1
|
Mo Y, Booraphun S, Li AY, Domthong P, Kayastha G, Lau YH, Chetchotisakd P, Limmathurotsakul D, Tambyah PA, Cooper BS. Individualised, short-course antibiotic treatment versus usual long-course treatment for ventilator-associated pneumonia (REGARD-VAP): a multicentre, individually randomised, open-label, non-inferiority trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:399-408. [PMID: 38272050 DOI: 10.1016/s2213-2600(23)00418-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/09/2023] [Accepted: 11/01/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is associated with increased mortality, prolonged hospitalisation, excessive antibiotic use and, consequently, increased antimicrobial resistance. In this phase 4, randomised trial, we aimed to establish whether a pragmatic, individualised, short-course antibiotic treatment strategy for VAP was non-inferior to usual care. METHODS We did an individually randomised, open-label, hierarchical non-inferiority-superiority trial in 39 intensive care units in six hospitals in Nepal, Singapore, and Thailand. We enrolled adults (age ≥18 years) who met the US Centers for Disease Control and Prevention National Healthcare Safety Network criteria for VAP, had been mechanically ventilated for 48 h or longer, and were administered culture-directed antibiotics. In culture-negative cases, empirical antibiotic choices were made depending on local hospital antibiograms reported by the respective microbiology laboratories or prevailing local guidelines. Participants were assessed until fever resolution for 48 h and haemodynamic stability, then randomly assigned (1:1) to individualised short-course treatment (≤7 days and as short as 3-5 days) or usual care (≥8 days, with precise durations determined by the primary clinicians) via permuted blocks of variable sizes (8, 10, and 12), stratified by study site. Independent assessors for recurrent pneumonia and participants were masked to treatment allocation, but clinicians were not. The primary outcome was a 60-day composite endpoint of death or pneumonia recurrence. The non-inferiority margin was prespecified at 12% and had to be met by analyses based on both intention-to-treat (all study participants who were randomised) and per-protocol populations (all randomised study participants who fulfilled the eligibility criteria, met fitness criteria for antibiotic discontinuation, and who received antibiotics for the duration specified by their allocation group). This study is registered with ClinicalTrials.gov, number NCT03382548. FINDINGS Between May 25, 2018, and Dec 16, 2022, 461 patients were enrolled and randomly assigned to the short-course treatment group (n=232) or the usual care group (n=229). Median age was 64 years (IQR 51-74) and 181 (39%) participants were female. 460 were included in the intention-to-treat analysis after excluding one withdrawal (231 in the short-course group and 229 in the usual care group); 435 participants received the allocated treatment and fulfilled eligibility criteria, and were included in the per-protocol population. Median antibiotic treatment duration for the index episodes of VAP was 6 days (IQR 5-7) in the short-course group and 14 days (10-21) in the usual care group. 95 (41%) of 231 participants in the short-course group met the primary outcome, compared with 100 (44%) of 229 in the usual care group (risk difference -3% [one-sided 95% CI -∞ to 5%]). Results were similar in the per-protocol population. Non-inferiority of short-course antibiotic treatment was met in the analyses, although superiority compared with usual care was not established. In the per-protocol population, antibiotic side-effects occurred in 86 (38%) of 224 in the usual care group and 17 (8%) of 211 in the short-course group (risk difference -31% [95% CI -37 to -25%; p<0·0001]). INTERPRETATION In this study of adults with VAP, individualised shortened antibiotic duration guided by clinical response was non-inferior to longer treatment durations in terms of 60-day mortality and pneumonia recurrence, and associated with substantially reduced antibiotic use and side-effects. Individualised, short-course antibiotic treatment for VAP could help to reduce the burden of side-effects and the risk of antibiotic resistance in high-resource and resource-limited settings. FUNDING UK Medical Research Council; Singapore National Medical Research Council. TRANSLATIONS For the Thai and Nepali translations of the abstract see Supplementary Materials section.
Collapse
Affiliation(s)
- Yin Mo
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore.
