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Patton MJ, Liu VX. Predictive Modeling Using Artificial Intelligence and Machine Learning Algorithms on Electronic Health Record Data: Advantages and Challenges. Crit Care Clin 2023; 39:647-673. [PMID: 37704332 DOI: 10.1016/j.ccc.2023.02.001] [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: 09/15/2023]
Abstract
The rapid adoption of electronic health record (EHR) systems in US hospitals from 2008 to 2014 produced novel data elements for analysis. Concurrent innovations in computing architecture and machine learning (ML) algorithms have made rapid consumption of health data feasible and a powerful engine for clinical innovation. In critical care research, the net convergence of these trends has resulted in an exponential increase in outcome prediction research. In the following article, we explore the history of outcome prediction in the intensive care unit (ICU), the growing use of EHR data, and the rise of artificial intelligence and ML (AI) in critical care.
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Affiliation(s)
- Michael J Patton
- Medical Scientist Training Program, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Hugh Kaul Precision Medicine Institute at the University of Alabama at Birmingham, 720 20th Street South, Suite 202, Birmingham, Alabama, 35233, USA.
| | - Vincent X Liu
- Kaiser Permanente Division of Research, Oakland, CA, USA.
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Molano Franco D, Arevalo‐Rodriguez I, Roqué i Figuls M, Montero Oleas NG, Nuvials X, Zamora J. Plasma interleukin-6 concentration for the diagnosis of sepsis in critically ill adults. Cochrane Database Syst Rev 2019; 4:CD011811. [PMID: 31038735 PMCID: PMC6490303 DOI: 10.1002/14651858.cd011811.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The definition of sepsis has evolved over time, along with the clinical and scientific knowledge behind it. For years, sepsis was defined as a systemic inflammatory response syndrome (SIRS) in the presence of a documented or suspected infection. At present, sepsis is defined as a life-threatening organ dysfunction resulting from a dysregulated host response to infection. Even though sepsis is one of the leading causes of mortality in critically ill patients, and the World Health Organization (WHO) recognizes it as a healthcare priority, it still lacks an accurate diagnostic test. Determining the accuracy of interleukin-6 (IL-6) concentrations in plasma, which is proposed as a new biomarker for the diagnosis of sepsis, might be helpful to provide adequate and timely management of critically ill patients, and thus reduce the morbidity and mortality associated with this condition. OBJECTIVES To determine the diagnostic accuracy of plasma interleukin-6 (IL-6) concentration for the diagnosis of bacterial sepsis in critically ill adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, and Web of Science on 25 January 2019. We screened references in the included studies to identify additional studies. We did not apply any language restriction to the electronic searches. SELECTION CRITERIA We included diagnostic accuracy studies enrolling critically ill adults aged 18 years or older under suspicion of sepsis during their hospitalization, where IL-6 concentrations were evaluated by serological measurement. DATA COLLECTION AND ANALYSIS Two review authors independently screened the references to identify relevant studies and extracted data. We assessed the methodological quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. We estimated a summary receiver operating characteristic (SROC) curve by fitting a hierarchical summary ROC (HSROC) non-linear mixed model. We explored sources of heterogeneity using the HSROC model parameters. We conducted all analyses in the SAS statistical software package and R software. MAIN RESULTS We included 23 studies (n = 4192) assessing the accuracy of IL-6 for the diagnosis of sepsis in critically ill adults. Twenty studies that were available as conference proceedings only are awaiting classification. The included participants were heterogeneous in terms of their distribution of age, gender, main diagnosis, setting, country, positivity threshold, sepsis criteria, year of publication, and origin of infection, among other factors. Prevalence of sepsis greatly varied across studies, ranging from 12% to 78%. We considered all studies to be at high risk of bias due to issues related to the index test domain in QUADAS-2. The SROC curve showed a great dispersion in individual studies accuracy estimates (21 studies, 3650 adult patients), therefore the considerable heterogeneity in the collected data prevented us from calculating formal accuracy estimates. Using a fixed prevalence of sepsis of 50% and a fixed specificity of 74%, we found a sensitivity of 66% (95% confidence interval 60 to 72). If we test a cohort 1000 adult patients under suspicion of sepsis with IL-6, we will find that 330 patients would receive appropriate and timely antibiotic therapy, while 130 patients would be wrongly considered to have sepsis. In addition, 370 out of 1000 patients would avoid unnecessary antibiotic therapy, and 170 patients would have been undiagnosed of sepsis. This numerical approach should be interpreted with caution due to the limitations described above. AUTHORS' CONCLUSIONS Our evidence assessment of plasma interleukin-6 concentrations for the diagnosis of sepsis in critically ill adults reveals several limitations. High heterogeneity of collected evidence regarding the main diagnosis, setting, country, positivity threshold, sepsis criteria, year of publication, and the origin of infection, among other factors, along with the potential number of misclassifications, remain significant constraints for its implementation. The 20 conference proceedings assessed as studies awaiting classification may alter the conclusions of the review once they are fully published and evaluated. Further studies about the accuracy of interleukin-6 for the diagnosis of sepsis in adults that apply rigorous methodology for conducting diagnostic test accuracy studies are needed. The conclusions of the review will likely change once the 20 studies pending publication are fully published and included.
