The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study

Protective Effects of Evodiamine against LPS-Induced Acute Kidney Injury through Regulation of ROS-NF-κB-Mediated Inflammation

Acute kidney injury (AKI) is a critical care syndrome, which is usually associated with sepsis-related endotoxemia. Evodiamine (EVO) is an active ingredient of many traditional medicinal formulations that possess a battery of biological activities. In the study, we aimed to evaluate the potential protective effect of EVO against lipopolysaccharide- (LPS-) induced AKI and cytotoxicity. LPS-resulted pathological injuries were significantly ameliorated by the administration of EVO. EVO reduced the levels of blood urea nitrogen (BUN) and creatinine in LPS-treated rats. EVO also inhibited LPS-induced reduction of cell viability in NRK-52E cells. LPS-resulting increase of TNFα and IL-1β in both serum and kidney of rats and NRK-52E cells was inhibited by EVO. LPS-induced increase of P65 NF-κB expression was markedly inhibited by EVO. EVO-induced reduction of TNFα and IL-1β expression in LPS-treated cells was blocked by overexpression of P65 NF-κB. Moreover, the increase of cell viability in LPS-treated cells induced by EVO was remarkably suppressed by overexpression of P65 NF-κB. LPS-resulting increase of reactive oxygen species (ROS) production was suppressed by EVO. H₂O₂ suppressed EVO-induced decrease of P65 NF-κB expression and increase of cell viability in LPS-treated NRK-52E cells. Moreover, the antioxidant NAC significantly promoted EVO-induced decrease of P65 NF-κB expression and increase of cell viability in LPS-treated NRK-52E cells. In conclusion, EVO had crucial protective effects against LPS-induced AKI and cytotoxicity through the antioxidant activities and thus the inhibition of inflammation. Our data highlight EVO as a potential candidate for the development of new strategies for the treatment of AKI.

Usefulness of qSOFA and SIRS scores for detection of incipient sepsis in general ward patients: A prospective cohort study

PURPOSE

To prospectively assess the diagnostic value of quick Sequential Organ Failure Assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores for sepsis in ward patients with infections.

MATERIALS AND METHODS

Consecutive patients admitted with infection or developing infection during hospital stay were included. All variables for calculating qSOFA, SIRS, and SOFA scores were collected, and the maximum scores were determined until hospital discharge, death, or day 28, whichever occurred earlier. The primary outcome was sepsis at 28 days. Diagnostic and prognostic values were assessed using the area under the receiver operating characteristic curve (AUROC) with the conventional cutoff value of 2.

RESULTS

Of 409 general ward patients, 146 patients and 371 patients met qSOFA and SIRS criteria, 229 patients developed sepsis. Although qSOFA score had a better overall diagnostic performance of sepsis (AUROC 0.75 vs. 0.69), it had a much lower sensitivity (53% vs. 98%) and higher specificity (87% vs. 18%) than SIRS score. In addition, qSOFA score had a better prognostic value than SIRS score (AUROC 0.86 vs. 0.67).

CONCLUSIONS

Neither SIRS score nor qSOFA score could serve as an ideal screening tool for early identification sepsis, whereas qSOFA score might help to identify patients with higher risk of poor clinical outcome.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02930070.

Time to positivity of blood cultures supports early re-evaluation of empiric broad-spectrum antimicrobial therapy

BACKGROUND

Blood cultures are considered the gold standard to distinguish bacteremia from non-bacteremic systemic inflammation. In current clinical practice, bacteraemia is considered unlikely if blood cultures have been negative for 48-72 hours. Modern BC systems have reduced this time-to-positivity (TTP), questioning whether the time frame of 48-72 hrs is still valid. This study investigates the distribution of TTP, the probability of blood culture positivity after 24 hours, and identifies clinical predictors of prolonged TTP.

METHODS

Adult patients with monomicrobial bacteremia in an academic hospital were included retrospectively over a three-year period. Clinical data were retrieved from the medical records. Predictors of TTP >24 hours were determined by uni- and multivariate analyses. The residual probability of bacteremia was estimated for the scenario of negative BCs at 24 hours after bedside collection.

RESULTS

The cohort consisted of 801 patients, accounting for 897 episodes of bacteremia. Mean age was 65 years (IQR 54-73), 534 (59.5%) patients were male. Median TTP was 15.7 (IQR 13.5-19.3) hours. TTP was ≤24 hours in 85.3% of episodes. Antibiotic pre-treatment (adjusted OR 1.77; 95%CI 1.14-2.74, p<0.01) was independently associated with prolonged TTP. The probability of bacteremia, if BC had remained negative for 24 hours, was 1.8% (95% CI 1.46-2.14).

CONCLUSION

With adequate hospital logistics, the probability of positive blood cultures after 24 hours of negative cultures was low. Combined with clinical reassessment, knowledge of this low probability may contribute to prioritization of the differential diagnosis and decisions on antimicrobial therapy. As a potential antibiotic stewardship tool, this strategy warrants further prospective investigation.

Kidney histopathology in lethal human sepsis

Purpose

The histopathology of sepsis-associated acute kidney injury (AKI) in critically ill patients remains an understudied area. Previous studies have identified that acute tubular necrosis (ATN) is not the only driver of sepsis-AKI. The focus of this study was to identify additional candidate processes that may drive sepsis-AKI. To do this we immunohistochemically characterized the histopathological and cellular features in various compartments of human septic kidneys.

Methods

We studied the following histopathological features: leukocyte subsets, fibroblast activation, cellular proliferation, apoptosis, and fibrin deposition in the glomerulus and the tubulointerstitium in human post-mortem kidney biopsy tissue. Biopsy tissue samples from 27 patients with sepsis-AKI were collected 33 min (range 24–150) after death in the ICU. The unaffected part of the kidneys from 12 patients undergoing total nephrectomy as a result of renal carcinoma served as controls.

Results

Immunohistochemical analysis revealed the presence of more neutrophils and macrophages in the glomeruli and more neutrophils in the tubulointerstitium of renal tissue from patients with sepsis compared to control renal tissue. Type II macrophages were predominant, with some macrophages expressing both type I and type II markers. In contrast, there were almost no macrophages found in control kidneys. The number of activated (myo)fibroblasts was low in the glomeruli of sepsis-AKI kidneys, yet this was not observed in the tubulointerstitium. Cell proliferation and fibrin deposition were more pronounced in the glomeruli and tubulointerstitium of sepsis-AKI than in control kidneys.

Conclusions

The extensive heterogeneity of observations among and within patients emphasizes the need to thoroughly characterize patients with sepsis-AKI in a large sample of renal biopsy tissue from patients with sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2287-3) contains supplementary material, which is available to authorized users.

