Sepsis severe or septic shock: outcome according to immune status and immunodeficiency profile

Clinical features and prognostic factors of early-onset sepsis: a 7.5-year experience in one neonatal intensive care unit

Purpose

In this study, we investigated the clinical features and prognostic factors of early-onset sepsis (EOS) in neonatal intensive care unit (NICU) patients.

Methods

A retrospective analysis was conducted on medical records from January 2010 to June 2017 (7.5 years) of a university hospital NICU.

Results

There were 45 cases of EOS (1.2%) in 3,862 infants. The most common pathogen responsible for EOS was group B Streptococcus (GBS), implicated in 10 cases (22.2%), followed by Escherichia coli, implicated in 9 cases (20%). The frequency of gram-positive sepsis was higher in term than in preterm infants, whereas the rate of gram-negative infection was higher in preterm than in term infants (P<0.05). The overall mortality was 37.8% (17 of 45), and 47% of deaths occurred within the first 3 days of infection. There were significant differences in terms of gestational age (26.8 weeks vs. 35.1 weeks) and birth weight (957 g vs. 2,520 g) between the death and survival groups. After adjustments based on the difference in gestational age and birth weight between the 2 groups, gram-negative pathogens (odds ratio [OR], 42; 95% confidence interval [CI], 1.4–1,281.8) and some clinical findings, such as neutropenia (OR, 46; 95% CI, 1.3–1,628.7) and decreased activity (OR, 34; 95% CI, 1.8–633.4), were found to be associated with fatality.

Conclusion

The common pathogens found to be responsible for EOS in NICU patients are GBS and E. coli. Gram-negative bacterial infections, decreased activity in the early phase of infection, and neutropenia were associated with poor outcomes.

Hospital Volume of Immunosuppressed Patients with Sepsis and Sepsis Mortality

RATIONALE

Immunosuppressive medical conditions are risk factors for mortality from severe infections. It is unknown whether hospital characteristics affect this risk.

OBJECTIVES

To determine whether the odds of death for an immunosuppressed patient with sepsis relative to a nonimmunosuppressed patient with sepsis varies according to the hospital's yearly case volume of immunosuppressed patients with sepsis.

METHODS

Patients with sepsis at hospitals in the Vizient database were characterized as immunosuppressed or not immunosuppressed on the basis of diagnosis codes and medication use. Hospitals were grouped into quartiles based on their average volumes of immunosuppressed patients with sepsis per year. Multilevel logistic regression with clustering of patients by hospital was used to determine whether the odds of in-hospital death from sepsis owing to a suppressed immune state varied by hospital quartile.

RESULTS

There were 350,183 patients with sepsis at 60 hospitals in the Vizient database from 2010 to 2012. Immunosuppressed patients with sepsis at the 15 hospitals in the lowest quartile (64 to 224 immunosuppressed patients with sepsis per year) had an increased odds of in-hospital death relative to nonimmunosuppressed patients with sepsis at these hospitals (adjusted odds ratio, 1.38; 95% confidence interval, 1.27-1.50; P < 0.001). The odds of in-hospital death for immunosuppressed patients with sepsis relative to nonimmunosuppressed patients with sepsis was similar for patients at hospitals in the second, third, and fourth quartiles (225 to 1,056 immunosuppressed patients with sepsis per year). The adjusted odds of death from sepsis owing to a suppressed immune state of 1.21 (95% confidence interval, 1.18-1.25; P < 0.001) for patients at these 45 hospitals was significantly less than for patients at the 15 hospitals in the lowest quartile (P = 0.004 for difference).

CONCLUSIONS

The risk of death from sepsis owing to a suppressed immune state was greatest at hospitals with the lowest volume of immunosuppressed patients with sepsis. Further study is needed to determine whether this finding is related to differences in patient characteristics or in care delivery at hospitals with different amounts of exposure to immunosuppressed patients.

Improving outcome of sepsis on the ward: introducing the 'Sepsis Six' bundle

BACKGROUND

The Sepsis Six bundle is designed to facilitate early intervention with three diagnostic and three therapeutic steps to be delivered within 1 h to patients with suspected sepsis.

AIMS AND OBJECTIVES

To investigate the effects of delivering the 'Sepsis Six' bundle by the Critical Care Outreach team on patient outcomes.

DESIGN

In a prospective observational study, all adult patients on the general wards from June 2012 to January 2014 with sepsis who were screened and treated by the Critical Care Outreach team were included.

