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Méndez R, González-Jiménez P, Mengot N, Menéndez R. Treatment Failure and Clinical Stability in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:225-236. [PMID: 38224700 DOI: 10.1055/s-0043-1778139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Treatment failure and clinical stability are important outcomes in community-acquired pneumonia (CAP). It is essential to know the causes and risk factors for treatment failure and delay in reaching clinical stability in CAP. The study of both as well as the associated underlying mechanisms and host response are key to improving outcomes in pneumonia.
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Affiliation(s)
- Raúl Méndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Paula González-Jiménez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
| | - Noé Mengot
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
| | - Rosario Menéndez
- Pneumology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
- Respiratory Infections, Health Research Institute La Fe (IISLAFE), Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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2
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Pei F, Gu B, Miao SM, Guan XD, Wu JF. Clinical practice of sepsis-induced immunosuppression: Current immunotherapy and future options. Chin J Traumatol 2024; 27:63-70. [PMID: 38040590 DOI: 10.1016/j.cjtee.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/07/2023] [Accepted: 08/17/2023] [Indexed: 12/03/2023] Open
Abstract
Sepsis is a potentially fatal condition characterized by the failure of one or more organs due to a disordered host response to infection. The development of sepsis is closely linked to immune dysfunction. As a result, immunotherapy has gained traction as a promising approach to sepsis treatment, as it holds the potential to reverse immunosuppression and restore immune balance, thereby improving the prognosis of septic patients. However, due to the highly heterogeneous nature of sepsis, it is crucial to carefully select the appropriate patient population for immunotherapy. This review summarizes the current and evolved treatments for sepsis-induced immunosuppression to enhance clinicians' understanding and practical application of immunotherapy in the management of sepsis.
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Affiliation(s)
- Fei Pei
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Bin Gu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Shu-Min Miao
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Xiang-Dong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China
| | - Jian-Feng Wu
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080, China; Guangdong Clinical Research Center for Critical Care Medicine, Guangzhou, 510080, China.
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3
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Davis D, Thadhani J, Choudhary V, Nausheem R, Vallejo-Zambrano CR, Mohammad Arifuddin B, Ali M, Carson BJ, Kanwal F, Nagarajan L. Advancements in the Management of Severe Community-Acquired Pneumonia: A Comprehensive Narrative Review. Cureus 2023; 15:e46893. [PMID: 37954793 PMCID: PMC10638673 DOI: 10.7759/cureus.46893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
Pneumonia, classified as a lower respiratory tract illness, affects different parts of the bronchial system as well as alveoli and can present with varying severities depending on co-morbidities and causative pathogens. It can be broadly classified using the setting in which it was acquired, namely the community or hospital setting, the former being more common and spreading through person-to-person droplet transmission. Community-acquired pneumonia (CAP) is currently the fourth leading cause of death worldwide, and its high mortality makes continual insight into the management of the condition worthwhile. This review explores the literature specifically for severe CAP (sCAP) and delves into the diagnosis, various modalities of treatment, and management of the condition. This condition can be defined as pneumonia requiring mechanical ventilation in the ICU and/or presenting with sepsis and organ failure due to pneumonia. The disease process is characterized by inflammation of the lung parenchyma, initiated by a combination of pathogens and lowered local defenses. Acute diagnosis of the condition is vital in reducing negative patient outcomes, namely through clinical presentation, blood/sputum cultures, imaging modalities such as computed tomography scan, and inflammatory markers, identifying common causative pathogens such as Streptococcus pneumoniae, rhinovirus, Legionella, and viral influenza. Pathogens such as Escherichia coli should also be investigated in patients with chronic obstructive pulmonary disease. The mainstay of treating sCAP includes rapid ICU admission once a diagnosis has been confirmed, initiating sepsis protocol, and treatment with combined empiric antibiotic regimens consisting of beta-lactams and macrolides. Corticosteroid use alongside antibiotics shows promise in reducing inflammation, but its use has to be judged on a case-by-case basis. New drugs such as omadacycline, delafloxacin, and zabofloxacin have shown valid evidence for the treatment of resistant causative organisms. The main guidelines for preventing sCAP include maintaining a healthy lifestyle, and annual pneumococcal and influenza vaccines are recommended for the most vulnerable patient groups, such as those with COPD and immunosuppression.
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Affiliation(s)
- Don Davis
- Medicine, Medical University of Varna, Varna, BGR
| | - Jainisha Thadhani
- Medicine, Royal College of Surgeons in Ireland, Medical University of Bahrain, Manama, BHR
| | | | | | | | | | - Mujahaith Ali
- Medicine, Ternopil National Medical University, Ternopil, UKR
| | - Bryan J Carson
- Emergency Medicine, Northern Health and Social Care Trust, Coleraine, GBR
| | - Fnu Kanwal
- Medical College, Chandka Medical College, Larkana, PAK
| | - Lavanya Nagarajan
- Department of Medicine, The Tamilnadu Dr.M.G.R. Medical University, Chennai, IND
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4
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Brandenburg K, Schromm AB, Weindl G, Heinbockel L, Correa W, Mauss K, Martinez de Tejada G, Garidel P. An update on endotoxin neutralization strategies in Gram-negative bacterial infections. Expert Rev Anti Infect Ther 2020; 19:495-517. [PMID: 33210958 DOI: 10.1080/14787210.2021.1834847] [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: 12/20/2022]
Abstract
INTRODUCTION Gram-negative bacterial infections represent still a severe problem of human health care, regarding the increase in multi-resistance against classical antibiotics and the lack of newly developed antimicrobials. For the fight against these germs, anti-infective agents must overcome and/or bind to the Gram-negative outer membrane consisting of a lipopolysaccharide (LPS, endotoxin) outer leaflet and an inner leaflet from phospholipids, with additional peripheral or integral membrane proteins (OMP's). AREAS COVERED The current article reviews data of existing therapeutic options and summarizes newer approaches for targeting and neutralizing endotoxins, ranging from in vitro over in vivo animal data to clinical applications by using databases such as Medline. EXPERT OPINION Conventional antibiotic treatment of the bacteria leads to their killing, but not necessary LPS neutralization, which may be a severe problem in particular for the systemic pathway. This is the reason why there is an increasing number of therapeutic approaches, which - besides combating whole bacteria - at the same time try to neutralize endotoxin within or outside the bacterial cells mainly responsible for the high inflammation induction in Gram-negative species.
