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Desantis V, Borrelli P, Panebianco T, Fusillo A, Bochicchio D, Solito A, Pappagallo F, Mascolo A, Ancona A, Cicco S, Cerchione C, Romano A, Montagnani M, Ria R, Vacca A, Solimando AG. Comprehensive analysis of clinical outcomes, infectious complications and microbiological data in newly diagnosed multiple myeloma patients: a retrospective observational study of 92 subjects. Clin Exp Med 2024; 24:137. [PMID: 38937383 PMCID: PMC11211138 DOI: 10.1007/s10238-024-01411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
Patients with multiple myeloma (MM) have an increased risk of sepsis due to underlying disease- and treatment-related immunosuppression. However, data on sepsis incidence, causative pathogens, and impact on outcomes in newly diagnosed MM (NDMM) are limited. We conducted a retrospective observational study of 92 NDMM patients who developed sepsis between 2022 and 2023 at a tertiary care center in Italy. Patient characteristics, sepsis criteria [Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome (SIRS)], microbiology results, and associations with progression-free survival (PFS) were analyzed. In this cohort of 92 critically-ill patients, pathogenic organisms were identified via microbiological culture in 74 cases. However, among the remaining 18 culture-negative patients, 9 exhibited a SIRS score of 2 and another 9 had a SIRS score of 4, suggestive of a clinical presentation consistent with sepsis despite negative cultures. Common comorbidities included renal failure (60%), anemia (71%), and bone disease (83%). Gram-negative (28%) and Gram-positive (23%) bacteria were frequent causative organisms, along with fungi (20%). Cox Univariate analyses for PFS showed statically significant HR in patients with albumin ≥ 3.5 vs < 3.5 (HR = 5.04, p < 0.001), Karnofsky performance status ≥ 80 vs < 80 (HR = 2.01, p = 0.002), and early-stage vs late-stage disease by International Staging System (HR = 4.76 and HR = 12.52, both p < 0.001) and Revised International Staging System (R-ISS III vs R-ISS I, HR = 7.38, p < 0.001). Sepsis is common in NDMM and associated with poor outcomes. Risk stratification incorporating sepsis severity, comorbidities, and disease stage may help guide preventive strategies and optimize MM management.
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Affiliation(s)
- Vanessa Desantis
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Section of Pharmacology, University of Bari "Aldo Moro" Medical School, Bari, Italy.
| | - Paola Borrelli
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Teresa Panebianco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonio Fusillo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Donatello Bochicchio
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Angelo Solito
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Fabrizio Pappagallo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonella Mascolo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Anna Ancona
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Sebastiano Cicco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Claudio Cerchione
- Department of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Alessandra Romano
- Department of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
- Department of General Surgery and Medical-Surgical Specialties, Hematology Section, University of Catania, Catania, Italy
| | - Monica Montagnani
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Section of Pharmacology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Roberto Ria
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Angelo Vacca
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonio Giovanni Solimando
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy.
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Cheng L, Niu J, Cheng Y, Liu J, Shi M, Huang S, Ding X, Li S. Risk Factors for Systemic Inflammatory Response Syndrome After Percutaneous Transhepatic Cholangioscopic Lithotripsy. J Inflamm Res 2024; 17:2575-2587. [PMID: 38686361 PMCID: PMC11057514 DOI: 10.2147/jir.s453653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/09/2024] [Indexed: 05/02/2024] Open
Abstract
Background There is a lack of validated predictive models for the occurrence of systemic inflammatory response syndrome (SIRS) after percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) for the treatment of hepatolithiasis. This is the first study to estimate the incidence of SIRS after PTCSL. Methods A retrospective analysis of 284 PTCSL sessions for the treatment of hepatolithiasis at our institution between January 2019 and January 2023 was performed. The development of SIRS after PTCSL was the primary study endpoint. Independent risk factors for SIRS after PTCSL were identified using univariate and multivariate logistic regression analyses. A nomogram prediction model was constructed using these independent risk factors, and the predictive value was assessed using receiver operating characteristic (ROC) curves. Results The incidence of SIRS after PTCSL was 20.77%. According to multivariate analysis, the number of PTCSL sessions (odds ratio [OR]=0.399, 95% confidence interval [CI]=0.202-0.786, p=0.008), stone location (OR=2.194, 95% CI=1.107-4.347, p=0.024), intraoperative use of norepinephrine (OR=0.301, 95% CI=0.131-0.689, p=0.004), intraoperative puncture (OR=3.476, 95% CI=1.749-6.906, P<0.001), preoperative gamma-glutamyltransferase (OR=1.002, 95% CI=1.001-1.004, p=0.009), and preoperative total lymphocyte count (OR=1.820, 95% CI=1.110-2.985, p=0.018) were found to be independent risk factors for the development of SIRS after PTCSL. These six independent risk factors were used to construct a nomogram prediction model, which showed satisfactory accuracy with an area under the ROC curve of 0.776 (95% CI: 0.702-0.850). Conclusion The number of PTCSL sessions, stone location, intraoperative use of norepinephrine, intraoperative puncture, preoperative gamma-glutamyltransferase, and preoperative total lymphocyte count may predict the occurrence of SIRS after PTCSL. This prediction model may help clinicians identify high-risk patients in advance.
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Affiliation(s)
- Lve Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Junwei Niu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Jie Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Mengjia Shi
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Shijia Huang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xiong Ding
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Shengwei Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Hsu PH, Chang R, Yin CH, Chen YS, Chen JS. Association between blood culture turnaround time and clinical prognosis in emergency department patients with community acquired bloodstream infection: A retrospective study based on electronic medical records. Heliyon 2024; 10:e27957. [PMID: 38532997 PMCID: PMC10963333 DOI: 10.1016/j.heliyon.2024.e27957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 02/16/2024] [Accepted: 03/08/2024] [Indexed: 03/28/2024] Open
Abstract
Importance Previous investigations have found that time to positive blood culture (TTP) is a prognostic factor for clinical outcomes. In fact, what the emergency physician sees from the medical information system is TAT (turnaround time) defined as time required to post a bacterial culture report. We propose a definition of blood culture TAT that more closely aligns with clinical considerations by measuring the time from starting specimen culture to the release of an official blood culture report.We were curious to know whether the duration of TAT is as intricately linked to the prognosis of bacteremia as TTP. Objectives To examine the association between TAT and outcomes of adult patients who present to the ED with community acquired bacteremia. Design Setting, and Participants: This retrospective study utilized electronic medical records from Kaohsiung Veterans General Hospital (KVGH), a 1000-bed tertiary medical center in Taiwan. Patients were adults aged 18 years and older who presented to ED (Emergency department) for initial diagnosis of community acquired bacteremia from January 1, 2016 to March 31, 2021. Data analysis was performed from December 2022 to January 2023.Main outcomes and measures.The primary outcomes included mortality in the ED, all-cause in-hospital mortality, length of hospital stay, and all-cause 30-day mortality in relation to the individual first report of positive blood culture TAT. Results A total of 4011 eligible patients with bacteremia were evaluated, of which 207 patients had a blood culture TAT of ≤48 h. The overall 30-day all-cause mortality rate was 13%. Contrary to expectation, no statistically significant differences were observed in clinical prognosis between the TAT groups (≤48 versus >48 h). Subgroup analyses indicated that the length of TAT did not have a significant effect on clinical prognosis in patients who underwent lactate level assessment. Furthermore, no difference in clinical outcome was noted between TAT groups (≤48 versus >48 h) in terms of Gram-negative bacilli or Gram-positive cocci bacteremia. However, in patients with delayed antibiotic treatment (>3 h), a shorter TAT was significantly associated with a fatal outcome. Conclusion In adults with community-acquired bacteremia, this study did not observe a significant association between blood culture TAT and clinical prognosis, except in cases of delayed antibiotic treatment.
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Affiliation(s)
- Po-Hsiang Hsu
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Renin Chang
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Institute of Health Care Management, National Sun Yat-sen University, Taiwan
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Taiwan
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Taiwan
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Taiwan
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Taiwan
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Baldirà J, Ruiz-Rodríguez JC, Ruiz-Sanmartin A, Chiscano L, Cortes A, Sistac DÁ, Ferrer-Costa R, Comas I, Villena Y, Larrosa MN, González-López JJ, Ferrer R. Use of Biomarkers to Improve 28-Day Mortality Stratification in Patients with Sepsis and SOFA ≤ 6. Biomedicines 2023; 11:2149. [PMID: 37626646 PMCID: PMC10452503 DOI: 10.3390/biomedicines11082149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
Early diagnosis and appropriate treatments are crucial to reducing mortality risk in septic patients. Low SOFA scores and current biomarkers may not adequately discern patients that could develop severe organ dysfunction or have an elevated mortality risk. The aim of this prospective observational study was to evaluate the predictive value of the biomarkers mid-regional pro-adrenomedullin (MR-proADM), procalcitonin (PCT), C-reactive protein (CRP), and lactate for 28-day mortality in patients with sepsis, and patients with a SOFA score ≤6. 284 were included, with a 28-day all-cause mortality of 8.45% (n = 24). Non-survivors were older (p = 0.003), required mechanical ventilation (p = 0.04), were ventilated for longer (p = 0.02), and had higher APACHE II (p = 0.015) and SOFA (p = 0.027) scores. Lactate showed the highest predictive ability for all-cause 28-day mortality, with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (0.55-0.79). The AUROC for all-cause 28-day mortality in patients with community-acquired infection was 0.69 (0.57-0.84) for SOFA and 0.70 (0.58-0.82) for MR-proADM. A 2.1 nmol/L cut-off point for this biomarker in this subgroup of patients discerned, with 100% sensibility, survivors from non-survivors at 28 days. In patients with community-acquired sepsis and initial SOFA score ≤ 6, MR-proADM could help identify patients at risk of 28-day mortality.
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Affiliation(s)
- Jaume Baldirà
- Intensive Care Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (J.B.); (D.Á.S.)
- Department de Medicina, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain (R.F.)
| | - Juan Carlos Ruiz-Rodríguez
- Department de Medicina, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain (R.F.)
- Intensive Care Department, Hospital Universitari Vall d’Hebron, Campus Vall d’Hebron, 08035 Barcelona, Spain; (A.R.-S.); (A.C.)
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca, Campus Vall d’Hebron, 08035 Barcelona, Spain
| | - Adolfo Ruiz-Sanmartin
- Intensive Care Department, Hospital Universitari Vall d’Hebron, Campus Vall d’Hebron, 08035 Barcelona, Spain; (A.R.-S.); (A.C.)
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca, Campus Vall d’Hebron, 08035 Barcelona, Spain
| | - Luis Chiscano
- Department de Medicina, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain (R.F.)
- Intensive Care Department, Hospital Universitari Vall d’Hebron, Campus Vall d’Hebron, 08035 Barcelona, Spain; (A.R.-S.); (A.C.)
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca, Campus Vall d’Hebron, 08035 Barcelona, Spain
| | - Alejandro Cortes
- Intensive Care Department, Hospital Universitari Vall d’Hebron, Campus Vall d’Hebron, 08035 Barcelona, Spain; (A.R.-S.); (A.C.)
