Epidemiology of Sepsis-3 in a sub-district of Beijing: secondary analysis of a population-based database

Dichloroacetate Prevents Sepsis Associated Encephalopathy by Inhibiting Microglia Pyroptosis through PDK4/NLRP3

Dichloroacetate (DCA), a pyruvate dehydrogenase kinase inhibitor, is often used to treat lactic acidosis and malignant tumors. Increasing studies have shown that DCA has neuroprotective effects. Here, we explored the role and mechanism of DCA in Sepsis associated encephalopathy (SAE). Single-cell analysis was used to determine the important role of PDK4 in SAE and identify the cell type. GO and GSEA analysis were used to determine the correlation between DCA and pyroptosis. Through LPS + ATP stimulation, a microglia pyroptosis model was established to observe the expression level of intracellular pyroptosis-related proteins under DCA intervention, and further detect the changes in intracellular ROS and JC-1. Additionally, a co-culture environment of microglia and neuron was simply constructed to evaluate the effect of DCA on activated microglia-mediated neuronal apoptosis. Finally, Novel object recognition test and the Morris water maze were used to explore the effect of DCA on cognitive function in mice from different groups after intervention. Based on the above experiments, this study concludes that DCA can improve the ratio of peripheral and central M1 macrophages, inhibit NLRP3-mediated pyroptosis through ROS and mitochondrial membrane potential (MMP). DCA can reduce neuron death caused by SAE and improve cognitive function in LPS mice. In SAE, DCA may be a potential candidate drug for the treatment of microglia-mediated neuroinflammation.

AQP4 Aggravates Cognitive Impairment in Sepsis-Associated Encephalopathy through Inhibiting Nav 1.6-Mediated Astrocyte Autophagy

The pathology of sepsis-associated encephalopathy (SAE) is related to astrocyte-inflammation associated with aquaporin-4 (AQP4). The aim here is to investigate the effects of AQP4 associated with SAE and reveal its underlying mechanism causing cognitive impairment. The in vivo experimental results reveal that AQP4 in peripheral blood of patients with SAE is up-regulated, also the cortical and hippocampal tissue of cecal ligation and perforation (CLP) mouse brain has significant rise in AQP4. Furthermore, the data suggest that AQP4 deletion could attenuate learning and memory impairment, attributing to activation of astrocytic autophagy, inactivation of astrocyte and downregulate the expression of proinflammatory cytokines induced by CLP or lipopolysaccharide (LPS). Furthermore, the activation effect of AQP4 knockout on CLP or LPS-induced PPAR-γ inhibiting in astrocyte is related to intracellular Ca2+ level and sodium channel activity. Learning and memory impairment in SAE mouse model are attenuated by AQP4 knockout through activating autophagy, inhibiting neuroinflammation leading to neuroprotection via down-regulation of Nav 1.6 channels in the astrocytes. This results in the reduction of Ca2+ accumulation in the cell cytosol furthermore activating the inhibition of PPAR-γ signal transduction pathway in astrocytes.

Cytokine hemoadsorption with CytoSorb® in patients with sepsis: a systematic review and meta-analysis

OBJECTIVE

To analyze the effect of CytoSorb® on mortality, interleukin levels, vasopressor use and adverse events in patients with sepsis.

METHODS

We searched MEDLINE®, Embase and the Cochrane Library for randomized controlled trials and cohort studies that reported the use of CytoSorb® among septic patients. The primary outcome was mortality, and secondary outcomes included the use of vasopressors, levels of inflammatory markers, predicted versus observed mortality, length of stay in the intensive care unit, and adverse events.

RESULTS

We included 6 studies enrolling 413 patients, and assessment for risk of bias indicated variations in study quality from high to moderate. The overall mortality rate was 45%, and no significant effect on mortality was found at 28 - 30 days (RR 0.98 [0.12 - 8.25] for the randomized clinical trial and RR 0.74 [0.49 - 1.13] for cohort studies). We did not perform a metanalysis for other outcomes due to the small number of studies found or the lack of data.

CONCLUSION

Our study found very low certainty evidence, due to imprecision, risk of bias, and heterogeneity, thereby showing no benefit of CytoSorb® use in terms of mortality at 28 - 30 days. We cannot recommend the use of CytoSorb® in septic or septic shock patients outside clinical trials. Further high-quality randomized trials with a common intervention arm are needed to evaluate the influence of CytoSorb® in this population.