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Affiliation(s)
- Klaus Brandenburg
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Andra B Schromm
- FG Immunobiophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Günther Weindl
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Universität Bonn, Universität Bonn Pharmazeutisches Institut Pharmakologie Und Toxikologie Bonn, Germany
| | - Lena Heinbockel
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany
| | - Wilmar Correa
- FG Biophysik, Forschungszentrum Borstel, Leibniz Lungenzentrum, Borstel, Germany
| | - Karl Mauss
- Brandenburg Antiinfektiva GmbH, c/o Forschungszentrum Borstel, Borstel, Germany.,Asklepios-Klinik Hamburg-Altona, Hamburg, Germany
| | - Guillermo Martinez de Tejada
- Department of Microbiology and Parasitology, University of Navarra, E-31008 Pamplona, Spain and Navarra Institute for Health Research (Idisna), Pamplona, Spain.,Department de Microbiologia, Universidad De Navarra, Pamplona, Spain
| | - Patrick Garidel
- Martin-Luther-Universität Halle-Wittenberg, Institut für Chemie, Halle/Saale, Germany
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5
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Torres A. New Insights into the Regulation of Endothelial Lung Permeability in Pneumonia. The Interplay between Angiopoietins 1 and 2. Am J Respir Crit Care Med 2019. [PMID: 29529378 DOI: 10.1164/rccm.201802-0377ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Antoni Torres
- 1 Hospital Clinic Universitat de Barcelona Barcelona, Spain and.,2 Icrea Academia Institut d'Investigacions Biomèdiques August Pi i Sunyer Barcelona, Spain
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6
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Abstract
Pneumonia is a highly prevalent disease with considerable morbidity and mortality. However, diagnosis and therapy still rely on antiquated methods, leading to the vast overuse of antimicrobials, which carries risks for both society and the individual. Furthermore, outcomes in severe pneumonia remain poor. Genomic techniques have the potential to transform the management of pneumonia through deep characterization of pathogens as well as the host response to infection. This characterization will enable the delivery of selective antimicrobials and immunomodulatory therapy that will help to offset the disorder associated with overexuberant immune responses.
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Affiliation(s)
- Samir Gautam
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Lokesh Sharma
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Charles S Dela Cruz
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA.
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7
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Ceccato A, Ferrer M, Barbeta E, Torres A. Adjunctive Therapies for Community-Acquired Pneumonia. Clin Chest Med 2018; 39:753-764. [DOI: 10.1016/j.ccm.2018.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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8
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Garnacho-Montero J, Barrero-García I, Gómez-Prieto MDG, Martín-Loeches I. Severe community-acquired pneumonia: current management and future therapeutic alternatives. Expert Rev Anti Infect Ther 2018; 16:667-677. [DOI: 10.1080/14787210.2018.1512403] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Irene Barrero-García
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | | | - Ignacio Martín-Loeches
- Department of Anaesthesia and Critical Care, St James University Hospital, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), Dublin, Ireland
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9
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German EL, Al-Hakim B, Mitsi E, Pennington SH, Gritzfeld JF, Hyder-Wright AD, Banyard A, Gordon SB, Collins AM, Ferreira DM. Anti-protein immunoglobulin M responses to pneumococcus are not associated with aging. Pneumonia (Nathan) 2018; 10:5. [PMID: 29992080 PMCID: PMC5987460 DOI: 10.1186/s41479-018-0048-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 05/10/2018] [Indexed: 11/16/2022] Open
Abstract
Background The incidence of community-acquired pneumonia and lower respiratory tract infection rises considerably in later life. Immunoglobulin M (IgM) antibody levels to pneumococcal capsular polysaccharide are known to decrease with age; however, whether levels of IgM antibody to pneumococcal proteins are subject to the same decline has not yet been investigated. Methods This study measured serum levels and binding capacity of IgM antibody specific to the pneumococcal surface protein A (PspA) and an unencapsulated pneumococcal strain in serum isolated from hospital patients aged < 60 and ≥ 60, with and without lower respiratory tract infection. A group of young healthy volunteers was used as a comparator to represent adults at very low risk of pneumococcal pneumonia. IgM serum antibody levels were measured by enzyme-linked immunosorbent assay (ELISA) and flow cytometry was performed to assess IgM binding capacity. Linear regression and one-way analysis of variance (ANOVA) tests were used to analyse the results. Results Levels and binding capacity of IgM antibody to PspA and the unencapsulated pneumococcal strain were unchanged with age. Conclusions These findings suggest that protein-based pneumococcal vaccines may provide protective immunity in the elderly. Trial registration The LRTI trial (LRTI and control groups) was approved by the National Health Service Research Ethics Committee in October 2013 (12/NW/0713). Recruitment opened in January 2013 and was completed in July 2013. Healthy volunteer samples were taken from the EHPC dose-ranging and reproducibility trial, approved by the same Research Ethics Committee in October 2011 (11/NW/0592). Recruitment for this study ran from October 2011 until December 2012. LRTI trial: (NCT01861184), EHPC dose-ranging and reproducibility trial: (ISRCTN85403723).