| | | | - Andrew Yunkai Li
- National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore
| | | | - Gyan Kayastha
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Yie Hui Lau
- Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Paul Anantharajah Tambyah
- National University Hospital, Singapore; Infectious Diseases Translational Research Program, National University of Singapore, Singapore
| | - Ben S Cooper
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
2
|
Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [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: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
Collapse
Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
3
|
Nedel W, Deutschendorf C, Portela LVC. Sepsis-induced mitochondrial dysfunction: A narrative review. World J Crit Care Med 2023; 12:139-152. [PMID: 37397587 PMCID: PMC10308342 DOI: 10.5492/wjccm.v12.i3.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/08/2023] [Accepted: 04/14/2023] [Indexed: 06/08/2023] Open
Abstract
Sepsis represents a deranged and exaggerated systemic inflammatory response to infection and is associated with vascular and metabolic abnormalities that trigger systemic organic dysfunction. Mitochondrial function has been shown to be severely impaired during the early phase of critical illness, with a reduction in biogenesis, increased generation of reactive oxygen species and a decrease in adenosine triphosphate synthesis of up to 50%. Mitochondrial dysfunction can be assessed using mitochondrial DNA concentration and respirometry assays, particularly in peripheral mononuclear cells. Isolation of monocytes and lymphocytes seems to be the most promising strategy for measuring mitochondrial activity in clinical settings because of the ease of collection, sample processing, and clinical relevance of the association between metabolic alterations and deficient immune responses in mononuclear cells. Studies have reported alterations in these variables in patients with sepsis compared with healthy controls and non-septic patients. However, few studies have explored the association between mitochondrial dysfunction in immune mononuclear cells and unfavorable clinical outcomes. An improvement in mitochondrial parameters in sepsis could theoretically serve as a biomarker of clinical recovery and response to oxygen and vasopressor therapies as well as reveal unexplored pathophysiological mechanistic targets. These features highlight the need for further studies on mitochondrial metabolism in immune cells as a feasible tool to evaluate patients in intensive care settings. The evaluation of mitochondrial metabolism is a promising tool for the evaluation and management of critically ill patients, especially those with sepsis. In this article, we explore the pathophysiological aspects, main methods of measurement, and the main studies in this field.
Collapse
Affiliation(s)
- Wagner Nedel
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre 91350200, Brazil
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-003, Brazil
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo 04039-002, Brazil
| | - Caroline Deutschendorf
- Infection Control Committee, Hospital de Clínicas de Porto Alegre, Porto Alegre 90410-000, Brazil
| | - Luis Valmor Cruz Portela
- Laboratory of Neurotrauma and Biomarkers, Departamento de Bioquímica, ICBS, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-003, Brazil
| |
Collapse
|
4
|
Hirschberger S, Schmid A, Kreth S. [Immunomodulation by nutritional intervention in critically ill patients]. DIE ANAESTHESIOLOGIE 2023; 72:229-244. [PMID: 36797533 PMCID: PMC9934515 DOI: 10.1007/s00101-023-01258-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 04/12/2023]
Abstract
Critically ill patients often suffer from a complex and severe immunological dysfunction. The differentiation and function of human immune cells are fundamentally controlled through metabolic processes. New concepts of immunonutrition therefore try to use enteral and parenteral nutrition to positively impact on the immune function of intensive care unit patients. This review article concisely presents the currently available evidence on the commonly used isolated supplements (anti-oxidative substances, amino acids, essential fatty acids) and difficulties related to their clinical use. The second part presents new and more comprehensive concepts of immunonutrition to influence the intestinal microbiome and to modulate the macronutrient composition. Immunonutrition of critically ill patients bears enormous potential and could become a valuable clinical tool for modulation of the immunometabolism of intensive care unit patients.
Collapse
Affiliation(s)
- Simon Hirschberger
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland
| | - Annika Schmid
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland
| | - Simone Kreth
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland.
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland.
| |
Collapse
|
5
|
Schlechte J, Zucoloto AZ, Yu IL, Doig CJ, Dunbar MJ, McCoy KD, McDonald B. Dysbiosis of a microbiota-immune metasystem in critical illness is associated with nosocomial infections. Nat Med 2023; 29:1017-1027. [PMID: 36894652 PMCID: PMC10115642 DOI: 10.1038/s41591-023-02243-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 01/30/2023] [Indexed: 03/11/2023]
Abstract
Critically ill patients in intensive care units experience profound alterations of their gut microbiota that have been linked to a high risk of hospital-acquired (nosocomial) infections and adverse outcomes through unclear mechanisms. Abundant mouse and limited human data suggest that the gut microbiota can contribute to maintenance of systemic immune homeostasis, and that intestinal dysbiosis may lead to defects in immune defense against infections. Here we use integrated systems-level analyses of fecal microbiota dynamics in rectal swabs and single-cell profiling of systemic immune and inflammatory responses in a prospective longitudinal cohort study of critically ill patients to show that the gut microbiota and systemic immunity function as an integrated metasystem, where intestinal dysbiosis is coupled to impaired host defense and increased frequency of nosocomial infections. Longitudinal microbiota analysis by 16s rRNA gene sequencing of rectal swabs and single-cell profiling of blood using mass cytometry revealed that microbiota and immune dynamics during acute critical illness were highly interconnected and dominated by Enterobacteriaceae enrichment, dysregulated myeloid cell responses and amplified systemic inflammation, with a lesser impact on adaptive mechanisms of host defense. Intestinal Enterobacteriaceae enrichment was coupled with impaired innate antimicrobial effector responses, including hypofunctional and immature neutrophils and was associated with an increased risk of infections by various bacterial and fungal pathogens. Collectively, our findings suggest that dysbiosis of an interconnected metasystem between the gut microbiota and systemic immune response may drive impaired host defense and susceptibility to nosocomial infections in critical illness.