Ascitic Bacterial Composition Is Associated With Clinical Outcomes in Cirrhotic Patients With Culture-Negative and Non-neutrocytic Ascites

Ascites bacterial burden is associated with poor clinical outcomes in patients with end-stage liver disease. However, the impact of ascitic microbial composition on clinical course was still not clear. In this study, the ascitic microbiota composition of 100 cirrhotic patients with culture-negative and non-neutrocytic ascites were researched with 16S rRNA pyrosequencing and enterotype-like cluster analysis. Results: By characterizing the ascitic microbial composition, two distinct microbial clusters were observed, Cluster 1 (86 patients) and Cluster 2 (14 patients). Cluster 1 showed lower microbial richness than Cluster 2. At the phylum level, Cluster 1 had greater abundance of Bacteroidetes and Firmicutes, but less abundance of Proteobacteria and Actinobacteria than Cluster 2. At the family level, family Bacteroidales S24-7 group, Prevotellaceae, Lachnospiraceae, Lactobacillaceae, Rikenellaceae, and Vibrionaceae were found over-represented in Cluster 1. And family Acetobacteraceae, Erysipelotrichaceae, Rickettsiaceae, and Streptococcaceae were found enriched in Cluster 2. The levels of plasma cytokine IL-17A, IL-7, and PDGF-BB were found significantly higher in Cluster 1 than in Cluster 2. There were four OTUs closely correlated with plasma cytokines, which were OTU 140 and OTU 271 (both from Bacteroidales S24-7 group), OTU 68 (Veillonellaceae), and OTU 53 (Helicobacteraceae). Patients from Cluster 1 showed significant higher short-term mortality than patients from Cluster 2. Conclusion: Our study demonstrated that the microbial composition of culture-negative and non-neutrocytic ascites in cirrhotic patients is associated with short-term clinical outcomes. The results here offer a rational for the identification of patients with high risk, and provide references for selective use of prophylactic methods.

Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study

INTRODUCTION

Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed.

METHODS

This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve.

RESULTS

Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76).

CONCLUSIONS

The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility.

Safety and efficacy of antibiotics among acutely decompensated cirrhosis patients

BACKGROUND AND AIM

Infection is a leading precipitant of acute-on-chronic liver failure. This study aims to determine the safety and efficacy of antibiotics within acute-on-chronic liver failure.

METHODS

Retrospective study of 457 acute-on-chronic liver failure patients admitted to the University of Arizona Health Network between January 1 and December 31, 2014. Eligibility criteria were as follows: at least 18 years of age and 6 months follow-up, data available to calculate systemic inflammatory response syndrome (SIRS), and acute-on-chronic liver failure. This study collected patient's clinical features and historical data. Key data points were infection, antibiotic use, and SIRS. This study used Cox proportional hazards to model the effects of clinical factors on risk of death.

RESULTS

A total of 521 of 1243 met the inclusion criteria, and 64 had missing data, leaving 457 patients. Infection resulted in higher hazard (hazard ratio [HR] = 1.6, confidence interval [CI]: 1.1-1.3, P = 0.01). Patients with infections and antibiotics, compared with non-infected patients without antibiotics, had higher hazard (HR = 1.633, CI: 1.022-2.609, P = .04). Of those infected patients with antibiotics, SIRS patients experienced higher hazard (HR = 1.9, CI: 1.1-3.0, P = .007). Multivariable Cox proportional hazards associated the following with higher hazard: SIRS (HR = 1.866, CI: 1.242-2.804, P = 0.003), vancomycin (HR = 1.640, CI: 1.119-2.405, P = 0.011), Model for End-Stage Liver Disease (HR = 1.051, CI: 1.030-1.073, P < 0.001), gastrointestinal bleeding (HR = 1.727, CI: 1.180-2.527, P = 0.005), and hepatic encephalopathy (HR = 1.807, CI: 1.247-2.618, P = 0.002).

CONCLUSION

Overall, treatment of infection with antibiotics did not improve survival; however, patients not meeting SIRS criteria had better outcomes, and vancomycin was associated with poorer survival among acute-on-chronic liver failure patients.

Early PREdiction of sepsis using leukocyte surface biomarkers: the ExPRES-sepsis cohort study

PURPOSE

Reliable biomarkers for predicting subsequent sepsis among patients with suspected acute infection are lacking. In patients presenting to emergency departments (EDs) with suspected acute infection, we aimed to evaluate the reliability and discriminant ability of 47 leukocyte biomarkers as predictors of sepsis (Sequential Organ Failure Assessment score ≥ 2 at 24 h and/or 72 h following ED presentation).

METHODS

In a multi-centre cohort study in four EDs and intensive care units (ICUs), we standardised flow-cytometric leukocyte biomarker measurement and compared patients with suspected acute infection (cohort-1) with two comparator cohorts: ICU patients with established sepsis (cohort-2), and ED patients without infection or systemic inflammation but requiring hospitalization (cohort-3).

RESULTS

Between January 2014 and February 2016, we recruited 272, 59 and 75 patients to cohorts 1, 2, and 3, respectively. Of 47 leukocyte biomarkers, 14 were non-reliable, and 17 did not discriminate between the three cohorts. Discriminant analyses for predicting sepsis within cohort-1 were undertaken for eight neutrophil (cluster of differentiation antigens (CD) CD15; CD24; CD35; CD64; CD312; CD11b; CD274; CD279), seven monocyte (CD35; CD64; CD312; CD11b; HLA-DR; CD274; CD279) and a CD8 T-lymphocyte biomarker (CD279). Individually, only higher neutrophil CD279 [OR 1.78 (95% CI 1.23-2.57); P = 0.002], higher monocyte CD279 [1.32 (1.03-1.70); P = 0.03], and lower monocyte HLA-DR [0.73 (0.55-0.97); P = 0.03] expression were associated with subsequent sepsis. With logistic regression the optimum biomarker combination was increased neutrophil CD24 and neutrophil CD279, and reduced monocyte HLA-DR expression, but no combination had clinically relevant predictive validity.

CONCLUSIONS

From a large panel of leukocyte biomarkers, immunosuppression biomarkers were associated with subsequent sepsis in ED patients with suspected acute infection.

CLINICAL TRIAL REGISTRATION

NCT02188992.

Management of patients with septic shock due to Candida infection

Septic shock represents a serious complication occurring between 6% and 30% of all hospitalized patients; Candida septic shock represents a challenge for clinicians due to the absence of specific risk factors, diagnostic tests, and management. Identification of specific risk factors and use of biomarkers are useful tools considering that differentiation of Candida from bacterial septic shock is demanding. Early effective antifungal treatment, preferably with echinocandins with an adequate source control, represents the best approach for improving survival of patients with septic shock due to Candida. Given the importance of adequate therapy and source control in septic shock attributable to Candida clinical strategies and pathways are needed. This review will focus on epidemiology of septic shock in patients with invasive candidiasis with special attention to diagnostic pathways and treatment strategies.

Increasing Sepsis Rates in the United States: Results From National Inpatient Sample, 2005 to 2014

Objectives:

To examine the trends in hospitalization rates, mortality, and costs for sepsis during the years 2005 to 2014.

Methods:

This was a retrospective serial cross-sectional analysis of patients ≥18 years admitted for sepsis in National Inpatient Sample. Trends in sepsis hospitalizations were estimated, and age- and sex-adjusted rates were calculated for the years 2005 to 2014.

Results:

There were 541 694 sepsis admissions in 2005 and increased to 1 338 905 in 2014. Sepsis rates increased significantly from 1.2% to 2.7% during the years 2005 to 2014 (relative increase: 123.8%; Ptrend< .001). However, the relative increase changed by 105.8% ( Ptrend< .001) after adjusting for age and sex and maintained significance. Although total cost of hospitalization due to sepsis increased significantly from US$22.2 to US$38.1 billion ( Ptrend< .001), the mean hospitalization cost decreased significantly from US$46,470 to US$29,290 ( Ptrend< .001).

Conclusions:

Hospitalizations for sepsis increased during the years 2005 to 2014. Our study paradoxically found declining rates of in-hospital mortality, length of stay, and mean hospitalization cost for sepsis. These findings could be due to biases introduced by International Classification of Diseases, Ninth Revision, Clinical Modification coding rules and increased readmission rates or alternatively due to increased awareness and surveillance and changing disposition status. Standardized epidemiologic registries should be developed to overcome these biases.

