Severe sepsis and septic shock in the elderly: An overview

Transient receptor potential ankyrin 1 protects against sepsis-induced kidney injury by modulating mitochondrial biogenesis and mitophagy

This study was undertaken to investigate the cytoprotective role of transient receptor potential ankyrin 1 (TRPA1) in sepsis-induced kidney injury. The Cecal ligation and puncture (CLP) was employed to induce septic kidney injury in C57BL/6 mice. Six hours before CLP or a sham procedure, mice were injected intraperitoneally with 10 mg/kg hemin or 30 mg/kg of the TRPA1 antagonist A-967079. Our study showed that mice treated with A-967079 exhibited less sepsis-induced mortality and kidney injury compared with those in the sham group. Moreover, A-967079 prevented multiple organ dysfunction, pathological changes, and increased secretion of in proinflammatory cytokines. In addition, A-967079 decreased the levels of mitochondrial lipid peroxidation and mitochondrial dysfunction in kidney tissues. The protein levels of mitochondrial biogenesis markers, including Sirt1, nuclear respiratory factor 1, and mitochondrial transcription factor A, were decreased in the A-967079 treatment group. Additionally, A-967079 treatment attenuated mitochondrial mitophagy. The levels of PTEN-induced putative kinase 1 increased and parkin levels decreased compared to the untreated CLP group. Our findings suggest that TRPA1 prevents septic injury by modulating mitochondrial biogenesis and mitophagy.

Comparison of long-term mortality in patients with acute myocardial infarction associated with or without sepsis

OBJECTIVES

Although the association between systemic infection and cardiovascular events has been identified, uncertainty remains regarding the incidence and prognosis of sepsis in acute myocardial infarction (AMI). The purpose of this research was to assess the impact of sepsis on survival after first AMI.

METHODS

This was a nationwide cohort study involving the analysis of data from the Taiwan National Health Insurance Research Database for the period 2000-2012, for patients with a primary diagnosis of first AMI. Among the 186112 prospective patients, sepsis was diagnosed in 13065 (7.0%). The propensity score matching technique was used to match 13065 controls to the patients with sepsis and AMI with similar baseline characteristics. Cox proportional hazards regression models, including sepsis, percutaneous coronary intervention (PCI), and comorbidities, were performed to further evaluate the different influences on the mortality risk in patients hospitalized for first AMI.

RESULTS

Overall, the 12-year survival rate was lower in AMI patients with sepsis than in those without sepsis (log rank p-value <0.001); this was also shown in the different age and sex groups. The AMI patients with sepsis had a longer length of hospital stay than those without sepsis (32.5days vs. 11.74 days, p<0.001). In the Cox proportional hazards regression analysis, sepsis was an independent risk factor for mortality in patients after AMI (hazard ratio 1.78; 95% confidence interval 1.72-1.83). Interventional management with PCI or coronary artery bypass grafting improved survival in both the sepsis and non-sepsis patients after first AMI.

CONCLUSIONS

In conclusion, sepsis significantly increased the mortality risk of patients after first AMI. PCI may improve the long-term survival of patients in comparison to those managed conservatively.

Microchip gel electrophoretic analysis of perchloric acid-soluble serum proteins in systemic inflammatory disorders

Perchloric acid (PCA) precipitation is a well-known method for the separation of heavily glycosylated proteins and for reducing the masking effect of major serum proteins. The aim of this study is to characterize PCA-soluble serum proteins in healthy individuals and in patients with systemic inflammatory diseases, such as Crohn's disease and sepsis. A PCA precipitation protocol was prepared and adapted to the analytical methods. After PCA treatment of the serum, the soluble proteins in the supernatant were analyzed by SDS-PAGE and by microchip gel electrophoresis (MGE). Characteristic changes of the electrophoretic patterns of the PCA-soluble fractions were observed. Four characteristic bands (at ∼11, ∼65, ∼85, and ∼120 kDa) with varying intensity were detected by MGE. The proportion of the ∼65, ∼85, and ∼120 kDa bands were significantly higher in systemic inflammatory conditions than in healthy individuals (p < 0.001), and characteristic patterns were observed in patients with acute inflammation. The marked differences in the acid-soluble protein patterns, which were observed in patients with ongoing systemic inflammation, might be a good indicator of inflammation. The MGE analysis is a fast screening and quantification method for the detection of characteristic changes among acid-soluble serum proteins.

Are Early Warning Scores Useful Predictors for Mortality and Morbidity in Hospitalised Acutely Unwell Older Patients? A Systematic Review

BACKGROUND

Early warning scores (EWSs) are used to identify deteriorating patients for appropriate interventions. We performed a systematic review to examine the usefulness of EWSs in predicting inpatient mortality and morbidity (transfer to higher-level care and length of hospital stay) in older people admitted to acute medical units with sepsis, acute cardiovascular events, or pneumonia.

METHODS

A systematic review of published and unpublished databases was conducted. Cochrane's tool for assessing Risk of Bias in Non-Randomised Studies-of Interventions (ROBINS-I) was used to appraise the evidence. A narrative synthesis was performed due to substantial heterogeneity.

RESULTS

Five studies (n = 12,057) were eligible from 1033 citations. There was an overall "moderate" risk of bias for all studies. The predictive ability of EWSs regarding mortality was reported in one study (n = 274), suggesting EWSs were better at predicting survival, (negative predictive value >90% for all scores). Three studies (n = 1819) demonstrated a significant association between increasing modified EWSs (MEWSs) and increased risk of mortality. Hazards ratios for a composite death/intensive care (ICU) admission with MEWSs ≥5 were significant in one study (p = 0.003). Two studies (n = 1421) demonstrated that a MEWS ≥6 was associated with 21 times higher probability of mortality (95% Confidence Interval (CI): 2.71⁻170.57) compared with a MEWS ≤1. A MEWS of ≥5 was associated with 22 times higher probability of mortality (95% CI: 10.45⁻49.16).

