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Bassi E, Tomazini BM, Carneiro BV, Siqueira ARDO, Siqueira SRDO, Guimarães T, Novo FDCF, Utiyama EM, Pelosi P, Malbouisson LMS. Impact of withholding early antibiotic therapy in nonseptic surgical patients with suspected nosocomial infection: a retrospective cohort analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744431. [PMID: 36965628 PMCID: PMC11148499 DOI: 10.1016/j.bjane.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Systemic inflammatory responses mimicking infectious complications are often present in surgical patients. METHODS The objective was to assess the association between withholding early antimicrobial therapy while investigating alternative diagnoses and worse outcomes in nonseptic patients with suspected nosocomial infection in a retrospective cohort of critically ill surgical patients. The initiation of antibiotic therapy within 24 h of the suspicion of infection was defined as the Early Empirical Antibiotic strategy (EEA) group and the initiation after 24 h of suspicion or not prescribed was defined as the Conservative Antibiotic strategy (CA) group. Primary outcome was composite: death, sepsis, or septic shock within 14 days. Main exclusion criteria were sepsis or an evident source of infection at inclusion. RESULTS Three hundred and forty patients were eligible for inclusion (74% trauma patients). Age, sex, reason for hospital admission, SAPS3 score, SOFA score, and use of vasopressors or mechanical ventilation were not different between the groups. Within 14 days of inclusion, 100% (130/130) of EEA patients received antibiotics compared to 57% (120/210) of CA patients. After adjusting for confounding variables, there was no association between primary outcome and the groups. In a post hoc subgroup analysis including only patients with a posteriori confirmed infection (by microbiological cultures), delay in initiation of adequate antimicrobial therapy was independently associated with the primary outcome (Odds Ratio = 1.19 per day of delay; 95% CI 1.05-1.37). CONCLUSIONS Withholding early empiric antibiotic therapy was not associated with progression of organ dysfunction within 14 days in nonseptic surgical patients with suspected nosocomial infection without an obvious source.
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Affiliation(s)
- Estevão Bassi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Alemão Oswaldo Cruz, Unidade de Tratamento Intensivo, São Paulo, SP, Brazil.
| | - Bruno Martins Tomazini
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil; Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil
| | - Bárbara Vieira Carneiro
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | | | | | - Thais Guimarães
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Controle de Infecção, São Paulo, SP, Brazil
| | - Fernando da Costa Ferreira Novo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Edivaldo Massazo Utiyama
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Departamento de Cirurgia, Disciplina de Cirurgia Geral e Traumatologia, São Paulo, SP, Brazil
| | - Paolo Pelosi
- University of Genoa, Department of Surgical Sciences and Integrated Diagnostics, Genoa, Italy; San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Anaesthesia and Intensive Care, Genoa, Italy
| | - Luiz Marcelo Sá Malbouisson
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas (HCFMUSP), Divisão de Anestesiologia, São Paulo, SP, Brazil
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Shi X, Sharma S, Chmielewski RA, Markovic MJ, VanEpps JS, Yau ST. Rapid diagnosis of bloodstream infections using a culture-free phenotypic platform. COMMUNICATIONS MEDICINE 2024; 4:77. [PMID: 38654117 DOI: 10.1038/s43856-024-00487-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 03/20/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Bloodstream infections (BSIs) are a life-threatening acute medical condition and current diagnostics for BSIs suffer from long turnaround time (TAT). Here we show the validation of a rapid detection-analysis platform (RDAP) for the diagnosis of BSIs performed on clinical blood samples METHODS: The validation was performed on a cohort of 59 clinical blood samples, including positive culture samples, which indicated confirmed bloodstream infections, and negative culture samples. The bacteria in the positive culture samples included Gram-positive and Gram-negative pathogenic species. RDAP is based on an electrochemical sandwich immunoassay with voltage-controlled signal amplification, which provides an ultra-low limit of detection (4 CFU/mL), allowing the platform to detect and identify bacteria without requiring culture and perform phenotypic antibiotic susceptibility testing (AST) with only 1-2 h of antibiotic exposure. The preliminary diagnostic performance of RDAP was compared with that of standard commercial diagnostic technologies. RESULTS Using a typical clinical microbiology laboratory diagnostic workflow that involved sample culture, agar plating, bacteria identification using matrix-assisted laser desorption ionization time-of-flight (MALDI TOF) mass spectrometry, and AST using MicroScan as a clinical diagnostic reference, RDAP showed diagnostic accuracy of 93.3% and 95.4% for detection-identification and AST, respectively. However, RDAP provided results at least 15 h faster. CONCLUSIONS This study shows the preliminary feasibility of using RDAP to rapidly diagnose BSIs, including AST. Limitations and potential mitigation strategies for clinical translation of the present RDAP prototype are discussed. The results of this clinical feasibility study indicate an approach to provide near real-time diagnostic information for clinicians to significantly enhance the treatment outcome of BSIs.
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Affiliation(s)
- Xuyang Shi
- Department of Electrical and Computer Engineering, Cleveland State University, Cleveland, OH, USA
| | | | | | - Mario J Markovic
- Department of Laboratory Medicine, Saint Vincent Charity Medical Center, Cleveland, OH, USA
| | - J Scott VanEpps
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
- Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA.
| | - Siu-Tung Yau
- Department of Electrical and Computer Engineering, Cleveland State University, Cleveland, OH, USA.
- Rapidect Inc., Solon, OH, USA.
- The Applied Bioengineering Program, Cleveland State University, Cleveland, OH, USA.
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Jouffroy R, Djossou F, Neviere R, Jaber S, Vivien B, Heming N, Gueye P. The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization. Ann Intensive Care 2024; 14:58. [PMID: 38625453 PMCID: PMC11019190 DOI: 10.1186/s13613-024-01282-6] [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: 10/06/2023] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France.
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM - Paris Saclay University, Paris, France.
- EA 7329 - Institut de Recherche Médicale et d'Épidémiologie du Sport - Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique - Hôpitaux de Paris, and Paris Saclay University, Saclay, France.
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Guyane and Laboratoire Ecosystèmes Amazoniens et Pathologie Tropicale EA 3593, Centre Hospitalier de Cayenne, Université de Guyane, Cayenne, France
| | - Rémi Neviere
- Service des Explorations Fonctionnelles Centre Hospitalier Universitaire de Martinique et UR5_3 PC2E Pathologie Cardiaque, toxicité Environnementale et Envenimations (ex EA7525, Université des Antilles, Antilles, France
| | - Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, INSERM U1046, Centre Hospitalier Universitaire Montpellier, Montpellier, 34295, France
| | - Benoît Vivien
- Service d'Anesthésie Réanimation, SAMU de Paris, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital, Laboratory of Infection & Inflammation - U1173, School of Medicine Simone Veil, FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), APHP University Versailles Saint Quentin - University Paris Saclay, University Versailles Saint Quentin - University Paris Saclay, INSERM, Garches, Garches, 92380, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, University of the Antilles, French West Indies, Antilles, France
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Jouffroy R, Holub M, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Vivien B, Gueye-Ngalgou P. Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting. Am J Emerg Med 2024; 76:48-54. [PMID: 37995523 DOI: 10.1016/j.ajem.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock. METHODS From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed. RESULTS Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]. CONCLUSION In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France; Centre de recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, France; EA 7329 - Institut de Recherche Médicale et d'Épidémiologie du Sport - Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
| | - Matthieu Holub
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, Paris 75013, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa Gueye-Ngalgou
- SAMU 972 CHU de Martinique Pierre Zobda, Quitman Hospital, Fort-de-France Martinique, France
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Kumar NR, Balraj TA, Kempegowda SN, Prashant A. Multidrug-Resistant Sepsis: A Critical Healthcare Challenge. Antibiotics (Basel) 2024; 13:46. [PMID: 38247605 PMCID: PMC10812490 DOI: 10.3390/antibiotics13010046] [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: 12/02/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Sepsis globally accounts for an alarming annual toll of 48.9 million cases, resulting in 11 million deaths, and inflicts an economic burden of approximately USD 38 billion on the United States healthcare system. The rise of multidrug-resistant organisms (MDROs) has elevated the urgency surrounding the management of multidrug-resistant (MDR) sepsis, evolving into a critical global health concern. This review aims to provide a comprehensive overview of the current epidemiology of (MDR) sepsis and its associated healthcare challenges, particularly in critically ill hospitalized patients. Highlighted findings demonstrated the complex nature of (MDR) sepsis pathophysiology and the resulting immune responses, which significantly hinder sepsis treatment. Studies also revealed that aging, antibiotic overuse or abuse, inadequate empiric antibiotic therapy, and underlying comorbidities contribute significantly to recurrent sepsis, thereby leading to septic shock, multi-organ failure, and ultimately immune paralysis, which all contribute to high mortality rates among sepsis patients. Moreover, studies confirmed a correlation between elevated readmission rates and an increased risk of cognitive and organ dysfunction among sepsis patients, amplifying hospital-associated costs. To mitigate the impact of sepsis burden, researchers have directed their efforts towards innovative diagnostic methods like point-of-care testing (POCT) devices for rapid, accurate, and particularly bedside detection of sepsis; however, these methods are currently limited to detecting only a few resistance biomarkers, thus warranting further exploration. Numerous interventions have also been introduced to treat MDR sepsis, including combination therapy with antibiotics from two different classes and precision therapy, which involves personalized treatment strategies tailored to individual needs. Finally, addressing MDR-associated healthcare challenges at regional levels based on local pathogen resistance patterns emerges as a critical strategy for effective sepsis treatment and minimizing adverse effects.
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Affiliation(s)
- Nishitha R. Kumar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
| | - Tejashree A. Balraj
- Department of Microbiology, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India;
| | - Swetha N. Kempegowda
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
| | - Akila Prashant
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
- Department of Medical Genetics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India
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Donnelly JP, Seelye SM, Kipnis P, McGrath BM, Iwashyna TJ, Pogue J, Jones M, Liu VX, Prescott HC. Impact of Reducing Time-to-Antibiotics on Sepsis Mortality, Antibiotic Use, and Adverse Events. Ann Am Thorac Soc 2024; 21:94-101. [PMID: 37934602 PMCID: PMC10867916 DOI: 10.1513/annalsats.202306-505oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/31/2023] [Indexed: 11/09/2023] Open
Abstract
Rationale: Shorter time-to-antibiotics is lifesaving in sepsis, but programs to hasten antibiotic delivery may increase unnecessary antibiotic use and adverse events. Objectives: We sought to estimate both the benefits and harms of shortening time-to-antibiotics for sepsis. Methods: We conducted a simulation study using a cohort of 1,559,523 hospitalized patients admitted through the emergency department with meeting two or more systemic inflammatory response syndrome criteria (2013-2018). Reasons for hospitalization were classified as septic shock, sepsis, infection, antibiotics stopped early, and never treated (no antibiotics within 48 h). We simulated the impact of a 50% reduction in time-to-antibiotics for sepsis across 12 hospital scenarios defined by sepsis prevalence (low, medium, or high) and magnitude of "spillover" antibiotic prescribing to patients without infection (low, medium, high, or very high). Outcomes included mortality and adverse events potentially attributable to antibiotics (e.g., allergy, organ dysfunction, Clostridiodes difficile infection, and culture with multidrug-resistant organism). Results: A total of 933,458 (59.9%) hospitalized patients received antimicrobial therapy within 48 hours of presentation, including 38,572 (2.5%) with septic shock, 276,082 (17.7%) with sepsis, 370,705 (23.8%) with infection, and 248,099 (15.9%) with antibiotics stopped early. A total of 199,937 (12.8%) hospitalized patients experienced an adverse event; most commonly, acute liver injury (5.6%), new MDRO (3.5%), and Clostridiodes difficile infection (1.7%). Across the scenarios, a 50% reduction in time-to-antibiotics for sepsis was associated with a median of 1 to 180 additional antibiotic-treated patients and zero to seven additional adverse events per death averted from sepsis. Conclusions: The impacts of faster time-to-antibiotics for sepsis vary markedly across simulated hospital types. However, even in the worst-case scenario, new antibiotic-associated adverse events were rare.
