00134-014-3525-z] [Citation(s) in RCA: 937] [Impact Index Per Article: 93.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 10/18/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock. METHODS The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact. RESULTS Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring. CONCLUSIONS This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
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Affiliation(s)
- Maurizio Cecconi
- Anaesthesia and Intensive Care, St George's Hospital and Medical School, SW17 0QT, London, UK,
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Ekpe K, Novara A, Mainardi JL, Fagon JY, Faisy C. Methicillin-resistant Staphylococcus aureus bloodstream infections are associated with a higher energy deficit than other ICU-acquired bacteremia. Intensive Care Med 2014; 40:1878-87. [PMID: 25288210 DOI: 10.1007/s00134-014-3502-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 09/18/2014] [Indexed: 01/15/2023]
Abstract
PURPOSE Caloric insufficiency during the first week of intensive care unit (ICU) stay was reported to be associated with increased infection rates, especially ICU-acquired bloodstream infection (ICU-BSI). However, the predisposition to ICU-BSI by a given pathogen remains not well known. We aimed to determine the impact of early energy-calorie deficit on the pathogens responsible for ICU-BSI. DESIGN Prospective, observational, cohort study in a 18-bed medical ICU of a tertiary care hospital. METHODS Daily energy balance (energy-calorie intakes minus calculated energy-calorie expenditure) was compared according to the microbiological results of the blood cultures of 92 consecutive prolonged (at least 96 h) acute mechanically ventilated patients who developed a first episode of ICU-BSI. RESULTS Among the 92 ICU-BSI, nine were due to methicillin-resistant Staphylococcus aureus (MRSA). The cumulated energy deficit of patients with MRSA ICU-BSI was greater than those with ICU-BSI caused by other pathogens (-1,348 ± 260 vs -1,000 ± 401 kcal/day from ICU admission to day of ICU-BSI, p = 0.008). ICU admission, risk factors for nosocomial infections, nutritional status, and conditions potentially limiting feeding did not differ significantly between the two groups. Patients with MRSA ICU-BSI had lower delivered energy and similar energy expenditure, causing higher energy deficits. More severe energy deficit and higher rate of MRSA blood cultures (p = 0.01 comparing quartiles) were observed. CONCLUSIONS Early in-ICU energy deficit was associated with MRSA ICU-BSI in prolonged acute mechanically ventilated patients. Results suggest that limiting the early energy deficit could be a way to optimize MRSA ICU-BSI prevention.
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Affiliation(s)
- Kenneth Ekpe
- Intensive Care Unit, Gustave Roussy, Cancer Campus, Grand Paris, Villejuif, France
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Rhee C, Murphy MV, Li L, Platt R, Klompas M. Comparison of trends in sepsis incidence and coding using administrative claims versus objective clinical data. Clin Infect Dis 2014; 60:88-95. [PMID: 25258352 DOI: 10.1093/cid/ciu750] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND National reports of a dramatic rise in sepsis incidence are largely based on analyses of administrative databases. It is unclear if these estimates are biased by changes in coding practices over time. METHODS We calculated linear trends in the annual incidence of septicemia, sepsis, and severe sepsis at 2 academic hospitals from 2003 to 2012 using 5 different claims methods and compared case identification rates to selected objective clinical markers, including positive blood cultures, vasopressors, and/or lactic acid levels. RESULTS The annual incidence of hospitalizations with sepsis claims increased over the decade, ranging from a 54% increase for the method combining septicemia, bacteremia, and fungemia codes (P < .001 for linear trend) to a 706% increase for explicit severe sepsis/septic shock