Cardiorenal Syndrome: An Overview

It is well established that a large number of patients with acute decompensated heart failure present with various degrees of heart and kidney dysfunction usually primary disease of heart or kidney often involve dysfunction or injury to the other. The term cardiorenal syndrome increasingly had been used without a consistent or well-accepted definition. To include the vast array of interrelated derangements and to stress the bidirectional nature of heart-kidney interactions, a new classification of the cardiorenal syndrome with 5 subtypes that reflect the pathophysiology, the time frame, and the nature of concomitant cardiac and renal dysfunction was proposed. Cardiorenal syndrome can generally be defined as a pathophysiological disorder of the heart and kidneys, in which acute or chronic dysfunction of one organ may induce acute or chronic dysfunction to the other. Although cardiorenal syndrome was usually referred to as acute kidney dysfunction following acute cardiac disease, it is now clearly established that impaired kidney function can have an adverse impact on cardiac function.

Umbilical cord-derived mesenchymal stem (stromal) cells for treatment of severe sepsis: aphase 1 clinical trial

The aim of this phase 1 clinical trial was to test the safety and feasibility of a single dose of allogeneic umbilical cord-derived mesenchymal stem cells (MSCs) in patients with severe sepsis. This is a single-center, open-label, dose-escalation phase 1 clinical trial of a single dose of intravenous MSCs in patients with severe sepsis. We enrolled 15 patients who averagely divided into low (1 × 10⁶ cells/kg), intermediate (2 × 10⁶ cells/kg), and high (3 × 10⁶ cells/kg) dosing cohorts. Primary outcomes included the incidence of infusion-associated events and serious adverse events. Secondary outcomes included systemic endpoints, mortality, and inflammation biologic markers. A historical case-matched comparison group was set as the control. This study enrolled 15 patients (10 male and 5 female), with a median age of 58. Compared to those in the historical, case-matched group, neither there were infusion-associated serious events or treatment-related adverse events in any of the 15 patients in this trial, nor were there any safety or efficacy signals for serious adverse events or the measured cytokines. A single intravenous infusion of allogeneic MSCs up to a dose of 3 × 10⁶ cells/kg was safe and well tolerated in 15 patients with severe sepsis.

Interleukin-6 significantly improves predictive value of systemic inflammatory response syndrome for predicting severe acute pancreatitis

BACKGROUND

Predicting severe acute pancreatitis (AP) is important for triage, prognosis, and designing therapeutic trials. Persistent systemic inflammatory response syndrome (SIRS) predicts severe AP but its diagnostic accuracy is suboptimal. Our objective was to study if cytokine levels could improve the predictive value of clinical variables for the development of severe AP.

METHODS

Consecutive patients with AP were included in a prospective cohort study at a tertiary care center. Serum levels of IL-6, TNF-α, IL-10, MCP-1, GM-CSF and IL-1β were measured at day 3 of onset of AP. Variables such as age, co-morbidity, etiology, SIRS, and cytokines were modeled to predict severe AP by multivariable regression analysis. Genotyping was done to correlate IL-6, TNF-α and MCP-1 gene polymorphisms with cytokine levels.

RESULTS

Of 236 patients with AP, 115 patients admitted within 7 days of onset formed the study group. 37 of the 115 (32%) patients developed organ failure. Independent predictors of organ failure were persistent SIRS (OR 34; 95% CI: 7.2-159) and day 3 serum IL-6 of >160 pg/ml (OR 16.1; 95% CI:1.8-142). IL-6 gene (-174 G/C) GG genotype was associated with significantly higher levels of IL-6 compared to CC/CG genotype. Serum IL-6 >160 pg/ml increased the positive predictive value of persistent SIRS from 56% to 85% and specificity from 64% to 95% for predicting OF without compromising its sensitivity and negative predictive value.

CONCLUSION

Serum IL-6 of >160 ng/ml added significantly to the predictive value of SIRS for severe AP.

Association of bacterial genotypes and epidemiological features with treatment failure in hemodialysis patients with methicillin-resistant Staphylococcus aureus bacteremia

OBJECTIVES

Methicillin-resistant Staphylococcus aureus (MRSA) infections in the hemodialysis (HD) population are epidemiologically classified as healthcare-associated infections. The data about the clinical impact and bacterial characteristics of hospital-onset (HO)- and community-onset (CO)-MRSA in HD patients are scarce. The current study analyzed the difference in the clinical and molecular characteristics of HO-MRSA and CO-MRSA.

METHODS

We performed a retrospective review and molecular analysis of clinical isolates from 106 HD patients with MRSA bacteremia from 2009 to 2014. CA genotypes were defined as isolates carrying the SCCmec type IV or V, and HA genotypes were defined as isolates harboring SCCmec type I, II, or III.

RESULTS

CO-MRSA infections occurred in 76 patients, and 30 patients had HO-MRSA infections. There was no significant difference in the treatment failure rates between patients with CO-MRSA infections and those with HO-MRSA infections. CA genotypes were associated with less treatment failure (odds ratio [OR]: 0.18; 95% confidence interval [95% CI], 0.07-0.49; p = 0.001). For isolates with a vancomycin minimum inhibitory concentration (MIC) < 1.5 mg/L, the multivariate analysis revealed that HA genotypes and cuffed tunneled catheter use were associated with treatment failure. For isolates with a vancomycin MIC ≥1.5 mg/L, the only risk factor for treatment failure was a higher Pitt score (OR: 1.76; 95% CI, 1.02-3.05; p = 0.043).

CONCLUSION

CA genotypes, but not the epidemiological classification of CO-MRSA, impacted the clinical outcome of MRSA bacteremia in the HD population.

An interoperable clinical decision-support system for early detection of SIRS in pediatric intensive care using openEHR

BACKGROUND

Clinical decision-support systems (CDSS) are designed to solve knowledge-intensive tasks for supporting decision-making processes. Although many approaches for designing CDSS have been proposed, due to high implementation costs, as well as the lack of interoperability features, current solutions are not well-established across different institutions. Recently, the use of standardized formalisms for knowledge representation as terminologies as well as the integration of semantically enriched clinical information models, as openEHR Archetypes, and their reuse within CDSS are theoretically considered as key factors for reusable CDSS.

OBJECTIVE

We aim at developing and evaluating an openEHR based approach to achieve interoperability in CDSS by designing and implementing an exemplary system for automated systemic inflammatory response syndrome (SIRS) detection in pediatric intensive care.

METHODS

We designed an interoperable concept, which enables an easy integration of the CDSS across different institutions, by using openEHR Archetypes, terminology bindings and the Archetype Query Language (AQL). The practicability of the approach was tested by (1) implementing a prototype, which is based on an openEHR based data repository of the Hannover Medical School (HaMSTR), and (2) conducting a first pilot study.

RESULTS

We successfully designed and implemented a CDSS with interoperable knowledge bases and interfaces by reusing internationally agreed-upon Archetypes, incorporating LOINC terminology and creating AQL queries, which allowed retrieving dynamic facts in a standardized and unambiguous form. The technical capabilities of the system were evaluated by testing the prototype on 16 randomly selected patients with 129 days of stay, and comparing the results with the assessment of clinical experts (leading to a sensitivity of 1.00, a specificity of 0.94 and a Cohen's kappa of 0.92).

CONCLUSIONS

We found the use of openEHR Archetypes and AQL a feasible approach to bridge the interoperability gap between local infrastructures and CDSS. The designed concept was successfully transferred into a clinically evaluated openEHR based CDSS. To the authors' knowledge, this is the first openEHR based CDSS, which is technically reliable and capable in a real context, and facilitates clinical decision-support for a complex task. Further activities will comprise enrichments of the knowledge base, the reasoning processes and cross-institutional evaluations.

