Epidemiology and outcome of sepsis in a tertiary-care hospital in a developing country

Prevalence of sepsis among adults in China: A systematic review and meta-analysis

Background

Sepsis is a major public health problem that cannot be ignored in China and even in the world. However, the prevalence of sepsis in Chinese adults varies among different studies.

Objective

To evaluate the prevalence of hospital-wide sepsis and intensive care unit (ICU) sepsis in Chinese adults.

Methods

PubMed, EMBASE, Cochrane Library, Web of science, China National Knowledge Infrastructure, Chinese biomedical literature service system, Wanfang Database, and VIP databases were systematically searched for studies on sepsis in China published before March 2, 2022. Random effects model was used to calculate pooled prevalence estimates with 95% confidence interval. Subgroup and sensitivity analyses were performed to address heterogeneity. Funnel plots and Egger's test were used to assess the publication bias.

Results

Overall, nine observational studies involving 324,020 Chinese patients (9,587 patients with sepsis) were analyzed. Four hospital-wide studies involving 301,272 patients showed pooled prevalence and mortality of 3.8% (95% CI: 2.9-4.7%, I ² = 99.9%) and 26% (95% CI: 16-36%, I ² = 98.0%), respectively. Five studies of ICU sepsis involving 22,748 patients presented pooled prevalence and mortality of 25.5% (95% CI: 13.9-37.0%, I ² = 99.8%) and 40% (95%CI: 34-47%, I ² = 95.9%), respectively. Subgroup analysis of sepsis in ICUs revealed that the pooled prevalence was higher among males [17% (95% CI 9-24%, I ² = 99.6%)], in lung infections [66% (95%CI: 54-77%, I ² = 98.7%)], and Gram-negative bacteria infections [37% (95%CI: 26-47%, I ² = 98.3%)]. The pooled prevalence of sepsis, severe sepsis and septic shock was 25.5% (95%CI: 13.9-37.0%, I ² = 99.8%), 19% (95%CI: 9-28%, I ² = 99.6%), and 13% (95%CI: 7-19%, I ² = 99.2%), respectively.

Conclusions

Sepsis is prevalent in 25.5% of ICU patients in China, and sex, sepsis severity, infection site, causative microorganism, and infection type are significant influencing factors. Larger trials are needed to evaluate the prevalence of sepsis in China, which may help the development of global strategies for sepsis management.

Systematic review registration

PROSPERO, identifier: CRD42022314274.

The Variation in Outcomes of Septic Patients: A Dual-Centre Comparative Study

Introduction Despite significant advances in the field of medicine, sepsis is constantly growing as a major public health concern. The global epidemic of sepsis imposes a significant economic burden on healthcare systems world-over. Furthermore, its high prevalence in society is inevitably paralleled by an excessive mortality rate, with approximately six million deaths reported every year. The primary aim of this study was to evaluate and compare, the management of acutely septic patients against outcomes in a tertiary teaching institution in Pakistan versus a similar one in the United Kingdom. Methods This study was a dual-centred, retrospective comparative analysis comparing all patients admitted through the emergency department at the respective tertiary centres. Patient details were collected and compared across the two sites to evaluate the effect of individual characteristics on prognosis. The outcomes of these presentations were analysed by comparing rates of in-hospital mortality, admission to the ICU or discharge. Results The total number of patients identified as having sepsis was 60 in the Pakistan cohort, and 92 in the Aberdeen cohort. No significant difference was found when comparing genders, and the results of basic observations were largely similar at presentation. Twenty-five per cent (25%) (n=38) of the total study population were deemed to have a poor outcome at 3 days, but 50% of the Pakistan cohort was deemed to have a poor outcome. Conclusion Managing sepsis has developed significantly in recent years, but most of this development was implemented in high-income countries. There was a significant delay in time to resuscitate septic patients in Pakistan, with significantly raised three-day morbidity and mortality. There is a need for further comparative studies of the management of sepsis in Pakistan and other low-income countries to identify the problems and tackle obstacles on every level of the healthcare system.

Predictive Score Model of Clinical Outcomes Sepsis in Intensive Care Unit Tertier Referral Hospital of Eastern Indonesia

AIM: This study aimed to design a predictive score model of clinical outcome sepsis and bacterial profiles of blood and sputum cultures in the intensive care unit (ICU) of a tertiary referral hospital. METHODS: An observational retrospective study was conducted in 2017–2020 using medical record data in the ICU of Dr. Soetomo Hospital as tertiary referral hospital. The predictor of sepsis prognosis was Acute Physiology and Chronic Health Evaluation II (APACHE II), blood and sputum culture results, procalcitonin (PCT) levels, and antimicrobial resistance in blood and sputum cultures. The model was prepared by logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS: Data from 355 subjects showed that predictor score was APACHE II, blood and sputum culture results; besides PCT levels were found to contribute significantly to predictive score of sepsis clinical output (p<0.05), while the predictor test of antimicrobial resistance in blood and sputum cultures was not significant to predictive score of sepsis clinical output (p > 0.05). The resulting scores to predict sepsis clinical outcomes include PCT level >2 ng/mL (1.61), APACHE score >20 (1), sputum culture as true pathogen (1.1), and blood culture as true pathogen (1.35). When the total score ≥3, the patient will die, while when the score <3, the patient will survive. ROC curves analysis obtained area under curve 0.859 (p < 0.05) which indicates that the equation is statistically significant in predicting the sepsis clinical outcome. Probability scores and death outcomes indicate that the higher the predictive score, the higher the probability of dying, with a score >3 the probability of dying is above 95.27%, whereas if the score is 5, the probability of dying is above 99%. The bacterial profile of blood cultures leading to mortality is predominately Gram-positive (34.4%), consisting of coagulase-negative Staphylococcus (22.9%), and Staphylococcus aureus (4.3%), while Gram-negative is only 14.7%, which consists of Enterobacteriaceae group (8.7%), Acinetobacter baumannii (4%), polymicrobial infection (2%), Burkholderia cepacia (0.8%), and Pseudomonas aeruginosa (0.4%). Sputum culture profile of patients with sepsis who died in the ICU of a tertiary referral RSUD Soetomo is dominated by Gram-negative, namely, A. baumannii (22.1%), Enterobacteriaceae group (20.6%), P. aeruginosa (11.1%), while Gram-positive is S. aureus (22.9%). CONCLUSION: The predictive score model for sepsis clinical outcomes in the ICU of a tertiary referral hospitals can be used as a basis for determining of patient management and the profile of the bacteria that causes sepsis that results in death.

