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Joannidis M, Zarbock A. Fluids in acute kidney injury: Why less may be more. J Crit Care 2024; 82:154810. [PMID: 38616434 DOI: 10.1016/j.jcrc.2024.154810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria..
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive care and Pain Medicine, University Hospital Münster, Münster, Germany
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Eichinger M, Shah K, Palt N, Eichlseder M, Pichler A, Zoidl P, Zajic P, Rief M. Association of prehospital lactate levels with base excess in various emergencies - a retrospective study. Clin Chem Lab Med 2024; 62:1602-1610. [PMID: 38373063 DOI: 10.1515/cclm-2024-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/08/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES Blood gas analysis, including parameters like lactate and base excess (BE), is crucial in emergency medicine but less commonly utilized prehospital. This study aims to elucidate the relationship between lactate and BE in various emergencies in a prehospital setting and their prognostic implications. METHODS We conducted a retrospective analysis of prehospital emergency patients in Graz, Austria, from October 2015 to November 2020. Our primary aim was to assess the association between BE and lactate. This was assessed using Spearman's rank correlation and fitting a multiple linear regression model with lactate as the outcome, BE as the primary covariate of interest and age, sex, and medical emergency type as confounders. RESULTS In our analysis population (n=312), lactate and BE levels were inversely correlated (Spearman's ρ, -0.75; p<0.001). From the adjusted multiple linear regression model (n=302), we estimated that a 1 mEq/L increase in BE levels was associated with an average change of -0.35 (95 % CI: -0.39, -0.30; p<0.001) mmol/L in lactate levels. Lactate levels were moderately useful for predicting mortality with notable variations across different emergency types. CONCLUSIONS Our study highlights a significant inverse association between lactate levels and BE in the prehospital setting, underscoring their importance in early assessment and prognosis in emergency care. Additionally, the findings from our secondary aims emphasize the value of lactate in diagnosing acid-base disorders and predicting patient outcomes. Recognizing the nuances in lactate physiology is essential for effective prehospital care in various emergency scenarios.
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Affiliation(s)
- Michael Eichinger
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
| | - Karan Shah
- Section of Biostatistics, Quantitative Health Sciences, 2569 Cleveland Clinic , Cleveland, OH, USA
| | - Niklas Palt
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
| | - Michael Eichlseder
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
| | - Alexander Pichler
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
| | - Philipp Zoidl
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
| | - Paul Zajic
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
| | - Martin Rief
- Department of Anaesthesiology and Intensive Care Medicine 1, 31475 Medical University of Graz , Graz, Austria
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3
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Lawrence JR, Lee BS, Fadahunsi AI, Mowery BD. Evaluating Sepsis Bundle Compliance as a Predictor for Patient Outcomes at a Community Hospital: A Retrospective Study. J Nurs Care Qual 2024; 39:252-258. [PMID: 38470467 PMCID: PMC11116060 DOI: 10.1097/ncq.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Clinicians are encouraged to use the Centers for Medicare & Medicaid Services early management bundle for severe sepsis and septic shock (SEP-1); however, it is unclear whether this process measure improves patient outcomes. PURPOSE The purpose of this study was to evaluate whether compliance with the SEP-1 bundle is a predictor of hospital mortality, length of stay (LOS), and intensive care unit LOS at a suburban community hospital. METHODS A retrospective observational study was conducted. RESULTS A total of 577 patients were included in the analysis. Compliance with the SEP-1 bundle was not a significant predictor for patient outcomes. CONCLUSIONS SEP-1 compliance may not equate with quality of health care. Efforts to comply with SEP-1 may help organizations develop systems and structures that improve patient outcomes. Health care leaders should evaluate strategies beyond SEP-1 compliance to ensure continuous improvement of outcomes for patients experiencing sepsis.
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Affiliation(s)
- John R Lawrence
- Author Affiliations: Inova Mount Vernon Hospital, Alexandria, Virginia (Mr Lawrence); George Mason University, Fairfax, Virginia (Drs Lee and Fadahunsi); and Inova Health System, Fairfax, Virginia (Dr Mowery)
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Klompas M, Rhee C. Victories and Opportunities in the Surviving Sepsis Campaign's Antibiotic Timing Guidance. Crit Care Med 2024; 52:1138-1141. [PMID: 38869386 DOI: 10.1097/ccm.0000000000006274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Garcia M, Al-Jaghbeer M, Morrison J, Boustany A, Ghimire B, Tapryal N, Mushtaq K, Orlosky K, Flowers-Surovi A, Murphy C, Rath P, Rahman M, Kickel C, Lee YC, Chang KY, Abi Fadel F. Multimodal Quality Initiatives in Sepsis Care: Assessing Impact on Core Measures and Outcomes. J Healthc Qual 2024; 46:245-250. [PMID: 38759142 DOI: 10.1097/jhq.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
ABSTRACT Providing timely and effective care for patients with sepsis is challenging due to delays in recognition and intervention. The Surviving Sepsis Campaign has developed bundles that have been shown to reduce sepsis mortality. However, hospitals have not consistently adhered to these bundles, resulting in suboptimal outcomes. To address this, a multimodal quality improvement sepsis program was implemented from 2017 to 2022 in a large urban tertiary hospital. The aim of this program was to enhance the Severe Sepsis and Septic Shock Management Bundle compliance and reduce sepsis mortality. At baseline, the Severe Sepsis and Septic Shock Management Bundle compliance rates were low, at 25%, with a sepsis observed/expected mortality ratio of 1.14. Our interventions included the formation of a multidisciplinary committee, the appointment of sepsis champions, the implementation of sepsis alerts and order sets, the formation of a Code Sepsis team, real-time audits, and peer-to-peer education. By 2022, compliance rose to 62%, and the observed/expected mortality ratio decreased to 0.73. Our approach led to improved outcomes and hospital rankings. These findings underscore the efficacy of a comprehensive sepsis care initiative, emphasizing the importance of interdisciplinary collaboration. A multimodal hospital-wide sepsis performance program is feasible and can contribute to improved outcomes. However, further research is necessary to determine the specific impact of individual strategies on sepsis outcomes.
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Taylor SP, Kowalkowski MA, Skewes S, Chou SH. Real-World Implications of Updated Surviving Sepsis Campaign Antibiotic Timing Recommendations. Crit Care Med 2024; 52:1002-1006. [PMID: 38385751 DOI: 10.1097/ccm.0000000000006240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To evaluate real-world implications of updated Surviving Sepsis Campaign (SSC) recommendations for antibiotic timing. DESIGN Retrospective cohort study. SETTING Twelve hospitals in the Southeastern United States between 2017 and 2021. PATIENTS One hundred sixty-six thousand five hundred fifty-nine adult hospitalized patients treated in the emergency department for suspected serious infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We determined the number and characteristics of patients affected by updated SSC recommendations for initiation of antibiotics that incorporate a risk- and probability-stratified approach. Using an infection prediction model with a cutoff of 0.5 to classify possible vs. probable infection, we found that 30% of the suspected infection cohort would be classified as shock absent, possible infection and thus eligible for the new 3-hour antibiotic recommendation. In real-world practice, this group had a conservative time to antibiotics (median, 5.5 hr; interquartile range [IQR], 3.2-9.8 hr) and low mortality (2%). Patients categorized as shock absent, probable infection had a median time to antibiotics of 3.2 hours (IQR, 2.1-5.1 hr) and mortality of 3%. Patients categorized as shock present, the probable infection had a median time to antibiotics 2.7 hours (IQR, 1.7-4.6 hr) and mortality of 17%, and patients categorized as shock present, the possible infection had a median time to antibiotics 6.9 hours (IQR, 3.5-16.3 hr) and mortality of 12%. CONCLUSIONS These data support recently updated SSC recommendations to align antibiotic timing targets with risk and probability stratifications. Our results provide empirical support that clinicians and hospitals should not be held to 1-hour targets for patients without shock and with only possible sepsis.
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Affiliation(s)
- Stephanie P Taylor
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Marc A Kowalkowski
- Department of Internal Medicine, Wake Forest University School of Medicine, Center for Health System Sciences, Atrium Health, Charlotte, NC
| | - Sable Skewes
- Division of Pulmonary and Critical Care, Wake Forest University, Winston-Salem, NC
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7
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Sayyad MS, Dehpour A, Poopak A, Azami A, Shafaroodi H. Investigating the efficacy of dapsone in treating sepsis induced by cecal ligation and puncture surgery in male mice. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03251-z. [PMID: 38940849 DOI: 10.1007/s00210-024-03251-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
Sepsis is a life-threatening condition caused by the body's response to an infection. Dapsone is a sulfone with antibiotic properties, and experimental evidence suggests it has significant anti-inflammatory and anti-oxidative stress effects. The objective of this study was to investigate the efficacy of dapsone in mice after CLP (cecal ligation and puncture) surgery, which is a model for inducing sepsis. The study divided animals into five groups: CLP, sham, and three groups receiving different doses of dapsone (0.5, 1, 2 mg/kg). Sepsis was induced through CLP surgery, followed by dapsone administration. In each group, half of the mice were used to evaluate levels of various markers and pathological changes at 24 h post-CLP, while the other half was used to record the mortality rates within 96 h. The results showed that single-dose administration of dapsone at (0.5, 1, 2 mg/kg) after CLP surgery improved survival compared to the CLP group. Dapsone was also associated with a significant reduction in pro-inflammatory cytokines TNF-α, IL-1β, IL-6, NO, and MPO, as well as lactate and creatinine serum levels. However, dapsone did not have a significant effect on urea serum levels. In conclusion, the data suggest that dapsone treatment leads to increased survival in septic mice after CLP, and due to its ability to reduce TNF-α, IL-1β, IL-6, MPO, and lactate levels, it has anti-inflammatory effects in sepsis. The sepsis treatment with dapsone in mice protects against inflammation and oxidative stress.
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Affiliation(s)
- Mohammad Shokati Sayyad
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Dehpour
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Poopak
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Atena Azami
- Department of Pathology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Hamed Shafaroodi
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Wang L, Chen Y, Wu H, Yu HH, Ma L. Slit2-Robo4 signal pathway and tight junction in intestine mediate LPS-induced inflammation in mice. Eur J Med Res 2024; 29:349. [PMID: 38937814 PMCID: PMC11209965 DOI: 10.1186/s40001-024-01894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/21/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Sepsis is one of the most common clinical diseases, which is characterized by a serious and uncontrollable inflammatory response. LPS-induced inflammation is a critical pathological event in sepsis, but the underlying mechanism has not yet been fully elucidated. METHODS The animal model was established for two batches. In the first batch of experiments, Adult C57BL/6J mice were randomly divided into control group and LPS (5 mg/kg, i.p.)group . In the second batch of experiments, mice were randomly divided into control group, LPS group, and LPS+VX765(10 mg/kg, i.p., an inhibitor of NLRP3 inflammasome) group. After 24 hours, mice were anesthetized with isoflurane, blood and intestinal tissue were collected for tissue immunohistochemistry, Western blot analysis and ELISA assays. RESULTS The C57BL/6J mice injected with LPS for twenty-four hours could exhibit severe inflammatory reaction including an increased IL-1β, IL-18 in serum and activation of NLRP3 inflammasome in intestine. The injection of VX765 could reverse these effects induced by LPS. These results indicated that the increased level of IL-1β and IL-18 in serum induced by LPS is related to the increased intestinal permeability and activation of NLRP3 inflammasome. In the second batch of experiments, results of western blot and immunohistochemistry showed that Slit2 and Robo4 were significant decreased in intestine of LPS group, while the expression of VEGF was significant increased. Meanwhile, the protein level of tight junction protein ZO-1, occludin, and claudin-5 were significantly lower than in control group, which could also be reversed by VX765 injection. CONCLUSIONS In this study, we revealed that Slit2-Robo4 signaling pathway and tight junction in intestine may be involved in LPS-induced inflammation in mice, which may account for the molecular mechanism of sepsis.
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Affiliation(s)
- Lv Wang
- Department of Emergency and Critical Care Medicine, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, People's Republic of China
| | - Yingtai Chen
- Emergency Department, Baoshan Branch of Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200444, People's Republic of China
| | - Hao Wu
- Department of Emergency and Critical Care Medicine, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, People's Republic of China
| | - He-Hua Yu
- Department of Emergency and Critical Care Medicine, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, People's Republic of China.
| | - Linhao Ma
- Department of Emergency and Critical Care Medicine, Shanghai Changzheng Hospital, Naval Medical University, Shanghai, 200003, People's Republic of China.
