Sepsis and sex: can we look beyond our hormones?

Multidrug-Resistant Sepsis: A Critical Healthcare Challenge

Sepsis globally accounts for an alarming annual toll of 48.9 million cases, resulting in 11 million deaths, and inflicts an economic burden of approximately USD 38 billion on the United States healthcare system. The rise of multidrug-resistant organisms (MDROs) has elevated the urgency surrounding the management of multidrug-resistant (MDR) sepsis, evolving into a critical global health concern. This review aims to provide a comprehensive overview of the current epidemiology of (MDR) sepsis and its associated healthcare challenges, particularly in critically ill hospitalized patients. Highlighted findings demonstrated the complex nature of (MDR) sepsis pathophysiology and the resulting immune responses, which significantly hinder sepsis treatment. Studies also revealed that aging, antibiotic overuse or abuse, inadequate empiric antibiotic therapy, and underlying comorbidities contribute significantly to recurrent sepsis, thereby leading to septic shock, multi-organ failure, and ultimately immune paralysis, which all contribute to high mortality rates among sepsis patients. Moreover, studies confirmed a correlation between elevated readmission rates and an increased risk of cognitive and organ dysfunction among sepsis patients, amplifying hospital-associated costs. To mitigate the impact of sepsis burden, researchers have directed their efforts towards innovative diagnostic methods like point-of-care testing (POCT) devices for rapid, accurate, and particularly bedside detection of sepsis; however, these methods are currently limited to detecting only a few resistance biomarkers, thus warranting further exploration. Numerous interventions have also been introduced to treat MDR sepsis, including combination therapy with antibiotics from two different classes and precision therapy, which involves personalized treatment strategies tailored to individual needs. Finally, addressing MDR-associated healthcare challenges at regional levels based on local pathogen resistance patterns emerges as a critical strategy for effective sepsis treatment and minimizing adverse effects.

A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis

The Surviving Sepsis Campaign recommends immediate antibiotics for all patients with suspected sepsis and septic shock, ideally within 1 hour of recognition. Immediate antibiotic treatment is lifesaving for some patients, but a substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions. Aggressive time-to-antibiotic targets risk promoting antibiotic overuse and antibiotic-associated harms for this subset of the population. An accurate understanding of the precise relationship between time-to-antibiotics and mortality for patients with possible sepsis is therefore critical to finding the best balance between assuring immediate antibiotics for those patients who truly need them versus allowing clinicians some time for rapid investigation to minimize the risk of overtreatment and antibiotic-associated harms for patients who are not infected. More than 30 papers have been published assessing the relationship between time-to-antibiotics and outcomes, almost all of which are observational cohort studies. Most report significant associations but all have important limitations. Key limitations include focusing just on the sickest subset of patients (only patients requiring intensive care and/or patients with septic shock), blending together mortality estimates from patients with very long intervals until antibiotics with patients with shorter intervals and reporting a single blended (and thus inflated) estimate for the average increase in mortality associated with each hour until antibiotics, and failure to control for large potential confounders including patients' presenting signs and symptoms and granular measures of comorbidities and severity of illness. In this study, we elaborate on these potential sources of bias and try to distill a better understanding of what the true relationship between time-to-antibiotics and mortality may be for patients with suspected sepsis or septic shock.

Antibiotic resistance in sepsis patients: evaluation and recommendation of antibiotic use

BACKGROUND

The appropriate selection of empirical antibiotics based on the pattern of local antibiotic resistance can reduce the mortality rate and increase the rational use of antibiotics.

AIMS

We analyze the pattern of antibiotic use and the sensitivity patterns of antibiotics to support the rational use of antibiotics in patients with sepsis.

MATERIALS AND METHODS

A retrospective observational study was conducted in adult sepsis patient at one of Indonesian hospital during January-December 2011. Data were collected from the hospital medical record department. Descriptive analysis was used in the processing and interpretation of data.

RESULTS

A total of 76 patients were included as research subjects. Lung infection was the highest source of infection. In the 66.3% of clinical specimens that were culture positive for microbes, Klebsiella pneumoniae, Escherichia coli, Staphylococcus hominis were detected with the highest frequency. The six most frequently used antibiotics, levofloxacin, ceftazidime, ciprofloxacin, cefotaxime, ceftriaxone, and erythromycin, showed an average resistance above 50%.

