Sepsis associated with immunosuppressive medications: an evidence-based review

Predictive performance of NEWS and qSOFA in immunocompromised sepsis patients at the emergency department

PURPOSE

Sepsis has a high incidence and a poor prognosis. Early recognition is important to facilitate timely initiation of adequate care. Sepsis screening tools, such as the (quick) Sequential Organ Failure Assessment ((q)SOFA) and National Early Warning Score (NEWS), could help recognize sepsis. These tools have been validated in a general immunocompetent population, while their performance in immunocompromised patients, who are particularly at risk of sepsis development, remains unknown.

METHODS

This study is a post hoc analysis of a prospective observational study performed at the emergency department. Inclusion criteria were age ≥ 18 years with a suspected infection, while ≥ two qSOFA and/or SOFA criteria were used to classify patients as having suspected sepsis. The primary outcome was in-hospital mortality.

RESULTS

1516 patients, of which 40.5% used one or more immunosuppressives, were included. NEWS had a higher prognostic accuracy as compared to qSOFA for predicting poor outcome among immunocompromised sepsis patients. Of all tested immunosuppressives, high-dose glucocorticoid therapy was associated with a threefold increased risk of both in-hospital and 28-day mortality.

CONCLUSION

In contrast to NEWS, qSOFA underestimates the risk of adverse outcome in patients using high-dose glucocorticoids. As a clinical consequence, to adequately assess the severity of illness among immunocompromised patients, health care professionals should best use the NEWS.

Blood-Stream Infections: Causative Agents, Antibiotic Resistance and Associated Factors in Older Patients

Background

The rate of multi-drug antibiotic resistance in nosocomial bloodstream infections in elderly patients is increasing. This study examined the data for bloodstream infections to gain a better understanding of bacterial antibiotic resistance.

Methods

This was a retrospective study of 817 patients with the first positive blood culture between January 1, 2016 and December 31, 2019.

Results

Moyen's age was 77.4 ± 9.8 years, male (52.4%) and SOFA 5.0 ± 4. ESBL(+) rate was 78/817 (9.5%). ESBL(+) rate for Escherichia coli and Klebsiella pneumoniae was 69/141 (48.9%) and 9/52 (17.3%), respectively. The most common isolates were Escherichia coli (17.3%), Stenotrophomonas maltophilia (13.7%), and Staphylococcus species (23.1%). The rate of septic shock and mortality accounted for 22.3% and 28.9%, respectively. Escherichia coli is highly sensitive to carbapenem, and resistant (>50%) with quinolone and aminoside. Klebsiella pneumoniae and Pseudomonas aeruginosa were highly sensitive to carbapenem. Acinetobacter baumannii was resistant to meropenem (75%). Stenotrophomonas maltophilia was sensitive to quinolone (13.8 %), and highly resistant to remaining antibiotics. Methicillin-resistant Staphylococcus aureus had a low resistance rate for vancomycin, teicoplanin, and linezolid. Multivariate analysis showed that the significant factors associated with mortality were age >75; SOFA >7; respiratory infection; intensive care unit treatment and presentation with septic shock.

Conclusion

The mortality rate was still high, especially for antibiotic-resistant agents.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Regulatory T Cells: Angels or Demons in the Pathophysiology of Sepsis?

Sepsis is a syndrome characterized by life-threatening organ dysfunction caused by the dysregulated host response to an infection. Sepsis, especially septic shock and multiple organ dysfunction is a medical emergency associated with high morbidity, high mortality, and prolonged after-effects. Over the past 20 years, regulatory T cells (Tregs) have been a key topic of focus in all stages of sepsis research. Tregs play a controversial role in sepsis based on their heterogeneous characteristics, complex organ/tissue-specific patterns in the host, the multi-dimensional heterogeneous syndrome of sepsis, the different types of pathogenic microbiology, and even different types of laboratory research models and clinical research methods. In the context of sepsis, Tregs may be considered both angels and demons. We propose that the symptoms and signs of sepsis can be attenuated by regulating Tregs. This review summarizes the controversial roles and Treg checkpoints in sepsis.

Prevalence of hospital readmissions and related factors in patients with autoimmune diseases

OBJECTIVE

Autoimmune diseases generate an impact on the morbidity and mortality of patients and are a burden for the health system through hospital admissions and readmissions. The prevalence of readmission of patients with these diseases has not yet been described as a group, but rather as sub-phenotype. The objective of this study is to determine the prevalence of hospital readmissions in a Colombian population with autoimmunity and the factors related to readmission.

