Gut Microbiota and Probiotics/Synbiotics for Modulation of Immunity in Critically Ill Patients

Patients suffering from critical illness have host inflammatory responses against injuries, such as infection and trauma, that can lead to tissue damage, organ failure, and death. Modulation of host immune response as well as infection and damage control are detrimental factors in the management of systemic inflammation. The gut is the motor of multiple organ failure following injury, and it is recognized that gut dysfunction is one of the causative factors of disease progression. The gut microbiota has a role in maintaining host immunity, and disruption of the gut microbiota might induce an immunosuppressive condition in critically ill patients. Treatment with probiotics and synbiotics has been reported to attenuate systemic inflammation by maintaining gut microbiota and to reduce postoperative infectious complications and ventilator-associated pneumonia. The administration of prophylactic probiotics/synbiotics could be an important treatment option for preventing infectious complications and modulating immunity. Further basic and clinical research is needed to promote intestinal therapies for critically ill patients.

Non-SARS-CoV-2 Infections Among Patients Evaluated for MIS-C Associated With COVID-19

Clinical features of Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 are nonspecific. In this retrospective cohort study of 39 patients evaluated for MIS-C, 11 had non-SARS-CoV-2 infections, 3 of whom were also diagnosed with MIS-C. Clinical features were similar in patients with MIS-C and patients with non-SARS-CoV-2 infections. Clinicians should consider non-SARS-CoV-2 infections in patients undergoing MIS-C evaluation.

Impact of Bacterial Translocation on Sarcopenia in Patients with Decompensated Cirrhosis

Advanced liver disease is associated with a persistent inflammatory state, derived from abnormal bacterial translocation from the gut, which may contribute to the development of sarcopenia in cirrhosis. We aim to document the association of chronic inflammation and bacterial translocation with the presence of sarcopenia in cirrhosis. We prospectively followed cirrhotic patients aged 18-70 years with medically refractory ascites at a single tertiary care center in Toronto, Canada. The baseline data included patient demographic variables, the presence of bacterial DNA in serum/ascitic fluid, systemic inflammatory response syndrome (SIRS) status, and nutritional assessment. Thirty-one patients were enrolled, 18 (58.1%) were sarcopenic, 9 (29%) had bacterial DNA in serum and ascites fluid. The mean MELD score was 11.5 ± 4.0 (6-23). Sarcopenic and non-sarcopenic patients did not differ significantly in their baseline MELD scores, caloric intake, resting energy expenditure, the incidence of bacterial translocation, or SIRS. While sarcopenia was not linked to increased hospital admissions or death, it was strongly associated with increased episodes of acute kidney injury (3 vs. 0, p = 0.05). This pilot study did not demonstrate an association between sarcopenia and SIRS or bacterial translocation. These results should be confirmed in future larger studies, encompassing a greater number of chronic inflammation events and quantifying levels of bacterial DNA.

Rapid Decompensation to Systemic Inflammatory Response Syndrome in Children with Osteomyelitis: A Report of Three Cases

CASE

We present 3 pediatric cases of osteomyelitis with delayed diagnosis, which resulted in systemic inflammatory response syndrome (SIRS) and complicated hospital stays.

CONCLUSION

These 3 cases illustrate that early treatment of osteomyelitis is imperative in order to avoid fatal complications, which can occur with SIRS. Subtle signs and symptoms should not be dismissed. Patients with fever, pain, and no history of trauma should be scrutinized.

DYSFUNCTION OF VARIOUS ORGAN SYSTEMS INDUCED BY SEPSIS WITH UNDERLYING SEVERE MYELOMIC DISEASES AND PROSTATE CANCER (CASE REPORT)

A 65-year-old male patient, unconscious, was admitted into the clinic by the Ambulance. From the patient's medical history it was revealed that several hours before the admission in the clinic the following symptoms were present: shortness of breath, fever, hypotonia, consciousness inhibition, because of which emergency brigade was called and was brought by the Emergency Brigade. The history is loaded by chronic pathologies: myeloma disease, prostate cancer, ciliary arrhythmia, heart failure; received several courses of polichemotherapy, last ten days has been treated for pneumonia with antibiotics of ceftriaxone group in outpatient setting. It is also noteworthy that for the last three months dysfunction of musculoskeletal system with muscle weakness, restricted motion has been present. Clinically there was present dysfunction syndrome of several organs: disorder of function of several organs that required emergency intervention, recovery chance was very low, correlation with morbidity in PIRO was high. By investigation it is known, that as SIRS aggravates, and turns into septic shock, lethal index increases, especially when the underlying severe diseases are present. On basis of certain data we can conclude that the severity of the disease may have some compatibility with results, although it is alteration of further clinical status of initial stage that has the closest compatibility with results. Sepsis toward MODS experiences progress with lethal results. Mortality rate in the patients with acute respiratory deficiency increases from 50% to 80%. In most patients with sepsis syndrome, who have 3 or more organs damaged, lethality is more than 90%. In this certain case organ systems that are mostly involved in the process during the sepsis, are respiratory, blood, renal and cardiovascular systems, were all involved , in the mentioned case a reasonable symptomatic and pathognomic treatment and the appropriate measures led to the recovery of the above mentioned patient. Sepsis syndrome is developed when the balance between the substances that contribute to the inflammation and anti-inflammatory substances is violated. By the mentioned case there is sepsis - induced polyorganic insufficiency with underlying severe somatic pathological condition, with violation of hemodynamics. Clinically the insufficiency of all the organic systems developed at the background of cardio-respiratory-cerebral insufficiency, with functional insufficiency of all the organ systems and violation of buffer system. With reasonable pathognomic and symptomatic treatment eradication of vicious circle was possible. The patient was discharged from the clinic with positive clinic-laboratory recovery. The condition is stable. Neurological status -contact, adequate, with high capacity to work, and with an achievement of 2 year remission.

A Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: The Optimizing Antibiotic Strategies in Sepsis (OASIS) Study

BACKGROUND.

Biomarkers that identify critically ill children with systemic inflammatory response syndrome (SIRS) at low risk for bacterial infection may help clinicians reduce unnecessary antibiotic use.

METHODS.

We conducted a prospective cohort study of children with SIRS and suspected infection admitted to a pediatric intensive care unit from January 5, 2012 to March 7, 2014. We enrolled patients upon initiation of new antibiotics (Time 0) and measured a panel of 8 serum biomarkers daily over 72 hours. Microbiology, imaging, and clinical data were reviewed to classify bacterial infections using Centers for Disease Control and Prevention definitions. We identified cut points of biomarker combinations to maximize the negative predictive value (NPV) and specificity for bacterial infection. Excess antibiotics were calculated as days of therapy beyond day 2 after SIRS onset in patients without bacterial infection.

RESULTS.

Infections were identified in 46 of 85 patients: bacterial (n = 22) and viral (24), whereas 39 patients had no infection identified. At Time 0, C-reactive protein (CRP) <5 mg/dL plus serum amyloid A <15.0 µg/mL had an NPV of 0.92 (95% confidence interval [CI], 0.79-1.0) and specificity of 0.54 (95% CI, 0.42-0.66) to identify patients without bacterial infection, whereas CRP <4 mg/dL plus procalcitonin <1.75 ng/mL had an NPV of 0.90 (95% CI, 0.79-1.0) and specificity of 0.43 (95% CI, 0.30-0.55). Patients without bacterial infection received a mean of 3.8 excess days of therapy.

CONCLUSIONS.

Early measurement of select biomarkers can identify children with SIRS in whom antibiotics might be safely discontinued when there is no other objective evidence of infection at 48 hours.