METHODS

The main outcome measure was the change in National Early Warning Score following the delivery of the Sepsis Six bundle within 24 h. Secondary outcomes were 90-day mortality and overall bundle compliance.

RESULTS

A total of 207 patients were included in the analysis. Overall bundle compliance was 84%. National Early Warning Scores decreased significantly 24 h after administering the Sepsis Six, from 7·4 ± 2·6 to 3·1 ± 2·4 (p < 0·001). The distribution of the National Early Warning Score changed significantly. Mortality was lower at 90 days when patients who presented with signs of sepsis within 48 h of hospital admission were compared with those who presented with signs of sepsis after 48 h of hospital admission (14·5% versus 35·4% p < 0·03) despite similar baseline physiological variables.

CONCLUSIONS

We found better outcomes after the administration of Sepsis Six. Reliable delivery of the bundle, defined as 80% of patients receiving the standard of care, is achievable, and our quality improvement data suggest that it is likely to be sustainable in our environment.

RELEVANCE TO CLINICAL PRACTICE

Sepsis Six can reduce physiological impairment, monitored by the National Early Warning Scores. Consistent delivery of the bundle can lead to better patient outcomes.

The Yin and Yang of Tyrosine Kinase Inhibition During Experimental Polymicrobial Sepsis

Neutrophils are the first cells of our immune system to arrive at the site of inflammation. They release cytokines, e.g., chemokines, to attract further immune cells, but also actively start to phagocytose and kill pathogens. In the case of sepsis, this tightly regulated host defense mechanism can become uncontrolled and hyperactive resulting in severe organ damage. Currently, no effective therapy is available to fight sepsis; therefore, novel treatment targets that could prevent excessive inflammatory responses are warranted. Src Family tyrosine Kinases (SFK), a group of tyrosine kinases, have been shown to play a major role in regulating immune cell recruitment and host defense. Leukocytes with SFK depletion display severe spreading and migration defects along with reduced cytokine production. Thus, we investigated the effects of dasatinib, a tyrosine kinase inhibitor, with a strong inhibitory capacity on SFKs during sterile inflammation and polymicrobial sepsis in mice. We found that dasatinib-treated mice displayed diminished leukocyte adhesion and extravasation in tumor necrosis factor-α-stimulated cremaster muscle venules in vivo. In polymicrobial sepsis, sepsis severity, organ damage, and clinical outcome improved in a dose-dependent fashion pointing toward an optimal therapeutic window for dasatinib dosage during polymicrobial sepsis. Dasatinib treatment may, therefore, provide a balanced immune response by preventing an overshooting inflammatory reaction on the one side and bacterial overgrowth on the other side.

Distinct T-helper cell responses to Staphylococcus aureus bacteremia reflect immunologic comorbidities and correlate with mortality

BACKGROUND

The dysregulated host immune response that defines sepsis varies as a function of both the immune status of the host and the distinct nature of the pathogen. The degree to which immunocompromising comorbidities or immunosuppressive medications affect the immune response to infection is poorly understood because these patients are often excluded from studies about septic immunity. The objectives of this study were to determine the immune response to a single pathogen (Staphylococcus aureus) among a diverse case mix of patients and to determine whether comorbidities affect immune and clinical outcomes.

METHODS

Blood samples were drawn from 95 adult inpatients at multiple time points after the first positive S. aureus blood culture. Cox proportional hazards modeling was used to determine the associations between admission neutrophil counts, admission lymphocyte counts, cytokine levels, and 90-day mortality. A nested case-control flow cytometric analysis was conducted to determine T-helper type 1 (Th1), Th2, Th17, and regulatory T-cell (Treg) subsets among a subgroup of 28 patients. In a secondary analysis, we categorized patients as either having immunocompromising disorders (human immunodeficiency virus and hematologic malignancies), receiving immunosuppressive medications, or being not immunocompromised.

RESULTS

Higher neutrophil-to-lymphocyte count ratios and higher Th17 cytokine responses relative to Th1 cytokine responses early after infection were independently associated with mortality and did not depend on the immune state of the patient (HR 1.93, 95% CI 1.17-3.17, p = 0.01; and HR 1.13, 95% CI 1.01-1.27, p = 0.03, respectively). On the basis of flow cytometric analysis of CD4 T-helper subsets, an increasing Th17/Treg response over the course of the infection was most strongly associated with increased mortality (HR 4.41, 95% CI 1.69-11.5, p < 0.01). This type of immune response was most common among patients who were not immunocompromised. In contrast, among immunocompromised patients who died, a decreasing Th1/Treg response was most common.