CONCLUSION

Increasing EWSs are strongly associated with mortality and ICU admission in older acutely unwell patients. Future research should be targeted at better understanding the usefulness of high and increasing EWSs for specific acute illnesses in older adults.

Epidemiology and Immune Pathogenesis of Viral Sepsis

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can be caused by a broad range of pathogens; however, bacterial infections represent the majority of sepsis cases. Up to 42% of sepsis presentations are culture negative, suggesting a non-bacterial cause. Despite this, diagnosis of viral sepsis remains very rare. Almost any virus can cause sepsis in vulnerable patients (e.g., neonates, infants, and other immunosuppressed groups). The prevalence of viral sepsis is not known, nor is there enough information to make an accurate estimate. The initial standard of care for all cases of sepsis, even those that are subsequently proven to be culture negative, is the immediate use of broad-spectrum antibiotics. In the absence of definite diagnostic criteria for viral sepsis, or at least to exclude bacterial sepsis, this inevitably leads to unnecessary antimicrobial use, with associated consequences for antimicrobial resistance, effects on the host microbiome and excess healthcare costs. It is important to understand non-bacterial causes of sepsis so that inappropriate treatment can be minimised, and appropriate treatments can be developed to improve outcomes. In this review, we summarise what is known about viral sepsis, its most common causes, and how the immune responses to severe viral infections can contribute to sepsis. We also discuss strategies to improve our understanding of viral sepsis, and ways we can integrate this new information into effective treatment.

Acute kidney injury and pancreatitis due to scorpion sting: case report and literature review

Despite the high number of accidents due to scorpion stings in Brazil, severe cases in adults are seldomly reported. In the Northeast region of Brazil, Tityus stigmurus is the most prevalent species. A 69 year-old woman who was stung by a scorpion attended the emergency room 5 hours after envenomation. She got worse due to abdominal pain. Clinical findings were concordant with class III scorpion envenomation (major systemic manifestations), complicated by acute kidney injury and acute pancreatitis. Intensive supportive therapy was adopted. In the follow-up, 3 months later, she was completely recovered. This report is being brought to recommend the thorough management of victims of scorpion accidents, enabling early diagnosis of severe complications, which could lead to death if aggressive supportive measures are not early and adequately taken.

Activity and Circadian Rhythm of Sepsis Patients in the Intensive Care Unit

Early mobilization of critically ill patients in the Intensive Care Unit (ICU) can prevent adverse outcomes such as delirium and post-discharge physical impairment. To date, no studies have characterized activity of sepsis patients in the ICU using granular actigraphy data. This study characterizes the activity of sepsis patients in the ICU to aid in future mobility interventions. We have compared the actigraphy features of 24 patients in four groups: Chronic Critical Illness (CCI) sepsis patients in the ICU, Rapid Recovery (RR) sepsis patients in the ICU, non-sepsis ICU patients (control-ICU), and healthy subjects. We used a total of 15 statistical and circadian rhythm features extracted from the patients' actigraphy data collected over a five-day period. Our results show that the four groups are significantly different in terms of activity features. In addition, we observed that the CCI and control-ICU patients show less regularity in their circadian rhythm compared to the RR patients. These results show the potential of using actigraphy data for guiding mobilization practices, classifying sepsis recovery subtype, as well as for tracking patients' recovery.

Targeting macrophage immunometabolism: Dawn in the darkness of sepsis

Sepsis is known since the time (470 BC) of great Greek physician, Hippocrates. Advancement in modern medicine and establishment of separate branches of medical science dealing with sepsis research have improved its outcome. However, mortality associated with sepsis still remains higher (25-30%) that further increases to 40-50% in the presence of septic shock. For example, sepsis-associated deaths account more in comparison to deaths-associated with myocardial-infarction and certain cancers (i.e. breast and colorectal cancer). However, it is now well established that profound activation of innate immune cells including macrophages play a very important role in the immunopathogenesis of sepsis. Macrophages are sentinel cells of the innate immune system with their location varying from peripheral blood to various target organs including lungs, liver, brain, kidneys, skin, testes, vascular endothelium etc. Thus, profound and dysregulated activation of these cells during sepsis can directly impact the outcome of sepsis. However, the emergence of the concept of immunometabolism as a major controller of immune response has raised a new hope for identifying new targets for immunomodulatory therapeutic approaches. Thus this present review starts with an introduction of sepsis as a major medical problem worldwide and signifies the role of dysregulated innate immune response including macrophages in its immunopathogenesis. Thereafter, subsequent sections describe changes in immunometabolic stage of macrophages (both M1 and M2) during sepsis. The article ends with the discussion of novel macrophage-specific therapeutic targets targeting their immunometabolism during sepsis and epigenetic regulation of macrophage immunometabolism and vice versa.

A systematic review on risk factors associated with sepsis in patients admitted to intensive care units

OBJECTIVE

We sought to systematically review data on the risk factors influencing the incidence of sepsis in patients admitted to intensive care units (ICUs).

REVIEW METHODS

An electronic search was undertaken in PubMed, MEDLINE, Scopus, and the Cochrane Library for studies reporting the risk factors of sepsis from the earliest available date up to December 30, 2016.