Combined Therapy With Adipose-Derived Mesenchymal Stem Cells and Ciprofloxacin Against Acute Urogenital Organ Damage in Rat Sepsis Syndrome Induced by Intrapelvic Injection of Cecal Bacteria

We hypothesized that combined treatment with autologous adipose-derived mesenchymal stem cell (ADMSC) and ciprofloxacin is superior to ciprofloxacin only in reducing sepsis-induced urogenital organ damage and mortality in rat sepsis syndrome (SS) caused by intrapelvic injection of cecal bacteria (1.0 × 10(4) cells per milliliter; total, 5.0 ml). Male Sprague-Dawley rats (n = 60) equally divided into group 1 (sham-control), group 2 (SS), group 3 (SS-ADMSC [5.0 × 10(5) intravenously at 0.5, 6, and 18 hours after sepsis induction]), group 4 (SS-ciprofloxacin [3.0 mg/kg, b.i.d.] for 5 days), and group 5 (SS-ADMSC-ciprofloxacin) were sacrificed by day 5. Mortality rate and creatinine level were highest in group 2 and lowest in group 1 and significantly higher in groups 3 and 4 than those in group 5, but there was no difference between groups 3 and 4 (all p < .005). The kidney injury score, inflammatory biomarker expressions at protein (tumor necrosis factor-1α, nuclear factor-κB, matrix metallopeptidase-9, regulated on activation, normal T-cell expressed and secreted, interleukin-1β) and cellular (CD14+, migratory inhibitor factor positive, CD68+) levels in kidneys and urinary bladder were lowest in group 1 and highest in group 2, higher in group 4 than in groups 3 and 5, and higher in group 3 than in group 5 (all p < .001). Protein expressions of apoptosis (Bax, cleaved caspase 3 and poly[ADP-ribose] polymerase 1, p21 protein [Cdc42/Rac]-activated kinase 2) and oxidative stress (oxidized protein, NADPH oxidase (NOX)-1, NOX-2) in these organs showed an identical pattern compared with that of inflammation in all groups (all p < .001). In conclusion, ADMSC-assisted ciprofloxacin therapy offered an additional benefit by reducing acute urogenital organ damage in rat.

SIGNIFICANCE

Autologous adipose-derived mesenchymal stem cell-assisted ciprofloxacin therapy offered an additional benefit by reducing acute urogenital organ damage in rats.

[Sepsis in children with cancer: problems to detect it and challenges for diminishing it]

Since 1992 the availability of the criteria of systemic inflammatory response syndrome (SIRS) has improved the identification of subjects with sepsis. Sepsis remains a major hospital complication worldwide, responsible for thousands of deaths in children with cancer. Different biomarkers have been proposed for discrimination of septic child, who is not, but its introduction and routine use in control programs and surveillance has not been possible so far. The challenge in septic cancer remains valid subject and makes it a public health problem. The research accompanying the treatment of these children and introducing them, depend on their effectiveness, financing and universal availability of methods; but especially strategic planning based on that knowledge.

Evaluation of the Septifast MGrade Test on Standard Care Wards--A Cohort Study

Background

The immediate need for appropriate antimicrobial therapy in septic patients requires the detection of the causative pathogen in a timely and reliable manner. In this study, the real-time PCR Septifast M^Grade test was evaluated in adult patients meeting the systemic inflammatory response syndrome (SIRS) criteria that were treated at standard care wards.

Methods

Patients with clinical suspected infection, drawn blood cultures (BC), the Septifast M^Grade test (SF) and sepsis biomarkers were prospectively screened for fulfillment of SIRS criteria and evaluated using the criteria of the European Centre of Disease Control (ECDC) for infection point prevalence studies.

Results

In total, 220 patients with SIRS were prospectively enrolled, including 56 patients with detection of bacteria in the blood (incidence: 25.5%). BC analysis resulted in 75.0% sensitivity (95% confidence interval, CI: 61.6%– 85.6%) with 97.6% specificity (CI: 93.9%– 99.3%) for detecting bacteria in the blood. In comparison to BC, SF presented with 80.4% sensitivity (CI: 67.6%– 89.8%) and with 97.6% specificity (CI: 93.9%– 99.3%). BC and SF analysis yielded comparable ROC-AUCs (0.86, 0.89), which did not differ significantly (p = 0.558). A trend of a shorter time-to-positivity of BC analysis was not seen in bacteremic patients with a positive SF test than those with a negative test result. Sepsis biomarkers, including PCT, IL-6 or CRP, did not help to explain discordant test results for BC and SF.

Conclusion

Since negative results do not exclude bacteremia, the Septifast M^Grade test is not suited to replacing BC, but it is a valuable tool with which to complement BC for faster detection of pathogens.

Comparative study of bacterial translocation control with nitric oxide donors and COX2 inhibitor

OBJECTIVE AND DESIGN

To evaluate the beneficial effects of exogenous NO and an inhibitor of the COX2, and their action levels in a model of SIRS/bacterial translocation (BT) induced by Zymosan A(®).

MATERIAL AND METHODS

Ninety Wistar rats were submitted to different treatments, and after 12h and 24h they were anaesthetized in order to collect blood, mesenteric lymph nodes, and kidney for subsequent biochemical analyses and microbiological examinations.

TREATMENTS

A nitric oxide donor, Molsidomine(®), was compared with a COX2 inhibitor, Celecoxib(®).

METHODS

Zymosan A(®) was administered to Wistar rats. The animals were divided into 6 groups: one group for survival study, Group (1) No manipulation (BASAL); Group (2) vehicle of Zymosan A(®) given intraperitoneally (SHAM); Group I (control), with Zymosan A(®) (0.6g/kg) intraperitoneally; Group II (Molsidomine), with Molsidomine(®) (4mg/kg) through the penis dorsal vein, 30min prior to administration of the Zy(®) (0.6g/kg); Group III (Celecoxib), with Celecoxib(®) (400mg/kg) orally through a stomach tube, 6h prior to administration of the Zy (0.6g/kg).

DETERMINATIONS

The parameters survival, bacterial translocation, renal function, neutrophil accumulation, oxygen free radicals (OFR), detoxifying enzymes, and cytokines were measured at different times after Zymosan administration.

RESULTS

The model established induced a mortality rate of 100% and generated BT and systemic inflammatory response syndrome (SIRS) in all samples. It also significantly increased all variables, with p<.001 for MPO and all pro-inflammatory cytokines, and p<.01 for all OFR. Treatment with Molsidomine reduced mortality to 0%, decreased BT, MPO, pro-inflammatory cytokines and OFR (p<.001) significantly and increased IL-10 and IL-6 production. Moreover, the Celecoxib(®) showed a lower capacity for SIRS regulation.

CONCLUSIONS

The exogenous administration of NO prevented BT and controlled SIRS. Therefore these results suggest that Molsidomine could be used as a therapeutic strategy to protect against BT.

[Campylobacteriosis at the Department of Infectious Diseases of the University Hospital Brno in 2011-2013: a retrospective study]

OBJECTIVE

To provide basic clinical, laboratory, and microbiological characteristics of adult patients with campylobacteriosis admitted to the Department of Infectious Diseases University Hospital Brno (UHB), in 2011-2013.

MATERIALS AND METHODS

A retrospective analysis of clinical and laboratory parameters of 160 patients hospitalized with campylobacteriosis at the Department of Infectious Diseases, UHB from 1 January 2011 to 31 December 2013.

RESULTS

There was no lethality or bacteremia reported in the study group of 160 adult patients (n=160) with campylobacteriosis. A more severe form of the disease with signs of systemic inflammatory response syndrome (SIRS) occurred in 24 patients, i.e. 15% of the study population. Transient mild to moderate leukocytopenia and thrombocytopenia were seen in 16 (10.0%) and 24 patients (15.0%), respectively, and seven patients (4.4%) had bicytopenia. The following factors correlated statistically significantly with the intestinal form of the disease and SIRS: age under 70 years (p=0.037), absence of arterial hypertension (p=0.044), immunosuppressive treatment (p=0.008), leukocyte count in the peripheral blood over 12.0×10(9)/l (p=0.023), and body temperature over 38.0 °C (p<0.001). Antibiotic treatment was used in 96.3% of patients with the intestinal form and in 100.0% of patients with SIRS. The average duration of antibiotic treatment was 8.8 and 9.3 days, respectively. Postantibiotic colitis due to Clostridium difficile occurred in seven patients (4.4%). There were no organ or autoimmune complications observed.

