Predictors of sepsis in moderately severely injured patients: an analysis of the National Trauma Data Bank

Advancements in Trauma-Induced Acute Kidney Injury: Diagnostic and Therapeutic Innovations

Acute kidney injury following trauma impacts patient recovery critically, necessitating an integrated approach to emergency care and nephrology. This review aims to provide a comprehensive understanding of trauma-induced nephropathy, highlighting recent advancements in pathophysiological insights, diagnostic techniques, and strategic interventions. Our key findings emphasize the role of biomarkers, like Neutrophil Gelatinase-Associated Lipocalin and Liver Fatty Acid-Binding Protein, and imaging techniques, such as contrast-enhanced ultrasound, in early AKI detection. Preventive strategies, including aggressive fluid resuscitation, avoidance of nephrotoxic agents, and hemodynamic optimization, are essential for mitigating AKI progression. Integrating these approaches into trauma care frameworks aims to enhance patient outcomes and set a foundation for future research and clinical improvements.

Preventive Antibiotic Use and Complications After Endoscopic Retrograde Cholangiopancreatography in Patients Hospitalized for Primary Sclerosing Cholangitis

BACKGROUND

The American Society for Gastrointestinal Endoscopy recommends prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) in primary sclerosing cholangitis (PSC). We assessed the impact of this approach on the incidence of post-ERCP outcomes using nationwide data.

METHODS

Using 2015-2021 Nationwide Inpatient Sample data and relevant ICD-10 codes, we analyzed adult hospitalizations for PSC who underwent ERCP, with and without antibiotic prophylaxis. Hierarchical multivariate logistic regression analysis was used to assess the association between prophylactic antibiotic use and post-ERCP complications including sepsis, acute cholangitis, and acute pancreatitis.

RESULTS

We analyzed 32,972 hospitalizations for PSC involving ERCP, with 12,891 admissions (39.1%) receiving antibiotics before ERCP (cases) and 20,081 (60.9%) serving as controls. Cases were older than controls (mean age: 64.2 ± 8.6 vs. 61.3 ± 6.1 years; P = 0.020). Compared with controls, hospitalizations with antibiotic prophylaxis had a higher male population (7,541 (58.5%) vs. 11,265 (56.1%); P < 0.001) and higher comorbidity burden (Charlson comorbidity index score of ≥2: 5,867 (45.5%) of cases vs. 8,996 (44.8%) of controls; P = 0.01). Incidence of post-ERCP septicemia was 19.1% (6,275) with 2,935 incidences (22.8%) among cases compared with 3,340 (16.6%) among controls. Antibiotic prophylaxis did not significantly improve the odds of septicemia (aOR: 0.85; 95% CI: 0.77 - 1.09; P = 0.179). Approximately 2,271 (6.9%) cases of acute cholangitis and 5,625 (17.1%) cases of acute post-ERCP pancreatitis were recorded. After adjustments for multiple variables, no significant difference was observed in the odds of cholangitis (aOR: 0.87; 95% CI: 0.98 - 1.45; P = 0.08). However, antibiotic prophylaxis was correlated with a statistically significant reduction in the odds ratio of acute post-ERCP pancreatitis (aOR: 0.61; 95% CI: 0.57 - 0.66; P < 0.001).

CONCLUSION

The use of antibiotic prophylaxis in hospitalizations with PSC was correlated with a significant reduction in the odds of post-ERCP pancreatitis. Antibiotic prophylaxis did not improve the odds of post-ERCP sepsis or cholangitis. Prophylactic use of antibiotics should be individualized, considering both their anti-infective benefits and potential impact on the biochemical markers of liver disease.

A biomarker panel of C-reactive protein, procalcitonin and serum amyloid A is a predictor of sepsis in severe trauma patients

Severe trauma could induce sepsis due to the loss of control of the infection, which may eventually lead to death. Accurate and timely diagnosis of sepsis with severe trauma remains challenging both for clinician and laboratory. Combinations of markers, as opposed to single ones, may improve diagnosis. We compared the diagnostic characteristics of routinely used biomarkers of sepsis alone and in combination, trying to define a biomarker panel to predict sepsis in severe patients. This prospective observational study included patients with severe trauma (Injury severity score, ISS = 16 or more) in the emergency intensive care unit (EICU) at a university hospital. Blood samples were collected and plasma levels of procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6) and serum amyloid A (SAA) were measured using commercial enzyme linked immunosorbent assay (ELISA) kits. A total of 100 patients were eligible for analysis. Of these, 52 were diagnosed with sepsis. CRP yielded the highest discriminative value followed by PCT. In multiple logistic regression, SAA, CRP, and PCT were found to be independent predictors of sepsis. Bioscore which was composed of SAA, CRP, and PCT was shown to be far superior to that of each individual biomarker taken individually. Therefore, compared with single markers, the biomarker panel of PCT, CRP, and SAA was more predictive of sepsis in severe polytrauma patients.

Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review

RATIONALE

Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis.

METHODS

A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review.

RESULTS

There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology.

CONCLUSIONS

The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.

The Regulation of Neutrophil Migration in Patients with Sepsis: The Complexity of the Molecular Mechanisms and Their Modulation in Sepsis and the Heterogeneity of Sepsis Patients

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Common causes include gram-negative and gram-positive bacteria as well as fungi. Neutrophils are among the first cells to arrive at an infection site where they function as important effector cells of the innate immune system and as regulators of the host immune response. The regulation of neutrophil migration is therefore important both for the infection-directed host response and for the development of organ dysfunctions in sepsis. Downregulation of CXCR4/CXCL12 stimulates neutrophil migration from the bone marrow. This is followed by transmigration/extravasation across the endothelial cell barrier at the infection site; this process is directed by adhesion molecules and various chemotactic gradients created by chemotactic cytokines, lipid mediators, bacterial peptides, and peptides from damaged cells. These mechanisms of neutrophil migration are modulated by sepsis, leading to reduced neutrophil migration and even reversed migration that contributes to distant organ failure. The sepsis-induced modulation seems to differ between neutrophil subsets. Furthermore, sepsis patients should be regarded as heterogeneous because neutrophil migration will possibly be further modulated by the infecting microorganisms, antimicrobial treatment, patient age/frailty/sex, other diseases (e.g., hematological malignancies and stem cell transplantation), and the metabolic status. The present review describes molecular mechanisms involved in the regulation of neutrophil migration; how these mechanisms are altered during sepsis; and how bacteria/fungi, antimicrobial treatment, and aging/frailty/comorbidity influence the regulation of neutrophil migration.

The Risk Factors for Mortality among Septic Trauma Patients: A Retrospective Cohort Study Using the National Trauma Data Bank

Introduction

In trauma patients, the development of sepsis as a hospital complication is significantly associated with morbidity and mortality. We aimed to assess the risk factors associated with in-hospital mortality among trauma patients who developed sepsis during their hospital stay. Material and methods. Using the 2017 National Trauma Data Bank, a retrospective cohort study was conducted to identify adult trauma patients who developed sepsis during their hospital stay. The primary outcome of interest was in-hospital mortality. Multivariate analysis was used to determine the risk factors associated with in-hospital mortality.