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Affiliation(s)
- Daniel Molano Franco
- Fundacion Universitaria de Ciencias de la Salud, Hospital de San JoséDepartment of Critical CareCarrera 19 # 8‐32BogotaBogotaColombia11001
| | - Ingrid Arevalo‐Rodriguez
- Hospital Universitario Ramón y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP)Clinical Biostatistics UnitCtra. Colmenar Km. 9,100MadridSpain28034
- Cochrane Associate Centre of MadridMadridSpain
- Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTECentro Asociado Cochrane de EcuadorQuitoEcuador
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
| | - Nadia G Montero Oleas
- Centro de Investigación de Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTECentro Asociado Cochrane de EcuadorQuitoEcuador
| | - Xavier Nuvials
- Hospital Vall d’HebronDepartment of Critical Care MedicinePasseig Vall d’Hebron 119‐129BarcelonaSpain08035
- Vall d'Hebron Institut de Recerca (VHIR)SODIR research groupBarcelonaSpain
| | - Javier Zamora
- Cochrane Associate Centre of MadridMadridSpain
- Women’s Health Research Unit, Centre for Primary Care and Public Health, Queen Mary University of LondonLondonUK
- Hospital Universitario Ramon y Cajal (IRYCIS). CIBER Epidemiology and Public Health (CIBERESP)Clinical Biostatistics UnitMadridSpain
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Mohammed H, Varoni EM, Cochis A, Cordaro M, Gallenzi P, Patini R, Staderini E, Lajolo C, Rimondini L, Rocchetti V. Oral Dysbiosis in Pancreatic Cancer and Liver Cirrhosis: A Review of the Literature. Biomedicines 2018; 6:biomedicines6040115. [PMID: 30544974 PMCID: PMC6316311 DOI: 10.3390/biomedicines6040115] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/03/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023] Open
Abstract
The human body is naturally colonized by a huge number of different commensal microbial species, in a relatively stable equilibrium. When this microbial community undergoes dysbiosis at any part of the body, it interacts with the innate immune system and results in a poor health status, locally or systemically. Research studies show that bacteria are capable of significantly influencing specific cells of the immune system, resulting in many diseases, including a neoplastic response. Amongst the multiple different types of diseases, pancreatic cancer and liver cirrhosis were significantly considered in this paper, as they are major fatal diseases. Recently, these two diseases were shown to be associated with increased or decreased numbers of certain oral bacterial species. These findings open the way for a broader perception and more specific investigative studies, to better understand the possible future treatment and prevention. This review aims to describe the correlation between oral dysbiosis and both pancreatic cancer and liver cirrhotic diseases, as well as demonstrating the possible diagnostic and treatment modalities, relying on the oral microbiota, itself, as prospective, simple, applicable non-invasive approaches to patients, by focusing on the state of the art. PubMed was electronically searched, using the following key words: "oral microbiota" and "pancreatic cancer" (PC), "liver cirrhosis", "systemic involvement", and "inflammatory mediators". Oral dysbiosis is a common problem related to poor oral or systemic health conditions. Oral pathogens can disseminate to distant body organs via the local, oral blood circulation, or pass through the gastrointestinal tract and enter into the systemic circulation. Once oral pathogens reach an organ, they modify the immune response and stimulate the release of the inflammatory mediators, this results in a disease. Recent studies have reported a correlation between oral dysbiosis and the increased risk of pancreatic and liver diseases and provided evidence of the presence of oral pathogens in diseased organs. The profound impact that microbial communities have on human health, provides a wide domain towards precisely investigating and clearly understanding the mechanism of many diseases, including cancer. Oral microbiota is an essential contributor to health status and imbalance in this community was correlated to oral and systemic diseases. The presence of elevated numbers of certain oral bacteria, particularly P. gingivalis, as well as elevated levels of blood serum antibodies, against this bacterial species, was associated with a higher risk of pancreatic cancer and liver cirrhosis incidence. Attempts are increasingly directed towards investigating the composition of oral microbiome as a simple diagnostic approach in multiple diseases, including pancreatic and liver pathosis. Moreover, treatment efforts are concerned in the recruitment of microbiota, for remedial purposes of the aforementioned and other different diseases. Further investigation is required to confirm and clarify the role of oral microbiota in enhancing pancreatic and liver diseases. Improving the treatment modalities requires an exertion of more effort, especially, concerning the microbiome engineering and oral microbiota transplantation.
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Affiliation(s)
- Hiba Mohammed
- Department of Health Sciences, Università del Piemonte Orientale UPO, 28100 Novara, Italy.
- Fondazione Novara Sviluppo, 28100 Novara, Italy.
| | - Elena Maria Varoni
- Department of Biomedical Sciences, Surgery and Dentistry, Università degli Studi di Milano, 20142 Milano, Italy.
| | - Andrea Cochis
- Department of Health Sciences, Università del Piemonte Orientale UPO, 28100 Novara, Italy.
- Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), 28100 Novara, Italy.
| | - Massimo Cordaro
- Institute of Dentistry and Maxillofacial Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Patrizia Gallenzi
- Institute of Dentistry and Maxillofacial Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Romeo Patini
- Institute of Dentistry and Maxillofacial Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Edoardo Staderini
- Institute of Dentistry and Maxillofacial Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Carlo Lajolo
- Institute of Dentistry and Maxillofacial Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Università Cattolica del Sacro Cuore, 00168 Rome, Italy.
| | - Lia Rimondini
- Department of Health Sciences, Università del Piemonte Orientale UPO, 28100 Novara, Italy.
- Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), 28100 Novara, Italy.
| | - Vincenzo Rocchetti
- Fondazione Novara Sviluppo, 28100 Novara, Italy.
- Department of Clinical and Experimental Medicine, Università del Piemonte Orientale UPO, 28100 Novara, Italy.
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DPIE [2-(1,2-diphenyl-1H-indol-3-yl)ethanamine] Augments Pro-Inflammatory Cytokine Production in IL-1β-Stimulated Primary Human Oral Cells. Int J Mol Sci 2018; 19:ijms19071835. [PMID: 29932110 PMCID: PMC6073580 DOI: 10.3390/ijms19071835] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023] Open
Abstract
Interleukin-1β (IL-1β) is a prominent pro-inflammatory cytokine that is implicated in a variety of autoimmune diseases and plays an important role in host defense against infections. IL-1β activity increases with its increasing binding capacity to IL-1 receptors (IL-1Rs). Thus, numerous studies have targeted the discovery of molecules modulating the interactions between IL-1β and IL-1R1. We have conducted an IL-1R1 structure-based virtual screening to identify small molecules that could alter IL-1β activity, using in silico computational analysis. Sixty compounds from commercial libraries were predicted to bind to IL-1R1, and their influence on cytokine production in IL-1β-stimulated gingival fibroblasts (GFs) was determined. Of these, only (2-(1,2-diphenyl-1H-indol-3-yl)ethanamine (DPIE) showed a synergistic increase in inflammatory molecules and cytokine production (IL-6, IL-8, and COX-2) at both mRNA and protein levels in IL-1β-stimulated GFs. The enhancing activity of DPIE in IL-1β-induced cytokine production increased in a dose-dependent manner without cytotoxicity. This pattern was also observed in IL-1β-stimulated primary human periodontal ligament cells (PDLs). Furthermore, we measured the impact of DPIE on the IL-1β–IL-1R1 system using surface plasmon resonance and demonstrated that DPIE increased the binding affinity of IL-1β to IL-1R1. These data indicate that DPIE boosts IL-1β signaling by enhancing the binding of IL-1β to IL-1R1 in oral primary cells.
