Epidemiological trends of sepsis in the twenty-first century (2000-2013): an analysis of incidence, mortality, and associated costs in Spain

The utility of an algorithm based on procalcitonin monitoring in patients with sepsis

OBJECTIVE

The aim of the study was to develop and validate an algorithm based on procalcitonin (PCT) monitoring to predict the prognosis of patients with sepsis.

DESIGN

The design was a retrospective and observational prospective study.

SETTING

The study was set in intensive care units (ICUs) in 2 different hospitals in Spain.

PATIENTS

Patients in the study included 101 patients with sepsis aged ≥18 years.

INTERVENTIONS

In the retrospective study, PCT results from patients admitted to the ICU in 2011-2012 were collected. In the prospective study, PCT was determined at specific time points as indicated by the algorithm from March 2018 to April 2019. The primary outcome measure, 28-day mortality, was the main variable of interest.

RESULTS

The study developed an algorithm based on early PCT monitoring for predicting the prognosis of patients with sepsis. The algorithm was initially developed retrospectively in 1 cohort and subsequently validated prospectively in another cohort.

CONCLUSIONS

The developed algorithm provides information on the prognosis of patients with sepsis, distinguishing between those with a good prognosis and those with a poor prognosis (defined as mortality).

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

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

Combined glycated hemoglobin index and red cell distribution width predict in-hospital mortality in critically ill sepsis patients based on MIMIC-IV analysis

Red cell distribution width (RDW) and glycated hemoglobin index (HGI) is considered an important tool for assessing the prognosis of sepsis patients, closely related to the risk of mortality associated with sepsis. This study investigates the association between the HGI combined with RDW and the risk of in-hospital mortality in patients with sepsis. We analyzed data from 13,726 sepsis patients who were admitted to the intensive care unit (ICU) for more than 24 h, sourced from the American Medical Information Mart for Intensive Care (MIMIC-IV) database. Kaplan-Meier survival curves and multivariable Cox regression analyses were employed to assess the impact of various variables on patient outcomes, stratified by quartiles of HGI and RDW. Additionally, restricted cubic spline (RCS) analysis was utilized to explore how changes in HGI and RDW might influence the studied outcomes. The results indicated that the highest quartile (Q4) of the combined metrics significantly increased in-hospital mortality compared to the lowest quartile (Q1) (p < 0.0001). Multivariable Cox regression analysis revealed that patients in Q4 faced the highest risk of in-hospital mortality (hazard ratio: 1.22, 95% confidence interval: [1.10-1.36], p < 0.001). RCS analysis demonstrated a nonlinear relationship between HGI-RDW and the risk of adverse outcomes. Further analysis identified significantly elevated risks in patients over 65 years old, those who were widowed, those receiving macrolide antibiotics, and those with congestive heart failure or severe liver disease. In conclusion, elevated levels of the combined HGI and RDW metrics are independent risk factors for adverse outcomes in critically ill patients with sepsis, associated with increased mortality.

Admissions, mortality and financial burden associated with acute hospitalisations for sepsis between 2006 and 2018: A national population-level study

Background

We assessed the healthcare and economic burden of sepsis in adult hospitalised patients in Wales, UK.

Methods

We analysed hospital admissions to all acute hospitals in Wales via the Secure Anonymised Information Linkage Databank. We included all adult patients, 2006-2018, with an inpatient admission including one or more explicit sepsis codes.

Results

38,564 patients had at least one admission for sepsis between 2006 and 2018. Most persons (86.7%) had just one admission. 3398 patients (8.4%) were admitted to ICU. The number of admissions increased yearly over the study period from 1548 in 2006 to 8708 in 2018. The largest annual increase (141.7% compared to the previous year) occurred in 2017. Admission numbers increased disproportionately amongst patients with high levels of comorbidities, but changes were consistent across all age groups, areas of deprivation and ICU admissions. Estimated inpatient sepsis costs were £340.34 million in total during the study period. The average cost per hospital spell was £7270. Patients readmitted to the hospital for sepsis amassed estimated treatment costs of over £72 million during the study period. Out of the 38,564 persons, 21,275 (55.2%) died within 3 years of their first admission. Inpatient mortality halved from 40.5% to 19.5%, and there was a trend towards reduced mortality at 6 months, 1 and 3 years post hospital discharge.

Conclusion

Sepsis related hospital admissions are increasing over time and still likely to be underreported. Although mortality appears to have fallen, prolonged hospitalisation and readmissions place a significant burden on healthcare system resources and costs.

Population Sepsis Incidence, Mortality, and Trends in Hong Kong Between 2009 and 2018 Using Clinical and Administrative Data

BACKGROUND

Sepsis surveillance using electronic health record (EHR)-based data may provide more accurate epidemiologic estimates than administrative data, but experience with this approach to estimate population-level sepsis burden is lacking.

METHODS

This was a retrospective cohort study including all adults admitted to publicly funded hospitals in Hong Kong between 2009 and 2018. Sepsis was defined as clinical evidence of presumed infection (clinical cultures and treatment with antibiotics) and concurrent acute organ dysfunction (≥2-point increase in baseline Sequential Organ Failure Assessment [SOFA] score). Trends in incidence, mortality, and case fatality risk (CFR) were modeled by exponential regression. Performance of the EHR-based definition was compared with 4 administrative definitions using 500 medical record reviews.

RESULTS

Among 13 540 945 hospital episodes during the study period, 484 541 (3.6%) had sepsis by EHR-based criteria with 22.4% CFR. In 2018, age- and sex-adjusted standardized sepsis incidence was 756 per 100 000 (relative change: +2.8%/y [95% CI: 2.0%-3.7%] between 2009 and 2018) and standardized sepsis mortality was 156 per 100 000 (relative change: +1.9%/y; 95% CI: .9%-2.8%). Despite decreasing CFR (relative change: -0.5%/y; 95% CI: -1.0%, -.1%), sepsis accounted for an increasing proportion of all deaths (relative change: +3.9%/y; 95% CI: 2.9%-4.8%). Medical record reviews demonstrated that the EHR-based definition more accurately identified sepsis than administrative definitions (area under the curve [AUC]: .91 vs .52-.55; P < .001).

CONCLUSIONS

An objective EHR-based surveillance definition demonstrated an increase in population-level standardized sepsis incidence and mortality in Hong Kong between 2009 and 2018 and was much more accurate than administrative definitions. These findings demonstrate the feasibility and advantages of an EHR-based approach for widescale sepsis surveillance.

The smell of sepsis: Electronic nose measurements improve early recognition of sepsis in the ED

OBJECTIVE

Early recognition of sepsis is essential for timely initiation of adequate care. However, this is challenging as signs and symptoms may be absent or nonspecific. The cascade of events leading to organ failure in sepsis is characterized by immune-metabolic alterations. Volatile organic compounds (VOCs) are metabolic byproducts released in expired air. We hypothesize that measuring the VOC profile using electronic nose technology (eNose) could improve early recognition of sepsis.

MATERIAL AND METHODS

In this cohort study, bedside eNose measurements were collected prospectively from ED patients with suspected infections. Sepsis diagnosis was retrospectively defined based on Sepsis-3 criteria. eNose sensor data were used in a discriminant analysis to evaluate the predictive performance for early sepsis recognition. The dataset was randomly split into training (67 %) and validation (33 %) subsets. The derived discriminant function from the training subset was then applied to classify new observations in the validation subset. Model performance was evaluated using receiver operating characteristic (ROC) curves and predictive values.

RESULTS

We analyzed a total of 160 eNose measurements. The eNose measurements had an area under the ROC (AUROC) of 0.78 (95 % CI: 0.69-0.87) for diagnosing sepsis, with a sensitivity of 72 %, specificity of 73 %, and an overall accuracy of 73 %. The validation model showed an AUC of 0.83 (95 % CI: 0.71-0.94), sensitivity of 71 %, specificity of 83 %, and an accuracy of 80 %.

CONCLUSION

eNose measurements can identify sepsis among patients with a suspected infection at the ED.

CLINICAL TRIAL REGISTRATION

The study is embedded in the Acutelines data-biobank (www.acutelines.nl), registered in Clinicaltrials.gov (NCT04615065).

Association of TyG index with mortality at 28 days in sepsis patients in intensive care from MIMIC IV database

The relationship between the triglyceride‒glucose (TyG) index and the clinical prognosis of septic patients in intensive care units (ICUs) remains unclear. This study aimed to explore the correlation between the TyG index and 28-day all-cause mortality in septic patients. A retrospective observational cohort study was conducted, including 8955 septic patients from the MIMIC IV 2.2 database. The primary outcome was 28-day all-cause mortality. Multivariate logistic regression analysis and restricted cubic spline regression analysis were used to assess the relationship between the TyG index and 28-day all-cause mortality in septic patients. Subgroup analyses and sensitivity analyses were performed to further validate the robustness of the results. A total of 8955 septic patients were included, 5219 (58.3%) of whom were male, with a mean age of 66.3 (15.8) years and an average TyG index of 9.08 (0.70) and the number of deaths within 28 days was 1639 (18.3%). The RCS curve demonstrated a U-shaped relationship between the TyG index and 28-day all-cause mortality (nonlinear P value = 0.0003). The risk of 28-day all-cause mortality was negatively associated with the TyG index until it decreased to 9.03 (adjusted odds ratio [OR] 0.727, 95% confidence interval [CI] 0.577-0.915). However, when the TyG index exceeded 9.03, the odds ratio for 28-day all-cause mortality significantly increased (adjusted OR 1.185, 95% CI 1.001-1.404). These findings were consistent across subgroups and various sensitivity analyses. Our study revealed a nonlinear U-shaped relationship between the TyG index and 28-day all-cause mortality, with a critical point at a TyG index of 9.03. Our results suggest that the TyG index may be a novel and important factor for the short-term clinical prognosis of critically ill septic patients.

