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Khan S, Bolotova O, Sahib H, Foster D, Mallipattu SK. Endotoxemia in Critically Ill Patients with COVID-19. Blood Purif 2021; 51:513-519. [PMID: 34515062 PMCID: PMC8450835 DOI: 10.1159/000518230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022]
Abstract
Introduction Mechanism(s) mediating critical illness in coronavirus disease 2019 (COVID-19) remain unclear. Previous reports demonstrate the existence of endotoxemia in viral infections without superimposed gram-negative bacteremia, but the rate and severity of endotoxemia in critically ill patients with COVID-19 requires further exploration. Materials and Methods This is a single-center cross-sectional study of 92 intensive care unit patients diagnosed with COVID-19 pneumonia. Endotoxin activity (EA) was measured in patients that met the following criteria: (1) age ≥18 years and (2) multi-organ dysfunction score >9 from March 24, 2020, to June 20, 2020. Results A total of 32 patients met the inclusion/exclusion criteria for measurement of EA. The median age of the study cohort was 60 years with a majority male (21/32, 65%) with hypertension (50%). A significant proportion of the patients exhibited either elevated EA in the intermediate range (0.40–0.59 EA units) (10/32, 31%) or high range (≥0.60 EA units) (14/32, 44%) or were nonresponders (NRs, low neutrophil response) to EA (6/32, 19%), with the presence of gram-negative bacteremia only in 2/32 (6%) patients. Low EA was reported in 2/32 patients. NRs (5/6, 83%) and patients with high EA (7/14, 50%) exhibited higher acute kidney injury (AKI) as compared to patients with low/intermediate EA level (1/12, 8.3%). Discussion/Conclusion Elevated EA was observed in a large majority of critically ill patients with COVID-19 and multi-organ dysfunction despite a low incidence of concurrent gram-negative bacteremia. While we observed that elevated EA and nonresponsiveness to EA were associated with AKI in critically ill patients with COVID-19, these findings require further validation in larger longitudinal cohorts.
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Affiliation(s)
- Sobia Khan
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Olena Bolotova
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Haseena Sahib
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | | | - Sandeep K Mallipattu
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA.,Renal Section, Northport VA Medical Center, Northport, New York, USA
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Skorup P, Maudsdotter L, Lipcsey M, Larsson A, Sjölin J. Mode of bacterial killing affects the inflammatory response and associated organ dysfunctions in a porcine E. coli intensive care sepsis model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:646. [PMID: 33189146 PMCID: PMC7666448 DOI: 10.1186/s13054-020-03303-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 09/21/2020] [Indexed: 11/25/2022]
Abstract
Background Sepsis is often treated with penicillin-binding protein 3 (PBP-3) acting β-lactam antibiotics, such as piperacillin-tazobactam, cefotaxime, and meropenem. They cause considerable bacterial structural changes and have in vitro been associated with an increased inflammatory response. In a clinically relevant large animal sepsis model, our primary aim was to investigate whether bacteria killed by a PBP-3-active antibiotic has a greater effect on the early inflammatory response and organ dysfunction compared with corresponding amounts of live or heat-killed bacteria. A secondary aim was to determine whether the addition of an aminoglycoside could mitigate the cefuroxime-induced response. Method Killed or live Escherichia coli were administrated as a 3-h infusion to 16 healthy pigs in a prospective, randomized controlled interventional experimental study. Cefuroxime was chosen as the PBP-3-active antibiotic and tobramycin represented the aminoglycosides. The animals were randomized to receive (I) bacteria killed by cefuroxime, (II) live bacteria, (III) bacteria killed by heat, or (IV) bacteria killed by the combination of cefuroxime and tobramycin. Plasma endotoxin, tumor necrosis factor alpha, interleukin-6, interleukin-10, leukocytes, and organ function were recorded at the start of the experiment and then hourly for 6 h. Results Differences in dynamics of concentration over time between the four treatment groups were found for the three cytokines (p < 0.001). Animals receiving cefuroxime-killed bacteria demonstrated higher responses than those receiving live (p < 0.05) or heat-killed bacteria (p < 0.01). The addition of tobramycin reduced the cefuroxime-induced responses (p < 0.001). The cytokine responses were associated with leucocyte activation that was further associated with pulmonary dysfunction and increases in lactate (p < 0.01). Conclusions In comparison with live or heat-killed bacteria, bacteria killed by a PBP-3-active antibiotic induced an increased inflammatory response that appears to be associated with deteriorated organ and cellular function. The addition of an aminoglycoside to the PBP-3-active antibiotic reduced that response.