CONCLUSIONS

Campylobacteriosis with SIRS occurs preferentially in persons under 70 years of age. Empirical antibiotic treatment is used too frequently without being adequately deescalated.

[SYSTEMIC INFLAMMATORY RESPONSE ON NOSOCOMIAL BACTEREMIA]

GOAL

study of special aspects in system inflammatory reaction caused by nosocomial bacteremia in dependence of the pathogen Gram-origin. The study included 85 patients with nosocomial bacteremia in ICU from 2010 till 2012. The main inclusion criteria was bacteria identification in blood, which was taken more than 48 hours from arrival to ICU within the appearance of system inflammatory response signs. Key options for clinical rating of system inflammatory response was dynamic of patients condition according APACHE II, SOFA, SAPS-III/PIRO, Pitt scales and its correlation with durations of mechanical ventilation, length of staying in ICU, total hospital period and outcome.

RESULTS

Gram-negative microorganisms are definitely leading in the modern ethiological structure of nosocomial bacteremia in ICU patients (64,4%). The main origin of Gram(+) agents is central venous catheter infections. The main reason of Gram(-) infections is ventilation-associated pneumonia. Appearance or persistence of system inflammatory response is associated with the rise of scale indexes (SOFA and Pitt from 5 scores and higher and SAPS-PIRO higher than 18 scores) and high risk of possible bacteremia.

Nuclease-assisted suppression of human DNA background in sepsis

Sepsis is a severe medical condition characterized by a systemic inflammatory response of the body caused by pathogenic microorganisms in the bloodstream. Blood or plasma is typically used for diagnosis, both containing large amount of human DNA, greatly exceeding the DNA of microbial origin. In order to enrich bacterial DNA, we applied the C₀t effect to reduce human DNA background: a model system was set up with human and Escherichia coli (E. coli) DNA to mimic the conditions of bloodstream infections; and this system was adapted to plasma and blood samples from septic patients. As a consequence of the C₀t effect, abundant DNA hybridizes faster than rare DNA. Following denaturation and re-hybridization, the amount of abundant DNA can be decreased with the application of double strand specific nucleases, leaving the non-hybridized rare DNA intact. Our experiments show that human DNA concentration can be reduced approximately 100,000-fold without affecting the E. coli DNA concentration in a model system with similarly sized amplicons. With clinical samples, the human DNA background was decreased 100-fold, as bacterial genomes are approximately 1,000-fold smaller compared to the human genome. According to our results, background suppression can be a valuable tool to enrich rare DNA in clinical samples where a high amount of background DNA can be found.

[A fatal case of septicemia by serotype A:3 Pasteurella multocida in human: review of 14 septic cases in Japan]

We report a case of systemic inflammatory response syndrome (SIRS) due to septicemia by Pasteurella multocida (P. multocida) who died three days after on admission. A few cases of septicemia by P. multocida were previously reported. In particular, capsular serotype analysis and somatic serotype analysis of P. multocida in human is very rare. Serotype A:3 P. multocida was identified in a diabetic patient with chronic obstructive pulmonary disease (COPD). There was high possibility that the isolate has been transmitted from an indoor companion dog since the patient had had close contact with the dog for one month. Here we discuss our case and 13 human cases of septicemia by P. multocida reported in Japan. Four cases from dogs and eleven cases from cats were included in these cases. The mortality rate of septicemia by P. multocida was 21.4% (3/14 cases). Two out of three cases died were diabetic.

Presepsin (sCD14-ST) in preoperative diagnosis of abdominal sepsis

BACKGROUND

The aim of the study was to identify the diagnostic significance of presepsin in acute abdominal conditions and also to examine the correlation between presepsin, procalcitonin (PCT) and other parameters.

METHODS

To detect presepsin we used a new rapid method based on a chemiluminescent enzyme immunoassay. The clinical usefulness of presepsin to differentiate bacterial and non-bacterial infection [including systemic inflammation response syndrome (SIRS)] was studied and compared with PCT, C-reactive protein (CRP) and white blood cells (WBC).

RESULTS

The presepsin values in different conditions were (mean±standard deviation): healthy group (n=70) 258.7±92.53 pg/mL; SIRS (n=30) 430.0±141.33 pg/mL; sepsis (n=30) 1508.3±866.6 pg/mL. The presepsin values were significantly higher in patients with sepsis than the SIRS group (p<0.0001, Mann-Whitney U-test). The area under the receiver operating characteristics (ROC) curve (AUC) for discriminating of the SIRS from the sepsis patients was 0.996 for presepsin and it was greater than the AUC of PCT (0.912), CRP (0.857) or WBC (0.777).

CONCLUSIONS

The ROC curve of the SIRS patient without infection and the sepsis patient showed that the presepsin concentration was a significantly sensitive indicator of sepsis and useful marker for the rapid diagnosis of sepsis.

Gram-positive and gram-negative bacterial toxins in sepsis: a brief review

Bacterial sepsis is a major cause of fatality worldwide. Sepsis is a multi-step process that involves an uncontrolled inflammatory response by the host cells that may result in multi organ failure and death. Both gram-negative and gram-positive bacteria play a major role in causing sepsis. These bacteria produce a range of virulence factors that enable them to escape the immune defenses and disseminate to remote organs, and toxins that interact with host cells via specific receptors on the cell surface and trigger a dysregulated immune response. Over the past decade, our understanding of toxins has markedly improved, allowing for new therapeutic strategies to be developed. This review summarizes some of these toxins and their role in sepsis.

In the absence of effector proteins, the Pseudomonas aeruginosa type three secretion system needle tip complex contributes to lung injury and systemic inflammatory responses

Herein we describe a pathogenic role for the Pseudomonas aeruginosa type three secretion system (T3SS) needle tip complex protein, PcrV, in causing lung endothelial injury. We first established a model in which P. aeruginosa wild type strain PA103 caused pneumonia-induced sepsis and distal organ dysfunction. Interestingly, a PA103 derivative strain lacking its two known secreted effectors, ExoU and ExoT [denoted PA103 (ΔU/ΔT)], also caused sepsis and modest distal organ injury whereas an isogenic PA103 strain lacking the T3SS needle tip complex assembly protein [denoted PA103 (ΔPcrV)] did not. PA103 (ΔU/ΔT) infection caused neutrophil influx into the lung parenchyma, lung endothelial injury, and distal organ injury (reminiscent of sepsis). In contrast, PA103 (ΔPcrV) infection caused nominal neutrophil infiltration and lung endothelial injury, but no distal organ injury. We further examined pathogenic mechanisms of the T3SS needle tip complex using cultured rat pulmonary microvascular endothelial cells (PMVECs) and revealed a two-phase, temporal nature of infection. At 5-hours post-inoculation (early phase infection), PA103 (ΔU/ΔT) elicited PMVEC barrier disruption via perturbation of the actin cytoskeleton and did so in a cell death-independent manner. Conversely, PA103 (ΔPcrV) infection did not elicit early phase PMVEC barrier disruption. At 24-hours post-inoculation (late phase infection), PA103 (ΔU/ΔT) induced PMVEC damage and death that displayed an apoptotic component. Although PA103 (ΔPcrV) infection induced late phase PMVEC damage and death, it did so to an attenuated extent. The PA103 (ΔU/ΔT) and PA103 (ΔPcrV) mutants grew at similar rates and were able to adhere equally to PMVECs post-inoculation indicating that the observed differences in damage and barrier disruption are likely attributable to T3SS needle tip complex-mediated pathogenic differences post host cell attachment. Together, these infection data suggest that the T3SS needle tip complex and/or another undefined secreted effector(s) are important determinants of P. aeruginosa pneumonia-induced lung endothelial barrier disruption.