Results

1782 trauma patients developed sepsis. 567 patients (31.8%) died during their hospital stay. The following patient factors were associated with higher odds of in-hospital mortality: age (OR = 1.045 95% CI = 1.036-1.054), chronic renal failure (OR = 2.564 95% CI = 1.528-4.301), and liver cirrhosis (OR = 3.699 95% CI = 2.267-6.033). Patients who developed cardiac arrest (OR = 4.994 95% CI = 3.381-7.378), acute kidney injury (OR = 3.808 95% CI = 2.837-5.110), acute respiratory distress syndrome (OR = 1.688 95% CI = 1.197-2.379), and stroke (OR = 1.998 95% CI = 1.075-3.714) during their hospital stay had higher odds of mortality. Higher Glasgow Coma Scale (13-15) at presentation was associated with lower odds of mortality (OR = 0.467 95% CI = 0.328-0.667).

Conclusion

Among trauma patients who developed sepsis, age, chronic renal failure, cirrhosis, the development of cardiac arrest, acute kidney injury, acute respiratory distress syndrome, and stroke in the hospital were associated with in-hospital mortality. These factors can be used to identify patients who are at higher risk of adverse outcomes and implement standardized or protocol-driven methods to improve patient care.

Sex and Gender Differences in Bacterial Infections

There is a growing awareness of the importance of sex and gender in medicine and research. Women typically have stronger immune responses to self and foreign antigens than men, resulting in sex-based differences in autoimmunity and infectious diseases. In both animals and humans, males are generally more susceptible than females to bacterial infections. At the same time, gender differences in health-seeking behavior, quality of health care, and adherence to treatment recommendations have been reported. This review explores our current understanding of differences between males and females in bacterial diseases. We describe how genetic, immunological, hormonal, and anatomical factors interact to influence sex-based differences in pathophysiology, epidemiology, clinical presentation, disease severity, and prognosis, and how gender roles affect the behavior of patients and providers in the health care system.

Spinal level and cord involvement in the prediction of sepsis development after vertebral fracture repair for traumatic spinal injury

OBJECTIVE

Despite understanding the associated adverse outcomes, identifying hospitalized patients at risk for sepsis is challenging. The authors aimed to characterize the epidemiology and clinical risk of sepsis in patients who underwent vertebral fracture repair for traumatic spinal injury (TSI).

METHODS

The authors conducted a retrospective cohort analysis of adults undergoing vertebral fracture repair during initial hospitalization after TSI who were registered in the National Trauma Data Bank from 2011 to 2014.

RESULTS

Of the 29,050 eligible patients undergoing vertebral fracture repair, 317 developed sepsis during initial hospitalization. Of these patients, most presented after a motor vehicle accident (63%) or fall (28%). Patients in whom sepsis developed had greater odds of being male (adjusted OR [aOR] 1.5, 95% CI 1.1-1.9), having diabetes mellitus (aOR 1.5, 95% CI 1.11-2.1), and being obese (aOR 1.9, 95% CI 1.4-2.5). Additionally, they had greater odds of presenting with moderate (aOR 2.7, 95% CI 1.8-4.2) or severe (aOR 3.9, 95% CI 2.9-5.2) Glasgow Coma Scale scores and of having concomitant abdominal injuries (aOR 1.9, 95% CI 1.5-2.5) but not cranial, thoracic, or lower-extremity injuries. Interestingly, cervical spine injury was significantly associated with developing sepsis (OR 1.4, 95% CI 1.1-1.8), but thoracic and lumbar spine injuries were not. Spinal cord injury (OR 1.9, 95% CI 1.5-2.5) was also associated with sepsis regardless of level. Patients with sepsis were hospitalized approximately 16 days longer. They had greater odds of being discharged to rehabilitative care or home with rehabilitative care (OR 2.4, 95% CI 1.8-3.2) and greater odds of death or discharge to hospice (OR 6.0, 95% CI 4.4-8.1).

CONCLUSIONS

Among patients undergoing vertebral fracture repair, those with cervical spine fractures, spinal cord injuries, preexisting comorbidities, and severe concomitant injuries are at highest risk for developing postoperative sepsis and experiencing adverse hospital disposition.

Female hormones prevent sepsis-induced cardiac dysfunction: an experimental randomized study

Although epidemiologic research has demonstrated significant differences in incidence and outcomes of sepsis according to sex, their underlying biological mechanisms are poorly understood. Here, we studied the influence of hormonal status by comparing in vivo cardiac performances measured by MRI in non-ovariectomized and ovariectomized septic female rats. Control and ovariectomized rats were randomly allocated to the following groups: sham, sepsis and sepsis plus landiolol. Sepsis was induced by caecum ligation and punction (CLP). Landiolol, a short-acting selective β1-adrenergic blocker improving the in vivo cardiac performance of septic male rats was perfused continuously after sepsis induction. Cardiac MRI was carried out 18 h after induction of sepsis to assess in vivo cardiac function. Capillary permeability was evaluated by Evans Blue administration and measurement of its tissue extravasation. Variation in myocardial gene and protein expression was also assessed by qPCR and western-blot in the left ventricular tissue. Sepsis reduced indexed stroke volume, cardiac index and indexed end-diastolic volume compared to sham group in ovariectomized females whereas it had no effect in control females. This was associated with an overexpression of JAK2 expression and STAT3 phosphorylation on Ser727 site, and an inhibition of the adrenergic pathways in OVR females. Landiolol increased the indexed stroke volume by reversing the indexed end-diastolic volume reduction after sepsis in ovariectomized females, while it decreased indexed stroke volume and cardiac index in control. This was supported by an overexpression of genes involved in calcium influx in OVR females while an inactivation of the β-adrenergic and a calcium efflux pathway was observed in control females. Sepsis decreased in vivo cardiac performances in ovariectomized females but not in control females, presumably associated with a more pronounced inflammation, inhibition of the adrenergic pathway and calcium efflux defects. Administration of landiolol prevents this cardiac dysfunction in ovariectomized females with a probable activation of calcium influx, while it has deleterious effects in control females in which calcium efflux pathways were down-regulated.

The burden of sepsis in critically ill patients with multiple sclerosis: A population-based cohort study

PURPOSE

Multiple sclerosis (MS) is associated with increased risk of critical illness, sepsis, and sepsis-related death, compared to the general population. The epidemiology of sepsis and its impact on the outcomes of critically ill patients with MS are unknown.

METHODS

A statewide dataset was used to identify retrospectively ICU admissions in Texas aged ≥18 years with a diagnosis of MS during 2010-2017. The prevalence of sepsis and its impact on inpatient resource utilization and short-term mortality (a combination of in-hospital death or discharge to hospice) were examined.

RESULTS

Among 19,837 ICU admissions with MS, 6244 (31.5%) had sepsis. Compared to ICU admissions without sepsis, those with sepsis were older (aged ≥65 years 34.1% vs 24.1%), less commonly racial/ethnic minority (32.6% vs 35.2%), and had higher mean [SD] Deyo comorbidity index (1.7 [1.8] vs 1.2 [1.7]). On adjusted analyses, sepsis was associated with 42.7% longer hospital length of stay and 26.2% higher total hospital charges. Risk-adjusted short-term mortality among ICU admissions with and without sepsis was 13.4% vs 3.3%, respectively.

CONCLUSIONS

Sepsis was present in nearly 1 in 3 ICU admissions with MS, had substantial adverse impact on hospital resource utilization, and was associated with over 4-times higher short-term mortality.