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9
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Desantis V, Borrelli P, Panebianco T, Fusillo A, Bochicchio D, Solito A, Pappagallo F, Mascolo A, Ancona A, Cicco S, Cerchione C, Romano A, Montagnani M, Ria R, Vacca A, Solimando AG. Comprehensive analysis of clinical outcomes, infectious complications and microbiological data in newly diagnosed multiple myeloma patients: a retrospective observational study of 92 subjects. Clin Exp Med 2024; 24:137. [PMID: 38937383 PMCID: PMC11211138 DOI: 10.1007/s10238-024-01411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
Patients with multiple myeloma (MM) have an increased risk of sepsis due to underlying disease- and treatment-related immunosuppression. However, data on sepsis incidence, causative pathogens, and impact on outcomes in newly diagnosed MM (NDMM) are limited. We conducted a retrospective observational study of 92 NDMM patients who developed sepsis between 2022 and 2023 at a tertiary care center in Italy. Patient characteristics, sepsis criteria [Quick Sequential Organ Failure Assessment, Systemic Inflammatory Response Syndrome (SIRS)], microbiology results, and associations with progression-free survival (PFS) were analyzed. In this cohort of 92 critically-ill patients, pathogenic organisms were identified via microbiological culture in 74 cases. However, among the remaining 18 culture-negative patients, 9 exhibited a SIRS score of 2 and another 9 had a SIRS score of 4, suggestive of a clinical presentation consistent with sepsis despite negative cultures. Common comorbidities included renal failure (60%), anemia (71%), and bone disease (83%). Gram-negative (28%) and Gram-positive (23%) bacteria were frequent causative organisms, along with fungi (20%). Cox Univariate analyses for PFS showed statically significant HR in patients with albumin ≥ 3.5 vs < 3.5 (HR = 5.04, p < 0.001), Karnofsky performance status ≥ 80 vs < 80 (HR = 2.01, p = 0.002), and early-stage vs late-stage disease by International Staging System (HR = 4.76 and HR = 12.52, both p < 0.001) and Revised International Staging System (R-ISS III vs R-ISS I, HR = 7.38, p < 0.001). Sepsis is common in NDMM and associated with poor outcomes. Risk stratification incorporating sepsis severity, comorbidities, and disease stage may help guide preventive strategies and optimize MM management.
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Affiliation(s)
- Vanessa Desantis
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Section of Pharmacology, University of Bari "Aldo Moro" Medical School, Bari, Italy.
| | - Paola Borrelli
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Teresa Panebianco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonio Fusillo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Donatello Bochicchio
- Department of Medical, Oral and Biotechnological Sciences, Laboratory of Biostatistics, University "G. d'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Angelo Solito
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Fabrizio Pappagallo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonella Mascolo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Anna Ancona
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Sebastiano Cicco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Claudio Cerchione
- Department of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Alessandra Romano
- Department of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
- Department of General Surgery and Medical-Surgical Specialties, Hematology Section, University of Catania, Catania, Italy
| | - Monica Montagnani
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Section of Pharmacology, University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Roberto Ria
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Angelo Vacca
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Antonio Giovanni Solimando
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), Unit of Internal Medicine "Guido Baccelli", University of Bari "Aldo Moro" Medical School, Bari, Italy.
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10
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Tu KJ, Vakkalanka JP, Okoro UE, Harland KK, Wymore C, Fuller BM, Campbell K, Swanson MB, Parker EA, Mack LJ, Bell A, DeJong K, Faine B, Zepeski A, Mueller K, Chrischilles E, Carpenter CR, Jones MP, Ward MM, Mohr NM. Provider-to-provider telemedicine for sepsis is used less frequently in communities with high social vulnerability. J Rural Health 2024. [PMID: 38924559 DOI: 10.1111/jrh.12861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/18/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated. METHODS We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use. FINDINGS Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38). CONCLUSIONS Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities.
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Affiliation(s)
- Kevin J Tu
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, Maryland, USA
- University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Uche E Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cole Wymore
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Edith A Parker
- Department of Community & Behavioral Health, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Luke J Mack
- Avel eCARE, Sioux Falls, South Dakota, USA
- Department of Family Medicine, University of South Dakota School of Medicine, Sioux Falls, South Dakota, USA
| | | | | | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pharmacy Practice & Science, College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
- Department of Health Management and Policy, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
- Department of Health Management and Policy, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Elizabeth Chrischilles
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | | | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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11
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Kawai Y, Nakayama A, Fukushima H. Identification of sepsis-causing bacteria from whole blood without culture using primers with no cross-reactivity to human DNA. J Microbiol Methods 2024; 223:106982. [PMID: 38942122 DOI: 10.1016/j.mimet.2024.106982] [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: 09/15/2023] [Revised: 05/03/2024] [Accepted: 06/25/2024] [Indexed: 06/30/2024]
Abstract
Sepsis is a major health concern globally, and identification of the causative organism usually takes several days. Furthermore, molecular amplification using whole blood from patients with sepsis remains challenging because of primer cross-reactivity with human DNA, which can delay appropriate clinical intervention. To address these concerns, we designed primers that could reduce cross-reactivity. By evaluating these primers against human DNA, we confirmed that the cross-reactivity observed with conventional primers was notably absent. In silico PCR further demonstrated the specificity and efficiency of the designed primers across 23 bacterial species that are often associated with sepsis. When tested using blood samples from sepsis patients, the designed primers showed moderate sensitivity and high specificity. Surprisingly, our method identified bacteria even in samples that were detected at other sites but tested negative using conventional blood culture methods. Although we identified some challenges, such as contamination with Acetobacter aceti due to the saponin pretreatment of samples, the developed method demonstrates remarkable potential for rapid identification of the causative organisms of sepsis and provides a new avenue for diagnosis in clinical practice.
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Affiliation(s)
- Yasuyuki Kawai
- Department of Emergency and Critical Care Medicine, Nara Medical University, Shijo-cho, Kashihara, Nara, Japan.
| | - Akifumi Nakayama
- Department of Medical Technology, School of Health Sciences, Gifu University of Medical Science, Ichihiraga, Seki, Gifu, Japan
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University, Shijo-cho, Kashihara, Nara, Japan
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12
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Marcy F, Goettfried K, Enghard P, Piper SK, Kunz JV, Schroeder T. Impact of AKI on metabolic compensation for respiratory acidosis in ICU patients with AECOPD. J Crit Care 2024; 83:154846. [PMID: 38936337 DOI: 10.1016/j.jcrc.2024.154846] [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: 01/03/2024] [Revised: 05/28/2024] [Accepted: 06/08/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can result in severe respiratory acidosis. Metabolic compensation is primarily achieved by renal retention of bicarbonate. The extent to which acute kidney injury (AKI) impairs the kidney's capacity to compensate for respiratory acidosis remains unclear. MATERIALS AND METHODS This retrospective analysis covers clinical data between January 2009 and December 2021 for 498 ICU patients with AECOPD and need for respiratory support. RESULTS 278 patients (55.8%) presented with or developed AKI. Patients with AKI exhibited higher 30-day-mortality rates (14.5% vs. 4.5% p = 0.001), longer duration of mechanical ventilation (median 90 h vs. 14 h; p = 0.001) and more severe hypercapnic acidosis (pH 7.23 vs. 7.28; pCO2 68.5 mmHg vs. 61.8 mmHg). Patients with higher AKI stages exhibited lower HCO3-/pCO2 ratios and did not reach expected HCO3- levels. In a mixed model analysis with random intercept per patient we analyzed the association of pCO2 (independent) and HCO3- (dependent variable). Lower estimates for averaged change in HCO3- were observed in patients with more severe AKI. CONCLUSION AKI leads to poor outcomes and compromises metabolic compensation of respiratory acidosis in ICU patients with AECOPD. While buffering agents may aid compensation for severe AKI, their use should be approached with caution.
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Affiliation(s)
- Florian Marcy
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany.
| | - Katharina Goettfried
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
| | - Philipp Enghard
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
| | - Sophie K Piper
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Strasse 2, 10178 Berlin, Germany; Charité - Universitätsmedizin Berlin, Institute of Medical Informatics Berlin, Germany
| | - Julius Valentin Kunz
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
| | - Tim Schroeder
- Charité - Universitätsmedizin Berlin, Department of Nephrology and Medical Intensive Care Medicine, Berlin, Germany
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13
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Mokart D, Boutaba M, Servan L, Bertrand B, Baldesi O, Lefebvre L, Gonzalez F, Bisbal M, Pastene B, Duclos G, Faucher M, Zieleskiewicz L, Chow-Chine L, Sannini A, Boher JM, Ronflé R, Leone M. Empirical antifungal therapy for health care-associated intra-abdominal infection: a retrospective, multicentre and comparative study. Ann Intensive Care 2024; 14:98. [PMID: 38916830 PMCID: PMC11199462 DOI: 10.1186/s13613-024-01333-y] [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: 03/10/2024] [Accepted: 06/10/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Current guidelines recommend using antifungals for selected patients with health care-associated intra-abdominal infection (HC-IAI), but this recommendation is based on a weak evidence. This study aimed to assess the association between early empirical use of antifungals and outcomes in intensive care unit (ICU) adult patients requiring re-intervention after abdominal surgery. METHODS A retrospective, multicentre cohort study with overlap propensity score weighting was conducted in three ICUs located in three medical institutions in France. Patients treated with early empirical antifungals for HC-IAI after abdominal surgery were compared with controls who did not receive such antifungals. The primary endpoint was the death rate at 90 days, and the secondary endpoints were the death rate at 1 year and composite criteria evaluated at 30 days following the HC-IAI diagnosis, including the need for re-intervention, inappropriate antimicrobial therapy and death, whichever occurred first. RESULTS At 90 days, the death rate was significantly decreased in the patients treated with empirical antifungals compared with the control group (11.4% and 20.7%, respectively, p = 0.02). No differences were reported for the secondary outcomes. CONCLUSION The use of early empirical antifungal therapy was associated with a decreased death rate at 90 days, with no effect on the death rate at 1 year, the death rate at 30 days, the rate of re-intervention, the need for drainage, and empirical antibiotic and antifungal therapy failure at 30 days.
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Affiliation(s)
- Djamel Mokart
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France.
| | - Mehdi Boutaba
- Department of Anesthesiology and Intensive Care Unit, Nord Hospital, Assistance Publique Hôpitaux Universitaires De Marseille, Aix Marseille University, Marseille, France
| | - Luca Servan
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Benjamin Bertrand
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Baldesi
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Centre Hospitalier du Pays d'Aix, Marseille, Aix-en-Provence, France
| | - Laurent Lefebvre
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Centre Hospitalier du Pays d'Aix, Marseille, Aix-en-Provence, France
| | - Frédéric Gonzalez
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Magali Bisbal
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Bruno Pastene
- Department of Anesthesiology and Intensive Care Unit, Nord Hospital, Assistance Publique Hôpitaux Universitaires De Marseille, Aix Marseille University, Marseille, France
| | - Gary Duclos
- Department of Anesthesiology and Intensive Care Unit, Nord Hospital, Assistance Publique Hôpitaux Universitaires De Marseille, Aix Marseille University, Marseille, France
| | - Marion Faucher
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Intensive Care Unit, Nord Hospital, Assistance Publique Hôpitaux Universitaires De Marseille, Aix Marseille University, Marseille, France
| | - Laurent Chow-Chine
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Antoine Sannini
- Department of Anesthesiology and Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Jean Marie Boher
- Biostatistics and Methodology Unit, Institut Paoli-Calmettes, Marseille, France
- Aix Marseille University, INSERM, IRD, SESSTIM, Marseille, France
| | - Romain Ronflé
- Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes, Centre Hospitalier du Pays d'Aix, Marseille, Aix-en-Provence, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Nord Hospital, Assistance Publique Hôpitaux Universitaires De Marseille, Aix Marseille University, Marseille, France
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14
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Ferrarese A, Senzolo M, Sasset L, Bassi D, Cillo U, Burra P. Multidrug-resistant bacterial infections in the liver transplant setting. Updates Surg 2024:10.1007/s13304-024-01903-6. [PMID: 38918314 DOI: 10.1007/s13304-024-01903-6] [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: 03/20/2024] [Accepted: 05/21/2024] [Indexed: 06/27/2024]
Abstract
Bacterial infections pose a life-threatening complication in patients with decompensated liver cirrhosis and acute-on-chronic liver failure. An increasing prevalence of infections caused by multidrug-resistant organisms (MDROs) has been observed in these patients, significantly impacting prognosis. A growing body of evidence has identified the most common risk factors for such infections, enabling the development of preventive strategies and therapeutic interventions. MDRO infections may also occur after liver transplantation (most commonly in the early post-operative phase), affecting both graft and patient survival. This review provides an overview of MDRO infections before and after liver transplantation, discussing epidemiological aspects, risk factors, prevention strategies, and novel therapeutic approaches. Furthermore, it examines the implications of MDRO infections in the context of prioritizing liver transplantation for the most severe patients, such as those with acute-on-chronic liver failure.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy.