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Affiliation(s)
- Esther L German
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Bahij Al-Hakim
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,3Present address: Aintree University Hospital, Liverpool, UK
| | - Elena Mitsi
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Shaun H Pennington
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jenna F Gritzfeld
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,Present address: Public Health England, Vaccine Evaluation Unit, Manchester, UK
| | | | - Antonia Banyard
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,5Present address: Cancer Research UK Manchester Institute, Manchester, UK
| | - Stephen B Gordon
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK.,6Present address: Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi
| | - Andrea M Collins
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Daniela M Ferreira
- 1Respiratory Infection Group, Liverpool School of Tropical Medicine, Liverpool, UK
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10
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Welte T, Dellinger RP, Ebelt H, Ferrer M, Opal SM, Singer M, Vincent JL, Werdan K, Martin-Loeches I, Almirall J, Artigas A, Ignacio Ayestarán J, Nuding S, Ferrer R, Sirgo Rodríguez G, Shankar-Hari M, Álvarez-Lerma F, Riessen R, Sirvent JM, Kluge S, Zacharowski K, Bonastre Mora J, Lapp H, Wöbker G, Achtzehn U, Brealey D, Kempa A, Sánchez García M, Brederlau J, Kochanek M, Reschreiter HP, Wise MP, Belohradsky BH, Bobenhausen I, Dälken B, Dubovy P, Langohr P, Mayer M, Schüttrumpf J, Wartenberg-Demand A, Wippermann U, Wolf D, Torres A. Efficacy and safety of trimodulin, a novel polyclonal antibody preparation, in patients with severe community-acquired pneumonia: a randomized, placebo-controlled, double-blind, multicenter, phase II trial (CIGMA study). Intensive Care Med 2018; 44:438-448. [PMID: 29632995 PMCID: PMC5924663 DOI: 10.1007/s00134-018-5143-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/17/2018] [Indexed: 01/05/2023]
Abstract
Purpose The CIGMA study investigated a novel human polyclonal antibody preparation (trimodulin) containing ~ 23% immunoglobulin (Ig) M, ~ 21% IgA, and ~ 56% IgG as add-on therapy for patients with severe community-acquired pneumonia (sCAP). Methods In this double-blind, phase II study (NCT01420744), 160 patients with sCAP requiring invasive mechanical ventilation were randomized (1:1) to trimodulin (42 mg IgM/kg/day) or placebo for five consecutive days. Primary endpoint was ventilator-free days (VFDs). Secondary endpoints included 28-day all-cause and pneumonia-related mortality. Safety and tolerability were monitored. Exploratory post hoc analyses were performed in subsets stratified by baseline C-reactive protein (CRP; ≥ 70 mg/L) and/or IgM (≤ 0.8 g/L). Results Overall, there was no statistically significant difference in VFDs between trimodulin (mean 11.0, median 11 [n = 81]) and placebo (mean 9.6; median 8 [n = 79]; p = 0.173). Twenty-eight-day all-cause mortality was 22.2% vs. 27.8%, respectively (p = 0.465). Time to discharge from intensive care unit and mean duration of hospitalization were comparable between groups. Adverse-event incidences were comparable. Post hoc subset analyses, which included the majority of patients (58–78%), showed significant reductions in all-cause mortality (trimodulin vs. placebo) in patients with high CRP, low IgM, and high CRP/low IgM at baseline. Conclusions No significant differences were found in VFDs and mortality between trimodulin and placebo groups. Post hoc analyses supported improved outcome regarding mortality with trimodulin in subsets of patients with elevated CRP, reduced IgM, or both. These findings warrant further investigation. Trial registration: NCT01420744. Electronic supplementary material The online version of this article (10.1007/s00134-018-5143-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tobias Welte
- Department of Pneumology and German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - R Phillip Dellinger
- Department of Medicine, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, NJ, USA
| | - Henning Ebelt
- Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Miguel Ferrer
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS, CibeRes (CB06/06/0028), University of Barcelona, Barcelona, Spain
| | - Steven M Opal
- Infectious Disease Division, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Karl Werdan
- Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO) Wellcome Trust - HRB Clinical Research Facility (CRF) at St. James's Hospital, Trinity Centre for Health Sciences, Dublin, Ireland.,Critical Care Center, CIBER Enfermedades Respiratorias, Corporació Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Jordi Almirall
- Unitat de Cures Intensives, Hospital de Mataró, Universitat Autónoma de Barcelona, Mataró, Barcelona, Spain
| | - Antonio Artigas
- Critical Care Center, CIBER Enfermedades Respiratorias, Corporació Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Jose Ignacio Ayestarán
- Unidad de Cuidados Intensivos, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Sebastian Nuding
- Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Ricard Ferrer
- Hospital Universitario Mútua de Terrassa, SODIR-VHIR Research Group, Barcelona, Spain
| | - Gonzalo Sirgo Rodríguez
- Intensive Care Unit, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Rovira i Virgili University, Tarragona, Spain
| | - Manu Shankar-Hari
- Intensive Care Medicine, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | | | - Reimer Riessen
- Universitätsklinikum Tübingen, Internistische Intensivstation, Tübingen, Germany
| | - Josep-Maria Sirvent
- Servicio de Medicina Intensiva, Hospital U. Girona Dr. Josep Trueta, Avinguda França, Girona, Spain
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Kai Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Juan Bonastre Mora