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca, Campus Vall d’Hebron, 08035 Barcelona, Spain
| | - Diego Ángeles Sistac
- Intensive Care Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain; (J.B.); (D.Á.S.)
| | - Roser Ferrer-Costa
- Clinical Laboratories, Clinical Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (R.F.-C.); (I.C.); (Y.V.)
| | - Inma Comas
- Clinical Laboratories, Clinical Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (R.F.-C.); (I.C.); (Y.V.)
| | - Yolanda Villena
- Clinical Laboratories, Clinical Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (R.F.-C.); (I.C.); (Y.V.)
| | - Maria Nieves Larrosa
- Microbiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (M.N.L.); (J.J.G.-L.)
- Microbiology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Juan José González-López
- Microbiology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (M.N.L.); (J.J.G.-L.)
- Microbiology Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Department of Genetics and Microbiology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ricard Ferrer
- Department de Medicina, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain (R.F.)
- Intensive Care Department, Hospital Universitari Vall d’Hebron, Campus Vall d’Hebron, 08035 Barcelona, Spain; (A.R.-S.); (A.C.)
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron Institut de Recerca, Campus Vall d’Hebron, 08035 Barcelona, Spain
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Yang X, Li S. Prediction of COVID-19 Using a WOA-BILSTM Model. Bioengineering (Basel) 2023; 10:883. [PMID: 37627768 PMCID: PMC10451184 DOI: 10.3390/bioengineering10080883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/13/2023] [Accepted: 07/22/2023] [Indexed: 08/27/2023] Open
Abstract
The COVID-19 pandemic has had a significant impact on the world, highlighting the importance of the accurate prediction of infection numbers. Given that the transmission of SARS-CoV-2 is influenced by temporal and spatial factors, numerous researchers have employed neural networks to address this issue. Accordingly, we propose a whale optimization algorithm-bidirectional long short-term memory (WOA-BILSTM) model for predicting cumulative confirmed cases. In the model, we initially input regional epidemic data, including cumulative confirmed, cured, and death cases, as well as existing cases and daily confirmed, cured, and death cases. Subsequently, we utilized the BILSTM as the base model and incorporated WOA to optimize the specific parameters. Our experiments employed epidemic data from Beijing, Guangdong, and Chongqing in China. We then compared our model with LSTM, BILSTM, GRU, CNN, CNN-LSTM, RNN-GRU, DES, ARIMA, linear, Lasso, and SVM models. The outcomes demonstrated that our model outperformed these alternatives and retained the highest accuracy in complex scenarios. In addition, we also used Bayesian and grid search algorithms to optimize the BILSTM model. The results showed that the WOA model converged fast and found the optimal solution more easily. Thus, our model can assist governments in developing more effective control measures.
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Affiliation(s)
| | - Shuangyin Li
- School of Computer Science, South China Normal University, Guangzhou 510631, China;
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Song Q, Fei W. Evaluation of Sepsis-1 and Sepsis-3 Diagnostic Criteria in Patients with Sepsis in Intensive Care Unit. JOURNAL OF HEALTHCARE ENGINEERING 2023; 2023:3794886. [PMID: 37457495 PMCID: PMC10348846 DOI: 10.1155/2023/3794886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/18/2021] [Accepted: 11/10/2021] [Indexed: 07/18/2023]
Abstract
Background The use of SIRS and SOFA criteria in diagnosing sepsis among patients has been characterized by increasingly growing criticism. Indeed, the definition of sepsis has attracted significant controversy in history across medical and academic realms. Methods The study used the Medical Information Mart for Intensive Care-III (MIMIC-III) database in assessing the effectiveness of the SIRS and SOFA diagnostic criteria. It ascertained the severity and specificity of sepsis infection in ICU patients. The Medical Information Mart for Intensive Care-III (MIMIC-III) database was established by the Beth Israel Deaconess Medical Center (BIDMC) and MIT's Computational Physiology Laboratory. The database is a voluminous single-center database containing information pertaining to 38,000 adults who were admitted to the BIDMC in the 11 years leading up to 2012. The identification of patients with sepsis was conducted using the International Classification of Diseases (ICD-10-CM) diagnosis codes. Results The analysis of data for this study was based on the chi-square test, which is significant in comparing the specificity, mortality, and sensitivity of the data. The process of screening the MIMIC-III database resulted in the identification of 21,368 patients with infections from the hospital admissions in the database. The results also indicate a significantly higher mortality rate within 28 days of admission in sepsis-3 patients compared with sepsis-1. In this experiment, we limited the study period to 28 days to restrict the potential of mortality caused by other factors. Additionally, we evaluated the clinical factors associated with the sepsis-1 or sepsis-3 and found out similar results in the analysis for sepsis-1 and sepsis-3. Conclusions The study results also portray numerous challenges in using the sepsis-3 criteria as a diagnostic tool. In particular, the ICD-10-CM diagnosis approach was limiting because it inhibited the measure of uncertainty of infection present at the beginning of the two diagnostic criteria of sepsis-1 and sepsis-3.
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Affiliation(s)
- Qianying Song
- Department of EICU, The Second Hospital of Dalian Medical University, 467 Zhongshan Road, Shahekou District, Dalian 116023, China
| | - Weiyu Fei
- Department of EICU, The Second Hospital of Dalian Medical University, 467 Zhongshan Road, Shahekou District, Dalian 116023, China
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Li X, Lu Y, Chen C, Luo T, Chen J, Zhang Q, Zhou S, Hei Z, Liu Z. Development and validation of a patient-specific model to predict postoperative SIRS in older patients: A two-center study. Front Public Health 2023; 11:1145013. [PMID: 37139371 PMCID: PMC10150121 DOI: 10.3389/fpubh.2023.1145013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/28/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction Postoperative systemic inflammatory response syndrome (SIRS) is common in surgical patients especially in older patients, and the geriatric population with SIRS is more susceptible to sepsis, MODS, and even death. We aimed to develop and validate a model for predicting postoperative SIRS in older patients. Methods Patients aged ≥65 years who underwent general anesthesia in two centers of Third Affiliated Hospital of Sun Yat-sen University from January 2015 to September 2020 were included. The cohort was divided into training and validation cohorts. A simple nomogram was developed to predict the postoperative SIRS in the training cohort using two logistic regression models and the brute force algorithm. The discriminative performance of this model was determined by area under the receiver operating characteristics curve (AUC). The external validity of the nomogram was assessed in the validation cohort. Results A total of 5,904 patients spanning from January 2015 to December 2019 were enrolled in the training cohort and 1,105 patients from January 2020 to September 2020 comprised the temporal validation cohort, in which incidence rates of postoperative SIRS were 24.6 and 20.2%, respectively. Six feature variables were identified as valuable predictors to construct the nomogram, with high AUCs (0.800 [0.787, 0.813] and 0.822 [0.790, 0.854]) and relatively balanced sensitivity (0.718 and 0.739) as well as specificity (0.718 and 0.729) in both training and validation cohorts. An online risk calculator was established for clinical application. Conclusion We developed a patient-specific model that may assist in predicting postoperative SIRS among the aged patients.
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Affiliation(s)
- Xiaoyue Li
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yaxin Lu
- Big Data and Artificial Intelligence Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chaojin Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Cell-gene Therapy Translational Medicine Research Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tongsen Luo
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jingjing Chen
- Big Data and Artificial Intelligence Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qi Zhang
- Cell-gene Therapy Translational Medicine Research Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaoli Zhou
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Shaoli Zhou,
| | - Ziqing Hei
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Department of Anesthesiology, Yuedong Hospital, The Third Affiliated Hospital of Sun Yat-sen University, Meizhou, China
- Ziqing Hei,
| | - Zifeng Liu
- Big Data and Artificial Intelligence Center, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zifeng Liu,
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Soni M, Handa M, Singh KK, Shukla R. Recent nanoengineered diagnostic and therapeutic advancements in management of Sepsis. J Control Release 2022; 352:931-945. [PMID: 36273527 PMCID: PMC9665001 DOI: 10.1016/j.jconrel.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022]
Abstract
COVID-19 acquired symptoms have affected the worldwide population and increased the load of Intensive care unit (ICU) patient admissions. A large number of patients admitted to ICU end with a deadly fate of mortality. A high mortality rate of patients was reported with hospital-acquired septic shock that leads to multiple organ failures and ultimately ends with death. The patients who overcome this septic shock suffer from morbidity that also affects their caretakers. To overcome these situations, scientists are exploring progressive theragnostic techniques with advanced techniques based on biosensors, biomarkers, biozymes, vesicles, and others. These advanced techniques pave the novel way for early detection of sepsis-associated symptoms and timely treatment with appropriate antibiotics and immunomodulators and prevent the undue effect on other parts of the body. There are other techniques like externally modulated electric-based devices working on the principle of piezoelectric mechanism that not only sense the endotoxin levels but also target them with a loaded antibiotic to neutralize the onset of inflammatory response. Recently researchers have developed a lipopolysaccharide (LPS) neutralizing cartridge that not only senses the LPS but also appropriately neutralizes with dual mechanistic insights of antibiotic and anti-inflammatory effects. This review will highlight recent developments in the new nanotechnology-based approaches for the diagnosis and therapeutics of sepsis that is responsible for the high number of deaths of patients suffering from this critical disease.
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Affiliation(s)
- Mukesh Soni
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research-Raebareli, Lucknow 226002, U.P., India
| | - Mayank Handa
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research-Raebareli, Lucknow 226002, U.P., India
| | - Kamalinder K. Singh
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston PR1 2HE, UK,Correspondence to: Prof. Kamalinder K. Singh, School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston PR1 2HE, United Kingdom
| | - Rahul Shukla
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research-Raebareli, Lucknow 226002, U.P., India,School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston PR1 2HE, UK,Correspondence to: Dr. Rahul Shukla (M. Pharm. PhD), National Institute of Pharmaceutical Education and Research (NIPER-Raebareli), Bijnor-Sisendi Road, Sarojini Nagar, Near CRPF Base Camp, Lucknow 226002, UP, India
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Chang JL, Pearson JC, Rhee C. Early Empirical Use of Broad-Spectrum Antibiotics in Sepsis. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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10
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Zou Q, Liu C, Hu N, Wang W, Wang H. miR-126 ameliorates multiple organ dysfunction in septic rats by regulating the differentiation of Th17/Treg. Mol Biol Rep 2022; 49:2985-2998. [PMID: 35122598 PMCID: PMC8817156 DOI: 10.1007/s11033-022-07121-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/04/2022] [Indexed: 10/25/2022]
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Ground truth labels challenge the validity of sepsis consensus definitions in critical illness. J Transl Med 2022; 20:27. [PMID: 35033120 PMCID: PMC8760797 DOI: 10.1186/s12967-022-03228-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/31/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sepsis is the leading cause of death in the intensive care unit (ICU). Expediting its diagnosis, largely determined by clinical assessment, improves survival. Predictive and explanatory modelling of sepsis in the critically ill commonly bases both outcome definition and predictions on clinical criteria for consensus definitions of sepsis, leading to circularity. As a remedy, we collected ground truth labels for sepsis. METHODS In the Ground Truth for Sepsis Questionnaire (GTSQ), senior attending physicians in the ICU documented daily their opinion on each patient's condition regarding sepsis as a five-category working diagnosis and nine related items. Working diagnosis groups were described and compared and their SOFA-scores analyzed with a generalized linear mixed model. Agreement and discriminatory performance measures for clinical criteria of sepsis and GTSQ labels as reference class were derived. RESULTS We analyzed 7291 questionnaires and 761 complete encounters from the first survey year. Editing rates for all items were > 90%, and responses were consistent with current understanding of critical illness pathophysiology, including sepsis pathogenesis. Interrater agreement for presence and absence of sepsis was almost perfect but only slight for suspected infection. ICU mortality was 19.5% in encounters with SIRS as the "worst" working diagnosis compared to 5.9% with sepsis and 5.9% with severe sepsis without differences in admission and maximum SOFA. Compared to sepsis, proportions of GTSQs with SIRS plus acute organ dysfunction were equal and macrocirculatory abnormalities higher (p < 0.0001). SIRS proportionally ranked above sepsis in daily assessment of illness severity (p < 0.0001). Separate analyses of neurosurgical referrals revealed similar differences. Discriminatory performance of Sepsis-1/2 and Sepsis-3 compared to GTSQ labels was similar with sensitivities around 70% and specificities 92%. Essentially no difference between the prevalence of SIRS and SOFA ≥ 2 yielded sensitivities and specificities for detecting sepsis onset close to 55% and 83%, respectively. CONCLUSIONS GTSQ labels are a valid measure of sepsis in the ICU. They reveal suspicion of infection as an unclear clinical concept and refute an illness severity hierarchy in the SIRS-sepsis-severe sepsis spectrum. Ground truth challenges the accuracy of Sepsis-1/2 and Sepsis-3 in detecting sepsis onset. It is an indispensable intermediate step towards advancing diagnosis and therapy in the ICU and, potentially, other health care settings.