Prevalence of the systemic inflammatory response syndrome in patients who underwent orthognathic surgery

PURPOSE

The systemic inflammatory response syndrome (SIRS) is the body's response to an insult, such as infection, trauma, burn, and surgical stress linked to several factors deemed potential for multiple organ failure if left untreated. Thus, the aim of this paper was a prospective study to examine the incidence of SIRS in postoperative patients who underwent orthognathic surgery from June/2013 to July/2016.

METHODS

The sample consisted of 80 patients who underwent bimaxillary orthognathic surgery, with data on vital signs and white blood cell count collected preoperatively, and the same data collected in the immediate postoperative period, in addition to CO₂ pressure in arterial blood by blood gas analysis. The data were tabulated and cases of SIRS (2 or more signs out of four pre-set signs) were identified within 24 h after surgery.

RESULTS

From the sample of 80 patients, 26 (32.5% of total) patients had SIRS with higher incidence in females who are 40 years old.

CONCLUSION

The incidence of patients who develop SIRS after orthognathic surgery is relatively high and we should pay attention to the possible complications that these cases can evolve.

Inflammatory Mediator Profiles Differ in Sepsis Patients With and Without Bacteremia

Systemic levels of cytokines are altered during infection and sepsis. This prospective observational study aimed to investigate whether plasma levels of multiple inflammatory mediators differed between sepsis patients with and those without bacteremia during the initial phase of hospitalization. A total of 80 sepsis patients with proven bacterial infection and no immunosuppression were included in the study. Plasma samples were collected within 24 h of hospitalization, and Luminex^® analysis was performed on 35 mediators: 16 cytokines, six growth factors, four adhesion molecules, and nine matrix metalloproteases (MMPs)/tissue inhibitors of metalloproteinases (TIMPs). Forty-two patients (52.5%) and 38 (47.5%) patients showed positive and negative blood cultures, respectively. There were significant differences in plasma levels of six soluble mediators between the two “bacteremia” and “non-bacteremia” groups, using Mann–Whitney U test (p < 0.0014): tumor necrosis factor alpha (TNFα), CCL4, E-selectin, vascular cell adhesion molecule-1 (VCAM-1), intracellular adhesion molecule-1 (ICAM-1), and TIMP-1. Ten soluble mediators also significantly differed in plasma levels between the two groups, with p-values ranging between 0.05 and 0.0014: interleukin (IL)-1ra, IL-10, CCL2, CCL5, CXCL8, CXCL11, hepatocyte growth factor, MMP-8, TIMP-2, and TIMP-4. VCAM-1 showed the most robust results using univariate and multivariate logistic regression. Using unsupervised hierarchical clustering, we found that TNFα, CCL4, E-selectin, VCAM-1, ICAM-1, and TIMP-1 could be used to discriminate between patients with and those without bacteremia. Patients with bacteremia were mainly clustered in two separate groups (two upper clusters, 41/42, 98%), with higher levels of the mediators. One (2%) patient with bacteremia was clustered in the lower cluster, which compromised most of the patients without bacteremia (23/38, 61%) (χ² test, p < 0.0001). Our study showed that analysis of the plasma inflammatory mediator profile could represent a potential strategy for early identification of patients with bacteremia.

Impact of bacterial translocation in calves with atresia coli

OBJECTIVE

To identify whether enteric bacteria pass into the mesenteric lymph nodes (MLNs) and peritoneal cavity in calves with atresia coli and to evaluate whether the presence of bacterial translocation (BT) has an impact on the success of surgical treatment.

DESIGN

Prospective clinical study.

ANIMALS

Twenty-six client-owned calves.

INTERVENTIONS

During laparotomy, swab samples were collected from the peritoneal cavity and MLNs using a sterile swab stick and were submitted for microbiological analysis.

MEASUREMENTS AND MAIN RESULTS

Bacterial cultures of swab samples revealed that 65% (n = 17) of the calves experienced BT. Of these, 14 calves experienced BT to the MLNs, 9 to the peritoneal cavity, and 5 to both regions. Of the bacteria isolated from the MLNs, 72% (n = 10) were Escherichia coli. Of the samples isolated from the peritoneal fluid, 33% (n = 3) contained E. coli and 33% (n = 3) contained E. coli + coagulase-negative Staphylococcus (CNS). In calves with BT that were discharged (n = 13) and without BT that were discharged (n = 7), the median survival was 30 days; these data were found to be similar in the 2 groups.

CONCLUSIONS

This study revealed that BT is observed in the majority of atresia coli cases. E. coli is more common in BT, and translocation occurs primarily through the lymphatic route. These results suggest that the presence of BT is closely related to the success of the operation for correction of atresia coli.

An update on classification and management of urosepsis

PURPOSE OF REVIEW

The urinary tract is the infection site in severe sepsis/septic shock in 10-30%.

RECENT FINDINGS

There is a new Sepsis definition focusing on severe sepsis. Urosepsis is mainly due to obstructed uropathy of the upper urinary tract. The pathogenesis of sepsis is complex and is driven by the innate immune system. In the further course immunosuppression is developing.Management of urosepsis includes early diagnosis, early initiation of treatment such as identification and control of the complicating factor in the urinary tract and the specific sepsis therapy. As part of early diagnosis the value of the new defining criteria is still to be known. The management bundles are regularly updated according to the surviving sepsis campaign guidelines.

SUMMARY

Sepsis has still a high morbidity and mortality rate. Although definition and diagnosis of sepsis has been recently updated, its translation into urosepsis management requires validation.

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.

Evaluation of updated sepsis scoring systems and systemic inflammatory response syndrome criteria and their association with sepsis in equine neonates

Background

The original equine sepsis score provided a method of identifying foals with sepsis. New variables associated with sepsis have been evaluated, but the sepsis score has not been updated.

Objectives

To evaluate the sensitivity and specificity of 2 updated sepsis scores and the systemic inflammatory response syndrome (SIRS) criteria in regard to detecting sepsis in foals.

Animals

Two‐hundred and seventy‐three ill foals and 25 healthy control foals.

Methods

Historical, physical examination, and clinicopathologic findings were used to calculate the original sepsis score and 2 updated sepsis scores. SIRS criteria were also evaluated. Sepsis scores and positive SIRS scores were statistically compared to foals with sepsis.

Results

One‐hundred and twenty‐six foals were septic and 147 sick‐nonseptic. The original and updated sepsis scores were significantly higher in septic foals as compared to sick‐nonseptic and healthy foals. The sensitivity and specificity of the updated sepsis scores to predict sepsis were not significantly better than those of the original sepsis score. One‐hundred and twenty‐seven of 273 (46.5%) foals met the original SIRS criteria and 88/273 (32%) foals met the equine neonatal SIRS criteria. The original SIRS criteria had similar sensitivity and specificity for predicting sepsis as did the 3 sepsis scores in our study.

Conclusions and Clinical Importance

The updated sepsis scores did not provide improved ability in predicting sepsis. Fulfilling the original SIRS criteria provided similar sensitivity and specificity in predicting sepsis as the modified sepsis score and might serve as a diagnostic aid in identifying foals at risk for sepsis.