RESULTS

Among the 2978 articles, 14 studies met the inclusion criteria with a total of 56 164 participants from nine countries. The extracted risk factors were from the following categories: demographic, critical care interventions, surgery-related factors, pre-existing comorbidities, severity of organ injury, and biomarkers and biochemical and molecular indicators. From demographic factors, older age and male gender were associated with an increased risk of sepsis among ICU-admitted patients.

CONCLUSION

Our analysis comprehensively summarised the risk factors of sepsis in patients admitted to medical, surgical, neurologic, trauma, and general ICUs. Age, sex, and comorbidities were non-modifiable risk factors; however, critical care interventions and surgery-related factors were modifiable factors and suggest that improving the care of surgical patients and effective management of critical care interventions may play a key role in decreasing the development of sepsis in patients admitted to the ICUs.

Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department

Elderly people are more susceptible to sepsis and experience more comorbidities and complications than young adults. Serum lactate is a useful biomarker to predict mortality in patients with sepsis. Lactate production is affected by the severity of sepsis, organ dysfunction, and adrenergic stimulation. Whether the predictive ability of serum lactate will be different between non-elderly and elderly patients is unknown.A retrospective cohort study was conducted to compare the prognostic value of hyperlactatemia in predicting the mortality between elderly (≥65 years) and non-elderly (<65 years) patients with sepsis.This is a single-center retrospective observational cohort study conducted from January 2007 to December 2013 in southern Taiwan. All patients with sepsis, who used antibiotics, with blood culture collected, and with available serum lactate levels in the emergency department, were included in the analysis. We evaluated the difference in serum lactate level between the elderly and non-elderly septic patients by using multiple regression models.A total of 7087 patients were enrolled in the study. Elderly and non-elderly patients accounted for 62.3% (4414) and 40.2% (2673) of all patients, respectively. Statistically significant difference of serum lactate levels was not observed between elderly and non-elderly survivors (2.9 vs 3.0 mmol/L; P = .57); however, elderly patients had lower lactate levels than those within the 28-day in-hospital mortality (5.5 vs 6.6 mmol/L, P < .01). Multiple logistic regression revealed higher adjusted mortality risk in elderly and non-elderly patients with lactate levels of ≥4.0 mmol/L (odds ratio [OR], 4.98 and 5.82; P < .01, respectively), and lactate level between 2 and 4 mmol/L (OR, 1.57 and 1.99; P < .01, respectively) compared to that in the reference group with lactate levels of <2.0 mmol/L in each group. In receiver operating characteristic curve analysis, sensitivity rates for predicting mortality were 0.80 and 0.77 for non-elderly and elderly patients, respectively, by using serum lactate levels higher than 2.0 mmol/L.Septic elderly non-survivors had 1 mmol/L lower serum lactate level than those of the non-elderly non-survivors. Lactate >2 mmol/L still could provide enough sensitivity in predicting sepsis mortality in elder patients.

Overview of the incidence, early identification and management of sepsis

Sepsis is a potentially life-threatening condition that is triggered by an infection. Sepsis is an urgent public health issue globally, and is one of the leading causes of death in emergency departments and hospitals. However, consensus definitions of sepsis are imprecise and the incidence and costs of the condition are thought to be underestimated. This article discusses the incidence of sepsis globally and nationally, and the effects of the condition. It emphasises the early identification and effective management of sepsis, which remain crucial to improving patient outcomes such as morbidity and mortality. It also outlines the nurse's role in providing sepsis care.

Hospital Readmission in Total Hip Replacement Patients in 2009 and 2014

OBJECTIVE

To document changes in 30-day hospital readmission rates and causes for returning to the hospital for care in THR patients.

DESIGN

Retrospective cross-sectional descriptive design.

SETTING

Community-based acute care hospitals.

PARTICIPANTS

Total sample size (N=142,022) included THR patients (identified as ICD-9-CM procedure code 81.51) in 2009 (n=31,232) and (n=32,863) in 2014.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

30-Day hospital readmission.

RESULTS

The overall readmission rate decreased by 1.3% from 2009 to 2014. The decrease in readmission rates varied by groups, with lesser improvements seen in THR patients who were younger, with private insurance, and residing in lower-income and rural communities. Device complications were the leading cause of readmission in THR patients, increasing from 19.8% in 2009 to 23.9% in 2014.

CONCLUSIONS

There has been little decrease in hospital 30-day readmission rates for US community hospitals between 2009 and 2014. Findings from this brief report indicate patient groups at greater risk for 30-day hospital readmission as well as leading causes for readmission in THR patients which can inform the development of tailored interventions for reduction.

The clinical impact of bacteremia on outcomes in elderly patients with pyelonephritis or urinary sepsis: A prospective multicenter study

Background

Bacteremia is common in severe urinary infections, but its influence on the outcomes is not well established. The aim of this study was to assess the association of bacteremia with outcomes in elderly patients admitted to hospital with pyelonephritis or urinary sepsis.

Methods

This prospective muticenter observational study was conducted at 5 Spanish hospitals. All patients aged >65 years with pyelonephritis or urinary sepsis admitted to the departments of internal medicine and with urine and blood cultures obtained at admission to hospital were eligible. Transfer to ICU, length of hospital stay, hospital mortality and all cause 30-day mortality in bacteremic and non-bacteremic groups were compared. Risk factors for all cause 30-day mortality was also estimated.