[Express diagnostics of endotoxaemia during postoperative period in cardiac surgical patients]

Medical technologies development and recent approaches in management of patients with septic complications during the early postoperative period present new obstacles to the laboratory service. Endotoxin is a main agent in the systemic inflammatory cascade and plays important role in sepsis pathogenesis. Recent express methods of diagnostics allow determining blood activity of endotoxin during 30-50 min. 55 ICU patients with clinical and laboratory signs of systemic inflammatory response syndrome (SIRS) after cardiac surgery were studied in the single-center prospective research. Endotoxaemia was diagnosed by express tests. Level of endotoxaemia was assessed before and after sorption in 15 patients receiving complex intensive care with selective lipopolysaccharide (LPS) adsorption. Endotoxaemia level assessment allows to define indications for different programs of intensive care in time and to assess its efficiency. Test systems for assessment endotoxin level based on the principle of interaction antigen - antibody (EAA and MACH-endotox spp.) is a most efficient for express diagnostics of endotoxaemia.

DNAemia detection by multiplex PCR and biomarkers for infection in systemic inflammatory response syndrome patients

Fast and reliable assays to precisely define the nature of the infectious agents causing sepsis are eagerly anticipated. New molecular biology techniques are now available to define the presence of bacterial or fungal DNA within the bloodstream of sepsis patients. We have used a new technique (VYOO®) that allows the enrichment of microbial DNA before a multiplex polymerase chain reaction (PCR) for pathogen detection provided by SIRS-Lab (Jena, Germany). We analyzed 72 sepsis patients and 14 non-infectious systemic inflammatory response syndrome (SIRS) patients. Among the sepsis patients, 20 had a positive blood culture and 35 had a positive microbiology in other biological samples. Of these, 51.4% were positive using the VYOO® test. Among the sepsis patients with a negative microbiology and the non-infectious SIRS, 29.4% and 14.2% were positive with the VYOO® test, respectively. The concordance in bacterial identification between microbiology and the VYOO® test was 46.2%. This study demonstrates that these new technologies offer great hopes, but improvements are still needed.

Type 1 interferons suppress accelerated osteoclastogenesis and prevent loss of bone mass during systemic inflammatory responses to Pneumocystis lung infection

HIV infection causes loss of CD4(+) T cells and type 1 interferon (IFN)-producing and IFN-responsive dendritic cells, resulting in immunodeficiencies and susceptibility to opportunistic infections, such as Pneumocystis. Osteoporosis and bone marrow failure are additional unexplained complications in HIV-positive patients and patients with AIDS, respectively. We recently demonstrated that mice that lack lymphocytes and IFN a/b receptor (IFrag(-/-)) develop bone marrow failure after Pneumocystis lung infection, whereas lymphocyte-deficient, IFN α/β receptor-competent mice (RAG(-/-)) had normal hematopoiesis. Interestingly, infected IFrag(-/-) mice also exhibited bone fragility, suggesting loss of bone mass. We quantified bone changes and evaluated the potential connection between progressing bone fragility and bone marrow failure after Pneumocystis lung infection in IFrag(-/-) mice. We found that Pneumocystis infection accelerated osteoclastogenesis as bone marrow failure progressed. This finding was consistent with induction of osteoclastogenic factors, including receptor-activated nuclear factor-κB ligand and the proapoptotic factor tumor necrosis factor-related apoptosis-inducing ligand, in conjunction with their shared decoy receptor osteoprotegerin, in the bone marrow of infected IFrag(-/-) mice. Deregulation of this axis has also been observed in HIV-positive individuals. Biphosphonate treatment of IFrag(-/-) mice prevented bone loss and protected loss of hematopoietic precursor cells that maintained activity in vitro but did not prevent loss of mature neutrophils. Together, these data show that bone loss and bone marrow failure are partially linked, which suggests that the deregulation of the receptor-activated nuclear factor-κB ligand/osteoprotegerin/tumor necrosis factor-related apoptosis-inducing ligand axis may connect the two phenotypes in our model.

Cytokine profiles in sepsis have limited relevance for stratifying patients in the emergency department: a prospective observational study

INTRODUCTION

Morbidity, mortality and social cost of sepsis are high. Previous studies have suggested that individual cytokines levels could be used as sepsis markers. Therefore, we assessed whether the multiplex technology could identify useful cytokine profiles in Emergency Department (ED) patients.

METHODS

ED patients were included in a single tertiary-care center prospective study. Eligible patients were >18 years and met at least one of the following criteria: fever, suspected systemic infection, ≥ 2 systemic inflammatory response syndrome (SIRS) criteria, hypotension or shock. Multiplex cytokine measurements were performed on serum samples collected at inclusion. Associations between cytokine levels and sepsis were assessed using univariate and multivariate logistic regressions, principal component analysis (PCA) and agglomerative hierarchical clustering (AHC).

RESULTS

Among the 126 patients (71 men, 55 women; median age: 54 years [19-96 years]) included, 102 had SIRS (81%), 55 (44%) had severe sepsis and 10 (8%) had septic shock. Univariate analysis revealed weak associations between cytokine levels and sepsis. Multivariate analysis revealed independent association between sIL-2R (p = 0.01) and severe sepsis, as well as between sIL-2R (p = 0.04), IL-1β (p = 0.046), IL-8 (p = 0.02) and septic shock. However, neither PCA nor AHC distinguished profiles characteristic of sepsis.

CONCLUSIONS

Previous non-multiparametric studies might have reached inappropriate conclusions. Indeed, well-defined clinical conditions do not translate into particular cytokine profiles. Additional and larger trials are now required to validate the limited interest of expensive multiplex cytokine profiling for staging septic patients.

Early systemic inflammatory response in mice after a single oral gavage with live Escherichia coli is evidenced by increased TNF-alpha and nitric oxide production

Twenty-four female BALB/c mice were orally inoculated with 10(8) CFU Escherichia coli ATCC 25922 and euthanized 2.5, 7, 13 and 25 h post-inoculation. The levels of organ nitric oxide (NO) and plasma endotoxin, TNF-alpha and nitrite/nitrate (NO(x)) were compared to those found in sham-inoculated mice, to evaluate systemic host-response to a low-level oral exposure to Gram-negative bacteria. Organ bacterial culture and immunohistochemistry for iNOS were performed on lungs, liver, kidneys and brain from all mice. Organ NO and plasma TNF-alpha levels were higher in E. coli-inoculated animals, but no differences were detected in plasma endotoxin levels, NO(x) or iNOS immunostaining for any of the animal groups. Single oral gavage with live E. coli stimulates an early systemic immune response in clinically healthy mice as evidenced by increased plasma TNF-alpha and organ NO levels, but bacteremia and endotoxemia are not related to this inflammatory response.

[Chronic pancreatitis: microbe-intestinal tissue complex and systemic inflammatory response]

Today in Russian Federation, we observe significant growth of the chronic pancreatitis incidence with the depression of its therapy efficiency (more than 20% of the patients) and complications rate growth. In many respects given tendency is associated with the inefficiency of traditional medications combination in the context of inflammation process reduction, gut dysbiosis correction and chronic inflammation reaction depression. Present-day studies indicates, that the grade and character of inflammation in the pancreas depends on the pro- and anti-inflammatory cytokines balance, which is associated with the elevation of the pathogenic microbiota concentration and permeability of the gut. We estimate clinical efficacy of complex treatment regimen (PPI, spasmolytic, multienzyme and prebiotic therapy) in the patients with chronic pancreatitis and its effect on chronic system inflammation. We established that efficacy of modern complex treatment regimen depends on its influence on chronic system inflammation and that prebiotics addition potentiates correction of dysbiotic changes in the gut microbial-tissular complex and reduces grade of system inflammation.