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12
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Zhang J, Wang T, Fang Y, Wang M, Liu W, Zhao J, Wang B, Wu Z, Lv Y, Wu R. Clinical Significance of Serum Albumin/Globulin Ratio in Patients With Pyogenic Liver Abscess. Front Surg 2021; 8:677799. [PMID: 34917645 PMCID: PMC8669143 DOI: 10.3389/fsurg.2021.677799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 11/09/2021] [Indexed: 12/30/2022] Open
Abstract
Pyogenic liver abscess (PLA) remains a significant challenge for modern clinicians. Serum albumin/globulin ratio (AGR) can reflect the progress of many diseases. However, the clinical significance of AGR in PLA has not been evaluated. The aim of this study was to explore the effect of AGR on the clinical characteristic and prognosis in PLA patients. This retrospective study included 392 PLA patients who admitted to the First Affiliated Hospital of Xi'an Jiaotong University from January, 2007 to December, 2016. The medical records on admission were collected. Compared with the healthy controls and the patients with extraperitoneal infection or non-infectious liver disease, PLA patients had lower levels of AGR. The mean level of AGR in PLA patients was 1.02 ± 0.25. There were 179 (45.4%) patients with AGR > 1.02 and 213 (54.6%) patients with AGR ≤ 1.02. The baseline data and treatment plans of PLA patients with high or low AGR were comparative. However, PLA patients with a low AGR had higher body temperature, leukocytes and neutrophils, lower hemoglobin, poorer liver and coagulation function, larger abscess diameter, higher positive rate of pus culture and proportion of Escherichia coli, and were more susceptible to multiple bacteria. Moreover, PLA patients with a low AGR had more complications, including systemic inflammatory response syndrome (SIRS), peritoneal effusion and pleural effusion. And it also needs longer time for temperature normalization and hospital stay. In conclusion, PLA patients have lower AGR and lower AGR is associated with worse clinical manifestations, more complications and poorer prognosis. Thus, monitoring of AGR is of great clinical significance for evaluating the progress of PLA patients.
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Affiliation(s)
- Jia Zhang
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Tao Wang
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yi Fang
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengzhou Wang
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wuming Liu
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Junzhou Zhao
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yi Lv
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Rongqian Wu
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Circulating Microvesicle-Associated Inducible Nitric Oxide Synthase Is a Novel Therapeutic Target to Treat Sepsis: Current Status and Future Considerations. Int J Mol Sci 2021; 22:ijms222413371. [PMID: 34948167 PMCID: PMC8705916 DOI: 10.3390/ijms222413371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 12/11/2022] Open
Abstract
To determine whether mitigating the harmful effects of circulating microvesicle-associated inducible nitric oxide (MV-A iNOS) in vivo increases the survival of challenged mice in three different mouse models of sepsis, the ability of anti-MV-A iNOS monoclonal antibodies (mAbs) to rescue challenged mice was assessed using three different mouse models of sepsis. The vivarium of a research laboratory Balb/c mice were challenged with an LD80 dose of either lipopolysaccharide (LPS/endotoxin), TNFα, or MV-A iNOS and then treated at various times after the challenge with saline as control or with an anti-MV-A iNOS mAb as a potential immunotherapeutic to treat sepsis. Each group of mice was checked daily for survivors, and Kaplan–Meier survival curves were constructed. Five different murine anti-MV-A iNOS mAbs from our panel of 24 murine anti-MV-A iNOS mAbs were found to rescue some of the challenged mice. All five murine mAbs were used to genetically engineer humanized anti-MV-A iNOS mAbs by inserting the murine complementarity-determining regions (CDRs) into a human IgG1,kappa scaffold and expressing the humanized mAbs in CHO cells. Three humanized anti-MV-A iNOS mAbs were effective at rescuing mice from sepsis in three different animal models of sepsis. The effectiveness of the treatment was both time- and dose-dependent. Humanized anti-MV-A iNOS rHJ mAb could rescue up to 80% of the challenged animals if administered early and at a high dose. Our conclusions are that MV-A iNOS is a novel therapeutic target to treat sepsis; anti-MV-A iNOS mAbs can mitigate the harmful effects of MV-A iNOS; the neutralizing mAb’s efficacy is both time- and dose-dependent; and a specifically targeted immunotherapeutic for MV-A iNOS could potentially save tens of thousands of lives annually and could result in improved antibiotic stewardship.
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Abstract
OBJECTIVES Assess the impact of heterogeneity among established sepsis criteria (Sepsis-1, Sepsis-3, Centers for Disease Control and Prevention Adult Sepsis Event, and Centers for Medicare and Medicaid severe sepsis core measure 1) through the comparison of corresponding sepsis cohorts. DESIGN Retrospective analysis of data extracted from electronic health record. SETTING Single, tertiary-care center in St. Louis, MO. PATIENTS Adult, nonsurgical inpatients admitted between January 1, 2012, and January 6, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In the electronic health record data, 286,759 encounters met inclusion criteria across the study period. Application of established sepsis criteria yielded cohorts varying in prevalence: Centers for Disease Control and Prevention Adult Sepsis Event (4.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (4.8%), International Classification of Disease code (7.2%), Sepsis-3 (7.5%), and Sepsis-1 (11.3%). Between the two modern established criteria, Sepsis-3 (n = 21,550) and Centers for Disease Control and Prevention Adult Sepsis Event (n = 12,494), the size of the overlap was 7,763. The sepsis cohorts also varied in time from admission to sepsis onset (hr): Sepsis-1 (2.9), Sepsis-3 (4.1), Centers for Disease Control and Prevention Adult Sepsis Event (4.6), and Centers for Medicare and Medicaid severe sepsis core measure 1 (7.6); sepsis discharge International Classification of Disease code rate: Sepsis-1 (37.4%), Sepsis-3 (40.1%), Centers for Medicare and Medicaid severe sepsis core measure 1 (48.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (54.5%); and inhospital mortality rate: Sepsis-1 (13.6%), Sepsis-3 (18.8%), International Classification of Disease code (20.4%), Centers for Medicare and Medicaid severe sepsis core measure 1 (22.5%), and Centers for Disease Control and Prevention Adult Sepsis Event (24.1%). CONCLUSIONS The application of commonly used sepsis definitions on a single population produced sepsis cohorts with low agreement, significantly different baseline demographics, and clinical outcomes.
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Gonzalez Del Castillo J, Clemente-Callejo C, Llopis F, Irimia A, Oltra-Hostalet F, Rechner C, Schwabe A, Fernandez-Rodriguez V, Sánchez-Mora C, Giol-Amich J, Prieto-García B, Bardés-Robles I, Ortega-de Heredia MD, García-Lamberechts EJ, Navarro-Bustos C. Midregional proadrenomedullin safely reduces hospitalization in a low severity cohort with infections in the ED: a randomized controlled multi-centre interventional pilot study. Eur J Intern Med 2021; 88:104-113. [PMID: 33906810 DOI: 10.1016/j.ejim.2021.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The midregional fragment of proadrenomedullin (MR-proADM) is known to provide accurate short-, mid- and long term prognostic information in the triage and multi-dimensional risk assessment of patients in the emergency department (ED). In two independent observational cohorts MR-proADM values identified low disease severity patients without risk of disease progression in the ED with no 28 days mortality that wouldn´t require hospitalization. In this interventional study we want to show that the combination of an MR-proADM algorithm with clinical assessment is able to identify low risk patients not requiring hospitalization to safely reduce the number of hospital admissions. METHODS A randomized-controlled interventional multicenter study in 4 EDs in Spain. The study protocol was approved by Ethics Committees. Control arm patients received Standard Care. MR-proADM guided arm patients with low MR-proADM value (≤0.87 nmol/L) were treated as out-patients, with high MR-proADM value (>0.87 nmol/L) were hospitalized. The hospitalization rate was compared between the study arms. RESULTS Two hundred patients with suspicion of infection were enrolled. In the MR-proADM guided arm the hospital admission rate in the intention-to-treat (ITT) population was 17% lower than in the control arm (40.6% vs. 57.6%, p=0.024) and 20% lower in the per protocol (PP) population (37.2% vs. 57.6%, p=0.009). No deaths of out-patients and no significant difference for the safety endpoints readmission and representation rates were observed. The readmission rate was only slightly higher in the MR-proADM guided arm compared to the control arm (PP population: at 14 days 9.3% vs. 7.1%, difference 2.1% (95% CI: -11.0% to 15.2%); and at 28 days 11.1% vs. 9.5%, difference 1.6% (95% CI: -12.2% to 15.4%)). The rate of 28 days representation was slightly lower in the MR-proADM guided arm compared to the control arm (20.4% vs. 26.2%, difference -5.8% (95% CI: -25.0% to 13.4%); PP population). CONCLUSIONS Implementing a MR-proADM algorithm optimizes ED workflows efficiently and sustainably. Hospitals can highly benefit from a reduced rate of hospitalizations by 20% using MR-proADM. The safety in the MR-proADM guided study arm was similar to the Standard Care arm. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03770533.