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McCullough RW. US oncology-wide incidence, duration, costs and deaths from chemoradiation mucositis and antimucositis therapy benefits. Future Oncol 2017; 13:2823-2852. [PMID: 29192505 DOI: 10.2217/fon-2017-0418] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Approximate oncology-wide incidence, duration, costs and deaths associated with mucositis and identify health economic benefits of antimucositis therapies. Review the literature relevant to the clinical experience of mucositis by pathophysiology, incidence, duration, costs and deaths. Use US insurance actuarial and epidemiology on cancer to generalize an oncology-wide impact of toxic mucositis. Toxic mucositis causes oropharyngoesophageal ulcerations, chemo-induced nausea, vomiting and diarrhea. Acutely, it lasts 102 days/six cycles of chemotherapy, 60 days in human stem-cell transplantation patients and 70-84 days in head and neck cancer patients at annual costs of US$13.23 billion/522,166 treated patients (US$20,892/erosive-type mucositis patient, US$25,337/physiologic mucositis patient) and 46,699 deaths. Using antimucositis therapies prior to 2013 provided fractional benefits at high costs. By completely preventing and rapidly reversing mucositis, high-potency polymerized cross-linked sucralfate promises superior health economic benefits.
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Affiliation(s)
- Ricky W McCullough
- Translational Medicine Clinic & Research Center, Department of Medical Research, 1768 Storrs Road, Storrs, CT 06268, USA.,Department of Medicine, Veterans Administration Medical Center Providence, Brown University Teaching Affliate, 830 Chaulkstone Ave, Providence, RI 02804, USA
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Cytokines regulate complement receptor immunoglobulin expression and phagocytosis of Candida albicans in human macrophages: A control point in anti-microbial immunity. Sci Rep 2017. [PMID: 28642550 PMCID: PMC5481325 DOI: 10.1038/s41598-017-04325-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Complement Receptor Immunoglobulin (CRIg), selectively expressed by macrophages, plays an important role in innate immunity by promoting phagocytosis of bacteria. Thus modulation of CRIg on macrophages by cytokines can be an important mechanism by which cytokines regulate anti-microbial immunity. The effects of the cytokines, tumor necrosis factor, transforming growth factor-β1, interferon-γ, interleukin (IL)-4, IL-13, IL-10, IL-1β, IL-6, lymphotoxin-α, macrophage-colony stimulating factor (M-CSF) and GM-CSF on CRIg expression were examined in human macrophages. We demonstrated that cytokines regulated the CRIg expression on macrophages during their development from monocytes in culture at the transcriptional level using qPCR and protein by Western blotting. Both CRIg spliced forms (Long and Short), were similarly regulated by cytokines. Direct addition of cytokines to matured CRIg+ macrophages also changed CRIg mRNA expression, suggesting that cytokines control macrophage function via CRIg, at two checkpoints. Interestingly the classical complement receptors, CR3 and CR4 were differentially regulated by cytokines. The changes in CRIg but not CR3/CR4 mRNA expression correlated with ability to phagocytose Candida albicans by macrophages. These findings suggest that CRIg is likely to be a control point in infection and immunity through which cytokines can mediate their effects, and is differentially regulated from CR3 and CR4 by cytokines.
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Boron Induces Lymphocyte Proliferation and Modulates the Priming Effects of Lipopolysaccharide on Macrophages. PLoS One 2016; 11:e0150607. [PMID: 26934748 PMCID: PMC4774930 DOI: 10.1371/journal.pone.0150607] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 02/17/2016] [Indexed: 12/26/2022] Open
Abstract
Chemical mediators of inflammation (CMI) are important in host defense against infection. The reduced capacity of host to induce the secretion of these mediators following infection is one of the factors in host susceptibility to infection. Boron, which has been suggested for its role in infection, is reported in this study to increase lymphocyte proliferation and the secretion of CMI by the lipopolysaccharide (LPS)-stimulated peritoneal macrophages in BALB/c mice. Boron was administered to mice orally as borax at different doses for 10 consecutive days, followed by the stimulation of animals with ovalbumin and isolation of splenocytes for proliferation assay. The lymphocyte subsets were determined by flow cytometry in spleen cell suspension. The mediators of inflammation, TNF-α, IL-6, IL-1β and nitric oxide (NO), were measured in culture supernatant of LPS-primed macrophages isolated from borax treated mice. TNF and ILs were measured by ELISA. NO was determined by Griess test. The expression of inducible nitric oxide synthase (iNOS) in macrophages was studied by confocal microscopy. Results showed a significant increase in T and B cell populations, as indicated by an increase in CD4 and CD19, but not CD8, cells. Boron further stimulated the secretion of TNF-α, IL-6, IL-1β, NO and the expression of iNOS by the LPS-primed macrophages. The effect was dose dependent and most significant at a dose level of 4.6 mg/kg b. wt. Taken together, the study concludes that boron at physiological concentration induces lymphocyte proliferation and increases the synthesis and secretion of pro-inflammatory mediators by the LPS-primed macrophages, more specifically the M1 macrophages, possibly acting through Toll-like receptor. The study implicates boron as a regulator of the immune and inflammatory reactions and macrophage polarization, thus playing an important role in augmenting host defense against infection, with possible role in cancer and other diseases.