CONCLUSIONS

The high use of antibiotic with a high level resistance requires a policy to support its rational use. Local microbial pattern based on site infection and pattern of antibiotics sensitivity test can be used as supporting data to optimize appropriateness of empirical antibiotics therapy in sepsis patients.

[Severe bacterial infection: increased mortality in elderly women with low body weight taking drugs prolonging the QTc interval]

AIMS

Women have a higher risk of acquired long QT syndrome which could be of vital importance in severe bacterial infections when macrolides or fluoroquinolones are administered. This study evaluated whether age, drugs prolonging the QTc interval and body weight were additional influencing factors on mortality in the critically ill with respect to gender.

METHODS

In an exploratory investigation 204 intensive care unit (ICU) patients (78 f, 126 m, 61.1±16.1 years) with severe bacterial infections were studied (mortality probability model II(0) 49.1±28%). Antibiotic therapy was carried out following standard guidelines. In 65.2% of patients potentially QTc prolonging drugs were administered for ≥48 h. Body weight was ascertained on ICU admission.

RESULTS

By comparable severity of illness and comparable effect of antibiotic therapy, age, QTc prolonging drugs and less body weight showed significant effects on survival in women (p<0.001, 0.008 and 0.009, respectively). For women mortality increased with age ≥60 years (p=0.01). The division between survival versus non-survival was intensified by addition of QTc prolonging medication and body weight. As such a best risk assessment in women was achieved if age, QTc prolonging therapy and less body weight were combined (p<0.001). In a direct comparison to men, women with at least two of these factors had a significantly poorer outcome (OR 2.37; 95% CI 1.13-4.98; p=0.022).

CONCLUSIONS

Age, QTc prolonging drugs and lower body weight can additionally increase mortality in critically ill women. If negative outcome is attributed to a higher dosage, an adjustment for body weight must be carried out. Until now it should be considered whether it would be better to replace QTc prolonging antibiotics in routinely performed drug alternation in elderly lean women.

The role of glucocorticoids in the immediate vs. delayed effects of acute ethanol exposure on cytokine production in a binge drinking model

BACKGROUND

Acute ethanol administration just prior to a stimulus, such as the viral mimic poly I:C, results in decreased proinflammatory cytokine production. Studies have indicated that this suppression is not primarily mediated by glucocorticoids (corticosterone in mice) released in the ethanol-induced stress response. Fewer studies have been done on the effects of acute ethanol administration 12 or more hours prior to a stimulus. The purpose of this study was to determine the role of corticosterone on these effects. Also, since gender differences occur in immune responses, separate experiments were performed using male and female mice.

METHODS

Mice were treated with ethanol 15 min or 12h before stimulation by poly I:C to demonstrate immunosuppressive effects of ethanol on cytokine production. A glucocorticoid synthesis inhibitor was used to manipulate corticosterone levels.

RESULTS

Short-term and persistent effects of acute ethanol exposure on corticosterone and cytokine levels were nearly identical in males and females. Blocking glucocorticoid synthesis altered the inhibition of some cytokines, particularly IL-6, in females, but not in males.

CONCLUSION

These results indicate that the short-term effects of acute ethanol on poly I:C-induced cytokine production are not primarily mediated by corticosterone in male or female mice. In female mice, however, corticosterone does appear to mediate the persistent effects of acute ethanol administration on poly I:C- induced IL-6 levels. Since many IL-6 related disorders are gender associated, further research into the bidirectional effects of the HPG and HPA axes on alterations in cytokine production mediated by ethanol is warranted.

Cytokine profile in elderly patients with sepsis

Context:

Sepsis is a serious health problem in the elderly with a high degree of mortality. There is very limited data available in elderly subjects regarding the markers for sepsis. Development of good markers will help in overall management and prediction of sepsis.

Objectives:

Serial estimation of Interleukin-6 (IL-6) and Tumor Necrosis Factor-Alpha (TNF-α) and their correlation with mortality in sepsis in elderly patients and to determine the influence of gender on cytokine production and mortality in elderly patients with sepsis.

