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Tulli G, Toccafondi G. Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal. Diagnosis (Berl) 2021; 8:dx-2020-0142. [PMID: 33544477 DOI: 10.1515/dx-2020-0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/13/2020] [Indexed: 11/15/2022]
Abstract
This is a first attempt to integrate the three pillars of infection management: the infection prevention and control (IPC), and surveillance (IPCS), antimicrobial stewardship (AMS), and rapid identification and management of sepsis (RIMS). The new 'Sepsis-3' definition extrapolates the diagnosis of sepsis from our previously slightly naïve concept of a stepwise evolving pattern. In doing so, however, we have placed the transition from infection toward sepsis in the domain of uncertainty and time-dependency. This now demands that clinical judgment be used in the risk stratification of patients with infection, and that pragmatic local solutions be used to prompt clinicians to evaluate formally for sepsis. We feel it is necessary to stimulate the development of a new generation of concepts and models aiming at embracing uncertainty. We see the opportunity for a heuristic approach focusing on the relevant clinical predictors at hand allowing to navigate the uncertainty of infection diagnosis under time constraints. The diverse and situated clinical approaches eventually emerging need to focus on the understanding of infection as the unbalanced interactions of host, pathogen, and environment. In order extend such approach throughout the patient journey we propose a holistic early warning system underpinned by the risk-based categories of hazards and vulnerabilities iteratively fostered by the information gathered by the infection prevention control and surveillance, clinical microbiology, and clinical chemistry services.
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Affiliation(s)
| | - Giulio Toccafondi
- Clinical Risk Management and Patient Safety Center - GRC, Florence, Italy
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Wang C, Zhu X, Cui Y, Miao H, Xu Y, Xiong X, Tang X, Shao L, Zhang Y. Serum proteome-wide identified ATP citrate lyase as a novel informative diagnostic and prognostic biomarker in pediatric sepsis: A pilot study. IMMUNITY INFLAMMATION AND DISEASE 2020; 9:389-397. [PMID: 33378581 PMCID: PMC8127565 DOI: 10.1002/iid3.399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 12/29/2022]
Abstract
Introduction ATP citrate lyase (ACLY) is involved in lipid metabolism and inflammatory response in immune cells. However, the serum level of ACLY and its clinical relevance in sepsis is totally unknown. Methods We conducted a prospective pilot study in patients with sepsis admitted to pediatric intensive care unit (PICU) from January 2018 to December 2018. Results Higher levels of ACLY were detected in sera of pediatric patients with sepsis than that of healthy children. The area under the receiver operating characteristic curve (AUC) of ACLY for diagnosis of sepsis was 0.855 (95% confidence interval [CI]: 0757–0.952), and an AUC of ACLY for predicting PICU mortality was 0.770 (95% CI: 0.626–0.915). ACLY levels ≤21 ng/ml on PICU admission predicted an unfavorable prognosis among patients with sepsis with a sensitivity of 87.5% and a specificity of 67.6%. Moreover, serum ACLY levels were correlated to platelet count, IL‐18 levels, and monocyte counts in pediatric patients with sepsis, implying the potential roles of ACLY in immunometabolic regulation in sepsis. Conclusions ACLY is firstly identified in sera of patients with sepsis. Serum ACLY level is an additional diagnostic and prognostic biomarker in pediatric patients with sepsis.
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Affiliation(s)
- Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China.,Clinical Research Unit, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yaya Xu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiao Tong University, Shanghai, China
| | - Xi Xiong
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaomeng Tang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Lujing Shao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Claxton A, Papafilippou L, Hadjidemetriou M, Kostarelos K, Dark P. The challenge of recognising sepsis: Future nanotechnology solutions. J Intensive Care Soc 2020; 21:241-246. [PMID: 32782464 PMCID: PMC7401438 DOI: 10.1177/1751143719896554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The urgent need to start anti-infective therapeutic interventions in suspected sepsis, and the lack of specific time-critical diagnostic information often lead to the widespread administration of broad-spectrum antimicrobial therapies, increasing the risk of unwanted patient harms and contributing to rising pathogen antimicrobial resistance. Nanotechnology, which involves engineering at the nanoscale, allows for the bespoke development of diagnostic solutions with multi-functionality and high sensitivity that has the potential to help provide time-critical information to make more accurate diagnoses and treatment decisions for sepsis. Nanotechnologies also have the potential to improve upon the current strategies used for novel biomarker discovery. Here we describe some of the current limitations to identifying sepsis and explore the potential role for nanotechnology solutions.
