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Giamarellos-Bourboulis EJ, Aschenbrenner AC, Bauer M, Bock C, Calandra T, Gat-Viks I, Kyriazopoulou E, Lupse M, Monneret G, Pickkers P, Schultze JL, van der Poll T, van de Veerdonk FL, Vlaar APJ, Weis S, Wiersinga WJ, Netea MG. The pathophysiology of sepsis and precision-medicine-based immunotherapy. Nat Immunol 2024; 25:19-28. [PMID: 38168953 DOI: 10.1038/s41590-023-01660-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Sepsis remains a major cause of morbidity and mortality in both low- and high-income countries. Antibiotic therapy and supportive care have significantly improved survival following sepsis in the twentieth century, but further progress has been challenging. Immunotherapy trials for sepsis, mainly aimed at suppressing the immune response, from the 1990s and 2000s, have largely failed, in part owing to unresolved patient heterogeneity in the underlying immune disbalance. The past decade has brought the promise to break this blockade through technological developments based on omics-based technologies and systems medicine that can provide a much larger data space to describe in greater detail the immune endotypes in sepsis. Patient stratification opens new avenues towards precision medicine approaches that aim to apply immunotherapies to sepsis, on the basis of precise biomarkers and molecular mechanisms defining specific immune endotypes. This approach has the potential to lead to the establishment of immunotherapy as a successful pillar in the treatment of sepsis for future generations.
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Affiliation(s)
- Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Anna C Aschenbrenner
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Bonn, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Christoph Bock
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Medical University of Vienna, Institute of Artificial Intelligence, Center for Medical Data Science, Vienna, Austria
| | - Thierry Calandra
- Service of Immunology and Allergy and Center of Human Immunology Lausanne, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Irit Gat-Viks
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Mihaela Lupse
- Infectious Diseases Hospital, University of Medicine and Pharmacy 'Iuliu Hatieganu', Cluj-Napoca, Romania
| | - Guillaume Monneret
- Joint Research Unit HCL-bioMérieux, EA 7426 'Pathophysiology of Injury-Induced Immunosuppression' (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon, bioMérieux), Lyon, France
- Immunology Laboratory, Edouard Herriot Hospital - Hospices Civils de Lyon, Lyon, France
| | - Peter Pickkers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joachim L Schultze
- Systems Medicine, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Bonn, Germany
- PRECISE Platform for Single Cell Genomics and Epigenomics, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) and the University of Bonn, Bonn, Germany
- Genomics and Immunoregulation, Life & Medical Sciences (LIMES) Institute, University of Bonn, Bonn, Germany
| | - Tom van der Poll
- Division of Infectious Diseases, Amsterdam University Medical Centers (Amsterdam UMC), Center for Experimental and Molecular Medicine (CEMM), University of Amsterdam, Amsterdam, The Netherlands
| | - Frank L van de Veerdonk
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology L.E.C.A. Amsterdam Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute-HKI, Jena, Germany
| | - W Joost Wiersinga
- Division of Infectious Diseases, Amsterdam University Medical Centers (Amsterdam UMC), Center for Experimental and Molecular Medicine (CEMM), University of Amsterdam, Amsterdam, The Netherlands
| | - Mihai G Netea
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
- Genomics and Immunoregulation, Life & Medical Sciences (LIMES) Institute, University of Bonn, Bonn, Germany.
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
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2
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Casalboni S, Valli G, Terlizzi F, Mastracchi M, Fidelio G, De Marco F, Bernardi C, Chieruzzi A, Curcio A, De Cicco F, Colella N, Papasidero ID, Tartarone E, Ruggieri MP, Di Somma S. 30 Days Mortality Prognostic Value of POCT Bio-Adrenomedullin and Proenkephalin in Patients with Sepsis in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121786. [PMID: 36556987 PMCID: PMC9783595 DOI: 10.3390/medicina58121786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Background and Objective: Sepsis is a worldwide severe disease with a high incidence and mortality rate. Sepsis is a frequent cause of admission to the emergency department (ED). Although prognostic scores (Sequential Organ Failure Assessment, SOFA; New Early Warning Score, NEWS; Rapid Emergency Medicine Score, REMS) are commonly used for risk stratification in septic patients, many of these scores are of poor utility in the ED. In this setting, biomarkers are promising alternatives, easier to perform and potentially more specific. Bio-adrenomedullin (Bio-ADM) and Proenkephalin (PenKid) seem to have a key role in the development of organ dysfunctions induced by sepsis and, therefore, could help in the risk stratification of patients with sepsis at ED admission. The aim of this study was to evaluate the utility of Bio-ADM and PenKid, obtained through a point of care (POCT) device, in predicting 30 days mortality for patients presenting to the ED with sepsis. Methods and Results: In total, 177 consecutive adult patients with a diagnosis of sepsis presenting to the ED of San Giovanni Addolorata Hospital in Rome, Italy, between May 2021 and April 2022 were enrolled in this prospective observational study. For each patient, Bio-ADM and PenKid were obtained at ED admission together with SOFA, NEWS and REMS scores. Next, 30 days follow-up data were collected to evaluate patient mortality. Both biomarkers (Bio-ADM and PenKid) and clinical scores (SOFA, NEWS and REMS) were good predictors of mortality at 30 days, with Bio-ADM and REMS outperforming the others. Moreover, PenKid resulted in being linked with the worsening of kidney function. Conclusions: In patients presenting with sepsis in the ED, Bio-ADM and PenKid, evaluated with a POCT device, predicted 30-day mortality. These two biomarkers seem even more useful when integrated with clinical risk scores at ED admission.