Potentially Important Therapeutic Interactions between Antibiotics, and a Specially Engineered Emulsion Drug Vehicle Containing Krill-Oil-Based Phospholipids and Omega-3 Fatty Acids

The incidence of antimicrobial resistance (AMR) worldwide is increasing as the pipeline for the development of new chemotherapeutic entities is decreasing. Clearly, overexposure to antibiotics, including excessive dosing, is a key factor that fuels AMR. In fact, most of the new antibacterial agents under development are derivatives of existing classes of antibiotics. Novel approaches involving unique antimicrobial combinations, targets, and/or delivery systems are under intense investigation. An innovative combination of active pharmaceutical ingredients (APIs) consisting of antimicrobial drug(s), krill-oil-based phospholipids, and omega-3 fatty acid triglycerides, that may extend the therapeutic viability of currently effective antibiotics, at least until new chemical entities are introduced, is described.

Thiamine as a Renal Protective Agent in Septic Shock. A Secondary Analysis of a Randomized, Double-Blind, Placebo-controlled Trial

RATIONALE

Acute kidney injury (AKI) is common in patients with sepsis and has been associated with high mortality rates. The provision of thiamine to patients with sepsis may reduce the incidence and severity of sepsis-related AKI and thereby prevent renal failure requiring renal replacement therapy (RRT).

OBJECTIVES

To test the hypothesis that thiamine supplementation mitigates kidney injury in septic shock.

METHODS

This was a secondary analysis of a single-center, randomized, double-blind trial comparing thiamine to placebo in patients with septic shock. Renal function, need for RRT, timing of hemodialysis catheter placement, and timing of RRT initiation were abstracted. The baseline creatinine and worst creatinine values between 3 and 24 hours, 24 and 48 hours, and 48 and 72 hours were likewise abstracted.

RESULTS

There were 70 patients eligible for analysis after excluding 10 patients in whom hemodialysis was initiated before study drug administration. Baseline serum creatinine in the thiamine group was 1.2 mg/dl (interquartile range, 0.8-2.5) as compared with 1.8 mg/dl (interquartile range, 1.3-2.7) in the placebo group (P = 0.3). After initiation of the study drug, more patients in the placebo group than in the thiamine group were started on RRT (eight [21%] vs. one [3%]; P = 0.04). In the repeated measures analysis adjusting for the baseline creatinine level, the worst creatinine levels were higher in the placebo group than in the thiamine group (P = 0.05).

CONCLUSIONS

In this post hoc analysis of a randomized controlled trial, patients with septic shock randomized to receive thiamine had lower serum creatinine levels and a lower rate of progression to RRT than patients randomized to placebo. These findings should be considered hypothesis generating and can be used as a foundation for further, prospective investigation in this area.

Emergence of multidrug-resistant sequence type 45 strains among mecA-positive borderline oxacillin-resistant Staphylococcus aureus causing bacteraemia in a medical centre in Taiwan

Clinical data related to bacteraemia caused by mecA-positive borderline oxacillin-resistant Staphylococcus aureus (BORSA) isolates [minimum inhibitory concentrations (MICs) of 0.5-4 mg/L] are limited. Patients aged ≥15 years with bacteraemia due to BORSA who were admitted to the emergency department of a Taiwanese tertiary hospital between January 2001 and December 2015 were evaluated. Clinical characteristics of patients with bacteraemia caused by BORSA, methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) were compared. MICs of 12 antibiotics were determined by agar dilution. Genetic characteristics of 64 available BORSA isolates were analysed by detection of the SCCmec gene, the mecA promoter region sequence and multilocus sequence typing (MLST). Pulsed-field gel electrophoresis (PFGE) was performed to identify the clonality of the emerging ST isolates. The quinolone resistance genes were analysed for the emerging ciprofloxacin-resistant ST45 clone isolates. Among the 65 BORSA bacteraemic patients, in-hospital mortality was 24.6%, significantly lower than that of MRSA patients (38.5%) (P = 0.03). Underlying conditions were similar between BORSA and MRSA patients, but with less dialysis in the former (P = 0.01). Multivariate analysis revealed that septic shock [odds ratio (OR) = 15.95] and bacteraemia originating from lower respiratory tract infection (OR = 5.78) were two independent risk factors for 30-day mortality. The ST45 clone with high-level ciprofloxacin resistance (MICs of 8-128 mg/L) replaced ST59 as the predominant clone since 2012, although no major clustering was detected. In conclusion, the emerging multidrug-resistant ST45 clone has replaced ST59 as the most common among BORSA isolates.

Burn injury mortality in patients with preexisting and new onset renal disease

INTRODUCTION

We sought to examine the impact of preexisting and new onset renal disease on burn injury mortality.

METHODS

Retrospective analysis of patients admitted to a regional burn center from 2002-2012 was performed. Variables analyzed included demographics, burn mechanism, inhalation injury status, and % TBSA. Poisson regression was performed to estimate risk of in-hospital burn mortality.

RESULTS

There were a total of 7640 patients over the study period. The adjusted 60-day risk of in-hospital mortality in patients with preexisting renal disease (PRD was 3 times higher compared to patients with no preexisting renal disease (IRR = 3.22, 95% CI = 1.26-8.25). The adjusted 60-day risk of mortality is 2 times higher for patients with new onset renal disease compared to those without (IRR = 2.11, 95% CI = 1.55-2.87).

CONCLUSION

Preexisting and new onset renal disease results in a significantly higher risk of mortality following burn injury compared to patients without renal disease. Prevention of new onset renal injury and careful management of patients with preexisting renal disease to prevent exacerbation should be pursued.

Systemic Inflammatory Response Syndrome Is Not an Indicator of Bacteremia in Hemodialysis Patients With Native Accesses: A Multicenter Study

Bloodstream infection (BSI) in hemodialysis (HD) patients is often difficult to diagnose. Systemic inflammatory response syndrome (SIRS) is a sensitive predictor of BSI in the general population. We aimed to assess the usefulness of SIRS in predicting BSI in HD patients. We designed a multicenter retrospective observational study of adult (age > 18 years) HD patients who underwent two sets of blood cultures for suspected BSI at first hospital visit from August 2011 to July 2012. Clinical, biological, and microbial data were evaluated to evaluate SIRS as a predictor of BSI upon initial presentation to the hospital. Data were obtained from 279 HD patients. Vascular access other than arteriovenous fistula and subcutaneously fixed superficial artery, and those administered antimicrobial drugs before visit were excluded; thus, a total of 202 patients were finally enrolled. Mean patient age was 71 years, 67.3% were male, 49.3% had diabetes, 28.2% had indwelling hardware, and 18.3% patients had BSI. Endocarditis and vertebral osteomyelitis were common infection sites, and Staphylococcus aureus was the most common pathogen. Of those with SIRS, 25.3% had BSI and 74.7% did not (odds ratio for SIRS, 2.10; 95% confidence interval, 0.90-4.91; p = 0.11). Thus, SIRS had a low sensitivity for predicting BSI in HD patients (sensitivity, 71.9%; specificity, 45.2%; positive likelihood ratio, 1.31; negative likelihood ratio, 0.62). Systemic inflammatory response syndrome has low sensitivity in identifying BSI in HD patients. A low threshold for drawing blood cultures and initiating antibiotic treatment should be considered for HD patients.