- Servicio de Cuidados Intensivos Adultos, Hospital Universitari y Politècnico La Fe, Valencia, Spain
| | - Harald Lapp
- 3 Medizinische Klinik, Kardiologie und Intensivmedizin, Helios Klinikum Erfurt, Erfurt, Germany
| | - Gabriele Wöbker
- Klinik für Intensivmedizin, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - Ute Achtzehn
- Innere Medizin IV - Pneumologie, Klinikum Chemnitz gGmbH, Chemnitz, Germany
| | - David Brealey
- Critical Care Unit, NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Axel Kempa
- Klinik für Allgemeine Innere Medizin, Katharinenhospital, Stuttgart, Germany
| | | | - Jörg Brederlau
- Helios Klinikum Berlin-Buch, Klinik für Intensivmedizin, Berlin, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Intensive Care Unit and Hemostasis, University Hospital of Cologne, Cologne, Germany
| | | | - Matthew P Wise
- Critical Care Unit, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Bernd H Belohradsky
- University Children's Hospital Munich, Ludwig-Maximilians University Munich, Munich, Germany
| | | | | | | | | | | | | | | | | | | | - Antoni Torres
- Servei de Pneumologia, Hospital Clínic, Universitat de Barcelona IDIBAPS, CIBERES, Barcelona, Spain
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11
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Cilloniz C, Ferrer M, Liapikou A, Garcia-Vidal C, Gabarrus A, Ceccato A, Puig de La Bellacasa J, Blasi F, Torres A. Acute respiratory distress syndrome in mechanically ventilated patients with community-acquired pneumonia. Eur Respir J 2018; 51:13993003.02215-2017. [PMID: 29545274 DOI: 10.1183/13993003.02215-2017] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/15/2018] [Indexed: 01/24/2023]
Abstract
Our aim was to assess the incidence, characteristics, aetiology, risk factors and mortality of acute respiratory distress syndrome (ARDS) in intensive care unit (ICU) patients with community-acquired pneumonia (CAP) using the Berlin definition.We prospectively enrolled consecutive mechanically ventilated adult ICU patients with CAP over 20 years, and compared them with mechanically ventilated patients without ARDS. The main outcome was 30-day mortality.Among 5334 patients hospitalised with CAP, 930 (17%) were admitted to the ICU and 432 required mechanical ventilation; 125 (29%) cases met the Berlin ARDS criteria. ARDS was present in 2% of hospitalised patients and 13% of ICU patients. Based on the baseline arterial oxygen tension/inspiratory oxygen fraction ratio, 60 (48%), 49 (40%) and 15 (12%) patients had mild, moderate and severe ARDS, respectively. Streptococcus pneumoniae was the most frequent pathogen, with no significant differences in aetiology between groups. Higher organ system dysfunction and previous antibiotic use were independent risk factors for ARDS in the multivariate analysis, while previous inhaled corticosteroids were independently associated with a lower risk. The 30-day mortality was similar between patients with and without ARDS (25% versus 30%, p=0.25), confirmed by propensity-adjusted multivariate analysis.ARDS occurs as a complication of CAP in 29% of mechanically ventilated patients, but is not related to the aetiology or mortality.
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Affiliation(s)
- Catia Cilloniz
- Dept of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Miquel Ferrer
- Dept of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | | | | | - Albert Gabarrus
- Dept of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | - Adrian Ceccato
- Dept of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
| | | | - Francesco Blasi
- Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antoni Torres
- Dept of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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12
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Ferrer M, Travierso C, Cilloniz C, Gabarrus A, Ranzani OT, Polverino E, Liapikou A, Blasi F, Torres A. Severe community-acquired pneumonia: Characteristics and prognostic factors in ventilated and non-ventilated patients. PLoS One 2018; 13:e0191721. [PMID: 29370285 PMCID: PMC5784994 DOI: 10.1371/journal.pone.0191721] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/10/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patients with severe community-acquired pneumonia (SCAP) and life-threatening acute respiratory failure may require invasive mechanical ventilation (IMV). Since use of IMV is often associated with significant morbidity and mortality, we assessed whether patients invasively ventilated would represent a target population for interventions aimed at reducing mortality of SCAP. METHODS We prospectively recruited consecutive patients with SCAP for 12 years. We assessed the characteristics and outcomes of patients invasively ventilated at presentation of pneumonia, compared with those without IMV, and determined the influence of risks factors on mortality with a multivariate weighted logistic regression using a propensity score. RESULTS Among 3,719 patients hospitalized with CAP, 664 (18%) had criteria for SCAP, and 154 (23%) received IMV at presentation of pneumonia; 198 (30%) presented with septic shock. In 370 (56%) cases SCAP was diagnosed based solely on the presence of 3 or more IDSA/ATS minor criteria. Streptococcus pneumoniae was the main pathogen in both groups. The 30-day mortality was higher in the IMV, compared to non-intubated patients (51, 33%, vs. 94, 18% respectively, p<0·001), and higher than that predicted by APACHE-II score (26%). IMV independently predicted 30-day mortality in multivariate analysis (adjusted odds-ratio 3·54, 95% confidence interval 1·45-8·37, p = 0·006). Other independent predictors of mortality were septic shock, worse hypoxemia and increased serum potassium. CONCLUSION Invasive mechanical ventilation independently predicted 30-day mortality in patients with SCAP. Patients invasively ventilated should be considered a different population with higher mortality for future clinical trials on new interventions addressed to improve mortality of SCAP.
