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Giamarellos-Bourboulis EJ, Siampanos A, Bolanou A, Doulou S, Kakavoulis N, Tsiakos K, Katopodis S, Schinas G, Skorda L, Alexiou Z, Armenis K, Katsaounou P, Chrysos G, Masgala A, Poulakou G, Antonakos N, Safarika A, Kyprianou M, Dakou K, Gerakari S, Papanikolaou IC, Milionis H, Marangos M, Dalekos GN, Tzavara V, Akinosoglou K, Hatziaggelaki E, Sympardi S, Kontopoulou T, Mouktaroudi M, Papadopoulos A, Niederman MS. Clarithromycin for early anti-inflammatory responses in community-acquired pneumonia in Greece (ACCESS): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med 2024; 12:294-304. [PMID: 38184008 DOI: 10.1016/s2213-2600(23)00412-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/06/2023] [Accepted: 10/27/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Addition of macrolide antibiotics to β-lactam antibiotics for the treatment of patients in hospital with community-acquired pneumonia is based on results from observational studies and meta-analyses rather than randomised clinical trials. We investigated if addition of the macrolide clarithromycin to treatment with a β-lactam antibiotic in this population could improve early clinical response-the new regulatory endpoint for community-acquired pneumonia-and explored the possible contribution of modulation of the inflammatory host response to that outcome. METHODS The ACCESS trial was a phase 3 prospective, double-blind, randomised controlled trial, in which adults in hospital with community-acquired pneumonia who had systemic inflammatory response syndrome, Sequential Organ Failure Assessment (SOFA) score of 2 or more, and procalcitonin 0·25 ng/mL or more were enrolled in 18 internal medicine departments of public Greek hospitals. Patients were randomly assigned (1:1) by computer-generated block randomisation to standard of care medication (including intravenous administration of a third-generation cephalosporin or intravenous administration of β-lactam plus β-lactamase inhibitor combination) plus either oral placebo or oral clarithromycin 500 mg twice daily for 7 days. Investigators, staff, and patients were masked to group allocation. The primary composite endpoint required that patients fulfilled both of the following conditions after 72 hours (ie, day 4 of treatment): (1) decrease in respiratory symptom severity score of 50% or more as an indicator of early clinical response and (2) decrease in SOFA score of at least 30% or favourable procalcitonin kinetics (defined as ≥80% decrease from baseline or procalcitonin <0·25 ng/mL), or both, as an indicator of early inflammatory response. Participants who were randomly assigned and received allocated treatment were included in the primary analysis population. This trial is complete and is registered with the EU Clinical Trials Register (2020-004452-15) and ClinicalTrials.gov (NCT04724044). FINDINGS Patients were enrolled between Jan 25, 2021, and April 11, 2023, and 278 individuals were randomly allocated to receive standard of care in combination with either clarithromycin (n=139) or placebo (n=139). 134 patients in the clarithromycin group (five withdrew consent) and 133 patients in the placebo group (six withdrew consent) were included in the analysis of the primary endpoint. The primary endpoint was met in 91 (68%) patients in the clarithromycin group and 51 (38%) patients in the placebo group (difference 29·6% [95% CI 17·7-40·3]; odds ratio [OR] 3·40 [95% CI 2·06-5·63]; p<0·0001). Serious treatment-emergent adverse events (TEAEs) occurred in 58 (43%) patients in the clarithromycin group and 70 (53%) patients in the placebo group (difference 9·4% [95% CI -2·6 to 20·9]; OR 0·67 [95% CI 0·42 to 1·11]; p=0·14). None of the serious TEAEs was judged to be related to treatment assignment. INTERPRETATION Addition of clarithromycin to standard of care enhances early clinical response and attenuates the inflammatory burden of community-acquired pneumonia. The mechanism of benefit is associated with changes in the immune response. These findings suggest the importance of adding clarithromycin to β-lactams for treatment of patients in hospital with community-acquired pneumonia to achieve early clinical response and early decrease of the inflammatory burden. FUNDING Hellenic Institute for the Study of Sepsis and Abbott Products Operations.
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Affiliation(s)
- Evangelos J Giamarellos-Bourboulis
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Hellenic Institute for the Study of Sepsis, Athens, Greece.
| | - Athanasios Siampanos
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Amalia Bolanou
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Sarantia Doulou
- Fifth Department of Internal Medicine, Evangelismos Athens General Hospital, Athens, Greece
| | - Nikolaos Kakavoulis
- First Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Konstantinos Tsiakos
- Third Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sokratis Katopodis
- Second Department of Propedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Schinas
- Department of Internal Medicine, University of Patras, Rion, Greece
| | - Lamprini Skorda
- Third Department of Internal Medicine and Infectious Diseases Unit, Korgialeneion-Benakeion General Hospital, Athens, Greece
| | - Zoi Alexiou
- Second Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Konstantinos Armenis
- First Department of Internal Medicine, G Gennimatas General Hospital of Athens, Athens, Greece
| | - Paraskevi Katsaounou
- First Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Chrysos
- Second Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Aikaterini Masgala
- Second Department of Internal Medicine, Konstantopouleio General Hospital, Athens, Greece
| | - Garyphalia Poulakou
- Third Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Antonakos
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Asimina Safarika
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Styliani Gerakari
- Emergency Department, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Ilias C Papanikolaou
- Department of Pulmonary Medicine, General Hospital of Corfu "Agia Eirini", Greece
| | - Haralampos Milionis
- First Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Markos Marangos
- Department of Internal Medicine, University of Patras, Rion, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Vasiliki Tzavara
- First Department of Internal Medicine, Korgialeneion-Benakeion General Hospital, Athens, Greece
| | | | - Eryfilli Hatziaggelaki
- Second Department of Propedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Styliani Sympardi
- First Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Theano Kontopoulou
- Fifth Department of Internal Medicine, Evangelismos Athens General Hospital, Athens, Greece; First Department of Internal Medicine, Evangelismos Athens General Hospital, Athens, Greece
| | - Maria Mouktaroudi
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Antonios Papadopoulos
- Fourth Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Weil Cornell Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
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Pan D, Chung S, Nielsen E, Niederman MS. Aspiration Pneumonia. Semin Respir Crit Care Med 2024; 45:237-245. [PMID: 38211629 DOI: 10.1055/s-0043-1777772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.
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Affiliation(s)
- Di Pan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Samuel Chung
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Erik Nielsen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
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Sartini C, Landoni G, Belletti A, Kotani Y, Maimeri N, Umbrello M, Yavorovskiy A, Jabaudon M. Beyond the Surviving Sepsis Campaign Guidelines: a systematic review of interventions affecting mortality in sepsis. Panminerva Med 2024; 66:55-62. [PMID: 38093626 DOI: 10.23736/s0031-0808.23.04986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Sepsis-related mortality is decreasing over time after the introduction of "Surviving Sepsis Campaign" Guidelines in 2004. The last Guidelines version collects 93 recommendations, but several interventions supported by randomized evidence of mortality reduction are not included. EVIDENCE ACQUISITION We performed a systematic review of all randomized controlled trials reporting a statistically significant mortality reduction in septic patients and compared the identified studies to the Surviving Sepsis Campaign Guidelines 2021 to highlight discrepancies. EVIDENCE SYNTHESIS We identified 83 randomized controlled trials (58 interventions) influencing mortality in sepsis. Only 9/58 of these interventions were included in the Guidelines: lactate measurement and lactate-guided hemodynamic management, procalcitonin-guided antibiotics discontinuation, balanced crystalloids as first choice fluids, albumin infusion, avoidance of starches, noradrenaline as first line vasopressor, vasopressin as an adjunctive vasopressor to noradrenaline, neuromuscular blocking agents in moderate-severe sepsis-associated acute respiratory distress syndrome, and corticosteroids use. Only 11/93 Guidelines recommendations were supported by randomized evidence with mortality difference. Five of the interventions with survival benefit in literature (vitamin C, terlipressin, polymyxin B, liberal transfusion strategy and immunoglobulins) were recommended to avoid in the Guidelines, while 44 interventions were not mentioned, including three interventions (esmolol, omega 3, and external warming) with at least two randomized controlled trials with a documented survival benefit. CONCLUSIONS Several discrepancies exist between the randomized controlled trials with mortality difference in septic patients and the latest Surviving Sepsis Campaign Guidelines. This systematic review can be of help for improving future guidelines and may guide research on specific promising topics.
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Affiliation(s)
- Chiara Sartini
- Neurosurgical Intensive Care Unit, ASST Santi Paolo e Carlo - San Carlo Borromeo Hospital, Milan, Italy
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy -
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Nicolò Maimeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Umbrello
- Section of Resuscitation and Anesthesia, Ospedale Nuovo di Legnano, ASST Ovest Milanese, Legnano, Milan, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Moscow, Russia
| | - Matthieu Jabaudon
- Institute of Genetics, Reproduction, and Development (iGReD), Clermont Auvergne University, National Center of Scientific Research, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
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Cui N, Zhang YY, Sun T, Lv XW, Dong XM, Chen N. Utilizing procalcitonin, C-reactive protein, and serum amyloid A in combination for diagnosing sepsis due to urinary tract infection. Int Urol Nephrol 2024:10.1007/s11255-024-03959-0. [PMID: 38376659 DOI: 10.1007/s11255-024-03959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/15/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVE In this study, we aimed to evaluate the combined diagnostic value of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in sepsis caused by urinary tract infection. METHOD A total of 80 patients with urosepsis who were hospitalized were included in the study group, and 80 patients with urinary tract infection without sepsis were included in the control group. We collected the PCT, SAA, and CRP levels of patients following admission. Subsequently, we conducted a comparative analysis to assess the specificity, accuracy, and sensitivity of combined diagnostic approaches in contrast to individual diagnostic methods for blood PCT, SAA, and CRP. RESULTS The levels of PCT, SAA, and CRP in the study group were significantly higher than those in the control group, and the differences were statistically significant (P < 0.01). Multi-factor logistic regression analysis revealed that the levels of PCT (P = 0.003) and SAA (P = 0.014) were associated with urosepsis. The sensitivity of PCT was 87.133% and the specificity was 93.066%, which were higher than that of SAA and CRP. The specificity of the combined detection of the three was 95.670%, which was higher than that of PCT, SAA, and CRP alone. Correlation analysis revealed that PCT had a significant positive correlation with CRP and SAA (P < 0.01), and a weak correlation with white blood cell count (WBC) and fibrinogen (FIB) (P = 0.03 for WBC, P = 0.04 for FIB). CONCLUSION PCT, SAA, and CRP indicators in patients with urosepsis are significantly elevated, and all three are valuable in the diagnosis of urosepsis. PCT alone has good diagnostic efficiency for urosepsis, and a certain correlation with other inflammatory factors. The diagnostic efficacy of the three indicators in combination is better than that of any one of the three, and is worthy of widespread clinical application.
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Affiliation(s)
- Na Cui
- Department of Critical Care Medicine, Affiliated Hospital of Hebei University, No. 212 of Yuha Road, Lianchi District, Baoding, 071000, China
- Hebei Key Laboratory of Precise Imaging of Inflammation Related Tumors, Baoding, 071000, China
| | - Yuan-Yuan Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Hebei University, No. 212 of Yuha Road, Lianchi District, Baoding, 071000, China
| | - Tao Sun
- Department of Critical Care Medicine, Affiliated Hospital of Hebei University, No. 212 of Yuha Road, Lianchi District, Baoding, 071000, China.
| | - Xiao-Wei Lv
- Department of Critical Care Medicine, Affiliated Hospital of Hebei University, No. 212 of Yuha Road, Lianchi District, Baoding, 071000, China
| | - Xu-Mei Dong
- Department of Critical Care Medicine, Affiliated Hospital of Hebei University, No. 212 of Yuha Road, Lianchi District, Baoding, 071000, China
| | - Ning Chen
- Department of Critical Care Medicine, Affiliated Hospital of Hebei University, No. 212 of Yuha Road, Lianchi District, Baoding, 071000, China
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Jiang J, Shu H, Wang DW, Hui R, Li C, Ran X, Wang H, Zhang J, Nie S, Cui G, Xiang D, Shao Q, Xu S, Zhou N, Li Y, Gao W, Chen Y, Bian Y, Wang G, Xia L, Wang Y, Zhao C, Zhang Z, Zhao Y, Wang J, Chen S, Jiang H, Chen J, Du X, Chen M, Sun Y, Li S, Ding H, Ma X, Zeng H, Lin L, Zhou S, Ma L, Tao L, Chen J, Zhou Y, Guo X. Chinese Society of Cardiology guidelines on the diagnosis and treatment of adult fulminant myocarditis. Sci China Life Sci 2024:10.1007/s11427-023-2421-0. [PMID: 38332216 DOI: 10.1007/s11427-023-2421-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/25/2023] [Indexed: 02/10/2024]
Abstract
Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.