| | - Marco Senzolo
- Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Lolita Sasset
- Infectious Disease Unit, Padua University Hospital, Padua, Italy
| | - Domenico Bassi
- Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
- Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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15
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Bowyer L, Cutts BA, Barrett HL, Bein K, Crozier TM, Gehlert J, Giles ML, Hocking J, Lowe S, Lust K, Makris A, Morton MR, Pidgeon T, Said J, Tanner HL, Wilkinson L, Wong M. SOMANZ position statement for the investigation and management of sepsis in pregnancy 2023. Aust N Z J Obstet Gynaecol 2024. [PMID: 38922822 DOI: 10.1111/ajo.13848] [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: 12/13/2023] [Accepted: 05/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The Society of Australia and New Zealand (SOMANZ) published its first sepsis in pregnancy and the postpartum period guideline in 2017 (Aust N Z J Obstet Gynaecol, 57, 2017, 540). In the intervening 6 years, maternal mortality from sepsis has remained static. AIMS To update clinical practice with a review of the subsequent literature. In particular, to review the definition and screening tools for the diagnosis of sepsis. MATERIALS AND METHODS A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women analysed the clinical evidence according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system following searches of Cochrane, Medline and EMBASE. Where there were conflicting views, the authors reviewed the topic and came to a consensus. All authors reviewed the final position statement. RESULTS This position statement has abandoned the use of the quick Sequential Organ Failure Assessment score (qSOFA) score to diagnose sepsis due to its poor performance in clinical practice. Whilst New Zealand has a national maternity observation chart, in Australia maternity early warning system charts and vital sign cut-offs differ between states. Rapid recognition, early antimicrobials and involvement of senior staff remain essential factors to improving outcomes. CONCLUSION Ongoing research is required to discover and validate tools to recognize and diagnose sepsis in pregnancy. Australia should follow New Zealand and have a single national maternity early warning system observation chart.
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Affiliation(s)
- Lucy Bowyer
- Department of Obstetrics, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Briony A Cutts
- Department of Obstetric Medicine, Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, Victoria, Australia
| | - Helen L Barrett
- Department of Obstetric Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Kendall Bein
- Emergency Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Timothy M Crozier
- Department of Intensive Care, Monash Health, Department of Intensive Care Services, Eastern Health, Melbourne, Victoria, Australia
| | - Jessica Gehlert
- Department of Obstetrics and Gynaecology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Michelle L Giles
- Department of Obstetrics and Gynaecology, Department of Infectious Diseases, Monash University, Melbourne, Victoria, Australia
| | - Jennifer Hocking
- Australian Breastfeeding Association, Melbourne, Victoria, Australia
| | - Sandra Lowe
- Department of Obstetric Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Karin Lust
- Department of Obstetric Medicine, Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Angela Makris
- Department of Nephrology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Mark R Morton
- Women's and Babies Division, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Tara Pidgeon
- Emergency Department, St Vincent's Private Hospital, Toowoomba, Queensland, Australia
| | - Joanne Said
- Department of Maternal Fetal Medicine, Joan Kirner Women's and Children's at Sunshine Hospital, Melbourne, Victoria, Australia
| | - Helen L Tanner
- Department of Obstetric Medicine, Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Lucille Wilkinson
- Department of Medicine, Northland District Health Board, Auckland, New Zealand
| | - Maggie Wong
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
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16
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Sajib MSI, Brunker K, Oravcova K, Everest P, Murphy ME, Forde T. Advances in host depletion and pathogen enrichment methods for rapid sequencing-based diagnosis of bloodstream infection. J Mol Diagn 2024:S1525-1578(24)00128-4. [PMID: 38925458 DOI: 10.1016/j.jmoldx.2024.05.008] [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: 12/20/2023] [Revised: 05/05/2024] [Accepted: 05/17/2024] [Indexed: 06/28/2024] Open
Abstract
Bloodstream infection remains a major cause of morbidity and death worldwide. Timely and appropriate treatment can reduce mortality among critically ill patients. Current diagnostic methods are too slow to inform precise antibiotic choice leading to the prescription of empirical antibiotics which may fail to cover the resistance profile of the pathogen, risking poor patient outcomes. Additionally, overuse of broad-spectrum antibiotics may lead to more resistant organisms, putting further pressure on the dwindling pipeline of antibiotics, and risk transmission of these resistant organisms in the healthcare environment. Therefore, rapid diagnostics are urgently required to better inform antibiotic choice early in the course of treatment. Sequencing offers great promise in reducing time to microbiological diagnosis; however, the amount of host DNA compared to the pathogen in patient samples presents a significant obstacle. To address this, various host-depletion and bacterial-enrichment strategies have been utilized in samples such as saliva, urine or tissue. However, these methods have yet to be collectively integrated and/or extensively explored for rapid bloodstream infection diagnosis. While most of these workflows possess individual strengths, their lack of analytical/clinical sensitivity and/or comprehensiveness demands additional improvements or synergistic application. Therefore, this review provides a distinctive classification system for these methods based on their working principles to guide future research, discusses their strengths and limitations, and explores potential avenues for improvement.
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Affiliation(s)
| | - Kirstyn Brunker
- School of Biodiversity, One Health & Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom; MRC-University of Glasgow Centre for Virus Research, Glasgow, United Kingdom
| | - Katarina Oravcova
- School of Biodiversity, One Health & Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Paul Everest
- School of Biodiversity, One Health & Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Michael E Murphy
- Department of Microbiology, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom; School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Taya Forde
- School of Biodiversity, One Health & Veterinary Medicine, University of Glasgow, Glasgow, United Kingdom
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17
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Saget F, Maamar A, Esvan M, Gacouin A, Bouget J, Levrel V, Tadié JM, Soulat L, Reuter PG, Peschanski N, Laviolle B. Development and validation of a community acquired sepsis-worsening score in the adult emergency department: a prospective cohort: the CASC score. BMC Emerg Med 2024; 24:102. [PMID: 38902668 PMCID: PMC11188267 DOI: 10.1186/s12873-024-01021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Sepsis is a leading cause of death and serious illness that requires early recognition and therapeutic management to improve survival. The quick-SOFA score helps in its recognition, but its diagnostic performance is insufficient. To develop a score that can rapidly identify a community acquired septic situation at risk of clinical complications in patients consulting the emergency department (ED). METHODS We conducted a monocentric, prospective cohort study in the emergency department of a university hospital between March 2016 and August 2018 (NCT03280992). All patients admitted to the emergency department for a suspicion of a community-acquired infection were included. Predictor variables of progression to septic shock or death within the first 90 days were selected using backward stepwise multivariable logistic regression to develop a clinical score. Receiver operating characteristic (ROC) curves were constructed to determine the discriminating power of the area under the curve (AUC). We also determined the threshold of our score that optimized the performance required for a sepsis-worsening score. We have compared our score with the NEWS-2 and qSOFA scores. RESULTS Among the 21,826 patients admitted to the ED, 796 patients were suspected of having community-acquired infection and 461 met the sepsis criteria; therefore, these patients were included in the analysis. The median [interquartile range] age was 72 [54-84] years, 248 (54%) were males, and 244 (53%) had respiratory symptoms. The clinical score ranged from 0 to 90 and included 8 variables with an area under the ROC curve of 0.85 (confidence interval [CI] 95% 0.81-0.89). A cut-off of 26 yields a sensitivity of 88% (CI 95% 0.79-0.93), a specificity of 62% (CI 95% 57-67), and a negative predictive value of 95% (CI 95% 91-97). The area under the ROC curve for our score was 0.85 (95% CI, 0.81-0.89) versus 0.73 (95% CI, 0.68-0.78) for qSOFA and 0.66 (95% CI, 0.60-0.72) for NEWS-2. CONCLUSIONS Our study provides an accurate clinical score for identifying septic patients consulting the ED early at risk of worsening disease. This score could be implemented at admission.
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Affiliation(s)
- François Saget
- Univ Rennes, CHU Rennes, service SAMU 35 / SMUR / Urgences Adultes, Rennes, F-35000, France.
- Univ Rennes, CHU Rennes, Inserm, CIC, Centre d'investigation Clinique de Rennes (CIC1414), Service de Pharmacologie Clinique, Rennes, F-35000, France.
| | - Adel Maamar
- Service de Maladies Infectieuses et Réanimation Médicale, Häpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033 Rennes cedex 9, Rennes, France
| | - Maxime Esvan
- Univ Rennes, CHU Rennes, Inserm, CIC, Centre d'investigation Clinique de Rennes (CIC1414), Service de Pharmacologie Clinique, Rennes, F-35000, France
| | - Arnaud Gacouin
- Service de Maladies Infectieuses et Réanimation Médicale, Häpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033 Rennes cedex 9, Rennes, France
| | - Jacques Bouget
- Univ Rennes, CHU Rennes, service SAMU 35 / SMUR / Urgences Adultes, Rennes, F-35000, France
| | - Vincent Levrel
- Univ Rennes, CHU Rennes, service SAMU 35 / SMUR / Urgences Adultes, Rennes, F-35000, France
| | - Jean-Marc Tadié
- Univ Rennes, CHU Rennes, Inserm, CIC, Centre d'investigation Clinique de Rennes (CIC1414), Service de Pharmacologie Clinique, Rennes, F-35000, France
- Service de Maladies Infectieuses et Réanimation Médicale, Häpital Pontchaillou, Université de Rennes 1, 2, rue Henri Le Guilloux, 35033 Rennes cedex 9, Rennes, France
| | - Louis Soulat
- Univ Rennes, CHU Rennes, service SAMU 35 / SMUR / Urgences Adultes, Rennes, F-35000, France
| | - Paul Georges Reuter
- Univ Rennes, CHU Rennes, service SAMU 35 / SMUR / Urgences Adultes, Rennes, F-35000, France
| | - Nicolas Peschanski
- Univ Rennes, CHU Rennes, service SAMU 35 / SMUR / Urgences Adultes, Rennes, F-35000, France
| | - Bruno Laviolle
- Univ Rennes, CHU Rennes, Inserm, CIC, Centre d'investigation Clinique de Rennes (CIC1414), Service de Pharmacologie Clinique, Rennes, F-35000, France
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18
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Papadimitriou-Olivgeris M, Senn L, Jacot D, Guery B. Predictors of mortality of Pseudomonas aeruginosa bacteraemia and the role of infectious diseases consultation and source control; a retrospective cohort study. Infection 2024:10.1007/s15010-024-02326-6. [PMID: 38900392 DOI: 10.1007/s15010-024-02326-6] [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: 04/22/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE To determine predictors of mortality among patients with Pseudomonas aeruginosa bacteraemia. METHODS Retrospective study. SETTING This study conducted at the Lausanne University Hospital, Switzerland included adult patients with P. aeruginosa bacteraemia from 2015 to 2021. RESULTS During the study period, 278 episodes of P. aeruginosa bacteraemia were included. Twenty (7%) isolates were multidrug-resistant. The most common type of infection was low respiratory tract infection (58 episodes; 21%). Sepsis was present in the majority of episodes (152; 55%). Infectious diseases consultation within 48 h of bacteraemia onset was performed in 203 (73%) episodes. Appropriate antimicrobial treatment was administered within 48 h in 257 (92%) episodes. For most episodes (145; 52%), source control was considered necessary, with 93 (64%) of them undergoing such interventions within 48 h. The 14-day mortality was 15% (42 episodes). The Cox multivariable regression model showed that 14-day mortality was associated with sepsis (P 0.002; aHR 6.58, CI 1.95-22.16), and lower respiratory tract infection (P < 0.001; aHR 4.63, CI 1.78-12.06). Conversely, interventions performed within 48 h of bacteraemia onset, such as infectious diseases consultation (P 0.036; HR 0.51, CI 0.27-0.96), and source control (P 0.009; aHR 0.17, CI 0.47-0.64) were associated with improved outcome. CONCLUSION Our findings underscore the pivotal role of early infectious diseases consultation in recommending source control interventions and guiding antimicrobial treatment for patients with P. aeruginosa bacteraemia.
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Affiliation(s)
- Matthaios Papadimitriou-Olivgeris
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland.
- Infection Prevention and Control Unit, Lausanne University Hospital, Lausanne, Switzerland.