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Affiliation(s)
- Miquel Ferrer
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Centro de Investigaciones biomedicas En Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-ISCIII, Barcelona, Spain
- * E-mail:
| | - Chiara Travierso
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Catia Cilloniz
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Centro de Investigaciones biomedicas En Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-ISCIII, Barcelona, Spain
| | - Albert Gabarrus
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Centro de Investigaciones biomedicas En Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-ISCIII, Barcelona, Spain
| | - Otavio T. Ranzani
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Pulmonary Division, Heart Institute, Medical School, University of São Paulo, São Paulo, Brazil
| | - Eva Polverino
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Centro de Investigaciones biomedicas En Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-ISCIII, Barcelona, Spain
| | - Adamantia Liapikou
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- 6 Department of Respiratory Medicine, Sotiria Chest Diseases Hospital, Athens, Greece
| | - Francesco Blasi
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Centro de Investigaciones biomedicas En Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-ISCIII, Barcelona, Spain
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13
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Langereis JD, Henriet SS, Kuipers S, Weemaes CMR, van der Burg M, de Jonge MI, van der Flier M. IgM Augments Complement Bactericidal Activity with Serum from a Patient with a Novel CD79a Mutation. J Clin Immunol 2018; 38:185-192. [PMID: 29335801 PMCID: PMC5840230 DOI: 10.1007/s10875-017-0474-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/27/2017] [Indexed: 01/13/2023]
Abstract
Antibody replacement therapy for patients with antibody deficiencies contains only IgG. As a result, concurrent IgM and IgA deficiency present in a large proportion of antibody deficient patients persists. Especially patients with IgM deficiency remain at risk for recurrent infections of the gastrointestinal and respiratory tract. The lack of IgM in the current IgG replacement therapy is likely to contribute to the persistence of these mucosal infections because this antibody class is especially important for complement activation on the mucosal surface. We evaluated whether supplementation with IgM increased serum bactericidal capacity in vitro. Serum was collected from a patient with agammaglobulinemia and supplemented with purified serum IgM to normal levels. Antibody and complement deposition on the bacterial surface was determined by multi-color flow cytometry. Bacterial survival in serum was determined by colony-forming unit counts. We present a patient previously diagnosed with agammaglobulinemia due to CD79A (Igα) deficiency revealing a novel pathogenic insertion variant in the CD79a gene (NM_001783.3:c.353_354insT). Despite IgG replacement therapy and antibiotic prophylaxis, this patient developed a Campylobacter jejuni spondylodiscitis of lumbar vertebrae L4–L5. We found that serum IgM significantly contributes to complement activation on the bacterial surface of C. jejuni. Furthermore, supplementation of serum IgM augmented serum bactericidal activity significantly. In conclusion, supplementation of intravenous IgG replacement therapy with IgM may potentially offer greater protection against bacterial infections, also in the context of increasing antibiotic resistance.
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Affiliation(s)
- Jeroen D Langereis
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Stefanie S Henriet
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia Kuipers
- Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Corry M R Weemaes
- Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mirjam van der Burg
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marien I de Jonge
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michiel van der Flier
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Pediatric Infectious Diseases and Immunology, Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
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14
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Welte T, Pletz M. Pneumonia and the Risk of Cardiovascular Death. Time to Change Our Strategy. Am J Respir Crit Care Med 2017; 196:541-543. [PMID: 28723315 DOI: 10.1164/rccm.201707-1421ed] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Tobias Welte
- 1 Department of Respiratory Medicine Medizinische Hochschule Hannover, Member of the German Center of Lung Research Hannover, Germany and
| | - Mathias Pletz
- 2 Center for Infectious Diseases and Infection Control Jena University Hospital Jena, Germany
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15
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Can Concurrent Abnormalities in Free Light Chains and Immunoglobulin Concentrations Identify a Target Population for Immunoglobulin Trials in Sepsis?*. Crit Care Med 2017; 45:1829-1836. [DOI: 10.1097/ccm.0000000000002627] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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16
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Cazzola M, Rogliani P, Aliberti S, Blasi F, Matera MG. An update on the pharmacotherapeutic management of lower respiratory tract infections. Expert Opin Pharmacother 2017; 18:973-988. [PMID: 28480770 DOI: 10.1080/14656566.2017.1328497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Our knowledge about lower respiratory tract infections (LRTIs) has improved substantially in the last years, but the management of respiratory infections is still a challenge and we are still far from using precision medicine in their treatment. Areas covered: The approaches developed in recent years to improve the pharmacotherapeutic management of LRTIs, such as novel diagnostic assays to facilitate medical decision-making, attempts for selecting an optimal empiric antibiotic regimen, and the role of new and possibly unproven adjunctive therapies, are described. Expert opinion: Early and appropriate antibiotics remain the cornerstone in the treatment of LRTIs. The updated trend is to apply antimicrobial stewardship principles and initiatives to optimize both the management and the outcomes of LTRIs. Biomarkers, mainly C-reactive protein (CRP) and procalcitonin (PCT), can improve the diagnostic and prognostic assessment of LRTIs and aid to guide antibiotic therapy. The widespread use of antimicrobial agents has greatly contributed to faster development of antibiotic resistance and the emergence of opportunistic pathogens, which substitute the indigenous microbiota. However, very few new antibiotics in development to overcome existing resistance and ensure continued success in the treatment of LRTIs have been approved, likely because antibiotic stewardship programs discourage the use of new agents.