METHODS

All patients with autoimmune diseases who were evaluated by the rheumatology service and hospitalized between August 2018 and December 2019 at the Fundación Hospital Infantil Universitario De San José de Bogotá were described. A bivariate analysis was done, and three multivariate logistic regression models were built with the dependent variable being readmission.

RESULTS

Of the total 199 admissions, 131 patients were evaluated and 32% were readmitted. The most frequent sub-phenotype in both groups (readmission and no readmission) was SLE (51% and 59%). The most frequent cause of hospitalization and readmission was disease activity (68.7% and 64.3%). History of hypertension was associated with readmission (adjusted OR: 2.98-95% CI: 1.15-7.72). In a second model adjusted for confounding variables, no factor was associated. In a third model analyzing the history of kidney disease and previous use of immunosuppressants (adjusted for confounding variables), the previous use of immunosuppressants was related to readmission (OR: 2.78-95% CI 1.12-6.89).

CONCLUSION

Up to a third of patients with autoimmunity were readmitted and arterial hypertension was an associated factor. This suggested a greater systemic compromise and accumulated damage in patients who have these two conditions that may favor readmission. A history of immunosuppressant use may play a role in readmission, possibly by increasing the risk of developing infections.

Critical Care of Patients With Cardiopulmonary Complications of Sarcoidosis

Sarcoidosis is a systemic inflammatory disease defined by the presence of aberrant granulomas affecting various organs. Due to its multisystem involvement, care of patients with established sarcoidosis becomes challenging, especially in the intensive care setting. While the lungs are typically involved, extrapulmonary manifestations also occur either concurrently or exclusively within a significant proportion of patients, complicating diagnostic and management decisions. The scope of this review is to focus on what considerations are necessary in the evaluation and management of patients with known sarcoidosis and their associated complications within a cardiopulmonary and critical care perspective.

Excess mortality risk from sepsis in patients with HIV - A meta-analysis

PURPOSE

Differences in HIV prevalence, access to antiretrovirals and ICU resources may result in wide variation in sepsis mortality in HIV patients. The aim of this study was to perform a meta-analysis to quantify the excess risk of sepsis mortality in HIV patients.

MATERIALS AND METHODS

A systematic review was performed using three databases. The systemic inflammatory response syndrome criteria was used for the presumptive diagnosis of sepsis. We only included studies that stratified sepsis mortality by HIV serostatus. A meta-analysis was performed using random effects models, with subgroup analyses performed using country income, sepsis severity, and time periods.

RESULTS

17 studies were included, containing 82,905 patients. Sepsis mortality was found to be 28% higher in the HIV positive patients (95% CI 1.13-1.46, p < .01). Relative risk of mortality was higher in patients treated in low-income countries (RR 1.43 in low-income vs. 1.29 in high-income countries). Mortality was more pronounced in HIV patients with severe sepsis (RR 1.32 in severe sepsis vs. RR 1.15 in sepsis).

CONCLUSIONS

HIV increases the risk of sepsis mortality compared to seronegative individuals across all time periods and geographic areas. We note that this effect is more pronounced in patients with organ dysfunction.

Etiology and prognosis of acute respiratory failure in patients with primary malignant brain tumors admitted to the intensive care unit

PURPOSE

Acute respiratory failure (ARF) is common and potentially fatal in patients with primary malignant brain tumors (PMBT). However, few data are available regarding its precipitating factors and prognosis. We sought to: (1) compare the causes of ARF and the outcome between patients with PMBT and patients with other peripheral solid tumors (PST), (2) identify the factors influencing ICU survival in PMBT patients.

METHODS

Two-center retrospective case-control study from March 1996 to May 2014. Primary central nervous system lymphomas were also included.