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Affiliation(s)
- Jiangang Jiang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hongyang Shu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dao Wen Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Rutai Hui
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chenze Li
- Zhongnan Hospital of Wuhan University, Wuhan, 430062, China
| | - Xiao Ran
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hong Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jing Zhang
- Fuwai Huazhong Cardiovascular Hospital, Zhengzhou, 450003, China
| | - Shaoping Nie
- Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Guanglin Cui
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dingcheng Xiang
- Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, 510010, China
| | - Qun Shao
- Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Shengyong Xu
- Union Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ning Zhou
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yuming Li
- Taida Hospital, Tianjin, 300457, China
| | - Wei Gao
- Peking University Third Hospital, Beijing, 100191, China
| | - Yuguo Chen
- Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Yuan Bian
- Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Guoping Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Liming Xia
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yan Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chunxia Zhao
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhiren Zhang
- Harbin Medical University Cancer Hospital, Harbin, 150081, China
| | - Yuhua Zhao
- Kanghua Hospital, Dongguan, Guangzhou, 523080, China
| | - Jianan Wang
- Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Shaoliang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Hong Jiang
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Jing Chen
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Xianjin Du
- Renmin Hospital of Wuhan University, Wuhan, 430060, Wuhan, China
| | - Mao Chen
- West China Hospital, Sichuan University, Chengdu, 610044, China
| | - Yinxian Sun
- First Hospital of China Medical University, Shenyang, 110002, China
| | - Sheng Li
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Hu Ding
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xueping Ma
- General Hospital of Ningxia Medical University, Yinchuan, 750003, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Li Lin
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shenghua Zhou
- The Second Xiangya Hospital, Central South University, Changsha, 410012, China
| | - Likun Ma
- The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 230002, China
| | - Ling Tao
- The First Affiliated Hospital of Air Force Medical University, Xi'an, 710032, China
| | - Juan Chen
- Central Hospital of Wuhan City, Wuhan, 430014, China
| | - Yiwu Zhou
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaomei Guo
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Cusack R, Little E, Martin-Loeches I. Practical Lessons on Antimicrobial Therapy for Critically Ill Patients. Antibiotics (Basel) 2024; 13:162. [PMID: 38391547 PMCID: PMC10886263 DOI: 10.3390/antibiotics13020162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis stands as a formidable global health challenge, with persistently elevated mortality rates in recent decades. Each year, sepsis not only contributes to heightened morbidity but also imposes substantial healthcare costs on survivors. This narrative review aims to highlight the targeted measures that can be instituted to alleviate the incidence and impact of sepsis in intensive care. Here we discuss measures to reduce nosocomial infections and the prevention of equipment and patient colonisation by resilient pathogens. The overarching global crisis of bacterial resistance to newly developed antimicrobial agents intensifies the imperative for antimicrobial stewardship and de-escalation. This urgency has been accentuated in recent years, notably during the COVID-19 pandemic, as high-dose steroids and opportunistic infections presented escalating challenges. Ongoing research into airway colonisation's role in influencing disease outcomes among critically ill patients underscores the importance of tailoring treatments to disease endotypes within heterogeneous populations, which are important lessons for intensivists in training. Looking ahead, the significance of novel antimicrobial delivery systems and drug monitoring is poised to increase. This narrative review delves into the multifaceted barriers and facilitators inherent in effectively treating critically ill patients vulnerable to nosocomial infections. The future trajectory of intensive care medicine hinges on the meticulous implementation of vigilant stewardship programs, robust infection control measures, and the continued exploration of innovative and efficient technological solutions within this demanding healthcare landscape.
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Affiliation(s)
- Rachael Cusack
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
| | - Elizabeth Little
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
- Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, 08180 Barcelona, Spain
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Kwa ALH, Aninda Sidharta BR, Son DN, Zirpe K, Periyasamy P, Plongla R, Swaminathan S, Loho T, Van Giap V, Apisarnthanarak A. Clinical utility of procalcitonin in implementation of procalcitonin-guided antibiotic stewardship in the South-East Asia and India: evidence and consensus-based recommendations. Expert Rev Anti Infect Ther 2024; 22:45-58. [PMID: 38112181 DOI: 10.1080/14787210.2023.2296066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION The South-East Asian (SEA) region and India are highly susceptible to antibiotic resistance, which is caused due to lack of antimicrobial stewardship (AMS) knowledge, uncontrolled use of antibiotics, and poor infection control. Nonadherence to national/local guidelines, developed to combat antimicrobial resistance, is a major concern. A virtual advisory board was conducted to understand the current AMS standards and challenges in its implementation in these regions. AREAS COVERED Procalcitonin (PCT)-guided antibiotic use was discussed in various clinical conditions across initiation, management, and discontinuation stages. Most experts strongly recommended using PCT-driven antibiotic therapy among patients with lower respiratory tract infections, sepsis, and COVID-19. However, additional research is required to understand the optimal use of PCT in patients with organ transplantation and cancer patients with febrile neutropenia. Implementation of the solutions discussed in this review can help improve PCT utilization in guiding AMS in these regions and reducing challenges. EXPERT OPINION Experts strongly support the inclusion of PCT in AMS. They believe that PCT in combination with other clinical data to guide antibiotic therapy may result in more personalized and precise targeted antibiotic treatment. The future of PCT in antibiotic treatment is promising and may result in effective utilization of this biomarker.
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Affiliation(s)
- Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases Program, Duke-National University of Singapore Medical School, Singapore, Singapore
| | | | - Do Ngoc Son
- Center for Critical Care Medicine, Bach Mai Hospital; Hanoi Medical University; School of Medicine and Pharmacy, Hanoi National University, Hanoi, Vietnam
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, India
| | - Petrick Periyasamy
- Infectious Diseases Unit, Medical Department, Hospital Canselor Tuanku Muhriz UKM, Kuala Lumpur, Malaysia
| | - Rongpong Plongla
- Division of Infectious Diseases, Department of Medicine and Center of Excellence in Antimicrobial Resistance and Stewardship; Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Tonny Loho
- Department of Clinical Pathology, Medistra Hospital; Medicine and Health Sciences, Universitas Kristen Krida Wacana, Jakarta, Indonesia
| | - Vu Van Giap
- Training and Direction of Healthcare Activities Center; Internal Medicine Department, Hanoi Medical University; Vietnam Respiratory Society; Vietnam Society of Sleep Medicine; Respiratory Center, Bach Mai Hospital, Hanoi, Vietnam
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Li D, Ding S, Li J, Liao X, Ru K, Liu L, Shang W. Diagnostic value of inflammatory indicators for surgical site infection in patients with breast cancer. Front Cell Infect Microbiol 2023; 13:1286313. [PMID: 37953798 PMCID: PMC10634473 DOI: 10.3389/fcimb.2023.1286313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/05/2023] [Indexed: 11/14/2023] Open
Abstract
Background Breast cancer is the most commonly diagnostic cancer in women worldwide. The main treatment for these patients is surgery. However, there is a high incidence of surgical site infection (SSI) in breast cancer patients. The aim of this study was to identify effective infection-related diagnostic markers for timely diagnosis and treatment of SSI. Methods This retrospective study included 263 breast cancer patients who were treated between July 2018 and March 2023 at the Shandong Cancer Hospital and Institute. We analyzed differences between the SSI group and control group and differences before and during infection in the SSI group. Finally, we tested the distribution of pathogenic microorganisms and their susceptibility to antibiotics. Results Compared with preoperative inflammatory indicators, white blood cells (WBC), neutrophils (NEU), absolute neutrophil count to the absolute lymphocyte count (NLR), D2 polymers (D-Dimer) and fibrinogen (FIB) were significantly increased, while lymphocytes (LYM), albumin (ALB) and prealbumin (PA) were significantly decreased in the SSI group. Compared with uninfected patients, WBC, NEU, NLR and FIB were significantly increased, ALB and PA were significantly decreased in SSI patients, while LYM and D-Dimer did not differ significantly. The distribution of infection bacteria in SSI patients showed that the proportion of patients with Staphylococcus aureus infection was as high as 70.41%; of those patients, 19.33% had methicillin-resistant Staphylococcus aureus (MRSA) infection. The area under the curves (AUCs) of the receiver operating curves (ROCs) for WBC, NEU, NLR, FIB, ALB and PA were 0.807, 0.811, 0.730, 0.705, 0.663 and 0.796, respectively. The AUCs for other inflammatory indicators were not statistically significant. There was no significant difference in antibiotic resistance for Staphylococcus aureus when compared to that of gram-positive bacteria. The resistance of gram-positive bacteria to ceftriaxone (CRO), cefoxitin (FOX), chloramphenicol (CHL), minocycline (MNO) and tetracycline (TCY) was lower than that of gram-negative bacteria, while the resistance to gentamicin (GEN) was higher. Conclusion This study demonstrated that WBC, NEU, NLR, FIB and PA have good predictive value for identifying patients at risk of SSI. The cut-off values of inflammatory indicators can be helpful in the prevention and diagnosis of SSI.
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Affiliation(s)
| | | | | | | | | | | | - Wenjing Shang
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
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Sun B, Chen Y, Man Y, Fu Y, Lin J, Chen Z. Clinical value of neutrophil-to-lymphocyte ratio and prognostic nutritional index on prediction of occurrence and development of diabetic foot-induced sepsis. Front Public Health 2023; 11:1181880. [PMID: 38026334 PMCID: PMC10630165 DOI: 10.3389/fpubh.2023.1181880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Background Diabetic foot-induced sepsis is a serious complication associated with increased disability and mortality in hospitalized patients. Early prediction of admission and detection effectively improve treatment options and prevent further deterioration. This study aims to evaluate the clinical value of the neutrophil-to-lymphocyte ratio (NLR) and prognostic nutritional index (PNI) to predict the risk of sepsis in patients with diabetic foot ulcers (DFU). Methods Retrospective analysis was performed on 216 patients who were admitted to the Fujian Medical University Union Hospital between January 2015 and December 2022. Patients with DFU were divided into the non-sepsis (n = 166) and the DFU-induced sepsis (n = 50) groups. The independent factors of DFU-induced sepsis were determined by univariate and multivariate logistic regression analyses. A receiver operating characteristic (ROC) curve was performed to compare the area under the curves (AUC) of PNI and NLR. Results Multivariate logistic regression analysis revealed that the PNI, NLR, international normalized ratio (INR), thrombin time (PT), and C-reactive protein (CRP) were independent prognostic factors for DFU-induced sepsis. After adjusting for potential confounders, the adjusted odds ratios of NLR for DFU-induced sepsis were 1.121 (1.072-1.172), 1.132 (1.077-1.189), and 1.080 (1.022-1.142), while those of PNI were 0.912 (0.873-0.953), 0.902 (0.856-0.950), and 1.004 (1.001-1.006). Moreover, the AUC of NLR was significantly greater than that of CRP (0.790, 95% CI: 0.689-0.891, p < 0.001 vs. 0.780, 95% CI: 0.686-0.873, p < 0.001). Conclusion NLR and PNI have been regarded as readily and independently predictive markers in patients with DFU-induced sepsis. NLR is critical for the early detection and effective treatment of DFU-induced sepsis and is superior to CRP.
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Affiliation(s)
- Bing Sun
- Burn & Wound Repair Department, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Institute, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yimin Chen
- Burn & Wound Repair Department, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Institute, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yulin Man
- Burn & Wound Repair Department, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Institute, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu Fu
- Burn & Wound Repair Department, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Institute, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianchang Lin
- Burn & Wound Repair Department, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Institute, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhaohong Chen
- Burn & Wound Repair Department, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Institute, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Burn Medical Center, Fujian Medical University Union Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Burn and Trauma, Fujian Medical University Union Hospital, Fuzhou, China
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Papp M, Kiss N, Baka M, Trásy D, Zubek L, Fehérvári P, Harnos A, Turan C, Hegyi P, Molnár Z. Procalcitonin-guided antibiotic therapy may shorten length of treatment and may improve survival-a systematic review and meta-analysis. Crit Care 2023; 27:394. [PMID: 37833778 PMCID: PMC10576288 DOI: 10.1186/s13054-023-04677-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Appropriate antibiotic (AB) therapy remains a challenge in the intensive care unit (ICU). Procalcitonin (PCT)-guided AB stewardship could help optimize AB treatment and decrease AB-related adverse effects, but firm evidence is still lacking. Our aim was to compare the effects of PCT-guided AB therapy with standard of care (SOC) in critically ill patients. METHODS We searched databases CENTRAL, Embase and Medline. We included randomized controlled trials (RCTs) comparing PCT-guided AB therapy (PCT group) with SOC reporting on length of AB therapy, mortality, recurrent and secondary infection, ICU length of stay (LOS), hospital LOS or healthcare costs. Due to recent changes in sepsis definitions, subgroup analyses were performed in studies applying the Sepsis-3 definition. In the statistical analysis, a random-effects model was used to pool effect sizes. RESULTS We included 26 RCTs (n = 9048 patients) in the quantitative analysis. In comparison with SOC, length of AB therapy was significantly shorter in the PCT group (MD - 1.79 days, 95% CI: -2.65, - 0.92) and was associated with a significantly lower 28-day mortality (OR 0.84, 95% CI: 0.74, 0.95). In Sepsis-3 patients, mortality benefit was more pronounced (OR 0.46 95% CI: 0.27, 0.79). Odds of recurrent infection were significantly higher in the PCT group (OR 1.36, 95% CI: 1.10, 1.68), but there was no significant difference in the odds of secondary infection (OR 0.81, 95% CI: 0.54, 1.21), ICU and hospital length of stay (MD - 0.67 days 95% CI: - 1.76, 0.41 and MD - 1.23 days, 95% CI: - 3.13, 0.67, respectively). CONCLUSIONS PCT-guided AB therapy may be associated with reduced AB use, lower 28-day mortality but higher infection recurrence, with similar ICU and hospital length of stay. Our results render the need for better designed studies investigating the role of PCT-guided AB stewardship in critically ill patients.