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Affiliation(s)
- Andrew Claxton
- Nanomedicine Lab, Faculty of Biology, Medicine
and Health, University of Manchester, Manchester, UK
- Department of Critical Care, Salford Royal
Foundation Trust, Salford, UK
| | - Lana Papafilippou
- Nanomedicine Lab, Faculty of Biology, Medicine
and Health, University of Manchester, Manchester, UK
| | - Marilena Hadjidemetriou
- Nanomedicine Lab, Faculty of Biology, Medicine
and Health, University of Manchester, Manchester, UK
| | - Kostas Kostarelos
- Nanomedicine Lab, Faculty of Biology, Medicine
and Health, University of Manchester, Manchester, UK
| | - Paul Dark
- Department of Critical Care, Salford Royal
Foundation Trust, Salford, UK
- Division of Immunity, Infection and
Respiratory Medicine, NIHR Biomedical Research Centre, Faculty of Biology, Medicine and
Health, University of Manchester, Manchester, UK
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Quick Sequential Organ Failure Assessment Is Not Good for Ruling Sepsis In or Out. Chest 2019; 156:197-199. [DOI: 10.1016/j.chest.2019.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 01/10/2023] Open
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Poutsiaka DD, Porto MC, Perry WA, Hudcova J, Tybor DJ, Hadley S, Doron S, Reich JA, Snydman DR, Nasraway SA. Prospective Observational Study Comparing Sepsis-2 and Sepsis-3 Definitions in Predicting Mortality in Critically Ill Patients. Open Forum Infect Dis 2019; 6:ofz271. [PMID: 31281865 PMCID: PMC6602380 DOI: 10.1093/ofid/ofz271] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/04/2019] [Indexed: 01/21/2023] Open
Abstract
Background Sepsis definitions have evolved, but there is a lack of consensus over adoption of the most recent definition, Sepsis-3. We sought to compare Sepsis-2 and Sepsis-3 in the classification of patients with sepsis and mortality risk at 30 days. Methods We used the following definitions: Sepsis-2 (≥2 systemic inflammatory response syndrome criteria + infection), Sepsis-3 (prescreening by quick Sequential Organ Failure Assessment [qSOFA] of ≥2 of 3 criteria followed by the complete score change ≥2 + infection), and an amended Sepsis-3 definition, iqSOFA (qSOFA ≥2 + infection). We used χ 2 or Wilcoxon rank-sum tests, receiver-operator characteristic curves, and survival analysis. Results We enrolled 176 patients (95% in an intensive care unit, 38.6% female, median age 61.4 years). Of 105 patients classified by Sepsis-2 as having sepsis, 80 had sepsis per Sepsis-3 or iqSOFA (kappa = 0.72; 95% confidence interval [CI], 0.62–0.82). Twenty-five (14.8%) died (20 of 100 with sepsis per Sepsis-2 [20%], and 20 of 77 [26.0%] with sepsis per Sepsis-3 or iqSOFA). Results for Sepsis-3 and iqSOFA were identical. The area under the curve of receiver-operator characteristic (ROC) curves for identifying those who died were 0.54 (95% CI, 0.41–0.68) for Sepsis-2, 0.84 (95% CI, 0.74–0.93) for Sepsis-3, and 0.69 (95% CI, 0.60–0.79) for iqSOFA (P < .01). Hazard ratios for death associated with sepsis were greatest for sepsis or septic shock per Sepsis-3. Conclusions Sepsis-3 and iqSOFA were better at predicting death than Sepsis-2. Using the SOFA score might add little advantage compared with the simpler iqSOFA score.