Results

Of the 424 patients included in the study 181 (42.7%) had bacteremia. Neither transfer to ICU (4.4% vs. 2.9%, p = 0.400), nor length of hospital stay (9.7±4.6 days vs. 9.0±7.3 days, p = 0.252), nor hospital mortality (3.3% vs. 6.2%, p = 0.187), nor all cause 30-day mortality (9.4% vs. 13.2%, p = 0.223) were different between bacteremic and non-bacteremic groups. By multivariate analysis, risk factors for all cause 30-day mortality were age (OR 1.05, 95% CI 1.00–1.10), McCabe index ≥2 (OR 10.47, 95% CI 2.96–37.04) and septic shock (OR 8.56, 95% CI 2.86–25.61); whereas, bacteremia was inversely associated with all cause 30-day mortality (OR 0.33, 95% CI 0.15–0.71).

Conclusions

In this cohort, bacteremia was not associated with a worse prognosis in elderly patients with pyelonephritis or urinary sepsis.

Intensive care unit-acquired Acinetobacter baumannii infections in a Moroccan teaching hospital: epidemiology, risk factors and outcome

Introduction

The objective of this study was to examine the epidemiology, risk factors and outcome associated with Acinetobacter baumannii infections in the intensive care units (ICUs) in a Moroccan teaching hospital.

Methods

This is a matched case-control study conducted as a joint collaboration between the clinical Bacteriology department and the two ICUs of Mohammed V Military Teaching Hospital from January 2015 to July 2016.

Results

Among 964 patients hospitalized in the ICUs, 81 (8.4%) developed A. baumannii infections. Multivariate logistic regression analysis identified the following independent risk factors for ICU-acquired A. baumannii infections: ICU stay ≥14 days (odds ratio (OR)=6.4), prior use of central venous catheters (OR=18), prior use of mechanical ventilation (OR=9.5), duration of invasive procedures ≥7 days (OR=7.8), previous exposure to imipenem (OR=9.1), previous exposure to amikacin (OR=5.2), previous exposure to antibiotic polytherapy (OR=11.8) and previous exposure to corticotherapy (OR=5). On the other hand, the admission for post-operative care was identified as a protective factor. The crude mortality in patients with A. baumannii infection was 74.1%. Multivariate analysis showed that septic shock (OR=19.2) and older age (≥65 years) (OR=4.9) were significantly associated to mortality risk in patients with A. baumannii infection.

Conclusion

Our results show that shortening the ICU stay, rational use of medical devices and optimizing antimicrobial therapy could reduce the incidence of these infections. Elderly patients and those with septic shock have a poor prognosis. These findings highlight the need for focusing on the high-risk patients to prevent these infections and improve clinical outcome.

Caring for critically ill oldest old patients: a clinical review

Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.

The most commonly used disease severity scores are inappropriate for risk stratification of older emergency department sepsis patients: an observational multi-centre study

Background

Sepsis recognition in older emergency department (ED) patients is difficult due to atypical symptom presentation. We therefore investigated whether the prognostic and discriminative performance of the five most commonly used disease severity scores were appropriate for risk stratification of older ED sepsis patients (≥70 years) compared to a younger control group (<70 years).

Methods

This was an observational multi-centre study using an existing database in which ED patients who were hospitalized with a suspected infection were prospectively included. Patients were stratified by age < 70 and ≥70 years. We assessed the association with in-hospital mortality (primary outcome) and the area under the curve (AUC) with receiver operator characteristics of the Predisposition, Infection, Response, Organ dysfunction (PIRO), quick Sequential Organ Failure Assessment (qSOFA), Mortality in ED Sepsis (MEDS), and the Modified and National Early Warning (MEWS and NEWS) scores.

Results

In-hospital mortality was 9.5% ((95%-CI); 7.4–11.5) in the 783 included older patients, and 4.6% (3.6–5.7) in the 1497 included younger patients. In contrast to younger patients, disease severity scores in older patients associated poorly with mortality. The AUCs of all disease severity scores were poor and ranged from 0.56 to 0.64 in older patients, significantly lower than the good AUC range from 0.72 to 0.86 in younger patients. The MEDS had the best AUC (0.64 (0.57–0.71)) in older patients. In older and younger patients, the newly proposed qSOFA score (Sepsis 3.0) had a lower AUC than the PIRO score (sepsis 2.0).

Conclusion

The prognostic and discriminative performance of the five most commonly used disease severity scores was poor and less useful for risk stratification of older ED sepsis patients.

Electronic supplementary material

The online version of this article (10.1186/s13049-017-0436-3) contains supplementary material, which is available to authorized users.

Epidemiology and prognosis of candidaemia in elderly patients

The aim of the study was to analyse the epidemiology and prognosis of candidaemia in elderly patients. We performed a comparison of clinical presentation of candidaemia according to age and a study of hazard factors within a prospective programme performed in 29 hospitals. One hundred and seventy-six episodes occurred in elderly patients (>75 years), 227 episodes in middle-aged patients (61-75 years) and 232 episodes in younger patients (16-60 years). Central venous catheter, parenteral nutrition, neutropenia, immunosuppressive therapy and candidaemia caused by Candida parapsilosis were less frequent in elderly patients. These patients received inadequate antifungal therapy (57.3%) more frequently than middle-aged and younger patients (40.5% P < .001). Mortality during the first week (20%) and 30 days (42%) was higher in elderly patients. The variables independently associated with mortality in elderly patients during the first 7 days were acute renal failure (OR: 2.64), Pitt score (OR: 1.57) and appropriate antifungal therapy (OR: 0.132). Primary candidaemia (OR: 2.93), acute renal failure (OR: 3.68), Pitt score (OR: 1.38), appropriate antifungal therapy (OR: 0.3) and early removal of the central catheter (OR: 0.47) were independently associated with 30-day mortality.In conclussion, inadequate antifungal treatment is frequently prescribed to elderly patients with candidaemia and is related with early and late mortality.

