Septic Shock Short-Term Outcomes in Patients With Psychiatric Disorders: Analysis From the National Inpatient Sample Database

BACKGROUND

Major psychiatric disorders are associated with lower life expectancy primarily due to comorbid illnesses and suboptimal access to health care. Large-scale contemporary data in the United States on in-hospital mortality of patients with major psychiatric disorder and sepsis are lacking.

OBJECTIVE

To describe the short-term outcomes of hospitalized patients with major psychiatric disorders and septic shock.

METHODS

We performed a retrospective cohort study using the National Inpatient Sample database from 2016 to 2019 to identify septic shock hospitalizations in patients with versus without major psychiatric disorder (defined as schizophrenia and affective disorders). Baseline variables and in-hospital mortality trends were compared between the 2 groups.

RESULTS

Out of 1,653,255 hospitalizations with septic shock identified between 2016 and 2019, 16.2% had a diagnosis of major psychiatric disorder as defined above. After adjusting for various patient-level and hospital-level demographics and coexisting clinical conditions in a multivariable logistic regression, the odds of in-hospital mortality in patients with any major psychiatric disorder were 0.71 times that of those without a diagnosis of psychiatric illness (95% confidence interval [CI], 0.69-0.73; P < 0.001). Similarly, when the disorders were divided into 2 categories for subanalysis, those with schizophrenia had 38% lower odds of dying compared to those without schizophrenia (adjusted odds ratio, 0.62; 95% CI, 0.58-0.66; P < 0.001). Those with affective disorders had 25% lower odds of in-hospital mortality than those without a diagnosis of an affective disorder (adjusted odds ratio, 0.75; 95% CI, 0.73-0.77; P < 0.001). The adjusted mean length of stay for those diagnosed with major psychiatric disorder was 0.38 days longer than those without significant psychiatric illness (95% CI, 0.28-0.49; P < 0.001). On the other hand, the mean hospitalization charges were $10,516 less for patients with a major psychiatric disorder compared to those without (95% CI, -$11,830 to -$9,201; P < 0.001).

CONCLUSIONS

Hospitalized patients with major psychiatric disorder and septic shock had lower risk of short-term mortality. Further studies are needed to examine the reasons behind this lower in-hospital mortality risk.

Beneficial Immune Regulation by Biological Response Modifier Glucans in COVID-19 and Their Envisaged Potentials in the Management of Sepsis

Sepsis is a life-threatening condition caused by an abnormal immune response induced by infection with no approved or specific therapeutic options. We present our perspectives for the therapeutic management of sepsis through a four-way approach: (1) infection control through immune enhancement; (2) immune suppression during the initial hyper-inflammatory phase; (3) balanced immune-modulation to counter the later immune-paralysis phase; and (4) advantageous effects on metabolic and coagulation parameters throughout. COVID-19 is a virus-triggered, accelerated sepsis-like reaction that is associated with the rapid progress of an inflammatory cascade involving a cytokine storm and multiorgan failure. Here, we discuss the potential of the biological response modifiers, β-glucans (BRMGs), in the management of sepsis based on their beneficial effects on inflammatory-immune events in COVID-19 clinical studies. In COVID-19 patients, apart from metabolic regulation, BRMGs, derived from a black yeast, Aureobasidium pullulans strain AFO-202, have been reported to stimulate immune responses. BRMGs, produced by another strain (N-163) of A. pullulans, have been implicated in the beneficial regulation of inflammatory markers and immunity, namely IL-6, C-reactive protein (CRP), D-Dimer, ferritin, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-C-reactive protein ratio (LCR), leucocyte-to-C-reactive protein ratio (LeCR), and leukocyte-to-IL-6 ratio (LeIR). Agents such as these β-glucans, which are safe as they have been widely consumed by humans for decades, have potential as adjuncts for the prevention and management of sepsis as they exert their beneficial effects across the spectrum of processes and factors involved in sepsis pathology, including, but not limited to, metabolism, infection, inflammation, immune modulation, immune enhancement, and gut microbiota.