The impact of selenium administration on severe sepsis or septic shock: a meta-analysis of randomized controlled trials

Introduction

The efficacy of selenium administration to treat severe sepsis or septic shock remains controversial. We conduct a systematic review and meta-analysis to explore the impact of selenium administration on severe sepsis or septic shock.

Methods

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through May 2020 for randomized controlled trials (RCTs) assessing the effect of selenium administration on severe sepsis or septic shock. Meta-analysis is performed using the random-effect model.

Results

Five RCTs involving 1482 patients are included in the meta-analysis. Overall, compared with control group in septic patients, selenium administration is not associated with reduced 28-day mortality (RR=0.93; 95% CI=0.73 to 1.19; P=0.58), but results in substantially decreased all-cause mortality (RR=0.78; 95% CI=0.63 to 0.98; P=0.03) and length of hospital stay (MD=-3.09; 95% CI=-5.68 to -0.50; P=0.02).

Conclusion

Selenium administration results in notable decrease in all-cause mortality and length of hospital stay, but shows no substantial influence on the 28-day mortality, length of ICU stay, duration of vasopressor therapy, the incidence of acute renal failure, adverse events, and serious adverse events for septic patients.

The Outcome of Sepsis Patients Admitted to the Intensive Care Unit: Experience of 100 Cases

Introduction:

The term sepsis has a deep root all over medical history. It defined by a many physician and myth such as Homer’s Iliad. Sepsis defined as a clinical syndrome as an outcome from both systemic inflammatory response syndrome and infection. It can complicate by disturb the function of the organ (severe sepsis) and shock (septic shock).

Aim:

Our study aims to recognize sepsis cases in Al-Sader Medical city during 2019 and evaluate the management’s management and the weak point in this management.

Methods:

It is a cross-sectional study done in Al-Sader Medical city; data collected from the archived files in the hospital during 2019, 100 cases reported in this period diagnosed and admitted as sepsis or admitted with other diagnosis evolved sepsis.

Results:

We found that one-third of the patients diagnosed as sepsis admitted to the intensive care unit, the mean duration of management 15.8 days. Many investigations did for these patients, the treatment which given to the patients was iv. fluids and antibiotics for entire patients, we also noted that death occurs in more than half of the patients in our study and death were prevalent among patient with a negative result in blood culture also the male patient was more predominant than the female patient and Najaf residency is more than three-quarters of them. Finally, we found that admission to the intensive care unit from units other than emergency or intensive care unit itself found is nearly one-third of the patient diagnosed as sepsis and the respiratory system was commonly involved and presented as pneumonia.

Conclusion:

More than half of the diagnosed cases died. The maximum common source of admission was from other hospital units, the severe sepsis and no growth of blood culture closely associated with death.

Ethyl pyruvate protects against sepsis-associated encephalopathy through inhibiting the NLRP3 inflammasome

BACKGROUND

With the advance of antibiotics and life support therapy, the mortality of sepsis has been decreasing in recent years. However, the incidence of sepsis-associated encephalopathy (SAE), a common complication of sepsis, is still high. There are few effective therapies to treat clinical SAE. We previously found that ethyl pyruvate (EP), a metabolite derivative, is able to effectively inhibit the NLRP3 inflammasome activation. Administration of ethyl pyruvate protects mice against polymicrobial sepsis in cecal ligation and puncture (CLP) model. The aim of present study is to investigate if ethyl pyruvate is able to attenuate SAE.

METHODS

After CLP, C57BL/6 mice were intraperitoneally or intrathecally injected with saline or ethyl pyruvate using the sham-operated mice as control. New Object Recognition (NOR) and Morris Water Maze (MWM) were conducted to determine the cognitive function. Brain pathology was assessed via immunohistochemistry. To investigate the mechanisms by which ethyl pyruvate prevent SAE, the activation of NLRP3 in the hippocampus and the microglia were determined using western blotting, and cognitive function, microglia activation, and neurogenesis were assessed using WT, Nlrp3-/- and Asc-/- mice in the sublethal CLP model. In addition, Nlrp3-/- and Asc-/- mice treated with saline or ethyl pyruvate were subjected to CLP.

RESULTS

Ethyl pyruvate treatment significantly attenuated CLP-induced cognitive decline, microglia activation, and impaired neurogenesis. In addition, EP significantly decreased the NLRP3 level in the hippocampus of the CLP mice, and inhibited the cleavage of IL-1β induced by NLRP3 inflammsome in microglia. NLRP3 and ASC deficiency demonstrated similar protective effects against SAE. Nlrp3-/- and Asc-/- mice significantly improved cognitive function and brain pathology when compared with WT mice in the CLP models. Moreover, ethyl pyruvate did not have additional effects against SAE in Nlrp3-/- and Asc-/- mice.

CONCLUSION

The results demonstrated that ethyl pyruvate confers protection against SAE through inhibiting the NLRP3 inflammasome.

The epidemiology of sepsis in a district hospital emergency centre in Durban, KwaZulu natal

INTRODUCTION

Sepsis is one of the leading causes of death worldwide. There is a paucity of data describing the epidemiology of sepsis in emergency centres in developing countries. This study aims to describe the clinical profile and management of patients presenting with sepsis in this setting.

METHODS

A retrospective chart review was conducted in an Emergency Centre (EC) of a district hospital in Durban from December 2015 to February 2016. All patients with a diagnosis of an infection that met the Surviving Sepsis Campaign criteria for sepsis syndrome were included in the study.

RESULTS

A total of 1195 patients who were diagnosed with an infection were screened. Of these, 52 of them met the inclusion criteria for the study. The criteria for severe sepsis was met in 40.3% (n 23) and 1.9% (n 1) met the criteria for septic shock. More than half of the patients were HIV positive and 30.7% did not know their HIV status. The most common sites of infection were respiratory tract, gastrointestinal and central nervous system respectively. Most patients were admitted to the general medical ward. The inpatient mortality rate was 15% for general medical ward admissions.