Outcomes of Mechanically Ventilated Critically Ill Geriatric Patients in Intensive Care Unit

INTRODUCTION

Increase in life expectancy across the globe has led to rise in geriatric population. Geriatric population is now living longer and healthier. This rise in geriatric population has also led to increase in the geriatric ailments leading to increased number of geriatric patients requiring intensive care including mechanical ventilation. Data on outcomes of geriatric patients requiring mechanical ventilation from India is scarce.

AIM

To study the profile and outcome of geriatric patients more than equal to 60 years requiring mechanical ventilation in Intensive Care Unit (ICU).

MATERIALS AND METHODS

The data of all the geriatric patients, more than 60 years of age, admitted to ICU between January 2008 to August 2014 requiring mechanical ventilation for various reasons were extracted from the hospital records. Various reasons for ventilation, duration of ventilation/hospital stay, mortality and associated comorbidities were recorded and analysed.

RESULTS

Total 140 geriatric patients were mechanically ventilated in the study period, out of which 43.5% (61/140) were above 70 years of age and 67.8% (95/140) were above 65 years of age. Chronic Obstructive Pulmonary Disease (COPD) was the most common cause for mechanical ventilation constituting 20% of patients followed by severe sepsis (17.8%), cerebro-vascular accident (12.8%), post-surgical patients (12.8%) and Coronary Artery Disease (CAD) in 10%. In our study, 44.28% of the geriatric patients requiring mechanical ventilation in the ICU were successfully weaned off the ventilator. Early tracheostomy helped in weaning off from ventilator as 83.33% (5/6) of patients requiring tracheostomy could be weaned off the ventilator suggesting that tracheostomy may help in improving the outcome. Reintubation carried a very poor prognosis and increased mortality, as 80% (4/5) of the patients who were reintubated in our study could not survive.

CONCLUSION

Our study revealed that in appropriate intensive care setting and with standard protocol based therapy for primary ailments, outcomes with mechanical ventilation in geriatric population can be comparable to outcomes in younger population.

Outpatient beta-blockers and survival from sepsis: Results from a national cohort of Medicare beneficiaries

BACKGROUND

Elderly Americans suffer increased mortality from sepsis. Given that beta-blockers have been shown to be cardioprotective in critical care, we investigated outpatient beta-blocker prescriptions and mortality among Medicare beneficiaries admitted for sepsis.

METHODS

We queried a 5% random sample of Medicare beneficiaries for patients admitted with sepsis. We used in-hospital and outpatient prescription drug claims to compare in-hospital and 30-day mortality based on pre-admission beta-blocker prescription and class of beta-blocker prescribed using univariate tests of comparison and multivariable logistic regression models and another class of medications for control.

RESULTS

Outpatient beta-blocker prescription was associated with a statistically significant decrease in in-hospital and 30-day mortality. In multivariable modeling, beta-blocker prescription was associated with 31% decrease in in-hospital mortality and 41% decrease in 30-day mortality. Both cardioselective and non-selective beta-blockers conferred mortality benefit.

CONCLUSIONS

Our data suggests that there may be a role for preadmission beta-blockers in reducing sepsis-related mortality.

CRH Affects the Phenotypic Expression of Sepsis-Associated Virulence Factors by Streptococcus pneumoniae Serotype 1 In vitro

Sepsis is a life-threatening health condition caused by infectious pathogens of the respiratory tract, and accounts for 28–50% of annual deaths in the US alone. Current treatment regimen advocates the use of corticosteroids as adjunct treatment with antibiotics, for their broad inhibitory effect on the activity and production of pro-inflammatory mediators. However, despite their use, corticosteroids have not proven to be able to reverse the death incidence among septic patients. We have previously demonstrated the potential for neuroendocrine factors to directly influence Streptococcus pneumoniae virulence, which may in turn mediate disease outcome leading to sepsis and septic shock. The current study investigated the role of Corticotropin-releasing hormone (CRH) in mediating key markers of pneumococcal virulence as important phenotypic determinants of sepsis and septic shock risks. In vitro cultures of serotype 1 pneumococcal strain with CRH promoted growth rate, increased capsule thickness and penicillin resistance, as well as induced pneumolysin gene expression. These results thus provide significant insights of CRH–pathogen interactions useful in understanding the underlying mechanisms of neuroendocrine factor's role in the onset of community acquired pneumonias (CAP), sepsis and septic shock.

The Reversal of Direct Oral Anticoagulants in Animal Models

Several direct oral anticoagulants (DOACs), including direct thrombin and factor Xa inhibitors, have been approved as alternatives to vitamin K antagonist anticoagulants. As with any anticoagulant, DOAC use carries a risk of bleeding. In patients with major bleeding or needing urgent surgery, reversal of DOAC anticoagulation may be required, presenting a clinical challenge. The optimal strategy for DOAC reversal is being refined, and may include use of hemostatic agents such as prothrombin complex concentrates (PCCs; a source of concentrated clotting factors), or DOAC-specific antidotes (which bind their target DOAC to abrogate its activity). Though promising, most specific antidotes are still in development.Preclinical animal research is the key to establishing the efficacy and safety of potential reversal agents. Here, we summarize published preclinical animal studies on reversal of DOAC anticoagulation. These studies (n = 26) were identified via a PubMed search, and used rodent, rabbit, pig, and non-human primate models. The larger of these animals have the advantages of similar blood volume/hemodynamics to humans, and can be used to model polytrauma. We find that in addition to varied species being used, there is variability in the models and assays used between studies; we suggest that blood loss (bleeding volume) is the most clinically relevant measure of DOAC anticoagulation-related bleeding and its reversal.The studies covered indicate that both PCCs and specific reversal agents have the potential to be used as part of a clinical strategy for DOAC reversal. For the future, we advocate the development and use of standardized, clinically, and pharmacologically relevant animal models to study novel DOAC reversal strategies.