- Infectious Diseases Service, Cantonal Hospital of Sion and Institut Central des Hôpitaux (ICH), Sion, 1951, Switzerland.
| | - Laurence Senn
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
- Infection Prevention and Control Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Damien Jacot
- Institute of Microbiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Benoit Guery
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
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19
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Tićac M, Grubić Kezele T, Bubonja Šonje M. Impact of Appropriate Empirical Antibiotic Treatment on the Clinical Response of Septic Patients in Intensive Care Unit: A Single-Center Observational Study. Antibiotics (Basel) 2024; 13:569. [PMID: 38927235 PMCID: PMC11201024 DOI: 10.3390/antibiotics13060569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
The appropriate antibiotic treatment of patients with bacterial sepsis in the intensive care unit (ICU) remains a challenge. Considering that current international guidelines recommend 7 days of antibiotic therapy as sufficient for most severe infections, our primary outcome was a comparison of clinical response to initial empirical therapy on day 7 and mortality between two groups of septic patients-with appropriate (AEAT) and inappropriate (IEAT) empirical antibiotic therapy according to the in vitro sensitivity of bacteria detected in a blood culture (BC). Adult patients admitted to the ICU between 2020 and 2023, who were diagnosed with sepsis according to the Sequential Organ Failure Assessment (SOFA) score ≥ 2 in association with a suspected or documented infection, were selected for the study. Of the 418 patients, 149 (35.6%) died within 7 days. Although the AEAT group had a lower mortality rate (30.3% vs. 34.2%) and better clinical improvement (52.8% vs. 47.4%) on day 7 after starting empirical antibiotic therapy, there was no significant difference. A causative organism was isolated from BCs in 30% of septic patients, with gram-negative bacteria (GNB) predominating in 60% of cases, and multidrug-resistant (MDR) or extensively drug-resistant (XDR) bacteria predominantly detected in the BCs of the IEAT group. Although the AEAT group had slightly worse clinical characteristics at the onset of sepsis than the IEAT group, the AEAT group showed faster improvement on days 7 and 14 of sepsis. In this retrospective cross-sectional study, the AEAT group was associated with better clinical response at day 7 after sepsis onset and lower mortality, but without a significant difference. Comorbidities and the type of bacterial pathogen should also be taken into account as they can also contribute to the prediction of the final outcome. These results demonstrate the importance of daily assessment of clinical factors to more accurately predict the clinical outcome of a septic patient.
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Affiliation(s)
- Mateo Tićac
- Department of Anesthesiology and Intensive Care, Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
- Department of Anesthesiology, Reanimatology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Tanja Grubić Kezele
- Department of Clinical Microbiology, Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Marina Bubonja Šonje
- Department of Clinical Microbiology, Clinical Hospital Center Rijeka, 51000 Rijeka, Croatia;
- Department of Microbiology and Parasitology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
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20
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Shigihara S, Shirakabe A, Matsushita M, Nishigoori S, Sawatani T, Tani K, Kiuchi K, Toguchi R, Kawakami S, Michiura Y, Sawahata M, Kobayashi N, Asai K. Ten-year trends in non-surgical patients requiring intensive care: Long-term prognostic differences by year of admission. J Cardiol 2024:S0914-5087(24)00109-6. [PMID: 38901474 DOI: 10.1016/j.jjcc.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/17/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The aim of the present study is to elucidate prognostic impact of temporal trends of non-surgical patients requiring intensive care over a 10-year period. METHODS AND RESULTS A total of 4276 non-surgical patients requiring intensive care from 2012 to 2021 were enrolled. Patients' backgrounds, in-hospital management, and prognoses were compared between five groups [2012-2013 (n = 825), 2014-2015 (n = 784), 2016-2017 (n = 864), 2018-2019 (n = 939), and 2020-2021 (n = 867)]. During the study period, mean age significantly increased from 69 years in 2012-2013 to 72 years in 2020-2021. Mean Acute Physiology and Chronic Health Evaluation scores significantly increased from 10 points in 2012-2013 to 12 points in 2020-2021. The median duration of intensive care unit stays increased from 3 to 4 days. Kaplan-Meier survival curve analysis showed that survival rates during 30- and 365-days were significantly lower in 2020-2021 than in 2012-2013, but it was not significantly different by a Cox proportional hazards regression model in 30 days. A Cox proportional hazards regression model revealed that the risks of 365-day all-cause death were significantly higher in patients enrolled in 2016-2017 (HR: 1.324, 95 % CI: 1.042-1.680, p = 0.021), in 2018-2019 (HR: 1.329, 95 % CI: 1.044-1.691, p = 0.021), and in 2020-2021 (HR: 1.409, 95 % CI: 1.115-1.779, p = 0.004). CONCLUSION The condition of patients requiring intensive care is becoming more critical year by year, leading to poorer long-term prognoses despite improvements in treatment strategies. These findings emphasize the importance of additional care management after admission into non-surgical intensive care units, particularly for the aging society of Japan.
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Affiliation(s)
- Shota Shigihara
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Akihiro Shirakabe
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan.
| | - Masato Matsushita
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Suguru Nishigoori
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Tomofumi Sawatani
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Kenichi Tani
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Kazutaka Kiuchi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Riku Toguchi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Shohei Kawakami
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Yu Michiura
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Mana Sawahata
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Nobuaki Kobayashi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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21
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Sisto UG, Di Bella S, Porta E, Franzoi G, Cominotto F, Guzzardi E, Artusi N, Giudice CA, Dal Bo E, Collot N, Sirianni F, Russo S, Sanson G. Predicting sepsis at emergency department triage: Implementing clinical and laboratory markers within the first nursing assessment to enhance diagnostic accuracy. J Nurs Scholarsh 2024. [PMID: 38886920 DOI: 10.1111/jnu.13002] [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: 04/08/2024] [Revised: 05/27/2024] [Accepted: 06/06/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Early identification of sepsis in the emergency department (ED) triage is both valuable and challenging. Numerous studies have endeavored to pinpoint clinical and biochemical criteria to assist clinicians in the prompt diagnosis of sepsis, but few studies have assessed the efficacy of these criteria in the ED triage setting. The aim of the study was to explore the accuracy of clinical and laboratory markers evaluated at the triage level in identifying patients with sepsis. METHODS A prospective study was conducted in a large academic urban hospital, implementing a triage protocol aimed at early identification of septic patients based on clinical and laboratory markers. A multidisciplinary panel of experts reviewed cases to ensure accurate identification of septic patients. Variables analyzed included: Charlson comorbidity index, mean arterial pressure (MAP), partial pressure of carbon dioxide (PetCO2), white cell count, eosinophil count, C-reactive protein to albumin ratio, procalcitonin, and lactate. RESULTS A total of 235 patients were included. Multivariable analysis identified procalcitonin ≥1 ng/mL (OR 5.2; p < 0.001); CRP-to-albumin ratio ≥32 (OR 6.6; p < 0.001); PetCO2 ≤ 28 mmHg (OR 2.7; p = 0.031), and MAP <85 mmHg (OR 7.5; p < 0.001) as independent predictors for sepsis. MAP ≥85 mmHg, CRP/albumin ratio <32, and procalcitonin <1 ng/mL demonstrated negative predictive values for sepsis of 90%, 89%, and 88%, respectively. CONCLUSIONS Our study underscores the significance of procalcitonin and mean arterial pressure, while introducing CRP/albumin ratio and PetCO2 as important variables to consider in the very initial assessment of patients with suspected sepsis in the ED. CLINICAL RELEVANCE Early identification of sepsis since the emergency department (ED) triage is challenging Implementing the ED triage protocol with simple clinical and laboratory markers allows to recognize patients with sepsis with a very good discriminatory power (AUC 0.88).
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Affiliation(s)
- Ugo Giulio Sisto
- Emergency Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
- Infectious Diseases Unit, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Elisa Porta
- Clinical Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Giorgia Franzoi
- Clinical Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Franco Cominotto
- Emergency Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Elena Guzzardi
- Emergency Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Nicola Artusi
- Emergency Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Caterina Anna Giudice
- Emergency Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Eugenia Dal Bo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Nicholas Collot
- Clinical Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Francesca Sirianni
- Medicine of Services Department, Clinical Analysis Laboratory, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Savino Russo
- Emergency Medicine Department, Azienda Sanitaria Friuli Centrale, Palmanova, Italy
| | - Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
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22
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McDonald R, Watchorn J, Mehta R, Ostermann M, Hutchings S. The REPERFUSE study protocol: The effects of vasopressor therapy on renal perfusion in patients with septic shock-A mechanistically focused randomised control trial. PLoS One 2024; 19:e0304227. [PMID: 38870103 PMCID: PMC11175393 DOI: 10.1371/journal.pone.0304227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/06/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is a common complication of septic shock and together these conditions carry a high mortality risk. In septic patients who develop severe AKI, renal cortical perfusion is deficient despite normal macrovascular organ blood flow. This intra-renal perfusion abnormality may be amenable to pharmacological manipulation, which may offer mechanistic insight into the pathophysiology of septic AKI. The aim of the current study is to investigate the effects of vasopressin and angiotensin II on renal microcirculatory perfusion in a cohort of patients with septic shock. METHODS AND ANALYSIS In this single centre, mechanistically focussed, randomised controlled study, 45 patients with septic shock will be randomly allocated to either of the study vasopressors (vasopressin or angiotensin II) or standard therapy (norepinephrine). Infusions will be titrated to maintain a mean arterial pressure (MAP) target set by the attending clinician. Renal microcirculatory assessment will be performed for the cortex and medulla using contrast-enhanced ultrasound (CEUS) and urinary oxygen tension (pO2), respectively. Renal macrovascular flow will be assessed via renal artery ultrasound. Measurement of systemic macrovascular flow will be performed through transthoracic echocardiography (TTE) and microvascular flow via sublingual incident dark field (IDF) video microscopy. Measures will be taken at baseline, +1 and +24hrs following infusion of the study drug commencing. Blood and urine samples will also be collected at the measurement time points. Longitudinal data will be compared between groups and over time. DISCUSSION Vasopressors are integral to the management of patients with septic shock. This study aims to further understanding of the relationship between this therapy, renal perfusion and the development of AKI. In addition, using CEUS and urinary pO2, we hope to build a more complete picture of renal perfusion in septic shock by interrogation of the constituent parts of the kidney. Results will be published in peer-reviewed journals and presented at academic meetings. TRIAL REGISTRATION The REPERFUSE study was registered on Clinical Trials.gov (NCT06234592) on the 30th Jan 24.
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Affiliation(s)
- Rory McDonald
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
- Academic Department of Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom
- Department of Critical Care, King’s College Hospital, London, United Kingdom
| | - James Watchorn
- Academic Department of Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Reena Mehta
- Department of Critical Care, King’s College Hospital, London, United Kingdom
- Pharmacy Department, King’s College Hospital, London, United Kingdom
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, United Kingdom
| | - Marlies Ostermann
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
- Department of Critical Care, Guy’s & St Thomas’ Hospital, London, United Kingdom
| | - Sam Hutchings
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
- Academic Department of Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom
- Department of Critical Care, King’s College Hospital, London, United Kingdom
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23
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Ishii J, Nishikimi M, De Bus L, De Waele J, Takaba A, Kuriyama A, Kobayashi A, Tanaka C, Hashi H, Hashimoto H, Nashiki H, Shibata M, Kanamoto M, Inoue M, Hashimoto S, Katayama S, Fujiwara S, Kameda S, Shindo S, Komuro T, Kawagishi T, Kawano Y, Fujita Y, Kida Y, Hara Y, Yoshida H, Fujitani S, Shime N. No improvement in mortality among critically ill patients with carbapenems as initial empirical therapy and more detection of multi-drug resistant pathogens associated with longer use: a post hoc analysis of a prospective cohort study. Microbiol Spectr 2024:e0034224. [PMID: 38864641 DOI: 10.1128/spectrum.00342-24] [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: 02/16/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024] Open
Abstract
Whether empirical therapy with carbapenems positively affects the outcomes of critically ill patients with bacterial infections remains unclear. This study aimed to investigate whether the use of carbapenems as the initial antimicrobial administration reduces mortality and whether the duration of carbapenem use affects the detection of multidrug-resistant (MDR) pathogens. This was a post hoc analysis of data acquired from Japanese participating sites from a multicenter, prospective observational study [Determinants of Antimicrobial Use and De-escalation in Critical Care (DIANA study)]. A total of 268 adult patients with clinically suspected or confirmed bacterial infections from 31 Japanese intensive care units (ICUs) were analyzed. The patients were divided into two groups: patients who were administered carbapenems as initial antimicrobials (initial carbapenem group, n = 99) and those who were not administered carbapenems (initial non-carbapenem group, n = 169). The primary outcomes were mortality at day 28 and detection of MDR pathogens. Multivariate logistic regression analysis revealed that mortality at day 28 did not differ between the two groups [18 (18%) vs 27 (16%), respectively; odds ratio: 1.25 (95% confidence interval (CI): 0.59-2.65), P = 0.564]. The subdistribution hazard ratio for detecting MDR pathogens on day 28 per additional day of carbapenem use is 1.08 (95% CI: 1.05-1.13, P < 0.001 using the Fine-Gray model with death regarded as a competing event). In conclusion, in-hospital mortality was similar between the groups, and a longer duration of carbapenem use as the initial antimicrobial therapy resulted in a higher risk of detection of new MDR pathogens.IMPORTANCEWe found no statistical difference in mortality with the empirical use of carbapenems as initial antimicrobial therapy among critically ill patients with bacterial infections. Our study revealed a lower proportion of inappropriate initial antimicrobial administrations than those reported in previous studies. This result suggests the importance of appropriate risk assessment for the involvement of multidrug-resistant (MDR) pathogens and the selection of suitable antibiotics based on risk. To the best of our knowledge, this study is the first to demonstrate that a longer duration of carbapenem use as initial therapy is associated with a higher risk of subsequent detection of MDR pathogens. This finding underscores the importance of efforts to minimize the duration of carbapenem use as initial antimicrobial therapy when it is necessary.