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Affiliation(s)
- Paul Skorup
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, 751 85, Uppsala, SE, Sweden.
| | - Lisa Maudsdotter
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Miklós Lipcsey
- Department of Surgical Sciences, Hedenstierna Laboratory, Anesthesiology & Intensive Care, Uppsala University, Uppsala, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Section of Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Jan Sjölin
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, 751 85, Uppsala, SE, Sweden
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Wienhold SM, Lienau J, Witzenrath M. Towards Inhaled Phage Therapy in Western Europe. Viruses 2019; 11:v11030295. [PMID: 30909579 PMCID: PMC6466303 DOI: 10.3390/v11030295] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 12/15/2022] Open
Abstract
The emergence of multidrug-resistant bacteria constitutes a great challenge for modern medicine, recognized by leading medical experts and politicians worldwide. Rediscovery and implementation of bacteriophage therapy by Western medicine might be one solution to the problem of increasing antibiotic failure. In some Eastern European countries phage therapy is used for treating infectious diseases. However, while the European Medicines Agency (EMA) advised that the development of bacteriophage-based therapies should be expedited due to its significant potential, EMA emphasized that phages cannot be recommended for approval before efficacy and safety have been proven by appropriately designed preclinical and clinical trials. More evidence-based data is required, particularly in the areas of pharmacokinetics, repeat applications, immunological reactions to the application of phages as well as the interactions and effects on bacterial biofilms and organ-specific environments. In this brief review we summarize advantages and disadvantages of phage therapy and discuss challenges to the establishment of phage therapy as approved treatment for multidrug-resistant bacteria.
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Affiliation(s)
- Sandra-Maria Wienhold
- Division of Pulmonary Inflammation, Charité⁻Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.
| | - Jasmin Lienau
- Division of Pulmonary Inflammation, Charité⁻Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.
| | - Martin Witzenrath
- Division of Pulmonary Inflammation, Charité⁻Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.
- Department of Infectious Diseases and Respiratory Medicine, Charité⁻Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.
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Cartwright M, Rottman M, Shapiro NI, Seiler B, Lombardo P, Gamini N, Tomolonis J, Watters AL, Waterhouse A, Leslie D, Bolgen D, Graveline A, Kang JH, Didar T, Dimitrakakis N, Cartwright D, Super M, Ingber DE. A Broad-Spectrum Infection Diagnostic that Detects Pathogen-Associated Molecular Patterns (PAMPs) in Whole Blood. EBioMedicine 2016; 9:217-227. [PMID: 27333027 PMCID: PMC4972566 DOI: 10.1016/j.ebiom.2016.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 01/01/2023] Open
Abstract
Background Blood cultures, and molecular diagnostic tests that directly detect pathogen DNA in blood, fail to detect bloodstream infections in most infected patients. Thus, there is a need for a rapid test that can diagnose the presence of infection to triage patients, guide therapy, and decrease the incidence of sepsis. Methods An Enzyme-Linked Lectin-Sorbent Assay (ELLecSA) that uses magnetic microbeads coated with an engineered version of the human opsonin, Mannose Binding Lectin, containing the Fc immunoglobulin domain linked to its carbohydrate recognition domain (FcMBL) was developed to quantify pathogen-associated molecular patterns (PAMPs) in whole blood. This assay was tested in rats and pigs to explore whether it can detect infections and monitor disease progression, and in prospectively enrolled, emergency room patients with suspected sepsis. These results were also compared with data obtained from non-infected patients with or without traumatic injuries. Results The FcMBL ELLecSA was able to detect PAMPS present on, or released by, 85% of clinical isolates representing 47 of 55 different pathogen species, including the most common causes of sepsis. The PAMP assay rapidly (< 1 h) detected the presence of active infection in animals, even when blood cultures were negative and bacteriocidal antibiotics were administered. In patients with suspected sepsis, the FcMBL ELLecSA detected infection in 55 of 67 patients with high sensitivity (> 81%), specificity (> 89%), and diagnostic accuracy of 0·87. It also distinguished infection from trauma-related inflammation in the same patient cohorts with a higher specificity than the clinical sepsis biomarker, C-reactive Protein. Conclusion The FcMBL ELLecSA-based PAMP assay offers a rapid, simple, sensitive and specific method for diagnosing infections, even when blood cultures are negative and antibiotic therapy has been initiated. It may help to triage patients with suspected systemic infections, and serve as a companion diagnostic to guide administration of emerging dialysis-like sepsis therapies. The FcMBL ELLecSA-based PAMP assay offers a rapid, simple, sensitive and specific method for diagnosing infections. The FcMBL ELLecSA distinguished infection from trauma-related inflammation. It can detect infection even when blood cultures are negative and antibiotic therapy has been initiated.