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Affiliation(s)
- John P. Donnelly
- Department of Learning Health Sciences
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- VA Center for Implementation and Evaluation Resources, Ann Arbor, Michigan
| | - Sarah M. Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brenda M. McGrath
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- OCHIN Inc., Portland, Oregon
| | - Theodore J. Iwashyna
- Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jason Pogue
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Makoto Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah; and
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Hallie C. Prescott
- Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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Lam JC, Bourassa-Blanchette S. Ten common misconceptions about antibiotic use in the hospital. J Hosp Med 2023; 18:1123-1129. [PMID: 37812004 DOI: 10.1002/jhm.13220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/28/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
Antimicrobials are one of the most administered medications in hospitals. Thoughtful and rational antibiotic prescribing by clinicians are important in reducing the adverse effects to both the host that takes the antibiotic and also the individuals in the host's community. Principles informing antibiotic prescribing in the hospital are commonly rooted in misconceptions. We review 10 common myths associated with antibacterial usage in hospitalized patients and share contemporary evidence in hopes of enhancing evidence-informed practice in this patient care setting.
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Affiliation(s)
- John C Lam
- Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Samuel Bourassa-Blanchette
- Division of Infectious Diseases, Department of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
- Division of Microbiology, Department of Pathology and Laboratory Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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Pak TR, Young J, McKenna CS, Agan A, DelloStritto L, Filbin MR, Dutta S, Kadri SS, Septimus EJ, Rhee C, Klompas M. Risk of Misleading Conclusions in Observational Studies of Time-to-Antibiotics and Mortality in Suspected Sepsis. Clin Infect Dis 2023; 77:1534-1543. [PMID: 37531612 PMCID: PMC10686960 DOI: 10.1093/cid/ciad450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/20/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Influential studies conclude that each hour until antibiotics increases mortality in sepsis. However, these analyses often (1) adjusted for limited covariates, (2) included patients with long delays until antibiotics, (3) combined sepsis and septic shock, and (4) used linear models presuming each hour delay has equal impact. We evaluated the effect of these analytic choices on associations between time-to-antibiotics and mortality. METHODS We retrospectively identified 104 248 adults admitted to 5 hospitals from 2015-2022 with suspected infection (blood culture collection and intravenous antibiotics ≤24 h of arrival), including 25 990 with suspected septic shock and 23 619 with sepsis without shock. We used multivariable regression to calculate associations between time-to-antibiotics and in-hospital mortality under successively broader confounding-adjustment, shorter maximum time-to-antibiotic intervals, stratification by illness severity, and removing assumptions of linear hourly associations. RESULTS Changing covariates, maximum time-to-antibiotics, and severity stratification altered the magnitude, direction, and significance of observed associations between time-to-antibiotics and mortality. In a fully adjusted model of patients treated ≤6 hours, each hour was associated with higher mortality for septic shock (adjusted odds ratio [aOR]: 1.07; 95% CI: 1.04-1.11) but not sepsis without shock (aOR: 1.03; .98-1.09) or suspected infection alone (aOR: .99; .94-1.05). Modeling each hour separately confirmed that every hour of delay was associated with increased mortality for septic shock, but only delays >6 hours were associated with higher mortality for sepsis without shock. CONCLUSIONS Associations between time-to-antibiotics and mortality in sepsis are highly sensitive to analytic choices. Failure to adequately address these issues can generate misleading conclusions.
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Affiliation(s)
- Theodore R Pak
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica Young
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Caroline S McKenna
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Anna Agan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Laura DelloStritto
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sameer S Kadri
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Jain K, Mohan KV, Roy G, Sinha P, Jayaraman V, Kiran, Yadav AS, Phasalkar A, Deepanshu, Pokhrel A, Perumal N, Sinha N, Chaudhary K, Upadhyay P. Reconditioned monocytes are immunomodulatory and regulate inflammatory environment in sepsis. Sci Rep 2023; 13:14977. [PMID: 37696985 PMCID: PMC10495550 DOI: 10.1038/s41598-023-42237-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023] Open
Abstract
Sepsis is caused by dysregulated immune response to severe infection and hyper inflammation plays a central role in worsening the disease. The immunomodulatory properties of mesenchymal stem cells (MSCs) have been evaluated as a therapeutic candidate for sepsis. Reconditioned monocytes (RM), generated from healthy human peripheral blood mononuclear cells (PBMCs) exhibit both macrophage and MSCs-like properties. RM were administered at different stages of sepsis in a mouse model. It reduced serum levels of IL6, MCP-1, IL-10, improved hypothermia, increased survival, and recovery from 0 to 66% when combined with antibiotics in the mouse model. The reduced human leucocyte antigen DR molecules expression on RM enables their co-culture with PBMCs of sepsis patients which resulted in reduced ROS production, and up-regulated TGF-β while down-regulating IL6, IL8, and IL-10 in-vitro. RM are potentially immunomodulatory, enhance survival in sepsis mouse model and modulate inflammatory behaviour of sepsis patient's PBMCs.
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Affiliation(s)
- Kshama Jain
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India
| | - K Varsha Mohan
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India
| | - Gargi Roy
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India
| | - Prakriti Sinha
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India
| | - Vignesh Jayaraman
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India
| | - Kiran
- Department of Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Ajit Singh Yadav
- Department of Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Akshay Phasalkar
- Department of Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Deepanshu
- Department of Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Anupa Pokhrel
- Department of Transfusion Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Nagarajan Perumal
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India
| | - Nitin Sinha
- Department of Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Kiran Chaudhary
- Department of Transfusion Medicine, Dr. Ram Mahohar Lohia Hospital, Baba Kharak Singh Road, New Delhi, 110001, India
| | - Pramod Upadhyay
- National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi, 110067, India.
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10
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Atkins PE, Bastin MLT, Morgan RJ, Laine ME, Flannery AH. Pharmacist Involvement in Sepsis Response and Time to Antibiotics: A Systematic Review. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023; 6:942-953. [PMID: 37608990 PMCID: PMC10441617 DOI: 10.1002/jac5.1723] [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: 08/12/2022] [Accepted: 09/28/2022] [Indexed: 08/24/2023]
Abstract
Introduction Sepsis is a life-threatening medical emergency and a leading cause of morbidity and mortality worldwide. Reductions in time to antibiotics in patients presenting with sepsis or septic shock are associated with reduced mortality, and Surviving Sepsis Campaign guidelines recommend antibiotics within one hour of recognition. Pharmacists are well-equipped to help navigate the therapeutic and operational challenges associated with achieving this goal. Objectives To assess the association of pharmacist involvement in sepsis response with time to antibiotics in hospitalized patients with sepsis and septic shock. Methods A systematic review of the following databases was conducted: PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. Studies must have included a designated role of an individual pharmacist in the management of sepsis or septic shock and not be considered an operational change. The primary outcome of interest was time to antibiotic administration, with secondary outcomes including intensive care unit (ICU) and hospital length of stay as well as in-hospital mortality. Results We identified 10 studies including 1772 patients with sepsis or septic shock that evaluated a sepsis response in which a pharmacist was included. Studies included patients in the ICU, emergency department, and hospital ward setting. Seven studies demonstrated a significant reduction in time to antibiotics, with two other studies supporting this conclusion in extrapolation or sensitivity analysis. There was not a consistent reduction in ICU or hospital length of stay nor in-hospital mortality between those interventions involving a pharmacist compared with their defined control groups. Conclusion Pharmacist involvement in sepsis response, often as part of a multi-professional team-based approach to sepsis care, is associated with a reduced time to antibiotic administration for hospitalized patients with sepsis or septic shock.
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Affiliation(s)
- Payton E. Atkins
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Rebecca J. Morgan
- University of Kentucky Medical Center Library, Lexington, Kentucky, USA
| | - Melanie E. Laine
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
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11
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Yang A, Kennedy JN, Reitz KM, Phillips G, Terry KM, Levy MM, Angus DC, Seymour CW. Time to treatment and mortality for clinical sepsis subtypes. Crit Care 2023; 27:236. [PMID: 37322546 PMCID: PMC10268363 DOI: 10.1186/s13054-023-04507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Sepsis is common, deadly, and heterogenous. Prior analyses of patients with sepsis and septic shock in New York State showed a risk-adjusted association between more rapid antibiotic administration and bundled care completion, but not an intravenous fluid bolus, with reduced in-hospital mortality. However, it is unknown if clinically identifiable sepsis subtypes modify these associations. METHODS Secondary analysis of patients with sepsis and septic shock enrolled in the New York State Department of Health cohort from January 1, 2015 to December 31, 2016. Patients were classified as clinical sepsis subtypes (α, β, γ, δ-types) using the Sepsis ENdotyping in Emergency CAre (SENECA) approach. Exposure variables included time to 3-h sepsis bundle completion, antibiotic administration, and intravenous fluid bolus completion. Then logistic regression models evaluated the interaction between exposures, clinical sepsis subtypes, and in-hospital mortality. RESULTS 55,169 hospitalizations from 155 hospitals were included (34% α, 30% β, 19% γ, 17% δ). The α-subtype had the lowest (N = 1,905, 10%) and δ-subtype had the highest (N = 3,776, 41%) in-hospital mortality. Each hour to completion of the 3-h bundle (aOR, 1.04 [95%CI, 1.02-1.05]) and antibiotic initiation (aOR, 1.03 [95%CI, 1.02-1.04]) was associated with increased risk-adjusted in-hospital mortality. The association differed across subtypes (p-interactions < 0.05). For example, the outcome association for the time to completion of the 3-h bundle was greater in the δ-subtype (aOR, 1.07 [95%CI, 1.05-1.10]) compared to α-subtype (aOR, 1.02 [95%CI, 0.99-1.04]). Time to intravenous fluid bolus completion was not associated with risk-adjusted in-hospital mortality (aOR, 0.99 [95%CI, 0.97-1.01]) and did not differ among subtypes (p-interaction = 0.41). CONCLUSION Timely completion of a 3-h sepsis bundle and antibiotic initiation was associated with reduced risk-adjusted in-hospital mortality, an association modified by clinically identifiable sepsis subtype.
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Affiliation(s)
- Anne Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh Medical Center, PA, Pittsburgh, USA.
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
| | - Jason N Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gary Phillips
- The Ohio State University, Center for Biostatistics, Columbus, OH, USA
| | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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12
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de Oliveira Rodrigues Junior E, de Santana IR, Durço AO, Conceição LSR, Barreto AS, Menezes IAC, Roman-Campos D, Dos Santos MRV. The effects of flavonoids in experimental sepsis: A systematic review and meta-analysis. Phytother Res 2023. [PMID: 37115723 DOI: 10.1002/ptr.7846] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/22/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023]
Abstract
Sepsis is a host's dysregulated immune response to an infection associated with systemic inflammation and excessive oxidative stress, which can cause multiple organ failure and death. The literature suggests that flavonoids, a broad class of secondary plant metabolites, have numerous biological activities which can be valuable in the treatment of sepsis. This study aimed to review the effects of flavonoids on experimental sepsis, focusing mainly on survival rate, and also summarizing information on its mechanisms of action. We searched in the main databases up to November 2022 using relevant keywords, and data were extracted and analyzed qualitatively and quantitatively. Thirty-two articles met the study criteria for review and 29 for meta-analysis. Overall, 30 different flavonoids were used in the studies. The flavonoids were able to strongly inhibit inflammatory response by reducing the levels of important pro-inflammatory mediators, for example, tumor necrosis factor-alpha and interleukin-1β, oxidative stress, and showed antibacterial and anti-apoptotic actions. The meta-analysis found an increase of 50% in survival rate of the animals treated with flavonoids. They appear to act as multi-target drugs and may be an excellent therapeutic alternative to reduce a number of the complications caused by sepsis, and consequently, to improve survival rate.