CONCLUSIONS

The association of both increased Th17 responses and increased neutrophil counts relative to lymphocyte counts with mortality suggests that an overwhelming inflammatory response is detrimental. However, the differential responses of patients according to immune state suggest that immune status is an important clinical indicator that should be accounted for in the management of septic patients, as well as in the development of novel immunomodulatory therapies.

Evaluation of a novel 5-group classification system of sepsis by vasopressor use and initial serum lactate in the emergency department

Prognostication in sepsis is limited by disease heterogeneity, and measures to risk-stratify patients in the proximal phases of care lack simplicity and accuracy. Hyperlactatemia and vasopressor dependence are easily identifiable risk factors for poor outcomes. This study compares incidence and hospital outcomes in sepsis based on initial serum lactate level and vasopressor use in the emergency department (ED). In a retrospective analysis of a prospectively identified dual-center ED registry, patients with sepsis were categorized by ED vasopressor use and initial serum lactate level. Vasopressor-dependent patients were categorized as dysoxic shock (lactate >4.0 mmol/L) and vasoplegic shock (≤4.0 mmol/L). Patients not requiring vasopressors were categorized as cryptic shock major (lactate >4.0 mmol/L), cryptic shock minor (>2.0 and ≤4.0 mmol/L), and sepsis without lactate elevation (≤2.0 mmol/L). Of 446 patients included, 4.9% (n = 22) presented in dysoxic shock, 11.7% (n = 52) in vasoplegic shock, 12.1% (n = 54) in cryptic shock major, 30.9% (n = 138) in cryptic shock minor, and 40.4% (n = 180) in sepsis without lactate elevation. Group mortality rates at 28 days were 50.0, 21.1, 18.5, 12.3, and 7.2%, respectively. After adjusting for potential confounders, odds ratios for mortality at 28 days were 15.1 for dysoxic shock, 3.6 for vasoplegic shock, 3.8 for cryptic shock major, and 1.9 for cryptic shock minor, when compared to sepsis without lactate elevation. Lactate elevation is associated with increased mortality in both vasopressor dependent and normotensive infected patients presenting to the emergency department (ED). Cryptic shock mortality (normotension + lactate >4 mmol/L) is equivalent to vasoplegic shock mortality (vasopressor requirement + lactate <4 mmol/L) in our population. The odds of normotensive, infected patients decompensating is three to fourfold higher with hyperlactemia. The proposed Sepsis-3 definitions exclude an entire group of high-risk ED patients. A simple classification in the ED by vasopressor requirement and initial lactate level may identify high-risk subgroups of sepsis. This study may inform prognostication and triage decisions in the proximal phases of care.

Outcomes in adult critically ill cancer patients with and without neutropenia: a systematic review and meta-analysis of the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH)

PURPOSE

Whether neutropenia has an impact on the mortality of critically ill cancer patients remains controversial, yet it is widely used as an admission criterion and prognostic factor.

METHODS

Systematic review and meta-analysis. Studies on adult cancer patients and intensive care units were searched on PubMed and Cochrane databases (2005-2015). Summary estimates of mortality risk differences were calculated using the random-effects model.

RESULTS

Among the 1,528 citations identified, 38 studies reporting on 6,054 patients (2,097 neutropenic patients) were included. Median mortality across the studies was 54% [45–64], with unadjusted mortality in neutropenic and non-neutropenic critically ill patients of 60% [53–74] and 47% [41–68], respectively. Overall, neutropenia was associated with a 10% increased mortality risk (6%-14%; I² = 50%). The admission period was not associated with how neutropenia affected mortality. Mortality significantly dropped throughout the study decade [−11% (−13.5 to −8.4)]. This mortality drop was observed in non-neutropenic patients [−12.1% (−15.2 to −9.0)] but not in neutropenic patients [−3.8% (−8.1 to +5.6)].

Sensitivity analyses disclosed no differences in underlying malignancy, mechanical ventilation use, or Granulocyte-colony stimulating factor use. Seven studies allowed the adjustment of severity results (1,350 patients). Although pooled risk difference estimates were similar to non-adjusted results, there was no significant impact of neutropenia on mortality (risk difference of mortality, 9%; 95% CI, −15 to +33)

CONCLUSION

Although the unadjusted mortality of neutropenic patients was 11% higher, this effect disappeared when adjusted for severity. Therefore, when cancer patients become critically ill, neutropenia cannot be considered as a decision-making criterion.