Collapse
Affiliation(s)
- Jared Schlechte
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amanda Z Zucoloto
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ian-Ling Yu
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary J Dunbar
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathy D McCoy
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
6
|
Khamooshpour G, Mahjubipour H, Farsaei S. Efficacy of an Herbal Preparation (Atomy's HemoHIM ®) against Ventilator-associated Pneumonia: A Randomized Controlled Clinical Trial. J Res Pharm Pract 2023; 12:58-63. [PMID: 38463188 PMCID: PMC10923201 DOI: 10.4103/jrpp.jrpp_9_23] [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: 01/09/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/12/2024] Open
Abstract
Objective Despite the standard guideline recommendations to prevent ventilator-associated pneumonia (VAP), it has remained one of the common lung infections in the intensive care unit (ICU). This clinical trial was designed to evaluate the effect of HemoHIM®, a mixture of traditional Korean medicinal plants, on preventing VAP in ICU patients. Methods This randomized controlled clinical trial was conducted on mechanically ventilated adult ICU patients with a clinical pulmonary infection score of VAP ≤6 in the first 48 h of ventilation. Patients in the intervention group received a packet of HemoHIM daily and orally for 7 days in addition to standard prevention strategies. However, in the control group, only standard prevention strategies were carried out. All patients were followed daily for VAP incidence for 14 days. Findings The overall VAP incidence was 36.4 and 57.4 episodes per 1000 days of mechanical ventilation in the intervention and control groups, respectively (P = 0.041; odds ratio = 0.26; 95% confidence interval = 0.070-0.944). The median length of mechanical ventilation during study follow-up was significantly lower in the intervention than in the control group (P = 0.033). The number of pneumonia-free days during the study was considerably higher in the intervention group (P value of the log-rank test = 0.023). Conclusion According to the results of this study, the HemoHIM herbal supplement had beneficial effects in preventing the occurrence of VAP and significantly reduced the incidence of pneumonia in the intervention group. Further comprehensive research is required to draw more accurate conclusions.
Collapse
Affiliation(s)
- Ghazal Khamooshpour
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hossein Mahjubipour
- Department of Anesthesiology and Critical Care, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Farsaei
- Department of Pharmaceutics, Faculty of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
7
|
Foster MA, Bentley C, Hazeldine J, Acharjee A, Nahman O, Shen-Orr SS, Lord JM, Duggal NA. Investigating the potential of a prematurely aged immune phenotype in severely injured patients as predictor of risk of sepsis. Immun Ageing 2022; 19:60. [PMID: 36471343 PMCID: PMC9720981 DOI: 10.1186/s12979-022-00317-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/24/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Traumatic injury elicits a hyperinflammatory response and remodelling of the immune system leading to immuneparesis. This study aimed to evaluate whether traumatic injury results in a state of prematurely aged immune phenotype to relate this to clinical outcomes and a greater risk of developing additional morbidities post-injury. METHODS AND FINDINGS Blood samples were collected from 57 critically injured patients with a mean Injury Severity Score (ISS) of 26 (range 15-75 years), mean age of 39.67 years (range 20-84 years), and 80.7% males, at days 3, 14, 28 and 60 post-hospital admission. 55 healthy controls (HC), mean age 40.57 years (range 20-85 years), 89.7% males were also recruited. The phenotype and frequency of adaptive immune cells were used to calculate the IMM-AGE score, an indicator of the degree of phenotypic ageing of the immune system. IMM-AGE was elevated in trauma patients at an early timepoint (day 3) in comparison with healthy controls (p < 0.001), driven by an increase in senescent CD8 T cells (p < 0.0001), memory CD8 T cells (p < 0.0001) and regulatory T cells (p < 0.0001) and a reduction in naïve CD8 T cells (p < 0.001) and overall T cell lymphopenia (p < 0 .0001). These changes persisted to day 60. Furthermore, the IMM-AGE scores were significantly higher in trauma patients (mean score 0.72) that developed sepsis (p = 0.05) in comparison with those (mean score 0.61) that did not. CONCLUSIONS The profoundly altered peripheral adaptive immune compartment after critical injury can be used as a potential biomarker to identify individuals at a high risk of developing sepsis and this state of prematurely aged immune phenotype in biologically young individuals persists for up to two months post-hospitalisation, compromising the host immune response to infections. Reversing this aged immune system is likely to have a beneficial impact on short- and longer-term outcomes of trauma survivors.