A clinical prediction model for safe early discharge of patients with an infection at the emergency department

BACKGROUND

Every hospital admission is associated with healthcare costs and a risk of adverse events. The need to identify patients who do not require hospitalization has emerged with the profound increase in hospitalization rates due to infectious diseases during the last decades, especially during the COVID-19 pandemic. This study aimed to identify predictors of safe early discharge (SED) in patients presenting to the emergency department (ED) with a suspected infection meeting the Systemic Inflammatory Response Syndrome (SIRS) criteria.

METHODS

We conducted a prospective cohort study on adult non-trauma patients with a suspected infection and at least two SIRS criteria. We defined SED as hospital discharge within 24 h (e.g. direct ED discharge or rapid ward discharge) without disease-related readmission to our hospital or death during the first seven days. A prediction model for SED was developed using multivariate logistic regression analysis and tested with k-fold cross-validation.

RESULTS

We included 1381 patients, of whom 1027 (74.4 %) were hospitalized for longer than 24 h or re-admitted within seven days and 354 (25.6 %) met SED criteria. Parameters associated with SED were relatively young age, absence of comorbidities, living independently, yellow or green triage urgency, lack of ambulance transport or general practitioner referral, normal clinical impression scores, and risk scores (i.e., qSOFA, PIRO, MEDS, NEWS, and SIRS), normal vital sign measurements and absence of kidney and respiratory failure. The model performance metrics showed an area under the curve of 0.824. The validation showed a minimal drop in performance and indicated a good fit.

CONCLUSION

We developed and validated a model to identify patients with an infection at the ED who can be safely discharged early.

EARLY ANALYSIS OF ENDOTHELIAL MARKERS TO PREDICT SEPSIS IN THE EMERGENCY DEPARTMENT

ABSTRACT

Background: Acute infections and sepsis are a leading cause of death. These patients are primarily encountered at the emergency department (ED), where early assessment for sepsis is necessary to improve outcome. In sepsis, the inflammatory response causes several characteristic pathophysiological changes, including a dysregulated and generalized activation of the endothelium. This study aimed to analyze endothelial markers released to the blood as diagnostic biomarkers for acute infection and sepsis in the ED, as smaller studies have previously shown promising results in other settings. Methods : Serum samples from n = 312 adult patients with suspected acute infections at presentation to the ED were utilized. Patients' courses of disease and outcomes were assessed by clinical adjudication. E-selectin, P-selectin, ICAM-1, and VCAM-1 were measured by ELISAs. The accuracy of each marker for predicting bacterial infection, sepsis, and in-hospital mortality was evaluated. Results : For sepsis, E-selectin and ICAM-1 both showed an area under the receiver operating characteristic (AUROC) of 0.62, lower than procalcitonin with 0.77 (both P < 0.01) and lactate with 0.73 ( P = 0.030 and 0.046, respectively), but similar to CRP with 0.60 ( P = 0.758 and 0.876, respectively). For 28-day in-hospital mortality among patients with infection, ICAM-1 performed best with an AUROC of 0.75. Conclusions : Despite promising results in small studies and specific cohorts, particularly in intensive care units, this large-scale evaluation of four endothelial biomarkers highlights their limited diagnostic utility in a broader inclusion setup design at the earliest possible time point of evaluation.

L-shaped association between triglyceride-glucose body mass index and short-term mortality in ICU patients with sepsis-associated acute kidney injury

Background

Sepsis is a systemic inflammatory response syndrome, with sepsis-associated acute kidney injury (SA-AKI) being a common complication. Insulin resistance (IR) is closely related to the stress response, inflammatory response, and severity of critical illness. The triglyceride-glucose body mass index (TyG-BMI) is a valuable tool for assessing IR. However, the relationships between TyG-BMI and clinical outcomes in patients with SA-AKI remain unclear.

Methods

We conducted a retrospective analysis of ICU patients with SA-AKI using data from the MIMIC-IV database. The Boruta algorithm was employed to select significant features for predicting short-term mortality in SA-AKI patients. Multivariate Cox proportional hazards regression, sensitivity analysis, restricted cubic spline (RCS) models, and Kaplan-Meier (K-M) survival analysis were used to assess the relationship between TyG-BMI and short-term mortality in SA-AKI patients. Subgroup analyses considered the effects of age, sex, ethnicity, comorbidities and septic shock.

Results

This study included 3,349 patients, with males accounting for 60.5% of the patients. The Boruta analysis identified the TyG-BMI as an important clinical feature. Higher TyG-BMI values were significantly associated with reduced short-term mortality rates (28, 90, and 180 days) in patients with SA-AKI; for each standard deviation increase in TyG-BMI, the risk of all-cause death decreased by 0.2% (p < 0.0001). Kaplan-Meier analysis demonstrated that patients with high TyG-BMIs had significantly lower mortality rates than did those with low TyG-BMIs. The RCS model revealed an L-shaped nonlinear relationship between the TyG-BMI and mortality. Sensitivity analyses indicated that the association remained significant even after excluding patients with myocardial infarction, congestive heart failure, or those who were hospitalized in the ICU for less than 2 days. Subgroup analyses revealed a significant interaction effect on short-term mortality in CRRT patients (p < 0.05).

Conclusion

The relationship between the TyG-BMI and short-term mortality in ICU patients with SA-AKI is significant, indicating its potential value for early risk assessment and clinical intervention.

Adult Code Sepsis: A Narrative Review of its Implementation and Impact

This narrative review explores the implementation and impact of sepsis code protocols, an urgent intervention strategy designed to improve clinical outcomes in patients with sepsis. We examined the degree of implementation, activation criteria, areas of implementation, personnel involved, responses after activation, goals and targets, impact on clinical indicators, and challenges in implementation. The reviewed evidence suggests that sepsis codes can significantly reduce sepsis-related mortality and enhance early administration of treatments. However, variability in activation criteria and inconsistent application present ongoing challenges. The review considers the incorporation of newer scoring systems, such as NEWS and MEWS, and the potential integration of machine learning tools for early sepsis detection. It highlights the importance of tailoring implementation to specific healthcare contexts and the value of ongoing training to optimize sepsis response. Limitations include the ongoing controversy surrounding sepsis definitions and the need for standardized, feasible quality indicators. Future research should focus on standardizing activation criteria, improving protocol adherence, and exploring emerging technologies to enhance early sepsis detection and management. Despite challenges, sepsis codes show promise in improving patient outcomes when implemented thoughtfully and consistently across healthcare settings.

The Global Burden of Sepsis and Septic Shock

A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.

Lactate Levels and Clearance: Key Predictors of Prognosis for COVID-19 and Non-COVID-19 Septic Shock Patients in the Emergency Department

BACKGROUND

This investigation assesses the prognostic value of lactate levels and their clearance in septic shock patients, particularly emphasizing the comparative analysis between COVID-19 and non-COVID-19 patients in the emergency department. This study aims to elucidate the unique prognostic implications of lactate dynamics in these distinct patient groups, thereby enhancing the management of septic shock.

METHODS

An observational prospective study was conducted, enrolling 114 septic shock patients from the Emergency County Hospital Resita, Romania, categorizing them into COVID-19 and non-COVID-19 groups to examine their initial lactate levels, clearance rates, and their correlation with patient outcomes.

RESULTS

This study identified significant differences in the initial lactate levels and clearance rates between the two groups, indicating higher initial lactate levels and slower clearance rates in COVID-19 patients. Survivors demonstrated significantly lower initial lactate levels (1.5 ± 0.4 mmol/L) and higher lactate clearance rates (33 ± 15%) compared to non-survivors (2.5 ± 0.5 mmol/L and 24 ± 9%, respectively; lactate levels p = 0.001, clearance rates p = 0.002).

CONCLUSIONS

Lactate monitoring, particularly clearance rates, is crucial in the prognostic assessment of septic shock patients. These findings highlight the need for targeted interventions in COVID-19 patients to improve outcomes, underscoring lactate dynamics as a vital component of septic shock management in differing patient populations.

Decrease in Mortality after the Implementation of a Hospital Model to Improve Performance in Sepsis Care: Princess Sepsis Code

Sepsis is a time-dependent disease whose prognosis is influenced by early diagnosis and therapeutic measures. Mortality from sepsis remains high, and for this reason, the guidelines of the Surviving Sepsis Campaign recommend establishing specific care programs aimed at patients with sepsis. We present the results of the application of a hospital model to improve performance in sepsis care, called Princess Sepsis Code, with the aim of reducing mortality. A retrospective study was conducted using clinical, epidemiological, and outcome variables in patients diagnosed with sepsis from 2015 to 2022. A total of 2676 patients were included, 32% of whom required admission to the intensive care unit, with the most frequent focus of the sepsis being abdominal. Mortality in 2015, at the beginning of the sepsis code program, was 24%, with a declining rate noted over the study period, with mortality reaching 17% in 2022. In the multivariate analysis, age > 70 years, respiratory rate > 22 rpm, deterioration in the level of consciousness, serum lactate > 2 mmol/L, creatinine > 1.6 mg/dL, and the focus of the sepsis were identified as variables independently related to mortality. The implementation of the Princess Sepsis Code care model reduces the mortality of patients exhibiting sepsis and septic shock.