Free Total Rhubarb Anthraquinones Protect Intestinal Injury via Regulation of the Intestinal Immune Response in a Rat Model of Severe Acute Pancreatitis

Intestinal mucosal immune barrier dysfunction plays a key role in the pathogenesis of severe acute pancreatitis (SAP). Rhubarb is a commonly used traditional Chinese medicine as a laxative in China. It markedly protects pancreatic acinar cells from trypsin-induced injury in rats. Free total rhubarb anthraquinones (FTRAs) isolated and extracted from rhubarb display the beneficial effects of antibacteria, anti-inflammation, antivirus, and anticancer. The principal aim of the present study was to investigate the effects of FTRAs on the protection of intestinal injury and modification of the intestinal barrier function through regulation of intestinal immune function in rats with SAP. We established a rat model of SAP by injecting 3.5% sodium taurocholate (STC, 350 mg/kg) into the biliopancreatic duct via retrograde injection and treated the rats with FTRAs (36 or 72 mg/kg) or normal saline (control) immediately and 12 h after STC injection. Then, we evaluated the protective effect of FTRAs on intestinal injury by pathological analysis and determined the levels of endotoxin (ET), interleukin 1β (IL-1β), tumor necrosis factor α (TNF-α), nitric oxide (NO), myeloperoxidase (MPO), capillary permeability, nucleotide-binding oligomerization domain-like receptors 3 (NLRP3), apoptosis-associated speck-like protein containing a CARD domain (ASC), casepase-1, secretary immunoglobulin A (SIgA), regulatory T cells (Tregs), and the ratio of Th1/Th2 in the blood and/or small intestinal tissues or mesenteric lymph node (MLN) cells. Moreover, the chemical profile of FTRAs was analyzed by HPLC-UV chromatogram. The results showed that FTRAs significantly protected intestinal damage and decreased the levels of ET, IL-1β, TNF-α, and NO in the blood and TNF-α, IL-1β, and protein extravasation in the intestinal tissues in SAP rats. Furthermore, FTRAs significantly decreased the expressions of NLRP3, ASC, and caspase-1, the number of Tregs and the ratio of Th1/Th2, while significantly increased the expression of SIgA in the intestinal tissues and/or MLN cells in SAP rats. Our results indicate that FTRAs could protect intestinal injury and improve intestinal mucosal barrier function through regulating immune function of SAP rats. Therefore, FTRAs may have the potential to be developed as the novel agent for the treatment of SAP clinically.

Oleic acid chlorohydrin, a new early biomarker for the prediction of acute pancreatitis severity in humans

BACKGROUND

The early prediction of the severity of acute pancreatitis still represents a challenge for clinicians. Experimental studies have revealed the generation of specific halogenated lipids, in particular oleic acid chlorohydrin, in the early stages of acute pancreatitis. We hypothesized that the levels of circulating oleic acid chlorohydrin might be a useful early prognostic biomarker in acute pancreatitis in humans.

METHODS

In a prospective, multicenter cohort study, plasma samples collected within 24 h after presentation in the emergency room from 59 patients with acute pancreatitis and from 9 healthy subjects were assessed for oleic acid chlorohydrin levels.

RESULTS

Pancreatitis was mild in 30 patients, moderately severe in 16 and severe in 13. Oleic acid chlorohydrin levels within 24 h after presentation were significantly higher in patients that later progressed to moderate and severe acute pancreatitis. Using 7.49 nM as the cutoff point, oleic acid chlorohydrin distinguished mild from moderately severe-to-severe pancreatitis with high sensitivity/specificity (96.6/90.0%) and positive/negative predictive values (90.3/96.4%). Using 32.40 nM as the cutoff value sensitivity, specificity, positive and negative predictive values were all 100% for severe acute pancreatitis. It was found to be a better prognostic marker than BISAP score, hematocrit at 48 h, SIRS at admission, persistent SIRS or C-reactive protein at 48 h.

CONCLUSIONS

Oleic acid chlorohydrin concentration in plasma is elevated in patients with acute pancreatitis on admission and correlates with a high degree with the final severity of the disease, indicating that it has potential to serve as an early prognostic marker for acute pancreatitis severity.

Outcomes of severe sepsis and septic shock patients after stratification by initial lactate value

BACKGROUND

In the setting of severe sepsis and septic shock, mortality increases when lactate levels are ≥ 4 mmol/L. However, the consequences of lower lactate levels in this population are not well understood. The study aimed to determine the in-hospital mortality associated with severe sepsis and septic shock when initial lactate levels are < 4 mmol/L.

METHODS

This is a retrospective cohort study of septic patients admitted over a 40-month period. Totally 338 patients were divided into three groups based on initial lactate values. Group 1 had lactate levels < 2 mmol/L; group 2: 2-4 mmol/L; and group 3: ≥ 4 mmol/L. The primary outcome was in-hospital mortality.

RESULTS

There were 111 patients in group 1, 96 patients in group 2, and 131 in group 3. The mortality rates were 21.6%, 35.4%, and 51.9% respectively. Univariate analysis revealed the mortality differences to be statistically significant. Multivariate logistic regression demonstrated higher odds of death with higher lactate tier group, however the findings did not reach statistical significance.

CONCLUSION

This study found that only assignment to group 3, initial lactic acid level of ≥ 4 mmol/L, was independently associated with increased mortality after correcting for underlying severity of illness and organ dysfunction. However, rising lactate levels in the other two groups were associated with increased severity of illness and were inversely proportional to prognosis.

Cell Membrane-Derived Microvesicles in Systemic Inflammatory Response

Human body reacts to physical, chemical and biological insults with a complex inflammatory reaction. Crucial components and executors of this response are endothelial cells, platelets, white blood cells, plasmatic coagulation system, and complement. Endothelial injury and inflammation are associated with elevated blood levels of cell membrane-derived microvesicles. Increased concentrations of microvesicles were found in several inflammatory reactions and diseases including acute coronary syndromes, stroke, vasculitis, venous thromboembolism, multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, anti-phospholipid antibody syndrome, inflammatory bowel disease, thrombotic thrombocytopenic purpura, viral myocarditis, sepsis, disseminated intravascular coagulation, polytrauma, and burns. Microvesicles can modulate a variety of cellular processes, thereby having an impact on pathogenesis of diseases associated with inflammation. Microvesicles are important mediators and potential biomarkers of systemic inflammation. Measurement of inflammatory cell-derived microvesicles may be utilized in diagnostic algorithms and used for detection and determination of severity in diseases associated with inflammatory responses, as well as for prediction of their outcome. This review focuses on the mechanisms of release of microvesicles in diseases associated with systemic inflammation and their potential role in the regulation of cellular and humoral interactions.

Clinical utility of an optimised multiplex real-time PCR assay for the identification of pathogens causing sepsis in Vietnamese patients

INTRODUCTION

For the identification of bacterial pathogens, blood culture is still the gold standard diagnostic method. However, several disadvantages apply to blood cultures, such as time and rather large volumes of blood sample required. We have previously established an optimised multiplex real-time PCR method in order to diagnose bloodstream infections.

MATERIAL AND METHODS

In the present study, we evaluated the diagnostic performance of this optimised multiplex RT-PCR in blood samples collected from 110 septicaemia patients enrolled at the 108 Military Central Hospital, Hanoi, Vietnam.

RESULTS

Positive results were obtained by blood culture, the Light Cylcler-based SeptiFast^® assay and our multiplex RT-PCR in 35 (32%), 31 (28%), and 31 (28%) samples, respectively. Combined use of the three methods confirmed 50 (45.5%) positive cases of bloodstream infection, a rate significantly higher compared to the exclusive use of one of the three methods (P=0.052, 0.012 and 0.012, respectively). The sensitivity, specificity and area under the curve (AUC) of our assay were higher compared to that of the SeptiFast^® assay (77.4%, 86.1% and 0.8 vs. 67.7%, 82.3% and 0.73, respectively). Combined use of blood culture and multiplex RT-PCR assay showed a superior diagnostic performance, as the sensitivity, specificity, and AUC reached 83.3%, 100%, and 0.95, respectively. The concordance between blood culture and the multiplex RT-PCR assay was highest for Klebsiella pneumonia (100%), followed by Streptococcus spp. (77.8%), Escherichia coli (66.7%), Staphylococcus spp. (50%) and Salmonella spp. (50%). In addition, the use of the newly established multiplex RT-PCR assay increased the spectrum of identifiable agents (Acintobacter baumannii, 1/32; Proteus mirabilis, 1/32).