CONCLUSION

A better understanding of the demographic and clinical profile of sepsis syndrome in South African ECs is required to guide clinical and operational policy development.

Effectiveness of Treatments and Diagnostic Tools and Declining Mortality in Patients With Severe Sepsis: A 12-Year Population-Based Cohort Study

Sepsis is a major cause of morbidity and mortality worldwide. With the advance of medical care, the mortality of sepsis has decreased in the past decades. Many treatments and diagnostic tools still lack supporting evidence. We conducted a retrospective population-based cohort study with propensity score matched subcohorts based on a prospectively collected national longitudinal health insurance database in Taiwan. Severe sepsis-associated hospital admissions from 2000 to 2011 based on International Classification of Diseases, Ninth Revision, Clinical Modification codes of infections and acute organ dysfunction were identified. To compare the effectiveness of treatment and diagnostic tool, propensity scores were generated to match the comparable control groups. During the 12-year period, 33 375 patients and 50 465 hospitalizations of severe sepsis were identified. The age-standardized 28-day in-hospital mortality decreased significantly from 21% in 2008 to 15% in 2011 with increasingly implemented treatment and diagnostic tool. After propensity score matching, procalcitonin (odds ratio [OR]: 0.70, 95% confidence interval [95% CI]: 0.61-0.81) and lactate testing (OR: 0.90, 95% CI: 0.84-0.97, respectively), transfusion of packed red blood cell (OR: 0.60, 95% CI: 0.52-0.69), albumin (OR: 0.72, 95% CI: 0.55-0.93), balanced crystalloid (OR: 0.29, 95% CI: 0.20-0.41), and use of dopamine (OR: 0.44, 95% CI: 0.39-0.49) were found to be significantly associated with lower mortality rate. However, inconsistent findings need to be further validated.

Epidemiology of sepsis in intensive care units in Turkey: a multicenter, point-prevalence study

BACKGROUND

The prevalence and mortality of sepsis are largely unknown in Turkey, a country with high antibiotic resistance. A national, multicenter, point-prevalence study was conducted to determine the prevalence, causative microorganisms, and outcome of sepsis in intensive care units (ICUs) in Turkey.

METHODS

A total of 132 ICUs from 94 hospitals participated. All patients (aged > 18 years) present at the participating ICUs or admitted for any duration within a 24-h period (08:00 on January 27, 2016 to 08:00 on January 28, 2016) were included. The presence of systemic inflammatory response syndrome (SIRS), severe sepsis, and septic shock were assessed and documented based on the consensus criteria of the American College of Chest Physicians and Society of Critical Care Medicine (SEPSIS-I) in infected patients. Patients with septic shock were also assessed using the SEPSIS-III definitions. Data regarding demographics, illness severity, comorbidities, microbiology, therapies, length of stay, and outcomes (dead/alive during 30 days) were recorded.

RESULTS

Of the 1499 patients included in the analysis, 237 (15.8%) had infection without SIRS, 163 (10.8%) had infection with SIRS, 260 (17.3%) had severe sepsis without shock, and 203 (13.5%) had septic shock. The mortality rates were higher in patients with severe sepsis (55.7%) and septic shock (70.4%) than those with infection alone (24.8%) and infection + SIRS (31.2%) (p < 0.001). According to SEPSIS-III, 104 (6.9%) patients had septic shock (mortality rate, 75.9%). The respiratory system (71.6%) was the most common site of infection, and Acinetobacter spp. (33.7%) were the most common isolated pathogen. Approximately, 74.9%, 39.1%, and 26.5% of Acinetobacter, Klebsiella, and Pseudomonas spp. isolates, respectively, were carbapenem-resistant, which was not associated with a higher mortality risk. Age, acute physiology and chronic health evaluation II score at ICU admission, sequential organ failure assessment score on study day, solid organ malignancy, presence of severe sepsis or shock, Candida spp. infection, renal replacement treatment, and a nurse-to-patient ratio of 1:4 (compared with a nurse-to-patient ratio of 1:2) were independent predictors of mortality in infected patients.

CONCLUSIONS

A high prevalence of sepsis and an unacceptably high mortality rate were observed in Turkish ICUs. Although the prevalence of carbapenem resistance was high in Turkish ICUs, it was not associated with a higher risk for mortality.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT03249246 . Date: August 15, 2017. Retrospectively registered.

Mortality outcomes based on ED qSOFA score and HIV status in a developing low income country

OBJECTIVE

To evaluate the utility of the quick Sepsis-related Organ Failure Assessment (qSOFA) score to predict risks for emergency department (ED) and hospital mortality among patients in a sub-Saharan Africa (SSA) setting.

METHODS

This retrospective cohort study was carried out at a tertiary-care hospital, in Kigali, Rwanda and included patients ≥15years, presenting for ED care during 2013 with an infectious disease (ID). ED and overall hospital mortality were evaluated using multivariable regression, with qSOFA scores as the primary predictor (reference: qSOFA=0), to yield adjusted relative risks (aRR) with 95% confidence intervals (CI). Analyses were performed for the overall population and stratified by HIV status.

RESULTS

Among 15,748 cases, 760 met inclusion (HIV infected 197). The most common diagnoses were malaria and intra-abdominal infections. Prevalence of ED and hospital mortality were 12.5% and 25.4% respectively. In the overall population, ED mortality aRR was 4.8 (95% CI 1.9-12.0) for qSOFA scores equal to 1 and 7.8 (95% CI 3.1-19.7) for qSOFA scores ≥2. The aRR for hospital mortality in the overall cohort was 2.6 (95% 1.6-4.1) for qSOFA scores equal to 1 and 3.8 (95% 2.4-6.0) for qSOFA scores ≥2. For HIV infected cases, although proportional mortality increased with greater qSOFA score, statistically significant risk differences were not identified.

CONCLUSION

The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed.

The epidemiology of sepsis in Brazilian intensive care units (the Sepsis PREvalence Assessment Database, SPREAD): an observational study

BACKGROUND

The sepsis burden on acute care services in middle-income countries is a cause for concern. We estimated incidence, prevalence, and mortality of sepsis in adult Brazilian intensive care units (ICUs) and association of ICU organisational factors with outcome.