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Affiliation(s)
- Márton Papp
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Saint John's Hospital, Budapest, Hungary
| | - Nikolett Kiss
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Máté Baka
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
| | - Domonkos Trásy
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
| | - László Zubek
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Üllői Út 26, 1082, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland.
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Khana TQ, Anwar KA. Detection of Inflammatory Biomarkers Among Patients with Sepsis of Gram-Negative Bacteria: A Cross-Sectional Study. Int J Gen Med 2023; 16:3963-3976. [PMID: 37670930 PMCID: PMC10476660 DOI: 10.2147/ijgm.s415200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023] Open
Abstract
Background Sepsis is a highly mixed ailment that affects patients with numerous conditions of infectious sources and can lead to multi-organ failure with dysregulated host immune response. Objective To determine inflammatory biomarkers in patients with sepsis caused by Gram-negative bacteria and compare their role in the early detection of sepsis. Methods This cross-sectional study was conducted on patients with sepsis admitted to the intensive care unit at different hospitals in Sulaimaniyah, Iraq, from May to December 2021. Patients (n=147) were enrolled in this study according to the primary diagnosis of sepsis by Sequential Organ Failure Assessment scores. Blood samples were taken from patients to investigate white blood cells, inflammatory biomarkers (pentraxin-3, procalcitonin, adrenomedullin, lipopolysaccharide binding protein, interleukin-17A, lactate dehydrogenase, and C-creative protein), blood culture, antibiotic susceptibility test, and coagulation biomarkers (Prothrombin time, activated partial thromboplastin time, and international normalized ratio). Then, isolated Gram-negative bacteria were tested for extended-spectrum β-lactamase enzymes production by screening and combined disc tests. Results A total of 51.7% samples were blood culture positive for different Gram-negative bacteria, and P. aeruginosa (51.95%) was a more isolated bacterium. Both males and females were affected by sepsis in a ratio of 1.23:1 with different age groups. Extended-spectrum β-lactamase was estimated to be 77.2% by antibiotic profile, and the rate decreased using two double-disc synergy tests. This was confirmed by combined disc test at a rate of 41.35%. The most prevalent biomarkers were procalcitonin (88.16%), adrenomedullin (84.21%), pentraxin-3 (22.37%), and lipopolysaccharide binding protein (11.84%). Conclusion Sepsis is a life-threatening condition that can be diagnosed early by several blood biomarkers such as procalcitonin, adrenomedullin, and pentraxin-3 combined with a standard blood culture technique to improve the patient outcome.
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Affiliation(s)
- Thikra Qader Khana
- Microbiology Department, Shar Teaching Hospital, Sulaimaniyah Directorate of Health, Sulaimaniyah, Iraq
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12
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Chen J, Tu X, Huang M, Xie Y, Lin Y, Hu J. Prognostic value of platelet combined with serum procalcitonin in patients with sepsis. Medicine (Baltimore) 2023; 102:e34953. [PMID: 37653816 PMCID: PMC10470786 DOI: 10.1097/md.0000000000034953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/22/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023] Open
Abstract
Sepsis, a common and life-threatening condition in critically ill patients, is a leading cause of death in intensive care units. Over the past few decades, there has been significant improvement in the understanding and management of sepsis. However, the mortality rate remains unacceptably high, posing a prominent challenge in modern medicine and a significant global disease burden. A total of 295 patients with sepsis admitted to the hospital from January 2021 to December 2022 were collected and divided into survival group and death group according to their 28-day survival status. The differences in general clinical data and laboratory indicators between the 2 groups were compared. Receiver operating characteristic curve analysis was used to evaluate the predictive value of platelet (PLT) and procalcitonin (PCT) for the prognosis of sepsis patients within 28 days. A total of 295 patients were diagnosed with sepsis, and 79 died, with a mortality rate of 26.78%. The PLT level in the death group was lower than that in the survival group; the PCT level in the death group was higher than that in the survival group. The receiver operating characteristic curve showed that the area under the curve of PCT and PLT for evaluating the prognosis of sepsis patients were 0.808 and 0.804, respectively. Kaplan-Meier survival analysis showed that the 28-day survival rate of the low PLT level group was 19.0% and that of the high PLT level group was 93.1% at the node of 214.97 × 109/L, and the difference between the 2 groups was statistically significant (χ2 = 216.538, P < .001). The 28-day survival rate of the low PCT level group was 93.4% and that of the high PCT level group was 51.7% at the node of 2.85 ng/mL, and the difference between the 2 groups was statistically significant (χ2 = 63.437, P < .001). There was a negative correlation between PCT level and PLT level (r = -0.412, P < .001). Platelet combined with serum procalcitonin detection has high predictive value for judging the 28-day prognosis of sepsis, and it can be used as an index for evaluating the patient's condition and prognosis, and is worthy of clinical promotion and application.
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Affiliation(s)
- Jianhui Chen
- Department of Critical Care Medicine, Affiliated Hospital of Putian University, Putian City, Fujian Province, China
| | - Xiaoyan Tu
- Department of Critical Care Medicine, Union Hospital Affiliated to Fujian Medical University, Fuzhou City, Fujian Province, China
| | - Minghuan Huang
- Department of Nephrology, Affiliated Hospital of Putian University, Putian City, Fujian Province, China
| | - Ying Xie
- School of Mechanical, Electrical and Information Engineering, Putian University, Putian City, China
| | - Yanya Lin
- Department of Critical Care Medicine, Affiliated Hospital of Putian University, Putian City, Fujian Province, China
| | - Jianxiong Hu
- The School of Clinical Medicine, Fujian Medical University, Fujian, China
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Ture Z, Güner R, Alp E. Antimicrobial stewardship in the intensive care unit. J Intensive Med 2023; 3:244-253. [PMID: 37533805 PMCID: PMC10391567 DOI: 10.1016/j.jointm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 08/04/2023]
Abstract
High resistance rates to antimicrobials continue to be a global health threat. The incidence of multidrug-resistant (MDR) microorganisms in intensive care units (ICUs) is quite high compared to in the community and other units in the hospital because ICU patients are generally older, have higher numbers of co-morbidities and immune-suppressed; moreover, the typically high rates of invasive procedures performed in the ICU increase the risk of infection by MDR microorganisms. Antimicrobial stewardship (AMS) refers to the implementation of coordinated interventions to improve and track the appropriate use of antibiotics while offering the best possible antibiotic prescription (according to dose, duration, and route of administration). Broad-spectrum antibiotics are frequently preferred in ICUs because of greater infection severity and colonization and infection by MDR microorganisms. For this reason, a number of studies on AMS in ICUs have increased in recent years. Reducing the use of broad-spectrum antibiotics forms the basis of AMS. For this purpose, parameters such as establishing an AMS team, limiting the use of broad-spectrum antimicrobials, terminating treatments early, using early warning systems, pursuing infection control, and providing education and feedback are used. In this review, current AMS practices in ICUs are discussed.
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Affiliation(s)
- Zeynep Ture
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Erciyes University, Kayseri 38039,Turkey
| | - Rahmet Güner
- Department of Infectious Diseases and Clinical Microbiology, Yıldırım Beyazıt University, Ankara 06800, Turkey
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Yıldırım Beyazıt University, Ankara 06800, Turkey
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Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
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Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
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Saura O, Luyt CE. Procalcitonin as a biomarker to guide treatments for patients with lower respiratory tract infections. Expert Rev Respir Med 2023; 17:651-661. [PMID: 37639716 DOI: 10.1080/17476348.2023.2251394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Lower respiratory tract infections are amongst the main causes for hospital/intensive care unit admissions and antimicrobial prescriptions. In order to reduce antimicrobial pressure, antibiotic administration could be optimized through procalcitonin-based algorithms. AREAS COVERED In this review, we discuss the performances of procalcitonin for the diagnosis and the management of community-acquired and ventilator-associated pneumonia. We provide up-to-date evidence and deliver clear messages regarding the purpose of procalcitonin to reduce unnecessary antimicrobial exposure. EXPERT OPINION Antimicrobial pressure and resulting antimicrobial resistances are a major public health issue as well as a daily struggle in the management of patients with severe infectious diseases, especially in intensive care units where antibiotic exposure is high. Procalcitonin-guided antibiotic administration has proven its efficacy in reducing unnecessary antibiotic use in lower respiratory tract infections without excess in mortality, hospital length of stay or disease relapse. Procalcitonin-guided algorithms should be implemented in wards taking care of patients with severe infections. However, procalcitonin performances are different regarding the setting of the infection (community versus hospital-acquired infections) the antibiotic management (start or termination of antibiotic) as well as patient's condition (immunosuppressed or in shock) and we encourage the physicians to be aware of these limitations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMRS_1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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Ozbay S, Ayan M, Ozsoy O, Akman C, Karcioglu O. Diagnostic and Prognostic Roles of Procalcitonin and Other Tools in Community-Acquired Pneumonia: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13111869. [PMID: 37296721 DOI: 10.3390/diagnostics13111869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Community-acquired pneumonia (CAP) is among the most common causes of death and one of the leading healthcare concerns worldwide. It can evolve into sepsis and septic shock, which have a high mortality rate, especially in critical patients and comorbidities. The definitions of sepsis were revised in the last decade as "life-threatening organ dysfunction caused by a dysregulated host response to infection". Procalcitonin (PCT), C-reactive protein (CRP), and complete blood count, including white blood cells, are among the most commonly analyzed sepsis-specific biomarkers also used in pneumonia in a broad range of studies. It appears to be a reliable diagnostic tool to expedite care of these patients with severe infections in the acute setting. PCT was found to be superior to most other acute phase reactants and indicators, including CRP as a predictor of pneumonia, bacteremia, sepsis, and poor outcome, although conflicting results exist. In addition, PCT use is beneficial to judge timing for the cessation of antibiotic treatment in most severe infectious states. The clinicians should be aware of strengths and weaknesses of known and potential biomarkers in expedient recognition and management of severe infections. This manuscript is intended to present an overview of the definitions, complications, and outcomes of CAP and sepsis in adults, with special regard to PCT and other important markers.
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Affiliation(s)
- Sedat Ozbay
- Department of Emergency Medicine, Sivas Numune Education and Research Hospital, Sivas 58040, Turkey
| | - Mustafa Ayan
- Department of Emergency Medicine, Sivas Numune Education and Research Hospital, Sivas 58040, Turkey
| | - Orhan Ozsoy
- Department of Emergency Medicine, Sivas Numune Education and Research Hospital, Sivas 58040, Turkey
| | - Canan Akman
- Department of Emergency Medicine, Canakkale Onsekiz Mart University, Canakkale 17100, Turkey
| | - Ozgur Karcioglu
- Department of Emergency Medicine, University of Health Sciences, Taksim Education and Research Hospital, Beyoglu, Istanbul 34098, Turkey
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Olver P, Bohn MK, Adeli K. Central role of laboratory medicine in public health and patient care. Clin Chem Lab Med 2023; 61:666-673. [PMID: 36436024 DOI: 10.1515/cclm-2022-1075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/18/2022] [Indexed: 11/28/2022]
Abstract
Clinical laboratories play a vital role in the healthcare system. Objective medical data provided by clinical laboratories supports approximately 60-70% of clinical decisions, however, evidence supporting this claim is poorly documented and laboratories still lack visibility, despite their indisputable impact on patient care and public health. The International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Task Force on Outcome Studies in Laboratory Medicine (TF-OSLM) was recently developed to support directed research evaluating the role of laboratory medicine on clinical outcomes. Establishing and documenting this evidence is key to enhance visibility of the field in the eye of the public and other healthcare professionals together with optimizing patient outcomes and health care system operations. In this review, we discuss four areas that exemplify the contribution of laboratory medicine directly to patient care. This includes high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide/B-type natriuretic peptides (NT-proBNP/BNP) for the diagnosis and prognosis of myocardial infarction and heart failure, respectively, and procalcitonin for the management of sepsis and antibiotic stewardship. Emerging markers of traumatic brain injury and the role of laboratory medicine in the fight against the COVID-19 pandemic are discussed along with an introduction to plans of IFCC TF-OSLM.