Impact of history of mental disorders on short-term mortality among hospitalized patients with sepsis: A population-based cohort study

Background

Mental disorders are associated with markedly reduced life expectancy, in part due to an increased risk of death due to infection, likely reflecting sepsis-associated mortality. Patients with mental disorders are at an increased risk of sepsis, but data on the prognostic impact of mental disorders in sepsis are sparse, showing conflicting findings.

Methods

We used statewide data to identify hospitalizations aged ≥18 years with sepsis in Texas during 2014–2017. Mental disorders, including mood, anxiety, psychosis, and personality disorders were identified using Clinical Classification Software codes. Multilevel, multivariable logistic regression with propensity adjustment (primary model), with propensity score matching, and multivariable logistic regression as alternative models, were used to estimate the association between mental disorders and short-term mortality (defined as in-hospital mortality or discharge to hospice). Additional models were fitted for sensitivity analyses and to estimate the prognostic associations of individual categories of mental disorders.

Results

Among 283,025 hospitalizations with sepsis, 56,904 (20.1%) had mental disorders. Hospitalizations with vs without mental disorders were younger (age 18–44 years 12.2% vs 10.6%), more commonly white (61.0% vs 49.8%), with lower burden of comorbidities (mean [SD] Deyo comorbidity index 2.53 [2.27] vs 2.73 [2.47]), and with lower need for organ support (mechanical ventilation 32.8% vs 36.0%); p<0.0001 for all comparisons. Crude short-term mortality among sepsis hospitalizations with and without mental disorders was 25.0% vs 32.8%, respectively. On adjusted analyses, mental disorders remained associated with lower odds of short-term mortality (adjusted odds ratio 0.792 [95% CI 0.772–0.812]). This finding was consistent on the alternative modeling approaches, sensitivity analyses, and examination of individual categories of mental disorders.

Conclusions

Mental disorders were associated, unexpectedly, with markedly lower risk of short-term mortality in sepsis. Further studies to examine the mechanisms underlying these findings may inform future efforts to improve sepsis outcomes.

Disseminated Mycobacterium abscessus Infection in a Burn Patient

Disseminated infection caused by non-tuberculous mycobacteria (NTM) is very rare, with an incidence of 1.0 to 1.8 cases per 100,000 persons, and typically only occurs in severely immunocompromised hosts. Burn patients suffer loss of the natural cutaneous barrier as well as injury-induced immune dysfunction, and as a result, commonly develop infections, especially with multidrug-resistant organisms. However, very few NTM infections in burn patients have been reported in the literature. Disseminated NTM infection, in particular, can be a challenge to diagnose in burn patients due to burn related physiology such as hyperpyrexia and widespread skin injury. We present a case of disseminated infection leading to bacteremia caused by Mycobacterium abscessus in a critically ill burn patient with a 74% total body surface area burn. M. abscessus belongs to the subgroup of NTM known as rapidly growing mycobacteria (RGM), which are notable for their ability to form colonies in a matter of days, rather than weeks, and because they are often highly drug-resistant, which complicates antimicrobial therapy. This is the third reported case of bacteremia caused by NTM in a burn patient and the second case that was successfully transitioned from intravenous antimicrobials to an oral regimen.

Epigenetic Profiling in Severe Sepsis: A Pilot Study of DNA Methylation Profiles in Critical Illness

OBJECTIVES

Epigenetic alterations are an important regulator of gene expression in health and disease; however, epigenetic data in sepsis are lacking. To demonstrate proof of concept and estimate effect size, we performed the first epigenome-wide methylation analysis of whole blood DNA samples from a cohort of septic and nonseptic critically ill patients.

DESIGN

A nested case-control study using genomic DNA isolated from whole blood from septic (n = 66) and nonseptic (n = 68) critically ill patients on "Day 1" of ICU admission. Methylation patterns were identified using Illumina 450K arrays with percent methylation expressed as β values. After quality control, 134 participants and 414,818 autosomal cytosine-phosphate-guanine sites were used for epigenome-wide methylation analyses.

SETTING

Tertiary care hospitals.

SUBJECTS

Critically ill septic and nonseptic patients.

INTERVENTIONS

Observational study.