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Affiliation(s)
- Juan Gonzalez Del Castillo
- Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain.
| | | | - Ferran Llopis
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Andreea Irimia
- Emergency Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain.
| | | | - Cindy Rechner
- Thermo Fisher Scientific, BRAHMS GmbH, Hennigsdorf, Germany.
| | - Andrej Schwabe
- Thermo Fisher Scientific, BRAHMS GmbH, Hennigsdorf, Germany.
| | - Verónica Fernandez-Rodriguez
- Emergency Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Catalina Sánchez-Mora
- Clinical Biochemistry Department. Hospital Universitario Virgen de la Macarena, Seville, Spain.
| | - Jordi Giol-Amich
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Belén Prieto-García
- Clinical Biochemistry Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo, Spain.
| | - Ignasi Bardés-Robles
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
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The association between four scoring systems and 30-day mortality among intensive care patients with sepsis: a cohort study. Sci Rep 2021; 11:11214. [PMID: 34045645 PMCID: PMC8159970 DOI: 10.1038/s41598-021-90806-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/18/2021] [Indexed: 12/28/2022] Open
Abstract
Several commonly used scoring systems (SOFA, SAPS II, LODS, and SIRS) are currently lacking large sample data to confirm the predictive value of 30-day mortality from sepsis, and their clinical net benefits of predicting mortality are still inconclusive. The baseline data, LODS score, SAPS II score, SIRS score, SOFA score, and 30-day prognosis of patients who met the diagnostic criteria of sepsis were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) intensive care unit (ICU) database. Receiver operating characteristic (ROC) curves and comparisons between the areas under the ROC curves (AUC) were conducted. Decision curve analysis (DCA) was performed to determine the net benefits between the four scoring systems and 30-day mortality of sepsis. For all cases in the cohort study, the AUC of LODS, SAPS II, SIRS, SOFA were 0.733, 0.787, 0.597, and 0.688, respectively. The differences between the scoring systems were statistically significant (all P-values < 0.0001), and stratified analyses (the elderly and non-elderly) also showed the superiority of SAPS II among the four systems. According to the DCA, the net benefit ranges in descending order were SAPS II, LODS, SOFA, and SIRS. For stratified analyses of the elderly or non-elderly groups, the results also showed that SAPS II had the most net benefit. Among the four commonly used scoring systems, the SAPS II score has the highest predictive value for 30-day mortality from sepsis, which is better than LODS, SIRS, and SOFA. The results of the DCA curves show that using the SAPS II score to predict the 30-day mortality of intensive care patients with sepsis to guide clinical applications may obtain the highest net benefit.
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The Development and Validation of a Machine Learning Model to Predict Bacteremia and Fungemia in Hospitalized Patients Using Electronic Health Record Data. Crit Care Med 2021; 48:e1020-e1028. [PMID: 32796184 DOI: 10.1097/ccm.0000000000004556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Bacteremia and fungemia can cause life-threatening illness with high mortality rates, which increase with delays in antimicrobial therapy. The objective of this study is to develop machine learning models to predict blood culture results at the time of the blood culture order using routine data in the electronic health record. DESIGN Retrospective analysis of a large, multicenter inpatient data. SETTING Two academic tertiary medical centers between the years 2007 and 2018. SUBJECTS All hospitalized patients who received a blood culture during hospitalization. INTERVENTIONS The dataset was partitioned temporally into development and validation cohorts: the logistic regression and gradient boosting machine models were trained on the earliest 80% of hospital admissions and validated on the most recent 20%. MEASUREMENTS AND MAIN RESULTS There were 252,569 blood culture days-defined as nonoverlapping 24-hour periods in which one or more blood cultures were ordered. In the validation cohort, there were 50,514 blood culture days, with 3,762 cases of bacteremia (7.5%) and 370 cases of fungemia (0.7%). The gradient boosting machine model for bacteremia had significantly higher area under the receiver operating characteristic curve (0.78 [95% CI 0.77-0.78]) than the logistic regression model (0.73 [0.72-0.74]) (p < 0.001). The model identified a high-risk group with over 30 times the occurrence rate of bacteremia in the low-risk group (27.4% vs 0.9%; p < 0.001). Using the low-risk cut-off, the model identifies bacteremia with 98.7% sensitivity. The gradient boosting machine model for fungemia had high discrimination (area under the receiver operating characteristic curve 0.88 [95% CI 0.86-0.90]). The high-risk fungemia group had 252 fungemic cultures compared with one fungemic culture in the low-risk group (5.0% vs 0.02%; p < 0.001). Further, the high-risk group had a mortality rate 60 times higher than the low-risk group (28.2% vs 0.4%; p < 0.001). CONCLUSIONS Our novel models identified patients at low and high-risk for bacteremia and fungemia using routinely collected electronic health record data. Further research is needed to evaluate the cost-effectiveness and impact of model implementation in clinical practice.
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Loots FJ, Smulders D, Giesen P, Hopstaken RM, Smits M. Vital signs of the systemic inflammatory response syndrome in adult patients with acute infections presenting in out-of-hours primary care: A cross-sectional study. Eur J Gen Pract 2021; 27:83-89. [PMID: 33978531 PMCID: PMC8118397 DOI: 10.1080/13814788.2021.1917544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Signs of the systemic inflammatory response syndrome (SIRS) – fever (or hypothermia), tachycardia and tachypnoea – are used in the hospital setting to identify patients with possible sepsis. Objectives To determine how frequently abnormalities in the vital signs of SIRS are present in adult out-of-hours (OOH) primary care patients with suspected infections and assess the association with acute hospital referral. Methods We conducted a cross-sectional study at the OOH GP cooperative in Nijmegen, the Netherlands, between August and October 2015. GPs were instructed to record the body temperature, heart rate and respiratory rate of all patients with suspected acute infections. Vital signs of SIRS, other relevant signs and symptoms, and referral state were extracted from the electronic registration system of the OOH GP cooperative retrospectively. Logistic regression analysis was used to evaluate the association between clinical signs and hospital referral. Results A total of 558 patients with suspected infections were included. At least two SIRS vital signs were abnormal in 35/409 (8.6%) of the clinic consultations and 60/149 (40.3%) of the home visits. Referral rate increased from 13% when no SIRS vital sign was abnormal to 68% when all three SIRS vital signs were abnormal. Independent associations for referral were found for decreased oxygen saturation, hypotension and rapid illness progression, but not for individual SIRS vital signs. Conclusion Although patients with abnormal vital signs of SIRS were referred more often, decreased oxygen saturation, hypotension and rapid illness progression seem to be most important for GPs to guide further management.
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Affiliation(s)
- Feike J Loots
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Daan Smulders
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Giesen
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | | | - Marleen Smits
- Scientific Centre for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Systemic Inflammatory Response Syndrome in Patients Hospitalized for Acute Decompensation of Cirrhosis. Can J Gastroenterol Hepatol 2021; 2021:5581587. [PMID: 33987144 PMCID: PMC8093053 DOI: 10.1155/2021/5581587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although recently challenged, systemic inflammatory response syndrome (SIRS) criteria are still commonly used in daily practice to define sepsis. However, several factors in liver cirrhosis may negatively impact its prognostic ability. Goals. To investigate the factors associated with the presence of SIRS, the characteristics of SIRS related to infection, and its prognostic value among patients hospitalized for acute decompensation of cirrhosis. Study. In this cohort study from two tertiary hospitals, 543 patients were followed up, up to 90 days. Data collection, including the prognostic models, was within 48 hours of admission. RESULTS SIRS was present in 42.7% of the sample and was independently associated with upper gastrointestinal bleeding (UGB), ACLF, infection, and negatively related to beta-blockers. SIRS was associated with mortality in univariate analysis, but not in multiple Cox regression analysis. The Kaplan-Meier survival probability of patients without SIRS was 73.0% and for those with SIRS was 64.7%. The presence of SIRS was not significantly associated with mortality when considering patients with or without infection, separately. Infection in SIRS patients was independently associated with Child-Pugh C and inversely related to UGB. Among subjects with SIRS, mortality was independently related to the presence of infection, ACLF, and Child-Pugh C. CONCLUSIONS SIRS was common in hospitalized patients with cirrhosis and was of no prognostic value, even in the presence of infection.
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Lavranou GA, Mentzelopoulos S, Katsaounou P, Siempos I, Kalomenidis I, Geranaki A, Routsi C, Zakynthinos S. Can Coagulation System Disorders and Cytokine and Inflammatory Marker Levels Predict the Temporary Clinical Deterioration or Improvement of Septic Patients on ICU Admission? J Clin Med 2021; 10:jcm10081548. [PMID: 33917002 PMCID: PMC8067680 DOI: 10.3390/jcm10081548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
Although coagulation disorders and immune/inflammatory response have been associated with the final outcome of patients with sepsis, their link with thetemporaryclinical deterioration or improvement of patients is unknown. We aimed to investigate this link. We prospectively included consecutive patients admitted to the intensive care unit (ICU) with a suspected diagnosis of infection and evaluated within the first 24 h from admission. Blood levels of many cytokines and inflammatory and coagulation factors were measured and their predictive value was assessed by calculating the Area Under the Receiver Operating Characteristic (AUROC) curves. Patients (n = 102) were allocated in five groups, i.e., sepsis (n = 14), severe sepsis (n = 17), septic shock (n = 28), Systemic Inflammatory Response Syndrome (SIRS) without infection (n = 17), and trauma/surgery without SIRS or infection (n = 26). In septic shock, coagulation factors FVII and FIX and Protein C had AUROCs 0.67-0.78. In severe sepsis, Antithrombin III, Protein C, C-reactive protein, Procalcitonin and Thrombopoietin had AUROCs 0.73-0.75. In sepsis, Tumor Necrosis Factor a, and Interleukins 1β and 10 had AUROCs 0.66-0.72. In patients admitted to the ICU with a suspected diagnosis of infection, coagulation factors and inhibitors, as well as cytokine and inflammatory marker levels, have substantial predictive value in distinct groups of septic patients.
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Affiliation(s)
- Georgia-Athanasia Lavranou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Spyros Mentzelopoulos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Paraskevi Katsaounou
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Ilias Siempos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Ioannis Kalomenidis
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Aikaterini Geranaki
- Hematology Laboratory, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece;
| | - Christina Routsi
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
| | - Spyros Zakynthinos
- First Department of Intensive Care Medicine, School of Medicine, National and Kapodistrian University of Athens, ‘Evangelismos’ Hospital, 45-47 Ipsilandou St, GR-10675 Athens, Greece; (G.-A.L.); (S.M.); (P.K.); (I.S.); (I.K.); (C.R.)
- Correspondence:
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Abstract
Introduction: Sepsis is a life-threatening organ dysfunction that is caused by a dysregulated host response to the infection. Urosepsis contributes up to 25% of all sepsis cases. An important part of the management of urosepsis is to rule out possible surgical causes such as urolithiasis, obstructive uropathy, or abscess formation along the urogenital tract. Objective: The aim of this study is to look at whether urological conditions and recent urological surgery contribute significantly to all patients admitted with urosepsis. Methods: A total of 2679 urine cultures and 654 blood cultures performed in Connolly Hospital Emergency Department were reviewed between 2016 and 2018. Patients were included if they had a matching urine culture and blood culture performed within 24 hours of admission. A retrospective chart review was performed for all patients included in the study. Results: Our study included 85 patients admitted with urosepsis between 2016 and 2018. The average age was 70.3 years (21–100 years), in which 61% (n = 52) of patients were female, 18% (n = 16) had a long-term indwelling catheter, 11.8% (n = 10) were admitted as urosepsis with a urological condition. The most common urological condition predisposing patients to urosepsis in this study was bladder outlet obstruction secondary to benign prostatic hyperplasia. A total of 4.7% (n = 4) of patients died during their admission. The complications as a result of urosepsis included a prostatic abscess, a psoas abscess, an ileus, an infected cyst, and 1 case of emphysematous pyelonephritis. Conclusion: In this study, the majority of patients admitted with urosepsis did not have an underlying urological condition or recent urological instrumentation. Clinicians should be aware of potential complications as a result of a urosepsis.