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Affiliation(s)
- Pyper Olver
- CALIPER Program, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mary Kathryn Bohn
- CALIPER Program, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Khosrow Adeli
- CALIPER Program, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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Tsangaris I, Antonakos N, Fantoni M, Kaplanski G, Kyriazopoulou E, Veas F, Clemens M. BIOMARKERS: CAN THEY REALLY GUIDE OUR DAILY PRACTICE? Shock 2023; 59:16-20. [PMID: 36867757 DOI: 10.1097/shk.0000000000001957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
ABSTRACT Optimal management of septic patients requires accurate assessment of both current severity status and prognosis. Since the 1990s, substantial advances have been made in the use of circulating biomarkers for such assessments. This summary of the session on "Biomarkers: can they really use guide our daily practice?" presented at the 2021 WEB-CONFERENCE OF THE EUROPEAN SHOCK SOCIETY, 6 November 2021. These biomarkers include ultrasensitive detection of bacteremia, circulating soluble urokina-type plasminogen activator receptor (suPAR), C-reactive protein (CRP) and ferritin and procalcitonin. In addition, the potential application of novel multiwavelength optical biosensor technology allows noninvasive monitoring of multiple metabolites that can be used to assess severity and prognosis in septic patients. The application these biomarkers and improved technologies provide the potential for improved personalized management of septic patients.
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Affiliation(s)
- Iraklis Tsangaris
- 2nd Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Antonakos
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Gilles Kaplanski
- Division of Internal Medicine and Clinical Immunology, Hôpital de la Conception, C2VN-INSERM U1263, Aix-Marseille University, Marseille, France
| | - Evdoxia Kyriazopoulou
- 2nd Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Mark Clemens
- Department of Biological Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina
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Shajiei A, Berends MS, Luz CF, van Oers JA, Harmsen HJM, Vos P, Klont R, Loef BG, Reidinga AC, Bormans-Russell L, Linsen K, Dormans T, Otten M, van der Bij A, Beishuizen A, de Lange DW, de Jong E, Nijsten MW. Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial. Front Med (Lausanne) 2023; 10:1080007. [PMID: 36817782 PMCID: PMC9932263 DOI: 10.3389/fmed.2023.1080007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Background In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients. Materials and methods Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients. Results In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33). Conclusions In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.
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Affiliation(s)
- Arezoo Shajiei
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Matthijs S. Berends
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Epidemiology, Certe Foundation, Groningen, Netherlands
| | - Christian F. Luz
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Jos A. van Oers
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Hermie J. M. Harmsen
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Piet Vos
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Rob Klont
- Laboratorium Microbiologie Twente Achterhoek, Hengelo, Netherlands
| | - Bert G. Loef
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | - Auke C. Reidinga
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | | | - Kitty Linsen
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Martine Otten
- Department of Intensive Care, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | | | - Dylan W. de Lange
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Evelien de Jong
- Department of Intensive Care, Beverwijk Hospital, Beverwijk, Netherlands,Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Maarten W. Nijsten
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,*Correspondence: Maarten W. Nijsten ✉
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20
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Li D, Li J, Zhao C, Liao X, Liu L, Xie L, Shang W. Diagnostic value of procalcitonin, hypersensitive C-reactive protein and neutrophil-to-lymphocyte ratio for bloodstream infections in pediatric tumor patients. Clin Chem Lab Med 2023; 61:366-376. [PMID: 36367370 DOI: 10.1515/cclm-2022-0801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/24/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Bloodstream infection (BSI) is one of the major causes of death in pediatric tumor patients. Blood samples are relatively easy to obtain and thus provide a ready source of infection-related biological markers for the prompt evaluation of infection risk. METHODS A total of 259 pediatric tumor patients were included from May 2019 to March 2022. Patients were divided into BSI group (n=70) and control group (n=189). Clinical and biological data were collected using electronic medical records. Differences in biological markers between BSI group and control group and differences before and during infection in BSI group were analyzed. RESULTS The infected group showed higher levels of procalcitonin (PCT) and hypersensitive C-reactive-protein (hsCRP), and lower prealbumin (PA) than the uninfected group. Area under the receiver-operating curve (ROC) curves (AUC) of PCT, hsCRP and NLR (absolute neutrophil count to the absolute lymphocyte count) were 0.756, 0.617 and 0.612. The AUC of other biomarkers was ≤0.6. In addition, PCT, hsCRP, NLR and fibrinogen (Fg) were significantly increased during infection, while PA and lymphocyte (LYM) were significantly decreased. Antibiotic resistant of Gram-positive bacteria to CHL, SXT, OXA and PEN was lower than that of Coagulase-negative Staphylococcus. Resistant of Gram-positive bacteria to CHL was lower, while to SXT was higher than that of Gram-negative bacteria. CONCLUSIONS This study explored the utility of biomarkers to assist in diagnosis and found that the PCT had the greatest predictive value for infection in pediatric tumor patients with BSI. Additionally, the PCT, hsCRP, NLR, PA, LYM and Fg were changed by BSI.
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Affiliation(s)
- Dongmei Li
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
| | - Jie Li
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
| | - Chuanxi Zhao
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
| | - Xianglu Liao
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
| | - Lisheng Liu
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
| | - Li Xie
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
| | - Wenjing Shang
- Department of Clinical Laboratory, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, P.R. China
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Mott T, Orme Z. Consider this tool to reduce antibiotic-associated adverse events in patients with sepsis. J Fam Pract 2023; 72:E13-E15. [PMID: 36749971 PMCID: PMC9909738 DOI: 10.12788/jfp.0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Predictive biomarker procalcitonin can aid clinical decision-making on continued antibiotic treatment in this patient population.
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Affiliation(s)
- Timothy Mott
- South Baldwin Regional Medical Center Family Medicine Residency Program, Foley, AL
| | - Zachary Orme
- South Baldwin Regional Medical Center Family Medicine Residency Program, Foley, AL
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Abstract
Severe community-acquired pneumonia is the most life-threatening form of community-acquired pneumonia, characterised by intensive care unit admission and high morbidity and mortality. In this review article, we cover in depth six aspects of severe community-acquired pneumonia that are still controversial: use of PCR molecular techniques for microbial diagnosis; the role of biomarkers for initial management; duration of treatment, macrolides or quinolones in the initial empirical antibiotic therapy; the use of prediction scores for drug-resistant pathogens to modify initial empiric therapy; the use of noninvasive mechanical ventilation and high-flow nasal oxygen; and the use of corticosteroids as adjunctive therapy in severe community-acquired pneumonia.
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Affiliation(s)
- Michael S. Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, Weill Cornell Medical College, New York, NY, USA,Both authors contributed equally
| | - Antoni Torres
- Dept of Pulmonology, Hospital Clinic, University of Barcelona, IDIBAPS, ICREA, CIBERES, Barcelona, Spain,Both authors contributed equally,Corresponding author: Antoni Torres ()
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23
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Abstract
Procalcitonin (PCT) was discovered as a useful marker for bacterial infection. Following its discovery, there have been a substantial number of clinical studies conducted to evaluate the presence of bacterial infections, and to guide antibiotic treatment by the stratified levels of PCT. Clinical evidence suggests that antibiotic treatment by PCT-guided antibiotic stewardship has been associated with a reduction in antibiotic usage without an increase in adverse outcomes. The use of PCT was approved by the Food and Drug Administration in the United States of America in 2017 to guide antibiotic treatment in sepsis and lower respiratory tract infections (LRTIs). In Korea, the use of PCT for sepsis and for pneumonia was approved in 2015 and 2022, respectively. This review will discuss the clinical utility of PCT on antibiotic stewardship in the management of sepsis and LRTIs including pneumonia.
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Affiliation(s)
- Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Ma Q, Zhang M, Zhang C, Teng X, Yang L, Tian Y, Wang J, Han D, Tan W. An automated DNA computing platform for rapid etiological diagnostics. Sci Adv 2022; 8:eade0453. [PMID: 36427311 PMCID: PMC9699674 DOI: 10.1126/sciadv.ade0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Rapid and accurate classification of the etiology for acute respiratory illness not only helps establish timely therapeutic plans but also prevents inappropriate use of antibiotics. Host gene expression patterns in peripheral blood can discriminate bacterial from viral causes of acute respiratory infection (ARI) but suffer from long turnaround time, as well as high cost resulting from the measurement methods of microarrays and next-generation sequencing. Here, we developed an automated DNA computing-based platform that can implement an in silico trained classification model at the molecular level with seven different mRNA expression patterns for accurate diagnosis of ARI etiology in 4 hours. By integrating sample loading, marker amplification, classifier implementation, and results reporting into one platform, we obtained a diagnostic accuracy of 87% in 80 clinical samples without the aid of computer and laboratory technicians. This platform creates opportunities toward an accurate, rapid, low-cost, and automated diagnosis of disease etiology in emergency departments or point-of-care clinics.
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Affiliation(s)
- Qian Ma
- Zhejiang Cancer Hospital, The Key Laboratory of Zhejiang Province for Aptamers and Theranostics, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Intellinosis Biotechnologies Co. Ltd., Shanghai, China
| | - Mingzhi Zhang
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Chao Zhang
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Intellinosis Biotechnologies Co. Ltd., Shanghai, China
- Corresponding author. (D.H.); (W.T.); (C.Z.)
| | - Xiaoyan Teng
- Department of Laboratory Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 201306, China
| | - Linlin Yang
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Yuan Tian
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Junyan Wang
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Da Han
- Zhejiang Cancer Hospital, The Key Laboratory of Zhejiang Province for Aptamers and Theranostics, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Corresponding author. (D.H.); (W.T.); (C.Z.)
| | - Weihong Tan
- Zhejiang Cancer Hospital, The Key Laboratory of Zhejiang Province for Aptamers and Theranostics, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
- Institute of Molecular Medicine, Shanghai Key Laboratory for Nucleic Acid Chemistry and Nanomedicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
- Corresponding author. (D.H.); (W.T.); (C.Z.)
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25
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Wang J, Zheng N, Chang X, Qian H, Han Y. Nutritional risk factors for all-cause mortality of critically ill patients: a retrospective cohort study. BMJ Open 2022; 12:e066015. [PMID: 36396305 PMCID: PMC9677028 DOI: 10.1136/bmjopen-2022-066015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES This study aimed to explore the predictive value of single and multiple risk factors for the clinical outcomes of critically ill patients receiving enteral nutrition and to establish an effective evaluation model. DESIGN Retrospective cohort study. SETTING Data from the 2020-2021 period were collected from the electronic records of the First Affiliated Hospital, Nanjing Medical University. PARTICIPANTS 459 critically ill patients with enteral nutrition in the geriatric intensive care unit were included in the study. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was 28-day mortality. The secondary outcomes were 28-day invasive mechanical ventilation time, intensive care unit stay, Nutrition Risk Screening 2002 (NRS2002) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. RESULTS Independent prognostic factors, including prealbumin/procalcitonin (PCT) ratio and APACHE II score, were identified using a logistic regression model and used in the nomogram. The area under the receiver operating characteristic curve and concordance index indicated that the predictive capacity of the model was 0.753. Moreover, both the prealbumin/PCT ratio and the combination model of PCT, prealbumin and NRS2002 had a higher predictive value for clinical outcomes. Subgroup analysis also identified that a higher inflammatory state (PCT >0.5 ng/mL) and major nutritional risk (NRS2002 >3) led to worse clinical outcomes. In addition, patients on whole protein formulae bore less nutritional risk than those on short peptide formulae. CONCLUSIONS This nomogram had a good predictive value for 28-day mortality in critically ill patients receiving enteral nutrition. Both the prealbumin/PCT ratio and the combination model (PCT, prealbumin and NRS2002), as composite models of inflammation and nutrition, could better predict the prognosis of critically ill patients.
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Affiliation(s)
- Jine Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Nan Zheng
- Department of Critical Care Medicine, The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xinyi Chang
- Department of Critical Care Medicine, The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Huitao Qian
- Department of Critical Care Medicine, The First School of Clinical Medicine, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yi Han
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Smith JT, Manickam RN, Barreda F, Greene JD, Bhimarao M, Pogue J, Jones M, Myers L, Prescott HC, Liu VX. Quantifying the breadth of antibiotic exposure in sepsis and suspected infection using spectrum scores. Medicine (Baltimore) 2022; 101:e30245. [PMID: 36254043 PMCID: PMC9575768 DOI: 10.1097/md.0000000000030245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
A retrospective cohort study. Studies to quantify the breadth of antibiotic exposure across populations remain limited. Therefore, we applied a validated method to describe the breadth of antimicrobial coverage in a multicenter cohort of patients with suspected infection and sepsis. We conducted a retrospective cohort study across 21 hospitals within an integrated healthcare delivery system of patients admitted to the hospital through the ED with suspected infection or sepsis and receiving antibiotics during hospitalization from January 1, 2012, to December 31, 2017. We quantified the breadth of antimicrobial coverage using the Spectrum Score, a numerical score from 0 to 64, in patients with suspected infection and sepsis using electronic health record data. Of 364,506 hospital admissions through the emergency department, we identified 159,004 (43.6%) with suspected infection and 205,502 (56.4%) with sepsis. Inpatient mortality was higher among those with sepsis compared to those with suspected infection (8.4% vs 1.2%; P < .001). Patients with sepsis had higher median global Spectrum Scores (43.8 [interquartile range IQR 32.0-49.5] vs 43.5 [IQR 26.8-47.2]; P < .001) and additive Spectrum Scores (114.0 [IQR 57.0-204.5] vs 87.5 [IQR 45.0-144.8]; P < .001) compared to those with suspected infection. Increased Spectrum Scores were associated with inpatient mortality, even after covariate adjustments (adjusted odds ratio per 10-point increase in Spectrum Score 1.31; 95%CI 1.29-1.33). Spectrum Scores quantify the variability in antibiotic breadth among individual patients, between suspected infection and sepsis populations, over the course of hospitalization, and across infection sources. They may play a key role in quantifying the variation in antibiotic prescribing in patients with suspected infection and sepsis.