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Affiliation(s)
| | - Izabel Rodrigues de Santana
- Department of Physiology, Federal University of Sergipe, Sao Cristovao, Sergipe, Brazil
- Health Sciences Graduate Program, Federal University of Sergipe, Hospital Universitário, Aracaju, Sergipe, Brazil
| | - Aimée Obolari Durço
- Health Sciences Graduate Program, Federal University of Sergipe, Hospital Universitário, Aracaju, Sergipe, Brazil
| | - Lino Sérgio Rocha Conceição
- Department of Physical Therapy, Federal University of Sergipe, Hospital Universitário, Aracaju, Sergipe, Brazil
| | - André Sales Barreto
- Health Sciences Graduate Program, Federal University of Sergipe, Hospital Universitário, Aracaju, Sergipe, Brazil
- Department of Health Education, Federal University of Sergipe, Lagarto, Sergipe, Brazil
| | | | - Danilo Roman-Campos
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
| | - Márcio Roberto Viana Dos Santos
- Department of Physiology, Federal University of Sergipe, Sao Cristovao, Sergipe, Brazil
- Health Sciences Graduate Program, Federal University of Sergipe, Hospital Universitário, Aracaju, Sergipe, Brazil
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13
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Hu XY, Zhang W, Wang D, Sun Y, Hu Z, Zang B, Feng Y, Wang H, Zhou J, Zhao Q, Liu H, Wang T, Jiang W, Wang CY, Jin C, Dong K, Chen S, Yao X, Hu P, Du B. Safety, tolerability, pharmacokinetics, and efficacy of kukoamine B in patients with sepsis: A randomized phase IIa trial. J Crit Care 2023; 76:154294. [PMID: 37116228 DOI: 10.1016/j.jcrc.2023.154294] [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: 12/07/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE To evaluate the safety, tolerability, pharmacokinetics, and efficacy of kukoamine B (KB), an alkaloid compound with high affinity for both lipopolysaccharide (LPS) and oligodeoxynucle-otides containing CpG motifs (CpG DNA), in patients with sepsis-induced organ failure. MATERIALS AND METHODS This was a multicenter, randomized, double-blind, placebo-controlled phase IIa trial. Patients with sepsis-induced organ failure were randomized to receive either KB (0.06, 0.12, or 0.24 mg/kg) or placebo, every 8 h for 7 days. Primary endpoint was safety, and secondary endpoints included pharmacokinetic (PK) parameters, changes in inflammatory mediators' level, and prognostic parameters. RESULTS Of 44 patients enrolled, adverse events occurred in 28 patients [n = 20, 66.7% (KB pooled); n = 8, 57.1% (placebo)], while treatment emergent adverse events were reported in 14 patients [n = 10, 33.3% (KB pooled); n = 4, 28.6% (placebo)]. Seven patients died at 28-day follow-up [n = 4, 13.3% (KB pooled); n = 3, 21.4% (placebo)], none was related to study drug. PK parameters suggested dose-dependent drug exposure and no drug accumulation. KB did not affect clinical outcomes such as ΔSOFA score, vasopressor-free days or ventilator-free days. CONCLUSIONS In patients with sepsis-induced organ failure, KB was safe and well tolerated. Further investigation is warranted. TRIAL REGISTRATION http://ClinicalTrials.gov, NCT03237728.
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Affiliation(s)
- Xiao-Yun Hu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing 100730, China; State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Weiwen Zhang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, No. 100 Minjiang Road, Kecheng District, Quzhou, Zhejiang 324000, China
| | - Difen Wang
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, 28 Guiyi Street, Guiyang, Guizhou 550004, China
| | - Yunbo Sun
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Shinan District, Qingdao, Shandong Province 266003, China
| | - Zhenjie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University and Hebei Cancer Hospital, 12 Jiankang Road, Shijiazhuang, Hebei Province 050011, China
| | - Bin Zang
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning Province 110004, China
| | - Yongwen Feng
- Department of Critical Care Medicine, Shenzhen Second People's Hospital, 3002 Sungang West Road, Futian District, Shenzhen, Guangdong Province 518035, China
| | - Huaxue Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, 287 Changhuai Road, Bengbu, Anhui Province 233004, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring West Road, Fengtai District, Beijing 100070, China
| | - Qian Zhao
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China; Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Hongzhong Liu
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China; Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Teng Wang
- Clinical Trial Center, West China hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wei Jiang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing 100730, China; State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Chun-Yao Wang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing 100730, China; State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China
| | - Chunyan Jin
- Clinical Research Center for Innovative Drugs, Tianjin Chasesun Pharmaceutical Co., Ltd., 20 Quan Fa Road, WuQing District, Tianjin 301700, China
| | - Kai Dong
- Clinical Research Center for Innovative Drugs, Tianjin Chasesun Pharmaceutical Co., Ltd., 20 Quan Fa Road, WuQing District, Tianjin 301700, China
| | - Shuai Chen
- Clinical Research Center for Innovative Drugs, Tianjin Chasesun Pharmaceutical Co., Ltd., 20 Quan Fa Road, WuQing District, Tianjin 301700, China
| | - Xiaoqing Yao
- Clinical Research Center for Innovative Drugs, Tianjin Chasesun Pharmaceutical Co., Ltd., 20 Quan Fa Road, WuQing District, Tianjin 301700, China.
| | - Pei Hu
- State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China; Clinical Pharmacology Research Center, Peking Union Medical College Hospital, State Key Laboratory of Complex Severe and Rare Diseases, NMPA Key Laboratory for Clinical Research and Evaluation of Drug, Beijing Key Laboratory of Clinical PK & PD Investigation for Innovative Drugs, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China.
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing 100730, China; State Key Laboratory of Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, 1 Shuai Fu Yuan, Beijing 100730, China.
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14
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Duan C, Wang Y, Wang Q, Li J, Xie J, Liu S, Yang J, Huang Y, Zhao W, Yin W. Gram-negative bacterial infection causes aggravated innate immune response in sepsis: Studies from clinical samples and cellular models. Biochem Biophys Res Commun 2023; 650:137-144. [PMID: 36801697 DOI: 10.1016/j.bbrc.2023.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Bacterial infection is the most common cause for sepsis. The purpose of this study was to evaluate the impact of different bacterial infection on sepsis based on human samples and cellular experiments. Physiological indexes and prognostic information of 121 sepsis patients were analysed based on whether they had a gram-positive or gram-negative bacterial infection. Moreover, murine RAW264.7 macrophages were treated with lipopolysaccharide (LPS) or peptidoglycan (PG) to simulate infection with gram-negative or gram-positive bacteria in sepsis, respectively. Exosomes derived from the macrophages were extracted for transcriptome sequencing. In patients with sepsis, most gram-positive bacterial infections were Staphylococcus aureus, and gram-negative infections were Escherichia coli. Gram-negative bacterial infection was significantly associated with high neutrophil and interleukin (IL)-6 levels in blood and shorter prothrombin (PT) and activated partial thromboplastin time (APTT). Intriguingly, the survival prognosis of sepsis patients was not affected by the type of bacterial infection, but it was significantly related to fibrinogen. Protein transcriptome sequencing of the macrophage-derived exosomes showed that differentially expressed proteins were significantly enriched in megakaryocyte differentiation, leukocyte and lymphocyte-mediated immunity, and complement and coagulation cascade pathways. The complement and coagulation-related proteins were significantly upregulated after LPS induction, which explained the shortened PT and APTT in gram-negative bacterial sepsis. Bacterial infection did not affect mortality in sepsis but did alter the host response. The immune disorder induced by gram-negative infection was more severe than that produced by gram-positive infection. This study provides references for the rapid identification and molecular research of different bacterial infections in sepsis.
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Affiliation(s)
- Chujun Duan
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Yutong Wang
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Qianmei Wang
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Junjie Li
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Jiangang Xie
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Shanshou Liu
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Jing Yang
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Yang Huang
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China
| | - Wei Zhao
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China.
| | - Wen Yin
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, 710032, China.
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15
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Liu R, Hunold KM, Caterino JM, Zhang P. Estimating treatment effects for time-to-treatment antibiotic stewardship in sepsis. NAT MACH INTELL 2023; 5:421-431. [PMID: 37125081 PMCID: PMC10135432 DOI: 10.1038/s42256-023-00638-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/02/2023] [Indexed: 05/02/2023]
Abstract
Sepsis is a life-threatening condition with a high in-hospital mortality rate. The timing of antibiotic administration poses a critical problem for sepsis management. Existing work studying antibiotic timing either ignores the temporality of the observational data or the heterogeneity of the treatment effects. Here we propose a novel method (called T4) to estimate treatment effects for time-to-treatment antibiotic stewardship in sepsis. T4 estimates individual treatment effects by recurrently encoding temporal and static variables as potential confounders, and then decoding the outcomes under different treatment sequences. We propose mini-batch balancing matching that mimics the randomized controlled trial process to adjust the confounding. The model achieves interpretability through a global-level attention mechanism and a variable-level importance examination. Meanwhile, we equip T4 with an uncertainty quantification to help prevent overconfident recommendations. We demonstrate that T4 can identify effective treatment timing with estimated individual treatment effects for antibiotic stewardship on two real-world datasets. Moreover, comprehensive experiments on a synthetic dataset exhibit the outstanding performance of T4 compared with the state-of-the-art models on estimation of individual treatment effect.
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Affiliation(s)
- Ruoqi Liu
- Department of Computer Science and Engineering, The Ohio State University, Columbus, OH, USA
| | - Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Ping Zhang
- Department of Computer Science and Engineering, The Ohio State University, Columbus, OH, USA
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
- Translational Data Analytics institute, The Ohio State University, Columbus, OH, USA
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16
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Van Heuverswyn J, Valik JK, Desirée van der Werff S, Hedberg P, Giske C, Nauclér P. Association Between Time to Appropriate Antimicrobial Treatment and 30-day Mortality in Patients With Bloodstream Infections: A Retrospective Cohort Study. Clin Infect Dis 2022; 76:469-478. [PMID: 36065752 PMCID: PMC9907509 DOI: 10.1093/cid/ciac727] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Effective antimicrobial treatment is key for survival in bloodstream infection (BSI), but the impact of timing of treatment remains unclear. Our aim was to assess the association between time to appropriate antimicrobial treatment and 30-day mortality in BSI patients. METHODS This was a retrospective cohort study using electronic health record data from a large academic center in Sweden. Adult patients admitted between the years 2012 and 2019, with onset of BSI at the emergency department or general wards, were included. Pathogen-antimicrobial drug combinations were classified as appropriate or inappropriate based on reported in vitro susceptibilities. To avoid immortal time bias, the association between appropriate therapy and mortality was assessed with multivariable logistic regression analysis at pre-specified landmark times. RESULTS We included 10 628 BSI-episodes, occurring in 9192 unique patients. The overall 30-day mortality was 11.8%. No association in favor of a protective effect between appropriate therapy and mortality was found at the 1, 3 and 6 hours landmark after blood culture collection. At 12 hours, the risk of death increased with inappropriate treatment (adjusted odds ratio 1.17 [95% confidence interval {CI}, 1.01-1.37]) and continued to increase gradually at 24, 48, and 72 hours. Stratifying by high or low SOFA score generated similar odds ratios, with wider confidence intervals. CONCLUSIONS Delays in appropriate antimicrobial treatment were associated with increased 30-day mortality after 12 hours from blood culture collection, but not at 1, 3, and 6 hours, in BSI. These results indicate a benchmark for providing rapid microbiological diagnostics of blood cultures.