codes (P = .001). In contrast, the incidence of hospitalizations with positive blood cultures decreased by 17% (P = .006), and hospitalizations with positive blood cultures with concurrent vasopressors and/or lactic acidosis remained stable (P = .098). The sensitivity of sepsis claims for capturing hospitalizations with positive blood cultures with concurrent vasopressors and/or lactic acidosis increased (P < .001 for all methods), whereas the proportion of septicemia hospitalizations with positive blood cultures decreased from 50% to 30% (P < .001). CONCLUSIONS The incidence of hospitalizations with sepsis codes rose dramatically while hospitalizations with corresponding objective clinical markers remained stable or decreased. Coding for sepsis has become more inclusive, and septicemia diagnoses are increasingly being applied to patients without positive blood cultures. These changes likely explain some of the apparent rise in sepsis incidence and underscore the need for more reliable surveillance methods.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael V Murphy
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Lingling Li
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
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De Santis V, Gresoiu M, Corona A, Wilson APR, Singer M. Bacteraemia incidence, causative organisms and resistance patterns, antibiotic strategies and outcomes in a single university hospital ICU: continuing improvement between 2000 and 2013. J Antimicrob Chemother 2014; 70:273-8. [DOI: 10.1093/jac/dku338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lowsby R, Gomes C, Jarman I, Lisboa P, Nee PA, Vardhan M, Eckersley T, Saleh R, Mills H. Neutrophil to lymphocyte count ratio as an early indicator of blood stream infection in the emergency department. Emerg Med J 2014; 32:531-4. [PMID: 25183249 DOI: 10.1136/emermed-2014-204071] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/05/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Early identification of patients with blood stream infection (BSI), especially bacteraemia, is important as prompt treatment improves outcome. The initial stages of severe infection may be characterised by increased numbers of neutrophils in the peripheral blood and depression of the lymphocyte count (LC). The neutrophil to LC ratio (NLCR) has previously been compared with conventional tests, such as C-reactive protein (CRP) and white cell count (WCC), and has been proposed as a useful marker in the timely diagnosis of bacteraemia. METHODS Data on consecutive adult patients presenting to the emergency department with pyrexial illness during the study period, November 2009 to October 2010, were analysed. The main outcome measure was positive blood cultures (bacteraemia). Sensitivity, specificity, positive and negative predictive values and likelihood ratios were determined for NLCR, CRP, WCC, neutrophil count and LC. RESULTS 1954 patients met the inclusion criteria. Blood cultures were positive in 270 patients, hence the prevalence of bacteraemia was 13.8%. With the exception of WCC, there were significant differences in the mean value for each marker between bacteraemic and non-bacteraemic patients (p<0.001). The area under the receiver operating characteristic curve was highest for NLCR (0.72; 95% CI 0.69 to 0.75) and LC (0.71; 0.68 to 0.74) and lowest for WCC (0.54; 0.40 to 0.57). The sensitivity and specificity of NLCR for predicting bacteraemia were 70% (64% to 75%) and 57% (55% to 60%), respectively. Positive and negative predictive values for NLCR were 0.20 (0.18 to 0.23) and 0.92 (0.91 to 0.94), respectively. The positive likelihood ratio was 1.63 (1.48 to 1.79) and the negative likelihood ratio was 0.53 (0.44 to 0.64). CONCLUSIONS Although NLCR outperforms conventional markers of infection, it is insufficient in itself to guide clinical management of patients with suspected BSI, and it offers no advantage over LC. However, it may offer some diagnostic utility when taken into account as part of the overall assessment.