Effect of Anti-Inflammatory and Antimicrobial Cosupplementations on Sepsis Prevention in Critically Ill Trauma Patients at High Risk for Sepsis

Background: Sepsis development in patients with trauma is associated with bad prognosis. This study investigated the effect of immunomodulatory interventions in major trauma patients at high risk for sepsis. Methods: In a randomized, double-blinded, controlled design, severe trauma patients were stratified by leukocyte anti-sedimentation rate (LAR) test into high risk (HR) and low risk (LR) for sepsis. The HR patients were randomly allocated into intravenous vitamin C plus vitamin B1 (HR-CB), intramuscular vitamin D plus oral Lactobacillus probiotics (HR-DP), or control (HR-C) groups. The clinical trial was registered at clinicaltrials.gov (https://clinicaltrials.gov/show/NCT04216459). Outcomes: The primary outcome was Acute Physiologic Assessment and Chronic Health Evaluation score II (APACHE II) score. Secondary outcomes included sepsis incidence, changes in Sequential Organ Failure Assessment (SOFA) score, and serum monocyte chemoattractant protein-1 (MCP-1) on day 6 from baseline, 28-day mortality, intensive care unit (ICU), and hospital discharge. Results: The HR-DP, HR-CB, and LR groups showed a significantly lower incidence of sepsis development (20%, 20%, and 16%, respectively, versus 60% in the HR-C group, p-value = 0.004). The three groups also showed a significant improvement in APACHE II and SOFA scores. Besides, MCP-1 levels were significantly decreased in HR-DP and HR-CB groups compared to the HR-C group (p-value ≤ 0.05). Significantly decreased mortality (10% and 16% versus 60% in the HR-C group) and increased ICU discharge (95% and 84% versus 45% in the HR-C group) were observed in HR-CB and LR groups (p-value = 0.001). Conclusion: Both combinations of interventions improved APACHE II scores and reduced sepsis incidence in trauma patients. The LAR combined with injury severity score were good sepsis predictors.

Sex Bias and Autoimmune Diseases

Sex bias in immune function has been well-described, and women have been shown to counter immunologically stimulating phenomena such as infection, malignancy, and trauma with more protective responses than men. Heightened immunity in women may also result in a predisposition for loss of self-tolerance and development of autoimmunity, reflected by the overwhelming female sex bias of patients with autoimmune diseases. In this review, we discuss the postulated evolutionary etiologies for sexual dimorphism in immunity. We also review the molecular mechanisms underlying divergent immune responses in men and women, including sex hormone effects, X chromosome dosage, and autosomal sex-biased genes. With increasing evidence that autoimmune disease susceptibility is influenced by numerous hormonal and genetic factors, a comprehensive understanding of these topics may facilitate the development of much-needed targeted therapeutics.

Sex- and Gender-Dependent Differences in Clinical and Preclinical Sepsis

ABSTRACT

In this mini-review we provide an overview of sex- and gender-dependent issues in both clinical and preclinical sepsis. The increasing recognition for the need to account for sex and gender in biomedical research brings a unique set of challenges and requires researchers to adopt best practices when conducting and communicating sex- and gender-based research. This may be of particular importance in sepsis, given the potential contribution of sex bias in the failures of translational sepsis research in adults and neonates. Clinical evidence of sex-dependent differences in sepsis is equivocal. Since clinical studies are limited to observational data and confounded by a multitude of factors, preclinical studies provide a unique opportunity to investigate sex differences in a controlled, experimental environment. Numerous preclinical studies have suggested that females may experience favorable outcomes in comparison with males. The underlying mechanistic evidence for sex-dependent differences in sepsis and other models of shock (e.g., trauma-hemorrhage) largely centers around the beneficial effects of estrogen. Other mechanisms such as the immunosuppressive role of testosterone and X-linked mosaicism are also thought to contribute to observed sex- and gender-dependent differences in sepsis. Significant knowledge gaps still exist in this field. Future investigations can address these gaps through careful consideration of sex and gender in clinical studies, and the use of clinically accurate preclinical models that reflect sex differences. A better understanding of sex-and gender-dependent differences may serve to increase translational research success.

The bone is the major source of high circulating intact fibroblast growth factor-23 in acute murine polymicrobial sepsis induced by cecum ligation puncture

Fibroblast growth factor-23 (FGF23), a bone-produced hormone, plays a critical role in mineral homeostasis. Human diseases associated with excessive intact circulating FGF23 (iFGF23) result in hypophosphatemia and low vitamin D hormone in patients with normal kidney function. In addition, there is accumulating evidence linking FGF23 with inflammation. Based on these studies and the frequent observation of hypophosphatemia among septic patients, we sought to elucidate further the relationship between FGF23 and mineral homeostasis in a clinically relevant murine polymicrobial sepsis model. Medium-severity sepsis was induced by cecum ligation puncture (CLP) in adult CD-1 mice of both sexes. Healthy CD-1 mice (without CLP) were used as controls. Forty-eight hours post-CLP, spontaneous urine was collected, and serum, organs and bones were sampled at necropsy. Serum iFGF23 increased ~20-fold in CLP compared to control mice. FGF23 protein concentration was increased in the bones, but not in spleen or liver of CLP mice. Despite the ~20-fold iFGF23 increase, we did not observe any significant changes in mineral homeostasis or parathyroid hormone levels in the blood of CLP animals. Urinary excretion of phosphate, calcium, and sodium remained unchanged in male CLP mice, whereas female CLP mice exhibited lower urinary calcium excretion, relative to healthy controls. In line with renal FGF23 resistance, expression of phosphate-, calcium- and sodium-transporting proteins did not show consistent changes in the kidneys of male and female CLP mice. Renal expression of the co-receptor αKlotho was downregulated in female, but not in male CLP mice. In conclusion, our data demonstrate that the dramatic, sex-independent rise in serum iFGF23 post-CLP was mainly caused by an upregulation of FGF23 secretion in the bone. Surprisingly, the upsurge in circulating iFGF23 did not alter humoral mineral homeostasis in the acutely septic mice. Hence, the biological function of elevated FGF23 in sepsis remains unclear and warrants further studies.

Cardiac and Brainstem Neuroinflammatory Pathways Account for Androgenic Incitement of Cardiovascular and Autonomic Manifestations in Endotoxic Male Rats

ABSTRACT

Inconsistent reports are available on the role of testosterone in end-organ damage caused by endotoxemia. Here, pharmacologic, surgical, and molecular studies were employed to assess the testosterone modulation of cardiovascular, autonomic, and peripheral and central inflammatory derangements caused by endotoxemia. Studies were performed in conscious male rats preinstrumented with femoral indwelling catheters for the measurement of blood pressure and subjected to castration or pharmacologic interventions that interrupt the biosynthetic cascade of testosterone. Compared with the effects of lipopolysaccharide (10 mg/kg intravenously) in sham operated rats, 2-week castration reduced the lipopolysaccharide-evoked (1) falls in blood pressure, (2) decreases in time- and frequency-domain indices of heart rate variability, (3) shifts in spectral measures of cardiac sympathovagal balance toward parasympathetic dominance, and (4) increases in protein expressions of toll-like receptor-4 and monocyte chemoattractant protein-1 in heart and medullary neurons of the nucleus tractus solitarius and rostral ventrolateral medulla. While the ameliorating actions of castration on endotoxic cardiovascular manifestations were maintained after testosterone replacement, the concomitant inflammatory signals were restored to near-sham levels. The favorable influences of castration on inflammatory and cardiovascular abnormalities of endotoxemia were replicated in intact rats pretreated with degarelix (gonadotropin-releasing hormone receptor blocker) or finasteride (5α-reductase inhibitor) but not formestane (aromatase inhibitor). The data signifies the importance of androgens and its biosynthetic enzymes in cardiovascular and autonomic insults induced by the endotoxic inflammatory response. Clinically, the interruption of testosterone biosynthesis could offer a potential strategy for endotoxemia management.