Interleukin-17 as predictor mortality of septic patients: a systematic review and meta-analysis

OBJECTIVE

Aim: This study aimed to prove the role of IL-17 on the clinical outcomes of septic patients.

PATIENTS AND METHODS

Materials and Methods: This study used a systematic review and meta-analysis design. Data were obtained by searching articles published between January 2001 and June 2022 in Pubmed, Science Direct, Scopus, and Medline databases to evaluate Interleukin-17 on clinical outcomes in septic patients. Only human studies were used in this study. Meta-analysis was undertaken using random effects models.

RESULTS

Results: Fourteen published studies were eligible, and four studies were included in the meta-analysis. Meta-analysis of the ratio of means (RoM) IL-17 concentration demonstrated a 5.96-fold higher level in non-survivor septic patients compared with survivors (four studies; n = 194 patients; RoM=5.96; 95% CI, 3.51-10.31; p < 0.00001; I2 = 92%).

CONCLUSION

Conclusions: IL-17 levels were significantly elevated in non-survivor and predicted mortality of septic patients.

Sepsis-coded hospitalisations and associated costs in Australia: a retrospective analysis

OBJECTIVE

To report trends in Australian hospitalisations coded for sepsis and their associated costs.

DESIGN

Retrospective analysis of Australian national hospitalisation data from 2002 to 2021.

METHODS

Sepsis-coded hospitalisations were identified using the Global Burden of Disease study sepsis-specific ICD-10 codes modified for Australia. Costs were calculated using Australian-Refined Diagnosis Related Group codes and National Hospital Cost Data Collection.

RESULTS

Sepsis-coded hospitalisations increased from 36,628 in 2002-03 to 131,826 in 2020-21, an annual rate of 7.8%. Principal admission diagnosis codes contributed 13,843 (37.8%) in 2002-03 and 44,186 (33.5%) in 2020-21; secondary diagnosis codes contributed 22,785 (62.2%) in 2002-03 and 87,640 (66.5%) in 2020-21. Unspecified sepsis was the most common sepsis code, increasing from 15,178 hospitalisations in 2002-03 to 68,910 in 2020-21. The population-based incidence of sepsis-coded hospitalisations increased from 18.6 to 10,000 population (2002-03) to 51.3 per 10,000 (2021-21); representing an increase from 55.1 to 10,000 hospitalisations in 2002-03 to 111.4 in 2020-21. Sepsis-coded hospitalisations occurred more commonly in the elderly; those aged 65 years or above accounting for 20,573 (55.6%) sepsis-coded hospitalisations in 2002-03 and 86,135 (65.3%) in 2020-21. The cost of sepsis-coded hospitalisations increased at an annual rate of 20.6%, from AUD199M (€127 M) in financial year 2012 to AUD711M (€455 M) in 2019.

CONCLUSION

Hospitalisations coded for sepsis and associated costs increased significantly from 2002 to 2021 and from 2012 to 2019, respectively.

PFKFB3 promotes sepsis-induced acute lung injury by enhancing NET formation by CXCR4hi neutrophils

CXCR4hi neutrophils, which are a subset of neutrophils with high CXCR4 expression, are important contributors to sepsis-induced acute lung injury (ALI). PFKFB3, a key glycolysis gene, plays an essential role in neutrophil inflammatory activation. However, the specific involvement of PFKFB3 in sepsis-induced ALI remains unclear. Here, we observed that PFKFB3 was upregulated in CXCR4hi neutrophils and facilitated sepsis-induced ALI. Mechanistically, we observed that PFKFB3 promoted sepsis-induced ALI by enhancing neutrophil extracellular trap (NET) formation by CXCR4hi neutrophils. Further study indicated that PFKFB3 promoted NET formation by upregulating glycolytic metabolism in CXCR4hi neutrophils. In summary, our study uncovered a new mechanism by which CXCR4hi neutrophils trigger sepsis-induced ALI by promoting NET formation, which is supported by PFKFB3-mediated glycolytic metabolism.

Extracorporeal blood purification strategies in sepsis and septic shock: An insight into recent advancements

BACKGROUND

Despite various therapies to treat sepsis, it is one of the leading causes of mortality in the intensive care unit patients globally. Knowledge about the pathophysiology of sepsis has sparked interest in extracorporeal therapies (ECT) which are intended to balance the dysregulation of the immune system by removing excessive levels of inflammatory mediators.

AIM

To review recent data on the use of ECT in sepsis and to assess their effects on various inflammatory and clinical outcomes.

METHODS

In this review, an extensive English literature search was conducted from the last two decades to identify the use of ECT in sepsis. A total of 68 articles from peer-reviewed and indexed journals were selected excluding publications with only abstracts.

RESULTS

Results showed that ECT techniques such as high-volume hemofiltration, coupled plasma adsorption/filtration, resin or polymer adsorbers, and CytoSorb^® are emerging as adjunct therapies to improve hemodynamic stability in sepsis. CytoSorb^® has the most published data in regard to the use in the field of septic shock with reports on improved survival rates and lowered sequential organ failure assessment scores, lactate levels, total leucocyte count, platelet count, interleukin- IL-6, IL-10, and TNF levels.

CONCLUSION

Clinical acceptance of ECT in sepsis and septic shock is currently still limited due to a lack of large random clinical trials. In addition to patient-tailored therapies, future research developments with therapies targeting the cellular level of the immune response are expected.

Dysregulated haemostasis in thrombo-inflammatory disease

Inflammatory disease is often associated with an increased incidence of venous thromboembolism in affected patients, although in most instances, the mechanistic basis for this increased thrombogenicity remains poorly understood. Acute infection, as exemplified by sepsis, malaria and most recently, COVID-19, drives 'immunothrombosis', where the immune defence response to capture and neutralise invading pathogens causes concurrent activation of deleterious prothrombotic cellular and biological responses. Moreover, dysregulated innate and adaptive immune responses in patients with chronic inflammatory conditions, such as inflammatory bowel disease, allergies, and neurodegenerative disorders, are now recognised to occur in parallel with activation of coagulation. In this review, we describe the detailed cellular and biochemical mechanisms that cause inflammation-driven haemostatic dysregulation, including aberrant contact pathway activation, increased tissue factor activity and release, innate immune cell activation and programmed cell death, and T cell-mediated changes in thrombus resolution. In addition, we consider how lifestyle changes increasingly associated with modern life, such as circadian rhythm disruption, chronic stress and old age, are increasingly implicated in unbalancing haemostasis. Finally, we describe the emergence of potential therapies with broad-ranging immunothrombotic functions, and how drug development in this area is challenged by our nascent understanding of the key molecular and cellular parameters that control the shared nodes of proinflammatory and procoagulant pathways. Despite the increasing recognition and understanding of the prothrombotic nature of inflammatory disease, significant challenges remain in effectively managing affected patients, and new therapeutic approaches to curtail the key pathogenic steps in immune response-driven thrombosis are urgently required.

PCR-based diagnosis of respiratory virus in postsurgical septic patients: A preliminary study before SARS-CoV-2 pandemic

Respiratory viruses are part of the normal microbiota of the respiratory tract, which sometimes cause infection with/without respiratory insufficiency and the need for hospital or ICU admission. The aim of this study is to determine the prevalence of respiratory viruses in nontransplanted postoperative septic patients as well as lymphocyte count influence in their presence and its relationship to mortality. 223 nontransplanted postsurgical septic patients were recruited on the Intensive Care Unit (ICU) at Hospital Clínico Universitario de Valladolid prior to the SARS-COV-2 pandemic. Patients were split into 2 groups according to the presence/absence of respiratory viruses. Multivariate logistic regression analysis was used to identify independent factors related to positive respiratory virus PCR test. Respiratory viruses were isolated in 28.7% of patients. 28-day mortality was not significantly different between virus-positive and virus-negative groups. Logistic regression analysis revealed that lymphocyte count ≤ 928/µl is independently associated with a positive PCR result [OR 3.76, 95% CI (1.71-8.26), P = .001] adjusted by platelet count over 128,500/µL [OR 4.27, 95% CI (1.92-9.50) P < .001] and the presence of hypertension [OR 2.69, 95% CI (1.13-6.36) P = .025] as confounding variables. Respiratory viruses' detection by using PCR in respiratory samples of nontransplanted postoperative septic patients is frequent. These preliminary results revealed that the presence of lymphopenia on sepsis diagnosis is independently associated to a positive virus result, which is not related to a higher 28-day mortality.

Cefepime Dosing Requirements in Elderly Patients Attended in the Emergency Rooms

Objective

This study aimed to assess the probability of reaching an adequate pharmacokinetic/pharmacodynamic (pK/pD) index for different cefepime dosages in frail patients with bacteremia treated in the emergency room.

Methods

Simulation study based on Gram-negative bacterial strains that cause bacteremia. The probability of reaching a time above the minimum inhibitory concentration (MIC) at 50% and 100% dosing intervals (fT > 50 and fT > 80% MIC) was assessed for two different renal clearance intervals.