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Affiliation(s)
- Richard Lowsby
- Departments of Emergency and Critical Care Medicine, St. Helens and Knowsley Hospitals NHS Trust, Whiston Hospital, Merseyside, UK
| | - Clint Gomes
- Departments of Emergency and Critical Care Medicine, St. Helens and Knowsley Hospitals NHS Trust, Whiston Hospital, Merseyside, UK
| | - Ian Jarman
- Liverpool John Moores University, Liverpool, UK
| | | | - Patrick A Nee
- Departments of Emergency and Critical Care Medicine, St. Helens and Knowsley Hospitals NHS Trust, Whiston Hospital, Merseyside, UK Liverpool John Moores University, Liverpool, UK
| | - Madhur Vardhan
- Departments of Emergency and Critical Care Medicine, St. Helens and Knowsley Hospitals NHS Trust, Whiston Hospital, Merseyside, UK
| | - Tom Eckersley
- Departments of Emergency and Critical Care Medicine, St. Helens and Knowsley Hospitals NHS Trust, Whiston Hospital, Merseyside, UK
| | - Roshan Saleh
- Departments of Emergency and Critical Care Medicine, St. Helens and Knowsley Hospitals NHS Trust, Whiston Hospital, Merseyside, UK
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Escherichia coli bacteraemia in adults: age-related differences in clinical and bacteriological characteristics, and outcome. Epidemiol Infect 2014; 142:2672-83. [PMID: 24559489 DOI: 10.1017/s0950268814000211] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
To explore the specificities of Escherichia coli bacteraemia in the elderly, the demographic, clinical and bacteriological characteristics and in-hospital mortality rate of 'young' (18-64 years, n = 395), 'old' (65-79 years, n = 372) and 'very old' (⩾80 years, n = 284) adult patients of the multicentre COLIBAFI cohort study were compared. Clinical and bacteriological risk factors for death were jointly identified by logistic regression and multivariate analysis within each group. 'Young' and 'old' patients had more comorbidities than 'very old' patients (comorbidity score: 1·5 ± 1·3 and 1·6 ± 1·2 vs. 1·2 ± 1·2, respectively; P < 0·001), and were more frequently nosocomially infected (22·3% and 23·8% vs. 8·8%, respectively; P < 0·001). 'Old' patients had the poorest prognosis (death rate: 16·4% vs.10·4% for 'young' and 12·0% for 'very old' patients, respectively; P = 0·039). Risk factors for death were age group-specific, suggesting a host-pathogen relationship evolving with age.
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Arneth BM, Ragaller M, Hommel K, Tiebel O, Menschikowski M, Siegert G. Novel parameters of extended complete blood cell count under fluorescence flow cytometry in patients with sepsis. J Clin Lab Anal 2014; 28:130-5. [PMID: 24395719 DOI: 10.1002/jcla.21656] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 06/04/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We first describe a patient who developed urosepsis from an ordinary urinary tract infection. In this case, the new hematological parameters of immature leukocytes, that is, the high-fluorescence lymphocyte cell (HFLC) and immature granulocyte (IG) counts peaked early, whereas the established infection parameters, that is, C-reactive protein (CRP) and total white blood cell count showed less dynamic regarding infection and therapy. METHODS To investigate this phenomenon in greater detail, the novel parameters HFLC and IG counts are investigated retrospectively in a cohort of 38 patients who were admitted to the anesthesia intensive care unit. Three groups of patients have been analyzed and compared: patients without signs of infection, patients with limited infections, and patients with sepsis. Data were collected with a Sysmex XE-5000 hematological analyzer. RESULTS In patients (n = 22) without any signs of infection, both values are very low. In patients with limited local infections (n = 10), moderate elevations of the IG and HFLC counts are seen. In patients with sepsis (n = 6), the IG and HFLC counts are significantly higher. CONCLUSION The total IG count seems to be useful for distinguishing a septic patient from a nonseptic (P < 0.004). Hematological parameters have the advantage of being measured easily during routine blood cell analysis.
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Affiliation(s)
- Borros M Arneth
- Institute of Clinical Chemistry and Laboratory Medicine, Carl Gustav Carus University Hospital, University of Technology, Dresden, Germany
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Abstract
Severe sepsis is a leading cause of death in the United States and the most common cause of death among critically ill patients in non-coronary intensive care units (ICU). Respiratory tract infections, particularly pneumonia, are the most common site of infection, and associated with the highest mortality. The type of organism causing severe sepsis is an important determinant of outcome, and gram-positive organisms as a cause of sepsis have increased in frequency over time and are now more common than gram-negative infections.
Recent studies suggest that acute infections worsen pre-existing chronic diseases or result in new chronic diseases, leading to poor long-term outcomes in acute illness survivors. People of older age, male gender, black race, and preexisting chronic health conditions are particularly prone to develop severe sepsis; hence prevention strategies should be targeted at these vulnerable populations in future studies.