Adrenomedullin and Its Possible Role in Improved Survival in Female Patients with Sepsis: A Study in the South East Asian Region

AIMS AND OBJECTIVES

Serum adrenomedullin (ADM) as a prognostic biomarker to study the gender-related differences in mortality pattern and its correlation with the sequential organ failure assessment (SOFA) and acute physiologic assessment and chronic health evaluation II (APACHE II) scores in patients of sepsis.

MEASUREMENTS AND MAIN RESULTS

Eighty patients of sepsis of which 36 were males and 44 were females, were taken in the study as per sepsis III guidelines. They were followed up for a period of 28 days. Serum ADM was measured on day 1 and day 5. The endpoint was mortality or survival at day 28 after admission. The death rate among males was higher, with 23 of the total 36 (63.89%) patients having died when compared with females in which 25 patients out of 44 (56.82%) had died. The observed mortality rates correlated well with average APACHE II scores. The average APACHE II score was slightly higher in males (29 ± 8.97) when compared with females (27.02 ± 8.69). Similarly, day 1 SOFA and mean SOFA values were higher in males (10.22 ± 5.36) and (10.73 ± 6.01) when compared with females (8.27 ± 4.79) and (8.89 ± 5.6), respectively. Males despite having higher mortality rates, higher APACHE II, SOFA, and mean SOFA values were still having less mean levels of serum ADM (454.40 ± 81.13 pg/mL) when compared with females (479.62 ± 126.97 pg/mL).

CONCLUSION

Adrenomedullin is a protective neurohormone with antibacterial and anti-inflammatory properties. It is elevated in all patients with sepsis but the rise is more so in the female when compared with males. Higher ADM levels in females may suggest the protective effect of ADM as a part of the general protective neurohormonal stress response, which may explain the low death rate in females in sepsis.

HOW TO CITE THIS ARTICLE

Daga MK, Kumar L, Mawari G, Kumar N, Singh S, Mishra TK. Adrenomedullin and Its Possible Role in Improved Survival in Female Patients with Sepsis: A Study in the South East Asian Region. Indian J Crit Care Med 2020;24(12):1180-1184.

Patient, provider, and system factors that contribute to health care-associated infection and sepsis development in patients after a traumatic injury: An integrative review

OBJECTIVES

Patients after traumatic injury continue to develop health care-associated infections. The aim of this review was to identify risk factors for developing hospital-acquired infection and sepsis in patients experiencing a traumatic injury.

DESIGN

This is an integrative review following the framework of Whittemore and Knafl.

DATA SOURCES

An electronic database search was undertaken using Scopus and Medline databases in early October 2019. Hand searching of key references was also conducted. The existing literature published between January 2007 and September 2019 was searched to identify clinically relevant studies that reflected current healthcare practices and systems.

REVIEW METHODS

Four reviewers independently assessed articles for inclusion eligibility. Full-text versions of the articles were systematically appraised using the Critical Appraisal Skills Programme. The Preferred Reporting Items for Systematic reviews and Meta-Analyses format was used.

RESULTS

A total of 15 studies from the United Kingdom, the United States of America, China, and South Korea were included. Twelve of the 15 studies were focused exclusively on patient-based risk factors including gender and comorbidities. Provider-based factors were identified as nurse staffing levels between different categories of nurses with various levels of proficiency. System-level risk factors included interhospital admissions, surgical interventions, and length of stay.

CONCLUSIONS

Hospital-acquired infections are preventable, and it is imperative that provider and system risk factors that contribute to patients with traumatic injuries from developing a hospital-acquired infection be identified. Patients with traumatic injuries are unable to amend any patient-related risk factors such as comorbidities or gender. However, the identification of provider and system risk factors that contribute to patients with traumatic injuries from developing a hospital-acquired infection would provide clinically relevant and applicable strategies at the macro and meso level being implemented.

Vitamin A supplementation boosts control of antibiotic-resistant Salmonella infection in malnourished mice

Disseminated disease from non-typhoidal Salmonella enterica strains results in >20% mortality globally. Barriers to effective treatment include emerging multidrug resistance, antibiotic treatment failure, and risk factors such as malnutrition and related micronutrient deficiencies. Individuals in sub-Saharan Africa are disproportionately affected by non-typhoidal S. enterica bloodstream infections. To inform a clinical trial in people, we investigated vitamin A as a treatment in the context of antibiotic treatment failure in a mouse model of vitamin A deficiency. Vitamin A-deficient (VAD) mice exhibited higher systemic bacterial levels with a multidrug-resistant clinical isolate in comparison to mice on a control diet. Sex-specific differences in vitamin A deficiency and disseminated infection with S. enterica serotype Typhimurium (S. Typhimurium) were observed. VAD male mice had decreased weight gain compared to control male mice. Further, infected VAD male mice had significant weight loss and decreased survival during the course of infection. These differences were not apparent in female mice. In a model of disseminated S. Typhimurium infection and antibiotic treatment failure, we assessed the potential of two consecutive doses of vitamin A in alleviating infection in male and female mice on a VAD or control diet. We found that subtherapeutic antibiotic treatment synergized with vitamin A treatment in infected VAD male mice, significantly decreasing systemic bacterial levels, mitigating weight loss and improving survival. These results suggest that assessing vitamin A as a therapy during bacteremia in malnourished patients may lead to improved health outcomes in a subset of patients, especially in the context of antibiotic treatment failure.

Non-typhoidal Salmonella serotypes generally cause diarrhea in people. However, there are certain factors that make people at risk of developing a more severe infection where the bacteria can enter the blood and cause fever and whole-body symptoms. Patients with this infection are usually hospitalized, and about one in five patients do not survive. The factors that make this bloodstream infection possible include pathogen features like resistance to antibiotics and patient factors like a malnourished state. Better treatments are needed. In this study, the authors assess vitamin A as a treatment during antibiotic treatment failure in a mouse model. Vitamin A-deficient male mice have better outcomes with vitamin A and antibiotic co-therapy, whereas female mice do not benefit. Despite similar levels of bacteria causing infection systemically, female mice show better outcomes in terms of weight loss and survival than male mice overall. This research provides evidence that a clinical study assessing vitamin A as a treatment in people could lead to improved survival for malnourished patients presenting with severe bloodstream infection.

Trends, Cost, and Mortality From Sepsis After Trauma in the United States: An Evaluation of the National Inpatient Sample of Hospitalizations, 2012-2016

OBJECTIVES

Identification and outcomes in patients with sepsis have improved over the years, but little data are available in patients with trauma who develop sepsis. We aimed to examine the cost and epidemiology of sepsis in patients hospitalized after trauma.

DESIGN

Retrospective cohort study.

PATIENTS

National Inpatient Sample.

INTERVENTIONS

Sepsis was identified between 2012 and 2016 using implicit and explicit International Classification of Diseases, Ninth and Tenth Revision codes. Analyses were stratified by injury severity score greater than or equal to 15. Annual trends were modeled using generalized linear models. Survey-adjusted logistic regression was used to compare the odds for in-hospital mortality, and the average marginal effects were calculated to compare the cost of hospitalization with and without sepsis.