MEASUREMENTS AND MAIN RESULTS

A total of 668 differentially methylated regions corresponding to 443 genes were identified. Known sepsis-associated genes included complement component 3; angiopoietin 2; myeloperoxidase; lactoperoxidase; major histocompatibility complex, class I, A; major histocompatibility complex, class II, isotype DR β I; major histocompatibility complex, class I, C; and major histocompatibility complex, class II, isotype DQ β I. When compared with whole blood gene expression data from seven external datasets containing septic and nonseptic patients, 81% of the differentially methylated region-associated genes were differentially expressed in one or more datasets and 31% in three or more datasets. Functional analysis showed enrichment for antigen processing and presentation, methyltransferase activity, cell adhesion, and cell junctions. Analysis by weighted gene coexpression network analysis revealed DNA comethylation modules that were associated with clinical traits including severity of illness, need for vasopressors, and length of stay.

CONCLUSIONS

DNA methylation marks may provide important causal and potentially biomarker information in critically ill patients with sepsis.

The association between autoimmune disease and 30-day mortality among sepsis ICU patients: a cohort study

Introduction

Sepsis results from a dysregulated host response to an infection that is associated with an imbalance between pro- and anti-inflammatory cytokines. This imbalance is hypothesized to be a driver of patient mortality. Certain autoimmune diseases modulate the expression of cytokines involved in the pathophysiology of sepsis. However, the outcomes of patients with autoimmune disease who develop sepsis have not been studied in detail. The objective of this study is to determine whether patients with autoimmune diseases have different sepsis outcomes than patients without these comorbidities.

Methods

Using the Multiparameter Intelligent Monitoring in Intensive Care III database (v. 1.4) which contains retrospective clinical data for over 50,000 adult ICU stays, we compared 30-day mortality risk for sepsis patients with and without autoimmune disease. We used logistic regression models to control for known confounders, including demographics, disease severity, and immunomodulation medications. We used mediation analysis to evaluate how the chronic use of immunomodulation medications affects the relationship between autoimmune disease and 30-day mortality.

Results

Our study found a statistically significant 27.00% reduction in the 30-day mortality risk associated with autoimmune disease presence. This association was found to be the strongest (OR 0.71, 95% CI 0.54–0.93, P = 0.014) among patients with septic shock. The autoimmune disease-30-day mortality association was not mediated through the chronic use of immunomodulation medications (indirect effect OR 1.07, 95% CI 1.01–1.13, P = 0.020).

Conclusions

We demonstrated that autoimmune diseases are associated with a lower 30-day mortality risk in sepsis. Our findings suggest that autoimmune diseases affect 30-day mortality through a mechanism unrelated to the chronic use of immunomodulation medications. Since this study was conducted within a single study center, research using data from other medical centers will provide further validation.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2357-1) contains supplementary material, which is available to authorized users.

Targeting macrophage immunometabolism: Dawn in the darkness of sepsis

Sepsis is known since the time (470 BC) of great Greek physician, Hippocrates. Advancement in modern medicine and establishment of separate branches of medical science dealing with sepsis research have improved its outcome. However, mortality associated with sepsis still remains higher (25-30%) that further increases to 40-50% in the presence of septic shock. For example, sepsis-associated deaths account more in comparison to deaths-associated with myocardial-infarction and certain cancers (i.e. breast and colorectal cancer). However, it is now well established that profound activation of innate immune cells including macrophages play a very important role in the immunopathogenesis of sepsis. Macrophages are sentinel cells of the innate immune system with their location varying from peripheral blood to various target organs including lungs, liver, brain, kidneys, skin, testes, vascular endothelium etc. Thus, profound and dysregulated activation of these cells during sepsis can directly impact the outcome of sepsis. However, the emergence of the concept of immunometabolism as a major controller of immune response has raised a new hope for identifying new targets for immunomodulatory therapeutic approaches. Thus this present review starts with an introduction of sepsis as a major medical problem worldwide and signifies the role of dysregulated innate immune response including macrophages in its immunopathogenesis. Thereafter, subsequent sections describe changes in immunometabolic stage of macrophages (both M1 and M2) during sepsis. The article ends with the discussion of novel macrophage-specific therapeutic targets targeting their immunometabolism during sepsis and epigenetic regulation of macrophage immunometabolism and vice versa.