RESULTS

Eighty-four patients with PMBT and 133 patients with PST were included. Acute infectious pneumonia was more frequent in PMBT than PST patients (77 vs. 36%, p < 0.001). Pulmonary embolism was also more frequent in PMBT patients (13% vs. 5%, p = 0.042), while cardiogenic pulmonary edema and acute-on-chronic respiratory failure were more frequent in PST patients (37 vs. 10%, p < 0.001). Among acute infectious pneumonia, Pneumocystis pneumonia and aspiration pneumonia were more frequent in PMBT patients (19 vs. 2%, p < 0.001 and 19 vs. 8%, p < 0.001, respectively). ICU mortality was similar between PMBT and PST patients (24% vs. 24%, p = 0.966). In multivariate analysis, cancer progression (OR 7.25 95% CI 1.13-46.45, p = 0.034), need for intubation (OR 7.01 95% CI 1.29-38.54, p = 0.022), were independently associated with ICU mortality in PMBT patients.

CONCLUSIONS

The cause of ARF in patients with PMBT differs significantly than those with PST and up to 50% may have been prevented. Mortality did not differ between the two groups. These results suggest that PMBT alone is not a relevant criterion for ICU recusal.

Epidemiology and Immune Pathogenesis of Viral Sepsis

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can be caused by a broad range of pathogens; however, bacterial infections represent the majority of sepsis cases. Up to 42% of sepsis presentations are culture negative, suggesting a non-bacterial cause. Despite this, diagnosis of viral sepsis remains very rare. Almost any virus can cause sepsis in vulnerable patients (e.g., neonates, infants, and other immunosuppressed groups). The prevalence of viral sepsis is not known, nor is there enough information to make an accurate estimate. The initial standard of care for all cases of sepsis, even those that are subsequently proven to be culture negative, is the immediate use of broad-spectrum antibiotics. In the absence of definite diagnostic criteria for viral sepsis, or at least to exclude bacterial sepsis, this inevitably leads to unnecessary antimicrobial use, with associated consequences for antimicrobial resistance, effects on the host microbiome and excess healthcare costs. It is important to understand non-bacterial causes of sepsis so that inappropriate treatment can be minimised, and appropriate treatments can be developed to improve outcomes. In this review, we summarise what is known about viral sepsis, its most common causes, and how the immune responses to severe viral infections can contribute to sepsis. We also discuss strategies to improve our understanding of viral sepsis, and ways we can integrate this new information into effective treatment.

Factors and outcomes in association with sepsis differ between simultaneous pancreas/kidney and single kidney transplant recipients

BACKGROUND

As immunosuppressive therapy has improved in simultaneous pancreas/kidney transplant recipients (SPKTRs), infection has become the major limitation of disease-free survival.

METHODS

We studied all SPKTRs and deceased-donor kidney transplant recipients (KTRs) between 2003 and 2015. Thirty-six of 134 SPKTRs (26.9%) were diagnosed with sepsis among which 13/36 SPKTRs (36.1%) developed severe sepsis/septic shock. A control group of 98 SPKTRs without sepsis and 61/538 KTRs (11.3%) with sepsis were used for comparison.

RESULTS

Among SPKTRs, female sex, low BMI, CMV seronegativity, CMV disease, and acute cellular rejection increased the risk for sepsis (P < .05). Patient and allograft survival was comparable among SPKTRs with and without sepsis (P > .05), but showed inferior kidney allograft function (P < .05). While urosepsis was less common among SPKTRs (45%), pneumonia (33%) and peritonitis (15%) as site of infections were more frequent (P < .05). Here, gram-positive and fungal sepsis were more common among SPKTRs compared to KTRs (P < .05). SPKTRs showed a higher incidence and an earlier onset of sepsis compared to KTRs (P < .001). SPKTRs with severe sepsis/septic shock were more likely to show pneumonia as site of infection with gram-positive/polymicrobial bacteremia (P < .05). Mortality from severe sepsis was 29% among SPKTRs compared to 58% among KTRs (P < .05).

CONCLUSION

Differences in incidence, site, causative pathogens, and onset of sepsis between SPKTRs and KTRs may be attributed to more intense immunosuppression, major surgery, and complications of diabetes among SPKTRs. Lower sepsis-related mortality may reflect younger age and more timely diagnosis, but also supports recent findings of less sepsis-related mortality among recipients of solid organ transplantation.

Inpatient Mortality Among Solid Organ Transplant Recipients Hospitalized for Sepsis and Severe Sepsis

BACKGROUND

Solid organ transplant (SOT) recipients are at elevated risk of sepsis. The impact of SOT on outcomes following sepsis is unclear.