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Affiliation(s)
- Mario Cazzola
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Paola Rogliani
- a Department of Systems Medicine , Università degli Studi di Roma "Tor Vergata" , Rome , Italy
| | - Stefano Aliberti
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Francesco Blasi
- b Department of Pathophysiology and Transplantation , Università degli Studi di Milano, IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Maria Gabriella Matera
- c Department of Experimental Medicine , Università degli Studi della Campania "Luigi Vanvitelli" , Naples , Italy
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17
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Martin-Loeches I, Muriel-Bombín A, Ferrer R, Artigas A, Sole-Violan J, Lorente L, Andaluz-Ojeda D, Prina-Mello A, Herrán-Monge R, Suberviola B, Rodriguez-Fernandez A, Merino P, Loza AM, Garcia-Olivares P, Anton E, Tamayo E, Trapiello W, Blanco J, Bermejo-Martin JF. The protective association of endogenous immunoglobulins against sepsis mortality is restricted to patients with moderate organ failure. Ann Intensive Care 2017; 7:44. [PMID: 28429310 PMCID: PMC5399013 DOI: 10.1186/s13613-017-0268-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 04/11/2017] [Indexed: 01/31/2023] Open
Abstract
Background Pre-evaluation of endogenous immunoglobulin levels is a potential strategy to improve the results of intravenous immunoglobulins in sepsis, but more work has to be done to identify those patients who could benefit the most from this treatment. The objective of this study was to evaluate the impact of endogenous immunoglobulins on the mortality risk in sepsis depending on disease severity. Methods This was a retrospective observational study including 278 patients admitted to the ICU with sepsis fulfilling the SEPSIS-3 criteria, coming from the Spanish GRECIA and ABISS-EDUSEPSIS cohorts. Patients were distributed into two groups depending on their Sequential Organ Failure Assessment score at ICU admission (SOFA < 8, n = 122 and SOFA ≥ 8, n = 156), and the association between immunoglobulin levels at ICU admission with mortality was studied in each group by Kaplan–Meier and multivariate logistic regression analysis. Results ICU/hospital mortality in the SOFA < 8 group was 14.8/23.0%, compared to 30.1/35.3% in the SOFA ≥ 8 group. In the group with SOFA < 8, the simultaneous presence of total IgG < 407 mg/dl, IgM < 43 mg/dl and IgA < 219 mg/dl was associated with a reduction in the survival mean time of 6.6 days in the first 28 days and was a robust predictor of mortality risk either during the acute or during the post-acute phase of the disease (OR for ICU mortality: 13.79; OR for hospital mortality: 7.98). This predictive ability remained in the absence of prior immunosuppression (OR for ICU mortality: 17.53; OR for hospital mortality: 5.63). Total IgG < 407 mg/dl or IgG1 < 332 mg/dl was also an independent predictor of ICU mortality in this group. In contrast, in the SOFA ≥ 8 group, we found no immunoglobulin thresholds associated with neither ICU nor hospital mortality. Conclusions Endogenous immunoglobulin levels may have a different impact on the mortality risk of sepsis patients based on their severity. In patients with moderate organ failure, the simultaneous presence of low levels of IgG, IgA and IgM was a consistent predictor of both acute and post-acute mortalities. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0268-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St. James's University Hospitals Dublin, James's St, Ushers, Dublin 8, Ireland
| | - Arturo Muriel-Bombín
- Intensive Care Department, Hospital Universitario Río Hortega de Valladolid, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Shock Organ Dysfunction and Resuscitation Research Group, Vall d' Hebron Research Institute, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Antonio Artigas
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Center, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Parc Taulí 1, 08208, Sabadell, Barcelona, Spain.,CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, C/Sinesio Delgado,4, 28029, Madrid, Spain
| | - Jordi Sole-Violan
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Medicine Service, Hospital Dr Negrin, Barranco de la Ballena, s/n, 35010 Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Leonardo Lorente
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Medicine Service, Hospital Universitario de Canarias, Carretera de Ofra, s/n, 38320 San Cristóbal de La Laguna, Santa Cruz De Tenerife, Spain
| | - David Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 3, 47003, Valladolid, Spain
| | - Adriele Prina-Mello
- Laboratory for Biological Characterisation of Advanced Materials, Trinity Translational Medicine Institute (TTMI), James's St, Dublin 8, Ireland
| | - Ruben Herrán-Monge
- Intensive Care Department, Hospital Universitario Río Hortega de Valladolid, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Borja Suberviola
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Medicine Service, Hospital Universitario Marqués de Valdecilla, Av. Valdecilla, 25, 39008, Santander, Spain
| | - Ana Rodriguez-Fernandez
- Microbiology Service, Hospital Marques de Valdecilla, Av. Valdecilla, 25, 39008, Santander, Spain
| | - Pedro Merino
- Intensive Care Department, Hospital Universitario Río Hortega de Valladolid, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Ana M Loza
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Medicine Service, Hospital Nuestra Señora de Valme, Av. de Bellavista, s/n, 41014, Seville, Spain
| | - Pablo Garcia-Olivares
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Medicine Service, Hospital General Universitario Gregorio Marañón, Calle del Dr. Esquerdo, 46, 28007, Madrid, Spain
| | - Eduardo Anton
- ABISS-Edusepsis (AntiBiotic Intervention in Severe Sepsis), Intensive Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Critical Care Medicine Service, Hospital de Manacor, Carretera Manacor Alcudia, s/n, 07500, Manacor, Spain
| | - Eduardo Tamayo
- Anesthesiology Service, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal, 47003, Valladolid, Spain
| | - Wysali Trapiello
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario, SACYL, Av. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Jesús Blanco
- Intensive Care Department, Hospital Universitario Río Hortega de Valladolid, Calle Dulzaina, 2, 47012, Valladolid, Spain.,CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, C/Sinesio Delgado,4, 28029, Madrid, Spain
| | - Jesús F Bermejo-Martin
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario, SACYL, Av. Ramón y Cajal 3, 47003, Valladolid, Spain.