[Phagocytic activity of neutrophils in conditions of experimental choleperitonitis]

In experiments on animals with choleperitonitis were signs of systemic inflammatory response syndrome, "rejuvenation" ofwbc as through the mobilization of neutrophils membrane pool and due to the activation of bone marrow reserve of granulocytes in response to the development of endogenous intoxication. The analysis of the results of the study also showed that animals with choleperitonitis have the change of the neutrophils functional state, which reflected in changes of their cytochemical profile, accompanied by a decrease in total activity and functional reserve of neutrophils, inhibition of nonspecific link of the immune system, manifested by a decrease of the neutrophils number, which are able to absorb and digest microbal cells.

Patterns of Gram-stained fecal flora as a quick diagnostic marker in patients with severe SIRS

BACKGROUND

The gut is an important target organ of injury during critically ill conditions. Although Gram staining is a common and quick method for identifying bacteria, its clinical application has not been fully evaluated in critically ill conditions.

AIMS

This study's aims were to identify patterns of Gram-stained fecal flora and compare them to cultured bacterial counts and to investigate the association between the patterns and septic complications in patients with severe systemic inflammatory response syndrome (SIRS).

METHODS

Fifty-two patients with SIRS were included whose Gram-stained fecal flora was classified into three patterns. In a diverse pattern, large numbers of multiple kinds of bacteria completely covered the field. In a single pattern, one specific kind of bacteria or fungi predominantly covered the field. In a depleted pattern, most bacteria were diminished in the field.

RESULTS

In the analysis of fecal flora, the numbers of total obligate anaerobes in the depleted pattern was significantly lower than those in the diverse pattern and single pattern (p < 0.05). The concentrations of total organic acids, acetic acid, and propionic acid in the depleted pattern were significantly lower than those in diverse pattern and single pattern (p < 0.05). Mortality due to multiple organ dysfunction syndrome for the single pattern (52%) and the depleted pattern (64%) was significantly higher than that for the diverse pattern (6%) (p < 0.05).

CONCLUSIONS

Gram-stained fecal flora can be classified into three patterns and are associated with both cultured bacterial counts and clinical information. Gram-stained fecal bacteria can be used as a quick bedside diagnostic marker for severe SIRS patients.

Systemic inflammatory response syndrome in home delivered neonates: a prospective observational study

OBJECTIVE

To determine the severity of systemic inflammatory response syndrome (SIRS) at admission, bacteriological profile, antibiotic sensitivity of pathogens and factors associated with fatality in home delivered neonates with sepsis.

METHODS

This was a prospective observational study conducted in the referral neonatal unit of a teaching hospital admitting extramural neonates. The subjects comprised of 80 home delivered neonates presenting with systemic inflammatory response syndrome at admission. Skin temperature, oxygen saturation, capillary refill time and blood sugar were recorded in all the neonates at admission. For Blood culture, blood collected by venipuncture was placed in a tryptic soy broth culture bottle. Serum TNF-α was measured by ELISA kit.

RESULTS

Early onset sepsis was seen in 27.5%. The commonest clinical feature in the study population was decreased oral acceptance (53.8%). The mean distance traveled to reach the hospital was 19 ± 3 km. At admission, acute physiological derangement in the form of abnormal skin temperature, oxygen saturation, perfusion and blood sugar was present in 53 neonates and 44% had more than one parameter deranged. Only 11% cases had early sepsis while the SIRS was well established in the rest. Klebsiella pneumoniae was the predominant bacteria isolated in 14 cases. Resistance of Klebsiella isolates to Ampicillin was 90% and to Gentamicin 57%. The fatality was higher in presence of advanced stages of SIRS at admission.

CONCLUSION

SIRS was well established in 89% cases at admission. Klebsiella resistant to antibiotics was the predominant etiological organism. Fatality was higher in culture positive sepsis and in those associated with meningitis and pneumonia.

Outer membrane vesicles derived from Escherichia coli induce systemic inflammatory response syndrome

Sepsis, characterized by a systemic inflammatory state that is usually related to Gram-negative bacterial infection, is a leading cause of death worldwide. Although the annual incidence of sepsis is still rising, the exact cause of Gram-negative bacteria-associated sepsis is not clear. Outer membrane vesicles (OMVs), constitutively secreted from Gram-negative bacteria, are nano-sized spherical bilayered proteolipids. Using a mouse model, we showed that intraperitoneal injection of OMVs derived from intestinal Escherichia coli induced lethality. Furthermore, OMVs induced host responses which resemble a clinically relevant condition like sepsis that was characterized by piloerection, eye exudates, hypothermia, tachypnea, leukopenia, disseminated intravascular coagulation, dysfunction of the lungs, hypotension, and systemic induction of tumor necrosis factor-alpha and interleukin-6. Our study revealed a previously unidentified causative microbial signal in the pathogenesis of sepsis, suggesting OMVs as a new therapeutic target to prevent and/or treat severe sepsis caused by Gram-negative bacterial infection.

[Clinical implication of stone culture in percutaneous nephrolithotomy]

OBJECTIVE

To evaluate the correlation between stone culture and SIRS, ascertain the clinical implication of stone culture in PCNL.

METHODS

Clinical data of 66 patients who underwent PCNL in our department were analyzed retrospectively. Eight risk factors including stone culture + drug sensitivity, urine culture + drug sensitivity, age, gender, prophylactic antibiotics, stone volume, operative time and the number of tract. Multiple statistics methods were used for analysis to evaluate the impact of SIRS, and compare the difference between stone culture and urine culture.

RESULTS

Univariate analysis and Multivariate logistic regression model showed that positive stone culture was the risk factor of SIRS (P < 0.05). Positive stone culture was found in 48.48% patients, which was higher than that of urine culture (30.30%). Fourteen patients (66.67%) of 21 postoperative SIRS patients were prescribed antibiotics according to the stone culture result. And all of them recovered unevenly without developing septic shock or MODS.

CONCLUSIONS

Positive stone culture is the important risk factor of post-PCNL SIRS. Stone culture is better than urine culture in directing postoperative antibiotics prescripsion and should be routinely used.

Relations among circulating monocytes, dendritic cells, and bacterial translocation in patients with intestinal obstruction

BACKGROUND

Little evidence is available regarding the relations among circulating monocytes, dendritic cells (DCs), and bacterial translocation (BT) in patients with intestinal obstruction.

METHODS

We investigated alterations in DCs in mesenteric lymph nodes (MLNs), circulating immune cells (white blood cell, lymphocyte, and monocyte counts), and BT to MLNs in 21 patients undergoing abdominal surgery because of intestinal obstruction. We also examined whether BT correlated with the development of perioperative systemic inflammatory response syndrome (SIRS) and postoperative septic complications.

RESULTS

BT subsequent to intestinal obstruction was observed in 7 (33%) patients. Preoperative circulating immune cell counts were significantly lower in BT-positive patients than those in BT-negative patients. The presence of preoperative SIRS was also significantly related to BT-positive status. A preoperative monocyte count <290/mm(3) was the best predictive factor for BT in MLNs during intestinal obstruction: sensitivity 85.7%; specificity 92.3%; positive and negative predictive values 85.7% and 92.9%, respectively. The area under the receiver operating characteristic curve was 0.944. The expression of S-100 protein-positive DCs in MLNs significantly increased in BT-positive patients.