Results

One hundred twenty nine strains were collected, the predominant species being Escherichia coli (n = 83 [64.3%]). In patients with a ClCr of 30 mL/min, an fT > 50% MIC was reached in more than 90% of the simulations. However, a dose of at least 1 g every 12 h must be administered to reach an fT > 80% MIC. In patients with a ClCr of 30–60 mL/min, the probability of reaching an fT > 50% MIC was higher than 90% with doses of 1 g every 8 h or more, but this value was not reached in > 90% simulations for any of the doses tested in this study.

Conclusions

Standard cefepime dosing can reach an adequate PK/PD index in frail patients. Nevertheless, a high dose or extended infusion is necessary to reach an fT > 80% MIC in patients with a ClCr > 60 mL/min.

Hyperoxemia in postsurgical sepsis/septic shock patients is associated with reduced mortality

BACKGROUND

Despite growing interest in treatment strategies that limit oxygen exposure in ICU patients, no studies have compared conservative oxygen with standard oxygen in postsurgical patients with sepsis/septic shock, although there are indications that it may improve outcomes. It has been proven that high partial pressure of oxygen in arterial blood (PaO2) reduces the rate of surgical-wound infections and mortality in patients under major surgery. The aim of this study is to examine whether PaO2 is associated with risk of death in adult patients with sepsis/septic shock after major surgery.

METHODS

We performed a secondary analysis of a prospective observational study in 454 patients who underwent major surgery admitted into a single ICU. Patients were stratified in two groups whether they had hyperoxemia, defined as PaO2 > 100 mmHg (n = 216), or PaO2 ≤ 100 mmHg (n = 238) at the day of sepsis/septic shock onset according to SEPSIS-3 criteria maintained during 48 h. Primary end-point was 90-day mortality after diagnosis of sepsis. Secondary endpoints were ICU length of stay and time to extubation.

RESULTS

In patients with PaO2 ≤ 100 mmHg, we found prolonged mechanical ventilation (2 [8] vs. 1 [4] days, p < 0.001), higher ICU stay (8 [13] vs. 5 [9] days, p < 0.001), higher organ dysfunction as assessed by SOFA score (9 [3] vs. 7 [5], p < 0.001), higher prevalence of septic shock (200/238, 84.0% vs 145/216) 67.1%, p < 0.001), and higher 90-day mortality (37.0% [88] vs. 25.5% [55], p = 0.008). Hyperoxemia was associated with higher probability of 90-day survival in a multivariate analysis (OR 0.61, 95%CI: 0.39-0.95, p = 0.029), independent of age, chronic renal failure, procalcitonin levels, and APACHE II score > 19. These findings were confirmed when patients with severe hypoxemia at the time of study inclusion were excluded.

CONCLUSIONS

Oxygenation with a PaO2 above 100 mmHg was independently associated with lower 90-day mortality, shorter ICU stay and intubation time in critically ill postsurgical sepsis/septic shock patients. Our findings open a new venue for designing clinical trials to evaluate the boundaries of PaO2 in postsurgical patients with severe infections.

Impact of Sepsis on High-Density Lipoprotein Metabolism

Background: High-density lipoproteins (HDL) are thought to play a protective role in sepsis through several mechanisms, such as promotion of steroid synthesis, clearing bacterial toxins, protection of the endothelial barrier, and antioxidant/inflammatory activities. However, HDL levels decline rapidly during sepsis, but the contributing mechanisms are poorly understood. Methods/Aim: In the present study, we investigated enzymes involved in lipoprotein metabolism in sepsis and non-sepsis patients admitted to the intensive care unit (ICU). Results: In 53 ICU sepsis and 25 ICU non-sepsis patients, we observed significant differences in several enzymes involved in lipoprotein metabolism. Lecithin-cholesterol acyl transferase (LCAT) activity, LCAT concentration, and cholesteryl transfer protein (CETP) activity were significantly lower, whereas phospholipid transfer activity protein (PLTP) and endothelial lipase (EL) were significantly higher in sepsis patients compared to non-sepsis patients. In addition, serum amyloid A (SAA) levels were increased 10-fold in sepsis patients compared with non-sepsis patients. Furthermore, we found that LCAT activity was significantly associated with ICU and 28-day mortality whereas SAA levels, representing a strong inflammatory marker, did not associate with mortality outcomes. Conclusion: We provide novel data on the rapid and robust changes in HDL metabolism during sepsis. Our results clearly highlight the critical role of specific metabolic pathways and enzymes in sepsis pathophysiology that may lead to novel therapeutics.

Clinical characteristics and prognosis in patients with urosepsis from intensive care unit in Shanghai, China: a retrospective bi-centre study

BACKGROUND

The purpose of this study was to retrospectively analyze clinical characteristics and prognostic risk factors of urosepsis patients admitted to two intensive care units in Shanghai, China.

METHODS

Clinical data from patients diagnosed with urosepsis were retrospectively retrieved and analyzed from ICU in two regional medical centers from January 2015 to December 2019.

RESULTS

Two hundred two patients were included in the subsequent analysis eventually, with an average age of 72.02 ± 9.66 years, 79.21% of the patients were female and the mortality rate of 15.84%.The proportion of patients with chronic underlying diseases such as diabetes and hypertension was relatively high (56.44, 49.50%, respectively), and the incidence of shock was also high (41.58%) correspondingly. The most common pathogen isolated was Escherichia coli (79.20%), of which the extended-spectrumβ-lactamases (ESBLs)(+) accounted for 42.57%. In multivariate analysis, the strongest predictors for death were mechanical ventilation (OR 7.260, 95% CI 2.200-23.963; P = 0.001),chronic kidney disease (CKD) (OR 5.140, 95% CI 1.596-16.550; P = 0.006), APACHE II score (OR 1.321, 95% CI 1.184-1.473; P < 0.001) and lactate (OR 1.258, 95% CI 1.037-1.527; P = 0.020). Both APACHE II score and lactate had the ideal predictive value, with the area under the ROC curve (AUC) of 0.858 and 0.805 respectively.

CONCLUSION

The patients with urosepsis were characterized by a higher proportion of female, older age, more percentage of comorbidities in this region, and patients with ESBLs (+) Escherichia coli infection were more prone to shock. Mechanical ventilation, comorbidity with CKD, APACHE II score and lactate were independent risk factors for death in urosepsis patient, but lactate level and APACHE II score had better predictive value for prognosis.

ATRvD1 Attenuates Renal Tubulointerstitial Injury Induced by Albumin Overload in Sepsis-Surviving Mice

Novel strategies for the prevention and treatment of sepsis-associated acute kidney injury and its long-term outcomes have been required and remain a challenge in critical care medicine. Therapeutic strategies using lipid mediators, such as aspirin-triggered resolvin D1 (ATRvD1), can contribute to the resolution of acute and chronic inflammation. In this study, we examined the potential effect of ATRvD1 on long-term kidney dysfunction after severe sepsis. Fifteen days after cecal ligation and puncture (CLP), sepsis-surviving BALB/c mice were subjected to a tubulointerstitial injury through intraperitoneal injections of bovine serum albumin (BSA) for 7 days, called the subclinical acute kidney injury (subAKI) animal model. ATRvD1 treatment was performed right before BSA injections. On day 22 after CLP, the urinary protein/creatinine ratio (UPC), histologic parameters, fibrosis, cellular infiltration, apoptosis, inflammatory markers levels, and mRNA expression were determined. ATRvD1 treatment mitigated tubulointerstitial injury by reducing proteinuria excretion, the UPC ratio, the glomerular cell number, and extracellular matrix deposition. Pro-fibrotic markers, such as transforming growth factor β (TGFβ), type 3 collagen, and metalloproteinase (MMP)-3 and -9 were reduced after ATRvD1 administration. Post-septic mice treated with ATRvD1 were protected from the recruitment of IBA1⁺ cells. The interleukin-1β (IL-1β) levels were increased in the subAKI animal model, being attenuated by ATRvD1. Tumor necrosis factor-α (TNF-α), IL-10, and IL-4 mRNA expression were increased in the kidney of BSA-challenged post-septic mice, and it was also reduced after ATRvD1. These results suggest that ATRvD1 protects the kidney against a second insult such as BSA-induced tubulointerstitial injury and fibrosis by suppressing inflammatory and pro-fibrotic mediators in renal dysfunction after sepsis.

The effects of early restrictive fluid resuscitation on the clinical outcomes in sepsis patients

OBJECTIVE

To investigate the effects of early restrictive fluid resuscitation (RFR) on the clinical outcomes in sepsis patients.

METHODS

A total of 122 sepsis patients admitted to our hospital were recruited for this study and divided into a study group (the SG, n=56) and a control group (the CG, n=66) according to the treatment method each patient was administered. The SG was administered early RFR, and the CG was administered adequate fluid resuscitation. The clinical data were analyzed retrospectively in both groups. The total infusion volumes, the hemorrhage amounts, the urine outputs, and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores were compared between the two groups. In addition, the heart rates, the mean arterial pressure levels, the central venous pressure levels, and the cardiac function indices were compared between the two groups at 1-7 days after the procedures. The survival and the complication incidence rates were followed up.

RESULTS

The SG showed significantly lower heart rates and mean arterial pressure levels and higher central venous pressure levels than the CG at 1-7 days after the procedures (P<0.05). The cardiac troponin, N-terminal brain pro-natriuretic peptide, and C-reactive protein levels at 3-7 days after the procedures in the SG were significantly lower than the levels in the CG (P<0.05). The cardiac output, stroke volume, and left ventricular ejection fraction scores in the SG were significantly higher than they were in the CG (P<0.05). The survival rate in the SG was significantly higher than it was in the CG at 16, 32, and 64 days after the procedures (P<0.05). The incidence of complications in the SG was lower than it was in the CG (P<0.05).