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Affiliation(s)
- Joshua T. Smith
- Pharmacy Quality and Medication Safety, Kaiser Permanente Northern California, Oakland, CA
| | - Raj N. Manickam
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Fernando Barreda
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - John D. Greene
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Meghana Bhimarao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jason Pogue
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - Makoto Jones
- Division of Epidemiology, VA Salt Lake City Health Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Laura Myers
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Lanckohr C, Bracht H. Antimicrobial stewardship. Curr Opin Crit Care 2022; 28:551-556. [PMID: 35942707 DOI: 10.1097/mcc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes. Antimicrobial stewardship (AMS) is a bundle of interventions aimed at promoting the responsible use of antiinfectives. The ICU is an important field of activity for AMS because of high rates of antimicrobial use, high prevalence of resistant pathogens and complex pharmacology. This review discusses aims and interventions of AMS with special emphasis on the ICU. RECENT FINDINGS AMS-interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes. The de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure. Owing to the complex nature of critical illness, the pharmacological optimization of antimicrobial therapy is an important goal in the ICU. AMS-objectives and strategies are also applicable to patients with sepsis. This is reflected in the most recent guidelines by the Surviving Sepsis Campaign. AMS-interventions need to be adapted to their respective setting and be mindful of local prescribing cultures and prescribers' attitudes. SUMMARY AMS in the ICU is effective and safe. Intensivists should be actively involved in AMS-programs and propagate responsible use of antimicrobials.
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Affiliation(s)
- Christian Lanckohr
- Antibiotic Stewardship Team, Institute of Hygiene, University Hospital Münster, Münster
| | - Hendrik Bracht
- Central Emergency Services, University Hospital Ulm, Ulm, Germany
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Zhou Y, Wu C, Ouyang L, Peng Y, Zhong D, Xiang X, Li J. Application of oXiris-continuous hemofiltration adsorption in patients with sepsis and septic shock: A single-centre experience in China. Front Public Health 2022; 10:1012998. [PMID: 36249210 PMCID: PMC9557776 DOI: 10.3389/fpubh.2022.1012998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 09/12/2022] [Indexed: 01/27/2023] Open
Abstract
oXiris is a new, high-adsorption membrane filter in continuous hemofiltration adsorption to reduce the inflammatory response in sepsis. The investigators retrospectively reviewed patients with sepsis/septic shock who underwent at least one oXiris-treatment from November 2020 to March 2022. The demographic data, baseline levels before treatment, clinical datas, prognosis, and the occurrence of adverse events during treatment were recorded. 90 patients were enrolled in this study. The hemodynamic indices, sequential organ failure assessment score, lactate, inflammatory biomarkers levels were significantly improved at 12 h and 24 h after treatment. Procalcitonin and interleukin-6 reduction post-treatment of oXiris were most pronounced in infection from skin and soft tissue, urinary and abdominal cavity. Logistic regression analysis showed that pre-treatment sequential organ failure assessment score (p = 0.034), percentage decrease in sequential organ failure assessment score (p = 0.004), and age (p = 0.011) were independent risk factors for intensive care unit mortality. In conclusion, oXiris-continuous hemofiltration adsorption may improve hemodynamic indicators, reduce the use of vasoactive drugs, reduce lactate level and infection indicators. Of note, oXiris improve organ function in sepsis, which may result to higher survival rate.
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von Groote T, Meersch-dini M. Biomarkers for the Prediction and Judgement of Sepsis and Sepsis Complications: A Step towards precision medicine? J Clin Med 2022; 11:5782. [PMID: 36233650 PMCID: PMC9571838 DOI: 10.3390/jcm11195782] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
Sepsis and septic shock are a major public health concern and are still associated with high rates of morbidity and mortality. Whilst there is growing understanding of different phenotypes and endotypes of sepsis, all too often treatment strategies still only employ a “one-size-fits-all” approach. Biomarkers offer a unique opportunity to close this gap to more precise treatment approaches by providing insight into clinically hidden, yet complex, pathophysiology, or by individualizing treatment pathways. Predicting and evaluating systemic inflammation, sepsis or septic shock are essential to improve outcomes for these patients. Besides opportunities to improve patient care, employing biomarkers offers a unique opportunity to improve clinical research in patients with sepsis. The high rate of negative clinical trials in this field may partly be explained by a high degree of heterogeneity in patient cohorts and a lack of understanding of specific endotypes or phenotypes. Moving forward, biomarkers can support the selection of more homogeneous cohorts, thereby potentially improving study conditions of clinical trials. This may finally pave the way to a precision medicine approach to sepsis, septic shock and complication of sepsis in the future.
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30
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Li P, Liu J, Liu J. Procalcitonin-guided antibiotic therapy for pediatrics with infective disease: A updated meta-analyses and trial sequential analysis. Front Cell Infect Microbiol 2022; 12:915463. [PMID: 36211950 PMCID: PMC9532766 DOI: 10.3389/fcimb.2022.915463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/23/2022] [Indexed: 11/18/2022] Open
Abstract
Objective We aimed to evaluate the effect of procalcitonin (PCT) guided therapy on antibiotic exposure in pediatric patients with infectious disease. Methods We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) identified in systematic searches of MEDLINE, Embase, the Cochrane Database, Google Scholar, and SinoMed (through July 2021). The primary outcome was the length of the antibiotic therapy. Required information size (RIS) was calculated using trial sequential analysis (TSA). Results Four RCTs with 1,313 patients with infectious disease were included. Overall, after a mean 22-day follow-up, PCT-guided antibiotic therapy was associated with a significantly shorter length of antibiotic therapy compared with the control group (WMD, −2.22 days; 95% CI, −3.41 to −1.03; P <0.001) and a decreased rate of antibiotic adverse events (RR, 0.25; 95% CI, 0.11–0.58; P <0.001). However, the length of hospital stay (WMD, −0.39 days; 95% CI, −0.84 to 0.07; P = 0.094), rates of antibiotic prescription (RR, 1.10; 95% CI, 0.97–1.25; P = 0.122), hospital readmission (RR, 1.03; 95% CI, 0.92–1.16; P = 0.613) and mortality (RR, 0.73; 95% CI, 0.17–3.19; P = 0.674) were comparable between the PCT-guided antibiotic and control groups. TSA showed that the RIS was 2,340, indicating a statistically significantly shorter length of antibiotic therapy between PCT-guided antibiotic and control groups (P <0.05). Conclusions PCT-guided management seems to be able to decrease antibiotic exposure in patients with infectious disease. However, much larger prospective clinical studies are warranted to confirm these findings.
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Affiliation(s)
- Peng Li
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - JiaLe Liu
- Department of Pediatric, Beijing Jingdou Children’s Hospital, Beijing, China
| | - Junjun Liu
- Department of Oncology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Junjun Liu,
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Yu C, Ling Q, Jiao J, Liu J, Huang Z, Wang F, Sun X, Kong X. Interleukin-22 protects from endotoxemia by inducing suppressive F4/80 +Ly6G hiLy6C hi cells population. BMC Immunol 2022; 23:45. [PMID: 36123595 PMCID: PMC9484229 DOI: 10.1186/s12865-022-00511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background Excessive inflammatory response is the primary cause of early death in patients with endotoxemia. Interleukin 22 (IL-22) has been shown to play critical roles in the modulation of infectious diseases, but its function in regulating immune responses during endotoxemia remains unclear. Methods Lipopolysaccharide (LPS) was used to induce endotoxemia mouse model with or without a recombinant fusion protein containing human IL-22 (F-652). IL-6, TNF-α, IL-1β, and MCP-1 were measured by ELISA assays. The type of macrophage was assessed by flow cytometry. Real-time PCR was used to detect the expression of S100A9.
Results We found that F-652 injection significantly improved the survival rates and reduced pro-inflammatory cytokines (IL-6, TNF-a, IL-1β, MCP-1) in LPS-induced endotoxemia mice. However, the mice injected with F-652 had a higher number of infiltrated immune cells after LPS treatment, suggesting an impaired immune response. Flow cytometry analysis showed a higher number of F4/80+Ly6GhiLy6Chi cells that highly expressed M2-like macrophage markers (Ym1, Arg, CCL17) in the peritoneal cavity of the F-652-treated endotoxemia mice. Further investigation found that these suppressive M2 macrophages might be induced by F-652 since the F-652 treatment could increase S100A9 in vitro. Conclusions Our study suggests that IL-22 has a protective role against endotoxemia by inducing the development of immunosuppressive cells through S100A9.
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Affiliation(s)
- Chang Yu
- Central Laboratory, Department of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, 528 Zhangheng Road, Shanghai, 201203, China
| | - Qihua Ling
- Department of Emergency Internal Medicine, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, China
| | - Junzhe Jiao
- Central Laboratory, Department of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, 528 Zhangheng Road, Shanghai, 201203, China
| | - Juhong Liu
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Zhihua Huang
- Evive Biotechnology (Shanghai) Ltd, Shanghai, China
| | - Fang Wang
- Central Laboratory, Department of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, 528 Zhangheng Road, Shanghai, 201203, China
| | - Xuehua Sun
- Central Laboratory, Department of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, 528 Zhangheng Road, Shanghai, 201203, China
| | - Xiaoni Kong
- Central Laboratory, Department of Liver Diseases, Shuguang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, 528 Zhangheng Road, Shanghai, 201203, China.
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Suo S, Luo L, Song Y, Huang H, Chen X, Liu C, Hashmi MF. Early Diagnosis and Prediction of Death Risk in Patients with Sepsis by Combined Detection of Serum PCT, BNP, Lactic Acid, and Apache II Score. Contrast Media & Molecular Imaging 2022; 2022:1-6. [PMID: 35935301 PMCID: PMC9325350 DOI: 10.1155/2022/8522842] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/22/2022]
Abstract
In order to investigate the expression levels of procalcitonin (PCT), B-type brain natriuretic peptide (BNP), and lactic acid (Lac) in serum of patients with sepsis, a retrospective analysis is conducted. 80 sepsis patients admitted to the ICU of our hospital from January 2019 to June 2020 are selected, and the application value of these factors combined with Apache II score in early diagnosis and prediction of death risk is analyzed. All patients are classified into survival group (n = 57) and death group (n = 23), and examined by blood routine. Lac, PCT, and BNP, and the serum PCT, BNP, and Lac levels were compared between the nonsepsis group and the control group. Furthermore, Acute Physiology and Chronic Health Status scoring System II (Apache II) is applied to evaluate the score difference between the sepsis group and the control group. The ROC curve demonstrates that PCT, BNP, and Lac combined with Apache II score can obtain high value for early diagnosis of sepsis. Compared with nonsepsis patients, the scores of serum Lac, PCT, and BNP and Apache II are significantly higher in sepsis patients. It is clearly evident that the combined detection of those indicators is valuable for early diagnosis and prediction of death, and will be suitable for widespread clinical application.
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Hellenthal KEM, Brabenec L, Wagner NM. Regulation and Dysregulation of Endothelial Permeability during Systemic Inflammation. Cells 2022; 11:cells11121935. [PMID: 35741064 PMCID: PMC9221661 DOI: 10.3390/cells11121935] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic inflammation can be triggered by infection, surgery, trauma or burns. During systemic inflammation, an overshooting immune response induces tissue damage resulting in organ dysfunction and mortality. Endothelial cells make up the inner lining of all blood vessels and are critically involved in maintaining organ integrity by regulating tissue perfusion. Permeability of the endothelial monolayer is strictly controlled and highly organ-specific, forming continuous, fenestrated and discontinuous capillaries that orchestrate the extravasation of fluids, proteins and solutes to maintain organ homeostasis. In the physiological state, the endothelial barrier is maintained by the glycocalyx, extracellular matrix and intercellular junctions including adherens and tight junctions. As endothelial cells are constantly sensing and responding to the extracellular environment, their activation by inflammatory stimuli promotes a loss of endothelial barrier function, which has been identified as a hallmark of systemic inflammation, leading to tissue edema formation and hypotension and thus, is a key contributor to lethal outcomes. In this review, we provide a comprehensive summary of the major players, such as the angiopoietin-Tie2 signaling axis, adrenomedullin and vascular endothelial (VE-) cadherin, that substantially contribute to the regulation and dysregulation of endothelial permeability during systemic inflammation and elucidate treatment strategies targeting the preservation of vascular integrity.