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Affiliation(s)
- Silvia Casalboni
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Gabriele Valli
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Ferdinando Terlizzi
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Marina Mastracchi
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Giacomo Fidelio
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Francesca De Marco
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Caterina Bernardi
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Anastasia Chieruzzi
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Alessia Curcio
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco De Cicco
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Nicola Colella
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Ilaria Dafne Papasidero
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Emanuele Tartarone
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Maria Pia Ruggieri
- Department of Emergency Medicine, San Giovanni Addolorata Hospital, 00184 Rome, Italy
| | - Salvatore Di Somma
- Postgraduate School of Emergency Medicine, Sapienza University of Rome, 00185 Rome, Italy
- GREAT Network (Global Research on Acute Condition Team), 00100 Rome, Italy
- Department of Medical -Surgery Sciences and Translational Medicine, Sapienza University of Rome, 00184 Rome, Italy
- Correspondence:
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Polilli E, Di Iorio G, Silveri C, Angelini G, Anelli MC, Esposito JE, D’Amato M, Parruti G, Carinci F. Monocyte Distribution Width as a predictor of community acquired sepsis in patients prospectively enrolled at the Emergency Department. BMC Infect Dis 2022; 22:849. [PMCID: PMC9661454 DOI: 10.1186/s12879-022-07803-7] [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: 07/06/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background Monocyte Distribution Width (MDW), a simple cellular marker of innate monocyte activation, can be used for the early recognition of sepsis. We performed an observational prospective monocentric study to assess the predictive role of MDW in detecting sepsis in a sample of consecutive patients presenting at the Emergency Department.
Methods Prospective observational study using demographic and clinical characteristics, past medical history and other laboratory measurements to predict confirmed sepsis using multivariate logistic regression.
Results A total of 2724 patients were included in the study, of which 272 (10%) had sepsis or septic shock. After adjusting for known and potential risk factors, logistic regression found the following independent predictors of sepsis: SIRS equal to 1 (OR: 2.32, 1.16–4.89) and 2 or more (OR: 27.8, 14.8–56.4), MDW > 22 (OR: 3.73, 2.46–5.70), smoking (OR: 3.0, 1.22–7.31), end stage renal function (OR: 2.3, 1.25–4.22), neurodegenerative disease (OR: 2.2, 1.31–3.68), Neutrophils ≥ 8.9 × 103/µL (OR: 2.73, 1.82–4.11), Lymphocytes < 1.3 × 103/µL (OR: 1.72, 1.17–2.53) and CRP ≥ 19.1 mg/L (OR: 2.57, 1.63–4.08). A risk score derived from predictive models achieved high accuracy by using an optimal threshold (AUC: 95%; 93–97%). Conclusions The study suggests that incorporating MDW in the clinical decision process may improve the early identification of sepsis, with minimal additional effort on the standard procedures adopted during emergency care.
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Affiliation(s)
- Ennio Polilli
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | - Giancarlo Di Iorio
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | - Claudio Silveri
- grid.461844.bEmergency Department, Pescara General Hospital, Pescara, Italy
| | - Gilda Angelini
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | | | - Jessica Elisabetta Esposito
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Pescara, Italy ,grid.158820.60000 0004 1757 2611Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Milena D’Amato
- grid.461844.bClinical Pathology Unit, Pescara General Hospital, Pescara, Italy
| | - Giustino Parruti
- grid.461844.bInfectious Diseases Unit, Pescara General Hospital, Pescara, Italy
| | - Fabrizio Carinci
- grid.6292.f0000 0004 1757 1758Department of Statistical Sciences, Bologna University, Bologna, Italy
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Tucker RV, Williams K, Theyyunni N, Fung CM. Sepsis-Induced Cardiomyopathy Detected With Focused Cardiac Ultrasound in the Emergency Department. J Emerg Med 2022; 63:e91-e99. [DOI: 10.1016/j.jemermed.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/04/2022] [Accepted: 06/04/2022] [Indexed: 12/05/2022]
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Ward MA, Kuttab HI, Tuck N, Taleb A, Okut H, Badgett RG. The Effect of Fluid Initiation Timing on Sepsis Mortality: A Meta-Analysis. J Intensive Care Med 2022; 37:1504-1511. [PMID: 35946105 DOI: 10.1177/08850666221118513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Current guidelines suggest the immediate initiation of crystalloid for sepsis-induced hypoperfusion but note that supporting evidence is low quality. The aim of this study is to examine the effect of timing of fluid initiation on mortality for adults with sepsis. DATA SOURCES Two authors independently reviewed relevant articles and extracted study details from PubMed, Scopus, Cochrane, Google Scholar, and previous relevant systematic reviews from 1-1-2000 to 1-6-2022. Registered with PROSPERO (CRD42021245431) and bias assessed using CLARITY. STUDY SELECTION A minimum of severe sepsis (Sepsis-2) or sepsis (Sepsis-3) for