CONCLUSIONS

A significant inverse correlation was observed between the circulating monocyte count and the ratio of DCs among all cells in MLNs (r(2)= 0.259). Postoperative septic complications were 3.3 times more common in BT-positive patients than in BT-negative patients. A significant increase in the expression of DCs in MLNs was observed in patients with BT subsequent to intestinal obstruction. Our findings suggested that a low monocyte count (<290 /mm(3)) and the presence of preoperative SIRS might be useful factors for predicting BT in patients with intestinal obstruction.

Does group B streptococcal infection contribute significantly to neonatal sepsis in Antigua and Barbuda?

Group B streptococcus is the most common cause of neonatal sepsis in the United States of America (USA). This study was undertaken to determine the contribution of group B streptococcus to neonatal septicaemia in Antigua and Barbuda. From 1994 to 2002, there were about 12,000 births, with 2500 Special Care Nursery admissions, 1100 (44%) with potential neonatal septicaemia. Blood cultures were done in 433/1100 (39%) and cerebrospinal fluid cultures in 52/1100 (5%). Positive cultures were seen in 41/433 (9.5%) with group B streptococcus in 1/41 (2.4%), streptococcus "species" in 3/41 (7.4%) and positive cerebrospinal fluid cultures were seen in 2/52 (one group B streptococcus) giving 5 per 12,000 or 0.4 cases per 1000 babies. Vaginal cultures from 1994 to 2002 revealed group B streptococcus in 14/163 (8.6%) of positive bacterial cultures. A sample of pregnant women from a private office had positive culture for group B streptococcus in 2/120 (1.7%). The prevalence rate of carriage (15 to 40%) and infection (1.7 to 4 per 1000 babies) was much higher in the USA in the same period Universal screening of mothers for group B streptococcus may not be as necessary or cost-effective in Antigua and Barbuda.

The intensity of the fetal inflammatory response in intraamniotic inflammation with and without microbial invasion of the amniotic cavity

OBJECTIVE

Intraamniotic inflammation is a risk factor for adverse pregnancy and neonatal outcome, regardless of the presence or absence of a positive amniotic fluid (AF) culture. The purpose of this study was to determine whether the intensity of a fetal inflammatory response (FIR) differs between cases of intraamniotic inflammation with microbiologically proven infection and cases with negative AF cultures.

STUDY DESIGN

The FIR was examined in 89 cases of women with preterm premature rupture of membranes who delivered singleton preterm newborn infants within 48 hours of amniocentesis. AF was cultured for aerobic and anaerobic bacteria and for genital mycoplasmas. AF white blood cell (WBC) count and matrix metalloproteinase-8 (MMP-8) determinations were performed to assess the presence of intraamniotic inflammation. Intraamniotic inflammation was defined as an elevated AF MMP-8 concentration (>23 ng/mL). The intensity of the FIR was determined by the umbilical cord plasma concentrations of C-reactive protein (CRP). Patients were divided into 3 groups according to the presence or absence of intraamniotic inflammation and AF culture results: group 1, without intraamniotic inflammation and with a negative AF culture (n = 28); group 2, with intraamniotic inflammation and with a negative AF culture (n = 26); group 3, with a positive AF culture (n = 35).

RESULTS

Neonates who were born to mothers with intraamniotic inflammation and negative AF cultures had a significantly higher median umbilical cord plasma CRP concentration than did those without intraamniotic inflammation and a negative AF culture (P < .005) but a significantly lower median cord plasma CRP concentration than did those with proven AF infection (P < .05). Patients with intraamniotic inflammation and a negative AF culture had significantly higher median AF MMP-8 concentrations and WBC count than did those without intraamniotic inflammation and a negative AF culture (P < .001). However, there was no significant difference in the median AF MMP-8 and WBC count between patients with intraamniotic inflammation and a negative AF culture and those with proven AF infection (MMP-8, P > .1, and WBC, P = .09).

CONCLUSION

Intraamniotic inflammation without documented AF infection is a risk factor for a systemic FIR. However, the magnitude of the FIR in those cases was lower than in those with documented AF infection.

[Sepsis and the theory of systemic inflammatory reaction is an attempt of clinicomorphological consensus]

The authors propose to put the 1991 US Consensus Conference criteria for sepsis into practice and research methodology. This will be helpful in reaching the consensus in definitions.

Antenatal infection/inflammation and fetal tissue injury

There is a clear association between antenatal infection/inflammation and preterm labour, with intrauterine infection complicating up to one third of preterm deliveries. In addition to this, there is now accumulating evidence that intrauterine infection and inflammation can lead to the development of a systemic inflammatory response in the fetus and subsequent tissue injury. The fetal inflammatory response is characterized by funisitis, high levels of pro-inflammatory cytokines in the amniotic fluid and cord blood, and systemic immune activation. This review discusses the evidence for this process and focuses on the clinical and experimental data supporting the hypothesis that these inflammatory processes contribute to brain and lung injury in the newborn.

Cytokine-Release Patterns in Elderly Patients with Systemic Inflammatory Response Syndrome

BACKGROUND

Information is scarce about the inflammatory responses to infection in elderly patients.

OBJECTIVE

To investigate the inflammatory pattern in elderly patients with systemic inflammatory response syndrome (SIRS).

METHODS

We assessed the value of pro-inflammatory cytokines (TNF-alpha, IL-6, IL-1beta) and C-reactive protein (CRP) in elderly patients with SIRS at the time of consultation in the emergency room and on the fourth day of hospitalization.

RESULTS

Of 100 patients with SIRS, 92 had a clinical suspicion of infection and 46 were microbiologically confirmed. Basal TNF-alpha and IL-6 levels were higher in patients with bacteremia (p < 0.001 and p = 0.017, respectively). Basal levels of TNF-alpha (p < 0.001) and fourth-day levels of CRP (p = 0.004), TNF-alpha (p < 0.001) and IL-6 (p = 0.002) had a positive correlation with the length of hospitalization. Higher IL-6 levels on the fourth day showed a correlation with mortality (p = 0.016), while the other cytokines and CRP did not show this association.

CONCLUSION

Febrile elderly patients showed an inflammatory response pattern to infection equivalent to that reported in younger patients. Despite some limitations of our study, among febrile elderly patients, pro-inflammatory cytokine levels can be good markers for evaluating the prognosis of infections.

[Sepsis in the critically-ill patient]

SIRS, sepsis, severe sepsis, and septic shock are complex syndromes ranging from early signs of infection to multiple organ dysfunction and shock. The reported incidence of sepsis is as high as 35% with mortality rates from 27% to 54% in sepsis and septic shock, respectively. Though aetiology and pathogenesis can vary significantly between septic patients, emphasis has been made to preserve sepsis as a clinical diagnosis ensuring high sensitivity. Since 2001 several new treatment strategies have been implemented, but early diagnosis, optimization of haemodynamics, rapid identification of pathogen and adequate antibiotic treatment are still of the highest importance.

Advanced age exacerbates the pulmonary inflammatory response after lipopolysaccharide exposure

OBJECTIVE

The aged population is at a higher risk of mortality as a result of complications of injury or infection, such as acute lung injury. The objective of this study was to analyze pulmonary inflammatory responses in young and aged mice after administration of lipopolysaccharide.

DESIGN

Prospective, controlled laboratory study.

SETTING

Animal resource facilities and research laboratory.

SUBJECTS

Young (2-3 months old) and aged (18-20 months old) female BALB/c mice.

INTERVENTIONS

Animals received intraperitoneal injection of lipopolysaccharide derived from Pseudomonas aeruginosa. Control mice received saline alone. After 24 hrs, mice were killed. Pulmonary neutrophil infiltration was assessed histologically and by myeloperoxidase activity. Pulmonary levels of the CXC chemokines, monocyte inflammatory protein-2 and KC, and cytokines, tumor necrosis factor-alpha and interleukin-1beta, were assessed by enzyme-linked immunosorbent assay.