METHODS

We performed a retrospective cohort study using data from University HealthSystem Consortium, a consortium of academic medical center affiliates. We examined the association between SOT and mortality among patients hospitalized with severe sepsis or explicitly coded sepsis in 2012-2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify severe sepsis, explicitly coded sepsis, and SOT (kidney, liver, heart, lung, pancreas, or intestine transplants). We fit random-intercept logistic regression models to account for clustering by hospital.

RESULTS

There were 903 816 severe sepsis hospitalizations (39 618 [4.4%] with SOT) and 410 623 sepsis hospitalizations (14 526 [3.9%] with SOT) in 250 hospitals. SOT recipients were younger and more likely to be insured by Medicare than those without SOT. Among hospitalizations for severe sepsis and sepsis, in-hospital mortality was lower among those with vs those without SOT (5.5% vs 9.4% for severe sepsis; 8.7% vs 12.7% for sepsis). After adjustment, the odds ratio for mortality comparing SOT patients vs non-SOT was 0.83 (95% confidence interval [CI], .79-.87) for severe sepsis and 0.78 (95% CI, .73-.84) for sepsis. Compared to non-SOT patients, kidney, liver, and co-transplant (kidney-pancreas/kidney-liver) recipients demonstrated lower mortality. No association was present for heart transplant, and lung transplant was associated with higher mortality.

CONCLUSIONS

Among patients hospitalized for severe sepsis or sepsis, those with SOT had lower inpatient mortality than those without SOT. Identifying the specific strategies employed for populations with improved mortality could inform best practices for sepsis among SOT and non-SOT populations.

8,9-Dehydrohispanolone-15,16-lactol diterpene prevents LPS-triggered inflammatory responses by inhibiting endothelial activation

Endothelial activation contributes to lung inflammatory disorders by inducing leucocyte recruitment to pulmonary parenchyma. Consequently, vascular-targeted therapies constitute promising strategies for the treatment of inflammatory pathologies. In the present study, we evaluated the effect of 8,9-dehydrohispanolone-15,16-lactol diterpene (DT) on lung endothelium during inflammation. Lung endothelial cells pre-treated with DT and activated with lipopolysaccharide (LPS) or tumour necrosis factor-α (TNF-α) exhibited reduced expression of the pro-inflammatory cytokines Cxcl10, Ccl5 and Cxcl1, whereas the anti-inflammatory molecules IL1r2 and IL-10 were induced. Consistent with this result, DT pre-treatment inhibited nuclear factor κB (NF-κB) nuclear translocation, by interfering with IκBα phosphorylation, and consequently NF-κB transcriptional activity in endothelium activated by LPS or TNF-α. Furthermore, DT, probably through p38 signalling, induced transcriptional activation of genes containing activator protein 1 (AP-1)-binding elements. Inhibition of p38 prevented IL1r2 mRNA expression in endothelium incubated with DT alone or in combination with LPS or TNF-α. Accordingly, conditioned medium (CM) from these cells failed to stimulate leucocytes as measured by a reduction in adhesive ability of the leucocyte cell line J774 to fibronectin (FN). Additionally, DT reduced the expression of the endothelial adhesion molecules E-selectin, vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1) after activation. Similarly, expression of VCAM-1 and ICAM-1 molecules on the lung endothelial layer of C57/BL6 mice pre-treated with DT and challenged with LPS were unchanged. Finally, inhibition of vascular adhesion molecule expression by DT decreased the interaction of J774 cells with lung endothelial cells in an inflammatory environment. Our findings establish DT as a novel endothelial inhibitor for the treatment of inflammatory-related diseases triggered by Gram-negative bacteria or by the associated cytokine TNF-α.

Sterile post-traumatic immunosuppression

After major trauma, the human immune system initiates a series of inflammatory events at the injury site that is later followed by suppression of local inflammation favoring the repair and remodeling of the damaged tissues. This local immune response involves complex interactions between resident cells such as macrophages and dendritic cells, soluble mediators such as cytokines and chemokines, and recruited cells such as neutrophils, monocytes and mesenchymal stromal cells. If of sufficient magnitude, these initial immune responses nevertheless have systemic consequences resulting in a state called post-traumatic immunosuppression (PTI). However, controversy exists regarding the exact immunological changes occurring in systemic compartments triggered by these local immune responses. PTI is one of the leading causes of post-surgical mortality and makes patients vulnerable to hospital-acquired infections, multiple organ failure and many other complications. In addition, hemorrhage, blood transfusion, immunesenescence and immunosuppressant drugs aggravate PTI. PTI has been intensively studied, but published results are frequently cloudy. The purpose of this review is to focus on the contributions made by different responsive modalities to immunosuppression following sterile trauma and to try to integrate these into an overall scheme of PTI.

