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Jensen JUS, Itenov TS, Thormar KM, Hein L, Mohr TT, Andersen MH, Løken J, Tousi H, Lundgren B, Boesen HC, Johansen ME, Ostrowski SR, Johansson PI, Grarup J, Vestbo J, Lundgren JD. Prediction of non-recovery from ventilator-demanding acute respiratory failure, ARDS and death using lung damage biomarkers: data from a 1200-patient critical care randomized trial. Ann Intensive Care 2016; 6:114. [PMID: 27873291 PMCID: PMC5118375 DOI: 10.1186/s13613-016-0212-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 07/26/2016] [Accepted: 11/02/2016] [Indexed: 12/14/2022] Open
Abstract
Background It is unclear whether biomarkers of alveolar damage (surfactant protein D, SPD) or conductive airway damage (club cell secretory protein 16, CC16) measured early after intensive care admittance are associated with one-month clinical respiratory prognosis. If patients who do not recover respiratory function within one month can be identified early, future experimental lung interventions can be aimed toward this high-risk group. We aimed to determine, in a heterogenous critically ill population, whether baseline profound alveolar damage or conductive airway damage has clinical respiratory impact one month after intensive care admittance. Methods Biobank study of biomarkers of alveolar and conductive airway damage in intensive care patients was conducted. This was a sub-study of 758 intubated patients from a 1200-patient randomized trial. We split the cohort into a “learning cohort” and “validating cohort” based on geographical criteria: northern sites (learning) and southern sites (validating). Results Baseline SPD above the 85th percentile in the “learning cohort” predicted low chance of successful weaning from ventilator within 28 days (adjusted hazard ratio 0.6 [95% CI 0.4–0.9], p = 0.005); this was confirmed in the validating cohort. CC16 did not predict the endpoint. The absolute risk of not being successfully weaned within the first month was 48/106 (45.3%) vs. 175/652 (26.8%), p < 0.0001 (high SPD vs. low SPD). The chance of being “alive and without ventilator ≥20 days within the first month” was lower among patients with high SPD (adjusted OR 0.2 [95% CI 0.2–0.4], p < 0.0001), confirmed in the validating cohort, and the risk of ARDS was higher among patients with high SPD (adjusted OR 3.4 [95% CI 1.0–11.4], p = 0.04)—also confirmed in the validating cohort. Conclusion Early profound alveolar damage in intubated patients can be identified by SPD blood measurement at intensive care admission, and high SPD level is a strong independent predictor that the patient suffers from ARDS and will not recover independent respiratory function within one month. This knowledge can be used to improve diagnostic and prognostic models and to identify the patients who most likely will benefit from experimental interventions aiming to preserve alveolar tissue and therefore respiratory function. Trial registration This is a sub-study to the Procalcitonin And Survival Study (PASS), Clinicaltrials.gov ID: NCT00271752, first registered January 1, 2006 Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0212-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jens-Ulrik S Jensen
- CHIP/Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen Ø, Denmark. .,Department of Clinical Microbiology, Copenhagen University Hospital, Hvidovre, Denmark.
| | - Theis S Itenov
- CHIP/Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen Ø, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hillerød, Denmark
| | - Katrin M Thormar
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Gentofte, Denmark
| | - Lars Hein
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hillerød, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Glostrup, Denmark
| | - Thomas T Mohr
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Gentofte, Denmark.,Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Glostrup, Denmark
| | - Mads H Andersen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper Løken
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hvidovre, Denmark
| | - Hamid Tousi
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Herlev, Denmark
| | - Bettina Lundgren
- Department of Clinical Microbiology, Copenhagen University Hospital, Hvidovre, Denmark
| | - Hans Christian Boesen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Glostrup, Denmark
| | - Maria E Johansen
- CHIP/Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen Ø, Denmark
| | - Sisse R Ostrowski
- Centre for Thrombosis and Hemostasis, Rigshospitalet, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | - Pär I Johansson
- Centre for Thrombosis and Hemostasis, Rigshospitalet, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | - Jesper Grarup
- CHIP/Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen Ø, Denmark
| | - Jørgen Vestbo
- Centre for Respiratory Medicine and Allergy, University South Manchester Hospital NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Jens D Lundgren
- CHIP/Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen Ø, Denmark