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Affiliation(s)
- Junki Ishii
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Mitsuaki Nishikimi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Liesbet De Bus
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jan De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | | | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | | | - Chie Tanaka
- Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Hideki Hashi
- Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | | | | | - Mami Shibata
- Department of Emergency and Critical Care Medicine, Wakayama Medical University Hospital, Wakayama, Japan
| | - Masafumi Kanamoto
- Department of Anesthesiology, Gunma Prefectural Cardiovascular Center, , Gunma, Japan
| | - Masashi Inoue
- Department of Anesthesiology, Nagoya City University Hospital, Aichi, Japan
| | - Satoru Hashimoto
- Non-Profit Organization ICU Collaboration Network (ICON), Tokyo, Japan
| | - Shinshu Katayama
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | | | - Shinya Kameda
- Jikei University School of Medicine Hospital, Tokyo, Japan
| | | | - Tetsuya Komuro
- Department of General Internal Medicine, TMG Muneoka Central Hospital, Saitama, Japan
| | | | | | | | - Yoshiko Kida
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuya Hara
- Yodogawa Christian Hospital, Osaka, Japan
| | - Hideki Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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24
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Brady RE, Giordullo EL, Harvey CA, Krabacher ND, Penick AM. Intravenous push antibiotics in the emergency department: Education and implementation. Am J Health Syst Pharm 2024; 81:531-538. [PMID: 38373159 DOI: 10.1093/ajhp/zxae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Indexed: 02/21/2024] Open
Abstract
PURPOSE Intravenous push antibiotics can serve as an alternative to intravenous piggyback antibiotics while providing the same pharmacodynamics and adverse effect profile, easing shortage pressures and decreasing order to administration time, as well as representing a potential cost savings. The purpose of this study was to determine whether intravenous push antibiotics could decrease the time from an order to the start of administration compared to piggyback antibiotics in emergency departments. This study also measured the cost savings of antibiotic preparation and administration and assessed nursing satisfaction when using intravenous push antibiotics. METHODS Sample instances of use of intravenous push and piggyback antibiotics were identified. Patients were included if they were 18 years of age or older and received at least a single dose of intravenous push or piggyback ceftriaxone, cefepime, cefazolin, or meropenem in one of the institution's emergency departments. The primary outcome of the study was to compare the time from the order to the start of administration of intravenous push vs piggyback antibiotics. The secondary outcome was to compare the cost of antibiotic preparation for the 2 methods. RESULTS The intravenous push and piggyback groups each had 43 patients. The time from the order to the start of administration decreased from 74 (interquartile range, 29-114) minutes in the piggyback group to 31 (interquartile range, 21-52) minutes in the push group (P = 0.003). When the estimated monthly cost savings for ceftriaxone, cefepime, and meropenem were added together, across the emergency departments, an estimated $227,930.88 is saved per year when using intravenous push antibiotics. CONCLUSION Intravenous push antibiotics decrease the time from ordering to the start of administration and result in significant cost savings.
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Affiliation(s)
- Rachel E Brady
- Department of Pharmacy, St. Elizabeth Healthcare, Edgewood, KY, USA
| | | | - Charles A Harvey
- Department of Pharmacy, St. Elizabeth Healthcare, Edgewood, KY, USA
| | | | - Alyssa M Penick
- Department of Pharmacy, St. Elizabeth Healthcare, Edgewood, KY, USA
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25
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Kelley M, Spooneybarger C, Howard M, Reinert J, Churchwell MD, Baki G. Physical compatibility of ceftriaxone and cefepime in 0.45% sodium chloride, Ringer's lactate solution, and Plasma-Lyte A. Eur J Hosp Pharm 2024:ejhpharm-2024-004128. [PMID: 38862193 DOI: 10.1136/ejhpharm-2024-004128] [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: 02/06/2024] [Accepted: 06/04/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVES The compatibility of intravenous fluids with medications is of paramount concern to pharmacists and is an imperative component of ensuring patient safety. Data regarding the physical compatibility of medications with intravenous fluids has not been examined, or published with conflicting results or the concentrations studied were not consistent with current practice. Our objective was to determine the physical compatibility of ceftriaxone and cefepime in 0.45% sodium chloride, Ringer's lactate solution, and Plasma-Lyte A. METHODS An in vitro analysis of the physical compatibility of ceftriaxone and cefepime at 10 mg/mL, 20 mg/mL, and 40 mg/mL concentrations was conducted in 0.45% sodium chloride, Ringer's lactate solution, and Plasma-Lyte A. Admixtures were evaluated in triplicate at hours 0, 1, 5, 8, and 24. Physical compatibility was assessed by visual inspection, spectrophotometry, and pH analysis. RESULTS Ceftriaxone 40 mg/mL was found to be physically incompatible in 0.45% sodium chloride and Ringer's lactate solution beyond 5 hours and in Plasma-Lyte A beyond 8 hours. Cefepime was found to be physically incompatible with all fluids and in all concentrations beyond 1 hour. CONCLUSIONS This work contributes to the body of literature dedicated to the evaluation of intravenous drug and fluid physical compatibility by identifying demonstrable changes in admixtures containing 0.45% sodium chloride, Plasma-Lyte A, and Ringer's lactate solution. Ceftriaxone should not be administered with 0.45% sodium chloride, Ringer's lactated solution, or Plasma-Lyte A at selected concentrations and time points and cefepime is not considered to be physically compatible at 10 mg/mL, 20 mg/mL, or 40 mg/mL in any of the studied fluids beyond 1 hour.
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Affiliation(s)
- Megan Kelley
- The University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Chloe Spooneybarger
- The University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Mitchell Howard
- The University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Justin Reinert
- The University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Mariann D Churchwell
- Pharmacy Practice, The University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Gabriella Baki
- The University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
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26
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Zuo L, Li X, Wang L, Yuan H, Liao Z, Zhou S, Wu J, Guan X, Liu Y. Heparin-binding protein as a biomarker for the diagnosis of sepsis in the intensive care unit: a retrospective cross-sectional study in China. BMJ Open 2024; 14:e078687. [PMID: 38858136 PMCID: PMC11168158 DOI: 10.1136/bmjopen-2023-078687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 05/28/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES This study aims to investigate the diagnostic value of heparin-binding protein (HBP) in sepsis and develop a sepsis diagnostic model incorporating HBP with key biomarkers and disease-related scores for rapid, and accurate diagnosis of sepsis in the intensive care unit (ICU). DESIGN Clinical retrospective cross-sectional study. SETTING A comprehensive teaching tertiary hospital in China. PARTICIPANTS Adult patients (aged ≥18 years) who underwent HBP testing or whose blood samples were collected when admitted to the ICU. MAIN OUTCOME MEASURES HBP, C reactive protein (CRP), procalcitonin (PCT), white blood cell count (WBC), interleukin-6 (IL-6), lactate (LAC), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) score were recorded. RESULTS Between March 2019 and December 2021, 326 patients were enrolled in this study. The patients were categorised into a non-infection group (control group), infection group, sepsis group and septic shock group based on the final diagnosis. The HBP levels in the sepsis group and septic shock group were 45.7 and 69.0 ng/mL, respectively, which were significantly higher than those in the control group (18.0 ng/mL) and infection group (24.0 ng/mL) (p<0.001). The area under the curve (AUC) value of HBP for diagnosing sepsis was 0.733, which was lower than those corresponding to PCT, CRP and SOFA but higher than those of IL-6, LAC and APACHE II. Multivariate logistic regression analysis identified HBP, PCT, CRP, IL-6 and SOFA as valuable indicators for diagnosing sepsis. A sepsis diagnostic model was constructed based on these indicators, with an AUC of 0.901, a sensitivity of 79.7% and a specificity of 86.9%. CONCLUSIONS HBP could serve as a biomarker for the diagnosis of sepsis in the ICU. Compared with single indicators, the sepsis diagnostic model constructed using HBP, PCT, CRP, IL-6 and SOFA further enhanced the diagnostic performance of sepsis.
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Affiliation(s)
- Lingyun Zuo
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoyun Li
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Luhao Wang
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hao Yuan
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zihuai Liao
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Si Zhou
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jianfeng Wu
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiangdong Guan
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongjun Liu
- Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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27
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Sartelli M, Barie P, Agnoletti V, Al-Hasan MN, Ansaloni L, Biffl W, Buonomo L, Blot S, Cheadle WG, Coimbra R, De Simone B, Duane TM, Fugazzola P, Giamarellou H, Hardcastle TC, Hecker A, Inaba K, Kirkpatrick AW, Labricciosa FM, Leone M, Martin-Loeches I, Maier RV, Marwah S, Maves RC, Mingoli A, Montravers P, Ordóñez CA, Palmieri M, Podda M, Rello J, Sawyer RG, Sganga G, Tattevin P, Thapaliya D, Tessier J, Tolonen M, Ulrych J, Vallicelli C, Watkins RR, Catena F, Coccolini F. Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery. World J Emerg Surg 2024; 19:22. [PMID: 38851700 PMCID: PMC11161965 DOI: 10.1186/s13017-024-00552-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/01/2024] [Indexed: 06/10/2024] Open
Abstract
Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62100, Italy.
| | - Philip Barie
- Department of Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
| | - Majdi N Al-Hasan
- Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, SC, USA
| | - Luca Ansaloni
- Department of General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Luis Buonomo
- Emergency, Urgency and Trauma Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Stijn Blot
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - William G Cheadle
- Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC - Riverside University Health System, Moreno Valley, CA, USA
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | | | | | - Paola Fugazzola
- Department of General and Emergency Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Helen Giamarellou
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Timothy C Hardcastle
- Department of Surgical Sciences, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, and Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Andrew W Kirkpatrick
- Department of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | | | - Marc Leone
- Department of Anaesthesia and Intensive Care Unit, AP-HM, Aix-Marseille University, North Hospital, Marseille, France
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation, St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
- Centro de Investigacion Biomedica En Red Entermedades Respiratorias, Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Ronald V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Sanjay Marwah
- Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Ryan C Maves
- Section of Infectious Diseases, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Philippe Montravers
- Anesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP, Université Paris Cité, Paris, France
| | - Carlos A Ordóñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Miriam Palmieri
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, Macerata, 62100, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Jordi Rello
- Global Health eCore, Vall d'Hebron University Hospital Campus, Barcelona, 08035, Spain
- Medicine Department, Universitat Internacional de Catalunya, Sant Cugat del Valles, Spain
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierre Tattevin
- Infectious Disease and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | | | - Jeffrey Tessier
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matti Tolonen
- Emergency Surgery department, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, Helsinki, Finland
| | - Jan Ulrych
- First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Carlo Vallicelli
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Richard R Watkins
- Department of Medicine, Division of Infectious Diseases, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Fausto Catena
- Emergency and General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, Pisa, Italy
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Triebwasser JE, Davies JK, Nestani A. COVID-19 therapeutics for the pregnant patient. Semin Perinatol 2024:151920. [PMID: 38866675 DOI: 10.1016/j.semperi.2024.151920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
SARS-CoV-2 infection can cause severe disease among pregnant persons. Pregnant persons were not included in initial studies of therapeutics for COVID-19, but cumulative experience demonstrates that most are safe for pregnant persons and the fetus, and effective for prevention or treatment of severe COVID-19.