Collapse
Affiliation(s)
- Mark A. Foster
- grid.415490.d0000 0001 2177 007XNIHR-Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK ,grid.415490.d0000 0001 2177 007XRoyal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Conor Bentley
- grid.415490.d0000 0001 2177 007XNIHR-Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK ,grid.415490.d0000 0001 2177 007XRoyal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jon Hazeldine
- grid.6572.60000 0004 1936 7486MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Animesh Acharjee
- grid.6572.60000 0004 1936 7486Institute of Cancer and Genomic Sciences, Centre for Computational Biology, University of Birmingham, Birmingham, B15 2TT UK
| | - Ornit Nahman
- grid.6451.60000000121102151Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Shai S. Shen-Orr
- grid.6451.60000000121102151Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Janet M. Lord
- grid.6572.60000 0004 1936 7486MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Niharika A. Duggal
- grid.6572.60000 0004 1936 7486MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| |
Collapse
|
8
|
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
Collapse
Affiliation(s)
- Ya Wang
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia. .,Centre for Immunology and Allergy Research, Westmead Institute for Medical Research, Westmead, NSW, Australia.
| | - Anthony S McLean
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
| |
Collapse
|
9
|
Notz Q, Lee ZY, Menger J, Elke G, Hill A, Kranke P, Roeder D, Lotz C, Meybohm P, Heyland DK, Stoppe C. Omega-6 sparing effects of parenteral lipid emulsions-an updated systematic review and meta-analysis on clinical outcomes in critically ill patients. Crit Care 2022; 26:23. [PMID: 35045885 PMCID: PMC8767697 DOI: 10.1186/s13054-022-03896-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/11/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Parenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in pro-inflammatory omega-6 fatty acids (FAs). Parenteral nutrition (PN) strategies with the aim of reducing omega-6 FAs may potentially decrease the morbidity and mortality in critically ill patients. METHODS A systematic search of MEDLINE, EMBASE, CINAHL and CENTRAL was conducted to identify all randomized controlled trials in critically ill patients published from inception to June 2021, which investigated clinical omega-6 sparing effects. Two independent reviewers extracted bias risk, treatment details, patient characteristics and clinical outcomes. Random effect meta-analysis was performed. RESULTS 1054 studies were identified in our electronic search, 136 trials were assessed for eligibility and 26 trials with 1733 critically ill patients were included. The median methodologic score was 9 out of 14 points (95% confidence interval [CI] 7, 10). Omega-6 FA sparing PN in comparison with traditional lipid emulsions did not decrease overall mortality (20 studies; risk ratio [RR] 0.91; 95% CI 0.76, 1.10; p = 0.34) but hospital length of stay was substantially reduced (6 studies; weighted mean difference [WMD] - 6.88; 95% CI - 11.27, - 2.49; p = 0.002). Among the different lipid emulsions, fish oil (FO) containing PN reduced the length of intensive care (8 studies; WMD - 3.53; 95% CI - 6.16, - 0.90; p = 0.009) and rate of infectious complications (4 studies; RR 0.65; 95% CI 0.44, 0.95; p = 0.03). When FO was administered as a stand-alone medication outside PN, potential mortality benefits were observed compared to standard care. CONCLUSION Overall, these findings highlight distinctive omega-6 sparing effects attributed to PN. Among the different lipid emulsions, FO in combination with PN or as a stand-alone treatment may have the greatest clinical impact. Trial registration PROSPERO international prospective database of systematic reviews (CRD42021259238).
Collapse
Affiliation(s)
- Quirin Notz
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Zheng-Yii Lee
- Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Johannes Menger
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Daniel Roeder
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christopher Lotz
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.
| |
Collapse
|
10
|
Udovicic I, Stanojevic I, Djordjevic D, Zeba S, Rondovic G, Abazovic T, Lazic S, Vojvodic D, To K, Abazovic D, Khan W, Surbatovic M. Immunomonitoring of Monocyte and Neutrophil Function in Critically Ill Patients: From Sepsis and/or Trauma to COVID-19. J Clin Med 2021; 10:jcm10245815. [PMID: 34945111 PMCID: PMC8706110 DOI: 10.3390/jcm10245815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/27/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022] Open
Abstract
Immune cells and mediators play a crucial role in the critical care setting but are understudied. This review explores the concept of sepsis and/or injury-induced immunosuppression and immuno-inflammatory response in COVID-19 and reiterates the need for more accurate functional immunomonitoring of monocyte and neutrophil function in these critically ill patients. in addition, the feasibility of circulating and cell-surface immune biomarkers as predictors of infection and/or outcome in critically ill patients is explored. It is clear that, for critically ill, one size does not fit all and that immune phenotyping of critically ill patients may allow the development of a more personalized approach with tailored immunotherapy for the specific patient. In addition, at this point in time, caution is advised regarding the quality of evidence of some COVID-19 studies in the literature.