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Brabenec L, Müller M, Hellenthal KE, Karsten OS, Pryvalov H, Otto M, Holthenrich A, Matos ALL, Weiss R, Kintrup S, Hessler M, Dell'Aquila A, Thomas K, Naß J, Margraf A, Nottebaum AF, Rossaint J, Zarbock A, Vestweber D, Gerke V, Wagner NM. Targeting Procalcitonin Protects Vascular Barrier Integrity. Am J Respir Crit Care Med 2022; 206:488-500. [PMID: 35699655 DOI: 10.1164/rccm.202201-0054oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Capillary leakage frequently occurs during sepsis and after major surgery and is associated with microvascular dysfunction and adverse outcome. Procalcitonin is a well-established biomarker in inflammation without known impact on vascular integrity. OBJECTIVE We determined how procalcitonin induces endothelial hyperpermeability and how targeting procalcitonin protects vascular barrier integrity. METHODS In a prospective observational clinical study, procalcitonin levels were assessed in 50 cardiac surgery patients and correlated to postoperative fluid and vasopressor requirements along with sublingual microvascular functionality. Effects of the procalcitonin signaling pathway on endothelial barrier and adherens junctional integrity were characterized in vitro and verified in mice. Inhibition of procalcitonin activation by dipeptidyl-peptidase 4 (DPP4) was evaluated in murine polymicrobial sepsis and clinically verified in cardiac surgery patients chronically taking the DPP4 inhibitor sitagliptin. MEASUREMENTS AND MAIN RESULTS Elevated postoperative procalcitonin levels identified patients with 2-fold increased fluid requirements (P<0.01), 1.8-fold higher vasopressor demand (P<0.05) and compromised microcirculation (reduction to 63.5±2.8% of perfused vessels, P<0.05). Procalcitonin induced 1.4-fold endothelial and 2.3-fold pulmonary capillary permeability (both P<0.001) by destabilizing VE-cadherin. Procalcitonin effects were dependent on activation by DPP4 and targeting the procalcitonin receptor or DPP4 during sepsis-induced hyperprocalcitonemia reduced capillary leakage by 54±10.1% and 60.4±6.9% (both P<0.01), respectively. Sitagliptin prior to cardiac surgery was associated with augmented microcirculation (74.1±1.7% vs. 68.6±1.9% perfused vessels in sitagliptin non-medicated patients, P<0.05) and 2.3-fold decreased fluid (P<0.05) and 1.8-fold reduced vasopressor demand postoperatively (P<0.05). CONCLUSION Targeting procalcitonin's action on the endothelium is a feasible means to preserve vascular integrity during systemic inflammation associated with hyperprocalcitonemia.
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Affiliation(s)
- Laura Brabenec
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Melanie Müller
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Katharina Em Hellenthal
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Ole S Karsten
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Heorhii Pryvalov
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Mandy Otto
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Anna Holthenrich
- University of Münster Faculty of Medicine, 98883, Münster, Germany
| | | | - Raphael Weiss
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Sebastian Kintrup
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Michael Hessler
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Angelo Dell'Aquila
- University Hospital Münster, Department of Cardiac and Thoracic Surgery, Münster, Germany
| | - Katharina Thomas
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | - Johannes Naß
- University of Münster Faculty of Medicine, 98883, Münster, Germany
| | - Andreas Margraf
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | | | - Jan Rossaint
- Universitätsklinikum Münster, 39069, Department of Anesthesiology, Intensive Care and Pain Medicine, Münster, Germany
| | - Alexander Zarbock
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany
| | | | - Volker Gerke
- University of Münster Faculty of Medicine, 98883, Münster, Germany
| | - Nana-Maria Wagner
- University Hospital Münster Department of Anesthesiology and Intensive Care Medicine, 235721, Münster, Germany;
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Spoto S, Daniel Markley J, Valeriani E, Abbate A, Argemi J, Markley R, Fogolari M, Locorriere L, Anguissola GB, Battifoglia G, Costantino S, Ciccozzi M, Bustos Guillén C, Angeletti S. Active Surveillance Cultures and Procalcitonin in Combination With Clinical Data to Guide Empirical Antimicrobial Therapy in Hospitalized Medical Patients With Sepsis. Front Microbiol 2022; 13:797932. [PMID: 35464939 PMCID: PMC9023116 DOI: 10.3389/fmicb.2022.797932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The prevalence of colonization with multidrug-resistant organisms (MDRO) has increased over the last decade, reaching levels as high as 23% in certain patient populations. Active surveillance cultures (ASC) represent a valuable tool to identify patients colonized with MDRO to apply preventive measures, reduce transmission, and guide empiric antimicrobial therapy. There is a paucity of data evaluating the impact of admission ASCs to predict future infection. The aim of this study was to evaluate the concordance between ASCs results and the development of clinical infection by the same microorganism identified in the surveillance swab ("swab-related infection"), in hospitalized septic patients, and to evaluate the presence of specific risk factors associated with the development of a swab-related infection. Methods All adults admitted to the Diagnostic and Therapeutic Medicine Department of the University Hospital Campus Bio-Medico of Rome with a diagnosis of infection or any other medical reason with admission surveillance swabs (rectal or nasal) between January 2018 and February 2021 were included in the study. A retrospective chart review was conducted to identify patients that developed infections with concordant MDROs identified on ASC, and the risk factors for swab-related infection. Secondary outcomes were need of intensive care unit transfer, length of stay, sepsis or septic shock development, and all-cause mortality. Results A total of 528 patients were included in the study, of which 97 (18.3%) had a positive surveillance swab. Among patients with positive surveillance swabs, 18 (18.5%) developed an infection with the same microorganism recovered from the swab, 57 (58.8%) developed an infection with a different microorganism than that recovered from the surveillance swab, and 22 (22.7%) did not develop an infection during hospitalization. The number of colonized sites, an interventional procedure within the previous 3 months, a Systemic Inflammatory Response Syndrome (SIRS) score ≥ 2, and a quick Sequential Organ Failure Assessment (q-SOFA) score ≥ 2 were associated with a significantly higher risk of developing a swab-related infection. SIRS and q-SOFA scores ≥ 2 and procalcitonin ≥ 0.43 ng/ml help for identifying patients with a swab-related infection. Conclusion Patients with positive surveillance swabs were at increased risk for development of infections by the same MDRO identified in surveillance swabs (swab-related infection). This study is the first to show that the positivity of surveillance swabs, in combination with anamnestic data, PCT values, and SIRS or q-SOFA scores, serves as a valuable tool to help clinicians predict patients at higher risk for swab-related infection development and guide the administration of appropriate empiric antimicrobial therapy in septic patients.
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Affiliation(s)
- Silvia Spoto
- Diagnostic and Therapeutic Medicine Department, Campus Bio Medico University of Rome, Rome, Italy
| | - John Daniel Markley
- Division of Infectious Disease and Epidemiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States.,Central Virginia, Veterans Administration Hospital, Richmond, VA, United States
| | - Emanuele Valeriani
- Diagnostic and Therapeutic Medicine Department, Campus Bio Medico University of Rome, Rome, Italy
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Josepmaria Argemi
- Liver Unit Clinica Universidad de Navarra Hepatology Program, Center for Applied Medical Research (CIMA), IdiSNA, Universidad de Navarra, Pamplona, Spain
| | - Roshanak Markley
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Marta Fogolari
- Unit of Clinical Laboratory Science, Campus Bio Medico University of Rome, Rome, Italy
| | - Luciana Locorriere
- Diagnostic and Therapeutic Medicine Department, Campus Bio Medico University of Rome, Rome, Italy
| | | | - Giulia Battifoglia
- Diagnostic and Therapeutic Medicine Department, Campus Bio Medico University of Rome, Rome, Italy
| | - Sebastiano Costantino
- Diagnostic and Therapeutic Medicine Department, Campus Bio Medico University of Rome, Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, Campus Bio Medico University of Rome, Rome, Italy
| | - César Bustos Guillén
- Division of Infectious Diseases, Department of Internal Medicine, Clinica Universidad de los Andes, Santiago, Chile
| | - Silvia Angeletti
- Unit of Clinical Laboratory Science, Campus Bio Medico University of Rome, Rome, Italy
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Ling L, Wong W, Lipman J, Joynt GM. A Narrative Review on the Approach to Antimicrobial Use in Ventilated Patients with Multidrug Resistant Organisms in Respiratory Samples—To Treat or Not to Treat? That Is the Question. Antibiotics (Basel) 2022; 11:452. [PMID: 35453203 PMCID: PMC9031060 DOI: 10.3390/antibiotics11040452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/01/2023] Open
Abstract
Multidrug resistant organisms (MDRO) are commonly isolated in respiratory specimens taken from mechanically ventilated patients. The purpose of this narrative review is to discuss the approach to antimicrobial prescription in ventilated patients who have grown a new MDRO isolate in their respiratory specimen. A MEDLINE and PubMed literature search using keywords “multidrug resistant organisms”, “ventilator-associated pneumonia” and “decision making”, “treatment” or “strategy” was used to identify 329 references as background for this review. Lack of universally accepted diagnostic criteria for ventilator-associated pneumonia, or ventilator-associated tracheobronchitis complicates treatment decisions. Consideration of the clinical context including signs of respiratory infection or deterioration in respiratory or other organ function is essential. The higher the quality of respiratory specimens or the presence of bacteremia would suggest the MDRO is a true pathogen, rather than colonization, and warrants antimicrobial therapy. A patient with higher severity of illness has lower safety margins and may require initiation of antimicrobial therapy until an alternative diagnosis is established. A structured approach to the decision to treat with antimicrobial therapy is proposed.
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Kyriazopoulou E, Giamarellos-Bourboulis EJ. Antimicrobial Stewardship Using Biomarkers: Accumulating Evidence for the Critically Ill. Antibiotics (Basel) 2022; 11:antibiotics11030367. [PMID: 35326830 PMCID: PMC8944654 DOI: 10.3390/antibiotics11030367] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 12/28/2022] Open
Abstract
This review aims to summarize current progress in the management of critically ill, using biomarkers as guidance for antimicrobial treatment with a focus on antimicrobial stewardship. Accumulated evidence from randomized clinical trials (RCTs) and observational studies in adults for the biomarker-guided antimicrobial treatment of critically ill (mainly sepsis and COVID-19 patients) has been extensively searched and is provided. Procalcitonin (PCT) is the best studied biomarker; in the majority of randomized clinical trials an algorithm of discontinuation of antibiotics with decreasing PCT over serial measurements has been proven safe and effective to reduce length of antimicrobial treatment, antibiotic-associated adverse events and long-term infectious complications like infections by multidrug-resistant organisms and Clostridioides difficile. Other biomarkers, such as C-reactive protein and presepsin, are already being tested as guidance for shorter antimicrobial treatment, but more research is needed. Current evidence suggests that biomarkers, mainly procalcitonin, should be implemented in antimicrobial stewardship programs even in the COVID-19 era, when, although bacterial coinfection rate is low, antimicrobial overconsumption remains high.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 2nd Department of Critical Care Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Evangelos J. Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-210-5831994
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Goggs R, Robbins SN, LaLonde‐Paul DM, Menard JM. Serial analysis of blood biomarker concentrations in dogs with pneumonia, septic peritonitis, and pyometra. J Vet Intern Med 2022; 36:549-564. [PMID: 35103342 PMCID: PMC8965213 DOI: 10.1111/jvim.16374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Prolonged antimicrobial drug (AMD) treatment is associated with antimicrobial resistance development. Biomarker measurement may aid treatment decision-making. OBJECTIVES Investigate temporal changes in blood biomarker concentrations in dogs undergoing treatment for pulmonary and intra-abdominal infections; compare time to biomarker concentration normalization with duration of clinician-directed AMD treatment. ANIMALS Forty-two client-owned dogs with pneumonia (n = 22), septic peritonitis (n = 10), or pyometra (n = 10). METHODS Plasma concentrations of C-reactive protein (CRP), serum amyloid A (SAA), haptoglobin, procalcitonin, nucleosomes, cell-free DNA (cfDNA), high-mobility group box-1 (HMGB1), CC-motif chemokine ligand-2 (CCL2), CXC-motif chemokine ligand-8 (CXCL8), and keratinocyte chemoattractant-like (KC-Like) were quantitated in samples collected on days 1, 3, 7, 14, 28, and 60. Treatment was directed by clinicians blinded to biomarker concentrations. RESULTS Concentrations of CCL2, CRP, and KC-Like were maximal on D1, concentrations of SAA, cfDNA, HMGB1, and nucleosomes were maximal on D3 and haptoglobin concentrations were maximal on D7. These maximal concentrations were significantly different from those on D60. Concentrations of CRP and SAA decreased by 80% from peak and into respective reference intervals before AMDs were discontinued. For CRP, the median (interquartile range [IQR]) times to 20% peak and normal were 7 (6-9) and 7 (6-12) days, respectively, and for SAA they were 4 (4, 5) and 6 (5-8) days, respectively, compared to a median (IQR) duration of AMD prescribing of 16 (12-23) days (all P < .0001). CONCLUSIONS AND CLINICAL IMPORTANCE Biomarker concentrations normalized within 7 to 14 days. Serial measurements of CRP and SAA might aid identification of disease resolution and could help guide AMD prescription decision-making.