Epidemiology and Outcomes

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

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation

Background:

Increased left ventricular afterload during peripheral venoarterial-extracorporeal membrane oxygenation (VA-ECMO) support frequently causes hydrostatic pulmonary oedema. Because physiological studies demonstrated left ventricular afterload decrease during VA-ECMO assistance combined with the intra-aortic balloon pump (IABP), we progressively changed our standard practice systematically to associate an IABP with VA-ECMO. This study aimed to evaluate IABP efficacy in preventing pulmonary oedema in VA-ECMO-assisted patients.

Methods:

A retrospective single-centre study.

Results:

Among 259 VA-ECMO patients included, 104 received IABP. Weinberg radiological score-assessed pulmonary oedema was significantly lower in IABP+ than IABP– patients at all times after ECMO implantation. This protection against pulmonary oedema persisted when death and switching to central ECMO were used as competing risks (subhazard ratio 0.49, 95% confidence interval (CI) 0.33–0.75; P<0.001). Multivariable analysis retained IABP as being independently associated with a lower risk of radiological pulmonary oedema (odds ratio (OR) 0.4, 95% CI 0.2–0.7; P=0.001) and a trend towards lower mortality (OR 0.54, 95% CI 0.29–1.01; P=0.06). Finally, the time on ECMO free from mechanical ventilation increased in IABP+ patients (2.2±4.3 vs. 0.7±2.0 days; P=0.0003). Less frequent pulmonary oedema and more days off mechanical ventilation were also confirmed in 126 highly comparable IABP+ and IABP– patients, propensity score matched for receiving an IABP.

Conclusions:

Associating an IABP with peripheral VA-ECMO was independently associated with a lower frequency of hydrostatic pulmonary oedema and more days off mechanical ventilation under ECMO.

Validation of a Method to Identify Immunocompromised Patients with Severe Sepsis in Administrative Databases

RATIONALE

Immunocompromised patients are at high risk for developing severe sepsis. Currently, there are no validated strategies for identifying this group of patients in large administrative databases.

OBJECTIVES

We set out to define and validate a method that could be used to identify immunocompromised patients with severe sepsis in administrative databases.

METHODS

Patients were categorized as immunocompromised based on the presence of International Classification of Diseases, 9th revision discharge diagnosis codes and medication data. We validated this strategy by comparing the discriminatory ability of the search algorithm to that of manual chart review.

MEASUREMENTS AND MAIN RESULTS

We identified 4,438 patients at a single academic center with severe sepsis using a definition applied to administrative data described by Angus and colleagues. There were 1,185 (26.7%) who were categorized as immunocompromised based on our novel administrative data search strategy. Compared with identification by medical record review, the new administrative data search strategy had positive and negative predictive values of 94.4% (95% confidence interval [CI], 88.8-97.7%) and 94.3% (95% CI, 91.0-96.6%). The sensitivity and specificity were 87.4% (95% CI, 80.6-92.5%) and 97.6% (95% CI, 95.0-99.9%).

CONCLUSIONS

Patients who are immunosuppressed are a large subgroup of those with severe sepsis. Following its validation as a search strategy using other large databases, and its adaptation for International Classification of Diseases, 10th revision, this novel method may allow researchers to account for a patient's immune state when examining outcomes.

Impact of HIV infection on the presentation, outcome and host response in patients admitted to the intensive care unit with sepsis; a case control study

Background

Sepsis is a prominent reason for intensive care unit (ICU) admission in patients with HIV. We aimed to investigate the impact of HIV infection on presentation, outcome and host response in sepsis.

Methods

We performed a prospective observational study in the ICUs of two tertiary hospitals. For the current analyses, we selected all patients diagnosed with sepsis within 24 hours after admission. Host response biomarkers were analyzed in a more homogeneous subgroup of admissions involving HIV-positive patients with pneumosepsis, matched to admissions of HIV-negative patients for age, gender and race. Matching was done by nearest neighbor matching with R package “MatchIt”.

Results

We analyzed 2251 sepsis admissions including 41 (1.8 %) with HIV infection (32 unique patients). HIV-positive patients were younger and admission of HIV-positive patients more frequently involved pneumonia (73.2 % versus 48.8 % of admissions of HIV-negative patients, P = 0.004). Disease severity and mortality up to one year after admission did not differ according to HIV status. Furthermore, sequential plasma levels of host response biomarkers, providing insight into activation of the cytokine network, the vascular endothelium and the coagulation system, were largely similar in matched admissions of HIV-positive and HIV-negative patients with pneumosepsis.