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Affiliation(s)
- Florian B Mayr
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; University of Pittsburgh; Pittsburgh, PA USA; Department of Critical Care Medicine; University of Pittsburgh, Pittsburgh, PA USA; Department of Medicine; University of Pittsburgh; Pittsburgh, PA USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; University of Pittsburgh; Pittsburgh, PA USA; Department of Critical Care Medicine; University of Pittsburgh, Pittsburgh, PA USA
| | - Derek C Angus
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center; University of Pittsburgh; Pittsburgh, PA USA; Department of Critical Care Medicine; University of Pittsburgh, Pittsburgh, PA USA
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Karlsson I, Wernersson S, Ambrosen A, Kindahl H, Södersten F, Wang L, Hagman R. Increased concentrations of C-reactive protein but not high-mobility group box 1 in dogs with naturally occurring sepsis. Vet Immunol Immunopathol 2013; 156:64-72. [DOI: 10.1016/j.vetimm.2013.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 07/23/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
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Ruiz-Giardin JM, Jimenez BC, Martin RM, Ortiz J, Condori Arenas MH, Sanmartin JV, Cabello N, Barrios AM, Rejas D, Fuentes Salazar M, Jaquetti J. Clinical diagnostic accuracy of suspected sources of bacteremia and its effect on mortality. Eur J Intern Med 2013; 24:541-5. [PMID: 23768564 DOI: 10.1016/j.ejim.2013.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 05/07/2013] [Accepted: 05/10/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although much has been written about bacteremia, evidence of the clinical diagnostic accuracy of bacteremia sources in the absence of microbiological results and the impact of diagnostic accuracy on mortality is scarce. METHODS This is a retrospective study of bacteremia episodes over a 2-year period at a general hospital in Madrid. Congruence analyses between clinically presumed and definite sources, acquisition, causative organism, empirical treatment and progression to death were performed. RESULTS The study included 323 bacteremia episodes. Clinicians' diagnostic accuracy was higher for gastrointestinal (88.8%; 95% CI: 79%-84%), respiratory (93.9%; 95% CI: 79%-99%) and urinary tract sources (83.6%; 95% CI: 75%-89%) and lower for skin and soft tissues (77.2%; 95% CI: 54%-92%) and, notably, intravascular sources (56%; 95% CI: 39%-71%). Overall, a non-significant (3.45%; 95% CI: -0.6%-13.5%, p=0.47) increase in mortality was observed in the incorrectly suspected bacteremia source group. Mortality related to a definitive source was significantly higher when an intravascular origin was not suspected, resulting in a 26% increase in mortality (95% CI: 1%-52%, p=0.03). Differences in mortality related to inaccurate source assumptions were non-significant when the definitive bacteremia sources were gastrointestinal, urinary, respiratory, skin and soft tissues or unknown. Mortality in the group receiving appropriate empirical antimicrobial treatment was 10.6% compared with 19.7% mortality in the group receiving inappropriate empirical antimicrobial treatment (OR 2; 95% CI: 1.01-4.25). CONCLUSIONS The diagnostic accuracy of bacteremia sources is high in all but intravascular sources. A non-suspected intravascular source and inappropriate empirical treatment are related to a higher mortality.
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Affiliation(s)
- Jose M Ruiz-Giardin
- Internal Medicine Department, Fuenlabrada University Hospital, Madrid, Spain.
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Pradipta IS, Sodik DC, Lestari K, Parwati I, Halimah E, Diantini A, Abdulah R. Antibiotic resistance in sepsis patients: evaluation and recommendation of antibiotic use. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:344-52. [PMID: 23923107 PMCID: PMC3731864 DOI: 10.4103/1947-2714.114165] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The appropriate selection of empirical antibiotics based on the pattern of local antibiotic resistance can reduce the mortality rate and increase the rational use of antibiotics. AIMS We analyze the pattern of antibiotic use and the sensitivity patterns of antibiotics to support the rational use of antibiotics in patients with sepsis. MATERIALS AND METHODS A retrospective observational study was conducted in adult sepsis patient at one of Indonesian hospital during January-December 2011. Data were collected from the hospital medical record department. Descriptive analysis was used in the processing and interpretation of data. RESULTS A total of 76 patients were included as research subjects. Lung infection was the highest source of infection. In the 66.3% of clinical specimens that were culture positive for microbes, Klebsiella pneumoniae, Escherichia coli, Staphylococcus hominis were detected with the highest frequency. The six most frequently used antibiotics, levofloxacin, ceftazidime, ciprofloxacin, cefotaxime, ceftriaxone, and erythromycin, showed an average resistance above 50%. CONCLUSIONS The high use of antibiotic with a high level resistance requires a policy to support its rational use. Local microbial pattern based on site infection and pattern of antibiotics sensitivity test can be used as supporting data to optimize appropriateness of empirical antibiotics therapy in sepsis patients.