Collapse
Affiliation(s)
- Ivo Udovicic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Ivan Stanojevic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Institute for Medical Research, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Dragan Djordjevic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Snjezana Zeba
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Goran Rondovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Tanja Abazovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
| | - Srdjan Lazic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Institute of Epidemiology, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Danilo Vojvodic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Institute for Medical Research, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Kendrick To
- Division of Trauma & Orthopaedic Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK; (K.T.); (W.K.)
| | - Dzihan Abazovic
- Emergency Medical Centar of Montenegro, Vaka Djurovica bb, 81000 Podgorica, Montenegro;
| | - Wasim Khan
- Division of Trauma & Orthopaedic Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK; (K.T.); (W.K.)
| | - Maja Surbatovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Correspondence: ; Tel.: +381-11-2665-125
| |
Collapse
|
11
|
Flatman LK, Fergusson DA, Lacroix J, Ducruet T, Papenburg J, Fontela PS. Association between leukoreduced red blood cell transfusions and hospital-acquired infections in critically ill children: A secondary analysis of the TRIPICU study. Vox Sang 2021; 117:545-552. [PMID: 34820856 DOI: 10.1111/vox.13224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Hospital-acquired infections (HAIs) are an important problem in critically ill children. Studies show associations between the transfusion of non-leukoreduced red blood cell units (RBC) and increased HAI incidence rates (IRs). We hypothesize that transfusing pre-storage leukoreduced RBC is also associated with increased HAI IR. We aim to evaluate the associations between (1) a leukoreduced RBC restrictive transfusion strategy and HAI IR, (2) leukoreduced RBC transfusions and HAI IR, and (3) the number or volume of leukoreduced RBC transfusions and HAI IR in critically ill children. MATERIALS AND METHODS This post hoc secondary analysis of the "Transfusion Requirement in Paediatric Intensive Care Units" (TRIPICU) randomized controlled trial (637 patients) used quasi-Poisson multivariable regression models to estimate HAI incidence rate ratios (IRRs) and 95% confidence intervals (CI). RESULTS A restrictive transfusion strategy yielded an IRR of 0.88 (95% CI 0.67, 1.16). The association between transfusing leukoreduced RBCs (IRR 1.25; 95% CI 0.73, 2.13) and HAI IR was not statistically significant. However, we observed significant associations between patients who received >20 cc/kg volume of leukoreduced RBC transfusions (IRR 2.14; 95% CI 1.15, 3.99) and ≥3 leukoreduced RBC transfusions (IRR 2.40; 95% CI 1.15, 4.99) and HAI IR. CONCLUSION Exposing critically ill children to >20 cc/kg or ≥3 leukoreduced RBC transfusions were associated with higher HAI IR, suggesting dose-response patterns.
Collapse
Affiliation(s)
- Leah K Flatman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Université de Montréal, Montreal, Canada
| | - Thierry Ducruet
- Unité de Recherche Clinique Appliquée, Université de Montréal, Centre de Recherche, CHU Sainte-Justine, Montreal, Canada
| | - Jesse Papenburg
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Division of Pediatric Infectious Diseases, Department of Pediatrics, McGill University, Montreal, Canada
| | - Patricia S Fontela
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGill University, Montreal, Canada
| |
Collapse
|
12
|
Wu X, Luo Q, Su Z, Li Y, Wang H, Liu Q, Yuan S, Yan F. Neutrophil-to-lymphocyte ratio as a predictor of mortality in intensive care unit patients: a retrospective analysis of the Medical Information Mart for Intensive Care III Database. BMJ Open 2021; 11:e053548. [PMID: 34764177 PMCID: PMC8587351 DOI: 10.1136/bmjopen-2021-053548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Identifying high-risk patients in the intensive care unit (ICU) is important given the high mortality rate. However, existing scoring systems lack easily accessible, low-cost and effective inflammatory markers. We aimed to identify inflammatory markers in routine blood tests to predict mortality in ICU patients and evaluate their predictive power. DESIGN Retrospective case-control study. SETTING Single secondary care centre. PARTICIPANTS We analysed data from the Medical Information Mart for Intensive Care III database. A total of 21 822 ICU patients were enrolled and divided into survival and death groups based on in-hospital mortality. PRIMARY AND SECONDARY OUTCOME MEASURES The predictive values of potential inflammatory markers were evaluated and compared using receiver operating characteristic curve analysis. After identifying the neutrophil-to-lymphocyte ratio (NLR) as having the best predictive ability, patients were redivided into low (≤1), medium (1-6) and high (>6) NLR groups. Univariate and multivariate logistic regression analyses were performed to evaluate the association between the NLR and mortality. The area under the curve (AUC), net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used to assess whether incorporating the NLR could improve the predictive power of existing scoring systems. RESULTS The NLR had the best predictive ability (AUC: 0.609; p<0.001). In-hospital mortality rates were significantly higher in the low (OR (OR): 2.09; 95% CI 1.64 to 2.66) and high (OR 1.64; 95% CI 1.50 to 1.80) NLR groups than in the medium NLR group. Adding the NLR to the Simplified Acute Physiology Score II improved the AUC from 0.789 to 0.798, with an NRI and IDI of 16.64% and 0.27%, respectively. CONCLUSIONS The NLR predicted mortality in ICU patients well. Both low and high NLRs were associated with elevated mortality rates, including the NLR may improve the predictive power of the Simplified Acute Physiology Score II.