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Affiliation(s)
| | - John Karlsson Valik
- Correspondence: J. K. Valik, Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden ()
| | - Suzanne Desirée van der Werff
- Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Pontus Hedberg
- Department of Medicine, Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Giske
- Clinical microbiology, Karolinska University Hospital, Stockholm, Sweden,Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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17
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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18
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Prescott HC, Seelye S, Wang XQ, Hogan CK, Smith JT, Kipnis P, Barreda F, Donnelly JP, Pogue JM, Iwashyna TJ, Jones MM, Liu VX. Temporal Trends in Antimicrobial Prescribing During Hospitalization for Potential Infection and Sepsis. JAMA Intern Med 2022; 182:805-813. [PMID: 35759274 PMCID: PMC9237797 DOI: 10.1001/jamainternmed.2022.2291] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Importance Some experts have cautioned that national and health system emphasis on rapid administration of antimicrobials for sepsis may increase overall antimicrobial use even among patients without sepsis. Objective To assess whether temporal changes in antimicrobial timing for sepsis are associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among all hospitalized patients at risk for sepsis. Design, Setting, and Participants This is an observational cohort study of hospitalized patients at 152 hospitals in 2 health care systems during 2013 to 2018, admitted via the emergency department with 2 or more systemic inflammatory response syndrome (SIRS) criteria. Data analysis was performed from June 10, 2021, to March 22, 2022. Exposures Hospital-level temporal trends in time to first antimicrobial administration. Outcomes Antimicrobial outcomes included antimicrobial use, days of therapy, and broadness of antibacterial coverage. Clinical outcomes included in-hospital mortality, 30-day mortality, length of hospitalization, and new multidrug-resistant (MDR) organism culture positivity. Results Among 1 559 523 patients admitted to the hospital via the emergency department with 2 or more SIRS criteria (1 269 998 male patients [81.4%]; median [IQR] age, 67 [59-77] years), 273 255 (17.5%) met objective criteria for sepsis. In multivariable models adjusted for patient characteristics, the adjusted median (IQR) time to first antimicrobial administration to patients with sepsis decreased by 37 minutes, from 4.7 (4.1-5.3) hours in 2013 to 3.9 (3.6-4.4) hours in 2018, although the slope of decrease varied across hospitals. During the same period, antimicrobial use within 48 hours, days of antimicrobial therapy, and receipt of broad-spectrum coverage decreased among the broader cohort of patients with SIRS. In-hospital mortality, 30-day mortality, length of hospitalization, new MDR culture positivity, and new MDR blood culture positivity decreased over the study period among both patients with sepsis and those with SIRS. When examining hospital-specific trends, decreases in antimicrobial use, days of therapy, and broadness of antibacterial coverage for patients with SIRS did not differ by hospital antimicrobial timing trend for sepsis. Overall, there was no evidence that accelerating antimicrobial timing for sepsis was associated with increasing antimicrobial use or impaired antimicrobial stewardship. Conclusions and Relevance In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among the broader population at-risk for sepsis, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.
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Affiliation(s)
- Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Xiao Qing Wang
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Joshua T. Smith
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Fernando Barreda
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - John P. Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
| | - Jason M. Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor
| | - Theodore J. Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Makoto M. Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
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Prehospital Bundle of Care Based on Antibiotic Therapy and Hemodynamic Optimization Is Associated With a 30-Day Mortality Decrease in Patients With Septic Shock. Crit Care Med 2022; 50:1440-1448. [PMID: 35904262 DOI: 10.1097/ccm.0000000000005625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study aims to investigate the association between the 30-day mortality in patients with septic shock (SS) and a prehospital bundle of care completion, antibiotic therapy administration, and hemodynamic optimization defined as a fluid expansion of at least 10 mL.kg-1.hr-1. DESIGN To assess the association between prehospital BUndle of Care (BUC) completion and 30-day mortality, the inverse probability treatment weighting (IPTW) propensity method was performed. SETTING International guidelines recommend early treatment implementation in order to reduce SS mortality. More than one single treatment, a bundle of care, including antibiotic therapy and hemodynamic optimization, is more efficient. PATIENTS From May 2016 to March 2021, patients with SS requiring prehospital mobile ICU (mICU) intervention were retrospectively analyzed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 529 patients with SS requiring action by the mICU enrolled in this study, 354 (67%) were analyzed. Presumed pulmonary, digestive, and urinary infections were the cause of the SS in 49%, 25%, and 13% of the cases, respectively. The overall 30-day mortality was 32%. Seventy-one patients (20%) received prehospital antibiotic therapy and fluid expansion. Log binomial regression weighted with IPTW resulted in a significant association between 30-day mortality and prehospital BUC completion (respiratory rate [RR] of 0.56 [0.33-0.89]; p = 0.02 and adjusted RR 0.52 [0.27-0.93]; p = 0.03). CONCLUSIONS A prehospital bundle of care, based on antibiotic therapy and hemodynamic optimization, is associated with a 30-day mortality decrease among patients suffering from SS cared for by an mICU.
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20
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Jouffroy R, Hajjar A, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients. BMC Infect Dis 2022; 22:345. [PMID: 35387608 PMCID: PMC8988327 DOI: 10.1186/s12879-022-07337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without an increase in adverse effects. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) > 65 mmHg at the end of the prehospital stage. Methods From April 06th, 2016 to December 31th, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, the propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP > 65 mmHg at the end of the prehospital stage and 30-day mortality.
Results Four hundred and seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg h−1, among which 84 (69%) were alive and 38 (31%) were deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after the propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality, with an adjusted hazard ratio of 0.42 [0.25–0.70], p < 10–3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among the prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10–3.
Conclusion In this study, we report that prehospital norepinephrine infusion in order to reach a MAP > 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion decreases septic shock mortality.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France. .,Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France. .,Centre de Recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Paris Saclay University, Paris, France. .,Institut de Recherche bioMédicale et d'Epidémiologie du Sport, EA7329, INSEP, Paris University, Paris, France. .,EA 7525 Université des Antilles, Pointe-à-Pitre, France.
| | - Adèle Hajjar
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles de Gaulle, 92100, Boulogne-Billancourt, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France.,Emergency Department, SMUR, Hôtel Dieu Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, Assistance Publique, Hôpitaux Paris, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique, Hôpitaux Paris, Paris, France
| | - Papa-Ngalgou Gueye
- EA 7525 Université des Antilles, Pointe-à-Pitre, France.,SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
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21
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Chang JL, Pearson JC, Rhee C. Early Empirical Use of Broad-Spectrum Antibiotics in Sepsis. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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22
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Friedrich B, Lyer S, Janko C, Unterweger H, Brox R, Cunningham S, Dutz S, Taccardi N, Bikker FJ, Hurle K, Sebald H, Lenz M, Spiecker E, Fester L, Hackstein H, Strauß R, Boccaccini AR, Bogdan C, Alexiou C, Tietze R. Scavenging of bacteria or bacterial products by magnetic particles functionalized with a broad-spectrum pathogen recognition receptor motif offers diagnostic and therapeutic applications. Acta Biomater 2022; 141:418-428. [PMID: 34999260 DOI: 10.1016/j.actbio.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 11/19/2022]
Abstract
Sepsis is a dysregulated host response of severe bloodstream infections, and given its frequency of occurrence and high mortality rate, therapeutic improvements are imperative. A reliable biomimetic strategy for the targeting and separation of bacterial pathogens in bloodstream infections involves the use of the broad-spectrum binding motif of human GP-340, a pattern-recognition receptor of the scavenger receptor cysteine rich (SRCR) superfamily that is expressed on epithelial surfaces but not found in blood. Here we show that these peptides, when conjugated to superparamagnetic iron oxide nanoparticles (SPIONs), can separate various bacterial endotoxins and intact microbes (E. coli, S. aureus, P. aeruginosa and S. marcescens) with high efficiency, especially at low and thus clinically relevant concentrations. This is accompanied by a subsequent strong depletion in cytokine release (TNF, IL-6, IL-1β, Il-10 and IFN-γ), which could have a direct therapeutic impact since escalating immune responses complicates severe bloodstream infections and sepsis courses. SPIONs are coated with aminoalkylsilane and capture peptides are orthogonally ligated to this surface. The particles behave fully cyto- and hemocompatible and do not interfere with host structures. Thus, this approach additionally aims to dramatically reduce diagnostic times for patients with suspected bloodstream infections and accelerate targeted antibiotic therapy. STATEMENT OF SIGNIFICANCE: Sepsis is often associated with excessive release of cytokines. This aspect and slow diagnostic procedures are the major therapeutic obstacles. The use of magnetic particles conjugated with small peptides derived from the binding motif of a broad-spectrum mucosal pathogen recognition protein GP-340 provides a highly efficient scavenging platform. These peptides are not found in blood and therefore are not subject to inhibitory mechanisms like in other concepts (mannose binding lectine, aptamers, antibodies). In this work, data are shown on the broad bacterial binding spectrum, highly efficient toxin depletion, which directly reduces the release of cytokines. Host cells are not affected and antibiotics not adsorbed. The particle bound microbes can be recultured without restriction and thus be used directly for diagnostics.
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Affiliation(s)
- Bernhard Friedrich
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung-Professorship, Universitätsklinikum Erlangen, Germany
| | - Stefan Lyer
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung-Professorship, Universitätsklinikum Erlangen, Germany
| | - Christina Janko
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung-Professorship, Universitätsklinikum Erlangen, Germany
| | - Harald Unterweger
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung-Professorship, Universitätsklinikum Erlangen, Germany
| | - Regine Brox
- Department of Transfusion Medicine and Hemostaseology, Universitätsklinikum Erlangen, Germany
| | - Sarah Cunningham
- Department of Transfusion Medicine and Hemostaseology, Universitätsklinikum Erlangen, Germany
| | - Silvio Dutz
- Institute of Biomedical Engineering and Informatics (BMTI), Technische Universität Ilmenau, Germany
| | - Nicola Taccardi
- Institute of Chemical Reaction Engineering, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Floris J Bikker
- Department of Oral Biochemistry, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam (UvA) and Vrije Universiteit Amsterdam (VU), the Netherlands
| | - Katrin Hurle
- GeoZentrum Nordbayern, Mineralogy, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Heidi Sebald
- Immunologie und Hygiene, Mikrobiologisches Institut - Klinische Mikrobiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Malte Lenz
- Institute of Micro- and Nanostructure Research and Center for Nanoanalysis and Electron Microscopy (CENEM), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; Interdisciplinary Center for Nanostructure Films (IZNF), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
| | - Erdmann Spiecker
- Institute of Micro- and Nanostructure Research and Center for Nanoanalysis and Electron Microscopy (CENEM), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany; Interdisciplinary Center for Nanostructure Films (IZNF), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
| | - Lars Fester
- Institute of Anatomy and Cell Biology Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Holger Hackstein
- Department of Transfusion Medicine and Hemostaseology, Universitätsklinikum Erlangen, Germany
| | - Richard Strauß
- Department of Medicine 1, Universitätsklinikum Erlangen, Germany
| | - Aldo R Boccaccini
- Institute of Biomaterials, Department of Materials Science and Engineering, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Christian Bogdan
- Immunologie und Hygiene, Mikrobiologisches Institut - Klinische Mikrobiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Christoph Alexiou
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung-Professorship, Universitätsklinikum Erlangen, Germany
| | - Rainer Tietze
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Experimental Oncology and Nanomedicine (SEON), Else Kröner-Fresenius-Stiftung-Professorship, Universitätsklinikum Erlangen, Germany.
