Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign

The pathogenesis and potential therapeutic targets in sepsis

Sepsis is defined as "a life-threatening organ dysfunction caused by dysregulated host systemic inflammatory and immune response to infection." At present, sepsis continues to pose a grave healthcare concern worldwide. Despite the use of supportive measures in treating traditional sepsis, such as intravenous fluids, vasoactive substances, and oxygen plus antibiotics to eradicate harmful pathogens, there is an ongoing increase in both the morbidity and mortality associated with sepsis during clinical interventions. Therefore, it is urgent to design specific pharmacologic agents for the treatment of sepsis and convert them into a novel targeted treatment strategy. Herein, we provide an overview of the molecular mechanisms that may be involved in sepsis, such as the inflammatory response, immune dysfunction, complement deactivation, mitochondrial damage, and endoplasmic reticulum stress. Additionally, we highlight important targets involved in sepsis-related regulatory mechanisms, including GSDMD, HMGB1, STING, and SQSTM1, among others. We summarize the latest advancements in potential therapeutic drugs that specifically target these signaling pathways and paramount targets, covering both preclinical studies and clinical trials. In addition, this review provides a detailed description of the crosstalk and function between signaling pathways and vital targets, which provides more opportunities for the clinical development of new treatments for sepsis.

Clinical and health inequality risk factors for non-COVID-related sepsis during the global COVID-19 pandemic: a national case-control and cohort study

Background

Sepsis, characterised by significant morbidity and mortality, is intricately linked to socioeconomic disparities and pre-admission clinical histories. This study aspires to elucidate the association between non-COVID-19 related sepsis and health inequality risk factors amidst the pandemic in England, with a secondary focus on their association with 30-day sepsis mortality.

Methods

With the approval of NHS England, we harnessed the OpenSAFELY platform to execute a cohort study and a 1:6 matched case-control study. A sepsis diagnosis was identified from the incident hospital admissions record using ICD-10 codes. This encompassed 248,767 cases with non-COVID-19 sepsis from a cohort of 22.0 million individuals spanning January 1, 2019, to June 31, 2022. Socioeconomic deprivation was gauged using the Index of Multiple Deprivation score, reflecting indicators like income, employment, and education. Hospitalisation-related sepsis diagnoses were categorised as community-acquired or hospital-acquired. Cases were matched to controls who had no recorded diagnosis of sepsis, based on age (stepwise), sex, and calendar month. The eligibility criteria for controls were established primarily on the absence of a recorded sepsis diagnosis. Associations between potential predictors and odds of developing non-COVID-19 sepsis underwent assessment through conditional logistic regression models, with multivariable regression determining odds ratios (ORs) for 30-day mortality.

Findings

The study included 224,361 (10.2%) cases with non-COVID-19 sepsis and 1,346,166 matched controls. The most socioeconomic deprived quintile was associated with higher odds of developing non-COVID-19 sepsis than the least deprived quintile (crude OR 1.80 [95% CI 1.77-1.83]). Other risk factors (after adjusting comorbidities) such as learning disability (adjusted OR 3.53 [3.35-3.73]), chronic liver disease (adjusted OR 3.08 [2.97-3.19]), chronic kidney disease (stage 4: adjusted OR 2.62 [2.55-2.70], stage 5: adjusted OR 6.23 [5.81-6.69]), cancer, neurological disease, immunosuppressive conditions were also associated with developing non-COVID-19 sepsis. The incidence rate of non-COVID-19 sepsis decreased during the COVID-19 pandemic and rebounded to pre-pandemic levels (April 2021) after national lockdowns had been lifted. The 30-day mortality risk in cases with non-COVID-19 sepsis was higher for the most deprived quintile across all periods.

Interpretation

Socioeconomic deprivation, comorbidity and learning disabilities were associated with an increased odds of developing non-COVID-19 related sepsis and 30-day mortality in England. This study highlights the need to improve the prevention of sepsis, including more precise targeting of antimicrobials to higher-risk patients.

Funding

The UK Health Security Agency, Health Data Research UK, and National Institute for Health Research.