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Tokodai K, Amada N, Haga I, Nakamura A, Kashiwadate T, Kawagishi N, Ohuchi N. Limited utility of blood cultures in the management of febrile outpatient kidney transplant recipients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 50:634-639. [PMID: 26699949 DOI: 10.1016/j.jmii.2015.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 09/22/2015] [Accepted: 11/03/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Blood cultures for patients suspected of having bacteremia are standard practice, although several studies demonstrate that blood cultures have limited utility because of a low true-positive rate and infrequent resultant changes in antibiotic treatment. However, most reports exclude immunocompromised patients such as transplant recipients. We assessed the utility of blood cultures in transplant recipients hospitalized for community-acquired infections and evaluated clinical characteristics to predict bacteremia. METHODS This retrospective study included 136 febrile cases in 97 kidney transplant recipients admitted to our hospital for whom blood cultures were performed between February 2001 and March 2013. RESULTS Among the 136 cases, blood cultures were positive, contaminated, and negative in seven (5.1%) cases, 12 (8.8%) cases, and 117 cases (86.1%), respectively. All bacteria detected in the seven cases were sensitive to the initial empirical antibiotics. Antibiotic treatment was changed based on the blood culture results only in one case for which the coverage was narrowed. The white blood cell count and C-reactive protein level were significantly higher in the patients with bacteremia. The predictive model based on these two factors successfully identified the high-risk group with a sensitivity and specificity of 86% and 91%, respectively. CONCLUSION Among the outpatient kidney transplant recipients, positive blood cultures were uncommon and scarcely affected antibiotic therapy, especially in patients with upper respiratory tract or urinary tract infections. Therefore, it may be reasonable to perform blood cultures only for patients with marked leukocytosis and high C-reactive protein level, even among transplant recipients.
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Affiliation(s)
- Kazuaki Tokodai
- Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan; Department of Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Japan.
| | - Noritoshi Amada
- Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
| | - Izumi Haga
- Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
| | - Atsushi Nakamura
- Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
| | - Toshiaki Kashiwadate
- Department of Surgery, Japan Community Health Care Organization Sendai Hospital, Sendai, Japan
| | - Naoki Kawagishi
- Department of Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Japan
| | - Noriaki Ohuchi
- Department of Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Sendai, Japan
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Parlato M, Cavaillon JM. Host response biomarkers in the diagnosis of sepsis: a general overview. Methods Mol Biol 2015; 1237:149-211. [PMID: 25319788 DOI: 10.1007/978-1-4939-1776-1_15] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Critically ill patients who display a systemic inflammatory response syndrome (SIRS) are prone to develop nosocomial infections. The challenge remains to distinguish as early as possible among SIRS patients those who are developing sepsis. Following a sterile insult, damage-associated molecular patterns (DAMPs) released by damaged tissues and necrotic cells initiate an inflammatory response close to that observed during sepsis. During sepsis, pathogen-associated molecular patterns (PAMPs) trigger the release of host mediators involved in innate immunity and inflammation through identical receptors as DAMPs. In both clinical settings, a compensatory anti-inflammatory response syndrome (CARS) is concomitantly initiated. The exacerbated production of pro- or anti-inflammatory mediators allows their detection in biological fluids and particularly within the bloodstream. Some of these mediators can be used as biomarkers to decipher among the patients those who developed sepsis, and eventually they can be used as prognosis markers. In addition to plasma biomarkers, the analysis of some surface markers on circulating leukocytes or the study of mRNA and miRNA can be helpful. While there is no magic marker, a combination of few biomarkers might offer a high accuracy for diagnosis.
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Affiliation(s)
- Marianna Parlato
- Unit of Cytokines and Inflammation, Institut Pasteur, 28 rue du Dr Roux, 75724, Paris Cedex 15, France
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Goto J, Matsuda K, Harii N, Moriguchi T, Yanagisawa M, Sakata O. Usefulness of a real-time bowel sound analysis system in patients with severe sepsis (pilot study). J Artif Organs 2014; 18:86-91. [PMID: 25373367 DOI: 10.1007/s10047-014-0799-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 10/12/2014] [Indexed: 12/29/2022]
Abstract
Healthy bowel function is an important factor when judging the advisability of early enteral nutrition in critically ill patients, but long-term observation and objective evaluation of gastrointestinal motility are difficult. In the study, real-time continuous measurement of gastrointestinal motility was performed in patients with severe sepsis using a developed bowel sound analysis system, and the correlation between bowel sounds and changes over time in blood concentrations of interleukin (IL)-6, which is associated with sepsis severity, was evaluated. The subjects were five adult patients in the acute phase of severe sepsis on a mechanical ventilator, with IL-6 blood concentrations ≥100 pg/mL, who had consented to participate in the study. Gastrointestinal motility was measured for a total of 62,399 min: 31,544 min in 3 subjects in the no-steroids group and 30,855 min in 2 subjects in the steroid treatment group. In the no-steroids group, the bowel sound counts were negatively correlated with IL-6 blood concentration, suggesting that gastrointestinal motility was suppressed as IL-6 blood concentration increased. However, in the steroid treatment group, gastrointestinal motility showed no correlation with IL-6 blood concentration (r = -0.25, p = 0.27). The IL-6 blood concentration appears to have decreased with steroid treatment irrespective of changes in the state of sepsis, whereas bowel sound counts with the monitoring system reflected the changes in the state of sepsis, resulting in no correlation. This monitoring system provides a useful method of continuously, quantitatively, and non-invasively evaluating gastrointestinal motility in patients with severe sepsis. Gastrointestinal motility might be useful as a parameter reflecting disease severity, particularly in patients treated with steroids.