CONCLUSION

The combination of culture and the multiplex RT-PCR assay provided an excellent diagnostic accomplishment and significantly supported the identification of causative pathogens in clinical samples obtained from septic patients.

Clinical implications of the plasma EphA2 receptor level in critically ill patients with septic shock

The Eph/ephrin receptor ligand system is known to play a role in inflammation induced by infection, injury, and inflammatory diseases. The present study aimed to evaluate plasma EphA2 receptor levels in critically ill patients with sepsis. This study was a prospective cohort study evaluating samples and clinical data from the medical intensive care unit (MICU) of a 2000-bed university tertiary referral hospital in South Korea. Positive correlations of the plasma EphA2 receptor level with the acute physiology and chronic health evaluation (APACHE) II score and the sequential organ failure assessment (SOFA) score were observed. The area under the curve (AUC) for the plasma EphA2 receptor level on a receiver operating characteristic curve was 0.690 (95% confidence interval [CI], 0.608-0.764); the AUCs for the APACHE II score and SOFA scores were 0.659 (95% CI, 0.576-0.736) and 0.745 (95% CI, 0.666-0.814), respectively. A Cox proportional hazard model identified an association between an increased plasma EphA2 receptor level (>51.5 pg mL-1) and increased risk of 28-day mortality in the MICU (hazard ratio = 3.22, 95% CI, 1.709-6.049). An increased plasma EphA2 receptor level was associated with sepsis severity and 28-day mortality among sepsis patients.

Predictors of Mortality in Septic Shock: Findings for 57 Patients Diagnosed on Admission to Emergency or within 24 hours of Admission to Intensive Care

Objective

To identify the risk factors that influence outcome for patients who are diagnosed with septic shock in the emergency department at presentation or within 24 hours after admission to intensive care unit.

Methods

A retrospective study of 57 adult patients with septic shock was conducted between March 1, 2006 and August 31, 2009.

Results

The patients were 23 males and 34 females with a median age of 67 years (20 to 92 years). Thirty-three (58%) of 57 patients died in hospital and 24 (42%) survived. Multivariate analysis identified low blood pH (OR <0.001; 95% CI <0.001-0.53) and low bicarbonate level (OR 0.81; 95% CI 0.70-0.95) at emergency department or intensive care unit admission as useful predictors of 3-day in-hospital mortality. Low blood pH (OR <0.001; 95% CI <0.001-0.05), low bicarbonate level (OR 0.75; 95% CIs 0.61-0.91), long duration of symptoms (OR 1.49; 95% CI 1.04-2.13), high MEDS score (OR 1.56; 95% CIs 1.06-2.30), and high SOFA score (OR 1.57; 95% CI 1.12-2.20) were risk factors for 14-day in-hospital mortality. Renal failure (OR 7.58; 95% CI 1.28-44.77), lower pulmonary tract infection (OR 3.58; 95% CI 1.10-11.58), high MEDS score (OR 1.42; 95% CI 1.05-1.93) and high APACHE II score (OR 1.34; 95% CI 1.13-1.60) were risk factors for 28-day in-hospital mortality.

Conclusions

Several factors signaling poor short-term outcome for this patient group are low blood pH, low serum bicarbonate level, longer duration of symptoms, lower respiratory tract infection and renal failure. MEDS and SOFA scores might be helpful in the ED to stratify patients with septic shock according to mortality risk.

Screening itself for disseminated intravascular coagulation may reduce mortality in sepsis: A nationwide multicenter registry in Japan

OBJECTIVES

Screening of patients with sepsis for disseminated intravascular coagulation (DIC) has been recommended in several guidelines. However, DIC screening is still not widely accepted as an essential component of sepsis management, partly because of a lack of evidence that DIC screening has an effect on mortality. We investigated whether DIC screening was associated with a survival benefit in patients with sepsis.

DESIGN

Post hoc analysis of a nationwide multicenter retrospective cohort study.

SETTING

42 intensive care units in Japan.

PARTICIPANTS

2663 adult patients diagnosed as having severe sepsis: 1893 (71.1%) patients were considered candidates for and 770 (28.9%) patients were not considered candidates for International Society of Thrombosis and Hemostasis (ISTH) overt DIC screening on ICU day 1.

MAIN OUTCOME MEASURES

The primary outcome measure was all-cause in-hospital mortality. Patients were stratified according to whether DIC screening was performed at the time of ICU admission (day 1) to investigate the survival effect associated with DIC screening. We also evaluated survival benefit by classifying patients according to whether DIC screening was performed on day 1 and repeated on day 3. Effects of screening on mortality were assessed using Cox proportional hazards models adjusted by the inverse probability of treatment weighting (IPTW) method using propensity scoring.

RESULTS

After adjustment for imbalances, ISTH overt DIC screening on day 1 was associated with significantly lower mortality (IPTW-adjusted HR: 0.836; 95% confidence interval [CI]: 0.711-0.984), and this association became even stronger when ISTH overt DIC screening was repeated on day 3 (IPTW-adjusted HR: 0.727; 95% CI: 0.597-0.884). Besides, we observed an almost comparable effect on mortality associated with DIC screening using the Japanese Association for Acute Medicine criteria.

CONCLUSION

DIC screening was associated with a reduction in mortality in patients with sepsis. This association could be even stronger by repeating DIC screening.

Tension pneumocephalus mimicking septic shock: a case report

Tension pneumocephalus can lead to rapid neurologic deterioration. We report for the first time its association with aseptic systemic inflammatory response syndrome mimicking septic shock and the efficacy of prompt neurosurgical intervention and critical care support in treating this condition. A 64-year-old man underwent 2-stage olfactory groove meningioma resection. The patient developed altered mental status and gait instability on postoperative day 6. Imaging showed significant pneumocephalus. The patient subsequently developed worsening mental status, respiratory failure, and profound shock requiring multiple vasopressors. Bedside needle decompression, identification and repair of the cranial fossa defect, and critical care support led to improved mental status and reversal of shock and multiorgan dysfunction. Thorough evaluation revealed no evidence of an underlying infection. In this case, tension pneumocephalus incited an aseptic systemic inflammatory response syndrome mimicking septic shock. Prompt neurosurgical correction of pneumocephalus and critical care support not only improved neurologic status, but also reversed shock. Such a complication indicates the importance of close monitoring of patients with progressive pneumocephalus.

Impact of systemic inflammatory response syndrome and surgical Apgar score on post-operative acute kidney injury

BACKGROUND

Surgical Apgar Score (SAS) is relatively weakly associated with post-operative outcomes in emergency surgery, compared with elective surgery. A combination of systemic inflammatory response syndrome (SIRS) and SAS may be useful for prediction of poor outcomes after emergency surgery.