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Research in community-acquired pneumonia: the next steps. Intensive Care Med 2017; 43:1395-1397. [PMID: 28421245 PMCID: PMC7095202 DOI: 10.1007/s00134-017-4774-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/11/2017] [Indexed: 12/23/2022]
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19
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François B, Barraud O, Jafri H. Antibody-based therapy to combat Staphylococcus aureus infections. Clin Microbiol Infect 2017; 23:219-221. [DOI: 10.1016/j.cmi.2017.02.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 11/25/2022]
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20
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Sibila O, Rodrigo-Troyano A, Torres A. Nonantibiotic Adjunctive Therapies for Community-Acquired Pneumonia (Corticosteroids and Beyond): Where Are We with Them? Semin Respir Crit Care Med 2016; 37:913-922. [PMID: 27960215 PMCID: PMC7171709 DOI: 10.1055/s-0036-1593538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Community-acquired pneumonia (CAP) is a leading cause of hospitalization, morbidity, and mortality. Despite advances in antibiotic treatments, mortality among patients with CAP is still high. For this reason, interest has been focused on nonantibiotic therapeutic measures directed to the host response rather than the microorganism. The development of an efficacious adjunctive treatment has important implications for reducing mortality in CAP. Some clinical studies performed in the last decade have shown a clinically beneficial effect of corticosteroids, possibly by diminishing local and systemic inflammatory host response. Recent meta-analyses showed faster resolution of symptoms, shorter time to clinically stability, reduction of mechanical ventilation needed, and reduction of mortality in the most severe population, although some methodological limitations must be taken into account. In addition, some studies using statins also suggested improved outcomes due to its anti-inflammatory effect in CAP, although this requires further research. Other adjunctive therapies such as immunoglobulins and stem cells are being explored, but are not yet in the stage of clinical trials. In summary, the use of corticosteroids and other adjuvant treatments are promising in CAP, but more studies are needed to determine their impact on mortality.
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Affiliation(s)
- Oriol Sibila
- Respiratory Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona (UAB), Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Ana Rodrigo-Troyano
- Respiratory Department, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona (UAB), Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Antoni Torres
- Pulmonolgy Department, Respiratory Institute (ICR), Hospital Clinic of Barcelona, Spain
- Centro de Investigación Biomedica En Red - Enfermedades Respiratorias, Barcelona, Spain
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21
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Prina E, Ceccato A, Torres A. New aspects in the management of pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:267. [PMID: 27716262 PMCID: PMC5045574 DOI: 10.1186/s13054-016-1442-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite improvements in the management of community-acquired pneumonia (CAP), morbidity and mortality are still high, especially in patients with more severe disease. Early and appropriate antibiotics remain the cornerstone in the treatment of CAP. However, two aspects seem to contribute to a worse outcome: an uncontrolled inflammatory reaction and an inadequate immune response. Adjuvant treatments, such as corticosteroids and intravenous immunoglobulins, have been proposed to counterbalance these effects. The use of corticosteroids in patients with severe CAP and a strong inflammatory reaction can reduce the time to clinical stability, the risk of treatment failure, and the risk of progression to acute respiratory distress syndrome. The administration of intravenous immunoglobulins seems to reinforce the immune response to the infection in particular in patients with inadequate levels of antibodies and when an enriched IgM preparation has been used; however, more studies are needed to determinate their impact on outcome and to define the population that will receive more benefit.
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Affiliation(s)
- Elena Prina
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Adrian Ceccato
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.,Seccion Neumologia, Hospital Nacional Alejandro Posadas, Palomar, Argentina
| | - Antoni Torres
- Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain. .,Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Barcelona, Spain. .,UVIR, Servei de Pneumologia, Hospital Clínic, Villarroel 170., 08036, Barcelona, Spain.
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22
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de la Torre MC, Palomera E, Serra-Prat M, Güell E, Yébenes JC, Bermejo-Martín JF, Almirall J. IgG2 as an independent risk factor for mortality in patients with community-acquired pneumonia. J Crit Care 2016; 35:115-9. [DOI: 10.1016/j.jcrc.2016.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 12/16/2022]
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Serum IgG levels and mortality in patients with severe sepsis and septic shock : The SBITS data. Med Klin Intensivmed Notfmed 2016; 112:462-470. [PMID: 27677760 DOI: 10.1007/s00063-016-0220-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/01/2016] [Accepted: 07/13/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of intravenous immune globulin (Ig) therapy in patients with severe sepsis and septic shock is discussed controversially. Low initial IgG levels could help to identify those patients who might benefit from an adjunctive Ig treatment. OBJECTIVES To investigate the effect of initial serum IgG levels on 28-day mortality in patients with severe sepsis and septic shock. MATERIALS AND METHODS In this retrospective analysis of the SBITS trial data, 543 patients were allocated to four groups (quartiles) depending on their initial serum IgG levels (1: IgG ≤ 6.1 g/l; 2: IgG 6.2-8.4 g/l; 3: IgG 8.5-11.9 g/l; 4: IgG > 11.9 g/l). The third quartile was taken as the reference quartile. For the applied logistic regression model clinically relevant confounders were defined and integrated into further risk-adjusted calculations. RESULTS Patients with the lowest IgG levels had a mortality rate similar to those patients with initial IgG levels in the second and third quartile, representing the physiological IgG range in healthy people. Surprisingly, patients with the highest IgG levels even showed a significantly higher mortality in a risk-adjusted calculation compared to the reference quartile (OR 1.69, CI 1.01-2.81, p = 0.05). Subgroup analyses revealed that initial IgG levels were of no prognostic value in patients presenting with vasopressor-dependent septic shock on admission as well as in patients with either gram-positive or gram-negative sepsis. CONCLUSIONS Initially low IgG levels do not discriminate between survival and nonsurvival in patients with severe sepsis and septic shock. Therefore, low IgG cannot help to identify those patients who might benefit from an adjunctive IgG sepsis therapy. Whether a high initial IgG serum level is an independent mortality risk factor needs to be investigated prospectively.