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23
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Tabah A, Lipman J, Barbier F, Buetti N, Timsit JF. Use of Antimicrobials for Bloodstream Infections in the Intensive Care Unit, a Clinically Oriented Review. Antibiotics (Basel) 2022; 11:antibiotics11030362. [PMID: 35326825 PMCID: PMC8944491 DOI: 10.3390/antibiotics11030362] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/22/2022] [Accepted: 02/26/2022] [Indexed: 01/06/2023] Open
Abstract
Bloodstream infections (BSIs) in critically ill patients are associated with significant mortality. For patients with septic shock, antibiotics should be administered within the hour. Probabilistic treatment should be targeted to the most likely pathogens, considering the source and risk factors for bacterial resistance including local epidemiology. Source control is a critical component of the management. Sending blood cultures (BCs) and other specimens before antibiotic administration, without delaying them, is key to microbiological diagnosis and subsequent opportunities for antimicrobial stewardship. Molecular rapid diagnostic testing may provide faster identification of pathogens and specific resistance patterns from the initial positive BC. Results allow for antibiotic optimisation, targeting the causative pathogen with escalation or de-escalation as required. Through this clinically oriented narrative review, we provide expert commentary for empirical and targeted antibiotic choice, including a review of the evidence and recommendations for the treatments of extended-spectrum β-lactamase-producing, AmpC-hyperproducing and carbapenem-resistant Enterobacterales; carbapenem-resistant Acinetobacter baumannii; and Staphylococcus aureus. In order to improve clinical outcomes, dosing recommendations and pharmacokinetics/pharmacodynamics specific to ICU patients must be followed, alongside therapeutic drug monitoring.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services, Redcliffe, QLD 4020, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Antimicrobial Optimisation Group, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia;
- Correspondence: ; Tel.: +61-(0)-7-3883-7777
| | - Jeffrey Lipman
- Antimicrobial Optimisation Group, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia;
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women’s Hospital, Metro North Hospital and Health Services, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - François Barbier
- Medical Intensive Care Unit, CHR Orléans, 45100 Orléans, France;
| | - Niccolò Buetti
- IAME, INSERM, Université de Paris, 75018 Paris, France; (N.B.); (J.-F.T.)
- Infection Control Program and WHO Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Jean-François Timsit
- IAME, INSERM, Université de Paris, 75018 Paris, France; (N.B.); (J.-F.T.)
- APHP Medical and Infectious Diseases Intensive Care Unit (MI), Bichat-Claude Bernard Hospital, 75018 Paris, France
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24
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Rüddel H, Thomas-Rüddel DO, Reinhart K, Bach F, Gerlach H, Lindner M, Marshall JC, Simon P, Weiss M, Bloos F, Schwarzkopf D. Adverse effects of delayed antimicrobial treatment and surgical source control in adults with sepsis: results of a planned secondary analysis of a cluster-randomized controlled trial. Crit Care 2022; 26:51. [PMID: 35227308 PMCID: PMC8883454 DOI: 10.1186/s13054-022-03901-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/16/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain. METHODS We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing. RESULTS Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1-3 h, or 1 h versus 3-6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04). CONCLUSIONS Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov ( NCT01187134 ). Registered 23 August 2010, NCT01187134.
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Affiliation(s)
- Hendrik Rüddel
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel O Thomas-Rüddel
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Konrad Reinhart
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health, Campus Virchow-Klinikum, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Friedhelm Bach
- Department for Infectious Diseases, Protestant Hospital of Bethel Foundation University Hospital, University of Bielefeld, Bethesdaweg 10, 33617, Bielefeld, Germany
| | - Herwig Gerlach
- Department for Anaesthesia, Intensive Care Medicine and Pain Management, Vivantes - Klinikum Neukoelln, Rudower Strasse 48, 12351, Berlin, Germany
| | - Matthias Lindner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
| | - Philipp Simon
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Liebigstraße 20, 04103, Leipzig, Germany
| | - Manfred Weiss
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Frank Bloos
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel Schwarzkopf
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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25
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Manjappachar NK, Cuenca JA, Ramírez CM, Hernandez M, Martin P, Reyes MP, Heatter AJ, Gutierrez C, Rathi N, Sprung CL, Price KJ, Nates JL. Outcomes and Predictors of 28-Day Mortality in Patients With Hematologic Malignancies and Septic Shock Defined by Sepsis-3 Criteria. J Natl Compr Canc Netw 2022; 20:45-53. [PMID: 34991066 DOI: 10.6004/jnccn.2021.7046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND To describe short-term outcomes and independent predictors of 28-dayx mortality in adult patients with hematologic malignancies and septic shock defined by the new Third International Consensus Definitions (Sepsis-3) criteria. METHODS We performed a retrospective cohort study of patients admitted to the medical ICU with septic shock from April 2016 to March 2019. Demographic and clinical features and short-term outcomes were collected. We used descriptive statistics to summarize patient characteristics, logistic regression to identify predictors of 28-day mortality, and Kaplan-Meier plots to assess survival. RESULTS Among the 459 hematologic patients with septic shock admitted to the ICU, 109 (23.7%) had received hematopoietic stem cell transplant. The median age was 63 years (range, 18-89 years), and 179 (39%) were women. Nonsurvivors had a higher Charlson comorbidity index (P=.007), longer length of stay before ICU admission (P=.01), and greater illness severity at diagnosis and throughout the hospital course (P<.001). The mortality rate at 28 days was 67.8% and increased with increasing sequential organ failure assessment score on admission (odds ratio [OR], 1.11; 95% CI, 1.03-1.20), respiratory failure (OR, 3.12; 95% CI, 1.49-6.51), and maximum lactate level (OR, 1.16; 95% CI, 1.10-1.22). Aminoglycosides administration (OR, 0.42; 95% CI, 0.26-0.69), serum albumin (OR, 0.51; 95% CI, 0.31-0.86), and granulocyte colony-stimulating factor (G-CSF) (OR, 0.40; 95% CI, 0.24-0.65) were associated with lower 28-day mortality. Life support limitations were present in 81.6% of patients at death. At 90 days, 19.4% of the patients were alive. CONCLUSIONS Despite efforts to enhance survival, septic shock in patients with hematologic malignancies is still associated with high mortality rates and poor 90-day survival. These results demonstrate the need for an urgent call to action with higher awareness, including the further evaluation of interventions such as earlier ICU admission, aminoglycosides administration, and G-CSF treatment.
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Affiliation(s)
| | - John A Cuenca
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Claudia M Ramírez
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Mike Hernandez
- 2Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Peyton Martin
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Maria P Reyes
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Alba J Heatter
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Cristina Gutierrez
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Nisha Rathi
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Charles L Sprung
- 3Department of Anesthesiology, Critical Care Medicine and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Kristen J Price
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
| | - Joseph L Nates
- 1Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, and
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26
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Baghela A, Pena OM, Lee AH, Baquir B, Falsafi R, An A, Farmer SW, Hurlburt A, Mondragon-Cardona A, Rivera JD, Baker A, Trahtemberg U, Shojaei M, Jimenez-Canizales CE, Dos Santos CC, Tang B, Bouma HR, Cohen Freue GV, Hancock REW. Predicting sepsis severity at first clinical presentation: The role of endotypes and mechanistic signatures. EBioMedicine 2022; 75:103776. [PMID: 35027333 PMCID: PMC8808161 DOI: 10.1016/j.ebiom.2021.103776] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/01/2021] [Accepted: 12/10/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Inter-individual variability during sepsis limits appropriate triage of patients. Identifying, at first clinical presentation, gene expression signatures that predict subsequent severity will allow clinicians to identify the most at-risk groups of patients and enable appropriate antibiotic use. METHODS Blood RNA-Seq and clinical data were collected from 348 patients in four emergency rooms (ER) and one intensive-care-unit (ICU), and 44 healthy controls. Gene expression profiles were analyzed using machine learning and data mining to identify clinically relevant gene signatures reflecting disease severity, organ dysfunction, mortality, and specific endotypes/mechanisms. FINDINGS Gene expression signatures were obtained that predicted severity/organ dysfunction and mortality in both ER and ICU patients with accuracy/AUC of 77-80%. Network analysis revealed these signatures formed a coherent biological program, with specific but overlapping mechanisms/pathways. Given the heterogeneity of sepsis, we asked if patients could be assorted into discrete groups with distinct mechanisms (endotypes) and varying severity. Patients with early sepsis could be stratified into five distinct and novel mechanistic endotypes, named Neutrophilic-Suppressive/NPS, Inflammatory/INF, Innate-Host-Defense/IHD, Interferon/IFN, and Adaptive/ADA, each based on ∼200 unique gene expression differences, and distinct pathways/mechanisms (e.g., IL6/STAT3 in NPS). Endotypes had varying overall severity with two severe (NPS/INF) and one relatively benign (ADA) groupings, consistent with reanalysis of previous endotype studies. A 40 gene-classification tool (accuracy=96%) and several gene-pairs (accuracy=89-97%) accurately predicted endotype status in both ER and ICU validation cohorts. INTERPRETATION The severity and endotype signatures indicate that distinct immune signatures precede the onset of severe sepsis and lethality, providing a method to triage early sepsis patients.
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Affiliation(s)
- Arjun Baghela
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada; Bioinformatics Graduate Program, Genome Sciences Centre, 570 W 7th Ave, Vancouver V5T 4S6, Canada
| | - Olga M Pena
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Amy H Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada
| | - Beverlie Baquir
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Reza Falsafi
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Andy An
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Susan W Farmer
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Andrew Hurlburt
- Vancouver General Hospital, 899 W 12th Ave, Vancouver V5Z 1M9, Canada
| | - Alvaro Mondragon-Cardona
- Hospital Universitario Hernando Moncaleano, Calle 9 No. 15-25, Neiva, Colombia; Department of Internal Medicine, Universidad Surcolombiana, Calle 9 Carrera 14, Neiva, Colombia
| | - Juan Diego Rivera
- Hospital Universitario Hernando Moncaleano, Calle 9 No. 15-25, Neiva, Colombia; Department of Internal Medicine, Universidad Surcolombiana, Calle 9 Carrera 14, Neiva, Colombia
| | - Andrew Baker
- Keenan Research Centre for Biomedical Science, Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5G1W8, Canada
| | - Uriel Trahtemberg
- Keenan Research Centre for Biomedical Science, Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5G1W8, Canada
| | - Maryam Shojaei
- The Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia
| | - Carlos Eduardo Jimenez-Canizales
- Hospital Universitario Hernando Moncaleano, Calle 9 No. 15-25, Neiva, Colombia; Department of Internal Medicine, Universidad Surcolombiana, Calle 9 Carrera 14, Neiva, Colombia
| | - Claudia C Dos Santos
- Keenan Research Centre for Biomedical Science, Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5G1W8, Canada
| | - Benjamin Tang
- The Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia
| | - Hjalmar R Bouma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 AV, the Netherland; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 AV, the Netherland
| | - Gabriela V Cohen Freue
- Department of Statistics, University of British Columbia, 2207 Main Mall, Vancouver V6T 1Z4, Canada
| | - Robert E W Hancock
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada.