PROSPERO REGISTER

CRD42021262219.

National incidence and mortality of hospitalized sepsis in China

BACKGROUND

Sepsis is a leading cause of preventable death around the world. Population-based estimation of sepsis incidence is lacking in China. In this study, we aimed to estimate the population-based incidence and geographic variation of hospitalized sepsis in China.

METHODS

We retrospectively identified hospitalized sepsis from the nationwide National Data Center for Medical Service (NDCMS) and the National Mortality Surveillance System (NMSS) by ICD-10 codes for the period from 2017 to 2019. In-hospital sepsis case fatality and mortality rate were calculated to extrapolate the national incidence of hospitalized sepsis. The geographic distribution of hospitalized sepsis incidence was examined using Global Moran's Index.

RESULTS

We identified 9,455,279 patients with 10,682,625 implicit-coded sepsis admissions in NDCMS and 806,728 sepsis-related deaths in NMSS. We estimated that the annual standardized incidence of hospitalized sepsis was 328.25 (95% CI 315.41-341.09), 359.26 (95% CI 345.4-373.12) and 421.85 (95% CI 406.65-437.05) cases per 100,000 in 2017, 2018 and 2019, respectively. We observed 8.7% of the incidences occurred among neonates less than 1 year old, 11.7% among children aged 1-9 years, and 57.5% among elderly older than 65 years. Significant spatial autocorrelation for incidence of hospitalized sepsis was observed across China (Moran's Index 0.42, p = 0.001; 0.45, p = 0.001; 0.26, p = 0.011 for 2017, 2018, 2019, respectively). Higher number of hospital bed supply and higher disposable income per capita were significantly associated with a higher incidence of hospitalized sepsis.

CONCLUSION

Our study showed a greater burden of sepsis hospitalizations than previous estimated. The geographical disparities suggested more efforts were needed in prevention of sepsis.

Update on Sepsis Epidemiology in the Era of COVID-19

Timely and accurate data on the epidemiology of sepsis is essential to inform public policy, clinical practice, and research priorities. Recent studies have illuminated several ongoing questions about sepsis epidemiology, including the incidence and outcomes of sepsis in non-Western countries and in specialized populations such as surgical patients, patients with cancer, and the elderly. There have also been new insights into the limitations of current surveillance methods using administrative data and increasing experience tracking sepsis incidence and outcomes using "big data" approaches that take advantage of detailed electronic health record data. The COVID-19 pandemic, however, has fundamentally changed the landscape of sepsis epidemiology. It has increased sepsis rates, helped highlight ongoing controversies about how to define sepsis, and intensified debate about the possible unintended consequences of overly rigid sepsis care bundles. Despite these controversies, there is a growing consensus that severe COVID-19 causing organ dysfunction is appropriate to label as sepsis, even though it is treated very differently from bacterial sepsis, and that surveillance strategies need to be modified to reliably identify these cases to fully capture and delineate the current burden of sepsis. This review will summarize recent insights into the epidemiology of sepsis and highlight several urgent questions and priorities catalyzed by COVID-19.

Prognostic Accuracy of the Different Scoring Systems for Assessing Coagulopathy in Sepsis: A Retrospective Study

There is no gold standard for the diagnosis of coagulation dysfunction in sepsis, and the use of the current scoring systems is still controversial. The purpose of this study was to assess the performance of sepsis-induced coagulopathy (SIC), the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), and the International Society on Thrombosis and Haemostasis overt DIC (ISTH overt-DIC). The relationship between each scoring system and 28-day all-cause mortality was examined. Among 452 patients (mean age, 65 [48,76] years), 306 [66.7%] were men, the median SOFA score was 6 [4,9], and the median APACHE II score was 15 [11,22]. A total of 132 patients (29.2%) died within 28 days. Both the diagnosis of SIC (AUROC, 0.779 [95% CI, 0.728-0.830], P < 0.001) and ISTH overt-DIC (AUROC, 0.782 [95% CI, 0.732-0.833], P < 0.001) performed equally well in the discrimination of 28-day all-cause mortality (between-group difference: SIC versus ISTH overt-DIC, -0.003 [95% CI, -0.025-0.018], P = 0.766). However, the SIC demonstrated greater calibration for 28-day all-cause mortality than ISTH overt-DIC (the coincidence of the calibration curve of the former is higher than that of the latter). The diagnosis of JAAM DIC was not independently associated with 28-day all-cause mortality in sepsis (RR, 1.115, [95% CI 0.660-1.182], P = 0.684). The SIC scoring system demonstrated superior prognostic prediction ability in comparison with the others and is the most appropriate standard for diagnosing coagulopathy in sepsis.