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Späth PJ, Schneider C, von Gunten S. Clinical Use and Therapeutic Potential of IVIG/SCIG, Plasma-Derived IgA or IgM, and Other Alternative Immunoglobulin Preparations. Arch Immunol Ther Exp (Warsz) 2016; 65:215-231. [DOI: 10.1007/s00005-016-0422-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 08/31/2016] [Indexed: 12/22/2022]
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Prucha M, Zazula R, Russwurm S. Immunotherapy of Sepsis: Blind Alley or Call for Personalized Assessment? Arch Immunol Ther Exp (Warsz) 2016; 65:37-49. [PMID: 27554587 DOI: 10.1007/s00005-016-0415-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/14/2016] [Indexed: 01/20/2023]
Abstract
Sepsis is the most frequent cause of death in noncoronary intensive care units. In the past 10 years, progress has been made in the early identification of septic patients and their treatment. These improvements in support and therapy mean that mortality is gradually decreasing, however, the rate of death from sepsis remains unacceptably high. Immunotherapy is not currently part of the routine treatment of sepsis. Despite experimental successes, the administration of agents to block the effect of sepsis mediators failed to show evidence for improved outcome in a multitude of clinical trials. The following survey summarizes the current knowledge and results of clinical trials on the immunotherapy of sepsis and describes the limitations of our knowledge of the pathogenesis of sepsis. Administration of immunomodulatory drugs should be linked to the current immune status assessed by both clinical and molecular patterns. Thus, a careful daily review of the patient's immune status needs to be introduced into routine clinical practice giving the opportunity for effective and tailored use of immunomodulatory therapy.
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Affiliation(s)
- Miroslav Prucha
- Department of Clinical Biochemistry, Hematology and Immunology, Hospital Na Homolce, Prague, Czech Republic.
| | - Roman Zazula
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and Thomayer Hospital, Prague, Czech Republic
| | - Stefan Russwurm
- Department of Anesthesiology and Intensive Care, University Hospital, Jena, Germany
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Nicolau DP, Dimopoulos G, Welte T, Luyt CE. Can we improve clinical outcomes in patients with pneumonia treated with antibiotics in the intensive care unit? Expert Rev Respir Med 2016; 10:907-18. [PMID: 27181707 DOI: 10.1080/17476348.2016.1190277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pneumonia in the intensive care unit (ICU) is associated with high morbidity, mortality and healthcare costs. However, treatment outcomes with conventional intravenous (IV) antibiotics remain suboptimal, and there is an urgent need for improved therapy options. AREAS COVERED We review how clinical outcomes in patients with pneumonia treated in the ICU could be improved; we discuss the importance of choosing appropriate outcome measures in clinical trials, highlight the current suboptimal outcomes in patients with pneumonia, and outline potential solutions. We have included key studies and papers based on our clinical expertise, therefore a systematic literature review was not conducted. Expert commentary: Reasons for poor outcomes in patients with nosocomial pneumonia in the ICU include inappropriate initial therapy, increasing bacterial resistance and the complexities of IV dosing in critically ill patients. Robust clinical trial endpoints are needed to enable an accurate assessment of the success of new treatment approaches, but progress in this field has been slow. In addition, only very few new antimicrobials are currently in development for nosocomial pneumonia; two potential alternative solutions to improve outcomes could therefore include the optimization of pharmacokinetic/pharmacodynamics (PK/PD) and dosing of existing therapies, and the refinement of antimicrobial delivery by inhalation.
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Affiliation(s)
- David P Nicolau
- a Center for Anti-infective Research and Development , Hartford Hospital , Hartford , CT , USA
| | - George Dimopoulos
- b Department of Critical Care Medicine, Medical School , University of Athens , Athens , Greece
| | - Tobias Welte
- c Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany
| | - Charles-Edouard Luyt
- d Service de Réanimation, Institut de Cardiologie , Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris , Paris , France.,e UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition , Sorbonne Universités , Paris , France
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Welte T. Prevention is better than cure: time to change the focus of community-acquired pneumonia management. Eur Respir J 2016; 45:1524-5. [PMID: 26028615 DOI: 10.1183/09031936.00064015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Tobias Welte
- Pulmonary Medicine, University of Hannover, Hannover, Germany
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Die schwere Pneumonie auf der Intensivstation. Med Klin Intensivmed Notfmed 2016; 111:279-89. [DOI: 10.1007/s00063-016-0165-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
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Heming N, Lamothe L, Ambrosi X, Annane D. Emerging drugs for the treatment of sepsis. Expert Opin Emerg Drugs 2016; 21:27-37. [DOI: 10.1517/14728214.2016.1132700] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Endogenous immunoglobulins and sepsis: New perspectives for guiding replacement therapies. Int J Antimicrob Agents 2015; 46 Suppl 1:S25-8. [PMID: 26597932 DOI: 10.1016/j.ijantimicag.2015.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The recently emerging concept of immunosuppression developing in the field of severe sepsis generated the need to measure circulating immunoglobulins as part of the necessary tests to evaluate immunocompetence status in patients suffering from this condition. Serum concentrations can be used as a surrogate marker of the final outcome and as a biomarker to explore the need for supplementation of the host with intravenous immunoglobulin preparations. Available evidence from recent clinical studies pinpoints the main observations. The first is that circulating IgM is a phenomenon associated with progression from severe sepsis to septic shock. Deficient kinetics of circulating IgM during the first 7 days following the start of vasopressors is linked with unfavourable outcome. The second is the development of immunoscores using low levels of IgM, IgG1 and IgA. These immunoscores can predict 28-day mortality with an odds ratio ranging between 3 and 5. Novel techniques for evaluating patient's immune status are shedding new light on the development of modern therapeutics where immunoglobulin replacement may be part of a personalised therapeutic approach.
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