MEASUREMENTS AND MAIN RESULTS

There were 320,450 (SE = 3,642) traumatic injury discharges from U.S. hospitals with sepsis between 2012 and 2016, representing 6.0% (95% CI, 5.9-6.0%) of the total trauma population (n = 5,329,714; SE = 47,447). In-hospital mortality associated with sepsis after trauma did not change over the study period (p > 0.40). In adjusted analysis, severe (injury severity score ≥ 15) and nonsevere injured septic patients had an odds ratio of 1.39 (95% CI, 1.31-1.47) and 4.32 (95% CI, 4.06-4.59) for in-hospital mortality, respectively. The adjusted marginal cost for sepsis compared with nonsepsis was $16,646 (95% CI, $16,294-$16,997), and it was greater than the marginal cost for severe injury compared with nonsevere injury $8,851 (95% CI, $8,366-$8,796).

CONCLUSIONS

While national trends for sepsis mortality have improved over the years, our analysis of National Inpatient Sample did not support this trend in the trauma population. The odds risk for death after sepsis and the cost of care remained high regardless of severity of injury. More rigor is needed in tracking sepsis after trauma and evaluating the effectiveness of hospital mandates and policies to improve sepsis care in patients after trauma.

Characteristics and outcomes of acute colitis diagnosed on cross-sectional imaging presenting via the emergency department in an Irish academic medical centre

BACKGROUND AND AIMS

A significant proportion of patients presenting to the Emergency Department with gastrointestinal symptoms that result in cross-sectional imaging receive a radiological diagnosis of colitis. We aimed to review the characteristics, outcomes, and final diagnoses of new emergency department presentations with colitis diagnosed on cross-sectional imaging.

METHODS

A radiology database was interrogated to identify patients admitted from the Emergency Department of St James's Hospital whose cross-sectional imaging demonstrated colitis. Baseline demographic data, information on inpatient investigations, final diagnoses, and outcomes were recorded. Adverse outcomes were defined as a requirement for surgery, intensive care unit (ICU) stay, or mortality RESULTS: A total of 118 patients, 67% female, were identified with a median age of 64 years (range 16.9-101.2). Median (range) admission duration was 10 days (1-241). Final colitis diagnoses were infectious (28%), undefined (27%), reactive (18%), inflammatory bowel disease (11%), ischaemic (9%), chemotherapy-associated (3%), diverticular (3%), and medication-associated (1%). Colonic perforation, colectomy, and mortality occurred in 1%, 5%, and 13% of the cohort respectively. On univariate analysis, low haemoglobin, low albumin, high lactate, and male gender were associated with adverse outcomes with the following odds ratios (OR) and 95% confidence intervals (95%CI) were low haemoglobin 1.49 [1.15-1.92] P = 0.002, low albumin 1.16 [1.07-1.25] P = 0.0002, lactate 1.65 [1.13-2.42] P = 0.009, and male gender 3.09 [1.23-7.77] P = 0.019. On multivariate analysis, male gender was associated with adverse outcomes.

CONCLUSION

Patients presenting to the Emergency Department with a colitis, requiring an abdominal CT are a heterogenous group with a proportion having concomitant intra-abdominal pathology resulting in critical illness. Hence their is a significant morbidity and mortality observed in this cohort which should not be extrapolated to a general population of patients presenting with colitis. In this cohort of patients, anaemia, hypoalbuminaemia, and elevated lactate in patients presenting to the ED with acute colitis are significantly associated with adverse outcomes. Early recognition of these prognostic factors may identify the cohort of patients who are best managed in a high-dependency setting.

Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study

Background

Sepsis is the most common cause of premature death among patients with systemic lupus erythematosus (SLE) aged ≤ 50 years in the United States, and infection is the most common cause of admission to the ICU among SLE patients. However, there are no population-level data on the patterns of the demand for critical care services among hospitalized septic patients with SLE or the outcomes of those admitted to the ICU.

Methods

We performed a retrospective cohort study, using the Texas Inpatient Public Use Data File, to identify SLE hospitalizations aged ≥ 18 years and the subgroups with sepsis and ICU admission during 2009–2014. The patterns of ICU admission among septic hospitalizations were examined. Logistic regression modeling was used to identify predictors of short-term mortality (defined as hospital death or discharge to hospice) among ICU admissions with sepsis and to estimate the risk-adjusted short-term mortality among ICU admissions with and without sepsis.

Results

Among 94,338 SLE hospitalizations, 17,037 (18.1%) had sepsis and 9409 (55.2%) of the latter were admitted to the ICU. Sepsis accounted for 51.5% of the growth in volume of ICU admissions among SLE hospitalizations during the study period. Among ICU admissions with sepsis, 25.3% were aged ≥ 65 years, 88.6% were female, and 64.4% were non-white minorities. The odds of short-term mortality among septic ICU admissions were increased among those lacking health insurance (adjusted odds ratio 1.40 [95% confidence interval 1.07–1.84]), while being unaffected by gender and race/ethnicity, and remaining unchanged over the study period. On adjusted analyses among ICU admissions, the short-term mortality among those with and without sepsis was 13% (95% CI 12.6–13.3) and 2.7% (95% CI 2.6–2.8), respectively. Sepsis was associated with 63.6% of all short-term mortality events.

Conclusions

Sepsis is a major, incremental driver of the demand for critical care services among SLE hospitalizations. Despite its relatively low mortality, sepsis was associated with most of the short-term deaths among ICU patients with SLE.

Sexual Dimorphism in Innate Immunity

Sexual dimorphisms account for differences in clinical manifestations or incidence of infectious or autoimmune diseases and malignancy between females and males. Females develop enhanced innate and adaptive immune responses than males and are less susceptible to many infections of bacterial, viral, parasitic, and fungal origin and malignancies but in contrast, they are more prone to develop autoimmune diseases. The higher susceptibility to infections in males is observed from birth to adulthood, suggesting that sex chromosomes and not sex hormones have a major role in sexual dimorphism in innate immunity. Sex-based regulation of immune responses ultimately contributes to age-related disease development and life expectancy. Differences between males and females have been described in the expression of pattern recognition receptors of the innate immune response and in the functional responses of phagocytes and antigen presenting cells. Different factors have been shown to account for the sex-based disparity in immune responses, including genetic factors and hormonal mediators, which contribute independently to dimorphism in the innate immune response. For instance, several genes encoding for innate immune molecules are located on the X chromosome. In addition, estrogen and/or testosterone have been reported to modulate the differentiation, maturation, lifespan, and effector functions of innate immune cells, including neutrophils, macrophages, natural killer cells, and dendritic cells. In this review, we will focus on differences between males and females in innate immunity, which represents the first line of defense against pathogens and plays a fundamental role in the activation, regulation, and orientation of the adaptive immune response.

Non-utility of sepsis scores for identifying infection in surgical intensive care unit patients

BACKGROUND

The Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) scores replaced the Systemic Inflammatory Response System (SIRS) criteria for defining sepsis, and are often utilized to identify infection, however remain understudied in surgical populations.

METHODS

Daily SOFA, qSOFA, and SIRS scores were prospectively collected in a surgical/trauma intensive care unit (ICU), comparing scores between patients with and without new infection. Multivariable analysis controlled for ICU type and pre-existing infection.