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Affiliation(s)
- Junko Goto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan,
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Arai T, Kumasaka K, Nagata K, Okita T, Oomura T, Hoshiai A, Koyama M, Ohta S, Yukioka T. Prediction of blood culture results by measuring procalcitonin levels and other inflammatory biomarkers. Am J Emerg Med 2013; 32:330-3. [PMID: 24462198 DOI: 10.1016/j.ajem.2013.12.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/15/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It would be helpful if we could predict positive or negative blood culture results. This study considered the usefulness of measuring procalcitonin (PCT) level and standard clinical biomarkers such as white blood cell (WBC) count, C-reactive protein (CRP) level, and platelet (PLT) count to predict blood culture results. METHOD We retrospectively analyzed the data from 422 specimens collected at our emergency center within the preceding 36 consecutive months. Primary component analysis (PCA) was used for detecting the degree of the relational contribution of each of the 4 biomarkers to the blood culture results. RESULTS Procalcitonin alone (cut-off value, 0.5 ng/mL) yielded a positive blood culture rate of 34.0%. Procalcitonin plus 3 biomarkers (WBC, CRP, and PLT) analyzed by PCA yielded 45.9% or 35.3% when a case was in the first or fourth quadrant, which was significantly higher than cases in the second or third quadrant. Primary component analysis also revealed that positive blood culture results were mainly affected by primary component 1, to which PCT and PLT (not WBC or CRP) predominantly contribute. CONCLUSION Although it is difficult to predict blood culture results, even using 4 biomarkers analyzed by PCA, our new finding that blood culture results are affected not by WBC and CRP, but mainly by PCT and PLT, might help explain the mechanism of sepsis.
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Affiliation(s)
- Takao Arai
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan.
| | - Kenichiro Kumasaka
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Katuhiro Nagata
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Taihei Okita
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Taishi Oomura
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Akira Hoshiai
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Masaharu Koyama
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Shoichi Ohta
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
| | - Tetsuo Yukioka
- Department of Emergency and Critical Care Medicine, Trauma and Emergency Center Hachioji Medical Center of Tokyo Medical University, 1163 Tatemachi, Hachioji-shi, Tokyo 193-0998, Japan
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DeSimone DC, Baddour LM, Lahr BD, Chung HH, Wilson WR, Steckelberg JM. Euthermic endocarditis. PLoS One 2013; 8:e80144. [PMID: 24244630 PMCID: PMC3823819 DOI: 10.1371/journal.pone.0080144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/07/2013] [Indexed: 12/17/2022] Open
Abstract
Background Most patients with infective endocarditis (IE) manifest fever. Comparison of endocarditis patients with and without fever, and whether the lack of fever in IE is a marker for poorer outcomes, such as demonstrated in other severe infectious diseases, have not been defined. Methods and Results Cases from the Mayo Clinic, Rochester, Minnesota, Division of Infectious Diseases IE registry, a single-center database that contains all cases of IE treated at our center. Diagnosis date between 1970 and 2006, which met the modified Duke criteria for definite endocarditis, without fever was included. There were 240 euthermic endocarditis cases included in this analysis, with 282 febrile controls selected by frequency matching on gender and decade of diagnosis. Euthermic patients had a median age of 63.6 years (±16.1) as compared to 59.0 years (±16.4) in the febrile control group (p=0.001). Median (IQR) symptom duration prior to diagnosis was 4.0 (1.0, 12.0) weeks in the euthermic group compared to 3.0 (1.0, 8.0) weeks in the febrile controls (p= 0.006). From unadjusted analyses, survival rates were 87% in euthermic cases versus 83% in febrile controls across 28-day follow-up (p=0.164), and 72% in euthermic group cases versus 69% in febrile controls across 1-year follow-up (p=0.345). Also unadjusted, the 1-year cumulative incidence rate of valve surgery was higher in euthermic cases versus febrile controls (50% vs. 39%, p= 0.004). Conclusions Patients with euthermic endocarditis are older, and lack of fever was associated with longer symptom duration and delayed diagnosis prior to IE diagnosis. Despite a higher unadjusted rate of valve surgery in euthermic patients, the result was not significant when adjusting for baseline confounders. Differences in survival rates at both 28-days and 365-days were not statistically significant between the two groups.
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Affiliation(s)
- Daniel C. DeSimone
- Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
- * E-mail:
| | - Larry M. Baddour
- Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
| | - Brian D. Lahr
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Heath H. Chung
- Infectious Diseases, John A. Burns School of Medicine, University of Hawaii, Handicap International, Honolulu, Hawaii, United States of America
| | - Walter R. Wilson
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - James M. Steckelberg
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
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13
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Serial and panel analyses of biomarkers do not improve the prediction of bacteremia compared to one procalcitonin measurement. J Infect 2012; 65:292-301. [DOI: 10.1016/j.jinf.2012.06.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 06/10/2012] [Accepted: 06/11/2012] [Indexed: 02/06/2023]
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14
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Affiliation(s)
- Luke SP Moore
- Department of Microbiology, Clinical and Investigative Sciences Clinical Programme Group, Imperial College Healthcare NHS Trust, London,
| | - James Hatcher
- Department of Microbiology, Chelsea and Westminster Hospital NHS Foundation Trust, London and
| | - Hugo Donaldson
- Department of Microbiology, Imperial College Healthcare NHS Trust, London
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15
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Stryjewski ME, Kanafani ZA, Chu VH, Pappas PA, Harding T, Drew LA, Benjamin DK, Reller LB, Lee BA, Corey GR, Fowler VG. Staphylococcus aureus bacteremia among patients with health care-associated fever. Am J Med 2009; 122:281-289.e2. [PMID: 19272489 DOI: 10.1016/j.amjmed.2008.09.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 08/25/2008] [Accepted: 09/11/2008] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although Staphylococcus aureus bacteremia is a common, serious infection, accurately identifying febrile patients with this diagnosis at the time of initial evaluation is difficult. The purpose of this investigation was to define clinical characteristics present at the time of the initial recognition of fever that were associated with the presence of any bloodstream infection and, in particular, with S. aureus bacteremia. METHODS All patients > or =18 years of age with a new episode of health care-associated fever (temperature > or =38 degrees C) and at least one blood culture drawn were eligible for enrollment into this prospective multicenter cohort study. Multivariable analyses were conducted and internally validated scoring systems were developed to categorize the risk of bacteremia. RESULTS Of 1015 patients enrolled, 181 patients (17.8%) had clinically significant bacteremia, including 77 patients (7.6%) with S. aureus bacteremia. Clinical characteristics associated with S. aureus bacteremia were the presence of a hemodialysis graft or shunt (odds ratio [OR] 3.22; 95% confidence interval [CI], 1.85-5.61), chills (OR 2.38; 95% CI, 1.43-3.98), and a history of S. aureus infection (OR 2.68; 95% CI, 1.38-5.20). Peripheral vascular catheters were inversely associated with S. aureus bacteremia (OR 0.42; 95% CI, 0.26-0.69). Clinical characteristics associated with any bloodstream infection were central venous access, chills, history of S. aureus infection, and hemodialysis access. CONCLUSIONS Among patients with health care-associated fever, the presence of easily recognizable clinical characteristics at the time of obtaining the initial blood cultures can help to identify patients at increased risk for any bloodstream infection, in particular for S. aureus bacteremia.