Sepsis and Immunosenescence in the Elderly Patient: A Review

Sepsis is a prevalent, serious medical condition with substantial mortality and a significant consumption of health-care resources. Its incidence has increased around 9% annually in general population over the last years and specially in aged patients group. Several risk factors such as comorbidities, preadmission status, malnutrition, frailty, and an impared function in the immune system called immunosenescence are involved in the higher predisposition to sepsis in the elderly patients. Immunosenescence status consists in a functional impairment in both cell-mediated immunity and humoral immune responses and increases not only the risk for develop sepsis but also lead to more severe presentation of infection and may be is also related with a higher mortality. There is a also a concern about to admit patients in the intensive care units taking into account that the outcome of elderly patients is poorer compared to younger people. Nevertheless, the management of septic elderly patients does not differ substantially from younger people. In addition, the quality of life in septic elderly survivors is also lower than in younger people. But age, as alone factor, should not be used to determine treatment options because the poorer outcomes is thought to be due to the increased comorbidities and frailty in this group of patients.

Efficacy and Safety of Vedolizumab in Ulcerative Colitis and Crohn's Disease Patients Stratified by Age

Introduction

The efficacy and safety of vedolizumab, a gut-selective α₄β₇ integrin antibody, were demonstrated in the GEMINI 1 and GEMINI 2 clinical trials of adults aged 18–80 years. We investigated the efficacy and safety of vedolizumab in patients stratified by age from the GEMINI trials.

Methods

Safety and efficacy, including clinical response, clinical remission, and corticosteroid-free remission, at week 6 and/or 52 were determined post hoc in patients aged <35, 35 to <55, and ≥55 years.

Results

At baseline, 353, 412, and 130 ulcerative colitis (UC) and 582, 443, and 90 Crohn’s disease (CD) patients were aged <35, 35 to <55, and ≥55. Of these patients, 56 were aged ≥65 years (UC: 33, CD: 23). Trends favoring vedolizumab over placebo were observed for most efficacy endpoints irrespective of patient age; some variability between subgroups was observed. Safety profiles of vedolizumab and placebo were similar in all age groups. Vedolizumab-treated patients aged ≥55 had the lowest incidence of serious infections (0.9 per 100 person–years) and adverse events leading to hospitalization (14.8 per 100 person–years). There were no age-related differences in the incidence of adverse hematological events, malignancy, or death.

Conclusions

The safety and efficacy of vedolizumab in patients with UC or CD were similar for all age groups. The number of patients in the oldest age group in these analyses was small; thus further studies of vedolizumab in larger cohorts of elderly patients are warranted.

Funding

Millennium Pharmaceuticals, Inc. (d/b/a Takeda Pharmaceuticals International Co.).

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-016-0467-6) contains supplementary material, which is available to authorized users.

Pitfalls in the Treatment of Sepsis

Sepsis is a challenging, dynamic, pathophysiology requiring expertise in diagnosis and management. Controversy exists as to the most sensitive early indicators of sepsis and sepsis severity. Patients presenting to the emergency department often lack complete history or clinical data that would point to optimal management. Awareness of these potential knowledge gaps is important for the emergency provider managing the septic patient. Specific areas of management including the initiation and management of mechanical ventilation, the appropriate disposition of the patient, and consideration of transfer to higher levels of care are reviewed.

Systemic inflammatory response syndrome is more associated with bacteremia in elderly patients with suspected sepsis in emergency departments

Early diagnosis of bacteremia for patients with suspected sepsis is 1 way to improve prognosis of sepsis. Systemic inflammatory response syndrome (SIRS) has long been utilized as a screening tool to detect bacteremia by front-line healthcare providers. The value of SIRS to predict bacteremia in elderly patients (≥65 years) with suspected sepsis has not yet been examined in emergency departments (EDs).We aimed to evaluate the performance of SIRS components in predicting bacteremia among elderly patients in EDs.We retrospectively evaluated patients with suspected sepsis and 2 sets of blood culture collected within 4 hours after admitting to ED in a tertiary teaching hospital between 2010 and 2012. Patients were categorized into 3-year age groups: young (18-64 years), young-old (65-74 years), and old patients (≥75 years). Vital signs and Glasgow Coma Scale with verbal response obtained at the triage, comorbidities, sites of infection, blood cultures, and laboratory results were retrieved via the electronic medical records.A total of 20,192 patients were included in our study. Among them, 9862 (48.9%) were the elderly patients (young-old and old patients), 2656 (13.2%) developed bacteremia. Among patients with bacteremia, we found the elderly patients had higher SIRS performance (adjusted odds ratio [aOR]: 2.40, 95% confidence interval [CI]: 1.90-3.03 in the young-old and aOR: 2.66, 95% CI: 2.19-3.23 in the old). Fever at the triage was most predictive of bacteremia, especially in the elderly patients (aOR: 2.19, 95% CI: 1.81-2.65 in the young-old and aOR: 2.27, 95% CI: 1.95-2.63 in the old), and tachypnea was not predictive of bacteremia among the elderly patients (all P > 0.2).The performance of SIRS to predict bacteremia was more suitable for elderly patients in EDs observed in this study. The elderly patients presented with more fever and less tachypnea when they had bacteremia.