Settings and Design:

The prospective study was conducted at our tertiary care center from April 2007 to September 2008. Elderly Patients satisfying the Systemic Inflammatory Response Syndrome (SIRS) criteria were included.

Methods and Material:

TNF-α and IL-6 were estimated in 30 elderly patients admitted to our intensive care unit with SIRS and sepsis. The estimations were done on day 1, 3 and 7 of admission.

Statistical Analysis Used:

Student and paired ‘t’ tests, and ANOVA, which were further followed up by post-hoc ‘t’ tests with Bonferroni correction using SPSS.

Results:

Reducing levels of IL-6 levels from day 1 to 7 was found in the survivor group. TNF-α level was significantly low on day 1 in the nonsurvivor female group.

Conclusions:

Serial estimation of cytokines in elderly patients with sepsis will help in prediction of mortality. Female gender was an independent predictor of increased morality in critically ill patients with sepsis.

Marital status and the epidemiology and outcomes of sepsis

BACKGROUND

Sepsis is a major public health problem. Social factors may affect health behaviors, economic resources, and immune response, leading to hospitalization for infection. This study examines the association between marital status and sepsis incidence and outcomes in a population-based cohort.

METHODS

We analyzed 1,113,581 hospitalizations in New Jersey in 2006. We estimated risk-adjusted incidence rate ratios (IRRs) for sepsis among divorced, widowed, legally separated, single, and married subjects using population data from the American Community Survey. We used multivariable logistic regression to estimate marital status-specific hospital mortality.

RESULTS

We identified 37,524 hospitalizations for sepsis, of which 40% were among married (14,924), 7% were among divorced (2,548), 26% were among widowed (9,934), 2% (763) were among legally separated, and 26% (9355) were among single subjects. The incidence of hospitalization for sepsis was 5.8 per 1,000 population. The age, sex, and race-adjusted IRR for hospitalization with sepsis was greatest for single (IRR = 3.47; 95% CI, 3.1, 3.9), widowed (IRR = 1.38; 95% CI, 1.2, 1.6), and legally separated (IRR = 1.46; 95% CI, 1.2, 1.8) subjects compared with married (referent). We observed that single men and women and divorced men had greater odds of in-hospital mortality compared with married men; widowed and legally separated men and all ever-married women had no excess mortality during hospitalization for sepsis.

CONCLUSIONS

Hospitalization for sepsis is more common among single, widowed, and legally separated individuals, independent of other demographic factors. Among patients hospitalized for sepsis, single and divorced men and single women experience greater hospital mortality, highlighting the need to characterize the potentially modifiable mechanisms linking marital status to its greater burden of critical illness.

Females have fewer complications and lower mortality following trauma than similarly injured males: a risk adjusted analysis of adults in the National Trauma Data Bank

BACKGROUND

Studies of sexual dimorphism in trauma outcomes suggest that women have a survival advantage compared to equivalently injured men. It is unknown if this gender disparity is mediated by potentially life-threatening complications.

OBJECTIVE

To determine (1) if there is a sex-based differences in the odds of developing inpatient complications after trauma, and (2) if are these complications associated with death among trauma patients.

METHODS

Review of adult trauma patients admitted to hospitals in the National Trauma Data Bank that report complications. Patient and injury severity covariates were adjusted using multiple logistic regression and the independent effect of sex on developing complications and associated mortality was determined.

RESULTS

A total of 681,730 adult patients met the inclusion criteria of hospital admission > or =3 days. Women demonstrated a 21% lower adjusted risk of death compared to males (OR 0.79, 95% CI 0.76-0.83). Females had decreased adjusted odds of developing life-threatening complications including pneumonia, acute respiratory distress syndrome, acute renal failure and pulmonary embolism. However, when compared to males with life-threatening complications, females with complications were found to be at greater risk of dying.

CONCLUSION

This study demonstrates that women are less likely than men to develop inpatient complications, suggesting that the survival advantage among women after traumatic injury may involve a reduced susceptibility to developing life-threatening complications.