patients ≥18 years old. Fluid initiation timing ranging from prehospital to 120 min within sepsis onset defined as "early" initiation. DATA EXTRACTION Included studies providing mortality-based odds ratios (or comparable) adjusting for confounders or prospective trials. DATA SYNTHESIS From 1643 citations, five retrospective cohort studies were included (n = 20,209) with in-hospital mortality of 21.8%. A pooled analysis (odds ratio = OR [95% CI]) did not observe an impact on mortality for the early initiation of fluids among all patients, OR = 0.79 [0.62-1.02]; heterogeneity: I2 = 86% [70-94%], but when studies analyzed cases of hypotension where available, a survival benefit was observed, OR = 0.74 [0.61-0.90]. Initiation of fluids in two prehospital studies did not impact mortality, OR = 0.82 [0.27-2.43]. However, both prehospital cohorts observed benefit among hypotensive patients individually, although heterogenous results precluded significance when pooled, OR = 0.50 [0.21-1.18]. Three hospital-based studies with initiation stratified at 30, 100, and 120 min, observed survival benefit both individually and when pooled, OR = 0.78 [0.63-0.97]. No differences were observed between prehospital versus hospital subgroups. CONCLUSION This meta-analysis supports the guideline recommendations for early fluid initiation once sepsis is recognized, especially in cases of hypotension. Findings are limited by the small number, heterogeneity, and retrospective nature of available studies. Further retrospective investigations may be worthwhile as randomized studies on fluid initiation are unlikely.
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Affiliation(s)
- Michael A Ward
- Department of Emergency, 5232University of Wisconsin-Madison, Madison, WI, USA
| | - Hani I Kuttab
- Department of Emergency, 5232University of Wisconsin-Madison, Madison, WI, USA
| | - Nicholas Tuck
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Ali Taleb
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Hayrettin Okut
- Office of Research, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Robert G Badgett
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
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Surviving Sepsis Campaign 2021 guideline: fails to appreciate the challenge of evaluating an undifferentiated patient. Eur J Emerg Med 2022; 29:99-100. [PMID: 35210377 DOI: 10.1097/mej.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ramgopal S, Horvat CM, Adler MD. Varying Estimates of Sepsis among Adults Presenting to US Emergency Departments: Estimates from a National Dataset from 2002-2018. J Intensive Care Med 2022; 37:1451-1459. [PMID: 35225727 PMCID: PMC9548922 DOI: 10.1177/08850666221080060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background A variety of approaches to defining sepsis using administrative datasets have been previously reported. We aimed to compare estimates, demographics, treatment factors, outcomes and longitudinal trends of patients identified with sepsis in United States emergency departments (EDs) using differing sets of sepsis criteria. Methods We performed a cross-sectional study using the National Healthcare Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters between 2002 to 2018. We obtained survey-weighted population-adjusted encounters of sepsis using the following criteria: explicit sepsis, severe sepsis, and quick Sequential Organ Failure Assessment (qSOFA) score combined with the presence of infection. Results Age-adjusted for US adults, 18.6, 16.1 and 8.9 encounters per 10 000 population were identified when using the explicit, severe sepsis and qSOFA definitions, respectively. A higher proportion of the explicit cohort was hospitalized and had blood cultures performed, compared to cohorts ascertained using severe sepsis and qSOFA criteria, though confidence intervals overlapped. Antibiotic use was highest in encounters meeting qSOFA criteria. When inspecting unweighted encounters meeting each set of criteria, there was minimal overlap, with only 3% meeting all three. Encounters meeting the explicit and severe sepsis criteria were increasing over time. Conclusion The explicit, severe sepsis and qSOFA criteria generated similar annual rates of presentation when applied to US ED encounters, with some evidence of the explicit sepsis cohort being higher acuity. There was minimal overlap of cases and instability in estimates when assessed longitudinally. Our findings inform research efforts to accurately identify sepsis among ED encounters using administrative data.
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Affiliation(s)
- Sriram Ramgopal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christopher M Horvat
- University of Pittsburgh School of Medicine; UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mark D Adler
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Fung CM, Meurer WJ. CMS is only happy when it rains. Acad Emerg Med 2021; 28:829-831. [PMID: 34346145 DOI: 10.1111/acem.14317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Christopher M. Fung
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Michigan Center for Integrative Research in Critical Care Ann Arbor Michigan USA
| | - William J. Meurer
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Michigan Center for Integrative Research in Critical Care Ann Arbor Michigan USA
- Department of Neurology University of Michigan Ann Arbor Michigan USA
- Stroke Program University of Michigan Ann Arbor Michigan USA
- Berry Consultants, LLC Austin Texas USA
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