The novel immunotherapeutic oligodeoxynucleotide IMT504 protects neutropenic animals from fatal Pseudomonas aeruginosa bacteremia and sepsis

IMT504 is a novel immunomodulatory oligonucleotide that has shown immunotherapeutic properties in early preclinical and clinical studies. IMT504 was tested in a neutropenic rat model of Pseudomonas aeruginosa bacteremia and sepsis. This animal system recapitulates many of the pathological processes found in neutropenic patients with Gram-negative, bacterial infections. The research was conducted in the setting of an academic research laboratory. The test subjects were Sprague-Dawley rats. Animals were rendered neutropenic by administration of cyclophosphamide, colonized with P. aeruginosa by oral feeding, and then randomized to receive IMT504 over a range of doses and treatment regimens representing early and late therapeutic interventions. IMT504 immunotherapy conferred a significant survival advantage over the 12-day study period compared with the results seen with placebo-treated animals when the therapy was administered at the onset of neutropenia and even in the absence of antibiotics and after the onset of fever and systemic infection. Notably, even late salvage IMT504 monotherapy was highly effective (13/14 surviving rats with IMT504 therapy versus 2/14 controls, P=<0.001). Moreover, late salvage IMT504 monotherapy was as effective as antibiotic therapy (13/14 surviving rats versus 21/21 rats, P=0.88). In addition, no antagonism or loss of therapeutic efficacy was noted with combination therapy of IMT504 plus antibiotics. IMT504 immunotherapy provides a remarkable survival advantage in bacteremia and sepsis in neutropenic animals and deserves further study as a new treatment option in patients with, or at risk for, severe Gram-negative bacterial infections and sepsis.

Oral infection control to assist infliximab therapy in a Behçet's disease patient with severe eye inflammation in response to dental treatment: a case report

Key Clinical Message

We report a case of Behçet's disease which was aggravated by psychological stress and oral infection. The control of oral infection under medical and dental collaboration is important for providing Behçet's disease patients with the optimal medical care and for facilitating the relief of the primary disease.

The burden of sepsis in critically ill human immunodeficiency virus-infected patients--a brief review

Since the advent of highly active antiretroviral therapy in 1996, we have seen dramatic changes in morbi-mortality rates from human immunodeficiency virus-positive patients. If on the one hand, the immunologic preservation-associated with the use of current antiretroviral therapy markedly diminishes the incidence of opportunistic infections, on the other hand it extended life expectancy of human immunodeficiency virus-infected individuals similarly to the general population. However, the management of critically ill human immunodeficiency virus-infected patients remains challenging and troublesome for practicing clinician. Sepsis - a complex systemic inflammatory syndrome in response to infection - is the second leading cause of intensive care unit admission in both human immunodeficiency virus-infected and uninfected populations. Recent data have emerged describing a substantial burden of sepsis in the infected population, in addition, to a much poorer prognosis in this group. Many factors contribute to this outcome, including specific etiologies, patterns of inflammation, underlying immune dysregulation related to chronic human immunodeficiency virus infection and delays in prompt diagnosis and treatment. This brief review explores the impact of sepsis in the context of human immunodeficiency virus infection, and proposes future directions for better management and prevention of human immunodeficiency virus-associated sepsis.

Use of methylene blue for treatment of severe sepsis in an immunosuppressed patient after liver transplantation

Sepsis in the immunosuppressed patient is associated with very high mortality and morbidity. Treatment of sepsis in immunocompromised patients is especially challenging due to an unbalanced systemic inflammatory reaction with subsequent development of profound vasoplegia. Methylene blue (MB) has been successfully used for the treatment of refractory hypotension, but its use has not previously been reported for treatment of sepsis in immunosuppressed patients. The mechanism of MB's action is thought to be due to its inhibitory effect on cGMP-mediated vasodilatation. This case report describes the successful use of MB for treatment of severe septic shock in an immunosuppressed patient after liver transplantation. Hypotension in this patient was refractory to volume repletion and a combination of vasopressors. After MB administration, hemodynamic stability was rapidly reestablished. In the setting of severe sepsis in an immunosuppressed patient, MB should be considered early as a therapeutic option for treatment of refractory vasoplegia.