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Affiliation(s)
- Ivan Surya Pradipta
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Dian Chairunnisa Sodik
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Keri Lestari
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Ida Parwati
- Departement of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Eli Halimah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Ajeng Diantini
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Rizky Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
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De Freitas Caires N, Legendre B, Parmentier E, Scherpereel A, Tsicopoulos A, Mathieu D, Lassalle P. Identification of a 14kDa endocan fragment generated by cathepsin G, a novel circulating biomarker in patients with sepsis. J Pharm Biomed Anal 2013; 78-79:45-51. [DOI: 10.1016/j.jpba.2013.01.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/23/2013] [Accepted: 01/25/2013] [Indexed: 10/27/2022]
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Quenot JP, Binquet C, Kara F, Martinet O, Ganster F, Navellou JC, Castelain V, Barraud D, Cousson J, Louis G, Perez P, Kuteifan K, Noirot A, Badie J, Mezher C, Lessire H, Pavon A. The epidemiology of septic shock in French intensive care units: the prospective multicenter cohort EPISS study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R65. [PMID: 23561510 PMCID: PMC4056892 DOI: 10.1186/cc12598] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 04/05/2013] [Indexed: 01/01/2023]
Abstract
INTRODUCTION To provide up-to-date information on the prognostic factors associated with 28-day mortality in a cohort of septic shock patients in intensive care units (ICUs). METHODS Prospective, multicenter, observational cohort study in ICUs from 14 French general (non-academic) and university teaching hospitals. All consecutive patients with septic shock admitted between November 2009 and March 2011 were eligible for inclusion. We prospectively recorded data regarding patient characteristics, infection, severity of illness, life support therapy, and discharge. RESULTS Among 10,941 patients admitted to participating ICUs between October 2009 and September 2011, 1,495 (13.7%) patients presented inclusion criteria for septic shock and were included. Invasive mechanical ventilation was needed in 83.9% (n=1248), inotropes in 27.7% (n=412), continuous renal replacement therapy in 32.5% (n=484), and hemodialysis in 19.6% (n=291). Mortality at 28 days was 42% (n=625). Variables associated with time to mortality, right-censored at day 28: age (for each additional 10 years) (hazard ratio (HR)=1.29; 95% confidence interval (CI): 1.20-1.38), immunosuppression (HR=1.63; 95%CI: 1.37-1.96), Knaus class C/D score versus class A/B score (HR=1.36; 95%CI:1.14-1.62) and Sepsis-related Organ Failure Assessment (SOFA) score (HR=1.24 for each additional point; 95%CI: 1.21-1.27). Patients with septic shock and renal/urinary tract infection had a significantly longer time to mortality (HR=0.56; 95%CI: 0.42-0.75). CONCLUSION Our observational data of consecutive patients from real-life practice confirm that septic shock is common and carries high mortality in general ICU populations. Our results are in contrast with the clinical trial setting, and could be useful for healthcare planning and clinical study design.