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Affiliation(s)
- Jourdan E Triebwasser
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, United States.
| | - Jill K Davies
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, United States
| | - Ajleeta Nestani
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, United States
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Teshome BF, Park T, Arackal J, Hampton N, Kollef MH, Micek ST. Preventing New Gram-negative Resistance Through Beta-lactam De-escalation in Hospitalized Patients With Sepsis: A Retrospective Cohort Study. Clin Infect Dis 2024:ciae253. [PMID: 38842541 DOI: 10.1093/cid/ciae253] [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: 03/07/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Whether antibiotic de-escalation reduces the risk of subsequent antibiotic resistance is uncertain. We sought to determine if beta-lactam (BL) antibiotic de-escalation is associated with decreased incidence of new Gram-negative resistance in hospitalized patients with sepsis. METHODS In a retrospective cohort study, patients with sepsis who were treated with at least 3 consecutive days of BL antibiotics, the first 2 days of which were with a broad-spectrum BL agent defined as a spectrum score (SS) of ≥7 were enrolled. Patients were grouped into three categories: (1) de-escalation of beta-lactam spectrum score (BLSS), (2) no change in BLSS, or (3) escalation of BLSS. The primary outcome was the isolation of a new drug-resistant Gram-negative bacteria from a clinical culture within 60 days of cohort entry. Fine-Gray proportional hazards regression modeling while accounting for in-hospital death as a competing risk was performed. FINDINGS Six hundred forty-four patients of 7742 (8.3%) patients developed new gram-negative resistance. The mean time to resistance was 23.7 days yielding an incidence rate of 1.85 (95% confidence interval [CI]: 1.71-2.00) per 1000 patient-days. The lowest incidence rate was observed in the de-escalated group 1.42 (95% CI: 1.16-1.68) per 1000 patient-days. Statistically significant reductions in the development of new gram-negative resistance were associated with BL de-escalation compared to no-change (hazards ratio (HR) 0.59 [95% CI: .48-.73]). CONCLUSIONS De-escalation was associated with a decreased risk of new resistance development compared to no change. This represents the largest study to date showing the utility of de-escalation in the prevention of antimicrobial resistance.
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Affiliation(s)
- Besu F Teshome
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
| | - Taehwan Park
- College of Pharmacy and Health Sciences, St. John's University, Queens, New York, USA
| | - Joel Arackal
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC Healthcare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott T Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
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Byrd TF, Phelan TA, Ingraham NE, Langworthy BW, Bhasin A, Kc A, Melton-Meaux GB, Tignanelli CJ. Beyond Unplanned ICU Transfers: Linking a Revised Definition of Deterioration to Patient Outcomes. Crit Care Med 2024:00003246-990000000-00339. [PMID: 38832836 DOI: 10.1097/ccm.0000000000006333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES To develop an electronic descriptor of clinical deterioration for hospitalized patients that predicts short-term mortality and identifies patient deterioration earlier than current standard definitions. DESIGN A retrospective study using exploratory record review, quantitative analysis, and regression analyses. SETTING Twelve-hospital community-academic health system. PATIENTS All adult patients with an acute hospital encounter between January 1, 2018, and December 31, 2022. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Clinical trigger events were selected and used to create a revised electronic definition of deterioration, encompassing signals of respiratory failure, bleeding, and hypotension occurring in proximity to ICU transfer. Patients meeting the revised definition were 12.5 times more likely to die within 7 days (adjusted odds ratio 12.5; 95% CI, 8.9-17.4) and had a 95.3% longer length of stay (95% CI, 88.6-102.3%) compared with those who were transferred to the ICU or died regardless of meeting the revised definition. Among the 1812 patients who met the revised definition of deterioration before ICU transfer (52.4%), the median detection time was 157.0 min earlier (interquartile range 64.0-363.5 min). CONCLUSIONS The revised definition of deterioration establishes an electronic descriptor of clinical deterioration that is strongly associated with short-term mortality and length of stay and identifies deterioration over 2.5 hours earlier than ICU transfer. Incorporating the revised definition of deterioration into the training and validation of early warning system algorithms may enhance their timeliness and clinical accuracy.
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Affiliation(s)
- Thomas F Byrd
- Division of Hospital Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, MN
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN
| | | | - Nicholas E Ingraham
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, MN
- Division of Pulmonary and Critical Care, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Benjamin W Langworthy
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN
| | - Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Abhinab Kc
- University of Minnesota Medical School, Minneapolis, MN
| | - Genevieve B Melton-Meaux
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, MN
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Christopher J Tignanelli
- Center for Learning Health System Sciences, University of Minnesota, Minneapolis, MN
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN
- Division of Acute Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN
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Kang AY, Elkomos M, Pham D, Guerrero M, Kupferwasser D, Miller LG. Effectiveness of empiric carbapenem versus non-carbapenem therapy for extended-spectrum β-lactamase producing Enterobacterales infections in non-intensive care unit patients: a real-world investigation in a hospital with high-prevalence of extended-spectrum β-lactamase producing Enterobacterales. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e100. [PMID: 38836043 PMCID: PMC11149041 DOI: 10.1017/ash.2024.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/18/2024] [Accepted: 04/20/2024] [Indexed: 06/06/2024]
Abstract
Objective To investigate whether empiric carbapenem therapy, compared to empiric non-carbapenem therapy, was associated with improved clinical outcomes among hospitalized, non-intensive care unit (ICU) patients with extended-spectrum β-lactamase (ESBL)-producing Enterobacterales infections. Methods We performed a retrospective cohort study of adult, non-ICU patients admitted with ESBL-producing Enterobacterales infections. Primary outcome was time to clinical stability from the first empiric antibiotic dose. Secondary outcomes were early clinical response and 30-day all-cause hospital readmission. We used multivariate regression methods to examine time to clinical stability. Results Of the 142 patients, 59 (42%) received empiric carbapenems and 83 (58%) received empiric non-carbapenems, most commonly ceftriaxone (49/83, 59%). Median age was 59 years. The most common infection source was urinary (71%). The carbapenem group had a higher proportion of patients who received antibiotics within 6 months of admission (55% vs 28%, P < .01) and history of ESBL (57% vs 17%, P < .01). There were no significant differences in hours until clinical stability between the carbapenem and non-carbapenem groups (22 (IQR: 0, 85) vs 19 (IQR: 0, 69), P = .54). Early clinical response (88% vs 90%, P = .79) and 30-day all-cause hospital readmission (17% vs 8%, P = .13) were similar between groups. Conclusion Among hospitalized non-ICU patients with ESBL-producing Enterobacterales infection, we found no difference in time to clinical stability after the first empiric antibiotic dose between those receiving carbapenems and those who did not. Our data suggest that empiric carbapenem use may not be an important driver of clinical response in patients with less severe ESBL-producing Enterobacterales infection.
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Affiliation(s)
- Amy Y Kang
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA, USA
- Department of Pharmacy, Harbor-UCLA Medical Center, Torrance, CA, USA
- Division of Infectious Diseases, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Mary Elkomos
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA, USA
| | - Danny Pham
- Department of Pharmacy, University of California Irvine Health, Orange, CA, USA
| | - Michelle Guerrero
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Deborah Kupferwasser
- Division of Infectious Diseases, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Loren G Miller
- Division of Infectious Diseases, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Division of Infectious Diseases, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
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Angus DC, Huang AJ, Lewis RJ, Abernethy AP, Califf RM, Landray M, Kass N, Bibbins-Domingo K. The Integration of Clinical Trials With the Practice of Medicine: Repairing a House Divided. JAMA 2024:2819411. [PMID: 38829654 DOI: 10.1001/jama.2024.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Importance Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine's ability to best serve society. Observations In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale. Conclusions and Relevance The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation-the clinical trials and health care delivery enterprises-operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.
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Affiliation(s)
- Derek C Angus
- JAMA , Chicago, Illinois
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania
| | | | - Roger J Lewis
- JAMA , Chicago, Illinois
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amy P Abernethy
- Verily Life Sciences, San Francisco, California
- Now with Highlander Health, Dallas, Texas
| | | | - Martin Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Protas, Manchester, United Kingdom
| | - Nancy Kass
- Johns Hopkins University, Baltimore, Maryland
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Rhee C, Chen T, Kadri SS, Lawandi A, Yek C, Walker M, Warner S, Fram D, Chen HC, Shappell CN, DelloStritto L, Klompas M. Trends in Empiric Broad-Spectrum Antibiotic Use for Suspected Community-Onset Sepsis in US Hospitals. JAMA Netw Open 2024; 7:e2418923. [PMID: 38935374 PMCID: PMC11211962 DOI: 10.1001/jamanetworkopen.2024.18923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/25/2024] [Indexed: 06/28/2024] Open
Abstract
Importance Little is known about the degree to which suspected sepsis drives broad-spectrum antibiotic use in hospitals, what proportion of antibiotic courses are unnecessarily broad in retrospect, and whether these patterns are changing over time. Objective To describe trends in empiric broad-spectrum antibiotic use for suspected community-onset sepsis. Design, Setting, and Participants This cross-sectional study used clinical data from adults admitted to 241 US hospitals in the PINC AI Healthcare Database. Eligible participants were aged 18 years or more and were admitted between 2017 and 2021 with suspected community-onset sepsis, defined by a blood culture draw, lactate measurement, and intravenous antibiotic administration on admission. Exposures Empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) and/or antipseudomonal β-lactam agent use. Main Outcomes and Measures Annual rates of empiric anti-MRSA and/or antipseudomonal β-lactam agent use and the proportion that were likely unnecessary in retrospect based on the absence of β-lactam resistant gram-positive or ceftriaxone-resistant gram-negative pathogens from clinical cultures obtained through hospital day 4. Annual trends were calculated using mixed-effects logistic regression models, adjusting for patient and hospital characteristics. Results Among 6 272 538 hospitalizations (median [IQR] age, 66 [53-78] years; 443 465 male [49.6%]; 106 095 Black [11.9%], 65 763 Hispanic [7.4%], 653 907 White [73.1%]), 894 724 (14.3%) had suspected community-onset sepsis, of whom 582 585 (65.1%) received either empiric anti-MRSA (379 987 [42.5%]) or antipseudomonal β-lactam therapy (513 811 [57.4%]); 311 213 (34.8%) received both. Patients with suspected community-onset sepsis accounted for 1 573 673 of 3 141 300 (50.1%) of total inpatient anti-MRSA antibiotic days and 2 569 518 of 5 211 745 (49.3%) of total antipseudomonal β-lactam days. Between 2017 and 2021, the proportion of patients with suspected sepsis administered anti-MRSA or antipseudomonal therapy increased from 63.0% (82 731 of 131 275 patients) to 66.7% (101 003 of 151 435 patients) (adjusted OR [aOR] per year, 1.03; 95% CI, 1.03-1.04). However, resistant organisms were isolated in only 65 434 cases (7.3%) (30 617 gram-positive [3.4%], 38 844 gram-negative [4.3%]) and the proportion of patients who had any resistant organism decreased from 9.6% to 7.3% (aOR per year, 0.87; 95% CI, 0.87-0.88). Most patients with suspected sepsis treated with empiric anti-MRSA and/or antipseudomonal therapy had no resistant organisms (527 356 of 582 585 patients [90.5%]); this proportion increased from 88.0% in 2017 to 91.6% in 2021 (aOR per year, 1.12; 95% CI, 1.11-1.13). Conclusions and Relevance In this cross-sectional study of adults admitted to 241 US hospitals, empiric broad-spectrum antibiotic use for suspected community-onset sepsis accounted for half of all anti-MRSA or antipseudomonal therapy; the use of these types of antibiotics increased between 2017 and 2021 despite resistant organisms being isolated in less than 10% of patients treated with broad-spectrum agents.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tom Chen
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Alexander Lawandi
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Quebec, Canada
| | - Christina Yek
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Morgan Walker
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - Sarah Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
- Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, Maryland
| | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | | | - Claire N. Shappell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Laura DelloStritto
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Haddad DN, Martinez Quinones P, Gummadi S, Martin ND. Conundrums in the surgical intensive care unit: fevers and antibiotic prophylaxis. Trauma Surg Acute Care Open 2024; 9:e001352. [PMID: 38836442 PMCID: PMC11149144 DOI: 10.1136/tsaco-2023-001352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
This editorial is in response to the three latest clinical consensus guidelines authored by the Critical Care Committee of the American Association for the Surgery of Trauma. Herein, we discuss their main findings and recommendations and their impact on the practice of Surgical Critical Care.