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Affiliation(s)
- Martin E Stryjewski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
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16
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Sanders J, Hawe E, Brull DJ, Hubbart C, Lowe GDO, Rumley A, Humphries SE, Montgomery HE. Higher IL-6 levels but not IL6 -174G>C or -572G>C genotype are associated with post-operative complication following coronary artery bypass graft (CABG) surgery. Atherosclerosis 2008; 204:196-201. [PMID: 18922529 DOI: 10.1016/j.atherosclerosis.2008.08.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 08/27/2008] [Accepted: 08/28/2008] [Indexed: 11/19/2022]
Abstract
Large increases in inflammatory markers, particularly IL-6, occur after cardiac surgery. However, despite interventions to reduce the inflammatory response, great variability still remains which could in part be attributable to genetic predisposition. Since increased IL-6 levels following surgery are also associated with poorer outcome we sought to determine whether baseline and post-operative levels of Interleukin-6 (IL-6) and functional common variants of the Interleukin-6 (IL6) gene are associated with post-operative outcome following coronary artery bypass grafting (CABG). Caucasian patients undergoing first-time elective CABG were studied. IL-6 levels were measured pre-, 6h and 24h following surgery and genotypes for IL6 gene variants -174G>C and -572G>C were obtained. Clinical data was collected daily until patient discharge. Patient outcome was categorised as with (ICUC, n=177) and without (NICUC, n=189) a post-operative complication during the ICU period and with (POC, n=215) and without (NC, n=151) a post-operative complication during hospitalisation. IL-6 levels pre- and at 24h were greater in POC and ICUC than NC and NICUC, respectively. Pre- IL-6 levels independently predicted (for 1 standard deviation increase in log IL-6) POC (OR 1.4, 95% CI 1.1-1.7, p=0.008) and ICUC (OR 1.3, 95% CI 1.0-1.6, p=0.02) outcomes. Overall, the IL6-572G>C had an effect over time on IL-6 levels (p=0.04) and on IL-6 levels in NC (P=0.008) and NICUC (p=0.006). However, no associations were found with the IL6 -572G>C or -174G>C variants on IL-6 levels at individual time-points or by outcome group. Thus, in conclusion, elevated pre-operative IL-6 levels, but not IL6 gene variants predict poor patient outcome following CABG.
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Affiliation(s)
- Julie Sanders
- Department of Surgery, University College London, London, UK.
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17
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Groeneveld ABJ, Hack CE. The role of the innate immune response in hospital- versus community-acquired infection in febrile medical patients. Int J Infect Dis 2008; 12:660-70. [PMID: 18514561 DOI: 10.1016/j.ijid.2008.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 03/10/2008] [Accepted: 03/11/2008] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES To study the role of the innate immune response in the higher mortality of hospital- than of community-acquired infections, in febrile medical patients. METHODS We studied presumably immunocompetent patients with new-onset fever and a clinically presumed focus of infection (N=212) at a university department of internal medicine. Clinical and microbiological data were collected for 2 days from inclusion, and circulating complement activation product C3a, secretory phospholipase A(2), interleukin (IL)-6, procalcitonin, and elastase-alpha(1)-antitrypsin were measured. Patients were followed for septic shock and outcome, up to a maximum of 7 and 28 days after inclusion, respectively. Infection was considered hospital-acquired if it developed at least 72h after admission. RESULTS Fifty-four patients had hospital-acquired infections and 158 had community-acquired infections, with septic shock and mortality rates of 15% and 24%, and 4% and 6% (p=0.001), respectively. Bloodstream infection predisposed to septic shock and the latter predisposed to death. Bloodstream infection was relatively more common in septic shock originating from community-acquired infection and was associated with an innate immune response in both hospital- and community-acquired infection, as judged from circulating immune variables. In contrast, circulating C3a, IL-6, and procalcitonin were more elevated when septic shock developed following hospital- than community-acquired infection, independent of infectious focus. The levels of C3a, secretory phospholipase A(2), IL-6, and elastase-alpha(1)-antitrypsin were more elevated in ultimate non-survivors than in survivors in both infection groups. CONCLUSIONS The data suggest that rates of septic shock and mortality from hospital- vs. community-acquired infections in febrile medical patients are not increased by impaired innate immunity. In contrast, proinflammatory factors may be particularly useful to predict a downhill course in hospital-acquired infections.
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Affiliation(s)
- A B Johan Groeneveld
- Department of Intensive Care, Institute for Cardiovascular Research, Vrije Universiteit Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands.