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Affiliation(s)
- Debra D Poutsiaka
- Division of Geographic Medicine and Infectious Diseases Tufts Medical Center, Boston, Massachusetts
| | - Maura C Porto
- Division of Geographic Medicine and Infectious Diseases Tufts Medical Center, Boston, Massachusetts
| | - Whitney A Perry
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jana Hudcova
- Department of Surgical Critical Care, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - David J Tybor
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Susan Hadley
- Division of Geographic Medicine and Infectious Diseases Tufts Medical Center, Boston, Massachusetts
| | - Shira Doron
- Division of Geographic Medicine and Infectious Diseases Tufts Medical Center, Boston, Massachusetts
| | - John A Reich
- Department of Anesthesia and Perioperative Medicine, Tufts Medical Center, Boston, Massachusetts
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases Tufts Medical Center, Boston, Massachusetts
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Yañez MC, Mota MS, Ferrer MF, Julián-Jiménez A, Piñera P, Llopis F, Gamazo del Rio J, Martínez Ortiz de Zarate M, Estella Á, Martín-Sánchez FJ, González del Castillo J. [Comparison of different strategies for short-term death prediction in the infected older patient]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:156-164. [PMID: 30808154 PMCID: PMC6441984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to determine the utility of a post hoc lactate added to SIRS and qSOFA score to predict 30-day mortality in older non-severely dependent patients attended for infection in the Emergency Department (ED). METHODS We performed an analytical, observational, prospective cohort study including patients of 75 years of age or older, without severe functional dependence, attended for an infectious disease in 69 Spanish ED for 2-day three seasonal periods. Demographic, clinical and analytical data were collected. The primary outcome was 30-day mortality after the index event.The antimicrobial susceptibility data and extended-spectrum beta-lactamase (ESBL) production in isolates recovered from intra-abdominal (IAI) (n=1,429) and urinary tract (UTI) (n=937) infections during the 2016- 2017 SMART study in 10 Spanish hospitals were analysed. RESULTS We included 739 patients with a mean age of 84.9 (SD 6.0) years; 375 (50.7%) were women. Ninety-one (12.3%) died within 30 days. The AUC was 0.637 (IC 95% 0.587-0.688; p<0.001) for SIRS ≥ 2 and 0.698 (IC 95% 0.635-0.761; p<0.001) for qSOFA ≥ 2. Comparing receiver operating characteristic (ROC) there was a better accuracy of qSOFA vs SIRS (p=0.041). Both scales improve the prognosis accuracy with lactate inclusion. The AUC was 0.705 (IC95% 0.652-0.758; p<0.001) for SIRS plus lactate and 0.755 (IC95% 0.696-0.814; p<0.001) for qSOFA plus lactate, showing a trend to statistical significance for the second strategy (p=0.0727). Charlson index not added prognosis accuracy to SIRS (p=0.2269) or qSOFA (p=0.2573). CONCLUSIONS Lactate added to SIRS and qSOFA score improve the accuracy of SIRS and qSOFA to predict short-term mortality in older non-severely dependent patients attended for infection. There is not effect in adding Charlson index.
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Affiliation(s)
| | - Manuel Salido Mota
- Servicio de Urgencias. Hospital Regional Universitario de Málaga. Málaga
| | - Manuel Fuentes Ferrer
- Servicio de Medicina Preventiva, Hospital Clínico San Carlos. Facultad de Ciencias de la Salud, Universidad Alfonso X el Sabio, Madrid,Instituto de Investigación Sanitaria del Hospital San Carlos. Madrid, España
| | | | - Pascual Piñera
- Servicio de Urgencias. Hospital Universitario Reina Sofía. Murcia
| | - Ferrán Llopis
- Servicio de Urgencias. Hospital Universitario de Bellvitge. Barcelona
| | | | | | | | - Francisco Javier Martín-Sánchez
- Instituto de Investigación Sanitaria del Hospital San Carlos. Madrid, España,Servicio de Urgencias. Hospital Clínico San Carlos. Madrid
| | - Juan González del Castillo
- Instituto de Investigación Sanitaria del Hospital San Carlos. Madrid, España,Servicio de Urgencias. Hospital Clínico San Carlos. Madrid
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Nishibori M, Wake H, Morimatsu H. Histidine-rich glycoprotein as an excellent biomarker for sepsis and beyond. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:209. [PMID: 30119699 PMCID: PMC6097411 DOI: 10.1186/s13054-018-2127-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/11/2018] [Indexed: 12/28/2022]
Abstract
Sepsis remains a critical problem with high morbidity and mortality worldwide. One of the problems we have in critical care is the need to find a good biomarker of sepsis to determine the existence of bacterial infection and the severity of patients. This would enable us to start appropriate treatment at an earlier stage of the disease course. We propose that decreases in the plasma protein histidine-rich glycoprotein (HRG) is an excellent biomarker of sepsis compared with the current markers. Based on the novel pathophysiological roles of HRG in the cascade of events during sepsis, we also discuss the potential for supplemental therapy with purified HRG.
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Affiliation(s)
- Masahiro Nishibori
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Hidenori Wake
- Department of Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology & Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8558, Japan
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Jouffroy R, Saade A, Muret A, Philippe P, Michaloux M, Carli P, Vivien B. Fluid resuscitation in pre-hospital management of septic shock. Am J Emerg Med 2018; 36:1754-1758. [PMID: 29395771 DOI: 10.1016/j.ajem.2018.01.078] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 10/18/2022] Open
Affiliation(s)
- Romain Jouffroy
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; Department of Anesthesia & Clinical Epidemiology and Biostatistics; Michael DeGroote School of Medicine; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute; David Braley Cardiac, Vascular and Stroke Research Institute; Perioperative Medicine and Surgical Research Unit; Hamilton, Ontario, Canada.
| | - Anastasia Saade
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Alexandre Muret
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Pascal Philippe
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Maud Michaloux
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Pierre Carli
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Benoit Vivien
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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