Exploring the Impact of Prior Beta-Blocker and Calcium Channel Blocker Usage on Clinical Outcomes in Critically Ill Patients With Sepsis: An Observational Study

Background Sepsis is associated with increased Ca++ levels in many cell types that can cause cytotoxicity and cell death through multiple mechanisms. In patients with sepsis, limiting beta-adrenergic stimulation may also be beneficial. The intense adrenergic stimulation of sepsis results in cardiac and extra-cardiac effects. In the intensive care unit (ICU), the question of whether to continue calcium channel blockers (CCBs) and beta-blockers in patients with sepsis who were using these medications before ICU admission is of significant concern. Methodology In this prospective observational study, we have included 114 patients who met the inclusion criteria of being diagnosed as having sepsis, aged 18 to 65 years, and expected to stay in the ICU for more than 72 hours. These patients were divided into three groups: group 1 consisted of patients taking CCBs before admission, group 2 included those taking beta-blockers before admission, and group 3 served as the control group, comprising patients who had not taken either of these medications before admission. Disease severity in the ICU was assessed and documented by the Sequential Organ Failure Assessment (SOFA) score. Clinical outcomes among three groups were compared regarding the need for vasopressor support, serum procalcitonin (PCT), serum lactate, serum quantitative C-reactive protein (qCRP), SOFA score, and 28 days mortality. Parametric data were expressed as mean ± standard deviation. The Kruskal-Wallis test was used to analyze parametric data between the two groups and among three groups. Results Mortality was found lower in group 1 (21.05%) and group 2 (26.31%) than in group 3 (47.36%), and this association was found to be statistically significant (P = 0.033). We also found a significant difference in mortality between groups 1 and 3 (P = 0.015) and no significant difference between groups 2 and 3 (P = 0.057). Mortality was found to be significantly associated with high SOFA scores on days 1, 3, and 7. Conclusions From the aforementioned results, we concluded that the mortality rate in patients with sepsis was improved when they were pretreated with beta-blockers or CCBs before admission to the ICU and that medication should be continued if not contraindicated in the ICU course.

Ultraporous Polyquaternium-Carboxylated Chitosan Composite Hydrogel Spheres with Anticoagulant, Antibacterial, and Rapid Endotoxin Removal Profiles for Sepsis Treatment

Hemoperfusion is an important method to remove endotoxins and save the lives of patients with sepsis. However, the current adsorbents for hemoperfusion have disadvantages of insufficient endotoxin adsorption capacity, poor blood compatibility, and so on. Herein, we proposed a novel emulsion templating (ET) method to prepare ultraporous and double-network carboxylated chitosan (CCS)-poly(diallyl dimethylammonium chloride) (PDDA) hydrogel spheres (ET-CCSPD), bearing both negative and positive charges. CCS was introduced to balance the strong positive charges of PDDA to improve hemocompatibility, and emulsion templates endowed the adsorbent with an ultraporous structure for enhanced adsorption efficacy. The ET-CCSPDs neither damaged blood cells nor activated complement responses. In addition, the activated partial thromboplastin time (APTT) was prolonged to 8.5 times, which was beneficial for reducing the injection of anticoagulant in patients. The ET-CCSPDs had excellent scavenging performance against bacteria and endotoxin, with removal ratios of 96.7% for E. coli and 99.8% for S. aureus, respectively, and the static removal ratio of endotoxin in plasma was as high as 99.1% (C₀ = 5.50 EU/mL, critical illness level). An adsorption cartridge filled with the ET-CCSPDs could remove 84.7% of endotoxin within 1 h (C₀ = 100 EU/mL in PBS). Interestingly, the ET-CCSPDs had a good inhibitory effect on the cytokines produced by endotoxin-mediated septic blood. By developing the ET method to prepare ultraporous and double-network adsorbents, the problems of low adsorption efficiency and poor blood compatibility of traditional endotoxin adsorbents have been solved, thus opening a new route to fabricate absorbents for blood purification.