METHODS

We did a 1-day point prevalence study with follow-up of patients in ICU with sepsis in a nationally representative pseudo-random sample. We produced a sampling frame initially stratified by geographical region. Each stratum was then stratified by hospitals' main source of income (serving general public vs privately insured individuals) and ICU size (ten or fewer beds vs more than ten beds), finally generating 40 strata. In each stratum we selected a random sample of ICUs so as to enrol the total required beds in 1690 Brazilian adult ICUs. We followed up patients until hospital discharge censored at 60 days, estimated incidence from prevalence and length of stay, and generated national estimates. We assessed mortality prognostic factors using random-effects logistic regression models.

FINDINGS

On Feb 27, 2014, 227 (72%) of 317 ICUs that were randomly selected provided data on 2632 patients, of whom 794 had sepsis (30·2 septic patients per 100 ICU beds, 95% CI 28·4-31·9). The ICU sepsis incidence was 36·3 per 1000 patient-days (95% CI 29·8-44·0) and mortality was observed in 439 (55·7%) of 788 patients (95% CI 52·2-59·2). Low availability of resources (odds ratio [OR] 1·67, 95% CI 1·02-2·75, p=0·045) and adequacy of treatment (OR 0·56, 0·37-0·84, p=0·006) were independently associated with mortality. The projected incidence rate is 290 per 100 000 population (95% CI 237·9-351·2) of adult cases of ICU-treated sepsis per year, which yields about 420 000 cases annually, of whom 230 000 die in hospital.

INTERPRETATION

The incidence, prevalence, and mortality of ICU-treated sepsis is high in Brazil. Outcome varies considerably, and is associated with access to adequate resources and treatment. Our results show the burden of sepsis in resource-limited settings, highlighting the need to establish programmes aiming for sepsis prevention, early diagnosis, and adequate treatment.

FUNDING

Fundação de Apoio a Pesquisa do Estado de São Paulo (FAPESP).

Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

Background

Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality.

Methods

We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance.

Results

We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle.

Conclusions

Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.

Epidemiology and Outcomes

Sepsis is a global public health concern. Internationally it contributes to more than 5 million deaths annually. Although rates are variable between countries, over the past 40 years reported incidence has continued to increase. Aside from potential differences in patient populations, the variation in reported rates also reflects differences in identification strategies, access to health care, and awareness of the diagnosis. Factors such as age, sex, socioeconomic status, comorbid disease, and type and site of infection impact the development of and outcomes from sepsis. Although advances have been made in treatment, its impact remains substantial.

A Comparative Study to Assess the Determinants and Outcomes of Sepsis Treated in Medical Wards and ICU in an Indian Teaching Hospital

INTRODUCTION

Sepsis is the primary cause of death from infection worldwide. In resource-limited countries, increasing number of sepsis is managed in non-ICU settings, in Medical Wards (MW).

AIM

To compare the burden, aetiology and short term outcome of sepsis treated in MW with ICU.

MATERIALS AND METHODS

Prospective, observational, analytical study in sepsis patients in general MW and medical ICU in a tertiary care hospital. Two hundred forty five sepsis patients (MW=150, ICU=95), ≥18 years, selected randomly, were studied to compare aetiology, co-morbidities, clinical & microbiological profile and short-term outcome between MW and ICU sepsis. Sepsis following surgery, trauma, those transferred to/from ICU, those with other life threatening diseases were excluded. Chi-square test/Fisher's-exact test was used for comparing ratios. A 'p-value' <0.05 was considered statistically significant.

RESULTS

Sepsis was more common in elderly males, both in MW and ICU (median age: 56.7, 59.2 years; male: female ratios = 1.34:1, 1.63:1 respectively). Frequency of presenting symptoms, co-morbidities and sources of sepsis were similar in both groups (p>0.05). Frequency of positive microbiological culture, pattern of microbial flora and antimicrobial resistance patterns were similar in both groups (p>0.05). Number of antibiotics used was significantly higher in ICU compared to MW (p<0.01); multi-organ dysfunction and mortality were significantly higher in ICU settings (55.8% vs. 38.7%, p=0.04; 48.4% vs. 32.6%, p=0.041 respectively). While sepsis and severe sepsis were significantly higher in MW (34.6% vs. 22.1 %, p=0.03; 47.3% vs. 26.3%, p<0.01 respectively), septic shock was significantly higher in ICU (51.6% vs. 18.0%, p<0.01). Mortality in both settings was highest in septic shock (55.5% and 61.2%, p>0.05) and multi-organ dysfunction (55.1% and 64.2%, p>0.05). Duration of hospital stay was significantly shorter in MW than ICU (7.3 vs. 11.0 days, p<0.01).

CONCLUSION

Our study aimed to identify determinants and outcome of sepsis in MW and compare with ICU settings. Antibiotic usage in the two settings differed: concurrent use of ≥3 antibiotics, and carbapenems & linezolid usage were significantly higher in ICU compared to MW. Sepsis in MW had significantly lower incidence of multi-organ failure, lower mortality and shorter hospital stay compared to ICU.

Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

IMPORTANCE

Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition.

OBJECTIVE

To develop a new definition and clinical criteria for identifying septic shock in adults.

DESIGN, SETTING, AND PARTICIPANTS

The Society of Critical Care Medicine and the European Society of Intensive Care Medicine convened a task force (19 participants) to revise current sepsis/septic shock definitions. Three sets of studies were conducted: (1) a systematic review and meta-analysis of observational studies in adults published between January 1, 1992, and December 25, 2015, to determine clinical criteria currently reported to identify septic shock and inform the Delphi process; (2) a Delphi study among the task force comprising 3 surveys and discussions of results from the systematic review, surveys, and cohort studies to achieve consensus on a new septic shock definition and clinical criteria; and (3) cohort studies to test variables identified by the Delphi process using Surviving Sepsis Campaign (SSC) (2005-2010; n = 28,150), University of Pittsburgh Medical Center (UPMC) (2010-2012; n = 1,309,025), and Kaiser Permanente Northern California (KPNC) (2009-2013; n = 1,847,165) electronic health record (EHR) data sets.