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Affiliation(s)
- Diane N Haddad
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sriharsha Gummadi
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Niels D Martin
- Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Piedmont S, Baier L, Ullrich N, Fitz I, Sprünken E, Toubekis E, Albrecht V, Neugebauer E. [Factors that influence the use of sepsis-related competencies in health professionals and how they promote their patients' sepsis knowledge: Results of a mixed methods study with health professionals]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024:S1865-9217(24)00085-0. [PMID: 38834485 DOI: 10.1016/j.zefq.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/22/2024] [Accepted: 04/27/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Sepsis is a life-threatening and relatively common emergency which is often recognized too late or not at all. Therefore, the "SepsisWissen" (SepsisKnowledge) project aimed to bring about changes in health care professionals' behavior in the area of sepsis prevention and early detection. It addressed the health care professionals themselves (e. g., their own vaccination, hygiene and early detection behavior) and their patient counseling behavior. To promote this behavior, the SepsisWissen campaign included offers such as trainings or print products. The subsequent core question is: From the health professionals' perspective, which barriers and facilitators affect their own application of sepsis competence and their promotion of their patients' sepsis competence? METHODS This paper was based on a cross-sectional mixed-methods study part of "SepsisWissen" withPart a) was analyzed using qualitative oriented content analysis based on Mayring, part b) was analyzed descriptively. The interviewees included physicians, nurses, pharmacists, assistants to physicians and pharmacists and, additionally, one paramedic in the quantitative sample. Some of them had attended "SepsisWissen" trainings. RESULTS The qualitative data analysis identified 41 conducive and hindering factors, which can be assigned to the following eight major topics: 1) syndrome sepsis; 2) predisposing factors for health professionals' own acquisition and application of sepsis competence; 3) enabling factors for health professionals themselves; 4) behavior and lifestyle of patients; 5) reinforcing factors for patients; 6) public health education; 7) political, administrative, and organizational context; 8) environmental factors. In the qualitative and quantitative surveys, the suggestion to improve the sepsis competence of the population and to reduce misinformation, respectively, through public education (e.g., via schools or the media). DISCUSSION Sepsis training for health professionals was considered as a facilitating factor for taking potential sepsis symptoms and patients' respective statements more seriously. Future training formats should convey more explicitly how health professionals can better communicate their own sepsis knowledge to their patients. They request instruments to support their communication, such as checklists for lay persons. According to the interviews, health workers themselves need recurring external reminders for the topic of sepsis. Organizational and political conditions should be improved. From the health professionals' point of view, it is essential to offer better reimbursement for prevention and counseling services and to allocate adequate time resources for both. CONCLUSION Health professionals could increase their potential to apply and promote sepsis competence if general conditions were optimized. From their perspective, it is most important to relieve them of some of their patient counselling burden by initiating more public education.
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Affiliation(s)
- Silke Piedmont
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland.
| | - Luisa Baier
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
| | - Nastja Ullrich
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
| | - Isabell Fitz
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
| | - Erin Sprünken
- Charité - Universitätsmedizin Berlin, Institut für Biometrie und klinische Epidemiologie, Campus Charité Mitte, Berlin, Deutschland
| | - Evjenia Toubekis
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte, Berlin, Deutschland
| | - Valentina Albrecht
- Charité - Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Charité Mitte, Berlin, Deutschland
| | - Edmund Neugebauer
- Brandenburg Medical School, Zentrum für Versorgungsforschung, Neuruppin, Deutschland
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Karvellas CJ, Bajaj JS, Kamath PS, Napolitano L, O'Leary JG, Solà E, Subramanian R, Wong F, Asrani SK. AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosis. Hepatology 2024; 79:1463-1502. [PMID: 37939273 DOI: 10.1097/hep.0000000000000671] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Jasmohan S Bajaj
- Virginia Commonwealth University, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Jacqueline G O'Leary
- Department of Medicine, Dallas Veterans Medical Center, University of Texas Southwestern Medical Center Dallas, Texas, USA
| | - Elsa Solà
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California, USA
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Stangl F, Wagenlehner F, Schneidewind L, Kranz J. [Urosepsis: pathophysiology, diagnosis, and management-an update]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:543-550. [PMID: 38639782 DOI: 10.1007/s00120-024-02336-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
Urinary tract infections vary widely in their clinical spectrum, ranging from uncomplicated cystitis to septic shock. Urosepsis accounts for 9-31% of all cases of septicemia and is often associated with nosocomial infections. A major risk factor for urosepsis is the presence of obstructive uropathy, caused by conditions such as urolithiasis, tumors, or strictures. The severity and course of urosepsis depend on both the virulence of the pathogen and the patient's specific immune response. Prompt therapy, including antimicrobial treatment and eradication of the infection source, along with supportive measures for circulatory and respiratory stabilization, and adjunctive therapies such as hemodialysis and glucocorticoid therapy, is crucial. Due to demographic changes, an increase in cases of urosepsis is expected-thus, it is of utmost importance for urologists to be familiar with targeted diagnostics and effective treatment.
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Affiliation(s)
- Fabian Stangl
- Universitätsklinik für Urologie, Universität Bern, Bern, Schweiz
| | - Florian Wagenlehner
- Klinik für Urologie, Kinderurologie und Andrologie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | | | - Jennifer Kranz
- Klinik für Urologie und Kinderurologie, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland.
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Sensen B, Nierhaus A, Kluge S. [Corticosteroids in intensive care medicine]. Dtsch Med Wochenschr 2024; 149:714-718. [PMID: 38781995 DOI: 10.1055/a-2128-5319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
In the case of septic shock, recent studies show benefits from a combination of hydrocortisone and fludrocortisone, but clear guideline recommendations are still lacking. For severe community-acquired pneumonia, early corticosteroid therapy is recommended. Corticosteroid therapy should not be used in influenza-associated community-acquired pneumonia. In contrast, a significantly lower 28-day mortality rate was observed for COVID-19 by the use of dexamethasone. Current guidelines also recommend the use of corticosteroids in Acute Respiratory Distress Syndrome. These recommendations are based primarily on studies that started steroid therapy early. However, many questions such as the type of corticosteroid, the timing and duration of therapy, and the dosage still remain unanswered.
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Affiliation(s)
- Barbara Sensen
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Axel Nierhaus
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Caspar Y, Deves A, Richarme C, Le Marechal M, Ponderand L, Mounayar AL, Lejeune S, Arata-Bardet J, Gallouche M, Recule C, Maubon D, Garnaud C, Cornet M, Veloso M, Chabani B, Maurin M, David-Tchouda S, Pavese P. Clinical impact and cost-consequence analysis of ePlex® blood culture identification panels for the rapid diagnosis of bloodstream infections: a single-center randomized controlled trial. Eur J Clin Microbiol Infect Dis 2024; 43:1193-1203. [PMID: 38536524 PMCID: PMC11178566 DOI: 10.1007/s10096-024-04820-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/21/2024] [Indexed: 06/15/2024]
Abstract
To assess clinical impact and perform cost-consequence analysis of the broadest multiplex PCR panels available for the rapid diagnosis of bloodstream infections (BSI). Single-center, randomized controlled trial conducted from June 2019 to February 2021 at a French University hospital with an institutional antimicrobial stewardship program. Primary endpoint was the percentage of patients with optimized antimicrobial treatment 12 h after transmission of positivity and Gram stain results from the first positive BC. This percentage was significantly higher in the multiplex PCR (mPCR) group (90/105 = 85.7% %, CI95% [77.5 ; 91.8] vs. 68/107 = 63.6%, CI95% [53.7 ; 72.6]; p < 10- 3) at interim analysis, resulting in the early termination of the study after the inclusion of 309 patients. For patients not optimized at baseline, the median time to obtain an optimized therapy was much shorter in the mPCR group than in the control group (6.9 h, IQR [2.9; 17.8] vs. 26.4 h, IQR [3.4; 47.5]; p = 0.001). Early optimization of antibiotic therapy resulted in a non-statistically significant decrease in mortality from 12.4 to 8.8% (p = 0.306), with a trend towards a shorter median length of stay (18 vs. 20 days; p = 0.064) and a non-significant reduction in the average cost per patient of €3,065 (p = 0.15). mPCR identified all the bacteria present in 88% of the samples. Despite its higher laboratory cost, the use of multiplex PCR for BSI diagnosis leads to early-optimised therapy, seems cost-effective and could reduce mortality and length of stay. Their impact could probably be improved if implemented 24/7.
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Affiliation(s)
- Yvan Caspar
- Laboratoire de Bactériologie-Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France.
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, CEA, IBS, Grenoble, 38000, France.
| | - A Deves
- Laboratoire de Bactériologie-Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France
| | - C Richarme
- Laboratoire de Bactériologie-Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France
| | - M Le Marechal
- Service des Maladies infectieuses et tropicales, CHU Grenoble Alpes, Grenoble, France
| | - L Ponderand
- Laboratoire de Bactériologie-Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France
- Univ. Grenoble Alpes, CNRS, CHU Grenoble Alpes, CEA, IBS, Grenoble, 38000, France
| | - A-L Mounayar
- Service des Maladies infectieuses et tropicales, CHU Grenoble Alpes, Grenoble, France
| | - S Lejeune
- Service des Maladies infectieuses et tropicales, CHU Grenoble Alpes, Grenoble, France
| | - J Arata-Bardet
- Service des Maladies infectieuses et tropicales, CHU Grenoble Alpes, Grenoble, France
| | - M Gallouche
- Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, 38000, France
- Service d'Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France
| | - C Recule
- Laboratoire de Bactériologie-Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France
| | - D Maubon
- Laboratoire de Parasitologie-Mycologie, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, TIMC, Grenoble, 38000, France
| | - C Garnaud
- Laboratoire de Parasitologie-Mycologie, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, TIMC, Grenoble, 38000, France
| | - M Cornet
- Laboratoire de Parasitologie-Mycologie, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, TIMC, Grenoble, 38000, France
| | - M Veloso
- Cellule d'ingénierie des données, CHU Grenoble Alpes, Grenoble, France
| | - B Chabani
- Unité d'évaluation médico-économique, Pôle Santé Publique, CHU Grenoble Alpes, Grenoble, France
| | - M Maurin
- Laboratoire de Bactériologie-Hygiène Hospitalière, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, CHU Grenoble Alpes, TIMC, Grenoble, 38000, France
| | - S David-Tchouda
- Unité d'évaluation médico-économique, Pôle Santé Publique, CHU Grenoble Alpes, Grenoble, France
- CIC 1406 Grenoble, INSERM, Grenoble, 38000, France
- Univ. Grenoble Alpes, TIMC-Imag UMR 5525, Grenoble, 38000, France
| | - P Pavese
- Service des Maladies infectieuses et tropicales, CHU Grenoble Alpes, Grenoble, France
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Seckel MA. Sepsis best practices: Definitions, guidelines, and updates. Nursing 2024; 54:31-39. [PMID: 38757994 DOI: 10.1097/nsg.0000000000000010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
ABSTRACT Sepsis remains a complex and costly disease with high morbidity and mortality. This article discusses Sepsis-2 and Sepsis-3 definitions, highlighting the 2021 Surviving Sepsis International guidelines as well as the regulatory requirements and reimbursement for the Severe Sepsis and Septic Shock Management Bundle (SEP-1) measure.
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Affiliation(s)
- Maureen A Seckel
- Maureen A. Seckel is a critical care clinical nurse specialist and sepsis consultant at MSeckel Education and Consulting
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Liu Q, Fu Y, Zhang Z, Li P, Nie H. Mean arterial pressure to norepinephrine equivalent dose ratio for predicting renal replacement therapy requirement: a retrospective analysis from the MIMIC-IV. Int Urol Nephrol 2024; 56:2065-2074. [PMID: 38236372 PMCID: PMC11090965 DOI: 10.1007/s11255-023-03908-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/03/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND This study aimed to assess the predictive value of the ratio of mean arterial pressure (MAP) to the corresponding peak rate of norepinephrine equivalent dose (NEQ) within the first day in patients with shock for the subsequent renal replacement therapy (RRT) requirement. METHODS Patients were identified using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The relationship was investigated using a restricted cubic spline curve, and propensity score matching(PSM) was used to eliminate differences between groups. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using logistic regression. Variable significance was assessed using extreme gradient boosting (XGBoost), and receiver operating characteristic (ROC) curves were generated. RESULTS Of the 5775 patients, 301 (5.2%) received RRT. The MAP/NEQ index showed a declining L-shaped relationship for RRT. After PSM, the adjusted OR per 100 mmHg/mcg/kg/min for RRT was 0.93(95% CI 0.88-0.98). The most influential factors for RRT were fluid balance, baseline creatinine, and the MAP/NEQ index. The threshold for the MAP/NEQ index predicting RRT was 161.7 mmHg/mcg/kg/min (specificity: 65.8%, sensitivity: 74.8%) with an area under the ROC curve of 75.9% (95% CI 73.1-78.8). CONCLUSIONS The MAP/NEQ index served as an alternative predictor of RRT necessity based on the NEQ for adult patients who received at least one vasopressor over 6 h within the first 24 h of intensive care unit(ICU) admission. Dynamic modulation of the MAP/NEQ index by the synergistic use of various low-dose vasopressors targeting urine output may be beneficial for exploring individualized optimization of MAP.