MEASUREMENTS AND MAIN RESULTS

Lungs of aged mice given lipopolysaccharide showed a six-fold higher neutrophil infiltration and three-fold higher level of myeloperoxidase activity than lungs of young mice given lipopolysaccharide. Pulmonary levels of monocyte inflammatory protein-2 and KC were significantly higher in the lungs of aged mice given lipopolysaccharide, compared with younger mice. Levels of tumor necrosis factor-alpha and interleukin-1beta in the lung were analyzed as well. After lipopolysaccharide treatment, there was no difference in the level of tumor necrosis factor-alpha in lungs of young and aged animals, but interleukin-1beta was two-fold higher in the lungs of the aged group. These data suggest that at this time point, interleukin-1beta may contribute to the higher production of CXC chemokines observed in lungs of aged mice vs. young mice receiving lipopolysaccharide.

CONCLUSIONS

The hyperreactive systemic inflammatory response seen in aged individuals after lipopolysaccharide administration is accompanied by an exacerbated pulmonary inflammatory response, which may contribute to the higher mortality seen in the aged given an inflammatory insult.

Diagnostic value and prognostic implications of serum procalcitonin after cardiac surgery: a systematic review of the literature

Introduction

Systemic inflammatory response syndrome is common after surgery, and it can be difficult to discriminate between infection and inflammation. We performed a review of the literature with the aims of describing the evolution of serum procalcitonin (PCT) levels after uncomplicated cardiac surgery, characterising the role of PCT as a tool in discriminating infection, identifying the relation between PCT, organ failure, and severity of sepsis syndromes, and assessing the possible role of PCT in detection of postoperative complications and mortality.

Methods

We performed a search on MEDLINE using the keyword 'procalcitonin' crossed with 'cardiac surgery,' 'heart,' 'postoperative,' and 'transplantation.' Our search was limited to human studies published between January 1990 and June 2006.

Results

Uncomplicated cardiac surgery induces a postoperative increase in serum PCT levels. Peak PCT levels are reached within 24 hours postoperatively and return to normal levels within the first week. This increase seems to be dependent on the surgical procedure and on intraoperative events. Although PCT values reported in infected patients are generally higher than in non-infected patients after cardiac surgery, the cutoff point for discriminating infection ranges from 1 to 5 ng/ml, and the dynamics of PCT levels over time may be more important than absolute values. PCT is superior to C-reactive protein in discriminating infections in this setting. PCT levels are higher with increased severity of sepsis and the presence of organ dysfunction/failure and in patients with a poor outcome or in those who develop postoperative complications. PCT levels typically remain unchanged after acute rejection but increase markedly after bacterial and fungal infections. Systemic infections are associated with greater PCT elevation than is local infection. Viral infections are difficult to identify based on PCT measurements.

Conclusion

The dynamics of PCT levels, rather than absolute values, could be important in identifying patients with infectious complications after cardiac surgery. PCT is useful in differentiating acute graft rejection after heart and/or lung transplantation from bacterial and fungal infections. Further studies are needed to define cutoff points and to incorporate PCT levels in useful prediction models.

SIRS and group-B streptococcal sepsis in newborns: pathogenesis and perspectives in adjunctive therapy

Clinical signs of systemic inflammation and suspected systemic infection are common in neonatal medicine. Yet, causative infectious organisms can only infrequently be isolated. In previously healthy infants at low risk of sepsis, group B streptococcus (GBS) is the most common isolate. In vitro and in vivo data suggest that immune cells from newborn infants have impaired antimicrobial properties against GBS. In contrast large amounts of inflammatory mediators are formed upon GBS challenge and Toll-like receptors (TLR) are critical host molecules in this context. Thus, the immune balance tilts towards inflammation, SIRS and sepsis. Adjunctive therapy of neonatal sepsis needs to adjust the inflammatory response without further impairing bacterial clearance. This article summarises the pathophysiological events leading to sepsis and suggests molecular targets for adjunctive therapy.

Systemic inflammatory response syndrome in adult patients with nosocomial bloodstream infections due to enterococci

BACKGROUND

Enterococci are the third leading cause of nosocomial bloodstream infection (BSI). Vancomycin resistant enterococci are common and provide treatment challenges; however questions remain about VRE's pathogenicity and its direct clinical impact. This study analyzed the inflammatory response of Enterococcal BSI, contrasting infections from vancomycin-resistant and vancomycin-susceptible isolates.

METHODS

We performed a historical cohort study on 50 adults with enterococcal BSI to evaluate the associated systemic inflammatory response syndrome (SIRS) and mortality. We examined SIRS scores 2 days prior through 14 days after the first positive blood culture. Vancomycin resistant (n = 17) and susceptible infections (n = 33) were compared. Variables significant in univariate analysis were entered into a logistic regression model to determine the affect on mortality.

RESULTS

60% of BSI were caused by E. faecalis and 34% by E. faecium. 34% of the isolates were vancomycin resistant. Mean APACHE II (A2) score on the day of BSI was 16. Appropriate antimicrobials were begun within 24 hours in 52%. Septic shock occurred in 62% and severe sepsis in an additional 18%. Incidence of organ failure was as follows: respiratory 42%, renal 48%, hematologic 44%, hepatic 26%. Crude mortality was 48%. Progression to septic shock was associated with death (OR 14.9, p < .001). There was no difference in A2 scores on days -2, -1 and 0 between the VRE and VSE groups. Maximal SIR (severe sepsis, septic shock or death) was seen on day 2 for VSE BSI vs. day 8 for VRE. No significant difference was noted in the incidence of organ failure, 7-day or overall mortality between the two groups. Univariate analysis revealed that AP2>18 at BSI onset, and respiratory, cardiovascular, renal, hematologic and hepatic failure were associated with death, but time to appropriate therapy >24 hours, age, and infection due to VRE were not. Multivariate analysis revealed that hematologic (OR 8.4, p = .025) and cardiovascular failure (OR 7.5, p = 032) independently predicted death.

CONCLUSION

In patients with enterococcal BSI, (1) the incidence of septic shock and organ failure is high, (2) patients with VRE BSI are not more acutely ill prior to infection than those with VSE BSI, and (3) the development of hematologic or cardiovascular failure independently predicts death.

Leptospirosis presenting to an intensive care unit in provincial New Zealand: a case series and review

BACKGROUND

Leptospirosis is a disease associated with meat and agricultural workers which is endemic in New Zealand and Australia. During 2003-2005, it resulted in 207 hospitalisations in New Zealand. Hawke's Bay had the highest regional incidence in 2004 and 2005. While admission to intensive care units with leptospirosis is not infrequent, no such cases have been described in the literature from New Zealand, and only five from Australia.

METHODS

A chart review of all patients admitted to the intensive care/high dependency unit of a regional hospital in New Zealand with a diagnosis of leptospirosis from June 1999 to May 2005. Admission features, progress and diagnostic tests were collated, and APACHE II score on admission and daily Sequential Organ Failure Assessment (SOFA) score were calculated.

RESULTS

15 cases were identified; median age was 44 years (range, 27-62), and 13 were men. Myalgia, headache, nausea and vomiting were common; nine had conjunctival suffusion. Ten had hypotension and 14 had renal failure before ICU admission. Eleven received vasoactive support, and three received renal replacement therapy. Median length of ICU stay was 4 days (range, 2- 11; mean, 4 days). Median hospital stay was 6 days (range, 2-13; mean, 7.6 days). All patients survived and were discharged free of dialysis.

CONCLUSION

Leptospirosis presents to the ICU with a variety of signs and symptoms. Renal failure is the most common organ dysfunction requiring intensive care, and its severity is disproportionate to other signs of severe sepsis. Leptospirosis has a good prognosis with early management in an ICU.