MAIN OUTCOMES AND MEASURES

Evidence for and agreement on septic shock definitions and criteria.

RESULTS

The systematic review identified 44 studies reporting septic shock outcomes (total of 166,479 patients) from a total of 92 sepsis epidemiology studies reporting different cutoffs and combinations for blood pressure (BP), fluid resuscitation, vasopressors, serum lactate level, and base deficit to identify septic shock. The septic shock-associated crude mortality was 46.5% (95% CI, 42.7%-50.3%), with significant between-study statistical heterogeneity (I2 = 99.5%; τ2 = 182.5; P < .001). The Delphi process identified hypotension, serum lactate level, and vasopressor therapy as variables to test using cohort studies. Based on these 3 variables alone or in combination, 6 patient groups were generated. Examination of the SSC database demonstrated that the patient group requiring vasopressors to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L (18 mg/dL) after fluid resuscitation had a significantly higher mortality (42.3% [95% CI, 41.2%-43.3%]) in risk-adjusted comparisons with the other 5 groups derived using either serum lactate level greater than 2 mmol/L alone or combinations of hypotension, vasopressors, and serum lactate level 2 mmol/L or lower. These findings were validated in the UPMC and KPNC data sets.

CONCLUSIONS AND RELEVANCE

Based on a consensus process using results from a systematic review, surveys, and cohort studies, septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation.

Epidemiology and Outcome of Severe Sepsis and Septic Shock in Surgical Intensive Care Units in Northern Taiwan

Severe sepsis remains the leading cause of mortality in the critically ill. Local epidemiological studies on sepsis are of paramount importance to increase our knowledge about sepsis features and to improve patient care and prognosis.Adult patients (≥20 years) admitted to the surgical intensive care units with severe sepsis or septic shock from 2009 to 2010 were retrospectively retrieved and analyzed. The primary outcome of interest was 28-day mortality.Of 7795 admissions, 536 (6.9%) patients had severe sepsis. The most common sites of infection were the respiratory tract (38%) and abdomen (33%). Gram-negative bacteria, particularly Klebsiella pneumoniae (8.6%) and Escherichia coli (6.0%), were the major infecting micro-organisms, responsible for approximately two-thirds of the severe sepsis episodes. The overall 28-day mortality rate was 61%, and a higher sequential organ failure assessment score and the use of mechanical ventilation were independently associated with a worse outcome.Admissions with severe sepsis are not uncommon and are associated with substantial 28-day mortality in surgical intensive care units in northern Taiwan. Establishment and optimization of each institutional sepsis care standard to improve the outcome of sepsis are warranted.

The effect of parenteral selenium on outcomes of mechanically ventilated patients following sepsis: a prospective randomized clinical trial

Background

Sepsis and septic shock is characterized by oxidative stress that mainly promotes systemic inflammation and organ failure due to excessive free radical production and depletion of antioxidant defenses. Therefore, we investigated the effect of selenium administration on antioxidant status, levels of cytokines and clinical outcomes.

Methodology

This study was a prospective randomized control trial (RCT) whereby patients received selenium as sodium selenite (2 mg IV bolus followed by 1.5 mg continuous infusion for 14 days) plus standard therapy. The control group received standard therapy without selenium. The primary endpoint was 28-day mortality. The changes in the mean levels of glutathione peroxidase (GPX) activity, IL-6, IL-8 and IL-10, the incidence of ventilator-associated pneumonia (VAP) and other secondary endpoints were also recorded. VAP was broken down into early VAP and late VAP to see the clinical significance of each. We also recorded any adverse outcomes from selenium infusion.

Results

Over 24-month period, 54 patients were recruited and randomized and an intention to treat (ITT) principle was applied (selenium, n = 29; control, n = 25) in the final analysis. There was no statistically significant difference between the two groups in 28-day mortality although it was lower in the selenium group compared with the control group: 9 (31 %) in the selenium versus 10 (40 %) in the control groups (p = 0.49). At day 0, GPX activity was 0.185 ± 0.3 versus 0.19 ± 0.3 U/mL (p = 0.9), day 3, GPX activity was 0.52 ± 0.5 versus 0.17 ± 0.2 U/mL (p = 0.02), at day 7 it was 0.55 ± 0.5 versus 0.24 ± 0.3 U/mL (p = 0.032), at day 10 it was 0.62 ± 0.7 versus 0.33 ± 0.4 U/mL (p = 0.048) and at day 14 it was 1.1 ± 1 versus 0.89 ± 1 U/mL (p = 0.70) for the selenium versus control groups, respectively. However, there were no significant differences between the mean plasma levels of all the three inflammatory cytokines at any point in time between the two groups. There was a significant reduction in occurrence of VAP in the selenium group compared with the control group (55.2 versus 84 %, p = 0.023), respectively.

Conclusion

High-dose selenium administration within the time frame of early goal-directed therapy was not resulted in reduction of 28-day mortality, but increased the activity of glutathione peroxidase with no effect on the levels of inflammatory cytokines at any point in time in mechanically ventilated septic patients. However, selenium supplementation in mechanically ventilated patients following sepsis was associated with reduced occurrence of VAP.

Trial registration: IRCT201212082887N4 at WHO Clinical Trial Registry, August 29, 2014

A "three delays" model for severe sepsis in resource-limited countries

PURPOSE

The developing world carries the greatest burden of sepsis-related mortality, but success in managing severe sepsis in resource-limited countries (RLCs) remains challenging. A "three delays" model has been developed to describe factors influencing perinatal mortality in developing nations. This model has been validated across different World Health Organization regions and has provided the framework for policymakers to plan targeted interventions. Here, we propose a three delays model for severe sepsis in RLCs.

MATERIALS AND METHODS

A literature review was performed using the PubMed, Google Scholar, and Ovid databases. Additional sources were found after review of the reference lists from retrieved articles.

RESULTS

We propose a three delays model for severe sepsis in adults in RLCs. The model highlights limitations in the 3 basic pillars of sepsis management: (1) sepsis recognition and diagnosis at the time of triage, (2) initial focused resuscitation, and (3) postresuscitation clinical monitoring and reassessment.

CONCLUSIONS

Characterizing the major barriers to effective treatment of severe sepsis in RLCs frames the problem in a language common to global health circles, which may stimulate further research, streamline treatment, and reduce sepsis-related mortality in the developing world.

Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock

BACKGROUND

Mortality from sepsis and septic shock remains high. Results of trials on intravenous immunoglobulins (IVIG) as adjunctive therapy for sepsis have been conflicting. This is an update of a Cochrane review that was originally published in 1999 and updated in 2002 and 2010.

OBJECTIVES

To estimate the effects of IVIG as adjunctive therapy in patients with bacterial sepsis or septic shock on mortality, bacteriological failure rates, and duration of stay in hospital.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1966 to December 2012), and EMBASE (1988 to December 2012). We contacted investigators in the field for unpublished data. The original search was performed in 1999 and updated in 2002 and 2008.

SELECTION CRITERIA

We included randomized controlled trials comparing IVIG (monoclonal or polyclonal) with placebo or no intervention in patients of any age with bacterial sepsis or septic shock.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion and undertook methodologic quality assessment and data abstraction. We conducted pre-specified subgroup analyses by type of immunoglobulin preparation.

MAIN RESULTS

We included 43 studies that met our inclusion criteria in this updated review out of 88 potentially eligible studies. The studies included a large polyclonal IVIG trial in neonates that was concluded in 2011 and classified as ongoing in the 2010 version of this review. Pooled analysis of polyclonal and monoclonal IVIG was not done due to clinical heterogeneity. Subgroup analysis of 10 polyclonal IVIG trials (n = 1430) and seven trials on IgM-enriched polyclonal IVIG (n = 528) showed significant reductions in mortality in adults with sepsis compared to placebo or no intervention (relative risk (RR) 0.81; 95% confidence interval (CI) 0.70 to 0.93 and RR 0.66; 95% CI 0.51 to 0.85, respectively). Subgroup analysis of polyclonal IVIG in neonates, which now includes the recently concluded large polyclonal IVIG trial, showed no significant reduction in mortality for standard IVIG (RR 1.00; 95% CI 0.92 to 1.08; five trials, n = 3667) and IgM-enriched polyclonal IVIG (RR 0.57; 95% CI 0.31 to 1.04; three trials, n = 164). Sensitivity analysis of trials with low risk of bias showed no reduction in mortality with polyclonal IVIG in adults (RR 0.97; 95% CI 0.81 to 1.15; five trials, n = 945) and neonates (RR 1.01; 95% CI 0.93 to 1.09; three trials, n = 3561). Mortality was not reduced among patients (eight trials, n = 4671) who received anti-endotoxin antibodies (RR 0.99; 95% CI 0.91 to1.06) while anti-cytokines (nine trials, n = 7893) demonstrated a marginal reduction in mortality (RR 0.92; 95% CI 0.86 to 0.97).

AUTHORS' CONCLUSIONS

Polyclonal IVIG reduced mortality among adults with sepsis but this benefit was not seen in trials with low risk of bias. Among neonates with sepsis, there is sufficient evidence that standard polyclonal IVIG, as adjunctive therapy, does not reduce mortality based on the inclusion of the large polyclonal IVIG trial on neonates. For Ig-M enriched IVIG, the trials on neonates and adults were small and the totality of the evidence is still insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.

Prediction of outcome from community-acquired severe sepsis and septic shock in tertiary-care university hospital in a developing country

Our aim was to determine the risk factors on mortality in adult patients with community-acquired severe sepsis and septic shock. The main outcome measure was hospital mortality. This prospective single centre study was conducted from January 1, 2008 to December 31, 2010, and included 184 patients, of whom 135 (73.4%) were with severe sepsis and 49 (26.6%) had septic shock. Overall, ninety-five (51.6%) patients have died, 60 (44.4%) in severe sepsis and 35 (71.4%) patients with septic shock. The lung was the most common site of infection 121 (65.8%), and chronic heart failure was the most frequent comorbidity 65 (35.3%). Logistic multivariate analysis identified three independent risk factors for mortality in patients with severe sepsis: positive blood culture (odds ratio, 2.39; 95% confidence interval, 1.13-5.06; P = 0.02), three or more organ dysfunctions (odds ratio, 3.93; 95% confidence interval, 1.62-9.53; P = 0.002), and Simplified Acute Physiology Score (SAPS) II (odds ratio, 1.02; 95% confidence interval, 1.00-1.04; P = 0.01). In addition to SAPS II, positive blood culture, and three or more organ dysfunctions are important independent risk factors for mortality in patients with severe sepsis and septic shock.

Feasibility of modified surviving sepsis campaign guidelines in a resource-restricted setting based on a cohort study of severe S. aureus sepsis [corrected]

Background

The Surviving Sepsis Campaign (SSC) guidelines describe best practice for the management of severe sepsis and septic shock in developed countries, but most deaths from sepsis occur where healthcare is not sufficiently resourced to implement them. Our objective was to define the feasibility and basis for modified guidelines in a resource-restricted setting.

Methods and Findings

We undertook a detailed assessment of sepsis management in a prospective cohort of patients with severe sepsis caused by a single pathogen in a 1,100-bed hospital in lower-middle income Thailand. We compared their management with the SSC guidelines to identify care bundles based on existing capabilities or additional activities that could be undertaken at zero or low cost. We identified 72 patients with severe sepsis or septic shock associated with S. aureus bacteraemia, 38 (53%) of who died within 28 days. One third of patients were treated in intensive care units (ICUs). Numerous interventions described by the SSC guidelines fell within existing capabilities, but their implementation was highly variable. Care available to patients on general wards covered the fundamental principles of sepsis management, including non-invasive patient monitoring, antimicrobial administration and intravenous fluid resuscitation. We described two additive care bundles, one for general wards and the second for ICUs, that if consistently performed would be predicted to improve outcome from severe sepsis.

Conclusion

It is feasible to implement modified sepsis guidelines that are scaled to resource availability, and that could save lives prior to the publication of international guidelines for developing countries.

The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals

OBJECTIVE

Our aim was to determine the frequency and the clinical and epidemiologic characteristics of sepsis in a hospital-based population in Colombia.

DESIGN

Prospective cohort.

SETTING

Ten general hospitals in the four main cities of Colombia.