RESULTS

Scores were recorded for 1942 patient-days, including 1385 (71%) with no infection, 439 (23%) with existing/treated infection, and 120 (6.2%) with new infection. Scores were globally elevated, with 98% having SOFA score ≥2, 82% with qSOFA score ≥2, and 92% meeting ≥2 SIRS criteria. Neither univariate nor multivariate analysis revealed a correlation between SOFA, qSOFA, or SIRS score and infection.

CONCLUSION

No scores correlated with new infection, potentially related to increased existing inflammation in this population.

SUMMARY

The Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) have replaced the Systemic Inflammatory Response System (SIRS) criteria for sepsis, however are not well investigated in surgical populations or for identifying infections, as they are often used in practice. In this study, neither daily SOFA, qSOFA, nor SIRS criteria correlated with new infection in a population of critically ill surgical patients. Scores were globally elevated in non-infected patients, potentially related to high levels of existing inflammation in this population.

Timing and Associated Factors for Sepsis-3 in Severe Trauma Patients: A 3-Year Single Trauma Center Experience

Background

We hypothesized that the recent change of sepsis definition by sepsis-3 would facilitate the measurement of timing of sepsis for trauma patients presenting with initial systemic inflammatory response syndrome. Moreover, we investigated factors associated with sepsis according to the sepsis-3 definition.

Methods

Trauma patients in a single level I trauma center were retrospectively reviewed from January 2014 to December 2016. Exclusion criteria were younger than 18 years, Injury Severity Score (ISS) <15, length of stay <8 days, transferred from other hospitals, uncertain trauma history, and incomplete medical records. A binary logistic regression test was used to identify the risk factors for sepsis-3.

Results

A total of 3,869 patients were considered and, after a process of exclusion, 422 patients were reviewed. Fifty patients (11.85%) were diagnosed with sepsis. The sepsis group presented with higher mortality (14 [28.0%] vs. 17 [4.6%], P<0.001) and longer intensive care unit stay (23 days [range, 11 to 35 days] vs. 3 days [range, 1 to 9 days], P<0.001). Multivariate analysis demonstrated that, in men, high lactate level and red blood cell transfusion within 24 hours were risk factors for sepsis. The median timing of sepsis-3 was at 8 hospital days and 4 postoperative days. The most common focus was the respiratory system.

Conclusions

Sepsis defined by sepsis-3 remains a critical issue in severe trauma patients. Male patients with higher ISS, lactate level, and red blood cell transfusion should be cared for with caution. Reassessment of sepsis should be considered at day 8 of hospital stay or day 4 postoperatively.

[Reality and prospects of sepsis epidemiology research]

Current foreign and Russian literature for sepsis epidemiology is reviewed. There is advanced incidence of sepsis in developing countries among young people as a rule. Absent high-quality epidemiological studies lead to overdiagnosis of sepsis and increased morbidity. National and territorial screening and diagnostic programs for sepsis became possible with introduction of new recommendations 'Sepsis-3'. Thus, there is a possibility to systematize regular epidemiological studies devoted to sepsis.

Sexual dimorphism in bacterial infections

Background

Sex differences are important epidemiological factors that impact in the frequency and severity of infectious diseases. A clear sexual dimorphism in bacterial infections has been reported in both humans and animal models. Nevertheless, the molecular mechanisms involved in this gender bias are just starting to be elucidated. In the present article, we aim to review the available data in the literature that report bacterial infections presenting a clear sexual dimorphism, without considering behavioral and social factors.

Main body

The sexual dimorphism in bacterial infections has been mainly attributed to the differential levels of sex hormones between males and females, as well as to genetic factors. In general, males are more susceptible to gastrointestinal and respiratory bacterial diseases and sepsis, while females are more susceptible to genitourinary tract bacterial infections. However, these incidences depend on the population evaluated, animal model and the bacterial species. Female protection against bacterial infections and the associated complications is assumed to be due to the pro-inflammatory effect of estradiol, while male susceptibility to those infections is associated with the testosterone-mediated immune suppression, probably via their specific receptors. Recent studies indicate that the protective effect of estradiol depends on the estrogen receptor subtype and the specific tissue compartment involved in the bacterial insult, suggesting that tissue-specific expression of particular sex steroid receptors contributes to the susceptibility to bacterial infections. Furthermore, this gender bias also depends on the effects of sex hormones on specific bacterial species. Finally, since a large number of genes related to immune functions are located on the X chromosome, X-linked mosaicism confers a highly polymorphic gene expression program that allows women to respond with a more expanded immune repertoire as compared with men.

Conclusion

Notwithstanding there is increasing evidence that confirms the sexual dimorphism in certain bacterial infections and the molecular mechanisms associated, further studies are required to clarify conflicting data and to determine the role of specific hormone receptors involved in the gender bias of bacterial infections, as well as their potential as therapeutic targets.

Interleukin-1 and estrogen protect against disseminating dentoalveolar infections

Dentoalveolar bacterial infections cause localized tissue and bone destruction, but usually remain well-localized within teeth in immunocompetent hosts. However, in certain cases these infections may invade head and neck tissues, resulting in orofacial abscesses, cellulitis and sepsis, with resultant high morbidity and even mortality. In the present studies, we developed a novel model of spreading dentoalveolar infections in mice by treatment with neutralizing antibodies against both interleukin-1α (IL-1α) and IL-1β. Surprisingly male but not female mice given anti-IL-1 antibodies developed orofacial abscesses, weight loss, splenomegaly and sepsis. Female mice developed abscesses and sepsis comparable to males following ovariectomy (OVX), which was reversed by estrogen supplementation. Anti-IL-1 blockade inhibited IL-12, interferon γ (IFNγ) and IL-6 but not IL-10 expression in infrabony lesions, suggestive of a local anti-inflammatory response. There was greater infiltration of neutrophils and other inflammatory cells into lesions in anti-IL-1-treated animals; however, blood leukocytes had reduced bacterial phagocytic and killing activity ex vivo. Estrogen directly stimulated IL-1 production by macrophages, suggesting that the resistance of females to disseminating dentoalveolar infections may be due to their heightened pro-inflammatory responses following bacterial challenge, leading to enhanced localization of these infections.

Processes of care in surgical patients who died with hospital-acquired infections in Australian hospitals

BACKGROUND

Infection may complicate surgical patients' hospital admission. The effect of hospital-acquired infections (HAIs) on processes of care among surgical patients who died is unknown.

AIM

To investigate the effect of HAIs on processes of care in surgical patients who died in hospital.

METHODS

Surgeon-recorded infection data extracted from a national Australian surgical mortality audit (2012-2016) were grouped into HAIs and no infection. The audit included all-age surgical patients, who died in hospital. Not all patients had surgery. Excluded from analysis were patients with community-acquired infection and those with missing timing of infection. Multivariate logistic regression was used to determine the adjusted effects of HAIs on the processes of care in these patients. Costs associated with HAIs were estimated.

FINDINGS

One-fifth of surgical patients who died did so with an HAI (2242 out of 11,681; 19.2%). HAI patients had increased processes of care compared to those who died without infection: postoperative complications [51.0% vs 30.3%; adjusted odds ratio (aOR): 2.20; 95% confidence interval (CI): 1.98-2.45; P < 0.001]; unplanned reoperations (22.6% vs 10.9%; aOR: 2.38; 95% CI: 2.09-2.71; P < 0.001) and unplanned intensive care unit admission (29.3% vs 14.8%; aOR: 2.18; 95% CI: 1.94-2.45; P < 0.001). HAI patients had longer hospital admissions and greater hospital costs than those without infection.