Prevalence of sepsis among adults in China: A systematic review and meta-analysis

Background

Sepsis is a major public health problem that cannot be ignored in China and even in the world. However, the prevalence of sepsis in Chinese adults varies among different studies.

Objective

To evaluate the prevalence of hospital-wide sepsis and intensive care unit (ICU) sepsis in Chinese adults.

Methods

PubMed, EMBASE, Cochrane Library, Web of science, China National Knowledge Infrastructure, Chinese biomedical literature service system, Wanfang Database, and VIP databases were systematically searched for studies on sepsis in China published before March 2, 2022. Random effects model was used to calculate pooled prevalence estimates with 95% confidence interval. Subgroup and sensitivity analyses were performed to address heterogeneity. Funnel plots and Egger's test were used to assess the publication bias.

Results

Overall, nine observational studies involving 324,020 Chinese patients (9,587 patients with sepsis) were analyzed. Four hospital-wide studies involving 301,272 patients showed pooled prevalence and mortality of 3.8% (95% CI: 2.9-4.7%, I ² = 99.9%) and 26% (95% CI: 16-36%, I ² = 98.0%), respectively. Five studies of ICU sepsis involving 22,748 patients presented pooled prevalence and mortality of 25.5% (95% CI: 13.9-37.0%, I ² = 99.8%) and 40% (95%CI: 34-47%, I ² = 95.9%), respectively. Subgroup analysis of sepsis in ICUs revealed that the pooled prevalence was higher among males [17% (95% CI 9-24%, I ² = 99.6%)], in lung infections [66% (95%CI: 54-77%, I ² = 98.7%)], and Gram-negative bacteria infections [37% (95%CI: 26-47%, I ² = 98.3%)]. The pooled prevalence of sepsis, severe sepsis and septic shock was 25.5% (95%CI: 13.9-37.0%, I ² = 99.8%), 19% (95%CI: 9-28%, I ² = 99.6%), and 13% (95%CI: 7-19%, I ² = 99.2%), respectively.

Conclusions

Sepsis is prevalent in 25.5% of ICU patients in China, and sex, sepsis severity, infection site, causative microorganism, and infection type are significant influencing factors. Larger trials are needed to evaluate the prevalence of sepsis in China, which may help the development of global strategies for sepsis management.

Systematic review registration

PROSPERO, identifier: CRD42022314274.

High-dose vitamin C on sepsis: Protocol of a prospective, multi-centered, double-blinded, randomized, and placebo-controlled superiority study

Background

Sepsis is an inflammatory syndrome with life-threatening organ dysfunction and high mortality. In the recent 10 years, high-dose intravenous injection of vitamin C, the first-line antioxidant of humans, has received highlighted attention in the field of critical care. The study aims to examine the efficacy and safety of high-dose intravenous injection of vitamin C in the treatment of sepsis.

Methods and design

Here, we are conducting a prospective, multi-centered, double-blinded, randomized, and placebo-controlled superiority study named High-Dose Vitamin C on Sepsis (HDVCOS). A total of 620 participants diagnosed with sepsis in four participating sites across China that satisfy the eligibility criteria will be randomized at a ratio of 1:1 to receive treatment with a high-dose intravenous injection of vitamin C (200 mg/kg/24 h) or placebo (saline) for 4 days. The primary outcome is 28 days of mortality. The secondary outcomes include the incidence of organ failure, Sequential Organ Failure Assessment (SOFA) score change, organ support, the relationship between plasma vitamin C concentration and outcomes, and adverse events.

Conclusion

The findings of this study will provide potential evidence for high-dose intravenous injection of vitamin C in the treatment of sepsis.

Clinical trial registration

[http://www.chictr.org.cn/showprojen.aspx?proj=29851], identifier [ChiCTR1800017633].

MALAT1 regulates PCT expression in sepsis patients through the miR‐125b/STAT3 axis

Background

Procalcitonin (PCT) is an important marker in diagnosing sepsis. However, some other diseases can also cause an increase in PCT. PCT still has some limitations in the clinical application of diagnosing sepsis. Therefore, it is of great significance to clarify the regulatory mechanism of PCT expression in sepsis and provide new therapeutic targets for sepsis.