Collapse
Affiliation(s)
- Xie Wu
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Qipeng Luo
- Department of Pain Medicine, Peking University Third Hospital, Beijing, China
| | - Zhanhao Su
- Department of Pediatric Cardiac Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yinan Li
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Hongbai Wang
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Qiao Liu
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW This study reviews the mechanisms of HDL cholesterol immunomodulation in the context of the mechanisms of chronic inflammation and immunosuppression causing persistent inflammation, immunosuppression and catabolism syndrome (PICS) and describes potential therapies and gaps in current research. RECENT FINDINGS Low HDL cholesterol is predictive of acute sepsis severity and outcome. Recent research has indicated apolipoprotein is a prognostic indicator of long-term outcomes. The pathobiologic mechanisms of PICS have been elucidated in the past several years. Recent research of the interaction of HDL pathways in related chronic inflammatory diseases may provide insights into further mechanisms and therapeutic targets. SUMMARY HDL significantly influences innate and adaptive immune pathways relating to chronic disease and inflammation. Further research is needed to better characterize these interactions in the setting of PICS.
Collapse
Affiliation(s)
- Grant Barker
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville
| | - Julia R Winer
- University of Florida College of Medicine, Gainesville, Florida
| | - Faheem W Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville
| | - Srinivasa Reddy
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, California, USA
| |
Collapse
|
14
|
Chua YY, Ho QY, Ngo NT, Krishnamoorthy TL, Thangaraju S, Kee T, Wong HM. Cytomegalovirus-associated pseudomembranous colitis in a kidney transplant recipient. Transpl Infect Dis 2021; 23:e13694. [PMID: 34288307 DOI: 10.1111/tid.13694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/02/2021] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
Pseudomembranous colitis (PMC) is classically associated with Clostridium difficile infection. We report a rare case of cytomegalovirus (CMV)-associated PMC in a 52-year-old female patient who had undergone kidney transplantation more than 20 years ago and was on low dose prednisolone and ciclosporin. She presented with an acute history of fever, lethargy, vomiting and diarrhoea on admission. Computed tomography of the abdomen showed extensive colitis, and colonoscopy revealed extensive pseudomembrane formation. Multiple tests for Clostridium difficile and other common microbiological causes of colitis were negative. CMV DNAemia and colonic biopsies confirmed the diagnosis of CMV colitis. The patient responded to prompt CMV treatment, as demonstrated by clinical, endoscopic, and histological response. While CMV is a common pathogen in the solid organ transplant population that is familiar to most transplant physicians, it may present atypically as PMC. Here, we review the literature on CMV-associated PMC and its relevance to solid organ transplant recipients. To our knowledge, this is the first reported case of CMV-associated PMC in a kidney transplant recipient.
Collapse
Affiliation(s)
- Yi Yi Chua
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Nye Thane Ngo
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Thinesh Lee Krishnamoorthy
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore.,SingHealth-Duke NUS Transplant Centre, SingHealth, Singapore
| | - Hei Man Wong
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| |
Collapse
|
15
|
Yao B, Liu JY, Cai SX, Zhao WJ, Xing JY. Alteration of gut microbiota and metabolomics in critically ill patients by sequential feeding: A pilot study. JPEN J Parenter Enteral Nutr 2021; 46:538-545. [PMID: 34042183 DOI: 10.1002/jpen.2198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sequential feeding (SF) is a new feeding mode for critically ill patients that involves a combination of continuous feeding (CF) in the beginning, rhythmic feeding in the second stage, and oral feeding in the last stage. In this study, we investigated the influence of SF on gut microbiota and metabolomics in critically ill patients. METHODS Stool specimens from 20 patients (10 patients with the SF group, 10 patients with the CF group) were collected for full-length 16S ribosomal RNA gene sequencing and untargeted metabolomics analysis. RESULTS The proportion of patients with low bacterial diversity (Shannon index < 4) in the SF group was much lower than that in the CF group, but there was no significant difference in the proportions (20% vs 50%, P = .350). The abundances of Actinobacteria/Actinobacteria (at the phylum and class levels), Pseudomonadaceae/Pseudomonas (at the family and genus levels), and Fusobacteria/Fusobacteriaceae/Fusobacteriales/Fusobacteria/Fusobacterium (at the phylum, class, order, family, and genus levels) were all higher in the SF group than in the CF group. Actinobacteria/Actinobacteria (at the phylum and class levels) were the most influential of these gut flora. Retinoic acid and leucine were upregulated in the SF group and were respectively responsible for the intestinal immune network for immunoglobulin A production and the mammalian target of rapamycin signaling pathway in the enriched pathways according to the Kyoto Encyclopedia of Genes and Genomes database classification. CONCLUSIONS SF could alter gut microbiota and metabolomics in critically ill patients. Because of the small sample size, further study is required.