CONCLUSION

HAIs were associated with increased processes of care and costs in surgical patients who died; these outcomes need to be investigated in surgical patients who survive.

Decreasing skeletal muscle as a risk factor for mortality in elderly patients with sepsis: a retrospective cohort study

Background

Older patients account for the majority of patients with sepsis. The objective of this study was to determine if decreased skeletal muscle mass is associated with outcomes in elderly patients with sepsis.

Methods

Patients (60 years and older) who were admitted to a tertiary medical center intensive care unit with a primary diagnosis of sepsis between January 2012 and February 2016 were included. Patients who had not undergone abdominal computed tomography on the day of admission, had cardiopulmonary arrest on arrival, or had iliopsoas abscess were excluded from the analyses. Cross-sectional muscle area at the 3rd lumber vertebra was quantified, and the relation to in-hospital mortality was analyzed. Multivariable logistic regression analysis that included sex and APACHE II score as explanatory variables was performed. The optimal cutoff value to define decreased muscle mass (sarcopenia) was calculated using receiver operating characteristic curve analysis, and the odds ratio for in-hospital mortality was determined.

Results

There were 150 elderly patients with sepsis (median age, 75 years) enrolled; in-hospital mortality and median APACHE II score were 38.7 and 24%, respectively. The skeletal muscle area of deceased patients was significantly lower than that of the survival group (P < 0.001). The multivariable logistic regression analysis demonstrated that decreased muscle mass was significantly associated with increased mortality (odds ratio = 0.94, 95% confidence interval = 0.90 to 0.97, P < 0.001). The optimal cutoff value of skeletal muscle area to predict in-hospital mortality was 45.2 cm² for men and 39.0 cm² for women. With these cutoff values, the adjusted odds ratio for decreased muscle area was 3.27 (95% CI, 1.61 to 6.63, P = 0.001).

Conclusions

Less skeletal muscle mass is associated with higher in-hospital mortality in elderly patients with sepsis. The results of this study suggest that identifying patients with low muscularity contributes to better stratification in this population.

An FcγRIIa polymorphism with decreased C-reactive protein binding is associated with sepsis and decreased monocyte HLA-DR expression in trauma patients

BACKGROUND

A dysregulated immune response leading to sepsis is the most frequent cause of late posttraumatic deaths. We have found a novel anti-inflammatory pathway that is initiated by the acute phase protein, C-reactive protein (CRP), interacting with Fcγ receptor (FcγR) on monocytes. This pathway is protective in animal models of endotoxin shock. We hypothesized that genetic polymorphisms in the FcγR might contribute to monocyte responses and susceptibility to infectious complications after severe trauma.

METHODS

We conducted an observational study on a prospectively identified cohort of adult patients with convenience enrollment admitted after severe trauma. We enrolled 66 patients and collected blood samples at enrollment and again at 48 hours and 72 hours. Patients were followed through their hospital stay, and any septic events before 14 days were recorded. Cytokine and CRP levels were determined in the plasma from all three blood draws. In addition, DNA was extracted from blood and analyzed for the 131 H/R FcγRIIa polymorphism that strongly affects the binding of IgG and CRP to this receptor.

RESULTS

Elevated levels of interleukin 8 (IL-8), IL-6, IL-10, monocyte chemotactic protein 1, and CRP were associated with reduced time to posttraumatic sepsis in Cox regression analysis. Expression of monocyte human leukocyte antigen DR less than 45% on patient monocytes was also associated with sepsis (hazard ratio, 3.15; 95% confidence interval, 1.45-6.93). Genetic analysis found that individuals with the polymorphism of the FcγRIIa receptor that binds CRP poorly were also more likely to have decreased monocyte human leukocyte antigen DR and posttraumatic sepsis. In vitro studies showed that CRP could attenuate monocyte deactivation in volunteers with the polymorphism of the FcγRIIa receptor that binds CRP.

CONCLUSION

Our findings suggest that a common genetic variation in the FcγRIIa receptor may contribute to infectious susceptibility in trauma patients. In vitro experiments suggest that this association is related to the inability of CRP to bind to this FcγRIIa receptor variant.

LEVEL OF EVIDENCE

Prognostic study, level III.

Risk factors for sepsis in Korean trauma patients

PURPOSE

Sepsis in severely injured patients is one of the leading causes of death in hospitals. The incidence of and risk factors for sepsis after trauma have been studied outside, but not within Korea. Therefore, this study investigated the incidence of sepsis and the independent risk factors for sepsis in moderately to severely injured patients in Korea.

METHODS

The electronic medical records of patients who visited the emergency department from January 2010 to December 2012 were reviewed retrospectively. Patients older than 18 years of age with an Injury Severity Score (ISS) greater than or equal to nine points were included.

RESULTS

A total of 183 patients met the study inclusion criteria. The median ISS was 14 (range 9-17) points and 15 (8 %) patients developed sepsis. The patients' age [adjusted OR, 1.053; 95 % confidence intervals (CI), 1.015-1.094], ISS (adjusted OR, 1.114; 95 % CI, 1.046-1.187), and emergency surgery (adjusted OR, 3.727; 95 % CI, 1.051-13.221) were independent risk factors for post-traumatic sepsis.

CONCLUSIONS

Among the risk factors identified in the literature, our research confirmed only the patients' age and ISS as risk factors for sepsis after trauma, and, additionally, identified emergency surgery as a risk factor in Korean patients. Therefore, trauma patients who have any of the risk factors mentioned above have a high risk of post-traumatic sepsis, which requires certain precautionary clinical measures.

Impact of Sepsis on Surgical Outcomes

BACKGROUND

Sepsis is among the leading causes of death in the United States, and patients undergoing surgical procedures are at greater risk for infectious complications. The incidence of sepsis and its association with outcomes among patients undergoing surgical procedures in various specialties were investigated. Additionally, the infectious sources and associated primary procedures were reported for sepsis-related deaths.

METHODS

Patients undergoing procedures performed by surgical services at our academic medical center between January 2010 and June 2013 were reviewed. Sepsis was identified by the assignment of related ICD-9-CM billing codes. Patient outcomes included hospital length of stay, intensive care unit (ICU) admission, ICU length of stay, and death. A subset of sepsis-related deaths was reviewed further for infectious sources and primary procedure codes.

RESULTS

A total of 25,522 patients underwent a procedure by a surgical service, and sepsis developed in 863 patients (3.38%) during their hospital stays. Overall, patients with sepsis had significantly longer hospital and ICU stays, greater likelihood of ICU admission, and a higher mortality rate. The incidence of sepsis was highest in patients with procedures performed by cardiothoracic surgery (8.39%), trauma/acute care surgery (7.55%), and plastic/reconstructive surgery (5.35%). Sepsis was associated with a significant increase in the mortality rate among vascular surgery, trauma/acute care surgery, and cardiothoracic surgery patients. The most common infectious sources in sepsis-related deaths were pulmonary infections (39.5%), blood stream infections (35.1%), and gastrointestinal infections (31.6%). The procedures associated with the greatest number of sepsis-related deaths were extracorporeal membrane oxygenation, small bowel resection, and insertion of implantable heart-assist systems.

CONCLUSIONS

Sepsis is not an uncommon condition and is associated with longer hospital and ICU stays, greater likelihood of ICU admission, and a higher mortality rate. Accurate benchmarking of sepsis is essential for the development and monitoring of sepsis-reduction quality-improvement initiatives.