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Jensen JUS, Hein L, Lundgren B, Bestle MH, Mohr T, Andersen MH, Løken J, Tousi H, Søe-Jensen P, Lauritsen AØ, Strange D, Petersen JA, Thormar K, Larsen KM, Drenck NE, Helweg-Larsen J, Johansen ME, Reinholdt K, Møller JK, Olesen B, Arendrup MC, Østergaard C, Cozzi-Lepri A, Grarup J, Lundgren JD. Invasive Candida infections and the harm from antibacterial drugs in critically ill patients: data from a randomized, controlled trial to determine the role of ciprofloxacin, piperacillin-tazobactam, meropenem, and cefuroxime. Crit Care Med 2015; 43:594-602. [PMID: 25493970 DOI: 10.1097/ccm.0000000000000746] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Use of antibiotics in critically ill patients may increase the risk of invasive Candida infection. The objective of this study was to determine whether increased exposure to antibiotics is associated with increased prevalence of invasive Candida infection. DESIGN Substudy using data from a randomized controlled trial, the Procalcitonin And Survival Study 2006-2010. SETTING Nine multidisciplinary ICUs across Denmark. PATIENTS A total of 1,200 critically ill patients. INTERVENTION Patients were randomly allocated to either a "high exposure" antibiotic therapy (intervention arm, n = 604) or a "standard exposure" guided by current guidelines (n = 596). MEASUREMENTS AND MAIN RESULTS Seventy-four patients met the endpoint, "invasive Candida infection," 40 in the high exposure arm and 34 in standard exposure arm (relative risk = 1.2; 95% CI, 0.7-1.8; p = 0.52). Among medical patients in the high exposure arm, the use of ciprofloxacin and piperacillin/tazobactam was 51% and 75% higher than in the standard exposure arm; no difference in antibiotic exposure was observed between the randomized arms in surgical patients. Among medical intensive care patients, invasive Candida infection was more frequent in the high exposure arm (6.2%; 27/437) than in standard exposure arm (3.3%; 14/424) (hazard ratio = 1.9; 95% CI, 1.0-3.6; p = 0.05). Ciprofloxacin used at study entry independently predicted invasive Candida infection (adjusted hazard ratio = 2.1 [1.1-4.1]); the risk gradually increased with duration of ciprofloxacin therapy: six of 384 in patients not exposed (1.6%), eight of 212 (3.8%) when used for 1-2 days (hazard ratio = 2.5; 95% CI, 0.9-7.3), and 31 of 493 (6.3%) when used for 3 days (hazard ratio = 3.8; 95% CI, 1.6-9.3; p = 0.002). Patients with any ciprofloxacin-containing antibiotic regimen the first 3 days in the trial had a higher risk of invasive Candida infection than did patients on any antibiotic regimen not containing ciprofloxacin (unadjusted hazard ratio = 3.7; 95% CI, 1.6-8.7; p = 0.003; adjusted hazard ratio, 3.4; 95% CI, 1.4-8.0; p = 0.006). CONCLUSIONS High exposure to antibiotics is associated to increased risk of invasive Candida infection in medical intensive care patients. Patients with ciprofloxacin-containing regimens had higher risk of invasive Candida infection. Other antibiotics, such as meropenem, piperacillin/tazobactam, and cefuroxime, were not associated with such a risk.
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Affiliation(s)
- Jens-Ulrik S Jensen
- 1CHIP, Department of Infectious Diseases and Rheumatology, Rigshospitalet - and the University of Copenhagen, Copenhagen, Denmark. 2Department of Clinical Microbiology, Copenhagen University Hospital, Hvidovre, Denmark. 3Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hillerød, Denmark. 4Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Glostrup, Denmark. 5Diagnostic Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark. 6Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Gentofte, Denmark. 7Department of Anesthesia and Intensive Care, Aarhus University Hospital, Skejby, Denmark. 8Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Hvidovre, Denmark. 9Department of Anesthesia and Intensive Care, Copenhagen University Hospital, Herlev, Denmark. 10Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark. 11Department of Anesthesia and Intensive Care, Roskilde University Hospital, Roskilde, Denmark. 12Department of Clinical Microbiology, Vejle Hospital, University of Southern Denmark, Vejle, Denmark. 13Department of Clinical Microbiology, Copenhagen University Hospital, Hillerød, Denmark. 14Mycology Unit, Statens Serum Institut, Copenhagen, Denmark. 15Department of Clinical Microbiology, Copenhagen University Hospital, Herlev, Denmark. 16Royal Free University College, London, United Kingdom
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Johansen ME, Johansson PI, Ostrowski SR, Bestle MH, Hein L, Jensen ALG, Søe-Jensen P, Andersen MH, Steensen M, Mohr T, Thormar K, Lundgren B, Cozzi-Lepri A, Lundgren JD, Jensen JU. Profound endothelial damage predicts impending organ failure and death in sepsis. Semin Thromb Hemost 2015; 41:16-25. [PMID: 25590523 DOI: 10.1055/s-0034-1398377] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Endothelial damage contributes to organ failure and mortality in sepsis, but the extent of the contribution remains poorly quantified. Here, we examine the association between biomarkers of superficial and profound endothelial damage (syndecan-1 and soluble thrombomodulin [sTM], respectively), organ failure, and death in sepsis. The data from