Methods

Blood samples from clinical patients were collected, and peripheral blood monocytes were isolated. Bioinformatics was performed to find the ceRNA regulatory network of STAT3/PCT. MALAT1 and miR‐125b were detected by qRT‐PCR. MALAT1 was located by fluorescence in situ hybridization (FISH) in U937 cells, and the regulatory relationship between MALAT1, miR‐125b, and STAT3 was verified by double luciferase activity report and RNA pull‐down assay. U937 cells were transfected with miR‐125b, and the effects of the MALAT1/miR‐125b/STAT3 pathway on gene and protein secretion levels of PCT were verified by qRT‐PCR, western blot, and ELISA.

Results

In the serum of sepsis patients and lipopolysaccharide(LPS)‐induced U937 cells, MALAT1, STAT3, and PCT gene expression levels were significantly increased, while miR‐125b expression level was decreased. FISH results showed that the MALAT1 transcript was mainly located in the nucleus. The double luciferase activity report and RNA pull‐down assay results suggested a targeted regulatory relationship between MALAT1, miR‐125b, and STAT3. LPS‐induced U937 cells transfection with MALAT1 siRNA decreased STAT3 protein expression and phosphorylation level and the expression of PCT. Co‐transfection with miR‐125b inhibitor effectively reversed this phenomenon.

Conclusions

MALAT1 could upregulate the expressions of STAT3 and PCT by targeted adsorption of miR‐125b.

Comparison between hospital- and community-acquired septic shock in children: a single-center retrospective cohort study

BACKGROUND

We explored the differences in baseline characteristics, pathogens, complications, outcomes, and risk factors between children with hospital-acquired septic shock (HASS) and community-acquired septic shock (CASS) in the pediatric intensive care unit (PICU).

METHODS

This retrospective study enrolled children with septic shock at the PICU of Beijing Children's Hospital from January 1, 2016, to December 31, 2019. The patients were followed up until 28 days after shock or death and were divided into the HASS and CASS group. Logistic regression analysis was used to identify risk factors for mortality.

RESULTS

A total of 298 children were enrolled. Among them, 65.9% (n = 91) of HASS patients had hematologic/oncologic diseases, mainly with Gram-negative bacterial bloodstream infections (47.3%). Additionally, 67.7% (n = 207) of CASS patients had no obvious underlying disease, and most experienced Gram-positive bacterial infections (30.9%) of the respiratory or central nervous system. The 28-day mortality was 62.6% and 32.7% in the HASS and CASS groups, respectively (P < 0.001). Platelet [odds ratio (OR) = 0.996, 95% confidence interval (CI) = 0.992-1.000, P = 0.028], positive pathogen detection (OR = 3.557, 95% CI = 1.307-9.684, P = 0.013), and multiple organ dysfunction syndrome (OR = 10.953, 95% CI = 1.974-60.775, P = 0.006) were risk factors for 28-day mortality in HASS patients. Lactate (OR = 1.104, 95% CI = 1.022-1.192, P = 0.012) and mechanical ventilation (OR = 8.114, 95% CI = 1.806-36.465, P = 0.006) were risk factors for 28-day mortality in patients with CASS.

CONCLUSIONS

The underlying diseases, pathogens, complications, prognosis, and mortality rates varied widely between the HASS and CASS groups. The predictors of 28-day mortality were different between HASS and CASS pediatric patients with septic shock.

Evaluation of the efficiency of corticosteroids in treating adult with sepsis: A protocol for systematic review and meta-analysis

BACKGROUND

Sepsis is a worldwide health problem that is a leading cause of mortality due to infection. Sepsis is prevalent in infections that are complicated with organ failure. Generally, sepsis is intricate and impaired corticosteroid metabolism leads to complex outcomes. Therefore, the provision of corticosteroids could lead to improved clinical outcomes. The effect of corticosteroids therapy in adult patients with sepsis is not well studied. Therefore, this study is an attempt to evaluate the efficacy of corticosteroids for treating adult cases of sepsis.

METHODS

We will systematically search the randomized controlled trials for potential eligible studies from online databases, which includes 5 English databases (PubMed, EMBASE, Web of Science, PsycINFO, and Cochrane Library) and 4 Chinese databases (China National Knowledge Infrastructure, WanFang Database, VIP information database, and China Biomedical Database) from their origin to March 2021. Languages were restricted to English and Chinese. Two independent authors will be screening the literature, collect, and perform data extraction and quality assessment. Data will be synthesized using appropriate statistical methods.