Collapse
Affiliation(s)
- Bo Yao
- The Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China.,Systems Biology and Medicine Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jian-Yu Liu
- Key Laboratory of Marine Drugs, The Ministry of Education of China, School of Medicine and Pharmacy, Ocean University of China, Qingdao, China
| | - Shi-Xia Cai
- The Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wan-Jun Zhao
- The Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jin-Yan Xing
- The Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
16
|
Rébillard RM, Charabati M, Grasmuck C, Filali-Mouhim A, Tastet O, Brassard N, Daigneault A, Bourbonnière L, Anand SP, Balthazard R, Beaudoin-Bussières G, Gasser R, Benlarbi M, Moratalla AC, Solorio YC, Boutin M, Farzam-Kia N, Descôteaux-Dinelle J, Fournier AP, Gowing E, Laumaea A, Jamann H, Lahav B, Goyette G, Lemaître F, Mamane VH, Prévost J, Richard J, Thai K, Cailhier JF, Chomont N, Finzi A, Chassé M, Durand M, Arbour N, Kaufmann DE, Prat A, Larochelle C. Identification of SARS-CoV-2-specific immune alterations in acutely ill patients. J Clin Invest 2021; 131:145853. [PMID: 33635833 DOI: 10.1172/jci145853] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/19/2021] [Indexed: 01/08/2023] Open
Abstract
Dysregulated immune profiles have been described in symptomatic patients infected with SARS-CoV-2. Whether the reported immune alterations are specific to SARS-CoV-2 infection or also triggered by other acute illnesses remains unclear. We performed flow cytometry analysis on fresh peripheral blood from a consecutive cohort of (a) patients hospitalized with acute SARS-CoV-2 infection, (b) patients of comparable age and sex hospitalized for another acute disease (SARS-CoV-2 negative), and (c) healthy controls. Using both data-driven and hypothesis-driven analyses, we found several dysregulations in immune cell subsets (e.g., decreased proportion of T cells) that were similarly associated with acute SARS-CoV-2 infection and non-COVID-19-related acute illnesses. In contrast, we identified specific differences in myeloid and lymphocyte subsets that were associated with SARS-CoV-2 status (e.g., elevated proportion of ICAM-1+ mature/activated neutrophils, ALCAM+ monocytes, and CD38+CD8+ T cells). A subset of SARS-CoV-2-specific immune alterations correlated with disease severity, disease outcome at 30 days, and mortality. Our data provide an understanding of the immune dysregulation specifically associated with SARS-CoV-2 infection among acute care hospitalized patients. Our study lays the foundation for the development of specific biomarkers to stratify SARS-CoV-2-positive patients at risk of unfavorable outcomes and to uncover candidate molecules to investigate from a therapeutic perspective.
Collapse
Affiliation(s)
- Rose-Marie Rébillard
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Marc Charabati
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Camille Grasmuck
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Abdelali Filali-Mouhim
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Olivier Tastet
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Nathalie Brassard
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Audrey Daigneault
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Lyne Bourbonnière
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Sai Priya Anand
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Quebec, Canada
| | - Renaud Balthazard
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Guillaume Beaudoin-Bussières
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Romain Gasser
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Mehdi Benlarbi
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Ana Carmena Moratalla
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Yves Carpentier Solorio
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Marianne Boutin
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Negar Farzam-Kia
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Jade Descôteaux-Dinelle
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Antoine Philippe Fournier
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Elizabeth Gowing
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Annemarie Laumaea
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Hélène Jamann
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Boaz Lahav
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Guillaume Goyette
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Florent Lemaître
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Victoria Hannah Mamane
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Jérémie Prévost
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Jonathan Richard
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Karine Thai
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Jean-François Cailhier
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Nicolas Chomont
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Andrés Finzi
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Microbiology and Immunology, McGill University, Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases and Immunology, and
| | - Michaël Chassé
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Madeleine Durand
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Nathalie Arbour
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Daniel E Kaufmann
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Alexandre Prat
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Catherine Larochelle
- Department of Neuroscience, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| |
Collapse
|
17
|
Agafonova EV, Rizvanova FF, Malanicheva TG, Abrahamyan L. Activation Markers and Regulatory T cells in Children with Chronic Pyelonephritis Associated with Bacterial Uropathogens. BIONANOSCIENCE 2020. [DOI: 10.1007/s12668-019-00676-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
18
|
Ho J, Chan H, Liang Y, Liu X, Zhang L, Li Q, Zhang Y, Zeng J, Ugwu FN, Ho IHT, Hu W, Yau JCW, Wong SH, Wong WT, Ling L, Cho CH, Gallo RL, Gin T, Tse G, Yu J, Chan MTV, Leung CCH, Wu WKK. Cathelicidin preserves intestinal barrier function in polymicrobial sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:47. [PMID: 32041659 PMCID: PMC7011568 DOI: 10.1186/s13054-020-2754-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/27/2020] [Indexed: 02/06/2023]
Abstract