a clinical trial, including critically ill patients predominantly suffering sepsis (Clinicaltrials.gov: NCT00271752) were studied. Syndecan-1 and sTM levels at the time of study enrollment were determined. The predictive ability of biomarker levels on death and organ failures during follow-up were assessed in Cox models adjusted for potential confounders including key organ dysfunction measures assessed at enrollment. Of the 1,103 included patients, 418 died. sTM levels at the time of enrollment independently predicted risk of death in adjusted models (hazard ratio [HR] [highest quartile > 14 ng/mL vs. lowest quartile < 7 ng/mL] 2.2 [95% confidence interval [CI]: 1.2-4.0], p = 0.02, respectively). Conversely, syndecan-1 levels failed to predict death (adjusted HR [> 240 vs. < 70 ng/mL] 1.0 [95% CI: 0.6-1.5], p = 0.67). sTM but not syndecan-1 levels at enrollment predicted risk of multiple organ failure during follow-up (HR [> 14 ng/mL vs. < 7 ng/mL] 3.5 [95% CI: 1.5-8.3], p = 0.005 and 2.0 [95% CI: 0.8-5.0], p = 0.1321, respectively). Profound damage to the endothelium independently predicts risk of multiple organ failure and death in septic patients. Our findings also suggest that the detrimental effect of profound endothelial damage on risk of death operates via mechanisms other than causing organ failures per se. Therefore, damage to the endothelium appears centrally involved in the pathogenesis of death in sepsis and could be a target for intervention.
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Affiliation(s)
- Maria E Johansen
- CHIP, Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Department of Surgery, University of Texas Medical School at Houston, Houston, Texas
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Denmark
| | - Morten H Bestle
- Department of Anesthesia and Intensive Care at Nordsjaellands Hospital, Denmark
| | - Lars Hein
- Department of Anesthesia and Intensive Care at Nordsjaellands Hospital, Denmark
| | - Anne L G Jensen
- Department of Anesthesia and Intensive Care at University Hospital Glostrup, Denmark
| | - Peter Søe-Jensen
- Department of Anesthesia and Intensive Care at University Hospital Herlev, Denmark
| | - Mads H Andersen
- Department of Anesthesia and Intensive Care at University Hospital Aarhus, Denmark
| | - Morten Steensen
- Department of Anesthesia and Intensive Care at University Hospital Hvidovre, Denmark
| | - Thomas Mohr
- Department of Anesthesia and Intensive Care at University Hospital Gentofte, Denmark
| | - Katrin Thormar
- Department of Anesthesia and Intensive Care at University Hospital Bispebjerg, Denmark
| | | | - Alessandro Cozzi-Lepri
- CHIP, Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Lundgren
- CHIP, Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Ulrik Jensen
- CHIP, Department of Infectious Diseases and Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Johansen ME, Jensen JU, Bestle MH, Ostrowski SR, Thormar K, Christensen H, Pedersen HP, Poulsen L, Mohr T, Kjær J, Cozzi-Lepri A, Møller K, Tønnesen E, Lundgren JD, Johansson PI. Mild induced hypothermia: effects on sepsis-related coagulopathy--results from a randomized controlled trial. Thromb Res 2014; 135:175-82. [PMID: 25466837 DOI: 10.1016/j.thromres.2014.10.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 06/14/2014] [Revised: 09/27/2014] [Accepted: 10/29/2014] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Coagulopathy associates with poor outcome in sepsis. Mild induced hypothermia has been proposed as treatment in sepsis but it is not known whether this intervention worsens functional coagulopathy. MATERIALS AND METHODS Interim analysis data from an ongoing randomized controlled trial; The Cooling And Surviving Septic shock (CASS) study. Patients suffering severe sepsis/septic shock are allocated to either mild induced hypothermia (cooling to 32-34°C for 24hours) or control (uncontrolled temperature). TRIAL REGISTRATION NCT01455116. Thrombelastography (TEG) is performed three times during the first day after study enrollment in all patients. Reaction time (R), maximum amplitude (MA) and patients' characteristics are here reported. RESULTS One hundred patients (control n=50 and intervention n=50; male n=59; median age 68years) with complete TEG during follow-up were included. At enrollment, 3%, 38%, and 59% had a hypocoagulable, normocoagulable, and hypercoagulable TEG clot strength (MA), respectively. In the hypothermia group, functional coagulopathy improved during the hypothermia phase, measured by R and MA, in patients with hypercoagulation as well as in patients with hypocoagulation (correlation between ΔR and initial R: rho=-0.60, p<0.0001 and correlation between ΔMA and initial MA: rho=-0.50, p=0.0002). Similar results were not observed in the control group neither for R (rho=-0.03, p=0.8247) nor MA (rho=-0.15, p=0.3115). CONCLUSION Mild induced hypothermia did seem to improve functional coagulopathy in septic patients. This improvement of functional coagulopathy parameters during the hypothermia intervention persisted after rewarming. Randomized trials are warranted to determine whether the positive effect on sepsis-related coagulopathy can be transformed to improved survival.