Prediction of multiple infections after severe burn trauma: a prospective cohort study

OBJECTIVE

To develop predictive models for early triage of burn patients based on hypersusceptibility to repeated infections.

BACKGROUND

Infection remains a major cause of mortality and morbidity after severe trauma, demanding new strategies to combat infections. Models for infection prediction are lacking.

METHODS

Secondary analysis of 459 burn patients (≥16 years old) with 20% or more total body surface area burns recruited from 6 US burn centers. We compared blood transcriptomes with a 180-hour cutoff on the injury-to-transcriptome interval of 47 patients (≤1 infection episode) to those of 66 hypersusceptible patients [multiple (≥2) infection episodes (MIE)]. We used LASSO regression to select biomarkers and multivariate logistic regression to built models, accuracy of which were assessed by area under receiver operating characteristic curve (AUROC) and cross-validation.

RESULTS

Three predictive models were developed using covariates of (1) clinical characteristics; (2) expression profiles of 14 genomic probes; (3) combining (1) and (2). The genomic and clinical models were highly predictive of MIE status [AUROCGenomic = 0.946 (95% CI: 0.906-0.986); AUROCClinical = 0.864 (CI: 0.794-0.933); AUROCGenomic/AUROCClinical P = 0.044]. Combined model has an increased AUROCCombined of 0.967 (CI: 0.940-0.993) compared with the individual models (AUROCCombined/AUROCClinical P = 0.0069). Hypersusceptible patients show early alterations in immune-related signaling pathways, epigenetic modulation, and chromatin remodeling.

CONCLUSIONS

Early triage of burn patients more susceptible to infections can be made using clinical characteristics and/or genomic signatures. Genomic signature suggests new insights into the pathophysiology of hypersusceptibility to infection may lead to novel potential therapeutic or prophylactic targets.

Increased mortality in adult patients with trauma transfused with blood components compared with whole blood

Hemorrhage is a preventable cause of death among patients with trauma, and management often includes transfusion, either whole blood or a combination of blood components (packed red blood cells, platelets, fresh frozen plasma). We used the 2009 National Trauma Data Bank data set to evaluate the relationship between transfusion type and mortality in adult patients with major trauma (n = 1745). Logistic regression analysis identified 3 independent predictors of mortality: Injury Severity Score, emergency medical system transfer time, and type of blood transfusion, whole blood or components. Transfusion of whole blood was associated with reduced mortality; thus, it may provide superior survival outcomes in this population.

Is operative management of fractures safe in the collocated burn and fracture injury?

AIMS

To review the management of a collocated major fracture and dermal burn injury in adult multi-trauma patients. In particular, this study examines the methods and timing for fracture fixation and the fracture complications observed.

METHODS

A retrospective chart review of all patients admitted to the Alfred Hospital, Melbourne, Australia from January 2000 to December 2012 with a collocated dermal burn and major fracture.

RESULTS

Of the 22 patients included (median abbreviated injury score-98 of 22 and total burn surface area of 8%), 17 underwent operative fracture fixation. Eleven patients had internal fixation, two had external fixation and four had temporary external fixation with delayed internal fixation. Median time to operative fixation was 5.7h (interquartile range: 3.5-16.8), with 15 of the 17 patients undergoing fixation within 24h. Nine patients experienced a fracture complication. Five patients had an infective fracture complication (wound infection or osteomyelitis), and all of these patients had had internal fixation. No fracture complications occurred in patients managed conservatively.

CONCLUSION

Previous studies have supported the use of internal fixation for early mobility and simplified wound care. However, we observed a high rate of fracture complications with internal fixation, despite undergoing management within 24h of presentation. At this point, we are unable to conclude on the safety of utilising internal fixation in the collocated injury.

Prediction of sepsis in trauma patients

Trauma is one of the leading causes of death worldwide. Approximately 39.5% of deaths occur in the hospital, and the mortality rate of delayed death caused by septic complications is still high. Early prediction of the development of sepsis can help promote early intervention and treatment for patients and contribute to improving patient outcomes. Thus so far, biomarkers, patient demographics and injury characteristics are the main methods used for predicting sepsis in trauma patients. However, studies that verify their predictive value are limited, and the results are still controversial. More work should be conducted to explore more efficient and accurate ways to predict post-traumatic sepsis.

Morbid obesity predisposes trauma patients to worse outcomes: a National Trauma Data Bank analysis

BACKGROUND

One third of US adults are obese. The impact of obesity on outcomes after blunt traumatic injury has been studied with discrepant results. The aim of our study was to evaluate outcomes in morbidly obese patients after blunt trauma. We hypothesized that morbidly obese patients have adverse outcomes as compared with nonobese patients after blunt traumatic injury.

METHODS

We performed a retrospective analysis of all blunt trauma patients (≥18 years) using the National Trauma Data Bank for years 2007 to 2010. Patients with recorded comorbidity of morbid obesity (body mass index ≥ 40) were identified. Patients transferred, dead on arrival, and with isolated traumatic brain injury were excluded. Propensity score matching was used to match morbidly obese patients to non-morbidly obese patients (body mass index < 40) in a 1:1 ratio based on age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and systolic blood pressure on presentation. The primary outcome was mortality, and the secondary outcome was hospital complications.

RESULTS

A total of 32,780 patients (morbidly obese, 16,390; nonobese, 16,390) were included in the study. Morbidly obese patients were more likely to have in-hospital complications (odds ratio [OR], 1.8, 95% confidence interval [CI], 1.6-1.9), longer hospital stay (OR, 1.2; 95% CI, 1.1-1.3), and longer intensive care unit stay (OR, 1.15; 95% CI, 1.09-1.2). The overall mortality rate was 2.8% (n = 851). Mortality was higher in morbidly obese patients compared with the nonobese patients (3.0 vs. 2.2; OR, 1.4; 95% CI, 1.1-1.5).

CONCLUSION

In a cohort of matched patients, morbid obesity is a risk factor for the development of in-hospital complications and mortality after blunt traumatic injury. The results of our study call for attention through focused injury prevention efforts. Future studies are needed to help define the consequences of obesity that influence outcomes.

LEVEL OF EVIDENCE

Prognostic study, level III.

Gender differences in sepsis: cardiovascular and immunological aspects

During sepsis, a complex network of cytokine, immune, and endothelial cell interactions occur and disturbances in the microcirculation cause organ dysfunction or even failure leading to high mortality in those patients. In this respect, numerous experimental and clinical studies indicate sex-specific differences in infectious diseases and sepsis.

Female gender has been demonstrated to be protective under such conditions, whereas male gender may be deleterious due to a diminished cell-mediated immune response and cardiovascular functions. Male sex hormones, i.e., androgens, have been shown to be suppressive on cell-mediated immune responses. In contrast, female sex hormones exhibit protective effects which may contribute to the natural advantages of females under septic conditions. Thus, the hormonal status has to be considered when treating septic patients.

Therefore, potential therapies could be derived from this knowledge. In this respect, administration of female sex hormones (estrogens and their precursors) may exert beneficial effects. Alternatively, blockade of male sex hormone receptors could result in maintained immune responses under adverse circulatory conditions. Finally, administration of agents that influence enzymes synthesizing female sex hormones which attenuate the levels of pro-inflammatory agents might exert salutary effects in septic patients. Prospective patient studies are required for transferring those important experimental findings into the clinical arena.