Objectives The intestinal epithelium compartmentalizes the sterile bloodstream and the commensal bacteria in the gut. Accumulating evidence suggests that this barrier is impaired in sepsis, aggravating systemic inflammation. Previous studies reported that cathelicidin is differentially expressed in various tissues in sepsis. However, its role in sepsis-induced intestinal barrier dysfunction has not been investigated. Design To examine the role of cathelicidin in polymicrobial sepsis, cathelicidin wild-(Cnlp+/+) and knockout (Cnlp−/−) mice underwent cecal-ligation and puncture (CLP) followed by the assessment of septic mortality and morbidity as well as histological, biochemical, immunological, and transcriptomic analyses in the ileal tissues. We also evaluated the prophylactic and therapeutic efficacies of vitamin D3 (an inducer of endogenous cathelicidin) in the CLP-induced murine polymicrobial sepsis model. Results The ileal expression of cathelicidin was increased by three-fold after CLP, peaking at 4 h. Knockout of Cnlp significantly increased 7-day mortality and was associated with a higher murine sepsis score. Alcian-blue staining revealed a reduced number of mucin-positive goblet cells, accompanied by reduced mucin expression. Increased number of apoptotic cells and cleavage of caspase-3 were observed. Cnlp deletion increased intestinal permeability to 4kD fluorescein-labeled dextran and reduced the expression of tight junction proteins claudin-1 and occludin. Notably, circulating bacterial DNA load increased more than two-fold. Transcriptome analysis revealed upregulation of cytokine/inflammatory pathway. Depletion of Cnlp induced more M1 macrophages and neutrophils compared with the wild-type mice after CLP. Mice pre-treated with cholecalciferol (an inactive form of vitamin D3) or treated with 1alpha, 25-dihydroxyvitamin D3 (an active form of VD3) had decreased 7-day mortality and significantly less severe symptoms. Intriguingly, the administration of cholecalciferol after CLP led to worsened 7-day mortality and the associated symptoms. Conclusions Endogenous cathelicidin promotes intestinal barrier integrity accompanied by modulating the infiltration of neutrophils and macrophages in polymicrobial sepsis. Our data suggested that 1alpha, 25-dihydroxyvitamin D3 but not cholecalciferol is a potential therapeutic agent for treating sepsis.
Collapse
Affiliation(s)
- Jeffery Ho
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Hung Chan
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Yonghao Liang
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Xiaodong Liu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Lin Zhang
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China.,State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, and Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Qing Li
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Yuchen Zhang
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Judeng Zeng
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Felix N Ugwu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Idy H T Ho
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Wei Hu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Johnny C W Yau
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Sunny H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Shatin, China
| | - Wai Tat Wong
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Chi H Cho
- Laboratory of Molecular Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
| | - Richard L Gallo
- Department of Dermatology, The University of California, San Diego, USA
| | - Tony Gin
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Gary Tse
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Shatin, China
| | - Jun Yu
- State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, and Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Shatin, China
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China.
| | - Czarina C H Leung
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China.
| | - William K K Wu
- Department of Anaesthesia and Intensive Care and Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China. .,State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, and Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China.
| |
Collapse
|
19
|
Costa RDP, Pinto MCS, Ruas JB, Pinto N. Lyme neuroborreliosis in a critically ill patient. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2020. [DOI: 10.4103/jisprm.jisprm_16_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
20
|
Oh TK, Song IA, Lee JH, Lim C, Jeon YT, Bae HJ, Jo YH, Jee HJ. Preadmission chronic opioid usage and its association with 90-day mortality in critically ill patients: a retrospective cohort study. Br J Anaesth 2019; 122:e189-e197. [PMID: 31005245 DOI: 10.1016/j.bja.2019.03.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the association of chronic opioid usage with 90-day mortality in critically ill patients after admission to the ICU. METHODS This retrospective cohort study analysed the medical records of adult patients admitted to ICUs in a tertiary academic hospital between January 2012 and December 2017. Patients taking opioids regularly for more than 4 weeks before ICU admission were defined as chronic opioid users, whereas the others were defined as opioid-naïve patients. RESULTS We selected 18 409 patients for this study, including 757 (4.1%) chronic opioid users. After propensity matching, 2990 patients (chronic opioid users, 757; opioid-naïve, patient: 2233) were included in the analysis. The odds of 90-day mortality were higher in chronic opioid users than in opioid-naïve patients using both the generalised estimating equation model for the propensity-matched cohort (odds ratio=1.90; 95% confidence interval, 1.57-2.31; P<0.001) and the multivariable logistic regression model for the entire cohort (odds ratio=2.20; 95% confidence interval, 1.81-2.66; P<0.001). Additionally, this association was significant in cancer patients and non-chronic kidney disease (CKD) patients and was not significant in non-cancer and CKD patients. CONCLUSIONS Our results suggest that in a cohort of critically ill adult patients, chronic opioid use is associated with an increase in 90-day mortality. This association was more evident in cancer patients and non-CKD patients.
Collapse
Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, South Korea.
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, South Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, South Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, South Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Stroke Center, South Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hee-Jung Jee
- Department of Biostatistics, College of Medicine, Korea University, Seoul, South Korea
| |
Collapse
|