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Affiliation(s)
- Maria E Johansen
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark.
| | - Jens-Ulrik Jensen
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anesthesia and Intensive Care, Nordsjaellands hospital, Denmark
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Denmark
| | - Katrin Thormar
- Department of Anesthesia and Intensive Care, Bispebjerg Hospital, Denmark
| | - Henrik Christensen
- Department of Anesthesia and Intensive Care, University Hospital Herlev, Denmark
| | | | - Lone Poulsen
- Department of Anesthesia and Intensive Care, University Hospital Køge, Denmark
| | - Thomas Mohr
- Department of Anesthesia and Intensive Care, University Hospital Gentofte, Denmark
| | - Jesper Kjær
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark
| | - Alessandro Cozzi-Lepri
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark; Department of Virology, Royal Free and University College Medical School London, United Kingdom
| | - Kirsten Møller
- Neurointensive Care Unit 2093, Department of Neuroanaesthesiology, University Hospital Rigshospitalet, Denmark
| | - Else Tønnesen
- Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Jens D Lundgren
- Centre for Health and Infectious Diseases Research (CHIP), Department of Infectious Diseases and Reumathology, Rigshospitalet,University of Copenhagen, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Denmark; Department of Surgery, University of Texas Medical School at Houston, TX, USA
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Abstract
We have shown heat-killed Saccharomyces (HKY) is a protective vaccine against aspergillosis and coccidioidomycosis. To test the hypothesis that the efficacy of HKY- induced protection may be due to the cross-reactive antigens in the cell walls of the different fungi, we studied the effect of HKY against systemic candidiasis. Male CD-1 mice were given different regimens of HKY subcutaneously prior to intravenous challenge with Candida albicans. Compared to PBS controls, the administration of HKY (6 × 10(7)) 3, 4 or 6 times prolonged survival (all P < 0.05) and reduced fungal load in the kidney (all P < 0.05). An HKY dose of 1.2 × 10(8) given 4 times prolonged survival (P = 0.02), but showed dose-limiting toxicity. HKY given by an oral route, or by a subcutaneous route with alum as an adjuvant, did not improve survival. Overall, we found that HKY protects mice from infection by Candida albicans in a dose-and regimen-dependent manner. To understand the protection induced by HKY against different fungal species, additional studies of epitope mapping are warranted.
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Affiliation(s)
- Min Liu
- California Institute for Medical Research, San Jose, CA 95128, USA
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Liu M, Capilla J, Johansen ME, Alvarado D, Martinez M, Chen V, Clemons KV, Stevens DA. Saccharomyces as a vaccine against systemic aspergillosis: ‘the friend of man’ a friend again? J Med Microbiol 2011; 60:1423-1432. [DOI: 10.1099/jmm.0.033290-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Min Liu
- Stanford University, Stanford, CA, USA
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
- California Institute for Medical Research, San Jose, CA, USA
| | - Javier Capilla
- Stanford University, Stanford, CA, USA
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
- California Institute for Medical Research, San Jose, CA, USA
| | - Maria E. Johansen
- California Institute for Medical Research, San Jose, CA, USA
- Stanford University, Stanford, CA, USA
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Danielle Alvarado
- Stanford University, Stanford, CA, USA
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
- California Institute for Medical Research, San Jose, CA, USA
| | - Marife Martinez
- California Institute for Medical Research, San Jose, CA, USA
| | - Vicky Chen
- California Institute for Medical Research, San Jose, CA, USA
| | - Karl V. Clemons
- Stanford University, Stanford, CA, USA
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
- California Institute for Medical Research, San Jose, CA, USA
| | - David A. Stevens
- Stanford University, Stanford, CA, USA
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
- California Institute for Medical Research, San Jose, CA, USA
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