Early apoptosis of monocytes contributes to the pathogenesis of systemic inflammatory response and of bacterial translocation in an experimental model of multiple trauma

The objective of this study was to investigate the occurrence of apoptosis of monocytes in an experimental model of multiple trauma and its probable correlation to bacterial translocation. Thirty-two rabbits were applied in three groups: A, controls; B, myotomy of the right femur; and C, myotomy and fracture of the right femur. Blood was sampled for the estimation of endotoxins [lipopolysaccharide (LPS)], tumour necrosis factor (TNF)-alpha, malondialdehyde (MDA) and isolation of peripheral blood mononuclear cells (PBMCs). PBMCs, derived after centrifugation over Ficoll, were incubated in flasks and apoptosis of non-adherent lymphocytes and adherent monocytes was estimated after staining for Annexin-V and flow cytometry. TNF-alpha of supernatants of cultured monocytes was also determined. Tissue segments were cultured after death. Median survival of groups A, B and C was > 14, > 14 and 9.00 days, respectively. Apoptosis of lymphocytes in group C was higher than group A at 2, 4 and 48 h and of monocytes in group C higher than group A at 2 and 4 hours. LPS in group C was higher than group A at 2, 4 and 48 h. Apoptosis of lymphocytes and monocytes was correlated positively with serum TNF-alpha and negatively with TNF-alpha of monocyte supernatants. Cultures of organ segments of group A were sterile. Pseudomonas aeruginosa was isolated from liver, lung and spleen in five animals in group B (45.45%) and in six in group C (54.54%). Early apoptosis of blood monocytes supervened after multiple trauma; the phenomenon was accompanied by apoptosis of blood lymphocytes and subsequent bacterial translocation.

Inflammatory response and clinical course of adult patients with nosocomial bloodstream infections caused by Candida spp

Candida spp. are an important cause of nosocomial bloodstream infection (nBSI) and are associated with significant morbidity and mortality. An historical cohort study was performed to evaluate the clinical course of 60 randomly selected adult patients with nBSIs caused by Candida spp. Patients with BSI caused by Candida albicans (n = 38) and non-albicans spp. (n = 22) were compared with 80 patients with Staphylococcus aureus BSI by serial systemic inflammatory response syndrome (SIRS) and APACHE II scores. The patients had a mean age of 52 years, the length of hospital stay before BSI averaged 21 days, and 57% of patients required care in an intensive care unit before BSI. The mean APACHE II score was 17 on the day of BSI, and 63% of BSIs were caused by C. albicans. Antifungal therapy within the first 24 h of onset of BSI was appropriate in 52% of patients. Septic shock occurred in 27% of patients, and severe sepsis in an additional 8%. Overall mortality was 42%, and the 7-day mortality rate was 27%. The inflammatory response and clinical course were similar for patients with BSI caused by C. albicans and non-albicans spp. In univariate analysis, progression to septic shock was correlated with high overall mortality, as was an APACHE II score >25 at the onset of BSI. In multivariate analysis, the APACHE II score at the onset of BSI and a systemic inflammatory response independently predicted overall mortality, but the 7-day mortality rate was only predicted independently by the APACHE II score. Clinical course and mortality in patients with Candida BSI were predicted by systemic inflammatory response and APACHE II score, but not by the infecting species.

Bacterial translocation as a source of Dacron-graft contamination in experimental aortic operation: the importance of controlling SIRS

BACKGROUND

Several experimental studies have shown the beneficial effects of nitric oxide (NO) in the modulation of the systemic inflammatory response syndrome (SIRS). Nitric oxide is involved in and affects almost all stages in the development of inflammation. We have attempted to ascertain whether the nitric oxide donor molsidomine prevents aortic graft contamination through control of the SIRS and a decrease in bacterial translocation (BT).

METHODS

Twenty-four mini-pigs were divided into 4 groups. The animals were subjected to suprarenal aortic/iliac cross-clamping (for 30 minutes) and by-pass with a Dacron-collagen prosthetic graft impregnated in rifampicin. Groups: 1) sham (aortic dissection alone); 2) cross-clamping and bypass; 3) hemorrhage of 40% of total blood volume before cross-clamping and by-pass; and 4) the same as in group 3 but also including the administration of the NO donor molsidomine (4 mg/kg) 5 minutes before cross-clamping.

VARIABLES

1) bacteriology of mesenteric lymph nodes (MLN), kidney, blood, and prosthesis; 2) serum TNF-alpha (ELISA); and 3) iNOS expression in kidney and liver (Western blot).

RESULTS

Aortic cross-clamping with or without hemorrhage was associated with BT in 80% and 100% of the animals, respectively. About 86% of the bacteria isolated in the graft were also present in MLN. This contamination coincided with an increase in TNF-alpha and with a greater expression of iNOS. Molsidomine administration decreased TNF-alpha and iNOS, decreased BT (from 100% to 20% of the animals), and decreased graft contamination (from 83% to 20%).

CONCLUSIONS

The present model induces high levels of BT and SIRS, both acted as sources of contamination for the implanted Dacron graft. Molsidomine administration decreased the presence of bacteria in the graft by controlling BT and modulating SIRS.

Systemic Inflammatory Response Syndrome in Nosocomial Bloodstream Infections with Pseudomonas aeruginosa and Enterococcus Species: Comparison of Elderly and Nonelderly Patients

OBJECTIVES

To determine whether the systemic inflammatory response syndrome (SIRS), clinical course, and outcome of monomicrobial nosocomial bloodstream infection (BSI) due to Pseudomonas aeruginosa or Enterococcus spp. is different in elderly patients than in younger patients.

DESIGN

Historical cohort study.

SETTING

An 820-bed tertiary care facility.

PARTICIPANTS

One hundred twenty-seven adults with P. aeruginosa or enterococcal BSI.

MEASUREMENTS

SIRS scores were determined 2 days before the first positive blood culture through 14 days afterwards. Elderly patients (> or =65, n=37) were compared with nonelderly patients (<65, n=90). Variables significant for predicting mortality in univariate analysis were entered into a logistic regression model.

RESULTS

No difference in SIRS was detected between the two groups. No significant difference was noted in the incidence of organ failure, 7-day mortality, or overall mortality between the two groups. Univariate analysis revealed that Acute Physiology And Chronic Health Evaluation (APACHE) II score of 15 or greater at BSI onset; adjusted APACHE II score (points for age excluded) of 15 or greater at BSI onset; and respiratory, cardiovascular, renal, hematological, and hepatic failure were predictors of mortality. Age, sex, use of empirical antimicrobial therapy, and infection with imipenem-resistant P. aeruginosa or vancomycin-resistant enterococci did not predict mortality. Multivariate analysis revealed that hematological failure (odds ratio (OR)=8.1, 95% confidence interval (CI)=2.78-23.47), cardiovascular failure (OR=4.7, 95% CI=1.69-13.10), and adjusted APACHE II > or = 15 at BSI onset (OR=3.1, 95% CI=1.12-8.81) independently predicted death.

CONCLUSION

Elderly patients did not differ from nonelderly patients with respect to severity of illness before or at the time of BSI. Elderly patients with pseudomonal or enterococcal BSIs did not have a greater mortality than nonelderly patients.

[Systemic inflammation after operations on the open heart: significance of a microbial factor]

The given review of the literature discusses, from the present standpoints, the pathogenetic, clinical, and diagnostic aspects of a systemic inflammatory reaction developing during cardiac surgery under extracorporeal circulation. There is evidence that endogenous infection is of importance in developing systemic inflammation during cardiosurgical interventions. Current approaches to the early diagnosis of systemic bacterial inflammation, by applying the procalcitonin test and the chromatographic mass-chromatographic technique are proposed. The prevention of systemic inflammation and its sequels is considered.