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Lingiah VA, Pyrsopoulos NT. Bacterial Infections in Cirrhotic Patients in a Tertiary Care Hospital. J Clin Transl Hepatol 2021; 9:32-39. [PMID: 33604253 PMCID: PMC7868695 DOI: 10.14218/jcth.2020.00076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/15/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are immunocompromised and at higher risk of developing infections compared to the general population. The aim of this study was to assess the incidence of infections in cirrhotic patients in a large academic liver center and investigate potential associations between infections, bacteria isolated, therapeutic regimens used, and mortality. METHODS This was a retrospective chart review study, including 192 patients. All patients had a diagnosis of cirrhosis and were admitted to University Hospital. Information collected included demographics, etiology of cirrhosis, identification of bacteria from cultures, multidrug-resistant (MDR) status, antibiotics administered, intensive care unit (ICU) admission, and patient mortality. RESULTS Infections were present in 105 (54.6%) patients, and 60 (31.2%) patients had multiple infections during a hospitalization(s) for infections. A total of 201 infections were identified. Urinary tract infections (UTIs) were the most common infection (37.8%), followed by bacteremia (20.4%), pneumonia (12.9%), spontaneous bacterial peritonitis (SBP) (11.9%), abscess/cellulitis (6.0%), infectious diarrhea (6.0%), and other (5.0%). Escherichia coli was the most common bacteria isolated (13.4%), both among sensitive and MDR infections. MDR bacteria were the cause for 41.3% of all infections isolated. Fungi accounted for 9.5% of infections. 21.9% of patients had decompensation from their infection(s) that required ICU care, and 14.6% of patients died during hospitalization or soon after discharge. CONCLUSIONS The incidence of infections in cirrhotic patients is much higher than in their non-cirrhotic counterparts (54.6%), even higher than prior studies suggest. As many of these infections are caused by MDR bacteria and fungal organisms, stronger empiric antibiotics and antifungals should be considered when initially treating this immunocompromised population. However, once organism sensitivities are discovered, narrowing of antibiotic regimens must occur to maintain good antibiotic stewardship.
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Affiliation(s)
- Vivek A. Lingiah
- Correspondence to: Nikolaos T. Pyrsopoulos and Vivek A. Lingiah, Division of Gastroenterology and Hepatology, Rutgers University, New Jersey Medical School, MSB H-355, 185 S Orange Ave, Newark, NJ 07103, USA. Tel: +1-973-972-5252, Fax: +1-973-972-3144, E-mail: (NTP) or (VAL)
| | - Nikolaos T. Pyrsopoulos
- Correspondence to: Nikolaos T. Pyrsopoulos and Vivek A. Lingiah, Division of Gastroenterology and Hepatology, Rutgers University, New Jersey Medical School, MSB H-355, 185 S Orange Ave, Newark, NJ 07103, USA. Tel: +1-973-972-5252, Fax: +1-973-972-3144, E-mail: (NTP) or (VAL)
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23
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Anesi GL, Chelluri J, Qasim ZA, Chowdhury M, Kohn R, Weissman GE, Bayes B, Delgado MK, Abella BS, Halpern SD, Greenwood JC. Association of an Emergency Department-embedded Critical Care Unit with Hospital Outcomes and Intensive Care Unit Use. Ann Am Thorac Soc 2020; 17:1599-1609. [PMID: 32697602 PMCID: PMC7706601 DOI: 10.1513/annalsats.201912-912oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 07/22/2020] [Indexed: 12/15/2022] Open
Abstract
Rationale: A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF).Objectives: To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017.Methods: The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total emergency department plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses used multivariable Cox proportional hazard and logistic regression.Results: In the baseline and intervention periods, 3,897 patients met the inclusion criteria for sepsis and 1,865 patients met the criteria for ARF. Among patients admitted with sepsis, opening of the emergency department-embedded CCU was not associated with hospital LOS (β = -1.82 d; 95% confidence interval [CI], -4.50 to 0.87; P = 0.17 for the first month after emergency department-embedded CCU opening compared with baseline; β = -0.26 d; 95% CI, -0.58 to 0.06; P = 0.10 for subsequent months). Among patients admitted with ARF, the emergency department-embedded CCU was not associated with a significant change in hospital LOS for the first month after emergency department-embedded CCU opening (β = -3.25 d; 95% CI, -7.86 to 1.36; P = 0.15) but was associated with a 0.64 d/mo shorter hospital LOS for subsequent months (β = -0.64 d; 95% CI, -1.12 to -0.17; P = 0.01). This result persisted among higher acuity patients requiring ventilatory support but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the emergency department, the emergency department-embedded CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (β = -0.099; 95% CI, -0.153 to -0.044; P = 0.002), followed by a 1.1% per month increase back toward baseline in subsequent months (β = 0.011; 95% CI, 0.003-0.019; P = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with emergency department plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF.Conclusions: The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Zaffer A. Qasim
- Department of Emergency Medicine
- Department of Anesthesiology and Critical Care, and
| | | | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Bayes
- Palliative and Advanced Illness Research Center
| | - M. Kit Delgado
- Palliative and Advanced Illness Research Center
- Department of Emergency Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin S. Abella
- Department of Emergency Medicine
- Center for Resuscitation Science, Perelman School of Medicine, and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research Center
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John C. Greenwood
- Department of Emergency Medicine
- Center for Resuscitation Science, Perelman School of Medicine, and
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Impact of different consensus definition criteria on sepsis diagnosis in a cohort of critically ill patients-Insights from a new mathematical probabilistic approach to mortality-based validation of sepsis criteria. PLoS One 2020; 15:e0238548. [PMID: 32898161 PMCID: PMC7478755 DOI: 10.1371/journal.pone.0238548] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Sepsis-3 definition uses SOFA score to discriminate sepsis from uncomplicated infection, replacing SIRS criteria that were criticized for being inaccurate. Eligibility of sepsis-3 criteria for sepsis diagnosis and the applied validation methodology using mortality as endpoint are topic of ongoing debate. We assessed the impact of different criteria on sepsis diagnosis in our ICU and devised a mathematical approach for mortality-based validation of sepsis criteria. As infectious status is often unclear at clinical deterioration, we integrated non-infected patients into analysis. Methods Suspected infection, SOFA and SIRS were captured for an ICU cohort of a university center over one year. For raw scores (SIRS/SOFA) and sepsis criteria (SIRS≥2/SOFA≥2/SOFA_change≥2) frequencies and associations with in-hospital mortality were assessed. Using a mathematical approach, we estimated the correlation between sepsis and in-hospital mortality serving as reference for evaluation of observed mortality correlations of sepsis criteria. Results Of 791 patients, 369 (47%) were infected and 422 (53%) non-infected, with an in-hospital mortality of 39% and 15%. SIRS≥2 indicated sepsis in 90% of infected patients, SOFA≥2 in 99% and SOFA_change≥2 in 77%. In non-infected patients, SIRS, SOFA and SOFA_change were ≥2 in 78%, 88% and 58%. In AUROC analyses neither SOFA nor SIRS displayed superior mortality discrimination in infected compared to non-infected patients. The mathematically estimated correlation of sepsis and in-hospital mortality was 0.10 in infected and 0 in non-infected patients. Among sepsis criteria, solely SIRS≥2 agreed with expected correlations in both subgroups (infected: r = 0.19; non-infected: r = 0.02). Conclusions SOFA≥2 yielded a more liberal sepsis diagnosis than SIRS≥2. None of the criteria showed an infection specific occurrence that would be essential for reliable sepsis detection. However, SIRS≥2 matched the mortality association pattern of a valid sepsis criterion, whereas SOFA-based criteria did not. With this study, we establish a mathematical approach to mortality-based evaluation of sepsis criteria.
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Riedel S. Predicting Bacterial Versus Viral Infection, or None of the Above: Current and Future Prospects of Biomarkers. Clin Lab Med 2020; 39:453-472. [PMID: 31383268 DOI: 10.1016/j.cll.2019.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Sepsis and pneumonia cause significant morbidity and mortality worldwide. Despite improvements in diagnostic methodologies for organism identification, the early recognition and further risk stratification of these infections can be challenging. Although traditional clinical scoring systems are beneficial for the management of sepsis and pneumonia, biomarkers supporting the diagnosis and management of these infectious diseases are needed. Many biomarkers have been identified and there is no lack of studies and meta-analyses assessing the utility of biomarkers. Focusing primarily on sepsis and pneumonia, this article discusses the most commonly used biomarkers for which clinical laboratory testing methods are available.
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Affiliation(s)
- Stefan Riedel
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Yamins 309, Boston, MA 02215, USA.
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26
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Bulatova YY, Maltabarova NA, Zhumabayev MB, Li TA, Ivanova MP. Modern Diagnostics of Sepsis and Septic Shock in Children. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2020. [DOI: 10.29333/ejgm/7879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Rosenqvist M, Bengtsson-Toni M, Tham J, Lanbeck P, Melander O, Åkesson P. Improved Outcomes After Regional Implementation of Sepsis Alert: A Novel Triage Model. Crit Care Med 2020; 48:484-490. [PMID: 32205594 DOI: 10.1097/ccm.0000000000004179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To assess whether the triage model Sepsis Alert for Emergency Departments results in improved initial care of patients with severe infections. DESIGN Interventional study comparing patient care before and after the start of a new triage model, including 90-day follow-up. SETTING Eight emergency departments in Skåne County, Sweden. SUBJECTS Patients with suspected severe infection. INTERVENTIONS Patients with severely deviating vital signs and suspected infection were triaged into a designated sepsis line called Sepsis Alert, for rapid evaluation supported by an infectious disease specialist. Also, all emergency department staff participated in a designated sepsis education before the model was introduced. MEASUREMENTS AND MAIN RESULTS Medical records were evaluated for a 3-month period 1 year before the triage system was started in 2016 and for a 3-month period 1 year after. Of 195,607 patients admitted to these emergency departments during two 3-month periods, a total of 5,321 patients presented severely abnormal vital signs. Of these, 1,066 patients who presented with fever greater thanor equal to 38°C or history of fever/chills were considered to be patients at risk of having severe sepsis. Among patients triaged according to Sepsis Alert, 89.3% received antibiotic treatment within 1 hour after arrival to the emergency department (median time to antibiotics, 26 min), which was significantly better than before the start of the new triage: 67.9% (median time to antibiotics, 37 min) (p < 0.001). Additionally, sepsis treatment quality markers were significantly improved after the introduction of Sepsis Alert, including number of blood cultures and lactate measurements taken, percentage of patients receiving IV fluids, and appropriate initial antibiotic treatment. There were no differences in 28- or 90-day mortality rates. CONCLUSIONS The implementation of the new triage model Sepsis Alert with special attention to severe sepsis patients led to faster and more accurate antibiotic treatment and improved diagnostic procedures and supportive care.