METHODS

A retrospective study was conducted in patients who underwent emergency abdominal or cerebral surgery from January 2005 to December 2010. AKI was diagnosed using Acute Kidney Injury Network criteria for 2 days after surgery. Pre-operative SIRS was defined as SIRS score ≥ 2. Patients were divided into those with SAS ≥ 5 and < 5. Independent risk factors for post-operative AKI were identified. Ability to predict post-operative AKI was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Of 742 patients, 175 (24%) had post-operative AKI. Pre-operative SIRS (OR 1.9, 95% CI: 1.2-2.9, P < 0.01) and SAS < 5 (OR 2.6, 95% CI: 1.7-4.1, P < 0.01) were independent risk factors for post-operative AKI. Patients without SIRS and SAS < 5 had an increased risk of post-operative AKI (odds ratio (OR) 3.6, 95% confidence interval (CI) 1.9-6.7, P < 0.01) and those with SIRS and SAS < 5 had increased risks of post-operative AKI (OR 5.9, 95% CI: 3.7-9.3, P < 0.01) and hospital mortality (OR 3.5, 95% CI: 1.9-6.3, P < 0.01). In ROC analysis, the c-statistic using both SIRS and SAS < 5 was 0.81 (95% CI: 0.77-0.84, P < 0.01) and higher than without use of these factors (P < 0.01).

CONCLUSION

Pre-operative SIRS and SAS are independently associated with post-operative AKI. Simultaneous use of pre-operative SIRS and SAS may improve prediction of poor post-operative outcomes.

Reducing patient mortality, length of stay and readmissions through machine learning-based sepsis prediction in the emergency department, intensive care unit and hospital floor units

Introduction

Sepsis management is a challenge for hospitals nationwide, as severe sepsis carries high mortality rates and costs the US healthcare system billions of dollars each year. It has been shown that early intervention for patients with severe sepsis and septic shock is associated with higher rates of survival. The Cape Regional Medical Center (CRMC) aimed to improve sepsis-related patient outcomes through a revised sepsis management approach.

Methods

In collaboration with Dascena, CRMC formed a quality improvement team to implement a machine learning-based sepsis prediction algorithm to identify patients with sepsis earlier. Previously, CRMC assessed all patients for sepsis using twice-daily systemic inflammatory response syndrome screenings, but desired improvements. The quality improvement team worked to implement a machine learning-based algorithm, collect and incorporate feedback, and tailor the system to current hospital workflow.

Results

Relative to the pre-implementation period, the post-implementation period sepsis-related in-hospital mortality rate decreased by 60.24%, sepsis-related hospital length of stay decreased by 9.55% and sepsis-related 30-day readmission rate decreased by 50.14%.

Conclusion

The machine learning-based sepsis prediction algorithm improved patient outcomes at CRMC.

Comparison of the performance of SOFA, qSOFA and SIRS for predicting mortality and organ failure among sepsis patients admitted to the intensive care unit in a middle-income country

INTRODUCTION

The Sepsis-3 definition provides a change of two or more scores from zero or a known baseline of the Sequential Organ Failure Assessment (SOFA) as criteria of sepsis. The aim of this study was to compare the SOFA score and the quick SOFA (qSOFA) to Systemic Inflammatory Response Syndrome (SIRS) criteria in predictive ability of mortality and organ failure.

METHODS

A-10year retrospective cohort study was conducted in a teaching hospital in Thailand.

RESULTS

A total of 2350 of mixed sepsis patients by Sepsis-2 definition were included. The all-cause hospital mortality rate was 44.5%. Of the total sample, 95.6% (n=2247) of patients met criteria for sepsis under the Sepsis-3 definition. The SOFA score presented the best discrimination with an area under the receiver operating characteristic curve (AUC) of 0.839. The AUC of SOFA score for hospital mortality was significantly higher than qSOFA (AUC 0.814, P=0.003) and SIRS (AUC 0.587, P<0.0001). Also, the SOFA score had superior performance than other scores for predicting intensive care unit (ICU) mortality and organ failure.

CONCLUSIONS

The SOFA is a superior prognostic tool for predicting mortality and organ failure than qSOFA and SIRS criteria among sepsis patients admitted to the ICU.

SIRS in the Time of Sepsis-3

Severe sepsis is a common, deadly, and diagnostically vexing condition. Recent recommendations for diagnosing sepsis, referred to as consensus guidelines, provide a definition of sepsis and remove the systemic inflammatory response syndrome (SIRS) as a component of the diagnostic process. A concise definition of sepsis is welcomed. However, the approach to developing these guidelines, although thorough, had weaknesses. Emphasis is placed on mortality prediction rather than on early diagnosis. Diagnostic criteria are recommended to replace current criteria without evidence of any effect that their use would have on mortality. SIRS is a prevalent feature of patients with sepsis, should remain an important component of the diagnostic process, and remains a valuable term for discussing patients with life-threatening organ dysfunction caused by infection.

Sepsis and Septic Shock Strategies

Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.

Sepsis Definitions: A Work in Progress

The word, sepsis, dates back more than 2 millennia but has, over the past 2 centuries, come to be applied first to the clinical state evoked by invasive infection and, more recently, to describe the syndrome resulting from the host response to infection. Further refinements embodied in the recently published Sepsis-3 definition underline the concept of a dysregulated immune response resulting in potentially modifiable life-threatening organ dysfunction. This review summarizes the evolution and limitations of efforts to characterize a common and complex disorder.

Bacterial outer membrane vesicles suppress tumor by interferon-γ-mediated antitumor response

Gram-negative bacteria actively secrete outer membrane vesicles, spherical nano-meter-sized proteolipids enriched with outer membrane proteins, to the surroundings. Outer membrane vesicles have gained wide interests as non-living complex vaccines or delivery vehicles. However, no study has used outer membrane vesicles in treating cancer thus far. Here we investigate the potential of bacterial outer membrane vesicles as therapeutic agents to treat cancer via immunotherapy. Our results show remarkable capability of bacterial outer membrane vesicles to effectively induce long-term antitumor immune responses that can fully eradicate established tumors without notable adverse effects. Moreover, systematically administered bacterial outer membrane vesicles specifically target and accumulate in the tumor tissue, and subsequently induce the production of antitumor cytokines CXCL10 and interferon-γ. This antitumor effect is interferon-γ dependent, as interferon-γ-deficient mice could not induce such outer membrane vesicle-mediated immune response. Together, our results herein demonstrate the potential of bacterial outer membrane vesicles as effective immunotherapeutic agent that can treat various cancers without apparent adverse effects.

Bacterial outer membrane vesicles (OMVs) contain immunogens but no study has yet examined their potential in treating cancer. Here, the authors demonstrate that OMVs can suppress established tumours and prevent tumour metastasis by an interferon-γ mediated antitumor response.

Clinical manifestations, risk factors and prognosis of patients with Morganella morganii sepsis

BACKGROUND

There are few studies of Morganella bacteremia. We evaluated risk factors and outcome of patients with Morganella bacteremia.

METHODS

Medical records of patients with Morganella bacteremia were reviewed (1997-2014). Control group patients with Escherichiacoli sepsis were matched by year of diagnosis and infection acquisition site.

RESULTS

The study group included 136 adult patients. Mean age and gender of study and control groups were similar. Complicated soft tissue infection was more prevalent in the study group (30% versus 3.2%, p < 0.05). The Charlson Comorbidity Index (CCI) was higher in the study group (4.3 ± 2.5 versus 3.4 ± 2.8, p < 0.05). Only 78 (62%) of the study patients versus 101 (83%) of the control group (p < 0.05), received appropriate empirical antibiotic treatment. A significantly higher in-hospital mortality rate (42% versus 25%, p < 0.05) as well as longer length of stay (25 ± 22 versus 14 ± 16 days, p < 0.05) was observed in the study group. Multivariate analysis revealed that a debilitative state, a CCI > 4, septic shock and a clinical syndrome other than UTI were all significant risk factors for mortality (p < 0.05).

CONCLUSIONS

Patients with Morganellamorganii sepsis had more co-morbidities and a worse degree of sepsis. There is an increased risk of inappropriate empirical treatment, longer hospitalization and higher death rate.