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Lee BS, Hwang JH, Lee SH, Jang SE, Jang ES, Jo HJ, Shin CM, Park YS, Kim JW, Jung SH, Kim N, Lee DH, Lee JK, Ahn S. Risk factors of organ failure in patients with bacteremic cholangitis. Dig Dis Sci 2013. [PMID: 23179153 DOI: 10.1007/s10620-012-2478-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bacteremic cholangitis carries a high mortality rate of up to 10 % in relation to organ failure (OF), including septic shock. AIM The purpose of this study was to elucidate predictive factors for OF in bacteremic cholangitis. METHODS A retrospective review of all patients diagnosed with acute cholangitis and proven bacteremia from 2003 to 2011 was performed. Comprehensive clinical and laboratory data of 211 patients were analyzed. RESULTS There were 42 cases (19.9 %) of OF and 5 deaths (2.4 %). In the multivariate logistic regression analysis, significant predictive factors for OF were successful biliary decompression, presence of extended-spectrum beta-lactamase organism (ESBL), higher total bilirubin, and higher blood urea nitrogen (BUN) level at admission with odds ratios (ORs) of 0.129, 6.793, 1.148, and 1.089, respectively. Subgroup analysis of 165 patients who underwent biliary decompression before an event (with OF: 20, without OF: 145) was performed to elucidate the risk factors for organ failure even after successful biliary drainage. Variables significantly associated with OF included ESBL and BUN (OR = 4.123 and 1.177, respectively). We developed a scoring system with regression coefficient of each significant variable. The organ failure score was calculated using the following equation: (1.4 × ESBL) + (0.2 × BUN). This scoring system for predicting OF was highly sensitive (85.0 %) and specific (83.4 %). CONCLUSIONS Biliary decompression, ESBL, total bilirubin, and BUN are prognostic determinants in patients with bacteremic cholangitis. An organ failure scoring system may allow clinicians to identify groups with poor prognosis even after successful biliary decompression.
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Affiliation(s)
- Ban Seok Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Tabah A, Koulenti D, Laupland K, Misset B, Valles J, Bruzzi de Carvalho F, Paiva JA, Cakar N, Ma X, Eggimann P, Antonelli M, Bonten MJM, Csomos A, Krueger WA, Mikstacki A, Lipman J, Depuydt P, Vesin A, Garrouste-Orgeas M, Zahar JR, Blot S, Carlet J, Brun-Buisson C, Martin C, Rello J, Dimopoulos G, Timsit JF. Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study. Intensive Care Med 2012. [PMID: 23011531 DOI: 10.1007/s00134-012-2695-9]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management. METHODS A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries. RESULTS We included 1,156 patients [mean ± standard deviation (SD) age, 59.5 ± 17.7 years; 65 % males; mean ± SD Simplified Acute Physiology Score (SAPS) II score, 50 ± 17] with HA-BSIs, of which 76 % were ICU-acquired. Median time to diagnosis was 14 [interquartile range (IQR), 7-26] days after hospital admission. Polymicrobial infections accounted for 12 % of cases. Among monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p < 0.001) by country. The 28-day all-cause fatality rate was 36 %. In the multivariable model including micro-organism, patient and centre variables, independent predictors of 28-day mortality included MDR isolate [odds ratio (OR), 1.49; 95 % confidence interval (95 %CI), 1.07-2.06], uncontrolled infection source (OR, 5.86; 95 %CI, 2.5-13.9) and timing to adequate treatment (before day 6 since blood culture collection versus never, OR, 0.38; 95 %CI, 0.23-0.63; since day 6 versus never, OR, 0.20; 95 %CI, 0.08-0.47). CONCLUSIONS MDR and XDR bacteria (especially gram-negative) are common in HA-BSIs in critically ill patients and are associated with increased 28-day mortality. Intensified efforts to prevent HA-BSIs and to optimize their management through adequate source control and antibiotic therapy are needed to improve outcomes.