Current diagnostics of sepsis using blood cultures and molecular diagnostic tests fail to detect bloodstream infections in most infected patients, whereas the inflammatory biomarkers of infection that have a higher sensitivity of detection, lack specificity in distinguishing infection from trauma-related inflammation. Therefore we have leveraged a broad-spectrum pathogen binding opsonin and developed a rapid test to directly diagnose the presence of infection in the blood to triage patients and guide antibiotic therapy.
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Affiliation(s)
- Mark Cartwright
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Martin Rottman
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States; Hôpitaux Universitaires Paris Ile de France Ouest (AP-HP), UMR INSERM U1173-UFR SSSV Université de Versailles St Quentin en Yvelines, Montigny, France
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Benjamin Seiler
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Patrick Lombardo
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Nazita Gamini
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Julie Tomolonis
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Alexander L Watters
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Anna Waterhouse
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Dan Leslie
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Dana Bolgen
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Amanda Graveline
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Joo H Kang
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Tohid Didar
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Nikolaos Dimitrakakis
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - David Cartwright
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Michael Super
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States
| | - Donald E Ingber
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, United States; Vascular Biology Program, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States; Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, MA, United States.
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Shmygalev S, Damm M, Knels L, Strassburg A, Wünsche K, Dumke R, Stehr SN, Koch T, Heller AR. IgM-enriched solution BT086 improves host defense capacity and energy store preservation in a rabbit model of endotoxemia. Acta Anaesthesiol Scand 2016; 60:502-12. [PMID: 26555358 PMCID: PMC5063102 DOI: 10.1111/aas.12652] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 07/14/2015] [Accepted: 09/09/2015] [Indexed: 12/26/2022]
Abstract
Introduction The therapeutic value of intravenous immunoglobulin (IVIG) as an adjuvant therapy in sepsis remains debatable. We hypothesized that intravenous administration of BT086, a predominantly IgM IVIG solution, would improve host defense in an established rabbit model of endotoxemia and systemic sepsis. Methods New Zealand white rabbits were randomized into the following four groups: (1) the negative control group without lipopolysaccharide (LPS, control), (2) the positive control group with LPS infusion (LPS group), (3) the albumin‐treated LPS group (ALB+LPS group), and (4) the BT086‐treated LPS group (BT086 + LPS group). A standardized amount of E. coli was intravenously injected into all of the animals. The vital parameters, the concentration of E. coli in the blood and other organs, the residual granulocyte phagocytosis activity, and the levels of the inflammatory mediators were measured. Histological changes in the lung and liver tissue were examined following autopsy. Results The elimination of E. coli from the bloodstream was expedited in the BT086‐treated group compared with the LPS‐ and albumin‐treated groups. The BT086 + LPS group exhibited higher phagocytic activity of polymorphonuclear neutrophils (PMNs) than the control and ALB+LPS groups. The liver energy stores were higher in the BT086 + LPS group than in the other groups. Conclusion Our data suggest that the IgM‐enriched IVIG has the potential to improve host defense in a rabbit model of endotoxemia. Studies using different animal models and dosages are necessary to further explore the potential benefits of IgM‐enriched IVIG solutions.