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Affiliation(s)
- Robert Goggs
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Sarah N. Robbins
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Denise M. LaLonde‐Paul
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Julie M. Menard
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary MedicineUniversity of CalgaryCalgaryAlbertaCanada
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Guarino M, Perna B, De Giorgi A, Gambuti E, Alfano F, Catanese EM, Volpato S, Strada A, Caio G, Contini C, De Giorgio R. A 2-year retrospective analysis of the prognostic value of MqSOFA compared to lactate, NEWS and qSOFA in patients with sepsis. Infection 2022. [PMID: 35179719 DOI: 10.1007/s15010-022-01768-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/28/2022] [Indexed: 11/12/2022]
Abstract
Purpose Sepsis is a life-threating organ dysfunction caused by a dysregulated host response to infection. Being a time-dependent condition, the present study aims to compare a recently established score, i.e., modified quick SOFA (MqSOFA), with other existing tools commonly applied to predict in-hospital mortality. Methods All cases of sepsis and septic shock consecutively observed at St. Anna University Hospital of Ferrara, Italy, from January 2017 to December 2018 were included in this study. Each patient was evaluated with MqSOFA, lactate assay, NEWS and qSOFA. Accurate statistical and logistic regression analyses were applied to our database. Results A total of 1001 consecutive patients with sepsis/septic shock were retrieved. Among them, 444 were excluded for incomplete details about vital parameters; thus, 556 patients were eligible for the study. Data analysis showed that MqSOFA, NEWS and lactate assay provided a better predictive ability than qSOFA in terms of in-hospital mortality (p < 0.001). Aetiology-based stratification in 5 subgroups demonstrated the superiority of NEWS vs. other tools in predicting fatal outcomes (p = 0.030 respiratory, p = 0.036 urinary, p = 0.044 abdominal, p = 0.047 miscellaneous and p = 0.041 for indeterminate causes). After Bonferroni’s correction, MqSOFA was superior to qSOFA over respiratory (p < 0.001) and urinary (p < 0.001) aetiologies. Age was an independent factor for negative outcomes (p < 0.001). Conclusions MqSOFA, NEWS and lactate assay better predicted in-hospital mortality compared to qSOFA. Since sepsis needs a time-dependent assessment, an easier and non-invasive score, i.e., MqSOFA, could be used to establish patients’ outcome in the emergency setting.
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Elnajdy D, El-Dahiyat F. Antibiotics duration guided by biomarkers in hospitalized adult patients; a systematic review and meta-analysis. Infect Dis (Lond) 2022; 54:387-402. [PMID: 35175169 DOI: 10.1080/23744235.2022.2037701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The impact of using biomarkers to determine the duration of antibiotics therapy has been studied. However, the question remains in clinical practice whether these biomarkers are reliable to determine antibiotics duration. AIM This study is aimed to see if employing c-reactive protein (CRP) and Procalcitonin (PCT) to determine the duration of antibiotic use in hospitalized adult patients is both effective and safe. METHODS Search databases that were used are Pubmed, Cochrane library, and Embase. Only randomized controlled trials conducted in adult (≥18 years) hospitalized patients were included. The primary outcome assessed is the duration of antibiotics used. Secondary outcomes assessed are the length of hospitalization, recurrence of infection/rehospitalization, in-hospital mortality, and 28-day mortality. RESULTS For the primary outcome, which is the duration of antibiotics use, PCT guided therapy significantly decreased the duration of antibiotics used in both sepsis and respiratory tract infections. For the secondary outcomes, there was no statistically significant difference in the outcomes of length of hospitalization, recurrence of infection/rehospitalization, and 28-day mortality. However, in-hospital mortality was significantly reduced (p = .02). CRP guided reduced antibiotic use duration, but there was no statistically significant difference in other outcomes including length of hospital stay, 28-day mortality, and infection recurrence. CONCLUSION Procalcitonin-guided antibiotics therapy was shown to be effective and safe in the reduction of antibiotics duration in both sepsis and respiratory tract infections. More research is needed to prove that CRP-guided therapy is safe and effective to determine the antibiotic duration in adult hospitalized patients. REVIEW REGISTRATION NUMBER PROSPERO (CRD42021264167).
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Affiliation(s)
- Dina Elnajdy
- Clinical Pharmacy Program, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates
| | - Faris El-Dahiyat
- Clinical Pharmacy Program, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates
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Ceccato A, Torres A. Defining Clinical and Microbiological Nonresponse in Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:229-233. [PMID: 35088404 DOI: 10.1055/s-0041-1740584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a severe complication of mechanical ventilation, with mortality reduced most effectively by adequate early antibiotic treatment. The clinical and microbiologic response can be assessed easily from 72 hours after starting antibiotic treatment. Evidence of nonresponse is based on several factors: (1) lack of clinical improvement, (2) radiographic progression, (3) an impaired Sequential Organ Failure Assessment (SOFA) score, (4) no improvement by days 3 to 5 on the Clinical Pulmonary Infection Score (CPIS), (5) no decreased in biomarkers on day 3, and (6) isolation of a new pathogen on day 3. Among the clinical markers of treatment failure, physicians should consider no improvement in the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2), persistence of fever or hypothermia, persistence of purulent respiratory secretions, and new-onset septic shock or multiple-organ dysfunction syndrome. Microbiological isolation of a new pathogen on day 3 is also associated with higher mortality, but persistence of the original pathogen does not seem to be associated with a worse prognosis. The real impact of changes to treatment after diagnosing nonresponsive VAP is unknown. Physicians must evaluate whether treatments are adequate in terms of sensitivity, dose, and route. Pharmacokinetically and pharmacodynamically optimized doses are recommended in these patients. Clinical stabilization of comorbidities or underlying conditions may be of benefit.
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Affiliation(s)
- Adrian Ceccato
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) Barcelona, Spain.,Intensive Care Unit, Hospital Universitari Sagrat Cor, Barcelona, Spain
| | - Antoni Torres
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona; Biomedical Research Networking Centres in Respiratory Diseases (CIBERES) Barcelona, Spain.,Department of Pneumology, Hospital Clinic of Barcelona, Barcelona, Spain
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Lau TMM, Daniel R, Hughes K, Wootton M, Hood K, Gillespie D. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac013. [PMID: 35233529 PMCID: PMC8874134 DOI: 10.1093/jacamr/dlac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/21/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Antimicrobial stewardship interventions (ASIs) aim to reduce the emergence of antimicrobial resistance. We sought to systematically evaluate how microbiological outcomes have been handled and analysed in randomized controlled trials (RCTs) evaluating ASIs. Methods We searched PubMed and Embase from 2011–21. Studies were selected if they were RCTs evaluating ASIs. A narrative synthesis approach was taken, identifying whether the study reported any microbiological data (bacterial genus/species; bacterial colony counts; prevalence of bacterial, microbiologically defined infections; and antibiotic susceptibility, measured pre-randomization or post-randomization in one arm only) or outcomes (post-randomization data compared between arms). Studies with or without microbiological data/outcomes were summarized in terms of study characteristics, methods of reporting and analysis of these outcomes. Results We identified 117 studies, with 34 (29.1%) collecting microbiological data and 18 (15.4%) reporting microbiological outcomes. Most studies with microbiological outcomes were conducted in secondary care (12/18, 66.7%) and targeted adult populations (14/18, 77.8%), and the intervention involved biomarker-guided rapid diagnostic testing (7/18, 38.9%). The overall quality of reporting and analysing microbiological outcomes was low and inconsistent. The selected study population in analyses and methods of handling missing data were unclear. Conclusions This review demonstrates that the quality of handling and reporting microbiological outcomes in RCTs of ASIs was low. The lack of consistency and clarity made it difficult to compare the findings across studies, limiting policy- and clinical decision-making. Therefore, there is a clear need for the development of guidance for handling microbiological outcomes in RCTs and adopting appropriate methods to evaluate these data carefully.
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Affiliation(s)
- Tin Man Mandy Lau
- Centre for Trials Research, Cardiff University, Cardiff, UK
- Corresponding author. E-mail:
| | - Rhian Daniel
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kathryn Hughes
- PRIME Centre Wales, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales, Cardiff, UK
| | - Kerry Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
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Abstract
In critically ill patients with sepsis and septic shock, the need for prompt and adequate antibiotic therapy is balanced by the risk of excessive antibiotic exposure that leads to emergence of multidrug-resistant pathogens. As such, antibiotic stewardship programs propose a set of operating rules from antibiotic treatment initiation to de-escalation and finally cessation. In this review, we will describe the rationale for early antibiotic treatment in septic patients, how to optimize initial antibiotic treatment, rules for early treatment discontinuation in pathogen-negative sepsis, and optimal duration of antimicrobial therapy.
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Affiliation(s)
- Etienne de Montmollin
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
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Imaeda T, Nakada TA, Takahashi N, Yamao Y, Nakagawa S, Ogura H, Shime N, Umemura Y, Matsushima A, Fushimi K. Trends in the incidence and outcome of sepsis using data from a Japanese nationwide medical claims database-the Japan Sepsis Alliance (JaSA) study group. Crit Care 2021; 25:338. [PMID: 34530884 PMCID: PMC8444487 DOI: 10.1186/s13054-021-03762-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/07/2021] [Indexed: 12/29/2022]
Abstract
Background Trends in the incidence and outcomes of sepsis using a Japanese nationwide database were investigated. Methods This was a retrospective cohort study. Adult patients, who had both presumed serious infections and acute organ dysfunction, between 2010 and 2017 were extracted using a combined method of administrative and electronic health record data from the Japanese nationwide medical claim database, which covered 71.5% of all acute care hospitals in 2017. Presumed serious infection was defined using blood culture test records and antibiotic administration. Acute organ dysfunction was defined using records of diagnosis according to the international statistical classification of diseases and related health problems, 10th revision, and records of organ support. The primary outcomes were the annual incidence of sepsis and death in sepsis per 1000 inpatients. The secondary outcomes were in-hospital mortality rate and length of hospital stay in patients with sepsis. Results The analyzed dataset included 50,490,128 adult inpatients admitted between 2010 and 2017. Of these, 2,043,073 (4.0%) patients had sepsis. During the 8-year period, the annual proportion of patients with sepsis across inpatients significantly increased (slope = + 0.30%/year, P < 0.0001), accounting for 4.9% of the total inpatients in 2017. The annual death rate of sepsis per 1000 inpatients significantly increased (slope = + 1.8/1000 inpatients year, P = 0.0001), accounting for 7.8 deaths per 1000 inpatients in 2017. The in-hospital mortality rate and median (interquartile range) length of hospital stay significantly decreased (P < 0.001) over the study period and were 18.3% and 27 (15–50) days in 2017, respectively. Conclusions The Japanese nationwide data indicate that the annual incidence of sepsis and death in inpatients with sepsis significantly increased; however, the annual mortality rates and length of hospital stay in patients with sepsis significantly decreased. The increasing incidence of sepsis and death in sepsis appear to be a significant and ongoing issue. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03762-8.
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Affiliation(s)
- Taro Imaeda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasuo Yamao
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Nakagawa
- National Center for Child Health and Development, Critical Care Medicine, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Graduate School of Medical Sciences, Nagoya City University, Aichi, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
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Abstract
Procalcitonin (PCT) is useful for differentiating between viral and bacterial infections and for reducing the unnecessary use of antibiotics. As the rise of antimicrobial resistance reaches “alarming” levels according to the World Health Organization, the importance of using biomarkers, such as PCT to limit unnecessary antibiotic exposure has further increased. Randomized trials in patients with respiratory tract infections have shown that PCT has prognostic implications and its use, embedded in stewardship protocols, leads to reductions in the use of antibiotics in different clinical settings without compromising clinical outcomes. However, available data are heterogeneous and recent trials found no significant benefit. Still, from these trials, we have learned several key considerations for the optimal use of PCT, which depend on the clinical setting, severity of presentation, and pretest probability for bacterial infection. For patients with respiratory infections and sepsis, PCT can be used to determine whether to initiate antimicrobial therapy in low-risk settings and, together with clinical data, whether to discontinue antimicrobial therapy in certain high-risk settings. There is also increasing evidence regarding PCT-guided therapy in patients with coronavirus disease 2019 (COVID-19). This review provides an up-to-date overview of the use of PCT in different clinical settings and diseases, including a discussion about its potential to improve the care of patients with COVID-19.