Sepsis in AIDS patients: clinical, etiological and inflammatory characteristics

INTRODUCTION

Intensive care mortality of HIV-positive patients has progressively decreased. However, critically ill HIV-positive patients with sepsis present a worse prognosis. To better understand this condition, we propose a study comparing clinical, etiological and inflammatory data, and the hospital course of HIV-positive and HIV-negative patients with severe sepsis or septic shock.

METHODS

A prospective observational study enrolling patients with severe sepsis or septic shock associated or not with HIV infection, and admitted to intensive care unit (ICU). Clinical, microbiological and inflammatory parameters were assessed, including C-reactive protein (CRP), procalcitonin (PCT), interleukin-6, interleukin-10 and TNF-α. Outcome measures were in-hospital and six-month mortality.

RESULTS

The study included 58 patients with severe sepsis/septic shock admitted to ICU, 36 HIV-positive and 22 HIV-negative. All HIV-positive patients met the criteria for AIDS (CDC/2008). The main foci of infection in HIV-positive patients were pulmonary and abdominal (p=0.001). Fungi and mycobacteria were identified in 44.4% and 16.7% of HIV-positive patients, respectively. In contrast, the main etiologies for sepsis in HIV-negative patients were Gram-negative bacilli (36.4%) and Gram-positive cocci (36.4%) (p=0.001). CRP and PCT admission concentrations were lower in HIV-positive patients (130 vs. 168 mg/dL p=0.005, and 1.19 vs. 4.06 ng/mL p=0.04, respectively), with a progressive decrease in surviving patients. Initial IL-10 concentrations were higher in HIV-positive patients (4.4 pg/mL vs. 1.0 pg/mL, p=0.005), with moderate accuracy for predicting death (area under receiver-operating characteristic curve =0.74). In-hospital and six-month mortality were higher in HIV-positive patients (55.6 vs. 27.3% p=0.03, and 58.3 vs. 27.3% p=0.02, respectively).

CONCLUSIONS

The course of sepsis was more severe in HIV-positive patients, with distinct clinical, etiological and inflammatory characteristics.

Critical analysis of the use of rituximab in mucous membrane pemphigoid: a review of the literature

BACKGROUND

Mucous membrane pemphigoid (MMP) is an autoimmune blistering disease. In patients who do not respond to conventional therapy, rituximab (RTX) may be an option. The current literature on the treatment of MMP with RTX is limited.

OBJECTIVE

In this review, the data on 28 patients with MMP treated with RTX are critically analyzed. The goal is to provide objective information useful in decision making and treatment.

METHODS

A PubMed search using the key words "rituximab" and "mucous membrane pemphigoid" was made in the English language only. The studies were divided into case reports and case series.

RESULTS

In the final analysis, 20 of 28 patients had a complete response, 3 had a partial response, 2 were nonresponders, and 1 had stabilization of disease. In 1 patient, stabilization of upper airway disease was observed but the patient developed bilateral blindness as a result of progression of disease. Hence, the patient was considered a treatment failure. One died from infection. At least half of the patients were treated with a second cycle because of relapse or lack of response.

LIMITATIONS

Long-term follow-up after RTX therapy is lacking. Hence, the clinical benefit of inducing long-term remissions cannot be assessed. Responses of individual mucosal sites cannot be differentiated. Studies on B-cell levels and antibody responses are lacking.

CONCLUSION

Using the protocol described, RTX benefits patients with recalcitrant MMP. Some patients fail treatment or experience a relapse. The ability of RTX to influence the clinical course of MMP remains to be determined.

Non-viral infections in children after renal transplantation

Renal transplantation has long been recognised as the gold standard treatment for children with end-stage renal failure. There has been an improvement over the years in patient and renal allograft survival because of improved immunosuppression, surgical techniques and living kidney donation. Despite reduced acute allograft rejection rates, non-viral infections continue to be a serious complication for paediatric renal transplant recipients (RTR). The risk of infections in RTR is determined by the pre-transplantation immunisation status, post-transplant exposure to potential pathogens and the amount of immunosuppression. The greatest risk of life-threatening and Cytomegalovirus infections is during the first 6 months post-transplant owing to a high immunosuppressive burden. The potential sources of bacterial infections are donor derived, transplant medium fluid, peritoneal and haemodialysis catheter and transplant ureteric stent. Urinary tract infections are frequent in patients with lower urinary tract dysfunction and can result in renal allograft damage. This review outlines the incidence, timing, risk factors, prevention and treatment of non-viral infections in paediatric RTR by critically reviewing current immunosuppressive regimens, their risk-benefit ratio in order to optimise renal allograft survival with reduced rates of rejection and infectious complications.