Patient, Public, and Healthcare Professional's Sepsis Awareness, Knowledge, and Information Seeking Behaviors: A Scoping Review

Sepsis awareness and understanding are important aspects of prevention, recognition, and clinical management of sepsis. We conducted a scoping review to identify and map the literature related to sepsis awareness, general knowledge, and information-seeking behaviors with a goal to inform future sepsis research and knowledge translation campaigns.

Bacteriological profile and antimicrobial resistance pattern among patients with sepsis: A retrospective cohort study

BACKGROUND

As the susceptibility pattern of different pathogens varies among different settings, the evaluation of appropriate clinical diagnosis and timely initiation of the empirical antibiotic treatment based on the local susceptibility data is crucial in the management of sepsis.

METHODS

A retrospective study was conducted among adult patients with sepsis at a charitable hospital in Mangaluru. The essential details such as patient demographics, culture specimens, organisms, resistance/susceptibility pattern, laboratory data, empirical therapy and clinical outcomes were collected from the medical records. Descriptive statistics were used in analysing the data.

RESULTS

A total of 425 patients diagnosed with sepsis during the study period were screened to meet the sample size of 373 positive cultures, among which 367 (91.3%) samples yielded the bacterial isolates, of which 250 (68.1%) and 117 (31.9%) were gram-negative and gram-positive organisms, respectively. The most common gram-negative organisms isolated were K pneumoniae (19.9%), A baumannii (19.6%) and E coli (12.8%); while Coagulase-negative staphylococcus (14.4%) and S aureus (8.4%) were the predominant gram-positive organisms. The isolated pathogens showed a resistance rate of >50% to the most commonly used antibiotics.

CONCLUSION

The present study provides information on the prevalence of the most common pathogens and their resistance pattern to different antibiotics, which plays a vital role in the selection and timely initiation of the appropriate empirical antibiotic therapy.

Norepinephrine Infusion in the Emergency Department in Septic Shock Patients: A Retrospective 2-Years Safety Report and Outcome Analysis

Hemodynamic optimization during sepsis and septic shock is based on a prompt and large fluid resuscitation strategy associated with early administration of norepinephrine. In our hospital, norepinephrine is administered in the emergency department (ED), within a protocol-guided management context, to reduce norepinephrine infusion timing due to central line insertion. This choice, however, can be associated with side effects. Objectives: We conducted a retrospective analysis regarding the safety of norepinephrine in the ED. We also appraised the association between in-hospital mortality and predefined ED variables and patients’ admission severity scores. Design, settings, and participants: This was a retrospective analysis of electronic sheets of the ED of a tertiary hospital in the North of Italy. Outcomes measure and analysis: Electronic documentation was assessed to identify local and systemic side effects. We considered two subgroups of patients according to the in-hospital clinical paths: (1) those admitted in the intensive care unit (ICU); and (2) those who received a ceiling of care decision. We collected and considered variables related to septic shock treatment in the ED and analyzed their association with in-hospital mortality. Main Results: We considered a two-year period, including 108,033 ED accesses, and ultimately analyzed data from 127 patients. Side effects related to the use of this drug were reported in five (3.9%) patients. Thirty patients (23.6%) were transferred to the ICU from the ED, of whom six (20.0%) died. Twenty-eight patients (22.0%) received a ceiling of care indication, of whom 21 (75.0%) died. Of the 69 (54.3%) finally discharged to either medical or surgical wards, 21 (30.4%) died. ICU admission was the only variable significantly associated to in-hospital mortality in the multivariable analysis [OR (95% CI) = 4.48 (1.52–13.22); p-value = 0.007]. Conclusions: Norepinephrine peripheral infusion in the ED was associated with a low incidence of adverse events requiring discontinuation (3.9%). It could be considered safe within <12 h when a specific line management protocol and pump infusion protocol are adopted. None of the variables related to septic shock management affected in-hospital mortality, except for the patient’s ICU admission.