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Affiliation(s)
- Mari Rosenqvist
- Infectious Disease Unit, Skåne University Hospital, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Maria Bengtsson-Toni
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Johan Tham
- Department of Translational Medicine, Clinical Infection Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter Lanbeck
- Infectious Disease Unit, Skåne University Hospital, Malmö, Sweden
| | - Olle Melander
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Per Åkesson
- Infectious Disease Unit, Skåne University Hospital, Lund, Sweden
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Daga S, Daga A, Mhatre S. <p>Antibiotic Therapy for Children with Diarrhea in a Low-Resource Setting: A Syndromic Approach</p>. Pediatric Health Med Ther 2020; 11:95-100. [PMID: 32214866 PMCID: PMC7082619 DOI: 10.2147/phmt.s235447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/02/2020] [Indexed: 11/23/2022] Open
Abstract
Objective Design Setting Participants Interventions Main Outcome Measures Results Conclusion
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Affiliation(s)
- Subhashchandra Daga
- Department of Pediatrics, MIMER Medical College, Talegaon Dabhade410507, India
- Correspondence: Subhashchandra Daga Department of Pediatrics, Pacific Medical College, Udaipur313001, IndiaTel +91 9960522259 Email
| | - Achla Daga
- Department of Community Medicine, Pacific Medical College, Udaipur313001, India
| | - Sameer Mhatre
- Department of Pediatrics, MIMER Medical College, Talegaon Dabhade410507, India
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Li T, Qian Y, Miao Z, Zheng P, Shi T, Jiang X, Pan L, Qian F, Yang G, An H, Zheng Y. Xuebijing Injection Alleviates Pam3CSK4-Induced Inflammatory Response and Protects Mice From Sepsis Caused by Methicillin-Resistant Staphylococcus aureus. Front Pharmacol 2020; 11:104. [PMID: 32153410 PMCID: PMC7047170 DOI: 10.3389/fphar.2020.00104] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/28/2020] [Indexed: 12/12/2022] Open
Abstract
A leading cause of death worldwide is sepsis that develops as a dysregulated immune response to infection. Serious infection caused by methicillin-resistant Staphylococcus aureus (MRSA) increases the difficulty of treatment in septic patients. Host-directed therapy (HDT) is an emerging approach to bacterial infections. Xuebijing injection (XBJ), a commercialized injectable prescription from traditional Chinese medicine, has been used as adjuvant therapy for sepsis with a history of 15 years. Whether it plays a protective role in severe infection caused by antibiotic-resistant bacteria is still unknown. In this study, XBJ significantly improved the survival of MRSA-induced sepsis mice. In MRSA-infected mouse model, XBJ down-regulated the expression of inflammatory cytokines interleukin (IL)-6, tumor necrosis factor (TNF)-α, MCP-1, MIP-2, and IL-10 in sera. Besides that, it decreased the bacterial load in spleens, livers, and alleviated tissue damage of lung, liver, and kidney. The combination of XBJ with vancomycin or dexamethasone exhibited a better down-regulatory role of the inflammatory response. Then, the protective mechanism of XBJ was further investigated. XBJ inhibited heat-killed MRSA-induced IL-6 and TNF-α production in mouse macrophages. XBJ also decreased Pam3CSK4 (a synthetic tripalmitoylated lipopeptide mimicking bacterial lipoproteins)-stimulated expression of IL-6, TNF-α, IL-1β, IL-12, etc. in mouse macrophages. Furthermore, XBJ down-regulated the activation of NF-κB, MAPK, and PI3K/Akt pathways in Pam3CSK4-stimulated mouse macrophages. In conclusion, our findings demonstrated that XBJ played a protective role in MRSA-challenged mice and down-regulated the inflammatory response and the activation of signaling pathways initiated by Pam3CSK4. It enlarged the clinical application of XBJ in the treatment of severe bacterial infection, e.g. caused by MRSA.
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Affiliation(s)
- Tiantian Li
- Department of Immunology and Microbiology, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiming Qian
- Department of Emergency, Yueyang Hospital of Integrated Chinese and Western Medicine affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhulei Miao
- Department of Immunology and Microbiology, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Peiyong Zheng
- Institute of Digestive Diseases, Longhua Hospital affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ting Shi
- Department of Immunology and Microbiology, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xinru Jiang
- Department of Immunology and Microbiology, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lingyun Pan
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fenghua Qian
- Department of Emergency, Yueyang Hospital of Integrated Chinese and Western Medicine affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guizhen Yang
- Department of Immunology and Microbiology, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Huazhang An
- Clinical Cancer Institute, Center of Translational Medicine, Second Military Medical University, Shanghai, China
| | - Yuejuan Zheng
- Department of Immunology and Microbiology, School of Basic Medical Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Baldirà J, Ruiz-Rodríguez JC, Wilson DC, Ruiz-Sanmartin A, Cortes A, Chiscano L, Ferrer-Costa R, Comas I, Larrosa N, Fàbrega A, González-López JJ, Ferrer R. Biomarkers and clinical scores to aid the identification of disease severity and intensive care requirement following activation of an in-hospital sepsis code. Ann Intensive Care 2020; 10:7. [PMID: 31940096 PMCID: PMC6962418 DOI: 10.1186/s13613-020-0625-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Few validated biomarker or clinical score combinations exist which can discriminate between cases of infection and other non-infectious conditions following activation of an in-hospital sepsis code, as well as provide an accurate severity assessment of the corresponding host response. This study aimed to identify suitable blood biomarker (MR-proADM, PCT, CRP and lactate) or clinical score (SOFA and APACHE II) combinations to address this unmet clinical need. METHODS A prospective, observational study of patients activating the Vall d'Hebron University Hospital sepsis code (ISC) within the emergency department (ED), hospital wards and intensive care unit (ICU). Area under the receiver operating characteristic (AUROC) curves, logistic and Cox regression analysis were used to assess performance. RESULTS 148 patients fulfilled the Vall d'Hebron ISC criteria, of which 130 (87.8%) were retrospectively found to have a confirmed diagnosis of infection. Both PCT and MR-proADM had a moderate-to-high performance in discriminating between infected and non-infected patients following ISC activation, although the optimal PCT cut-off varied significantly across departments. Similarly, MR-proADM and SOFA performed well in predicting 28- and 90-day mortality within the total infected patient population, as well as within patients presenting with a community-acquired infection or following a medical emergency or prior surgical procedure. Importantly, MR-proADM also showed a high association with the requirement for ICU admission after ED presentation [OR (95% CI) 8.18 (1.75-28.33)] or during treatment on the ward [OR (95% CI) 3.64 (1.43-9.29)], although the predictive performance of all biomarkers and clinical scores diminished between both settings. CONCLUSIONS Results suggest that the individual use of PCT and MR-proADM might help to accurately identify patients with infection and assess the overall severity of the host response, respectively. In addition, the use of MR-proADM could accurately identify patients requiring admission onto the ICU, irrespective of whether patients presented to the ED or were undergoing treatment on the ward. Initial measurement of both biomarkers might therefore facilitate early treatment strategies following activation of an in-hospital sepsis code.
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Affiliation(s)
- Jaume Baldirà
- Intensive Care Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain. .,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain.
| | - Darius Cameron Wilson
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Alejandro Cortes
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Luis Chiscano
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Roser Ferrer-Costa
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Inma Comas
- Biochemistry Department, Clinical Laboratories, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Department de Genètica i Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Fàbrega
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Juan José González-López
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Department de Genètica i Microbiologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.,Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institute of Research, Barcelona, Spain
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Flow Cytometry-Based Quantification of Neutrophil Extracellular Traps Shows an Association with Hypercoagulation in Septic Shock and Hypocoagulation in Postsurgical Systemic Inflammation-A Proof-of-Concept Study. J Clin Med 2020; 9:jcm9010174. [PMID: 31936385 PMCID: PMC7019434 DOI: 10.3390/jcm9010174] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 12/27/2019] [Accepted: 01/04/2020] [Indexed: 12/23/2022] Open
Abstract
This proof-of-concept study aimed to evaluate a novel method of flow cytometry-based quantification of neutrophil extracellular traps (NETs) in septic shock patients and to identify possible interactions between the number of free-circulating NETs and alterations of the coagulatory system. Patients suffering from septic shock, a matched control group (CTRL), and patients suffering from systemic inflammation after cardiac (CABG) or major abdominal surgery (MAS) were enrolled in this prospective proof-of-concept study. Compared to the matched controls, free-circulating NETs were significantly elevated in septic shock and postsurgical patients (data are presented in median (IQR)); septic shock: (2.7 (1.9-3.9); CABG: 2.7 (2.1-3.7); MAS: 2.7 (2.1-3.9); CTRL: 1.6 (1-2); CTRL vs. septic shock: p = 0.001; CTRL vs. CABG: p < 0.001; CTRL vs. MAS: p < 0.001). NETs correlated positively with FIBTEM mean clot firmness (MCF) in septic shock patients (r = 0.37, p < 0.01) while they correlated negatively in surgical patients (CABG: r = -0.28, p < 0.01; MAS: r = -0.25, p = 0.03). Flow-cytometric quantification of NETs showed a significant increase in free-circulating NETs under inflammatory conditions. Furthermore, this study hints to an association of the number of NETs with hypercoagulation in septic shock patients and hypocoagulation in surgery-induced inflammation.
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Kumar V. Sepsis roadmap: What we know, what we learned, and where we are going. Clin Immunol 2019; 210:108264. [PMID: 31655168 DOI: 10.1016/j.clim.2019.108264] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 07/02/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening condition originating as a result of systemic blood infection causing, one or more organ damage due to the dysregulation of the immune response. In 2017, the world health organization (WHO) declared sepsis as a disease of global health priority, needing special attention due to its high prevalence and mortality around the world. Most of the therapeutics targeting sepsis have failed in the clinics. The present review highlights the history of the sepsis, its immunopathogenesis, and lessons learned after the failure of previously used immune-based therapies. The subsequent section, where to go describes in details the importance of the complement system (CS), autophagy, inflammasomes, and microbiota along with their targeting to manage sepsis. These systems are interconnected to each other, thus targeting one may affect the other. We are in an urgent need for a multi-targeting therapeutic approach for sepsis.
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Affiliation(s)
- Vijay Kumar
- Children's Health Queensland Clinical Unit, School of Clinical Medicine, Faculty of Medicine, Mater Research, University of Queensland, ST Lucia, Brisbane, Queensland 4078, Australia; School of Biomedical Sciences, Faculty of Medicine, University of Queensland, ST Lucia, Brisbane, Queensland 4078, Australia.
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Schlapbach LJ, Berger C, Aebi C, Agyeman PKA. SIRS in the Time of Sepsis-3: What About the Children? Chest 2019; 153:1512. [PMID: 29884267 DOI: 10.1016/j.chest.2018.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Luregn J Schlapbach
- Faculty of Medicine, Mater Research Institute, University of Queensland, Brisbane, Australia; Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland, Brisbane, Australia; Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia; Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Christoph Aebi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Simpson SQ. Response. Chest 2019; 153:1513. [PMID: 29884269 DOI: 10.1016/j.chest.2018.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 04/15/2018] [Accepted: 04/16/2018] [Indexed: 11/26/2022] Open
Affiliation(s)
- Steven Q Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, KS.
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36
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Mylotte JM. What is the Role of Nursing Homes in the Surviving Sepsis Campaign? J Am Med Dir Assoc 2019; 21:41-45. [PMID: 31537482 DOI: 10.1016/j.jamda.2019.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 12/21/2022]
Abstract
Recently, there have been several publications advocating for an expansive role for nursing homes (NHs) in the Surviving Sepsis Campaign (SSC). The rationale for this effort is the problem of high rates of 30-day readmissions from NHs and a disproportionate percentage of residents with a diagnosis of sepsis in emergency departments. This article provides a brief history of the SSC and the evolution of the definition of sepsis and of the timing of interventions that make up a "sepsis bundle." Screening tools for sepsis that may be used in the NH setting are discussed. It is emphasized that there is no gold standard for the diagnosis of sepsis, and this limits the ability to identify a screening tool with high sensitivity. Three recent publications that discuss the recognition and management of sepsis in the NH are reviewed, although there is very little published information about this problem. Despite the lack of information about sepsis in NHs, several states have developed protocols for identification and management of sepsis in NHs but there are no results of the impact of these efforts on hospitalization or readmission rates or resident outcome. Based on the review of this information, the ability of NH providers and staff to identify residents with possible sepsis is unclear given no effective screening tool and the recent change in the definition of sepsis that focuses on a point late in the continuum from infection to sepsis with organ dysfunction. Also, NH capability to perform, in a timely fashion, interventions recommended in a sepsis bundle such as insertion of an intravenous catheter, performing blood cultures, administering antibiotics, and fluid resuscitation will likely vary considerably. There is a need for more intensive study of sepsis in the NH setting to identify screening tools with better sensitivity and identification of interventions suitable for the NH setting and that have an impact on various outcomes.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, Division of Infectious Diseases, Jacobs School of Medicine and Biomedical Science, State University of New York at Buffalo, Buffalo, NY.