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Affiliation(s)
- S. Shmygalev
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Carl Gustav Carus Dresden Technische Universität DresdenDresden Germany
| | - M. Damm
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Carl Gustav Carus Dresden Technische Universität DresdenDresden Germany
| | - L. Knels
- Institute of Anatomy Medical Faculty Carl Gustav Carus Technische Universität Dresden Dresden Germany
| | - A. Strassburg
- Medical Faculty Carl Gustav Carus Technische Universität Dresden Dresden Germany
| | - K. Wünsche
- Medical Faculty Carl Gustav Carus Technische Universität Dresden Dresden Germany
| | - R. Dumke
- Institute of Medical Microbiology and Hygiene Medical Faculty Carl Gustav Carus Technische Universität Dresden Dresden Germany
| | - S. N. Stehr
- Department of Anaesthesiology and Intensive Care Medicine University Medical char Schleswig‐Holstein Lübeck Germany
| | - T. Koch
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Carl Gustav Carus Dresden Technische Universität DresdenDresden Germany
| | - A. R. Heller
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Carl Gustav Carus Dresden Technische Universität DresdenDresden Germany
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The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Med 2015; 43:1907-15. [PMID: 26121073 DOI: 10.1097/ccm.0000000000001142] [Citation(s) in RCA: 287] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES We sought to systematically review and meta-analyze the available data on the association between timing of antibiotic administration and mortality in severe sepsis and septic shock. DATA SOURCES A comprehensive search criteria was performed using a predefined protocol. STUDY SELECTION INCLUSION CRITERIA adult patients with severe sepsis or septic shock, reported time to antibiotic administration in relation to emergency department triage and/or shock recognition, and mortality. EXCLUSION CRITERIA immunosuppressed populations, review article, editorial, or nonhuman studies. DATA EXTRACTION Two reviewers screened abstracts with a third reviewer arbitrating. The effect of time to antibiotic administration on mortality was based on current guideline recommendations: 1) administration within 3 hours of emergency department triage and 2) administration within 1 hour of severe sepsis/septic shock recognition. Odds ratios were calculated using a random effect model. The primary outcome was mortality. DATA SYNTHESIS A total of 1,123 publications were identified and 11 were included in the analysis. Among the 11 included studies, 16,178 patients were evaluable for antibiotic administration from emergency department triage. Patients who received antibiotics more than 3 hours after emergency department triage (< 3 hr reference) had a pooled odds ratio for mortality of 1.16 (0.92-1.46; p = 0.21). A total of 11,017 patients were evaluable for antibiotic administration from severe sepsis/septic shock recognition. Patients who received antibiotics more than 1 hour after severe sepsis/shock recognition (< 1 hr reference) had a pooled odds ratio for mortality of 1.46 (0.89-2.40; p = 0.13). There was no increased mortality in the pooled odds ratios for each hourly delay from less than 1 to more than 5 hours in antibiotic administration from severe sepsis/shock recognition. CONCLUSION Using the available pooled data, we found no significant mortality benefit of administering antibiotics within 3 hours of emergency department triage or within 1 hour of shock recognition in severe sepsis and septic shock. These results suggest that currently recommended timing metrics as measures of quality of care are not supported by the available evidence.
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Ratzinger F, Eichbichler K, Schuardt M, Tsirkinidou I, Mitteregger D, Haslacher H, Perkmann T, Schmetterer KG, Doffner G, Burgmann H. Sepsis in standard care: patients' characteristics, effectiveness of antimicrobial therapy and patient outcome--a cohort study. Infection 2015; 43:345-52. [PMID: 25840554 DOI: 10.1007/s15010-015-0771-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 03/24/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Fast diagnosis and initiation of appropriate antibiotic therapy is pivotal for the survival of sepsis patients. However, most studies on suspected sepsis patients are conducted in the intensive care unit or in the emergency room setting, neglecting the standard care setting. This study evaluated sepsis risk factors, microbiological accurateness of the initial empiric antimicrobial therapy and its effect on hospital mortality in standard care patients. METHODS In this prospective observational cohort study, patients with clinically suspected sepsis meeting two or more SIRS criteria were screened on standard care wards. After hospital discharge, occurrence of an infection was assessed according to standardized criteria, and empirical antibiotic therapy was evaluated using antibiograms of recognized pathogens by expert review. RESULTS Of the 2384 screened patients, 298 fulfilled two or more SIRS criteria. Among these were 28.2 % SIRS patients without infection, 46.3 % non-bacteremic/fungemic sepsis patients and 25.5 % bacteremic/fungemic sepsis patients. Occurrence of a malignant disease and chills were associated with a higher risk of patients having bacteremic/fungemic sepsis, whereas other described risk factors remained insignificant. In total, 91.1 % of suspected sepsis patients received empirical antimicrobial therapy, but 41.1 % of bacteremic sepsis patients received inappropriate therapy. Non-surviving bacteremic sepsis patients received a higher proportion of inappropriate therapy than those who survived (p = 0.022). CONCLUSIONS A significant proportion of bacteremic sepsis patients receive inappropriate empiric antimicrobial therapy. Our results indicate that rapid availability of microbiological results is vital, since inappropriate antimicrobial therapy tended to increase the hospital mortality of sepsis patients.
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Affiliation(s)
- Franz Ratzinger
- Division of Medical and Chemical Laboratory Diagnostics, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
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