A proposed Primary Health Early Warning Score (PHEWS) with emphasis on early detection of sepsis in the elderly

There are several secondary care early warning scores which alert for severe illness including sepsis. None are specifically adjusted for primary care. A Primary Health Early Warning Score (PHEWS) is proposed which incorporates practical parameters from both secondary and primary care.

Temporal trends in the utilization of vasopressors in intensive care units: an epidemiologic study

Background

The choice of vasopressor use in the intensive care unit (ICU) depends primarily on provider preference. This study aims to describe the rate of vasopressor utilization and the trends of each vasoactive agent usage in the ICU over the span of 7 years in a tertiary referral center.

Methods

All adult ICU admissions, including medical, cardiac, and surgical ICUs from January 1st, 2007 through December 31st, 2013 were included in this study. Vasopressor use was defined as the continuous intravenous administration of epinephrine, norepinephrine, phenylephrine, dopamine, or vasopressin within a given ICU day. The vasopressor utilization index (VUI) was defined as the proportion of ICU days on each vasoactive agent divided by the total ICU days with vasopressor usage.

Results

During the study period, 72,005 ICU admissions and 272,271 ICU days were screened. Vasopressors were used in 19,575 ICU admissions (27 %) and 59,811 ICU days (22 %). Vasopressin was used in 24,496 (41 %), epinephrine in 23,229 (39 %), norepinephrine in 20,648 (34 %), dopamine in 9449 (16 %), and phenylephrine in 7508 (13 %) ICU days. The VUI_{norepinephrine} increased from 0.24 in 2007 to 0.46 in 2013 and VUI_{phenylephrine} decreased from 0.20 in 2007 to 0.08 in 2013 (p < 0.001 both). For epinephrine, dopamine, and vasopressin VUI did not change over the course of study.

Conclusion

Vasopressors were used in about one fourth of ICU admissions and about one-fifth of ICU days. Although vasopressin is the most commonly used vasopressor, the use of norepinephrine found to have an increasing trajectory.

Electronic supplementary material

The online version of this article (doi:10.1186/s40360-016-0063-z) contains supplementary material, which is available to authorized users.

Role of TFEB Mediated Autophagy, Oxidative Stress, Inflammation, and Cell Death in Endotoxin Induced Myocardial Toxicity of Young and Aged Mice

Elderly patients are susceptible to sepsis. LPS induced myocardial injury is a widely used animal model to assess sepsis induced cardiac dysfunction. The age dependent mechanisms behind sepsis susceptibility were not studied. We analyzed age associated changes to cardiac function, cell death, inflammation, oxidative stress, and autophagy in LPS induced myocardial injury. Both young and aged C57BL/6 mice were used for LPS administration. The results demonstrated that LPS induced more cardiac injury (creatine kinase, lactate dehydrogenase, troponin I, and cardiac myosin-light chains 1), cardiac dysfunction (left ventricular inner dimension, LVID, and ejection fraction (EF)), cell death, inflammation, and oxidative stress in aged mice compared to young mice. However, a significant age dependent decline in autophagy was observed. Translocation of Transcription Factor EB (TFEB) to nucleus and formation of LC3-II were significantly reduced in LPS administered aged mice compared to young ones. In addition to that, downstream effector of TFEB, LAMP-1, was induced in response to LPS challenge in young mice. The present study newly demonstrates that TFEB mediated autophagy is crucial for protection against LPS induced myocardial injury particularly in aging senescent heart. Targeting this autophagy-oxidative stress-inflammation-cell death axis may provide a novel therapeutic strategy for cardioprotection in the elderly.

Risk Factors for Urosepsis in Older Adults: A Systematic Review

Objective: To identify factors that predispose older adults to urosepsis and urosepsis-related mortality. Method: A systematic search using PubMed and CINAHL databases. Articles that met inclusion criteria were assessed using the Strengthening the Reporting of OBservational studies in Epidemiology (STROBE) criteria and were scored on a 4-point Likert-type scale. Results: A total of 180 articles were identified, and six met inclusion criteria. The presence of an internal urinary catheter was associated with the development of urosepsis and septic shock. Although a number of factors were examined, functional dependency, number of comorbidities, and low serum albumin were associated with mortality across multiple studies included in this review. Discussion: Little scientific evidence is available on urosepsis, its associated risk factors, and those factors associated with urosepsis-related mortality in older adults. More research is warranted to better understand urosepsis in this vulnerable population in an effort to improve the quality of patient care.

Bloodstream infections in older patients

Bloodstream infections (BSIs) are both common and fatal in older patients. We describe data from studies evaluating older patients hospitalized with BSIs. Most older patients with BSIs present "typically" with either fever or leukocytosis. The most common source of BSI in older patients is the urinary tract, and accordingly, Gram-negative organisms predominate. A significant part of these BSIs may thus be preventable by removal of unnecessary urinary catheters. Increased long term mortality is reported following BSIs in older patients, however, data on other long-term outcomes, including functional capacity, cognitive decline and others are lacking. Management of BSIs may include less invasive procedures due to the fragility of older patients. This approach may delay the diagnosis and treatment in some cases. Older patients are probably under-represented in clinical trials assessing treatment of bacteremia. Physicians treating older patients should consider the relevance of these studies' outcomes.