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37
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Simpson SQ. Response. Chest 2019; 153:1278-1279. [PMID: 29731040 DOI: 10.1016/j.chest.2018.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 02/14/2018] [Accepted: 02/16/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Steven Q Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, KS.
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Probst L, Schalk E, Liebregts T, Zeremski V, Tzalavras A, von Bergwelt-Baildon M, Hesse N, Prinz J, Vehreschild JJ, Shimabukuro-Vornhagen A, Eichenauer DA, Garcia Borrega J, Kochanek M, Böll B. Prognostic accuracy of SOFA, qSOFA and SIRS criteria in hematological cancer patients: a retrospective multicenter study. J Intensive Care 2019; 7:41. [PMID: 31410290 PMCID: PMC6686367 DOI: 10.1186/s40560-019-0396-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/24/2019] [Indexed: 12/21/2022] Open
Abstract
Background With Sepsis-3, the increase in sequential organ failure assessment (SOFA) as a clinical score for the identification of patients with sepsis and quickSOFA (qSOFA) for the identification of patients at risk of sepsis outside the intensive care unit (ICU) were introduced in 2016. However, their validity has been questioned, and their applicability in different settings and subgroups, such as hematological cancer patients, remains unclear. We therefore assessed the validity of SOFA, qSOFA, and the systemic inflammatory response syndrome (SIRS) criteria regarding the diagnosis of sepsis and the prediction of in-hospital mortality in a multicenter cohort of hematological cancer patients treated on ICU and non-ICU settings. Methods We retrospectively calculated SIRS, SOFA, and qSOFA scores in our cohort and applied the definition of sepsis as "life-threatening organ dysfunction caused by dysregulated host response to infection" as reference. Discriminatory capacity was assessed using the area under the receiver operating characteristic curve (AUROC). Results Among 450 patients with hematological cancer (median age 58 years, 274 males [61%]), 180 (40%) had sepsis of which 101 (56%) were treated on ICU. For the diagnosis of sepsis, sensitivity was 86%, 64%, and 42% for SIRS, SOFA, and qSOFA, respectively. However, the AUROCs of SOFA and qSOFA indicated better discrimination for sepsis than SIRS (SOFA, 0.69 [95% CI, 0.64-0.73] p < 0.001; qSOFA, 0.67 [95% CI, 0.62-0.71] p < 0.001; SIRS, 0.57 [95% CI, 0.53-0.61] p < 0.001).In-hospital mortality was 40% and 14% in patients with and without sepsis, respectively (p < 0.001). Regarding patients with sepsis, mortality was similar in patients with positive and negative SIRS scores (39% vs. 40% (p = 0.899), respectively). For patients with qSOFA ≥ 2, mortality was 49% compared to 33% for those with qSOFA < 2 (p = 0.056), and for SOFA 56% vs. 11% (p < 0.001), respectively. SOFA allowed significantly better discrimination for in-hospital mortality (AUROC 0.74 [95% CI, 0.69-0.79] p < 0.001) than qSOFA (AUROC 0.65 [95% CI, 0.60-0.71] p < 0.001) or SIRS (AUROC 0.49 [95% CI, 0.44-0.54] p < 0.001). Conclusions An increase in SOFA score of ≥ 2 had better prognostic accuracy for both diagnosis of sepsis and in-hospital mortality in this setting, and especially on ICU, we observed limited validity of SIRS criteria and qSOFA in identifying hematological patients with sepsis and at high risk of death.
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Affiliation(s)
- Lucie Probst
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Enrico Schalk
- 2Department of Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Tobias Liebregts
- 3Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Vanja Zeremski
- 2Department of Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Asterios Tzalavras
- 3Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Nina Hesse
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Johanna Prinz
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Jörg Janne Vehreschild
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.,German Centre for Infection Research, partner-site Bonn-Cologne, Cologne, Germany.,6Medical Department 2, Hematology/Oncology, Goethe University of Frankfurt, Frankfurt, Germany
| | - Alexander Shimabukuro-Vornhagen
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Dennis A Eichenauer
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Jorge Garcia Borrega
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Matthias Kochanek
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Boris Böll
- 1University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
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Anand V, Zhang Z, Kadri SS, Klompas M, Rhee C. Epidemiology of Quick Sequential Organ Failure Assessment Criteria in Undifferentiated Patients and Association With Suspected Infection and Sepsis. Chest 2019; 156:289-297. [PMID: 30978329 DOI: 10.1016/j.chest.2019.03.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/07/2019] [Accepted: 03/15/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of Quick Sequential Organ Failure Assessment (qSOFA) criteria in sepsis screening and management is controversial, particularly as they were derived only in patients with suspected infection. We examined the epidemiology and prognostic value of qSOFA in undifferentiated patients. METHODS We identified patients with ≥ 2 qSOFA criteria within 1 day of admission among all adults admitted to 85 US hospitals from 2012 to 2015 and assessed for suspected infection (using clinical cultures and administration of antibiotics) and sepsis (as defined on the basis of Sepsis-3 criteria). We also examined the discrimination of qSOFA for in-hospital mortality among patients with and without suspected infection, using regression models. RESULTS Of 1,004,347 hospitalized patients, 271,500 (27.0%) were qSOFA-positive on admission. Compared with qSOFA-negative patients, qSOFA-positive patients were older (median age, 65 vs 58 years), required ICU admission more often (28.5% vs 6.5%), and had higher mortality (6.7% vs 0.8%) (P < .001 for all comparisons). Sensitivities of qSOFA for suspected infection and sepsis were 41.3% (95% CI, 41.1%-41.5%) and 62.8% (95% CI, 62.4%-63.1%), respectively; positive predictive values were 31.0% (95% CI, 30.8%-31.1%) and 17.4% (95% CI, 17.2%-17.5%). The area under the receiver operating characteristic curve for mortality was lower for qSOFA in patients with suspected infection vs those without (0.814 vs 0.875; P < .001). CONCLUSIONS Only one in three patients who are qSOFA-positive on admission has suspected infection, and one in six has sepsis. qSOFA also has low sensitivity for identifying suspected infection and sepsis, and its prognostic significance is not specific to infection. More sensitive and specific tools for sepsis screening and risk stratification are needed.
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Affiliation(s)
- Vijay Anand
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Chanu Rhee
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA.
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40
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Saeed K, Wilson DC, Bloos F, Schuetz P, van der Does Y, Melander O, Hausfater P, Legramante JM, Claessens YE, Amin D, Rosenqvist M, White G, Mueller B, Limper M, Callejo CC, Brandi A, Macchi MA, Cortes N, Kutz A, Patka P, Yañez MC, Bernardini S, Beau N, Dryden M, van Gorp ECM, Minieri M, Chan L, Rood PPM, Del Castillo JG. The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:40. [PMID: 30736862 PMCID: PMC6368690 DOI: 10.1186/s13054-019-2329-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 01/18/2019] [Indexed: 12/16/2022]
Abstract
Background There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need. Methods An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days. Results One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR [95%CI], 45.5 [10.0–207.6], 23.4 [11.1–49.3] and 32.6 [9.4–113.6], respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities. Conclusions In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment. Electronic supplementary material The online version of this article (10.1186/s13054-019-2329-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kordo Saeed
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK. .,University of Southampton, School of Medicine, Southampton, UK.
| | | | - Frank Bloos
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.,Center for Sepsis Control & Care (CSCC), Jena University Hospital, Jena, Germany
| | - Philipp Schuetz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Yuri van der Does
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Olle Melander
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Pierre Hausfater
- Emergency Department hôpital Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris and Sorbonne Universités GRC-14 BIOSFAST and INSERM UMR-S 1166, Paris, France
| | - Jacopo M Legramante
- Emergency Department, Policlinico Tor Vergata, Rome, Italy.,Department of Medical Systems, Universita di Tor Vergata, Rome, Italy
| | - Yann-Erick Claessens
- Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France
| | - Deveendra Amin
- Department of Critical Care, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL, 33756, USA
| | - Mari Rosenqvist
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.,Infectious Disease Unit, Skåne University Hospital, Malmö, Sweden
| | - Graham White
- Department of Blood Sciences, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK
| | - Beat Mueller
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht University, Utrecht, Netherlands
| | | | | | - Marc-Alexis Macchi
- Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France
| | - Nicholas Cortes
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.,University of Southampton, School of Medicine, Southampton, UK.,Gibraltar Health Authority, St Bernard's Hospital, Gibraltar, Spain
| | - Alexander Kutz
- Division of General and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Switzerland
| | - Peter Patka
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Sergio Bernardini
- Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy.,Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Nathalie Beau
- Department of Emergency Medicine, Monaco Princess Grace Hospital, Monaco, France
| | - Matthew Dryden
- Department of Microbiology, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK.,University of Southampton, School of Medicine, Southampton, UK.,Rare and Imported Pathogen Laboratories, Public Health England, Porton Down, UK
| | - Eric C M van Gorp
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marilena Minieri
- Department of Laboratory Medicine, Policlinico Tor Vergata, Rome, Italy
| | - Louisa Chan
- Department of accident and emergency, Hampshire Hospitals NHS Foundation Trust, Winchester and Basingstoke, UK
| | - Pleunie P M Rood
- Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Juan Gonzalez Del Castillo
- Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
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Englert JA, Bobba C, Baron RM. Integrating molecular pathogenesis and clinical translation in sepsis-induced acute respiratory distress syndrome. JCI Insight 2019; 4:e124061. [PMID: 30674720 PMCID: PMC6413834 DOI: 10.1172/jci.insight.124061] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Sepsis-induced acute respiratory distress syndrome (ARDS) has high morbidity and mortality and arises after lung infection or infection at extrapulmonary sites. An aberrant host response to infection leads to disruption of the pulmonary alveolar-capillary barrier, resulting in lung injury characterized by hypoxemia, inflammation, and noncardiogenic pulmonary edema. Despite increased understanding of the molecular biology underlying sepsis-induced ARDS, there are no targeted pharmacologic therapies for this devastating condition. Here, we review the molecular underpinnings of sepsis-induced ARDS with a focus on relevant clinical and translational studies that point toward novel therapeutic strategies.