CONCLUSION

Early RFR can remarkably improve the clinical outcomes, the myocardial injury and survival rates, and the multiple complications incidence rate in sepsis patients.

A Novel 29-Messenger RNA Host-Response Assay From Whole Blood Accurately Identifies Bacterial and Viral Infections in Patients Presenting to the Emergency Department With Suspected Infections: A Prospective Observational Study

OBJECTIVES

The rapid diagnosis of acute infections and sepsis remains a serious challenge. As a result of limitations in current diagnostics, guidelines recommend early antimicrobials for suspected sepsis patients to improve outcomes at a cost to antimicrobial stewardship. We aimed to develop and prospectively validate a new, 29-messenger RNA blood-based host-response classifier Inflammatix Bacterial Viral Non-Infected version 2 (IMX-BVN-2) to determine the likelihood of bacterial and viral infections.

DESIGN

Prospective observational study.

SETTING

Emergency Department, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Germany.

PATIENTS

Three hundred twelve adult patients presenting to the emergency department with suspected acute infections or sepsis with at least one vital sign change.

INTERVENTIONS

None (observational study only).

MEASUREMENTS AND MAIN RESULTS

Gene expression levels from extracted whole blood RNA was quantified on a NanoString nCounter SPRINT (NanoString Technologies, Seattle, WA). Two predicted probability scores for the presence of bacterial and viral infection were calculated using the IMX-BVN-2 neural network classifier, which was trained on an independent development set. The IMX-BVN-2 bacterial score showed an area under the receiver operating curve for adjudicated bacterial versus ruled out bacterial infection of 0.90 (95% CI, 0.85-0.95) compared with 0.89 (95% CI, 0.84-0.94) for procalcitonin with procalcitonin being used in the adjudication. The IMX-BVN-2 viral score area under the receiver operating curve for adjudicated versus ruled out viral infection was 0.83 (95% CI, 0.77-0.89).

CONCLUSIONS

IMX-BVN-2 demonstrated accuracy for detecting both viral infections and bacterial infections. This shows the potential of host-response tests as a novel and practical approach for determining the causes of infections, which could improve patient outcomes while upholding antimicrobial stewardship.

Trends in the incidence and outcome of sepsis using data from a Japanese nationwide medical claims database-the Japan Sepsis Alliance (JaSA) study group

Background

Trends in the incidence and outcomes of sepsis using a Japanese nationwide database were investigated.

Methods

This was a retrospective cohort study. Adult patients, who had both presumed serious infections and acute organ dysfunction, between 2010 and 2017 were extracted using a combined method of administrative and electronic health record data from the Japanese nationwide medical claim database, which covered 71.5% of all acute care hospitals in 2017. Presumed serious infection was defined using blood culture test records and antibiotic administration. Acute organ dysfunction was defined using records of diagnosis according to the international statistical classification of diseases and related health problems, 10th revision, and records of organ support. The primary outcomes were the annual incidence of sepsis and death in sepsis per 1000 inpatients. The secondary outcomes were in-hospital mortality rate and length of hospital stay in patients with sepsis.

Results

The analyzed dataset included 50,490,128 adult inpatients admitted between 2010 and 2017. Of these, 2,043,073 (4.0%) patients had sepsis. During the 8-year period, the annual proportion of patients with sepsis across inpatients significantly increased (slope = + 0.30%/year, P < 0.0001), accounting for 4.9% of the total inpatients in 2017. The annual death rate of sepsis per 1000 inpatients significantly increased (slope = + 1.8/1000 inpatients year, P = 0.0001), accounting for 7.8 deaths per 1000 inpatients in 2017. The in-hospital mortality rate and median (interquartile range) length of hospital stay significantly decreased (P < 0.001) over the study period and were 18.3% and 27 (15–50) days in 2017, respectively.

Conclusions

The Japanese nationwide data indicate that the annual incidence of sepsis and death in inpatients with sepsis significantly increased; however, the annual mortality rates and length of hospital stay in patients with sepsis significantly decreased. The increasing incidence of sepsis and death in sepsis appear to be a significant and ongoing issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03762-8.

Propensity-Score Analysis Reveals that Sex is Not a Prognostic Factor for Mortality in Intensive Care Unit-Admitted Patients with Septic Bacteremia

OBJECTIVE

Men have been considered to have a higher incidence of infectious diseases, with controversy over the possibility that sex could influence the prognosis of the infection. This study aimed to explore this assumption in patients admitted to the intensive care unit (ICU) with septic bacteremia.

METHODS

A retrospective analysis (2006-2017) of septic patients with microbiologically confirmed bacteremia (n=440) was performed. Risk of ICU and in-hospital mortality in males versus females was compared by univariate analysis and a propensity score analysis integrating their clinical characteristics.

RESULTS

Sepsis more frequently occurred in males (80.2% vs 76.1%) as well as in-hospital (48.0% vs 41.3%) and ICU (39.9% vs 36.5%) mortality. Univariate analyses showed that males had a higher Charlson comorbidity index and worse McCabe prognostic score. However, the propensity score in 296 matched patients demonstrated that females had higher risk of both ICU (OR 1.39; 95% CI 0.89-2.19) and in-hospital mortality (OR 1.18; 95% CI 0.77-1.83), but without statistical significance.

CONCLUSION

Males with sepsis had worse clinical characteristics when admitted to the ICU, but sex had no influence on mortality. These data contribute to helping reduce the sex-dependent gap present in healthcare provision.

Distinguishing septic shock from non-septic shock in postsurgical patients using gene expression

OBJECTIVES

To obtain a gene expression signature to distinguish between septic shock and non-septic shock in postoperative patients, since patients with both conditions show similar signs and symptoms.

METHODS

Differentially expressed genes were selected by microarray analysis in the discovery cohort. These genes were evaluated by quantitative real time polymerase chain reactions in the validation cohort to determine their reliability and predictive capacity by receiver operating characteristic curve analysis.

RESULTS

Differentially expressed genes selected were IGHG1, IL1R2, LCN2, LTF, MMP8, and OLFM4. The multivariate regression model for gene expression presented an area under the curve value of 0.922. These genes were able to discern between both shock conditions better than other biomarkers used for diagnosis of these conditions, such as procalcitonin (0.589), C-reactive protein (0.705), or neutrophils (0.605).

CONCLUSIONS

Gene expression patterns provided a robust tool to distinguish septic shock from non-septic shock postsurgical patients and shows the potential to provide an immediate and specific treatment, avoiding the unnecessary use of broad-spectrum antibiotics and the development of antimicrobial resistance, secondary infections and increase health care costs.

Endothelial Dysfunction and Neutrophil Degranulation as Central Events in Sepsis Physiopathology

Sepsis is a major health problem worldwide. It is a time-dependent disease, with a high rate of morbidity and mortality. In this sense, an early diagnosis is essential to reduce these rates. The progressive increase of both the incidence and prevalence of sepsis has translated into a significant socioeconomic burden for health systems. Currently, it is the leading cause of noncoronary mortality worldwide and represents one of the most prevalent pathologies both in hospital emergency services and in intensive care units. In this article, we review the role of both endothelial dysfunction and neutrophil dysregulation in the physiopathology of this disease. The lack of a key symptom in sepsis makes it difficult to obtain a quick and accurate diagnosis of this condition. Thus, it is essential to have fast and reliable diagnostic tools. In this sense, the use of biomarkers can be a very important alternative when it comes to achieving these goals. Both new biomarkers and treatments related to endothelial dysfunction and neutrophil dysregulation deserve to be further investigated in order to open new venues for the diagnosis, treatment and prognosis of sepsis.

Inertial-based Fluidic Platform for Rapid Isolation of Blood-borne Pathogens

INTRODUCTION

Bacterial sepsis is a life-threatening disease and a significant clinical problem caused by host responses to a microbial infection. Sepsis is a leading cause of death worldwide and, importantly, a significant cause of morbidity and mortality in combat settings, placing a considerable burden on military personnel and military health budgets. The current method of treating sepsis is restricted to pathogen identification, which can be prolonged, and antibiotic administration, which is, initially, often suboptimal. The clinical trials that have been performed to evaluate bacterial separation as a sepsis therapy have been unsuccessful, and new approaches are needed to address this unmet clinical need.

MATERIALS AND METHODS

An inertial-based, scalable spiral microfluidic device has been created to overcome these previous deficiencies through successful separation of infection-causing pathogens from the bloodstream, serving as a proof of principle for future adaptations. Fluorescent imaging of fluorescent microspheres mimicking the sizes of bacteria cells and blood cells as well as fluorescently stained Acinetobacter baumannii were used to visualize flow within the spiral. The particles were imaged when flowing at a constant volumetric rate of 0.2 mL min-1 through the device. The same device was functionalized with colistin and exposed to flowing A. baumannii at 0.2 mL h-1.

RESULTS

Fluorescent imaging within the channel under a constant volumetric flow rate demonstrated that smaller, bacteria-sized microspheres accumulated along the inner wall of the channel, whereas larger blood cell-sized microspheres accumulated within the center of the channel. Additionally, fluorescently stained A. baumannii displayed accumulation along the channel walls in agreement with calculated performance. Nearly 106 colony-forming units of A. baumannii were extracted with 100% capture efficiency from flowing phosphate-buffered saline at 0.2 mL h-1 in this device; this is at least one order of magnitude more bacteria than present in the blood of a human at the onset of sepsis.