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Jouffroy R, Gilbert B, Hassan A, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Adequacy of probabilistic prehospital antibiotic therapy for septic shock. Am J Emerg Med 2021; 53:80-85. [PMID: 34995860 DOI: 10.1016/j.ajem.2021.12.062] [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: 09/22/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Guidelines on sepsis management recommend early recognition, diagnosis and treatment, especially early antibiotic therapy (ABT) administration in order to reduce septic shock (SS) mortality. However, the adequacy of probabilistic prehospital ABT remains unknown. METHODS From May 2016 to March 2021, all consecutive patients with SS cared for by a prehospital mICU intervention were retrospectively analyzed. RESULTS Among 386 patients retrospectively analyzed, 119 (33%) received probabilistic prehospital ABT, among which 74% received a 3rd generation cephalosporin: 31% cefotaxime and 42% ceftriaxone. No patient had a serious adverse effect related to ABT administration. Overall mortality rate on day-30 was 29%. Among the 119 patients with prehospital ABT, bacteriological identification was obtained for 81 (68%) patients with adequate prehospital ABT for 65 patients (80%) of which 10 (15%) deceased on day-30. Conversely, among the 16 (20%) patients with inadequate prehospital ABT, 9 patients (56%) were deceased on day-30. Prehospital adequate ABT was significantly different between alive and deceased patients on day-30 (p = 4.10-3). After propensity score matching, a significant association between adequate prehospital ABT administration and day-30 mortality was observed (aOR = 0.09 [0.01-0.47]). Inverse probability treatment weighting with multivariable logistic regression reported a day-30 mortality decrease in the adequate prehospital ABT group: aOR = 0.70 [0.53-0.93]. CONCLUSIONS Among SS cared for by a mICU, probabilistic prehospital ABT is adequate most of the time and associated with a day-30 mortality decrease. Further prospective studies are needed to confirm these results and the weight of prehospital ABT in the prehospital bundle of care for SS.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, University Hospital Ambroise Paré, Boulogne Billancourt, France; Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France; Centre de recherche en Epidémiologie et Santé des Populations, U1018 INSERM, Université Paris Saclay, France; Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP, Université de Paris, France; EA 7525 Université des Antilles, France.
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; Paris Fire Brigade, Paris, France
| | - Anna Hassan
- Intensive Care Unit, University Hospital Ambroise Paré, Boulogne Billancourt, France
| | - Jean-Pierre Tourtier
- Emergency Department, Cochin Hospital, Paris, France; Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Emmanuel Bloch-Laine
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013 Paris, France
| | | | - Josiane Boularan
- SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; Paris Fire Brigade, Paris, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Papa Gueye
- EA 7525 Université des Antilles, France; SAMU 972 University Hospital of Martinique, Fort-de-France, Martinique, France
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Zhai GH, Zhang W, Xiang Z, He LZ, Wang WW, Wu J, Shang AQ. Diagnostic Value of sIL-2R, TNF-α and PCT for Sepsis Infection in Patients With Closed Abdominal Injury Complicated With Severe Multiple Abdominal Injuries. Front Immunol 2021; 12:741268. [PMID: 34745113 PMCID: PMC8569904 DOI: 10.3389/fimmu.2021.741268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022] Open
Abstract
Objective We aimed to evaluate the diagnostic value of soluble interleukin-2 receptor (sIL-2R), tumor necrosis factor-α (TNF-α), procalcitonin (PCT), and combined detection for sepsis infection in patients with closed abdominal injury complicated with severe multiple abdominal injuries. Patients and Methods One hundred forty patients with closed abdominal injury complicated with severe multiple abdominal injuries who were diagnosed and treated from 2015 to 2020 were divided into a sepsis group (n = 70) and an infection group (n = 70). Results The levels of sIL-2R, TNF-α, and PCT in the sepsis group were higher than those in the infection group (p < 0.05). The receiver operating characteristic (ROC) curve showed that the areas under the ROC curve (AUCs) of sIL-2R, TNF-α, PCT and sIL-2R+TNF-a+PCT were 0.827, 0.781, 0.821, and 0.846, respectively, which were higher than those of white blood cells (WBC, 0.712), C-reactive protein (CRP, 0.766), serum amyloid A (SAA, 0.666), and IL-6 (0.735). The AUC of the three combined tests was higher than that of TNF-α, and the difference was statistically significant (p < 0.05). There was no significant difference in the AUCs of sIL-2R and TNF-α, sIL-2R and PCT, TNF-α and PCT, the three combined tests and sIL-2R, and the three combined tests and PCT (p > 0.05). When the median was used as the cut point, the corrected sIL-2R, TNF-α, and PCT of the high-level group were not better than those of the low-level group (p > 0.05). When the four groups were classified by using quantile as the cut point, the OR risk values of high levels of TNF-α and PCT (Q4) and the low level of PCT (Q1) after correction were 7.991 and 21.76, respectively, with statistical significance (p < 0.05). Conclusions The detection of sIL-2R, TNF-α, and PCT has good value in the diagnosis of sepsis infection in patients with closed abdominal injury complicated with severe multiple abdominal injuries. The high concentrations of PCT and TNF-α can be used as predictors of the risk of septic infection.
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Affiliation(s)
- Guang-Hua Zhai
- Department of Clinical Laboratory, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, China
| | - Wei Zhang
- Department of Laboratory Medicine, Jiaozuo Fifth People's Hospital, Jiaozuo, China
| | - Ze Xiang
- Zhejiang University School of Medicine, Hangzhou, China
| | - Li-Zhen He
- Department of Laboratory, Jiaozuo Second People's Hospital, Jiaozuo, China.,Department of Laboratory Medicine, The First Affiliated Hospital of Henan Polytechnic University, Henan, China
| | - Wei-Wei Wang
- Department of Pathology, Tinghu People's Hospital of Yancheng City, Yancheng, China
| | - Jian Wu
- Department of Clinical Laboratory, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, China
| | - An-Quan Shang
- Department of Laboratory Medicine, Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
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Schinkel M, Paranjape K, Kundert J, Nannan Panday RS, Alam N, Nanayakkara PWB. Towards Understanding the Effective Use of Antibiotics for Sepsis. Chest 2021; 160:1211-1221. [PMID: 33905680 PMCID: PMC8546240 DOI: 10.1016/j.chest.2021.04.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 03/09/2021] [Accepted: 04/18/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The benefits of early antibiotics for sepsis have recently been questioned. Evidence for this mainly comes from observational studies. The only randomized trial on this subject, the Prehospital Antibiotics Against Sepsis (PHANTASi) trial, did not find significant mortality benefits from early antibiotics. That subgroups of patients benefit from this practice is still plausible, given the heterogeneous nature of sepsis. RESEARCH QUESTION Do subgroups of sepsis patients experience 28-day mortality benefits from early administration of antibiotics in a prehospital setting? And what key traits drive these benefits? STUDY DESIGN AND METHODS We used machine learning to conduct exploratory partitioning cluster analysis to identify possible subgroups of sepsis patients who may benefit from early antibiotics. We further tested the influence of several traits within these subgroups, using a logistic regression model. RESULTS We found a significant interaction between age and benefits of early antibiotics (P = .03). When we adjusted for this interaction and several other confounders, there was a significant benefit of early antibiotic treatment (OR, 0.07; 95% CI, 0.01-0.79; P = .03). INTERPRETATION An interaction between age and benefits of early antibiotics for sepsis has not been reported before. When validated, it can have major implications for clinical practice. This new insight into benefits of early antibiotic treatment for younger sepsis patients may enable more effective care.
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Affiliation(s)
- Michiel Schinkel
- Section of General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands; Center of Experimental and Molecular Medicine (C.E.M.M.), Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Ketan Paranjape
- Section of General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands; Roche Diagnostics Corporation, Indianapolis, IN
| | | | - Rishi S Nannan Panday
- Section of General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands; Center for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Nadia Alam
- Section of General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Section of General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands.
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30
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Han X, Spicer A, Carey KA, Gilbert ER, Laiteerapong N, Shah NS, Winslow C, Afshar M, Kashiouris MG, Churpek MM. Identifying High-Risk Subphenotypes and Associated Harms From Delayed Antibiotic Orders and Delivery. Crit Care Med 2021; 49:1694-1705. [PMID: 33938715 PMCID: PMC8448901 DOI: 10.1097/ccm.0000000000005054] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Early antibiotic administration is a central component of sepsis guidelines, and delays may increase mortality. However, prior studies have examined the delay to first antibiotic administration as a single time period even though it contains two distinct processes: antibiotic ordering and antibiotic delivery, which can each be targeted for improvement through different interventions. The objective of this study was to characterize and compare patients who experienced order or delivery delays, investigate the association of each delay type with mortality, and identify novel patient subphenotypes with elevated risk of harm from delays. DESIGN Retrospective analysis of multicenter inpatient data. SETTING Two tertiary care medical centers (2008-2018, 2006-2017) and four community-based hospitals (2008-2017). PATIENTS All patients admitted through the emergency department who met clinical criteria for infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient demographics, vitals, laboratory values, medication order and administration times, and in-hospital survival data were obtained from the electronic health record. Order and delivery delays were calculated for each admission. Adjusted logistic regression models were used to examine the relationship between each delay and in-hospital mortality. Causal forests, a machine learning method, was used to identify a high-risk subgroup. A total of 60,817 admissions were included, and delays occurred in 58% of patients. Each additional hour of order delay (odds ratio, 1.04; 95% CI, 1.03-1.05) and delivery delay (odds ratio, 1.05; 95% CI, 1.02-1.08) was associated with increased mortality. A patient subgroup identified by causal forests with higher comorbidity burden, greater organ dysfunction, and abnormal initial lactate measurements had a higher risk of death associated with delays (odds ratio, 1.07; 95% CI, 1.06-1.09 vs odds ratio, 1.02; 95% CI, 1.01-1.03). CONCLUSIONS Delays in antibiotic ordering and drug delivery are both associated with a similar increase in mortality. A distinct subgroup of high-risk patients exist who could be targeted for more timely therapy.
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Affiliation(s)
- Xuan Han
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Alexandra Spicer
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Kyle A Carey
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Emily R Gilbert
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Neda Laiteerapong
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Nirav S Shah
- Department of Medicine, The University of Chicago, Chicago, Illinois
- Department of Medicine, NorthShore University Healthcare, Evanston, Illinois
| | - Christopher Winslow
- Department of Medicine, NorthShore University Healthcare, Evanston, Illinois
| | - Majid Afshar
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Markos G Kashiouris
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
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31
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Affiliation(s)
- Sean R Townsend
- Division of Pulmonary, Critical Care Medicine, California Pacific Medical Center, San Francisco, CA
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA
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32
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Wallgren UM, Sjölin J, Järnbert-Pettersson H, Kurland L. Performance of NEWS2, RETTS, clinical judgment and the Predict Sepsis screening tools with respect to identification of sepsis among ambulance patients with suspected infection: a prospective cohort study. Scand J Trauma Resusc Emerg Med 2021; 29:144. [PMID: 34593001 PMCID: PMC8485465 DOI: 10.1186/s13049-021-00958-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/19/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND There is little evidence of which sepsis screening tool to use in the ambulance setting. The primary aim of the current study was to compare the performance of NEWS2 (National Early Warning score 2) and RETTS (Rapid Emergency Triage and Treatment System) with respect to identification of sepsis among ambulance patients with clinically suspected infection. The secondary aim was to compare the performance of the novel Predict Sepsis screening tools with that of NEWS2, RETTS and clinical judgment. METHODS Prospective cohort study of 323 adult ambulance patients with clinically suspected infection, transported to hospitals in Stockholm, during 2017/2018. The sensitivity, specificity, and AUC (Area Under the receiver operating Curve) were calculated and compared by using McNemar´s test and DeLong's test. RESULTS The prevalence of sepsis in the current study population was 44.6% (144 of 323 patients). No significant difference in AUC was demonstrated between NEWS2 ≥ 5 and RETTS ≥ orange. NEWS2 ≥ 7 demonstrated a significantly greater AUC than RETTS red. The Predict Sepsis screening tools ≥ 2 demonstrated the highest sensitivity (range 0.87-0.91), along with RETTS ≥ orange (0.83), but the lowest specificity (range 0.39-0.49). The AUC of NEWS2 (0.73) and the Predict Sepsis screening tools (range 0.75-0.77) was similar. CONCLUSIONS The results indicate that NEWS2 could be the better alternative for sepsis identification in the ambulance, as compared to RETTS. The Predict Sepsis screening tools demonstrated a high sensitivity and AUCs similar to that of NEWS2. However, these results need to be interpreted with caution as the Predict Sepsis screening tools require external validation. TRIAL REGISTRATION ClinicalTrials.gov, NCT03249597. Registered 15 August 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03249597 .