PATIENTS

Consecutive patients admitted in emergency rooms, intensive care units, and general wards from September 1, 2007, to February 29, 2008, with confirmation of infection according to the Centers for Disease Control and Prevention definitions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The following information was recorded: demographic, clinical, and microbiologic characteristics; Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores; requirement for intensive care unit; length of stay; and 28-day all-cause mortality. During a period of 6 months, 2,681 patients were recruited: 69% and 31% with community-acquired and hospital-acquired infections, respectively. The mean age was 55 yrs (SD = 21), 51% were female, and the median length of stay was 10 days (interquartile range, 5-19). The mean Acute Physiology and Chronic Health Evaluation score was 11.5 (SD = 7) and the mean Sequential Organ Failure Assessment score was 3.8 (SD = 3). A total of 422 patients with community-acquired infections (16%) were admitted to the intensive care unit as a consequence of their infection and the median length of stay was 4.5 days in the intensive care unit. At admission, 2516 patients (94%) met at least one sepsis criterion and 1,658 (62%) met at least one criterion for severe sepsis. Overall, the 28-day mortality rates of patients with infection without sepsis, sepsis without organ dysfunction, severe sepsis without shock, and septic shock were 3%, 7.3%, 21.9%, and 45.6%, respectively. In community-acquired infections, the most frequent diagnosis was urinary tract infection in 28.6% followed by pneumonia in 22.8% and soft tissue infections in 21.8%. Within hospital-acquired infections, pneumonia was the most frequent diagnosis in 26.6% followed by urinary tract infection in 20.4% and soft tissue infections in 17.4%.

CONCLUSIONS

In a general inpatient population of Colombia, the rates of severe sepsis and septic shock are higher than those reported in the literature. The observed mortality is higher than the predicted by the Acute Physiology and Chronic Health Evaluation II score.

Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers

Introduction

It is unknown whether resources necessary to implement the Surviving Sepsis Campaign guidelines and sepsis bundles are available in Africa. This self-reported, continent-wide survey compared the availability of these resources between African and high-income countries, and between two African regions (Sub-Sahara Africa vs. South Africa, Mauritius and the Northern African countries).

Methods

The study was conducted as an anonymous questionnaire-based, cross-sectional survey among anaesthesia providers attending a transcontinental congress. Based on the respondents' country of practice, returned questionnaires were grouped into African and high-income countries. The questionnaire contained 74 items and evaluated all material resources required to implement the most recent Surviving Sepsis Campaign guidelines. Group comparisons were performed with the Chi², Fisher's Exact or Mann Whitney U test, as appropriate.

Results

The overall response rate was 74.3% (318/428). Three-hundred-seven questionnaires were analysed (African countries, n = 263; high-income countries, n = 44). Respondents from African hospitals were less likely to have an emergency room (85.5 vs. 97.7%, P = 0.03) or intensive care unit (73.8 vs. 100%, P < 0.001) than respondents from high-income countries. Drugs, equipment, and disposable materials required to implement the Surviving Sepsis Campaign guidelines or sepsis bundles were less frequently available in African than high-income countries. Of all African and Sub-Saharan African countries, 1.5% (4/263) and 1.2% (3/248) of respondents had the resources available to implement the Surviving Sepsis Campaign guidelines in entirety. The percentage of implementable recommendations was lower in African than in high-income countries (72.6 (57.7 to 87.7)% vs. 100 (100 to 100)%, P < 0.001) and lower in Sub-Saharan African countries than South Africa, Mauritius, and the Northern African countries (72.6 (56.2 to 86.3)% vs. 90.4 (71.2 to 94.5)%, P = 0.02).

Conclusions

The results of this self-reported survey strongly suggest that the most recent Surviving Sepsis guidelines cannot be implemented in Africa, particularly not in Sub-Saharan Africa, due to a shortage of required hospital facilities, equipment, drugs and disposable materials. However, availability of resources to implement the majority of strong Surviving Sepsis Campaign recommendations and the sepsis bundles may allow modification of current sepsis guidelines based on available resources and implementation of a substantial number of life-saving interventions into sepsis care in Africa.

Nationwide survey on resource availability for implementing current sepsis guidelines in Mongolia

OBJECTIVE

To assess if secondary and tertiary hospitals in Mongolia have the resources needed to implement the 2008 Surviving Sepsis Campaign (SSC) guidelines.

METHODS

To obtain key informant responses, we conducted a nationwide survey by sending a 74-item questionnaire to head physicians of the intensive care unit or department for emergency and critically ill patients of 44 secondary and tertiary hospitals in Mongolia. The questionnaire inquired about the availability of the hospital facilities, equipment, drugs and disposable materials required to implement the SSC guidelines. Descriptive methods were used for statistical analysis. Comparisons between central and peripheral hospitals were performed using non-parametric tests.

FINDINGS

The response rate was 86.4% (38/44). No Mongolian hospital had the resources required to consistently implement the SSC guidelines. The median percentage of implementable recommendations and suggestions combined was 52.8% (interquartile range, IQR: 45.8-67.4%); of implementable recommendations only, 68% (IQR: 58.0-80.5%) and of implementable suggestions only, 43.5% (IQR: 34.8-57.6%). These percentages did not differ between hospitals located in the capital city and those located in rural areas.

CONCLUSION

The results of this study strongly suggest that the most recent SSC guidelines cannot be implemented in Mongolia due to a dramatic shortage of the required hospital facilities, equipment, drugs and disposable materials. Further studies are needed on current awareness of the problem, development of national reporting systems and guidelines for sepsis care in Mongolia, as well as on the quality of diagnosis and treatment and of the training of health-care professionals.