CONCLUSIONS

This type of bacterial separation device potentially provides an ideal approach for treating soldiers in combat settings. It eliminates the need for immediate pathogen identification and determination of antimicrobial susceptibility, making it suitable for rapid use within low-resource environments. The overall simplicity and durability of this design also supports its broad translational potential to improve military mortality rates and overall patient outcomes.

OLFM4 polymorphisms predict septic shock survival after major surgery

BACKGROUND

Higher expression of olfactomedin-4 (OLFM4), a gene regulated by nuclear factor-kappa B (NF-κB), has been related to a higher risk of organ failure and death in patients with septic shock. We aimed to evaluate the association between OLFM4 single nucleotide polymorphisms (SNPs) and septic shock-related death in 175 patients who underwent major surgery, as well as its performance in predicting mortality.

MATERIALS AND METHODS

We carried out a retrospective study. A total of seven OLFM4 SNPs were genotyped by Agena Bioscience's MassARRAY platform. Statistical analysis was performed by Kaplan-Meier and Cox regression tests. The diagnostic performance for predicting septic shock-related death was evaluated by the area under the receiver-operating characteristic (AUROC) curve.

RESULTS

Patients with rs17552047 A allele and rs1891944 TT genotype had higher survival than patients with rs17552047 G allele (P-value = .024) and patients with rs1891944 CC/CT genotype (P-value = .038). However, only rs17552047 was associated with a lower risk of death under an additive inheritance model (adjusted hazard ratio [aHR] = 0.44, 95% CI = 0.27-0.71). The multivariate model with the most significant clinical variables (lactate, chronic kidney disease, peritonitis, heart disease and elective surgery) showed an AUROC of 0.776 for predicting septic shock-related death. When we added the OLFM4 rs17552047 SNP to the previous model, the AUROC was 0.811 and was close to reaching significant differences with the previous model (P-value = .065).

CONCLUSION

OLFM4 rs17552047 A allele predicts septic shock survival in patients who underwent major surgery. Furthermore, rs17552047, together with clinical variables, could be useful to predict the outcome of septic shock.

Did Economic Crisis Affect Mortality Due to Infectious Diseases? Trends of Infectious Diseases Mortality in Greece Before and After Economic Crisis

Introduction

Economic crisis and the restrictive policies applied in Greece and other countries raise questions about whether financial crises may affect the declining trend of infectious diseases. The aim of this study is to explore the impact of the economic crisis on mortality due to infectious diseases in Greece and its possible correlation with socio-economic variables affected by the crisis. 

Methods

Data including all deaths due to infectious diseases in Greece during 2001-2016 were analyzed. Annual total and cause-specific standardized death rates (SDR) and age-specific mortality rates were calculated. Cumulative SDRs and standardized rate ratios of the exposed and the non-exposed to austerity periods were computed. The correlation of mortality with Gross Domestic Product (GDP), unemployment, long-term unemployment and hospital expenditure was explored.

Results

During the exposed-to-austerity period, the SDR of infectious diseases recorded a significant increase by 5% (2.4%-7.7%), exhibiting different trends in the various groups of diseases. The cause-specific SDR increased significantly in intestinal infections, viral diseases, pneumonia, and influenza, and declined in tuberculosis and meningitis. Overall mortality was positively correlated with GDP and unemployment, and adversely with hospital expenditure.

Conclusions

The mortality of infectious disease was adversely affected by economic crisis and austerity, but the effects were found disease-dependent, with significant differences between the various groups of infectious disease. Unemployment and hospital expenditure were the main socio-economic determinants of mortality. Causal mechanisms of the impact remain unclear, requiring further research.

A fast and high-sensitivity liquid chromatography-tandem mass spectrometry method combined with in vivo microdialysis for quantification of meropenem in rabbits with sepsis under the simultaneous infusion of total parenteral nutrition: Application to a pharmacokinetic study

A fast and high-sensitivity liquid chromatography-tandem mass spectrometry (LC-MS/MS) method assisted by microdialysis was established for the determination of meropenem in total parenteral nutrition (TPN) infused plasma. A 10-times dilution was arranged for sample preparation to overcome the severe matrix effect caused by the high salt content in dialysate and complex composition of TPN. This quantification method was proved to be satisfied in selectivity, accuracy, precision, linearity (R²  > 0.998), recovery, matrix effect and stability. In the optimized conditions, the calibration curve range was set from 2 to 2000 ng/ml. This validated method was applied to pharmacokinetics study of meropenem in rabbits with sepsis (induced by cecal ligation and punctures) under simultaneous infusion of TPN to simulate the clinical practice. The results demonstrated that the LC-MS/MS method assisted by microdialysis can be used successfully for the determination of meropenem in TPN-infused plasma. Moreover, the area under the curve and the maximum concentrations in the plasma of meropenem in control rabbits were significantly smaller (P < 0.05), while clearance and distribution volumes were significantly greater (P < 0.05) than in those with sepsis. It could be speculated that drug monitoring in patients with sepsis may be necessary.

Glycoproteoform Profiles of Individual Patients' Plasma Alpha-1-Antichymotrypsin are Unique and Extensively Remodeled Following a Septic Episode

Sepsis and septic shock remain the leading causes of death in intensive care units (ICUs), yet the pathogenesis originating from the inflammatory response during sepsis remains ambiguous. Acute-phase proteins are typically highly glycosylated, and the nature of the glycans have been linked to the incidence and severity of such inflammatory responses. To further build upon these findings we here monitored, the longitudinal changes in the plasma proteome and, in molecular detail, glycoproteoform profiles of alpha-1-antichymotrypsin (AACT) extracted from plasma of ten individual septic patients. For each patient we included four different time-points, including post-operative (before sepsis) and following discharge from the ICU. We isolated AACT from plasma depleted for albumin, IgG and serotransferrin and used high-resolution native mass spectrometry to qualitatively and quantitatively monitor the multifaceted glycan microheterogeneity of desialylated AACT, which allowed us to monitor how changes in the glycoproteoform profiles reflected the patient's physiological state. Although we observed a general trend in the remodeling of the AACT glycoproteoform profiles, e.g. increased fucosylation and branching/LacNAc elongation, each patient exhibited unique features and responses, providing a resilient proof-of-concept for the importance of personalized longitudinal glycoproteoform profiling. Importantly, we observed that the AACT glycoproteoform changes induced by sepsis did not readily subside after discharge from ICU.

Therapeutic Effect of an Anti-Human Programmed Death-Ligand 1 (PD-L1) Nanobody on Polymicrobial Sepsis in Humanized Mice

BACKGROUND Immunosuppression is regarded as the main cause of death induced by sepsis. Anti-programmed death-ligand 1 (PD-L1) therapy is promising in reversing sepsis-induced immunosuppression but no evidence is available on use of commercially available anti-PD-L1 medications for this indication. The present preclinical study was performed to investigate the therapeutic effect of an anti-PD-L1 nanobody (KN035) in sepsis. MATERIAL AND METHODS The level of expression of PD-L1 in PD-L1 humanized mice was confirmed with flow cytometry. Plasma concentrations of KN035 at different dosages at different time points were detected using an enzyme-linked immunosorbent assay. PD-L1 humanized mice were allocated into 4 groups: sham, cecal ligation and puncture (CLP), isotype (isotype+CLP), and PD-L1 (KN035+CLP). The 7-day survival rate was observed to investigate outcomes in CLP mice. Disease severity was assessed with histopathological scoring of mice lungs and livers. Immune status was assessed based on cell apoptosis in the spleen and bacterial clearance. RESULTS PD-L1 levels were significantly elevated in peripheral lymphocytes, monocytes, and neutrophils after CLP surgery. Blood concentrations of KN035 showed that 2.5 mg/kg had potential to be an ideal dosage for KN035 therapy. Survival analysis demonstrated that KN035 was associated with significantly reduced mortality on Day 7 after surgery (P=0.0083). The histopathological tests showed that KN035 alleviated sepsis-induced injury in the lungs and liver. KN035 reduced the number of apoptotic cells in the spleen and almost eliminated bacterial colonies in the peritoneal lavage fluid from the CLP mice. CONCLUSIONS KN035, an anti-PD-L1 antibody, can improve the rate of survival in CLP mice and alleviate sepsis-induced apoptosis in the spleen.

The Prevalence, Risk Factors, and Outcomes of Sepsis in Critically Ill Patients in China: A Multicenter Prospective Cohort Study

Background: Sepsis is a main cause of morbidity and mortality in critically ill patients. The epidemiology of sepsis in high-income countries is well-known, but information on sepsis in middle- or low-income countries is still deficient, especially in China. The purpose of this study was to explore the prevalence, characteristics, risk factors, treatment, and outcomes of sepsis in critically ill patients in tertiary hospitals in China. Methods: A multicenter prospective observational cohort study was performed with consecutively collected data from adults who stayed in any intensive care unit (ICU) for at least 24 h; data were collected from 1 January 2014 to 31 August 2015, and patients were followed until death or discharge from the hospital. Results: A total of 4,910 patients were enrolled in the study. Of these, 2,086 (42.5%) presented with sepsis or septic shock on admission to the ICU or within the first 48 h after admission to the ICU. ICU mortality was higher in patients with sepsis (13.1%) and septic shock (39.0%) and varied according to geographical region. Acinetobacter, Pseudomonas, and Staphylococcus infections were associated with increased ICU mortality. In addition, age, Acute Physiology, and Chronic Health Evaluation II (APACHE II) scores, pre-existing cardiovascular diseases, malignant tumors, renal replacement therapy (RRT), and septic shock were independent risk factors for mortality in patients with sepsis. The prompt administration of antibiotics (OR 0.65, 95% CI 0.46-0.92) and 30 mL/kg of initial fluid resuscitation during the first 3 h (OR 0.43, 95% CI 0.30-0.63) improved the outcome in patients with septic shock. Conclusions: Sepsis was common and was associated with a high mortality rate in critically ill patients in tertiary hospitals in China. The prompt administration of antibiotics and 30 mL/kg fluid resuscitation decreased the risk of mortality.