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Affiliation(s)
- Ulrika M Wallgren
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, 118 83, Stockholm, Sweden.,Fisksätra Vårdcentral (Primary Health Care Center), Fisksätra torg 20, 133 41, Saltsjöbaden, Sweden.,Department of Medical Sciences, Örebro University, Campus USÖ, Södra Grev Rosengatan 32, 701 12, Örebro, Sweden
| | - Jan Sjölin
- Department of Medical Sciences, Akademiska Sjukhuset, Uppsala University, 751 85, Uppsala, Sweden
| | - Hans Järnbert-Pettersson
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, 118 83, Stockholm, Sweden
| | - Lisa Kurland
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, 118 83, Stockholm, Sweden. .,Department of Medical Sciences, Örebro University, Campus USÖ, Södra Grev Rosengatan 32, 701 12, Örebro, Sweden.
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33
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Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. Evidence for the Application of Sepsis Bundles in 2021. Semin Respir Crit Care Med 2021; 42:706-716. [PMID: 34544188 DOI: 10.1055/s-0041-1733899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
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34
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Siewers K, Abdullah SMOB, Sørensen RH, Nielsen FE. Time to administration of antibiotics and mortality in sepsis. J Am Coll Emerg Physicians Open 2021; 2:e12435. [PMID: 34027515 PMCID: PMC8119622 DOI: 10.1002/emp2.12435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To examine the association between delay of antibiotic treatment and 28-day mortality in a study of septic patients identified by the Sepsis-3 criteria. METHODS A prospective observational cohort study of patients (≥ 18 years) with sepsis admitted to a Danish emergency department between October 2017 and March 2018. The interval between arrival to the ED and first delivery of antibiotics was used as time to antibiotic treatment (TTA). Logistic regression was used in the analysis of the association between TTA and mortality adjusted for potential confounding. RESULTS A total of 590 patients, median age 74.2 years, were included. Overall 28-day mortality was 14.6% (95% confidence interval [CI], 11.8-17.7). Median TTA was 4.7 hours (interquartile range 2.7-8.1). The mortality in patients with TTA ≤1 hour was 26.5% (95% CI, 12.8-44.4), and 15.3% (95% CI, 9.8-22.5), 10.5% (95% CI, 6.6-15.8), and 12.8 (95% CI, 7.3-20.1) in the timespans 1-3, 3-6, and 6-9 hours, respectively, and 18.8% (95% CI, 12.0-27.2) in patients with TTA >9 hours. With patients with lowest mortality (TTA timespan 3-6 hours) as reference, the adjusted odds ratio of mortality was 4.53 (95% CI, 1.67-3.37) in patients with TTA ≤1 hour, 1.67 (95% CI, 0.83-3.37) in TTA timespan 1-3 hours, 1.17 (95% CI, 0.56-2.49) in timespan 6-9 hours, and 1.91 (95% CI, 0.96-3.85) in patient with TTA >9 hours. CONCLUSIONS The adjusted odds of 28-day mortality were lowest in emergency department (ED) patients with sepsis who received antibiotics between 1 and 9 hours and highest in patients treated within 1 and >9 hours after admission to the ED.
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Affiliation(s)
- Karina Siewers
- Respiratory Research Unit, Department of Respiratory MedicineCopenhagen University HospitalBispebjerg and FrederiksbergCopenhagenDenmark
- Department of Emergency MedicineCopenhagen University Hospital‐Bispebjerg and FrederiksbergCopenhagenDenmark
| | | | | | - Finn Erland Nielsen
- Department of Emergency MedicineCopenhagen University Hospital‐Bispebjerg and FrederiksbergCopenhagenDenmark
- Copenhagen Center for Translational ResearchCopenhagen University Hospital, Bispebjerg and FrederiksbergCopenhagenDenmark
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Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Bounes V, Boularan J, Léguillier T, Gueye-Ngalgou P, Vivien B. Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality. PREHOSP EMERG CARE 2021; 25:317-324. [PMID: 32352890 DOI: 10.1080/10903127.2020.1763532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. Methods: From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Results: Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). Conclusion: In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.
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Ling L, Joynt GM, Lipman J. A narrative review on antimicrobial therapy in septic shock: updates and controversies. Curr Opin Anaesthesiol 2021; 34:92-98. [PMID: 33470662 DOI: 10.1097/aco.0000000000000954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Antibiotics are an essential treatment for septic shock. This review provides an overview of the key issues in antimicrobial therapy for septic shock. We include a summary of available evidence with an emphasis on data published in the last few years. RECENT FINDINGS We examine apparently contradictory data supporting the importance of minimizing time to antimicrobial therapy in sepsis, discuss approaches to choosing appropriate antibiotics, and review the importance and challenges presented by antimicrobial dosing. Lastly, we evaluate the evolving concepts of de-escalation, and optimization of the duration of antimicrobials. SUMMARY The topics discussed in this review provide background to key clinical decisions in antimicrobial therapy for septic shock: timing, antibiotic choice, dosage, de-escalation, and duration. Although acknowledging some controversy, antimicrobial therapy in septic shock should be delivered early, be of the adequate spectrum, appropriately and individually dosed, rationalized when possible, and of minimal effective duration.
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Affiliation(s)
- Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Jeffrey Lipman
- Intensive Care Services, Royal Brisbane and Women's Hospital
- The University of Queensland Centre for Clinical Research, Brisbane, Australia
- Scientific Consultant, Nimes University Hospital, University of Montpellier, Nimes, France
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Asner SA, Desgranges F, Schrijver IT, Calandra T. Impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis and septic shock. J Infect 2021; 82:125-134. [PMID: 33722641 DOI: 10.1016/j.jinf.2021.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To review the impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis or septic shock. METHODS We searched MEDLINE, EMBASE, the Cochrane Library, Web of Science, Open-SIGLE databases, ClinicalTrials.gov and the metaRegister of Controlled Trials on July 27, 2020 for relevant studies on the timing of antibiotic therapy in adult patients with sepsis or septic shock. The primary outcome measure was all-cause crude or adjusted mortality at reported time points. RESULTS We included 35 sepsis studies involving 154,330 patients. Nineteen studies (54%) provided information on the appropriateness of antibiotic therapy in 20,062 patients of whom 16,652 patients (83%) received appropriate antibiotics. Twenty-four studies (68.6%) reported an association between time-to-antibiotics and mortality. Time thresholds associated with patient's outcome varied considerably between studies consisting of a wide range of time cutoffs (1 h, 125 min, 3 h or 6 h) in 14 studies, hourly delays (derived from the analyses of time intervals ranging from to 1 to 24 h) in 8 studies or time-to-antibiotic in 2 studies. Analyses of subsets of studies that focused on patients with septic shock (11 studies, 12,756 patients) or with sepsis (6 studies, 24,281 patients) yielded similar results. CONCLUSIONS While two-thirds of sepsis studies reported an association between early administration of antibiotic therapy and patient outcome, the time-to-antibitiocs metrics varied significantly across studies and no robust time thresholds emerged.
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Affiliation(s)
- Sandra A Asner
- Pediatric Infectious Diseases and Vaccinology Unit, Department Mother-Woman-Child, Lausanne University Hospital, University of Lausanne, Switzerland; Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Florian Desgranges
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Irene T Schrijver
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland.
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Prehospital hemodynamic optimisation is associated with a 30-day mortality decrease in patients with septic shock. Am J Emerg Med 2021; 45:105-111. [PMID: 33684866 DOI: 10.1016/j.ajem.2021.02.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Septic shock (SS) is characterized by low blood pressure resulting in organ failure and poor prognosis. Among SS treatments, in hospital studies reported a beneficial effect of early hemodynamic resuscitation on mortality rate. This study aims to investigate the relationship between prehospital hemodynamic optimisation and 30-day mortality in patients with SS. METHODS From April 6th, 2016 to December 31th, 2019, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (mICU) were included. Prehospital hemodynamic optimisation was defined as a arterial blood pressure of >65 mmHg, or >75 mmHg if previous hypertension history, at the end of the prehospital stage. RESULTS Three hundred thirty-seven patients were retrospectively analysed. The mean age was 69 ± 15 years, and 226 patients (67%) were male. One hundred and thirty-six patients (40%) had previous hypertension history. Pulmonary, digestive and urinary infections were the suspected cause of the SS in respectively 46%, 23% and 15% of the cases. 30-day overall mortality was 30%. Prehospital hemodynamic optimisation was complete for 204 patients (61%). Cox regression analysis reports a significant association between prehospital hemodynamic optimisation and 30-day mortality (HRa = 0.52 95%CI [0.31-0.86], p = 0.01). CONCLUSION In this study, we report that prehospital hemodynamic optimisation is associated with a decrease in 30-day mortality in patients with SS cared for by a mICU in the prehospital setting. An individualized mean arterial pressure target, based on previous hypertension history, may be considered from the prehospital stage of SS resuscitation.
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Sepsis alerts called in the field vs the ED: impact of severity and in-hospital confounders. Am J Emerg Med 2020; 38:1940. [DOI: 10.1016/j.ajem.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 11/24/2022] Open
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40
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Gu X, Zhou F, Wang Y, Fan G, Cao B. Respiratory viral sepsis: epidemiology, pathophysiology, diagnosis and treatment. Eur Respir Rev 2020; 29:29/157/200038. [PMID: 32699026 DOI: 10.1183/16000617.0038-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022] Open
Abstract
According to the Third International Consensus Definition for Sepsis and Septic Shock, sepsis is a life-threatening organ dysfunction resulting from dysregulated host responses to infection. Epidemiological data about sepsis from the 2017 Global Burden of Diseases, Injuries and Risk Factor Study showed that the global burden of sepsis was greater than previously estimated. Bacteria have been shown to be the predominant pathogen of sepsis among patients with pathogens detected, while sepsis caused by viruses is underdiagnosed worldwide. The coronavirus disease that emerged in 2019 in China and now in many other countries has brought viral sepsis back into the vision of physicians and researchers worldwide. Although the current understanding of the pathophysiology of sepsis has improved, the differences between viral and bacterial sepsis at the level of pathophysiology are not well understood. Diagnosis methods that can broadly differentiate between bacterial and viral sepsis at the initial stage after the development of sepsis are limited. New treatments that can be applied at clinics for sepsis are scarce and this situation is not consistent with the growing understanding of pathophysiology. This review aims to give a brief summary of current knowledge of the epidemiology, pathophysiology, diagnosis and treatment of viral sepsis.
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Affiliation(s)
- Xiaoying Gu
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China.,Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Fei Zhou
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Yeming Wang
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Guohui Fan
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China.,Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Bin Cao
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China .,Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China.,Dept of Respiratory Medicine, Capital Medical University, Beijing, China.,Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
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Plata-Menchaca EP, Ferrer R, Ruiz Rodríguez JC, Morais R, Póvoa P. Antibiotic treatment in patients with sepsis: a narrative review. Hosp Pract (1995) 2020; 50:203-213. [PMID: 32627615 DOI: 10.1080/21548331.2020.1791541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Juan Carlos Ruiz Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal
| | - Pedro Póvoa
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
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Font MD, Thyagarajan B, Khanna AK. Sepsis and Septic Shock - Basics of diagnosis, pathophysiology and clinical decision making. Med Clin North Am 2020; 104:573-585. [PMID: 32505253 DOI: 10.1016/j.mcna.2020.02.011] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis and septic shock are major causes of mortality among hospitalized patients. The sepsis state is due to dysregulated host response to infection, leading to inflammatory damage to nearly every organ system. Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality. This review summarizes the current understanding of the epidemiology, pathophysiology, diagnosis, and treatment of sepsis and septic shock.