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Affiliation(s)
- Joshua A. Englert
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher Bobba
- Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Rebecca M. Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Delahanty RJ, Alvarez J, Flynn LM, Sherwin RL, Jones SS. Development and Evaluation of a Machine Learning Model for the Early Identification of Patients at Risk for Sepsis. Ann Emerg Med 2019; 73:334-344. [PMID: 30661855 DOI: 10.1016/j.annemergmed.2018.11.036] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 11/14/2018] [Accepted: 11/27/2018] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The Third International Consensus Definitions (Sepsis-3) Task Force recommended the use of the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score to screen patients for sepsis outside of the ICU. However, subsequent studies raise concerns about the sensitivity of qSOFA as a screening tool. We aim to use machine learning to develop a new sepsis screening tool, the Risk of Sepsis (RoS) score, and compare it with a slate of benchmark sepsis-screening tools, including the Systemic Inflammatory Response Syndrome, Sequential Organ Failure Assessment (SOFA), qSOFA, Modified Early Warning Score, and National Early Warning Score. METHODS We used retrospective electronic health record data from adult patients who presented to 49 urban community hospital emergency departments during a 22-month period (N=2,759,529). We used the Rhee clinical surveillance criteria as our standard definition of sepsis and as the primary target for developing our model. The data were randomly split into training and test cohorts to derive and then evaluate the model. A feature selection process was carried out in 3 stages: first, we reviewed existing models for sepsis screening; second, we consulted with local subject matter experts; and third, we used a supervised machine learning called gradient boosting. Key metrics of performance included alert rate, area under the receiver operating characteristic curve, sensitivity, specificity, and precision. Performance was assessed at 1, 3, 6, 12, and 24 hours after an index time. RESULTS The RoS score was the most discriminant screening tool at all time thresholds (area under the receiver operating characteristic curve 0.93 to 0.97). Compared with the next most discriminant benchmark (Sequential Organ Failure Assessment), RoS was significantly more sensitive (67.7% versus 49.2% at 1 hour and 84.6% versus 80.4% at 24 hours) and precise (27.6% versus 12.2% at 1 hour and 28.8% versus 11.4% at 24 hours). The sensitivity of qSOFA was relatively low (3.7% at 1 hour and 23.5% at 24 hours). CONCLUSION In this retrospective study, RoS was more timely and discriminant than benchmark screening tools, including those recommend by the Sepsis-3 Task Force. Further study is needed to validate the RoS score at independent sites.
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Affiliation(s)
| | | | | | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, MI
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Kashyap R, Singh TD, Rayes H, O'Horo JC, Wilson G, Bauer P, Gajic O. Association of septic shock definitions and standardized mortality ratio in a contemporary cohort of critically ill patients. J Crit Care 2019; 50:269-274. [PMID: 30660915 DOI: 10.1016/j.jcrc.2019.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE The newly proposed septic shock definition has provoked a substantial controversy in the emergency and critical care communities. We aim to compare new (SEPSIS-III) versus old (SEPSIS-II) definitions for septic shock in a contemporary cohort of critically ill patients. MATERIAL AND METHODS Retrospective cohort of consecutive patients, age ≥ 18 years admitted to intensive care units at the Mayo Clinic between January 2009 and October 2015. We compared patients who met old, new, both, or neither definition of sepsis shock. SMR were calculated using APACHE IV predicted mortality. RESULTS The initial cohort consisted of 16,720 patients who had suspicion of infection, 7463 required vasopressor support. The median (IQR) age was 65(54-75) years and 4167(55.8%) were male. Compared to patients with old definition, the patients with new definition had higher APACHE III score (median IQR); (73 (57-92) vs. 70 (56-89), p < .01); SOFA score; (6 (4-10) vs. 6 (4-9), p < .01), were older (70 (59-79) vs. 64 (54-74) years, p = .03). They also had higher hospital mortality, N (%) 71, (19.7%) vs. 40 (12.6%), p < .01) and a higher SMR (0.66 vs. 0.45, p < .01). CONCLUSIONS Compared to SEPSIS-II, SEPSIS-III definition of septic shock identifies patients further along disease trajectory with higher likelihood of poor outcome.
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Affiliation(s)
- Rahul Kashyap
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States; Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, United States.
| | - Tarun D Singh
- Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Department of Neurology and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Hamza Rayes
- Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - John C O'Horo
- Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States; Division of Infectious Disease, Mayo Clinic, Rochester, MN, United States
| | - Gregory Wilson
- Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, United States
| | - Philippe Bauer
- Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care- METRIC, Mayo Clinic, Rochester, MN, United States; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
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Abstract
Despite numerous advances in understanding the pathophysiology of sepsis and its treatment, sepsis morbidity and mortality remain high. The 2016 Surviving Sepsis Campaign guidelines incorporated the latest research to formulate new sepsis diagnoses and updated treatment recommendations. This article reviews how to manage patients with sepsis and provides insight into the 2016 guidelines, updates, and suggestions.
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Lin GL, McGinley JP, Drysdale SB, Pollard AJ. Epidemiology and Immune Pathogenesis of Viral Sepsis. Front Immunol 2018; 9:2147. [PMID: 30319615 PMCID: PMC6170629 DOI: 10.3389/fimmu.2018.02147] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/30/2018] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can be caused by a broad range of pathogens; however, bacterial infections represent the majority of sepsis cases. Up to 42% of sepsis presentations are culture negative, suggesting a non-bacterial cause. Despite this, diagnosis of viral sepsis remains very rare. Almost any virus can cause sepsis in vulnerable patients (e.g., neonates, infants, and other immunosuppressed groups). The prevalence of viral sepsis is not known, nor is there enough information to make an accurate estimate. The initial standard of care for all cases of sepsis, even those that are subsequently proven to be culture negative, is the immediate use of broad-spectrum antibiotics. In the absence of definite diagnostic criteria for viral sepsis, or at least to exclude bacterial sepsis, this inevitably leads to unnecessary antimicrobial use, with associated consequences for antimicrobial resistance, effects on the host microbiome and excess healthcare costs. It is important to understand non-bacterial causes of sepsis so that inappropriate treatment can be minimised, and appropriate treatments can be developed to improve outcomes. In this review, we summarise what is known about viral sepsis, its most common causes, and how the immune responses to severe viral infections can contribute to sepsis. We also discuss strategies to improve our understanding of viral sepsis, and ways we can integrate this new information into effective treatment.
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Affiliation(s)
- Gu-Lung Lin
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Joseph P McGinley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Simon B Drysdale
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom.,Department of Paediatrics, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
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Jung AD, Baker J, Droege CA, Nomellini V, Johannigman J, Holcomb JB, Goodman MD, Pritts TA. Sooner is better: use of a real-time automated bedside dashboard improves sepsis care. J Surg Res 2018; 231:373-379. [PMID: 30278956 DOI: 10.1016/j.jss.2018.05.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/04/2018] [Accepted: 05/31/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Minimizing the interval between diagnosis of sepsis and administration of antibiotics improves patient outcomes. We hypothesized that a commercially available bedside clinical surveillance visualization system (BSV) would hasten antibiotic administration and decrease length of stay (LOS) in surgical intensive care unit (SICU) patients. METHODS A BSV, integrated with the electronic medical record and displayed at bedside, was implemented in our SICU in July 2016. A visual sepsis screen score (SSS) was added in July 2017. All patients admitted to SICU beds with bedside displays equipped with a BSV were analyzed to determine mean SSS, maximum SSS, time from positive SSS to antibiotic administration, SICU LOS, and mortality. RESULTS During the study period, 232 patients were admitted to beds equipped with the clinical surveillance visualization system. Thirty patients demonstrated positive SSS followed by confirmed sepsis (23 Pre-SSS versus 7 Post-SSS). Mean and maximum SSS were similar. Time from positive SSS to antibiotic administration was decreased in patients with a visual SSS (55.3 ± 15.5 h versus 16.2 ± 9.2 h; P < 0.05). ICU and hospital LOS was also decreased (P < 0.01). CONCLUSIONS Implementation of a visual SSS into a BSV led to a decreased time interval between the positive SSS and administration of antibiotics and was associated with shorter SICU and hospital LOS. Integration of a visual decision support system may help providers adhere to Surviving Sepsis Guidelines.
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Affiliation(s)
- Andrew D Jung
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer Baker
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center, Cincinnati Ohio
| | | | - Jay Johannigman
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - John B Holcomb
- Department of Surgery, University of Texas Health Science Center at Houston, Houston Texas
| | | | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio.
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47
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New Organ Failure as an Alternative Endpoint to Develop Diagnostic Criteria for Sepsis. Chest 2018; 153:1278. [DOI: 10.1016/j.chest.2017.11.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 11/05/2017] [Accepted: 11/07/2017] [Indexed: 01/28/2023] Open
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Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. The systemic inflammatory response syndrome criteria and their differential association with mortality. J Crit Care 2018; 46:29-36. [PMID: 29660669 DOI: 10.1016/j.jcrc.2018.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/31/2018] [Accepted: 04/03/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Despite the recent Sepsis-3 consensus, the Systemic Inflammatory Response Syndrome (SIRS) criteria continue to be assessed and recommended. Such use implies equivalence and interchangeability of criteria. Thus, we aimed to test whether such criteria are indeed equivalent and interchangeable. MATERIALS AND METHODS From 2000 to 2015, we identified patients with infection, organ failure, and at least one SIRS criterion in 179 Intensive Care Units in Australia and New. Zealand. We studied the association of different SIRS criteria with hospital mortality. RESULTS Among 131,016 patients with infection and organ failure, mortality increased from 10.6% for the respiratory rate criterion to 15.8% for the heart rate criterion (P<0.01); from 10.1% for the high leukocyte count criterion to 20.0% for a low count and from 10.1% for a high temperature to 14.4% for a low temperature criterion. With any two SIRS criteria, hospital mortality varied from 11.5% to 30.8% depending on the combination of criteria. This difference remained unchanged after adjustments and was consistent over time. CONCLUSIONS Different individual and combinations of SIRS criteria were associated with marked differences in hospital mortality. These differences remained unchanged after adjustment and over time and imply that individual SIRS criteria are not equivalent or interchangeable.
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Affiliation(s)
- Kirsi-Maija Kaukonen
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia; ANZICS Centre for Outcome and Resource Evaluation CORE, Melbourne, Australia.
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Unit, Austin Health, Heidelberg, Australia.
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49
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Abstract
BACKGROUND Discussion of outcomes of surgical sepsis is no longer straightforward. Definitions of sepsis have changed recently and updated data are scant. Surgical patient populations are often heterogeneous; the patient population being considered must be described with precision. Traditional 30-d operative mortality may not be the most relevant outcome to consider. What should change or be the emphasis going forward? METHODS Review and synthesis of pertinent English-language literature. RESULTS Epidemiologic data are abundant for short-term outcomes of sepsis in general, but despite the fact that approximately 30% of patients with sepsis are surgical patients, sepsis outcome data for surgical patients are scant, especially for durations longer than 30 d, and essentially non-existent for patients defined under the new Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria. Interpretability of extant data is hampered by non-standard and changing definitions. CONCLUSIONS Sepsis and organ dysfunction may be decreasing in prevalence and magnitude among surgical patients, but terminology must be standardized to enhance the interpretability of data generated in the future. It behooves journal editors, reviewers, and authors to insist upon standardized definitions and rigorous study design and data interpretation. Longer term data (e.g., 90-d mortality as opposed to in-hospital or traditional 30-d mortality) will be needed to justify to payers the complex, expensive care that these patients require. There is an urgent need to redefine the research agenda for surgical infections.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Division of Trauma, Burns, Acute and Critical Care; Department of Medicine, Division of Medical Ethics, Weill Cornell Medicine. Anne and Max A. Cohen Surgical Intensive Care Unit, NewYork-Presbyterian Hospital Hospital/Weill Cornell Medical Center , New York, New York
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