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Affiliation(s)
- Alexis Tabah
- Albert Michallon University Hospital, Université Grenoble 1, Grenoble, France
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Tabah A, Koulenti D, Laupland K, Misset B, Valles J, Bruzzi de Carvalho F, Paiva JA, Cakar N, Ma X, Eggimann P, Antonelli M, Bonten MJM, Csomos A, Krueger WA, Mikstacki A, Lipman J, Depuydt P, Vesin A, Garrouste-Orgeas M, Zahar JR, Blot S, Carlet J, Brun-Buisson C, Martin C, Rello J, Dimopoulos G, Timsit JF. Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study. Intensive Care Med 2012; 38:1930-45. [PMID: 23011531 DOI: 10.1007/s00134-012-2695-9] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 08/21/2012] [Indexed: 12/16/2022]
Abstract
PURPOSE The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management. METHODS A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries. RESULTS We included 1,156 patients [mean ± standard deviation (SD) age, 59.5 ± 17.7 years; 65 % males; mean ± SD Simplified Acute Physiology Score (SAPS) II score, 50 ± 17] with HA-BSIs, of which 76 % were ICU-acquired. Median time to diagnosis was 14 [interquartile range (IQR), 7-26] days after hospital admission. Polymicrobial infections accounted for 12 % of cases. Among monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p < 0.001) by country. The 28-day all-cause fatality rate was 36 %. In the multivariable model including micro-organism, patient and centre variables, independent predictors of 28-day mortality included MDR isolate [odds ratio (OR), 1.49; 95 % confidence interval (95 %CI), 1.07-2.06], uncontrolled infection source (OR, 5.86; 95 %CI, 2.5-13.9) and timing to adequate treatment (before day 6 since blood culture collection versus never, OR, 0.38; 95 %CI, 0.23-0.63; since day 6 versus never, OR, 0.20; 95 %CI, 0.08-0.47). CONCLUSIONS MDR and XDR bacteria (especially gram-negative) are common in HA-BSIs in critically ill patients and are associated with increased 28-day mortality. Intensified efforts to prevent HA-BSIs and to optimize their management through adequate source control and antibiotic therapy are needed to improve outcomes.
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Affiliation(s)
- Alexis Tabah
- Albert Michallon University Hospital, Université Grenoble 1, Grenoble, France
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Huston JM. The vagus nerve and the inflammatory reflex: wandering on a new treatment paradigm for systemic inflammation and sepsis. Surg Infect (Larchmt) 2012; 13:187-93. [PMID: 22913335 DOI: 10.1089/sur.2012.126] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The immune system protects the host against dangerous pathogens and toxins. The central nervous system is charged with monitoring and coordinating appropriate responses to internal and external stimuli. The inflammatory reflex sits at the crossroads of these crucial homeostatic systems. This review highlights how the vagus nerve-mediated inflammatory reflex facilitates rapid and specific exchange of information between the nervous and immune systems to prevent tissue injury and infection. METHODS Review of the pertinent English-language literature. Nearly two decades of research has elucidated some of the essential anatomic, physiologic, and molecular connections of the inflammatory reflex. The original descriptions of how these key components contribute to afferent and efferent anti-inflammatory vagus nerve signaling are summarized. RESULTS The central nervous system recognizes peripheral inflammation via afferent vagus nerve signaling. The brain can attenuate peripheral innate immune responses, including pro-inflammatory cytokine production, leukocyte recruitment, and nuclear factor kappa β activation via α7-nicotinic acetylcholine receptor subunit-dependent, T-lymphocyte-dependent, vagus nerve signaling to spleen. This efferent arm of the inflammatory reflex is referred to as the "cholinergic anti-inflammatory pathway." Activation of this pathway via vagus nerve stimulation or pharmacologic α7 agonists prevents tissue injury in multiple models of systemic inflammation, shock, and sepsis. CONCLUSIONS The vagus nerve-mediated inflammatory reflex is a powerful ally in the fight against lethal tissue damage after injury and infection. Further studies will help translate the beneficial effects of this pathway into clinical use for our surgical patients.
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Affiliation(s)
- Jared M Huston
- Division of General Surgery, Trauma, Surgical Critical Care, and Burns, Stony Brook University Medical Center, Stony Brook, New York 11794, USA.