Environmental factors are associated with hospital admissions for sepsis-related pneumonia: A bidirectional case-crossover design

OBJECTIVE

Pneumonia is a common cause of morbidity and sepsis worldwide, mainly in the elderly. We evaluated the impact of short-term exposure to environmental factors on hospital admissions for sepsis-related pneumonia in a nationwide study in Spain.

METHODS

We conducted a bidirectional case-crossover study in patients who had sepsis-related pneumonia in 2013. Data were obtained from the Minimum Basic Data Set (MBDS) and the State Meteorological Agency (AEMET) of Spain. Conditional logistic regressions were used to evaluate the association between environmental factors (temperature, relative humidity, NO₂, SO₂, O₃, PM₁₀, and CO) and hospital admissions with sepsis-related pneumonia.

RESULTS

A total of 3,262,758 hospital admissions were recorded in the MBDS, of which, 253,467 were patients with sepsis. Among those, 67,443 had sepsis-related pneumonia and zip code information. We found inverse associations [adjusted odds ratio (aOR) values < 1] between short-term exposure to temperature and hospital admissions for sepsis-related pneumonia. Moreover, short-term exposure to higher levels of relative humidity, NO₂, SO₂, O₃, PM₁₀, and CO were directly associated (aOR values > 1) with a higher risk of hospital admissions for sepsis-related pneumonia. Overall, the impact of environmental factors was more prominent with increasing age, mainly among the elderly aged 65 or over.

CONCLUSION

Short-term exposure to environmental factors (temperature, relative humidity, NO₂, SO₂, O₃, CO, and PM₁₀) was associated with a higher risk of hospital admissions for sepsis-related pneumonia. Our findings support the role of environmental factors in monitoring the risk of hospital admissions for sepsis-related pneumonia and can help plan and prepare public health resources.

Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis

PURPOSE

To investigate the global burden of sepsis in hospitalized adults by updating and expanding a systematic review and meta-analysis and to compare findings with recent Institute for Health Metrics and Evaluation (IHME) sepsis estimates.

METHODS

Thirteen electronic databases were searched for studies on population-level sepsis incidence defined according to clinical criteria (Sepsis-1, -2: severe sepsis criteria, or sepsis-3: sepsis criteria) or relevant ICD-codes. The search of the original systematic review was updated for studies published 05/2015-02/2019 and complemented by a search targeting low- or middle-income-country (LMIC) studies published 01/1979-02/2019. We performed a random-effects meta-analysis with incidence of hospital- and ICU-treated sepsis and proportion of deaths among these sepsis cases as outcomes.

RESULTS

Of 4746 results, 28 met the inclusion criteria. 21 studies contributed data for the meta-analysis and were pooled with 30 studies from the original meta-analysis. Pooled incidence was 189 [95% CI 133, 267] hospital-treated sepsis cases per 100,000 person-years. An estimated 26.7% [22.9, 30.7] of sepsis patients died. Estimated incidence of ICU-treated sepsis was 58 [42, 81] per 100,000 person-years, of which 41.9% [95% CI 36.2, 47.7] died prior to hospital discharge. There was a considerably higher incidence of hospital-treated sepsis observed after 2008 (+ 46% compared to the overall time frame).

CONCLUSIONS

Compared to results from the IHME study, we found an approximately 50% lower incidence of hospital-treated sepsis. The majority of studies included were based on administrative data, thus limiting our ability to assess temporal trends and regional differences. The incidence of sepsis remains unknown for the vast majority of LMICs, highlighting the urgent need for improved epidemiological sepsis surveillance.

Epidemiology, management and costs of sepsis in Spain (2008-2017): a retrospective multicentre study

Objective: To update the profile of patients attended with sepsis in specialised care centres in Spain, to analyse in-hospital mortality, disease management and costs between 2008 and 2017.Methods: Admission records registered between 1 January 2008 and 31 December 2017 obtained from a Spanish National hospital discharge database for public and private hospitals. Centres are responsible for data codification, evaluation and confidentiality. The database is validated internally and is subjected to periodic audits. Files corresponding to patients with sepsis and septic shock were selected by means of the International Statistical Classification of Diseases and Related Health Problems, 9th version and 10th version codes. These criteria claimed 311,674 records of 288,211 patients. Direct medical costs of secondary healthcare include expenses derived from the admission: examination, medication, treatment and costs of nutrition, personnel, medical equipment and resources.Results: More than 53% of all patients were males, with a mean age of 73.0 years. Fifty-one percent of the identified admissions were due to a sepsis without organ dysfunction, 21.5% to sepsis with organ dysfunction, and 27.3% registered a septic shock. The incidence of sepsis increased 2.7 times between 2008 and 2017, reaching a hospital incidence of 5.7 per 10,000 inhabitants in 2017. Case fatality rate (CFR) was 23.2% and 35.0% in patients without and with organ dysfunction in 2017, respectively, and 42.9% in patient with septic shock, decreasing over time. Mean annual direct medical costs of specialised care over the study period were €6664 and €8084 per patient in patients with sepsis without and with organ dysfunction, respectively, and €11,359 per patient in those with septic shock.Conclusions: The social and economic burden of sepsis in Spain continues to grow (incidence, total costs). Despite its general decreasing trend, CFR remains elevated, thus, patients could benefit from further research and protocol revision.

Epidemiological Trend of Sepsis in Patients with Hospital Admissions Related to Hepatitis C in Spain (2000-2015): A Nationwide Study

Background: Hepatitis C virus (HCV) infection predisposes patients to other infectious diseases, such as sepsis. We aimed to analyze epidemiological trends of sepsis-related admissions, deaths, and costs in hospital admissions with chronic hepatitis C who had a hospital admission in Spain. Methods: We performed a retrospective study of all hospitalizations involving chronic hepatitis C in the Spanish Minimum Basic Data Set (MBDS) between 2000 and 2015. This period was divided into four calendar periods (2000–2004, 2005–2007, 2008–2011, and 2012–2015). Results: We selected 868,523 hospital admissions of patients with chronic hepatitis C over 16 years in the Spanish MBDS. Among them, we found 70,976 (8.17%) hospital admissions of patients who developed sepsis, of which 13,915 (19.61%) died during admission. We found an upward trend, from 2000–2003 to 2012–2015, in the rate of sepsis-related admission (from 6.18% to 10.64%; p < 0.001), the risk of sepsis-related admission (from 1.31 to 1.55; p < 0.001), and the sepsis-related cost per hospital admission (from 7198€ to above 9497€; p < 0.001). However, we found a downward trend during the same study period in the sepsis case-fatality rate (from 21.99% to 18.16%; p < 0.001), the risk of sepsis-related death (from 0.81 to 0.56; p < 0.001), and the length of hospital stay (LOHS) (from 16.9 to 13.9; p < 0.001). Moreover, the rate of bacterial Gram-positive and candidiasis infections decreased, while Gram-negative microorganisms increased from 2000–2003 to 2012–2015. Conclusions: Sepsis, in chronic hepatitis C patients admitted to the hospital, has increased the period 2000–2015 and has been an increasing burden for the Spanish public health system. However, there has also been a significant reduction in lethality and LOHS during the study period. In addition, the most prevalent specific microorganisms have also changed in this period.

Comparison of quick SOFA and SIRS scales at the bedside of patients with Staphylococcus aureus bacteremia

Introducción:

Staphylococcus aureus es una de las principales causas de bacteriemia, adquirida en la comunidad o asociada con la atención en salud, la cual presenta un gran porcentaje de complicaciones y elevadas tasas de morbilidad y mortalidad. Los criterios SRIS (Systemic Inflammatory Response Syndrome) se han usado tradicionalmente con el fin de establecer la presencia de sepsis; sin embargo, recientemente se ha cuestionado su valor predictivo dada su baja sensibilidad y especificidad. En el 2016, apareció la escala qSOFA (quick Sequential Organ Failure Assessment), como una nueva herramienta para la evaluación rápida de las infecciones en los servicios de urgencias.

Objetivo.

Comparar las herramientas qSOFA y SRIS para la predicción de la bacteriemia por S. aureus.

Materiales y métodos.

Se hizo un estudio observacional sobre el comportamiento clínico de pacientes con bacteriemia por S. aureus para evaluar el perfil de resistencia fenotípica, algunas características sociodemográficas, clínicas y de laboratorio, las complicaciones y la mortalidad, así como los resultados de las evaluaciones con la escala qSOFA y los criterios SRIS, para establecer cuál podría predecir mejor la presencia de bacteriemia por S. aureus.

Resultados.