17(R)-Resolvin D1 differentially regulates TLR4-mediated responses of primary human macrophages to purified LPS and live E. coli

Detection and clearance of bacterial infection require balanced effector and resolution signals to avoid chronic inflammation. Detection of GNB LPS by TLR4 on m induces inflammatory responses, contributing to chronic inflammation and tissue injury. LXs and Rvs are endogenous lipid mediators that enhance resolution of inflammation, and their actions on primary human m responses toward GNB are largely uncharacterized. Here, we report that LXA(4), LXB(4), and RvD1, tested at 0.1-1 μM, inhibited LPS-induced TNF production from primary human m, with ATL and 17(R)-RvD1, demonstrating potent inhibition at 0.1 μM. In addition, 17(R)-RvD1 inhibited LPS-induced primary human m production of IL-7, IL-12p70, GM-CSF, IL-8, CCL2, and MIP-1α without reducing that of IL-6 or IL-10. Remarkably, when stimulated with live Escherichia coli, m treated with 17(R)-RvD1 demonstrated increased TNF production and enhanced internalization and killing of the bacteria. 17(R)-RvD1-enhanced TNF, internalization, and killing were not evident for an lpxM mutant of E. coli expressing hypoacylated LPS with reduced inflammatory activity. Furthermore, 17(R)-RvD1-enhanced, E. coli-induced TNF production was evident in WT but not TLR4-deficient murine m. Thus, Rvs differentially modulate primary human m responses to E. coli in an LPS- and TLR4-dependent manner, such that this Rv could promote resolution of GNB/LPS-driven inflammation by reducing m proinflammatory responses to isolated LPS and increasing m responses important for clearance of infection.

How I manage haematology patients with septic shock

Patients with a variety of haematological conditions are at risk of infection and its most serious complication: septic shock. Mortality for septic shock remains high and especially so in patients with haematological malignancy and following bone marrow transplantation. However, advances in the treatment of severe sepsis have improved mortality rates even though evidence for the management of severe sepsis in haematology patients is limited. Wherever possible this review will concentrate on evidence directly applicable to haematology patients but inevitably will have to extrapolate evidence from other patient groups. The Surviving Sepsis Guidelines 2008 provide information on best practice in the management of patients with severe sepsis and septic shock and are broadly applicable though not specific to haematology patients. This review summarizes a practical approach to the management of severe sepsis in haematology patients and highlights areas of research which may bring new treatments in the future. The review is limited to the management and initial resuscitation of septic shock in adult haematology patients and will not address the detailed intensive care management of these patients or the management of severe sepsis in children.

Antibiotic management of sepsis: current concepts

BACKGROUND

The development of guidelines for sepsis management has improved disease survival and reduced treatment costs. Adequate antibiotic therapy is the cornerstone of sepsis treatment. Specific rules should be established in every institution according to its profiles.

OBJECTIVES

To review the current knowledge about the best drugs to be used as empiric treatment for sepsis based on their clinical efficacy and costs.

METHODS

Medline 1950 - 2008 was searched using the following terms: sepsis, organ failure, system failure, SIRS, septic shock, antibiotic, pneumonia, urinary tract infection, urosepsis, catheter-related infection, bloodstream, abdominal infection, and surgical wound.

RESULTS/CONCLUSION

For most septic shock patients, monotherapy is adequate and treatment should be initiated in the first hour after first sepsis-induced organ dysfunction. The drug of choice varies in different situations and choosing the right antibiotic enables better survival, fewer complications and shorter stays in intensive care.

Hemofiltration and immune response in severe sepsis

BACKGROUND

Levels of pro- and anti-inflammatory cytokines have been determined in numerous investigations. However, measurements of isolated cytokines do not allow conclusions on the resulting immune state. The purpose of this study was to determine resulting immune functions in patients' plasma. Additionally, similar measurements were performed with ultrafiltrate gained from continuous venovenous hemofiltration (CVVH).