Conclusions

Sepsis is more often caused by pneumonia in HIV-positive patients. HIV infection has little impact on the disease severity, mortality and host response during sepsis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1469-0) contains supplementary material, which is available to authorized users.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

Severe infections in neutropenic patients

PURPOSE OF REVIEW

Severe infections in neutropenic patients can rapidly progress to septic shock and multiorgan failure with a high associated mortality. In this article we discuss current practice, emerging trends and controversies, including the prophylactic and empiric use of antimicrobial therapy, and advances in cellular and immunotherapy.

RECENT FINDINGS

Neutropenia is no longer a consistent factor predicting poor outcome in haematological patients admitted to the ICU. Severe infections in neutropenic patients are often polymicrobial, and pathogen resistance remains a challenge. Invasive fungal infection is still predictive of poor outcome. There has been a rapid expansion in the diagnostics and treatment modalities available for patients with invasive fungal infection. Use of growth factors, polyvalent immunoglobulin, and cellular therapy appear to be of value in certain groups of patients. There is a move away from the use of noninvasive ventilation and the use of high-flow nasal oxygen therapy is one of a number of novel respiratory support strategies that is yet to be evaluated in this patient population.

SUMMARY

Translation of current advances in antimicrobial, cellular and immunotherapy, and diagnostics to aid clinical management by the bedside is important in reducing morbidity and mortality for neutropenic patients with severe infection.

Neutropenic sepsis is associated with distinct clinical and biological characteristics: a cohort study of severe sepsis

Background

Immunocompromised patients who develop sepsis while neutropenic are at high risk for morbidity and mortality; however, it is unknown if neutropenic sepsis is associated with distinct clinical and biological characteristics.

Methods

We conducted a prospective cohort study of patients admitted to the medical intensive care unit of an academic medical center with severe sepsis. Patients were followed for the development of acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and mortality. Plasma proteins, representing the host inflammatory response, anti-inflammatory response, and endothelial leak were measured in 30 % of subjects. Clinical characteristics and plasma protein concentrations of patients with neutropenia at enrollment were compared to patients without neutropenia.

Results

Of 797 subjects enrolled, 103 (13 %) were neutropenic at ICU admission. The neutropenic subjects were more often in shock, admitted from the hospital ward, had higher APACHE III scores, and more likely bacteremic. Neutropenia was an independent risk factor for AKI (RR 1.28; 95 % CI 1.04, 1.57; p = 0.03), but not ARDS (RR 0.90; 95 % CI 0.70, 1.17; p = 0.42) or 30-day mortality (RR 1.05; 95 % CI 0.85, 1.31; p = 0.65). Neutropenic subjects had higher plasma interleukin (IL)-6 (457 vs. 249 pg/ml; p = 0.03), IL-8 (581 vs. 94 pg/ml; p <0.001), and granulocyte colony-stimulating factor (G-CSF) (3624 vs. 99 pg/ml; p <0.001). Angiopoietin-2 and IL-1 receptor antagonist concentrations did not differ between groups.

Conclusions

Neutropenic sepsis is associated with a higher AKI risk and concentrations of inflammatory mediators IL-6, IL-8, and G-CSF relative to non-neutropenic patients. These differences may have implications for future therapies targeting neutropenic sepsis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1398-y) contains supplementary material, which is available to authorized users.

Characteristics and Outcome of Patients With AIDS in Dutch ICUs Between 1997 and 2014

OBJECTIVE

Knowledge on characteristics and outcome of ICU patients with AIDS is highly limited. We aimed to determine the main reasons for admission and outcome in ICU patients with AIDS and trends over time therein.

DESIGN

A retrospective study within the Dutch National Intensive Care Evaluation registry.

SETTING

Dutch ICUs.

PATIENTS

We used data collected between 1997 and 2014. Characteristics of patients with AIDS were compared with ICU patients without AIDS, matched for age, sex, admission type, and admission year. Joinpoint regression analysis was applied to study trends over time.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 1,127 patients with AIDS and 4,479 matched controls. The main admission diagnoses of patients with AIDS were respiratory infection (28.6%) and sepsis (16.9%), which were less common in controls (7.7% and 7.5%, respectively; both p < 0.0001). Patients with AIDS had increased severity of illness and in-hospital mortality (28.2% vs 17.8%; p < 0.0001) compared with controls, which was associated with a higher rate of infections at admission in patients with AIDS (58.4% vs 25.5%). Over time, the proportion of patients with AIDS admitted with an infection decreased (75% in 1999 to 56% in 2013). Mortality declined in patients with AIDS (39% in 1999 to 16% in 2013), both in patients with or without an infection. Mortality also declined in matched controls without AIDS, but to a lesser extent.