CD1d- and MR1-Restricted T Cells in Sepsis

Dysregulated immune responses to infection, such as those encountered in sepsis, can be catastrophic. Sepsis is typically triggered by an overwhelming systemic response to an infectious agent(s) and is associated with high morbidity and mortality even under optimal critical care. Recent studies have implicated unconventional, innate-like T lymphocytes, including CD1d- and MR1-restricted T cells as effectors and/or regulators of inflammatory responses during sepsis. These cell types are typified by invariant natural killer T (iNKT) cells, variant NKT (vNKT) cells, and mucosa-associated invariant T (MAIT) cells. iNKT and vNKT cells are CD1d-restricted, lipid-reactive cells with remarkable immunoregulatory properties. MAIT cells participate in antimicrobial defense, and are restricted by major histocompatibility complex-related protein 1 (MR1), which displays microbe-derived vitamin B metabolites. Importantly, NKT and MAIT cells are rapid and potent producers of immunomodulatory cytokines. Therefore, they may be considered attractive targets during the early hyperinflammatory phase of sepsis when immediate interventions are urgently needed, and also in later phases when adjuvant immunotherapies could potentially reverse the dangerous state of immunosuppression. We will highlight recent findings that point to the significance or the therapeutic potentials of NKT and MAIT cells in sepsis and will also discuss what lies ahead in research in this area.

Melting Temperature Mapping Method: A Novel Method for Rapid Identification of Unknown Pathogenic Microorganisms within Three Hours of Sample Collection

Acquiring the earliest possible identification of pathogenic microorganisms is critical for selecting the appropriate antimicrobial therapy in infected patients. We herein report the novel “melting temperature (Tm) mapping method” for rapidly identifying the dominant bacteria in a clinical sample from sterile sites. Employing only seven primer sets, more than 100 bacterial species can be identified. In particular, using the Difference Value, it is possible to identify samples suitable for Tm mapping identification. Moreover, this method can be used to rapidly diagnose the absence of bacteria in clinical samples. We tested the Tm mapping method using 200 whole blood samples obtained from patients with suspected sepsis, 85% (171/200) of which matched the culture results based on the detection level. A total of 130 samples were negative according to the Tm mapping method, 98% (128/130) of which were also negative based on the culture method. Meanwhile, 70 samples were positive according to the Tm mapping method, and of the 59 suitable for identification, 100% (59/59) exhibited a “match” or “broad match” with the culture or sequencing results. These findings were obtained within three hours of whole blood collection. The Tm mapping method is therefore useful for identifying infectious diseases requiring prompt treatment.

Septic Shock in Advanced Age: Transcriptome Analysis Reveals Altered Molecular Signatures in Neutrophil Granulocytes

Sepsis is one of the highest causes of mortality in hospitalized people and a common complication in both surgical and clinical patients admitted to hospital for non-infectious reasons. Sepsis is especially common in older people and its incidence is likely to increase substantially as a population ages. Despite its increased prevalence and mortality in older people, immune responses in the elderly during septic shock appear similar to that in younger patients. The purpose of this study was to conduct a genome-wide gene expression analysis of circulating neutrophils from old and young septic patients to better understand how aged individuals respond to severe infectious insult. We detected several genes whose expression could be used to differentiate immune responses of the elderly from those of young people, including genes related to oxidative phosphorylation, mitochondrial dysfunction and TGF-β signaling, among others. Our results identify major molecular pathways that are particularly affected in the elderly during sepsis, which might have a pivotal role in worsening clinical outcomes compared with young people with sepsis.

Infection, sepsis, and immune function in the older adult receiving critical care

The elderly are vulnerable to developing sepsis due to functional and immune changes, and frequent instrumentation and contact with the health care system. Those infected often present with nonspecific complaints and are at risk for underrecognition and undertreatment, with greater likelihood of rapid progression to severe sepsis and septic shock; however, often respond well to early, organized, and aggressive interventions. Survivors may not return to baseline level of function and may require long-term care facilities after discharge from the hospital. Patient and family preferences for goals of care should be explored as early as possible and incorporated into treatment plans.

Combination of Acute Physiology and Chronic Health Evaluation II score, early lactate area, and N-terminal prohormone of brain natriuretic peptide levels as a predictor of mortality in geriatric patients with septic shock

BACKGROUND

Given the high mortality rates in elderly patients with septic shock, the early recognition of patients at greatest risk of death is crucial for the implementation of early intervention strategies. Serum lactate and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels are often elevated in elderly patients with septic shock and are therefore important biomarkers of metabolic and cardiac dysfunction. We hypothesized that a risk stratification system that incorporates the Acute Physiology and Chronic Health Evaluation (APACHE) II score and lactate and NT-proBNP biomarkers would better predict mortality in geriatric patients with septic shock than the APACHE II score alone.

METHODS

A single-center prospective study was conducted from January 2012 to December 2013 in a 30-bed intensive care unit of a triservice hospital. The lactate area score was defined as the sum of the area under the curve of serial lactate levels measured during the 24 hours following admission divided by 24. The NT-proBNP score was assigned based on NT-proBNP levels measured at admission. The combined score was calculated by adding the lactate area and NT-proBNP scores to the APACHE II score. Multivariate logistic regression analyses and receiver operating characteristic curves were used to evaluate which variables and scoring systems served as the best predictors of mortality in elderly septic patients.

RESULTS

A total of 115 patients with septic shock were included in the study. The overall 28-day mortality rate was 67.0%. When compared to survivors, nonsurvivors had significantly higher lactate area scores, NT-proBNP scores, APACHE II scores, and combined scores. In the multivariate regression model, the combined score, lactate area score, and mechanical ventilation were independent risk factors associated with death. Receiver operating characteristic curves indicated that the combined score had significantly greater predictive power when compared to the APACHE II score or the NT-proBNP score (P < .05).

CONCLUSIONS

A combined score that incorporates the APACHE II score with early lactate area and NT-proBNP levels is a useful method for risk stratification in geriatric patients with septic shock.