MATERIALS AND METHODS

Nine septic patients and six critically ill patients with renal dysfunction in a surgical intensive care unit were observed. Two immune functions were chosen for detailed investigation over a time period of 72 h. The ability of patients' plasma to induce or suppress beta(2)-integrin expression on neutrophils of healthy controls served as marker for leukocyte activation. Interleukin (IL)-6 production or inhibition in washed whole blood cells induced through patients' plasma was used as a marker of cytokine secretion.

RESULTS

Plasma from septic patients led to a constantly increased expression of beta(2)-integrins on isolated, unstimulated neutrophils. At the same time, septic plasma permanently suppressed the production of IL-6 and IL-10 in stimulated whole blood. Ultrafiltrate from CVVH mirrors the equivalent immune response patterns found for plasma. We did not find significant differences pre- and postfilter or over the next 72 h in the potential to cause IL-6 and IL-10 production or beta(2)-integrin expression.

CONCLUSIONS

Plasma from septic patients triggers an increased expression of adhesion molecules and inhibited secretion of IL-6 and IL-10 in stimulated whole blood cells compared with nonseptic critically ill patients. Moreover, CVVH withdraws triggering mediators from plasma in equally bioactive proportions.

Multiple pulmonary abscesses caused by Legionella pneumophila infection in an infant with croup

Legionella infections are uncommon in childhood. We report the case of an infant who developed multiple pulmonary abscesses caused by Legionella pneumophila after receiving prolonged corticosteroid treatment of severe croup. Diagnosis was not suspected because immunosuppression was not initially considered. Caution should be used when prolonging high-dose corticosteroids in children with respiratory diseases.

Clinical Characteristics and Treatment Responses of Tuberculosis in Patients With Malignancy Receiving Anticancer Chemotherapy

STUDY OBJECTIVES

The aim of this study was to elucidate the clinical characteristics and treatment responses of tuberculosis developing in patients receiving anticancer chemotherapy.

DESIGN

Retrospective case-control study.

SETTING

The Seoul National University Hospital, a tertiary referral hospital in South Korea.

PATIENTS

From January 1, 2000, to July 31, 2004, patients with tuberculosis detected during the course of anticancer chemotherapy were enrolled as cases. Age- and sex-matched tuberculosis patients without any malignant disease were selected as control subjects.

MEASUREMENTS AND RESULTS

Twenty-four patients and 48 control subjects were enrolled. Their mean +/- SD age was 56.3 +/- 14.3 years, and the male-to-female ratio was 3:1. The most common malignancy was gastric cancer (43%). Lymphoma (17%), lung cancer (8%), and head and neck cancer (8%) were also common. In both groups, the lung was the most common site of tuberculosis involvement (87.8% and 79.2%, retrospectively). The presence of scar tissue suggesting old tuberculosis on radiography was more common in patients with tuberculosis receiving anticancer chemotherapy (66.7% vs 43.8%, p = 0.07). No difference in radiographic severity was observed between groups. A regimen based on first-line antituberculosis drugs was started in all subjects. Frequency of completion of the expected antituberculosis chemotherapy was lower in patients with tuberculosis developing with anticancer chemotherapy (58.3% vs 79.2%, p = 0.02), but it was not different after excluding the loss due to progression of underlying malignancies. Bacteriologic/radiographic responses to treatment and toxicity of antituberculosis medication sufficient to change or stop treatment were not different in both groups.

CONCLUSIONS

With regard to radiographic and clinical responses to antituberculosis treatment, tuberculosis developing during anticancer chemotherapy is not clinically different from tuberculosis developing in ordinary situations. Findings in this study suggest that anticancer chemotherapy is not an obstacle in treating tuberculosis.

Pilzsepsis - Therapeutische Strategie. Fungal sepsis - therapeutical strategy

The incidence of fungal infection as well as fungal sepsis has increased dramatically during the last decade. Changes of local microbial flora after broad-spectrum antibiotic therapy allow overgrowth of Candida species. Prophylactic strategies to lower fungal infection and sepsis include adequate and restrictive antibiotic therapy. Concerning the treatment of the septic syndrome, supportive as well as adjunctive strategies like early-goal-directed cardiovascular therapy, hydrocortisone replacement therapy, intense insulin application to achieve normoglycemia as well as the application of activated Protein C besides a consequent source control regimen and standard intensive care therapy, are able to improve significantly the outcome of septic patients.