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Affiliation(s)
- Qiang Liu
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yawen Fu
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zhuo Zhang
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ping Li
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hu Nie
- Department of Emergency, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
- West China Xiamen Hospital of Sichuan University, Xiamen, Fujian, China.
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Sankararaman S, Venegas C, Seth S, Palchaudhuri S. "Feed a Cold, Starve a Fever?" A Review of Nutritional Strategies in the Setting of Bacterial Versus Viral Infections. Curr Nutr Rep 2024; 13:314-322. [PMID: 38587572 DOI: 10.1007/s13668-024-00536-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE OF REVIEW Some data, mostly originally derived from animal studies, suggest that low glucose intake is protective in bacterial sepsis but detrimental in overwhelming viral infections. This has been interpreted into a broad belief that different forms of sepsis may potentially require different nutritional management strategies. There are a few mechanistic differences between the host interactions with virus and bacteria which can explain why there may be opposing responses to macronutrient and micronutrient during the infected state. Here, we aim to review relevant evidence on the mechanisms and pathophysiology of nutritional management strategies in various infectious syndromes and summarize their clinical implications. RECENT FINDINGS Newer literature - in the context of the SARS-CoV-19 pandemic - offers some insight to viral infections. There is still limited clinically applicable data during infection that clearly delineate the role of nutrition during an active viral vs bacterial infections. Based on contrasting findings in different models of viruses and bacteria, the macronutrient and micronutrient needs may depend more on specific infectious organisms that may not be generalizable as bacterial versus viral. Overall, the metabolic effects of sepsis are context dependent, and various host-specific (e.g., age, baseline nutritional status, immune status, comorbidities) and illness variables (phase, duration, and severity of illness) play a significant role in determining the outcome besides pathogen-specific (virus or bacterial or fungi and combined infections) factors. Microbe therapy (probiotics and prebiotics) seems to have therapeutic potential in both viral and bacterial infected states, and this seems like a promising area for further practical research.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Carla Venegas
- Department Critical Care Medicine and Nutrition Support Team, Mayo Clinic, Jacksonville, FL, USA
| | - Sonia Seth
- Upstate Medical University, Syracuse, NY, USA
| | - Sonali Palchaudhuri
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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43
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Rhee C, Filbin MR. Can Procalcitonin and Other Biomarkers Help Rapidly Identify Sepsis Among Undifferentiated High-Risk Patients in the Emergency Department? Crit Care Med 2024; 52:979-982. [PMID: 38752815 DOI: 10.1097/ccm.0000000000006241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston MA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Alber S, Tanabe K, Hennigan A, Tregear H, Gilliland S. Year in Review 2023: Noteworthy Literature in Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2024; 28:66-79. [PMID: 38669120 DOI: 10.1177/10892532241249582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).
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45
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Zhou J, Li H, Zhang L, Chen G, Wang G, Zhu H, Hao Y, Wu G. Removal of inflammatory factors and prognosis of patients with septic shock complicated with acute kidney injury by hemodiafiltration combined with HA330-II hemoperfusion. Ther Apher Dial 2024; 28:460-466. [PMID: 38317412 DOI: 10.1111/1744-9987.14108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION To explore the effect of CRRT using CVVHDF + HP on the removal of inflammatory mediators in patients with septic shock complicated with AKI. METHODS A total of 20 patients between January 1, 2018, and December 31, 2021, were included. The patients were randomly divided into the treatment group (CVVHDF + HP) and the control group (CVVHDF). Changes in inflammatory factors, including IL-1β, IL-6, IL-8, TNF-α, PCT, and CRP were compared. Other observed measures were also analyzed, for example, Lac, Scr, BUN, SOFA, and norepinephrine (NE) dosage. The clinical outcomes of both groups were followed up for 28 days. RESULTS The IL-6 and PCT levels in the treatment group were significantly lower (p = 0.005, 0.007). Although the IL-1β, TNFα, and CRP levels in the treatment group decreased, there were no statistical differences (p > 0.05). There were significant differences in Lac, SOFA, and NE dosage levels between both groups (p = 0.023, 0.01, 0.023). Survival analysis showed that the 28-day survival rate was significantly higher in the treatment group. CONCLUSION CRRT using CVVHDF+HP can effectively remove inflammatory factors and improve the prognosis of patients.
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Affiliation(s)
- Juan Zhou
- Department of ICU, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Haopeng Li
- Department of Urology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lei Zhang
- Department of ICU, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Guangjian Chen
- Department of ICU, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gang Wang
- Department of ICU, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - HuiHui Zhu
- Department of ICU, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yingxin Hao
- Department of ICU, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gang Wu
- Department of Urology, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
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Drekonja DM. Urinary Tract Infection in Male Patients: Challenges in Management. Infect Dis Clin North Am 2024; 38:311-323. [PMID: 38575494 DOI: 10.1016/j.idc.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Urinary tract infections in male patients share many of the management principles as used in the management of female patients, including the need to accurately define the clinical syndrome, choose empirical therapy based on the severity of illness and the potential for antimicrobial resistance, and consider the need for source control in severely ill patients. The microbiology of the causative organisms is more unpredictable compared to female patients, and data to inform treatment decisions from clinical trials specific to male patients are relatively scarce.
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Affiliation(s)
- Dimitri M Drekonja
- Infectious Disease Section, Minneapolis VA Health Care System, University of Minnesota, Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive, Mail code 111F, Minneapolis, MN 55417, USA.
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Peters EJ, Frydland MS, Hassager C, Bos LD, van Vught LA, Cremer OL, Møller JE, van den Born BJH, Vlaar AP, Henriques JP. Biomarker patterns in patients with cardiogenic shock versus septic shock. IJC HEART & VASCULATURE 2024; 52:101424. [PMID: 38784047 PMCID: PMC11112335 DOI: 10.1016/j.ijcha.2024.101424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/11/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
Background In cardiogenic shock (CS), contractile failure is often accompanied by a systemic inflammatory response syndrome. In contrast, many patients with septic shock (SS) develop cardiac dysfunction. A similar hemodynamic support strategy is often deployed in both syndromes but it is unclear whether this is justified based on profiles of biomarkers expressing neurohormonal activation and cardiovascular stress. Methods In this prospective, multicenter cohort, 111 patients with acute myocardial infarction related CS were identified, and matched to patients with SS. Clinical parameters were collected and blood samples were obtained on day 1-3 of Intensive Care admission. Results In this shock cohort comprising 222 patients, with a mean age of 61 (±13.5) years and of whom 161 (37 %) were male, we found that despite obvious clinical disparities on admission, mortality at 30-days did not differ (CS: 40.5 % vs. SS 43.1 %, p = 0.56). Overall, plasma concentrations of all biomarkers were higher in SS patients, with the largest difference on the first day. However, only in CS patients the biomarker concentrations were associated with mortality. Conclusion In this prospective, multicenter cohort SS and CS patients showed similarities in baseline conditions and had similar mortality. However, several biomarkers only showed prognostic value in CS.
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Affiliation(s)
- Elma J. Peters
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Martin S. Frydland
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lieuwe D.J. Bos
- Intensive Care, Department of Respiratory Medicine, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Lonneke A. van Vught
- Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Olaf L. Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacob E. Møller
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Bert-Jan H. van den Born
- Department of Internal/vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P.J. Vlaar
- Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Jose P.S. Henriques
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - on behalf of the MARS consortium
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Intensive Care, Department of Respiratory Medicine, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care Medicine & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Internal/vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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P K R, Kumar A, Sahu AK, Malhotra C, Gopinath B, Bhoi S, Jamshed N, Mishra P, Ekka M. Novel sepsis screening tool for low and middle income country in a high volume emergency department - A validation study. Am J Emerg Med 2024:S0735-6757(24)00262-6. [PMID: 38862343 DOI: 10.1016/j.ajem.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/13/2024] Open
Affiliation(s)
- Roshan P K
- Department of Emergency Medicine, Travancore Medicity, Kollam, India
| | - Akshay Kumar
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Charu Malhotra
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bharath Gopinath
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prakash Mishra
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Meera Ekka
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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Fanous MS, de la Cruz JE, Michael OS, Afolabi JM, Kumar R, Adebiyi A. EARLY FLUID PLUS NOREPINEPHRINE RESUSCITATION DIMINISHES KIDNEY HYPOPERFUSION AND INFLAMMATION IN SEPTIC NEWBORN PIGS. Shock 2024; 61:885-893. [PMID: 38662580 DOI: 10.1097/shk.0000000000002343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT Sepsis is the most frequent risk factor for acute kidney injury (AKI) in critically ill infants. Sepsis-induced dysregulation of kidney microcirculation in newborns is unresolved. The objective of this study was to use the translational swine model to evaluate changes in kidney function during the early phase of sepsis in newborns and the impact of fluid plus norepinephrine resuscitation. Newborn pigs (3-7-day-old) were allocated randomly to three groups: 1) sham, 2) sepsis (cecal ligation and puncture) without subsequent resuscitation, and 3) sepsis with lactated Ringer plus norepinephrine resuscitation. All animals underwent standard anesthesia and mechanical ventilation. Cardiac output and glomerular filtration rate were measured noninvasively. Mean arterial pressure, total renal blood flow, cortical perfusion, medullary perfusion, and medullary tissue oxygen tension (mtPO 2 ) were determined for 12 h. Cecal ligation and puncture decreased mean arterial pressure and cardiac output by more than 50%, with a proportional increase in renal vascular resistance and a 60-80% reduction in renal blood flow, cortical perfusion, medullary perfusion, and mtPO 2 compared to sham. Cecal ligation and puncture also decreased glomerular filtration rate by ~79% and increased AKI biomarkers. Isolated foci of tubular necrosis were observed in the septic piglets. Except for mtPO 2 , changes in all these parameters were ameliorated in resuscitated piglets. Resuscitation also attenuated sepsis-induced increases in the levels of plasma C-reactive protein, proinflammatory cytokines, lactate dehydrogenase, alanine transaminase, aspartate aminotransferase, and renal NLRP3 inflammasome. These data suggest that newborn pigs subjected to cecal ligation and puncture develop hypodynamic septic AKI. Early implementation of resuscitation lessens the degree of inflammation, AKI, and liver injury.
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Affiliation(s)
| | | | | | - Jeremiah M Afolabi
- Department of Physiology, University of TN Health Science Center, Memphis, Tennessee
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50
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Segev G, Cortellini S, Foster JD, Francey T, Langston C, Londoño L, Schweighauser A, Jepson RE. International Renal Interest Society best practice consensus guidelines for the diagnosis and management of acute kidney injury in cats and dogs. Vet J 2024; 305:106068. [PMID: 38325516 DOI: 10.1016/j.tvjl.2024.106068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 12/10/2023] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
Acute kidney injury (AKI) is defined as an injury to the renal parenchyma, with or without a decrease in kidney function, as reflected by accumulation of uremic toxins or altered urine production (i.e., increased or decreased). AKI might result from any of several factors, including ischemia, inflammation, nephrotoxins, and infectious diseases. AKI can be community- or hospital-acquired. The latter was not previously considered a common cause for AKI in animals; however, recent evidence suggests that the prevalence of hospital-acquired AKI is increasing in veterinary medicine. This is likely due to a combination of increased recognition and awareness of AKI, as well as increased treatment intensity (e.g., ventilation and prolonged hospitalization) in some veterinary patients and increased management of geriatric veterinary patients with multiple comorbidities. Advancements in the management of AKI, including the increased availability of renal replacement therapies, have been made; however, the overall mortality of animals with AKI remains high. Despite the high prevalence of AKI and the high mortality rate, the body of evidence regarding the diagnosis and the management of AKI in veterinary medicine is very limited. Consequently, the International Renal Interest Society (IRIS) constructed a working group to provide guidelines for animals with AKI. Recommendations are based on the available literature and the clinical experience of the members of the working group and reflect consensus of opinion. Fifty statements were generated and were voted on in all aspects of AKI and explanatory text can be found either before or after each statement.
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Affiliation(s)
- Gilad Segev
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, Hebrew University of Jerusalem, Israel.
| | - Stefano Cortellini
- Department of Clinical Science and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire, UK
| | - Jonathan D Foster
- Department of Nephrology and Urology, Friendship Hospital for Animals, Washington DC, USA
| | - Thierry Francey
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty University of Bern, Bern, Switzerland
| | - Catherine Langston
- Veterinary Clinical Science, The Ohio State University, Columbus, OH, USA
| | - Leonel Londoño
- Department of Critical Care, Capital Veterinary Specialists, Jacksonville, FL, USA
| | - Ariane Schweighauser
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty University of Bern, Bern, Switzerland
| | - Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire, UK
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