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Oltean S, Ţǎţulescu D, Bondor C, Slavcovici A, Cismaru C, Lupşe M, Muntean M, Jianu C, Marcu C, Oltean M. Charlson's weighted index of comorbidities is useful in assessing the risk of death in septic patients. J Crit Care 2012; 27:370-5. [DOI: 10.1016/j.jcrc.2011.08.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 08/12/2011] [Accepted: 08/27/2011] [Indexed: 11/26/2022]
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Rodelo JR, De la Rosa G, Valencia ML, Ospina S, Arango CM, Gómez CI, García A, Nuñez E, Jaimes FA. D-dimer is a significant prognostic factor in patients with suspected infection and sepsis. Am J Emerg Med 2012; 30:1991-9. [PMID: 22795996 DOI: 10.1016/j.ajem.2012.04.033] [Citation(s) in RCA: 207] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 04/01/2012] [Accepted: 04/27/2012] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The aim of the study was to determine whether C-reactive protein (CRP), procalcitonin (PCT), and d-dimer (DD) are markers of mortality in patients admitted to the emergency department (ED) with suspected infection and sepsis. BASIC PROCEDURES We conducted a prospective cohort in a university hospital in Medellín, Colombia. Patients were admitted between August 1, 2007, and January 30, 2009. Clinical and demographic data and Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores as well as blood samples for CRP, PCT, and DD were collected within the first 24 hours of admission. Survival was determined on day 28 to establish its association with the proposed biomarkers using logistic regression and receiver operating characteristic curves. MAIN FINDINGS We analyzed 684 patients. The median Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores were 10 (interquartile range [IQR], 6-15) and 2 (IQR, 1-4), respectively. The median CRP was 9.6 mg/dL (IQR, 3.5-20.4 mg/dL); PCT, 0.36 ng/mL (IQR, 0.1-3.7 ng/mL); and DD, 1612 ng/mL (IQR, 986-2801 ng/mL). The median DD in survivors was 1475 ng/mL (IQR, 955-2627 ng/mL) vs 2489 ng/mL (IQR, 1698-4573 ng/mL) in nonsurvivors (P=.0001). The discriminatory ability showed area under the curve-receiver operating characteristic for DD, 0.68; CRP, 0.55; and PCT, 0.59. After multivariate analysis, the only biomarker with a linear relation with mortality was DD, with an odds ratio of 2.07 (95% confidence interval, 0.93-4.62) for values more than 1180 and less than 2409 ng/mL and an odds ratio of 3.03 (95% confidence interval, 1.38-6.62) for values more than 2409 ng/mL. PRINCIPAL CONCLUSIONS Our results suggest that high levels of DD are associated with 28-day mortality in patients with infection or sepsis identified in the emergency department.
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Affiliation(s)
- Joaquín R Rodelo
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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Skogberg K, Lyytikäinen O, Ollgren J, Nuorti J, Ruutu P. Population-based burden of bloodstream infections in Finland. Clin Microbiol Infect 2012; 18:E170-6. [DOI: 10.1111/j.1469-0691.2012.03845.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Adib-Conquy M, Cavaillon JM. [Host inflammatory and anti-inflammatory response during sepsis]. ACTA ACUST UNITED AC 2012; 60:306-13. [PMID: 22542429 DOI: 10.1016/j.patbio.2012.03.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
Sepsis still remains the major complication for patients admitted in intensive care units (ICU), and is responsible for numerous deaths. ICU patients admitted after sepsis, hemorrhagic shock, severe trauma, severe burns or major surgery show a systemic inflammatory response syndrome (SIRS). This syndrome is characterized by an exacerbation of inflammation, with increased levels of pro- (IL-1β, TNFα, IL-6, IL-8) as well as anti-inflammatory (IL-10, IL-1Ra, TGFβ) cytokines into their bloodstream. During sepsis, the bacteria release microbial motifs such as peptidoglycan, lipopolysaccharide (LPS) and DNA that initiate the inflammatory response, and are involved in the onset of multiple organ failure. The same microbial motifs can also be found in patients with a SIRS of non-infectious origin, following the translocation of bacteria from their digestive tract. This translocation is certainly contributing to the difficulty of discriminating between septic and SIRS patients using biological markers. Furthermore, the host response is accompanied by an alteration of the ex vivo response of circulating leukocytes, particularly monocytes. This hyporesponsiveness to LPS is associated with a decreased activation of the transcription factor NF-κB (required for the expression of pro-inflammatory cytokines) and an increased expression of negative regulators of the NF-κB pathway. However, the leukocyte hyporesponsiveness is not a global phenomenon, it depends on the type of patient, on the receptor-activator pair, on the timing, and on the cytokine.
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Affiliation(s)
- M Adib-Conquy
- Unité cytokines et inflammation, département infection et épidémiologie, Institut Pasteur, 28, rue du Dr-Roux, 75015 Paris, France.
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