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Affiliation(s)
- Michael D Font
- Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, 1, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Braghadheeswar Thyagarajan
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, 1, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, 1, Medical Center Boulevard, Winston-Salem, NC 27157, USA; Outcomes Research Consortium, Cleveland, OH 44195, USA.
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43
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44
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Ascuntar J, Mendoza D, Jaimes F. Antimicrobials administration time in patients with suspected sepsis: is faster better? An analysis by propensity score. J Intensive Care 2020; 8:28. [PMID: 32337048 PMCID: PMC7178597 DOI: 10.1186/s40560-020-00448-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/15/2020] [Indexed: 12/29/2022] Open
Abstract
Background Early use of antimicrobials is a critical intervention in the treatment of patients with sepsis. The exact time of initiation is controversial and its early administration may be a difficult task in crowded emergency departments (ED). The aim of this study was to estimate, using a matched propensity score, the effect on hospital mortality of administration of antimicrobials within 1 or 3 hours, in patients admitted to the ED with sepsis. Methods This was a secondary analysis of a multicenter prospective cohort. Patients included in the study were older than 18 years, hospitalized between 2014 and 2016 with suspected sepsis, and admitted to ED of three tertiary care university hospitals in Medellín, Colombia. A propensity score analysis for administration of antimicrobials, both within 1 and 3 h of admission by the ED, was fitted with 28 variables related with clinical attention and physiological changes. As a sensitivity analysis, a logistic regression model was fitted for antimicrobial use adjusted both by propensity score and confounding variables. Results The study cohort was composed of 2454 patients with a median age of 62 years (IQR = 46-74). Among them, 32% (n = 781) received antibiotics within 3 h and 14% (n = 340) within the first hour. The main diagnoses were urinary tract infection (28%, n = 682) and pneumonia (27%, n = 671). Blood cultures were obtained in 87% (n = 2140) and yielded positive in 29% (n = 629), mainly with Escherichia coli (37%, n = 230), Staphylococcus aureus (21%, n = 132), and Klebsiella pneumoniae (10.2%, n = 64). The hospital mortality rate was 11.5% (n = 283). There were no significant differences in mortality, after adjustment, using antimicrobials either in the first hour (OR 1.03; 95% CI = 0.63; 1.70) or 3 h (OR 0.85; 95% CI = 0.61; 1.20). There were no changes with different models for sensitivity analysis. Conclusions Despite the obvious constraints given for sample size and residual confounding, our results suggest that we need a more comprehensive approach to sepsis and its treatment, considering early detection, multiple interventions, and goals beyond the simple time-to-antimicrobials.
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Affiliation(s)
- Johana Ascuntar
- 1GRAEPIC-Clinical Epidemiology Academic Group (Grupo Académico de Epidemiología Clínica), the University of Antioquia, Medellín, Colombia
| | | | - Fabián Jaimes
- 1GRAEPIC-Clinical Epidemiology Academic Group (Grupo Académico de Epidemiología Clínica), the University of Antioquia, Medellín, Colombia.,3Department of Internal Medicine, University of Antioquia, Medellín, Colombia.,Hospital San Vicente Fundación, Medellín, Colombia
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Abstract
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of β‑lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).
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Ko BS, Choi SH, Kang GH, Shin TG, Kim K, Jo YH, Ryoo SM, Kim YJ, Park YS, Kwon WY, Han KS, Choi HS, Chung SP, Suh GJ, Kang H, Lim TH, Kim WY. Time to Antibiotics and the Outcome of Patients with Septic Shock: A Propensity Score Analysis. Am J Med 2020; 133:485-491.e4. [PMID: 31622578 DOI: 10.1016/j.amjmed.2019.09.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/18/2019] [Accepted: 09/22/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Current sepsis guidelines recommend administration of antibiotics within 1 hour of emergency department (ED) triage. However, the quality of the supporting evidence is moderate, and studies have shown mixed results regarding the association between antibiotic administration timing and outcomes in septic shock. We investigated to evaluate the association between antibiotic administration timing and in-hospital mortality in septic shock patients in the ED, using propensity score analysis. METHODS An observational study using a prospective, multicenter registry of septic shock, comprising data collected from 10 EDs, was conducted. Septic shock patients were included, and patients were divided into 4 groups by the interval from triage to first antibiotic administration: group 1 (≤1 hour; reference), 2 (1-2 hours), 3 (2-3 hours), and 4 (>3 hours). The primary endpoint was in-hospital mortality. After inverse probability of treatment weighting, the outcomes of the groups were compared. RESULTS A total of 2250 septic shock patients were included, and the median time to first antibiotic administration was 2.29 hours. The in-hospital mortality of groups 2 and 4 were significantly higher than those of group 1 (odds ratio [OR] 1.248; 95% confidence interval [CI], 1.053-1.478; P = .011; OR 1.419; 95% CI, 1.203-1.675; P < .001, respectively), but those of group 3 was not (OR 1.186; 95% CI, 0.999-1.408; P = .052). Subgroup analyses of patients (n = 2043) with appropriate antibiotics presented similar results. CONCLUSIONS In patients with septic shock, rapid administration of antibiotics was generally associated with a decrease in in-hospital mortality, but no "every hour delay" was seen.
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Affiliation(s)
- Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Gu Hyun Kang
- Department of Emergency Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, College of Medicine, Seoul National University, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Kap Su Han
- Department of Emergency Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Han Sung Choi
- Department of Emergency Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Ulsan University, College of Medicine, Asan Medical Center, Seoul, Korea.
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47
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Martínez ML, Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. An approach to antibiotic treatment in patients with sepsis. J Thorac Dis 2020; 12:1007-1021. [PMID: 32274170 PMCID: PMC7139065 DOI: 10.21037/jtd.2020.01.47] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, which is time-dependent and associated with unacceptably high mortality. Thus, when treating suspicious or confirmed cases of sepsis, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Optimizing antibiotic use is essential to ensure successful outcomes and to reduce adverse antibiotic effects, as well as preventing drug resistance. All likely pathogens involved should be considered to provide an appropriate antibiotic coverage. Clinicians must investigate on the previous risk of multidrug-resistant (MDR) pathogens, and the principle of individualized dosing should replace the principle of standard dosing. The loading dose is an initial higher dose of an antibiotic for all patients, yet an individualized treatment approach for further doses should be implemented according to pharmacokinetics (PK)/pharmacodynamics (PD) and the presence of renal/liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring (TDM) can help to achieve therapeutic levels of antimicrobials. Reevaluation of duration and appropriateness of treatment at regular intervals are also necessary. De-escalation and shortened courses of antimicrobials must be considered for most patients, except in some justified circumstances. Leadership, teamwork, antimicrobial stewardship (AS) frameworks, guideline’s recommendations on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients’ quality of care.
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Affiliation(s)
- María Luisa Martínez
- Department of Intensive Care, Hospital Universitario General de Catalunya, Barcelona, Spain
| | - Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias, Barcelona, Spain
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Schinkel M, Nannan Panday RS, Wiersinga WJ, Nanayakkara PWB. Timeliness of antibiotics for patients with sepsis and septic shock. J Thorac Dis 2020; 12:S66-S71. [PMID: 32148927 DOI: 10.21037/jtd.2019.10.35] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
For many years, sepsis guidelines have focused on early administration of antibiotics. While this practice may benefit some patients, for others it might have detrimental consequences. The increasingly shortened timeframes in which administration of antibiotics is recommended, have forced physicians to sacrifice diagnostic accuracy for speed, encouraging the overuse of antibiotics. The evidence supporting this practice is based on retrospective data, with all the limitations attached, while the only randomized trial on this subject does not show a mortality benefit from early administration of antibiotics in a population of patients with sepsis as often seen in the emergency department (ED). Physicians are challenged to treat patients suspected of having sepsis within a short period of time, while the real challenge should be to identify patients who would not be harmed by withholding treatment with antibiotics until the diagnosis of infection with a bacterial origin is confirmed and the appropriateness of a course of antibiotics can be evaluated more adequately. Therefore, in the general population of patients with sepsis, taking the time to gather additional data to confirm the diagnosis should be encouraged without a specific timeframe, although physicians should be encouraged to perform an adequate work-up as soon as possible. Patients with suspected sepsis and signs of shock should immediately be treated with antibiotics, as there is no margin for error.
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Affiliation(s)
- Michiel Schinkel
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands.,Section Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Rishi S Nannan Panday
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Section Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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49
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Alsadoon A, Alhamwah M, Alomar B, Alsubaiel S, Almutairi AF, Vishwakarma RK, Alharthy N, Kazzaz YM. Association of Antibiotics Administration Timing With Mortality in Children With Sepsis in a Tertiary Care Hospital of a Developing Country. Front Pediatr 2020; 8:566. [PMID: 33014945 PMCID: PMC7509148 DOI: 10.3389/fped.2020.00566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/04/2020] [Indexed: 12/23/2022] Open
Abstract
Objective: To investigate the association between antibiotics administration timing with morbidity and mortality in children with severe sepsis and septic shock, presenting to a tertiary care center in a developing country. Methods: This is a retrospective study of children aged 14 years or younger diagnosed with severe sepsis or septic shock at a free-standing tertiary children's hospital in Saudi Arabia between April 2015 and February 2018. We investigated the association between antibiotic administration timing and pediatric intensive care unit (PICU) mortality, PICU length of stay (LOS), hospital LOS, and ventilation-free days after adjusting for confounders. Results: Among the 189 admissions, 77 patients were admitted with septic shock and 112 with severe sepsis. Overall, the mortality rate was 16.9%. The overall median time from sepsis recognition to antibiotic administration was 105 min (IQR: 65-185.5 min); for septic shock patients, it was 85 min (IQR: 55-148 min), and for severe sepsis, 130 min (IQR: 75.5-199 min). Delayed antibiotic administration (> 3 h) was associated with 3.85 times higher PICU mortality (95% confidence intervals 1.032-14.374) in children with septic shock than in children who receive antibiotics within 3 h, after controlling for severity of illness, age, comorbidities, and volume resuscitation. However, delayed antibiotics administration was not significantly associated with higher PICU mortality in children diagnosed with severe sepsis. Conclusions: Delayed antibiotics administration in children with septic shock admitted to a free-standing children's hospital in a developing country was associated with PICU mortality.
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Affiliation(s)
- Alaa Alsadoon
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia
| | - Moudi Alhamwah
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia
| | - Bassam Alomar
- Pediatrics Emergency Department, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia
| | - Sara Alsubaiel
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia
| | - Adel F Almutairi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Science and Technology Unit, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ramesh K Vishwakarma
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Nesrin Alharthy
- Pediatrics Emergency Department, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia.,College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yasser M Kazzaz
- Department of Pediatrics, Ministry of National Guards-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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50
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Seok H, Jeon JH, Park DW. Antimicrobial Therapy and Antimicrobial Stewardship in Sepsis. Infect Chemother 2020; 52:19-30. [PMID: 32239809 PMCID: PMC7113444 DOI: 10.3947/ic.2020.52.1.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Indexed: 12/27/2022] Open
Abstract
Since sepsis was first defined, sepsis management has remained challenging. To improve mortality rates for sepsis and septic shock, an accurate diagnosis and prompt administration of appropriate antibiotics are essential. The goals of antimicrobial stewardship are to achieve optimal clinical outcomes and to ensure cost-effectiveness and minimal unintended consequences, such as toxic effects and development of resistant pathogens. A combination of inadequate diagnostic criteria for sepsis and time pressure to provide broad-spectrum antimicrobial therapy remains an obstacle for antimicrobial stewardship. Efforts such as selection of appropriate empirical antibiotics and de-escalation or determination of whether or not to stop antibiotics may help to improve a patient's clinical prognosis as well as the successful implementation of antimicrobial stewardship.
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Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hoon Jeon
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea.
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