MAP kinase phosphatase-1, a critical negative regulator of the innate immune response

Mitogen-activated protein (MAP) kinase cascades are crucial signal transduction pathways in the regulation of the host inflammatory response to infection. MAP kinase phosphatase (MKP)-1, an archetypal member of the MKP family, plays a pivotal role in the deactivation of p38 and JNK. In vitro studies using cultured macrophages have provided compelling evidence for a central role of MKP-1 in the restraint of pro-inflammatory cytokine biosynthesis. Studies using MKP-1 knockout mice have strengthened the findings from in vitro studies and defined the critical importance of MKP-1 in the regulation of pro-inflammatory cytokine synthesis in vivo during the host response to bacterial cell wall components. Upon challenge with Toll-like receptor ligands MKP-1 knockout mice produced dramatically greater amounts of inflammatory cytokines, developed severe hypotension and multi-organ failure, and exhibited a remarkable increase in mortality. More recent investigations using intact bacteria confirmed these observations and further revealed novel functions of MKP-1 in host defense against bacterial infection. These studies demonstrate that MKP-1 is an essential feedback regulator of the innate immune response, and that it plays a critical role in preventing septic shock and multi-organ dysfunction during pathogenic infection. In this review, we will summarize the studies on the function of MKP-1 in innate immune responses and discuss the regulation of this novel protein phosphatase.

The epidemiology of, and risk factors for, mortality from severe sepsis and septic shock in a tertiary-care university hospital setting

This study investigated the clinical characteristics of, and outcomes and risk factors for hospital mortality of 390 patients admitted with severe sepsis or septic shock in an intensive care unit (ICU). Prospectively collected data from patients collected between 1 July 2004 and 30 June 2006 were analysed. Overall hospital mortality was 49.7% and comorbidities were found in 40.3% of patients, the most common of which was haematological malignancy. The respiratory tract was the most common site of infection (50%). Hospital-acquired infections accounted for 55.6% of patients with Gram-negative bacteria predominant (68%). Multivariate analysis showed that acute respiratory distress syndrome, pulmonary artery catheter placement, comorbidities, hospital-acquired infection, APACHE II score and maximum LOD score, were independent risk factors for hospital mortality. In conclusion, severe sepsis and septic shock are common causes of ICU admission. Patients with risk factors for increased mortality should be carefully monitored and aggressive treatment administered.

Strategies to reduce mortality from bacterial sepsis in adults in developing countries

Sharon Peacock and colleagues discuss management of adult patients with sepsis in low- and middle-income settings, with a particular emphasis on tropical regions.

Epidemiology of severe sepsis in critically ill surgical patients in ten university hospitals in China*

OBJECTIVES

To determine the occurrence rate, outcomes, and the characteristics of severe sepsis in surgical intensive care units in multiple medical centers within China and to assess the cost and resource use of severe sepsis in China.

DESIGN AND SETTING

Prospective, observational study of surgical intensive care unit patients at ten university hospitals in six provinces in China.

PATIENTS

All adult admissions in studied intensive care units from December 1, 2004, to November 30, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The criteria of severe sepsis were based on the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definition. Analysis of data from 3,665 intensive care unit admissions identified 318 (8.68%) cases of severe sepsis, 64.8% of which were men. The median age (interquartile range) of patients with severe sepsis was 64 (47-74) yrs. Microbes had been isolated from 228 (71.7%) patients, including 171 (53.8%) with Gram-negative bacteria and 146 (45.9%) with Gram-positive bacteria. A total of 90 (22.0%) patients had invasive fungal infection, 20 (6.3%) of which had fungemia. The abdomen was the most common site of infections (72.3%), followed by lung (52.8%). The overall hospital mortality of severe sepsis was 48.7%. Risk factors for hospital mortality included age, chronic comorbidity of malignant neoplasm, Gram-positive bacterial infection, invasive fungal infection, admission Acute Physiology Score, and admission Sequential Organ Failure Assessment score of respiratory dysfunction and cardiovascular dysfunction. The median Therapeutic Intervention Scoring System-28 score was 43 (38-49). The mean hospital cost was $11,390 per patient and $502 per patient per day.

CONCLUSIONS

Severe sepsis is a common, expensive, and frequently fatal syndrome in critically ill surgical patients in China. Other than the microbiological patterns, the incidence, mortality, and major characteristics of severe sepsis in Chinese surgical intensive care units are close to those documented in developed countries.

Intravenous immunoglobulin for treating sepsis and septic shock

BACKGROUND

Death from severe sepsis and septic shock is common, and researchers have explored whether antibodies to the endotoxins in some bacteria reduces mortality.

OBJECTIVES

To estimate the effects of intravenous immunoglobulin (IVIG) in patients with bacterial sepsis or septic shock on mortality, bacteriological failure rates, and duration of stay in hospital.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized register up to November 2001; the Cochrane Controlled Trials Register, The Cochrane Library issue 4, 2001; MEDLINE 1966 to November 2001; and EMBASE 1988 to September 2001. We contacted investigators active in the field for unpublished data.

SELECTION CRITERIA

Randomised trials comparing intravenous immunoglobulin (monoclonal or polyclonal) with placebo or no intervention, in patients with bacterial sepsis or septic shock.

DATA COLLECTION AND ANALYSIS

Inclusion criteria, trial quality assessment, and data abstraction were done in duplicate. We conducted pre-specified subgroup analyses by type of immunoglobulin preparation.

MAIN RESULTS

Twenty-seven out of 55 studies met our inclusion criteria. Pooled analysis of all types of IVIG preparations revealed a significant trend toward reduction of mortality (n= 8,856; RR=0.91; 95%CI 0.86-0.96). Overall mortality was reduced in patients who received polyclonal IVIG (n=492; RR=0.64; 95% CI 0.51 to 0.80). For the two high-quality trials on polyclonal IVIG, the RR for overall mortality was 0.30, but the confidence interval was wide (95% CI 0.09 to 0.99, n=91). Mortality was not reduced among patients who received monoclonal antibodies such as anti-endotoxins (n=2,826 in 5 good-quality studies; RR=0.97; 95% CI 0.88 to 1.07) or anti-cytokines (n=4,318; RR=0.93; 95% CI 0.86 to 1.01). A few studies measured secondary outcomes (deaths from sepsis or length of hospitalisation) but no differences in the intervention and control groups were identified except among those who received polyclonal IVIG, where sepsis-related mortality was significantly reduced (n=161; RR=0.35; 95% CI 0.18 to 0.69).

REVIEWER'S CONCLUSIONS

Polyclonal IVIG significantly reduced mortality and and is a promising adjuvant in the treatment of sepsis and septic shock. However, all the trials were small and the totality of the evidence is insufficient to support a robust conclusion of benefit. Adjunctive therapy with monoclonal IVIGs remains experimental.