RESULTS

This study will summarize present evidence to evaluate the efficacy of corticosteroids for the treatment of adult cases of sepsis.

CONCLUSION

The results of the present study will provide the latest, reliable, superior quality evidence for the clinical application of corticosteroids for treating sepsis patients.

ETHICS AND DISSEMINATION

The present study will use published data and does not require ethics approval.

PROTOCOL REGISTRATION NUMBER

March 28, 2021.osf.io/tm6sw. (https://osf.io/tm6sw/).

Efficacy of alanyl glutamine in nutritional support therapy for patients with sepsis: A protocol for systematic review and meta-analysis

BACKGROUND

Sepsis is a systemic inflammatory response caused by infection, which is a common complication after severe infection, trauma, shock, and surgery, and is also an important factor in inducing septic shock and multiple organ dysfunction syndrome (MODS), and has become one of the important causes of death in critically ill patients. Septic patients with gastrointestinal transport function weakened, are prone to malnutrition, resulting in decreased immune function, thereby affecting the therapeutic effect. Clinical practice shows that the nutritional metabolism and immune response of patients with sepsis can be effectively improved by giving alanyl glutamine nutritional support treatment, but there is no evidence of evidence-based medicine. The study carried out in this protocol aims to evaluate the effectiveness of alanyl glutamine in nutritional support therapy for patients with sepsis.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, WHO International Clinical Trials Registry Platform, CNKI, CBM, VIP, and Wanfang databases were searched by computer, to retrieve all randomized controlled trials (RCTs) on nutritional support for the treatment of sepsis with alanyl glutamine from the date of database establishment to December 2020. Two researchers independently selected the study, extracted and managed the data. RevMan5.3 software was used to analyze the included literature.

RESULTS

This study observed the changes of serum albumin (ALB), prealbumin (PAB), hemoglobin (Hb), C-reactive protein (CRP), immunoglobulin (IgG, IgA, and IgM), APACHE II score before and after treatment to evaluate the efficacy of alanyl glutamine in nutritional support therapy for patients with sepsis.

CONCLUSION

This study will provide reliable evidence for the application of alanyl glutamine in nutritional support therapy for patients with sepsis.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/VRZPJ.

The SAPS 3 score as a predictor of hospital mortality in a South African tertiary intensive care unit: A prospective cohort study

BACKGROUND

No African countries were included in the development of the Simplified Acute Physiology Score 3 (SAPS 3). This study aimed to assess the performance of the SAPS 3 as a predictor of hospital mortality in patients admitted to a multi-disciplinary tertiary intensive care unit (ICU) in South Africa.

METHODS

A prospective cohort study was undertaken in a tertiary single-centre closed multidisciplinary ICU with 16 beds over 12 months in 2017. First time admissions 12 years and over were included. Exclusions were patients who died within six hours of admission, incomplete data sets and unknown outcome after ICU discharge. Demographic data, clinical admission data and co-morbidities were recorded. The SAPS 3 score was calculated within the first hour of ICU admission. The highest Sequential Organ Failure Assessment score, vasopressor use, mechanical ventilation requirements and details of acute kidney injury, if present, were recorded. Discrimination of the model was evaluated using an area under the receiver operating characteristic curve (AUROC) and calibration by the Hosmer-Lemeshow (HL) Goodness of Fit Test (Ĉ and Ĥ statistic). The observed versus the SAPS 3 model predicted mortality ratios were compared and the standardized mortality ratio (SMR) was calculated.

RESULTS

A total of 829 admissions with a mean SAPS 3 (SD) of 48.1 (16) were included. Of patients with a known human immunodeficiency virus (HIV) status, 32,4% were positive. The ICU and hospital mortality rates were 13.3% and 21.4% respectively. The SAPS 3 model had a AUROC of 0.796 and HL Ĉ and Ĥ statistics were 12.1 and 11.8 (p-values 0.15 and 0.16). The SMR for the model was 1.002 (95%CI: 0.91-1.10). The mortality of 41% for the subgroup with sepsis/septic shock was higher than predicted with a SMR of 1.24 (95% CI 1.11-1.37).

CONCLUSIONS

The SAPS 3 model showed good calibration and fair discrimination when applied to the cohort. The SAPS 3 model can be used to describe the case mix in this African ICU with a high incidence of HIV. Ongoing efforts should be made to improve outcomes of septic patients.