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18
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Dumestre-Pérard C, Doerr E, Colomb MG, Loos M. Involvement of complement pathways in patients with bacterial septicemia. Mol Immunol 2007; 44:1631-8. [PMID: 17049606 DOI: 10.1016/j.molimm.2006.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Revised: 08/07/2006] [Accepted: 08/08/2006] [Indexed: 11/25/2022]
Abstract
The complement system is a major humoral portion of the innate immune system, playing a significant role in host defence against microorganisms. The biological importance of this system is underlined by the fact that at least three different pathways for its activation exist, the classical, the MBL and the alternative pathway. To elucidate the involvement of the classical and/or the MBL pathway during bacterial septicemia, 32 patients with gram-positive and 30 patients with gram-negative bacterial infections were investigated. In patients with gram-positive bacteria, a significant consumption of C1q (p=0.005) but not of mannose-binding lectin (MBL) (p=0.2) was found during the acute phase of infection. In contrast, in patients with gram-negative bacterial infections, a significant reduction of MBL (p=0.002) and only a moderate, less significant reduction of C1q (p=0.03) were observed. As a model for the binding of MBL to gram-negative bacteria, Salmonella strains with defined mutations in their lipopolysaccharide (LPS) structure were used. The comparison of the binding of MBL to these Salmonella strains with that of the corresponding isolated LPS forms bound to microtiter plates revealed a similar binding pattern, supporting the interpretation that LPS on the surface of gram-negative bacteria is the major acceptor molecule for MBL on these bacteria, which according to our results obviously also takes place during gram-negative bacterial septicaemia. Furthermore, we were able to demonstrate that MBL bound to LPS was able to initiate activation of the complement cascade as measured by the occurrence of the cleavage product C4c.
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Affiliation(s)
- Chantal Dumestre-Pérard
- Institute of Medical Microbiology and Hygiene, Johannes Gutenberg-University, Hochhaus am Augustusplatz, 55101 Mainz, Germany.
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19
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Kaul DR, Flanders SA, Beck JM, Saint S. Brief report: incidence, etiology, risk factors, and outcome of hospital-acquired fever: a systematic, evidence-based review. J Gen Intern Med 2006; 21:1184-7. [PMID: 17026728 PMCID: PMC1831668 DOI: 10.1111/j.1525-1497.2006.00566.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Temperature is universally measured in the hospitalized patient, but the literature on hospital-acquired fever has not been systematically reviewed. This systematic review is intended to provide clinicians with an overview of the incidence, etiology, and outcome of hospital-acquired fever. DATA SOURCES We searched MEDLINE (1970 to 2005), EMBASE (1988 to 2004), and Web of Knowledge. References of all included articles were reviewed. Articles that focused on children, fever in the developing world, classic fever of unknown origin, or specialized patient populations were excluded. REVIEW METHODS Articles were reviewed independently by 2 authors before inclusion; a third author acted as arbiter. RESULTS Of over 1,000 studies reviewed, 7 met the criteria for inclusion. The incidence of hospital-acquired fever ranged from 2% to 17%. The etiology of fever was infection in 37% to 74%. Rates of antibiotic use for patients with a noninfectious cause of fever ranged from 29% to 55% for a mean duration of 6.6 to 9.6 days. Studies varied widely in their methodology and the patient population studied. CONCLUSIONS Limited information is available to guide an evidence-based approach to hospital-acquired fever. We propose criteria to help standardize future studies of this important clinical situation.
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Affiliation(s)
- Daniel R Kaul
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109-0378, USA.
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20
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Sungurtekin H, Sungurtekin U, Balci C. Circulating complement (C3 and C4) for differentiation of SIRS from sepsis. Adv Ther 2006; 23:893-901. [PMID: 17276958 DOI: 10.1007/bf02850211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The systemic inflammatory response of the body to invading microorganisms, called sepsis, leads to profound activation of the complement (C3 and C4) system. The present study was conducted to compare the use of serum C3 and C4 levels with C-reactive protein (CRP) and thrombocyte and leukocyte counts in differentiating patients with systemic inflammatory response syndrome (SIRS) from those with sepsis. Over a 6-mo period, all patients with SIRS or sepsis who stayed in the intensive care unit for >24 h were enrolled in the study. At admission, each patient's clinical status was recorded, and blood was taken for laboratory analysis (complete blood count, CRP, C3, and C4). A total of 58 patients with SIRS and 41 patients with sepsis were admitted to the study. The mean+/-SD thrombocyte count was found to be significantly lower in septic patients (179,975+/-95,615) than in those with SIRS (243,165+/-123,706) (P=.005); no difference in plasma concentrations of CRP and levels of C3 and C4 was noted between groups. The thrombocyte count was determined to be the most reliable parameter for differentiating between SIRS and sepsis (highest area under the curve=0.656).
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Affiliation(s)
- Hülya Sungurtekin
- Department of Anesthesiology and Reanimation, Pamukkale University School of Medicine, Denizli, Turkey
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21
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Saenger Y, Wolchok J. Cytokines in cytotherapy. Cytotherapy 2006; 8:313-4. [PMID: 16923605 DOI: 10.1080/14653240600861226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Ym Saenger
- Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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22
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Tuma R, Almyroudis N, Sohn S, Panageas K, Rice R, Galinkin D, Blain M, Montefusco M, Pamer E, Nimer S, Kewalramani T. The serum IL-12:IL-6 ratio reliably distinguishes infectious from non-infectious causes of fever during autologous stem cell transplantation. Cytotherapy 2006; 8:327-34. [PMID: 16923608 DOI: 10.1080/14653240600845237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Fever during neutropenia and after neutrophil engraftment (post-engraftment fever) occurs commonly during autologous transplantation (ASCT), but infections are infrequently identified. Tests that reliably exclude infection may reduce the cost and toxicity of unnecessary diagnostic testing and empiric treatment. We assessed whether serum levels of inflammatory cytokines could distinguish infectious from non-infectious causes of fever in patients undergoing ASCT. METHODS Serum levels of IL-1beta, IL-2, IL-6, IL-8, IL-10, IL-12(p70), TNF-alpha and IFN-gamma were measured by sandwich ELISA at multiple pre-determined times and at the onset of the first fever during neutropenia and after neutrophil engraftment in patients with hematologic malignancies undergoing ASCT. Standard clinical criteria were used to assess for the presence of infection. RESULTS Seventy-two febrile episodes occurred in 54 of 65 enrolled patients; 29 (40%) of the episodes occurred after neutrophil engraftment. Infections were identified as the cause of 28% and 24% of the neutropenic and post-engraftment febrile episodes, respectively. The level of IL-12 decreased and that of IL-6 increased significantly during fever because of infection, such that the IL-12:IL-6 ratio accurately excluded infection. The area under the ROC curve for the IL-12:IL-6 ratio was 0.88 (95% CI 0.79-0.97). The sensitivity, specificity, positive predictive and negative predictive values associated with a cut-off ratio of 4.1 were 95%, 75%, 60%, and 97%, respectively. DISCUSSION The IL-12:IL-6 ratio effectively discriminates infectious from non-infectious causes of fever during ASCT. It may be useful in assessing the probability of infection in patients with post-engraftment fever.