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Affiliation(s)
| | | | - Philipp Schuetz
- Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
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Zhang J, Li X, Huang G, Wang A, Zhang F. Clinical Features and Etiology of Musculoskeletal Infection with or without Sepsis in the Emergency Department. Int J Gen Med 2021; 14:3511-3516. [PMID: 34295179 PMCID: PMC8290349 DOI: 10.2147/ijgm.s321662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background Musculoskeletal infection (MSKI) is a common reason to seek medical care in the emergency department (ED). We aimed to determine the clinical characteristics and etiology of patients with MSKI in our ED, the characteristics of MSKI with sepsis, and the predictors of death in sepsis patients. Methods The study retrospectively analyzed patients with MSKI from April 1, 2017, to March 31, 2021. The patients were divided into non-sepsis and sepsis groups. Clinical data of these patients including their basic information, laboratory results, diagnostic results, and outcomes were collected. Statistical analysis was carried out using GraphPad Prism 5. Results In all, 106 patients (70 male, 36 female) were enrolled in this study: 43 MSKI patients with sepsis and 63 MSKI patients without sepsis. Five patients with sepsis died. The patients’ age and sex ratio were no significantly different between the sepsis and non-sepsis groups. In the sepsis group, the ratio of rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis was significantly different than that in the non-sepsis group (all p<0.05). Fifty-six patients (54.37%) had positive etiology results. Staphylococcus, streptococcus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli were the most common bacteria found in both groups, but sepsis patients had more Candida albicans infections than non-sepsis patients (p=0.0331, p<0.05). The five patients who died in the sepsis group had higher serum levels of creatinine and procalcitonin (PCT). Multivariate logistic regression analyses showed that PCT (p=0.026; odds ratio, 1.038) was significantly related to mortality. Conclusion In MSKI patients, rheumatic diseases, diabetes, coronary heart disease, and deep vein thrombosis are the risk factors for sepsis. Staphylococcus, streptococcus, K. pneumoniae, P. aeruginosa, and E. coli were the most common bacteria in MSKI patients, while MSKI patients with sepsis had more C. albicans infections. Elevated PCT was significantly related to death in sepsis patients.
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Affiliation(s)
- Juan Zhang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Xiangmin Li
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Guoqing Huang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Aimin Wang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
| | - Fangjie Zhang
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, People's Republic of China
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Safarika A, Wacker JW, Katsaros K, Solomonidi N, Giannikopoulos G, Kotsaki A, Koutelidakis IM, Coyle SM, Cheng HK, Liesenfeld O, Sweeney TE, Giamarellos-Bourboulis EJ. A 29-mRNA host response test from blood accurately distinguishes bacterial and viral infections among emergency department patients. Intensive Care Med Exp 2021; 9:31. [PMID: 34142256 PMCID: PMC8211458 DOI: 10.1186/s40635-021-00394-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Whether or not to administer antibiotics is a common and challenging clinical decision in patients with suspected infections presenting to the emergency department (ED). We prospectively validate InSep, a 29-mRNA blood-based host response test for the prediction of bacterial and viral infections. METHODS The PROMPT trial is a prospective, non-interventional, multi-center clinical study that enrolled 397 adult patients presenting to the ED with signs of acute infection and at least one vital sign change. The infection status was adjudicated using chart review (including a syndromic molecular respiratory panel, procalcitonin and C-reactive protein) by three infectious disease physicians blinded to InSep results. InSep (version BVN-2) was performed using PAXgene Blood RNA processed and quantified on NanoString nCounter SPRINT. InSep results (likelihood of bacterial and viral infection) were compared to the adjudicated infection status. RESULTS Subject mean age was 64 years, comorbidities were significant for diabetes (17.1%), chronic obstructive pulmonary disease (13.6%), and severe neurological disease (6.8%); 16.9% of subjects were immunocompromised. Infections were adjudicated as bacterial (14.1%), viral (11.3%) and noninfected (0.25%): 74.1% of subjects were adjudicated as indeterminate. InSep distinguished bacterial vs. viral/noninfected patients and viral vs. bacterial/noninfected patients using consensus adjudication with AUROCs of 0.94 (95% CI 0.90-0.99) and 0.90 (95% CI 0.83-0.96), respectively. AUROCs for bacterial vs. viral/noninfected patients were 0.88 (95% CI 0.79-0.96) for PCT, 0.80 (95% CI 0.72-89) for CRP and 0.78 (95% CI 0.69-0.87) for white blood cell counts (of note, the latter biomarkers were provided as part of clinical adjudication). To enable clinical actionability, InSep incorporates score cutoffs to allocate patients into interpretation bands. The Very Likely (rule in) InSep bacterial band showed a specificity of 98% compared to 94% for the corresponding PCT band (> 0.5 µg/L); the Very Unlikely (rule-out) band showed a sensitivity of 95% for InSep compared to 86% for PCT. For the detection of viral infections, InSep demonstrated a specificity of 93% for the Very Likely band (rule in) and a sensitivity of 96% for the Very Unlikely band (rule out). CONCLUSIONS InSep demonstrated high accuracy for predicting the presence of both bacterial and viral infections in ED patients with suspected acute infections or suspected sepsis. When translated into a rapid, point-of-care test, InSep will provide ED physicians with actionable results supporting early informed treatment decisions to improve patient outcomes while upholding antimicrobial stewardship. Registration number at Clinicaltrials.gov NCT03295825.
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Affiliation(s)
- Asimina Safarika
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece
| | | | | | - Nicky Solomonidi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece
| | | | - Antigone Kotsaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece
| | | | | | - Henry K Cheng
- Inflammatix Inc, Clinical Affairs, Burlingame, CA, USA
| | | | | | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, ATTIKON University Hospital, 1 Rimini Str, 12462, Athens, Greece.
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Kyriazopoulou E, Karageorgos A, Liaskou-Antoniou L, Koufargyris P, Safarika A, Damoraki G, Lekakis V, Saridaki M, Adamis G, Giamarellos-Bourboulis EJ. BioFire ® FilmArray ® Pneumonia Panel for Severe Lower Respiratory Tract Infections: Subgroup Analysis of a Randomized Clinical Trial. Infect Dis Ther 2021; 10:1437-1449. [PMID: 34120316 PMCID: PMC8197784 DOI: 10.1007/s40121-021-00459-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The epidemiology of severe lower respiratory tract infections (LRTI) is constantly changing. We aimed to describe it using the BioFire® FilmArray® Pneumonia plus (PNplus) Panel. METHODS In a sub-study of the PROGRESS trial, sputum samples of 90 patients with sepsis and LRTI were retrospectively studied. The primary endpoint was the comparative detection rate of pathogens between conventional microbiology and PNplus Panel; secondary endpoints were microbiology and the association with the inflammatory host response. RESULTS Fifty-six patients with community-acquired pneumonia without risk factors for multidrug-resistant (MDR) pathogens and another 34 patients with risk factors for MDR were studied; median pneumonia severity index (PSI) was 113 (88-135). PNplus detection rate was 72.2% compared to 10% by conventional microbiology (p < 0.001); Streptococcus pneumoniae was the most common pathogen. PSI and procalcitonin were greater among patients with bacterial pathogens than viral pathogens. Median procalcitonin was 0.49 ng/ml and 0.18 ng/ml among patients with ≥ 105 and < 105 copies/ml of detected bacteria, respectively (p = 0.004). Resistance reached 14.4%. CONCLUSION PNplus detects severe pneumonia pathogens at a greater rate than conventional microbiology. High levels of inflammation accompany bacterial detection. TRIAL REGISTRATION PROGRESS, ClinicalTrials.gov NCT03333304, 06/11/2017.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Athanasios Karageorgos
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Lydia Liaskou-Antoniou
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Panagiotis Koufargyris
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Asimina Safarika
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Georgia Damoraki
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Vasileios Lekakis
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - Maria Saridaki
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece
| | - George Adamis
- 1st Department of Internal Medicine, G. Gennimatas General Hospital, Athens, Greece
| | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, Medical School, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 124 62, Athens, Greece.
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Ruggerone B, Scavone D, Troìa R, Giunti M, Dondi F, Paltrinieri S. Comparison of Protein Carbonyl (PCO), Paraoxonase-1 (PON1) and C-Reactive Protein (CRP) as Diagnostic and Prognostic Markers of Septic Inflammation in Dogs. Vet Sci 2021; 8:vetsci8060093. [PMID: 34072427 PMCID: PMC8228102 DOI: 10.3390/vetsci8060093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 02/07/2023] Open
Abstract
Reliable diagnostic and prognostic markers of sepsis are lacking, but essential in veterinary medicine. We aimed to assess the accuracy of C-Reactive Protein (CRP), protein carbonyls (PCO) and paraoxonase-1 (PON1) in differentiating dogs with sepsis from those with sterile inflammation and healthy ones, and predict the outcome in septic dogs. These analytes were retrospectively evaluated at admission in 92 dogs classified into healthy, septic and polytraumatized. Groups were compared using the Kruskal–Wallis test, followed by a Mann–Whitney U test to assess differences between survivors and non-survivors. Correlation between analytes was assessed using the Spearman’s test, and their discriminating power was assessed through a Receiver Operating Characteristic (ROC) curve. PON1 and CRP were, respectively, significantly lower and higher in dogs with sepsis compared with polytraumatized and clinically healthy dogs (p < 0.001 for both the analytes), and also in dogs with trauma compared with healthy dogs (p = 0.011 and p = 0.017, respectively). PCO were significantly increased in septic (p < 0.001) and polytraumatized (p < 0.005) as compared with healthy dogs. PON1 and CRP were, respectively, significantly lower and higher in dogs that died compared with survivors (p < 0.001 for both analytes). Ultimately, evaluation of CRP and PON1 at admission seems a reliable support to diagnose sepsis and predict outcomes.
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Affiliation(s)
- Beatrice Ruggerone
- Department of Veterinary Medicine, University of Milan, Via Celoria, 10, 20133 Milano, Italy; (B.R.); (D.S.); (S.P.)
- Veterinary Teaching Hospital, University of Milan, Via dell’Università 6, 26900 Lodi, Italy
- Ospedale Veterinario I Portoni Rossi, Via Roma, 57/a, Zola Predosa, 40069 Bologna, Italy
| | - Donatella Scavone
- Department of Veterinary Medicine, University of Milan, Via Celoria, 10, 20133 Milano, Italy; (B.R.); (D.S.); (S.P.)
- Veterinary Teaching Hospital, University of Milan, Via dell’Università 6, 26900 Lodi, Italy
| | - Roberta Troìa
- Department of Veterinary Medical Science, Alma Mater Studiorum, University of Bologna, Ozzano dell’Emila (BO), 40064 Bologna, Italy; (R.T.); (F.D.)
| | - Massimo Giunti
- Department of Veterinary Medical Science, Alma Mater Studiorum, University of Bologna, Ozzano dell’Emila (BO), 40064 Bologna, Italy; (R.T.); (F.D.)
- Correspondence:
| | - Francesco Dondi
- Department of Veterinary Medical Science, Alma Mater Studiorum, University of Bologna, Ozzano dell’Emila (BO), 40064 Bologna, Italy; (R.T.); (F.D.)
| | - Saverio Paltrinieri
- Department of Veterinary Medicine, University of Milan, Via Celoria, 10, 20133 Milano, Italy; (B.R.); (D.S.); (S.P.)
- Veterinary Teaching Hospital, University of Milan, Via dell’Università 6, 26900 Lodi, Italy
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Silvetti S, Lembo R, Mesini A, Landoni G, Castagnola E, Nuri H, Pome G, Moscatelli A. Procalcitonin and Early Postoperative Infection After Pediatric Cardiopulmonary Bypass Surgery. J Cardiothorac Vasc Anesth 2021; 35:3688-3693. [PMID: 34127358 DOI: 10.1053/j.jvca.2021.04.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/19/2021] [Accepted: 04/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Systemic inflammation and bacterial infections are critical occurrences after pediatric cardiac surgery. Elevated white blood cell count and C-reactive protein cannot discriminate between these two conditions in the early postoperative period. The aim of this study was to understand whether procalcitonin (PCT) values within 48 hours of surgery could be a useful marker of postoperative infection. DESIGN Retrospective observational study. SETTING The study was performed in a teaching hospital. PARTICIPANTS All patients ≤six years of age. INTERVENTIONS Cardiac surgery on cardiopulmonary bypass from January 1, 2017 to January 1, 2020. MEASUREMENT AND MAIN RESULTS PCT, white blood cell count, and C-reactive protein values were measured at intensive care unit admission and at 24 and 48 hours after surgery. All positive cultures in the first seven days after surgery were recorded. Out of 177 consecutive patients, 22 (12%) developed infections. PCT at 48 hours after surgery was the only laboratory predictor of infections in the first seven days after surgery (p = 0.02). Receiver operating curve analyses on PCT values at 48 hours identified an optimal cut-off value of 1.85 ng/mL in the overall population. Area under the curve was 0.63, sensitivity 63%, and specificity 69%. CONCLUSIONS In light of this preliminary result, the clinical relevance and predictive accuracy of PCT are promising in patients with increasing values of PCT but need to be confirmed in a larger sample.
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Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Institute, Milan, Italy
| | - Alessio Mesini
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milan, Italy.
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pome
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
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