Infection Control Practices Among Private Practicing Dentists in Nairobi During the Pre-coronavirus Disease 2019 Period

Background: Cross-infection control is a dynamic field that requires frequent updates due to emerging diseases, advancement in technology, and scientific knowledge. Despite wide publication of guidelines, a laxity in compliance to the standard precautions for infection control by dental health-care personnel (DHCP) has been reported globally. Therefore, there is need to review previous shortcomings in order to adequately secure dental practices during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to determine knowledge and infection control practices by dentists in private practices. The study was done a few months before the first COVID-19 case was confirmed in Kenya. Materials and Methods: The study design was a descriptive cross-sectional study that was carried out in selected private dental clinics located in Nairobi. Data were collected using an interviewer-administered questionnaire. Convenience sampling method was utilized, while data were analyzed using SPSS 20.0.0.0. Results: A total of 71 private dentists participated in the study. Their mean age was 38 years with an age range of 27-55 years. Almost all (70, 98.6%) the dentists were able to define cross infection correctly. Majority (62, 87.3%) correctly differentiated between sterilization and disinfection, while 9 (12.7%) had difficulties. Most (68, 95.8%) of the respondents were aware of the standard precautions for cross-infection control. All participants used face masks and gloves. About half of them (38, 54%) practiced hand washing after removal of gloves and 31 (43.7%) before and after wearing of gloves, while 2 (2.8%) washed hands only before wearing gloves. Only 31 (42.3%) and 26 (36.6%) participants reported use of rubber dam isolation and impervious barrier, respectively. All the dentists reported disposal of sharps into especially labeled containers, while about half reported use of disposable suction traps and amalgam separators. Conclusion: The dentists had a good knowledge on various aspects of infection control measures that were studied. Use of basic personal protective equipment was widely practiced. There were irregularities in hand hygiene, use of rubber dam, surface barriers, and waste management. The work highlights that many dentists were unprepared to manage infectious risk during the COVID-19 outbreak, which justified the closure of the dental facilities. Development of strategies to promote adequate and safe practice is highly recommended.

Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study

BACKGROUND

Sepsis is life-threatening organ dysfunction due to a dysregulated host response to infection. It is considered a major cause of health loss, but data for the global burden of sepsis are limited. As a syndrome caused by underlying infection, sepsis is not part of standard Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimates. Accurate estimates are important to inform and monitor health policy interventions, allocation of resources, and clinical treatment initiatives. We estimated the global, regional, and national incidence of sepsis and mortality from this disorder using data from GBD 2017.

METHODS

We used multiple cause-of-death data from 109 million individual death records to calculate mortality related to sepsis among each of the 282 underlying causes of death in GBD 2017. The percentage of sepsis-related deaths by underlying GBD cause in each location worldwide was modelled using mixed-effects linear regression. Sepsis-related mortality for each age group, sex, location, GBD cause, and year (1990-2017) was estimated by applying modelled cause-specific fractions to GBD 2017 cause-of-death estimates. We used data for 8·7 million individual hospital records to calculate in-hospital sepsis-associated case-fatality, stratified by underlying GBD cause. In-hospital sepsis-associated case-fatality was modelled for each location using linear regression, and sepsis incidence was estimated by applying modelled case-fatality to sepsis-related mortality estimates.

FINDINGS

In 2017, an estimated 48·9 million (95% uncertainty interval [UI] 38·9-62·9) incident cases of sepsis were recorded worldwide and 11·0 million (10·1-12·0) sepsis-related deaths were reported, representing 19·7% (18·2-21·4) of all global deaths. Age-standardised sepsis incidence fell by 37·0% (95% UI 11·8-54·5) and mortality decreased by 52·8% (47·7-57·5) from 1990 to 2017. Sepsis incidence and mortality varied substantially across regions, with the highest burden in sub-Saharan Africa, Oceania, south Asia, east Asia, and southeast Asia.

INTERPRETATION

Despite declining age-standardised incidence and mortality, sepsis remains a major cause of health loss worldwide and has an especially high health-related burden in sub-Saharan Africa.

FUNDING

The Bill & Melinda Gates Foundation, the National Institutes of Health, the University of Pittsburgh, the British Columbia Children's Hospital Foundation, the Wellcome Trust, and the Fleming Fund.