CONCLUSION

Infections are still the main reason for ICU admission in patients with AIDS, but their prevalence is declining. Outcome of patients with AIDS continued to improve during a time of widespread availability of combination antiretroviral therapy, and mortality is reaching levels similar to ICU patients without AIDS.

The utility of initial procalcitonin and procalcitonin clearance for prediction of bacterial infection and outcome in critically ill patients with autoimmune diseases: a prospective observational study

Background

The diagnostic value of procalcitonin (PCT) for patients with autoimmune diseases (AID) remains controversial and few studies focused on ICU patients. We sought to determine its diagnostic and prognostic values in this clowd.

Methods

A prospective observational study was conducted in AID patients admitted to the ICU. Serum PCT levels were measured on ICU admission and subsequently at days 1, 3, 5 and 7, and peak PCT levels within 24 h (PCT_peak) were analyzed the utility for bacterial infection. The relationship of PCT_peak and SOFA score and severity of sepsis was performed correlation analysis. The change of PCT over time reflected as PCT clearance was compared to ICU 28-day mortality.

Results

One hundred twelve patients were divided into bacterial infection group (group I, n = 54) and nonbacterial condition group (group II, n = 58). The median PCTpeak (range, μg/L) was higher in the group I than that in the group II (1.95 [0.38–37.56] vs. 0.64 [0.05–7.83], p = 0.002). PCTpeak had the best single predictor of bacterial infection (area under the curve [AUC], 0.902, p < 0.001) with a sensitivity of 79.6 % and a specificity of 89.6 % at the threshold of 0.94 μg/L. PCTpeak was also positive correlation with severity of sepsis (r = 0.731, p = 0.002), but its correlation with SOFA score was only found in subjects with bacterial infection (r = 0.798, p < 0.001). Importantly, the 5-day PCT clearance (PCTc-d5), rather than absolute PCT values, could earlier discriminate survivors (n = 73) from nonsurvivors (n = 39) (68.8 ± 9.8 vs. 21.8 ± 17.5 %, p < 0.001, respectively). PCTc-d5 < 50 % was an independent predictor of mortality (odds ratio 5.1, 95 % confidence interval 3.5 to 7.5; p = 0.001).

Conclusions

In critically ill patients with AID, elevated PCT levels are valuable for bacterial infection and are significantly positive correlation with the septic severity. Five-day PCT clearance may provide independent prognostic information. Larger, prospective trials are warranted to confirm the benefit.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-015-0122-9) contains supplementary material, which is available to authorized users.

Timing and causes of death in septic shock

Background

Most studies about septic shock report a crude mortality rate that neither distinguishes between early and late deaths nor addresses the direct causes of death. We herein aimed to determine the modalities of death in septic shock.

Methods

This was a 6-year (2008–2013) monocenter retrospective study. All consecutive patients diagnosed for septic shock within the first 48 h of intensive care unit (ICU) admission were included. Early and late deaths were defined as occurring within or after 3 days following ICU admission, respectively. The main cause of death in the ICU was determined from medical files. A multinomial logistic regression analysis using the status alive as the reference category was performed to identify the prognostic factors associated with early and late deaths.

Results

Five hundred forty-three patients were included, with a mean age of 66 ± 15 years and a high proportion (67 %) of comorbidities. The in-ICU and in-hospital mortality rates were 37.2 and 45 %, respectively. Deaths occurred early for 78 (32 %) and later on for 166 (68 %) patients in the ICU (n = 124) or in the hospital (n = 42). Early deaths were mainly attributable to intractable multiple organ failure related to the primary infection (82 %) and to mesenteric ischemia (6.4 %). In-ICU late deaths were directly related to end-of-life decisions in 29 % of patients and otherwise mostly related to ICU-acquired complications, including nosocomial infections (20.4 %) and mesenteric ischemia (16.6 %). Independent determinants of early death were age, malignancy, diabetes mellitus, no pathogen identification, and initial severity. Among 3-day survivors, independent risk factors for late death were age, cirrhosis, no pathogen identification, and previous corticosteroid treatment.

Conclusions

Our study provides a comprehensive assessment of septic shock-related deaths. Identification of risk factors of early and late deaths may determine differential prognostic patterns.