Se seleccionaron 26 pacientes con bacteriemia, en cuyas muestras S. aureus había sido el segundo germen más frecuentemente aislado. Se encontró una mortalidad del 50 % (13 casos) y una prevalencia del 30 % de S. aureus resistente a meticilina (SARM). Según los puntajes clínicos obtenidos, la escala qSOFA fue positiva en 30,8 % de los pacientes y los criterios SRIS lo fueron en el 92,3 %.

Discusión.

Se encontró una elevada mortalidad en la población analizada. La escala qSOFA fue menos efectiva para el diagnóstico que los criterios clásicos de reacción inflamatoria sistémica.

Identifying Septic Shock Populations Benefitting From Polymyxin B Hemoperfusion: A Prospective Cohort Study Incorporating a Restricted Cubic Spline Regression Model

INTRODUCTION

Polymyxin B hemoperfusion (PMX-HP) is an adjuvant therapy for sepsis or septic shock that removes circulating endotoxin. However, PMX-HP has seldom achieved expectations in randomized trials targeting nonspecific overall sepsis patients. If used in an optimal population, PMX-HP may be beneficial. This study aimed to identify the optimal population for PMX-HP in patients with septic shock.

METHODS

We used a prospective nationwide cohort targeting consecutive adult patients with severe sepsis (Sepsis-2) in 59 intensive care units in Japan. Associations between PMX-HP therapy and in-hospital mortality were assessed using multivariable Cox proportional hazard regression models. To identify best targets for PMX-HP, we developed a non-linear restricted cubic spline model including two-way interaction term (treatment × Acute Physiology and Chronic Health Evaluation [APACHE] II score/Sequential Organ Failure Assessment [SOFA] score) and three-way interaction term (treatment × age × each score).

RESULTS

The final study cohort comprised 741 sepsis patients (92 received PMX-HP, 625 did not). Cox proportional hazards regression model adjusted for the covariates suggested no association between PMX-HP therapy and improved mortality overall. Effect modification of PMX-HP by APACHE II score was statistically significant (P for interaction = 0.189) but non-significant for SOFA score (P for interaction = 0.413). Three-way interaction analysis revealed suppressed risk hazard in the PMX-HP group versus control group only in septic shock patients with high age and in the most severe subset of both scores, whereas increased risk hazard was observed in those with high age but in the lower severity subset of both scores.

CONCLUSIONS

Our results suggested that although PMX-HP did not reduce in-hospital mortality among overall septic shock patients, it may benefit a limited population with high age and higher disease severity.

Machine learning for the prediction of sepsis: a systematic review and meta-analysis of diagnostic test accuracy

PURPOSE

Early clinical recognition of sepsis can be challenging. With the advancement of machine learning, promising real-time models to predict sepsis have emerged. We assessed their performance by carrying out a systematic review and meta-analysis.

METHODS

A systematic search was performed in PubMed, Embase.com and Scopus. Studies targeting sepsis, severe sepsis or septic shock in any hospital setting were eligible for inclusion. The index test was any supervised machine learning model for real-time prediction of these conditions. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, with a tailored Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist to evaluate risk of bias. Models with a reported area under the curve of the receiver operating characteristic (AUROC) metric were meta-analyzed to identify strongest contributors to model performance.

RESULTS

After screening, a total of 28 papers were eligible for synthesis, from which 130 models were extracted. The majority of papers were developed in the intensive care unit (ICU, n = 15; 54%), followed by hospital wards (n = 7; 25%), the emergency department (ED, n = 4; 14%) and all of these settings (n = 2; 7%). For the prediction of sepsis, diagnostic test accuracy assessed by the AUROC ranged from 0.68-0.99 in the ICU, to 0.96-0.98 in-hospital and 0.87 to 0.97 in the ED. Varying sepsis definitions limit pooling of the performance across studies. Only three papers clinically implemented models with mixed results. In the multivariate analysis, temperature, lab values, and model type contributed most to model performance.

CONCLUSION

This systematic review and meta-analysis show that on retrospective data, individual machine learning models can accurately predict sepsis onset ahead of time. Although they present alternatives to traditional scoring systems, between-study heterogeneity limits the assessment of pooled results. Systematic reporting and clinical implementation studies are needed to bridge the gap between bytes and bedside.

Old subjects with sepsis in the emergency department: trend analysis of case fatality rate

Background

The burden of sepsis represents a global health care problem. We aimed to assess the case fatality rate (CFR) and its predictors in subjects with sepsis admitted to a general Italian hospital from 2009 to 2016, stratified by risk score.

Methods

We performed a retrospective analysis of all sepsis-related hospitalizations after Emergency Department (ED) visit in a public Italian hospital in an 8-year period. A risk score to predict CFR was computed by logistic regression analysis of selected variables in a training set (2009–2012), and then confirmed in the whole study population. A trend analysis of CFR during the study period was performed dividing patient as high-risk (upper tertile of risk score) or low-risk.

Results

Two thousand four hundred ninety-two subjects were included. Over time the incidental admission rate (no. of sepsis-related admissions per 100 total admissions) increased from 4.1% (2009–2010) to 5.4% (2015–2016); P < 0.001, accompanied by a reduced CFR (from 38.0 to 18.4%; P < 0.001). A group of 10 variables (admission to intensive care unit, cardio-vascular dysfunction, HIV infection, diabetes, age ≥ 80 years, respiratory diseases, number of organ dysfunction, digestive diseases, dementia and cancer) were selected by the logistic model to predict CFR with good accuracy: AUC 0.873 [0.009]. Along the years CFR decreased from 31.8% (2009–2010) to 25.0% (2015–2016); P = 0.007. The relative proportion of subjects ≥80 years (overall, 52.9% of cases) and classified as high-risk did not change along the years. CFR decreased only in low-risk subjects (from 13.3 to 5.2%; P < 0.001), and particularly in those aged ≥80 (from 18.2 to 6.6%; P = 0.003), but not in high-risk individuals (from 69.9 to 64.2%; P = 0.713).

Conclusion

Between 2009 and 2016 the incidence of sepsis-related hospitalization increased in a general Italian hospital, with a downward trend in CFR, only limited to low-risk patients and particularly to subjects ≥80 years.

Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.

A novel cross-linked haemoglobin-based oxygen carrier is beneficial to sepsis in rats

Pathological hypoxia-induced organ dysfunction contributes to the high mortality of sepsis. Because of the microcirculation dysfunction following severe sepsis, it is difficult for erythrocytes to transport oxygen to hypoxic tissues. Haemoglobin-based oxygen carriers (HBOCs) are capable of delivering oxygen to hypoxic tissues. The aim of this study is to observe the potential benefits of a novel bovine-derived, non-polymerized, cell-free HBOC solution, YQ23, on sepsis in rats. Cecum ligation and puncture was performed to induce sepsis in Sprague-Dawley rats. Effects of Lactate Ringer's solution (LR), YQ23, and whole blood on oxygen delivery and consumption, mitochondrial function, organ protection and animal survival were observed. LR failed to restore oxygen delivery and the therapeutic effects were limited, whereas low dosage of YQ23 and whole blood significantly increased the tissue oxygen delivery and consumption, improved the mitochondrial function of heart, liver, kidney and intestine, prevented the vital organs injuries and improved the animal survival. The effects of 0.15 g·kg^-1 YQ23 resembled that of the whole blood. In addition, YQ23 did not induce renal toxicity, severe oxidative effect and acute vasoconstriction. Thus, YQ23 is a safe and effective resuscitation fluid for sepsis.

P2X4 receptors, immunity, and sepsis

Sepsis is life-threatening systemic organ dysfunction caused by a deregulated host response to an infectious insult. Currently, the treatment of sepsis is limited to the use of antibiotics, fluids, and cardiovascular/respiratory support. Despite these interventions, septic mortality remains high, with reduced life quality in survivors. For this reason, the identification of novel drug targets is a pressing task of modern pharmacology. According to a recent research, it appears that P2 purinergic receptors, which can regulate the host's response to infections, have been identified as potential targets for the treatment of sepsis. Among P2 receptors, the P2X4 receptor has recently captured the attention of the research community owing to its role in protecting against infections, inflammation, and organ injury. The present review provides an outline of the role played by P2X4 receptors in the modulation of the host's response to sepsis and the promise that targeting this receptor holds in the treatment of sepsis.

Risk and Prognostic Factors in Very Old Patients with Sepsis Secondary to Community-Acquired Pneumonia

Background: Little is known about risk and prognostic factors in very old patients developing sepsis secondary to community-acquired pneumonia (CAP). Methods: We conducted a retrospective observational study of data prospectively collected at the Hospital Clinic of Barcelona over a 13-year period. Consecutive patients hospitalized with CAP were included if they were very old (≥80 years) and divided into those with and without sepsis for comparison. Sepsis was diagnosed based on the Sepsis-3 criteria. The main clinical outcome was 30-day mortality. Results: Among the 4219 patients hospitalized with CAP during the study period, 1238 (29%) were very old. The prevalence of sepsis in this age group was 71%. Male sex, chronic renal disease, and diabetes mellitus were independent risk factors for sepsis, while antibiotic therapy before admission was independently associated with a lower risk of sepsis. Thirty-day and intensive care unit (ICU) mortality did not differ between patients with and without sepsis. In CAP-sepsis group, chronic renal disease and neurological disease were independent risk factors for 30-day mortality. Conclusion: In very old patients hospitalized with CAP, in-hospital and 1-year mortality rates were increased if they developed sepsis. Antibiotic therapy before hospital admission was associated with a lower risk of sepsis.