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Affiliation(s)
- Ra Tuma
- Infectious Disease Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10121, USA
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Bogar L, Molnar Z, Kenyeres P, Tarsoly P. Sedimentation characteristics of leucocytes can predict bacteraemia in critical care patients. J Clin Pathol 2006; 59:523-5. [PMID: 16533954 PMCID: PMC1860278 DOI: 10.1136/jcp.2005.033035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Early detection of blood stream infection can be lifesaving, but the results of blood cultures are not usually available before 24 hours after blood sampling. An earlier indication would lead to the initiation of immediate and adequate antibiotic treatment with obvious advantages for the patient. OBJECTIVE To evaluate the ability of leucocyte count, serum procalcitonin (PCT) concentration, erythrocyte sedimentation rate (ESR), and leucocyte antisedimentation rate (LAR) in predicting the blood culture results in critical care patients. METHODS 39 consecutive patients with their first febrile episode were investigated prospectively. LAR was determined as the percentage of leucocytes crossing the midline of a blood column upward during one hour of gravity sedimentation. The relevance of the different variables was estimated by likelihood ratio tests and area under receiver operating characteristic curves (AUC). RESULTS 23 patients had positive blood culture results and 16 negative. LAR was significantly higher in bacteraemic patients than in non-bacteraemic patients (p = 0.001), but leucocyte count, ESR and PCT level failed to show significant differences. Leucocyte count, PCT, and ESR yielded low discriminative values with the AUCs of 0.66, 0.64, and 0.52, respectively. LAR provided a likelihood ratio of 3.6 and an AUC of 0.80 (95% confidence interval, 0.64 to 0.95) (p = 0.002). CONCLUSIONS The simple LAR test can predict blood culture results and support urgent treatment decisions in critical care patients in their first febrile episode.
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Affiliation(s)
- L Bogar
- Department of Anaesthesiology and Critical Care, University of Pecs, Hungary.
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Tavares E, Maldonado R, Ojeda ML, Miñano FJ. Circulating inflammatory mediators during start of fever in differential diagnosis of gram-negative and gram-positive infections in leukopenic rats. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2005; 12:1085-93. [PMID: 16148175 PMCID: PMC1235789 DOI: 10.1128/cdli.12.9.1085-1093.2005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Gram-negative and gram-positive infections have been considered the most important causes of morbidity and mortality in patients with leukopenia following chemotherapy. However, discrimination between bacterial infections and harmless fever episodes is difficult. Because classical inflammatory signs of infection are often absent and fever is frequently the only sign of infection, the aim of this study was to assess the significance of serum interleukin-6 (IL-6), IL-10, macrophage inflammatory protein-2 (MIP-2), procalcitonin (PCT), and C-reactive protein (CRP) patterns in identifying bacterial infections during start of fever in normal and cyclophosphamide-treated (leukopenic) rats following an injection of lipopolysaccharide (LPS) or muramyl dipeptide (MDP) as a model for gram-negative and gram-positive bacterial infections. We found that, compared to normal rats, immunosuppressed animals exhibited significantly higher fevers and lesser production of all mediators, except IL-6, after toxin challenge. Moreover, compared to rats that received MDP, both groups of animals that received an equivalent dose of LPS showed significantly higher fevers and greater increase in serum cytokine levels. Furthermore, in contrast to those in immunocompetent rats, serum levels of IL-6 and MIP-2 were not significantly changed in leukopenic animals after MDP injection. Other serum markers such as PCT and CRP failed to discriminate between bacterial stimuli in both groups of animals. These results suggest that the use of the analyzed serum markers at an early stage of fever could give useful information for the clinician for excluding gram-negative from gram-positive infections.
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Affiliation(s)
- Eva Tavares
- Unidad de Investigación, Laboratorio de Farmacología Clinica y Experimental, Hospital Universitario Virgen De Valme, Seville, Spain
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25
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Stryjewski GR, Nylen ES, Bell MJ, Snider RH, Becker KL, Wu A, Lawlor C, Dalton H. Interleukin-6, interleukin-8, and a rapid and sensitive assay for calcitonin precursors for the determination of bacterial sepsis in febrile neutropenic children. Pediatr Crit Care Med 2005; 6:129-35. [PMID: 15730597 DOI: 10.1097/01.pcc.0000149317.15274.48] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Children with cancer often develop febrile illnesses after cytotoxic chemotherapy. Determining which children have serious bacterial infections in this vulnerable period would be valuable. We evaluated the ability of a rapid and sensitive assay for the concentration of calcitonin precursors (CTpr) as a sensitive diagnostic marker for bacterial sepsis in febrile, neutropenic children and determined the utility of measuring cytokines to improve the predictive value of this approach. DESIGN Prospective cohort study. SETTING Academic children's hospital. PATIENTS Fifty-six children (aged 5 months to 17 yrs) with a known malignancy who presented with fever and neutropenia. INTERVENTIONS Serial blood samples were obtained (admission, 24 hrs, and 48 hrs), and concentrations of CTpr, interleukin-6, and interleukin-8 were determined. Demographic and laboratory data from the patients were collected from the medical record. MEASUREMENTS AND MAIN RESULTS Sixteen (29%) of the children met the criteria for bacterial sepsis. Plasma levels of CTpr and interleukin-8, but not interleukin-6, were increased at all time points in children with sepsis compared with those without sepsis. CTpr at 24 and 48 hrs after admission were reliable markers for sepsis (area under the curve = 0.92 and 0.908, respectively). Logistic regression using CTpr at 24 hrs in addition to interleukin-8 at 48 hrs produced the best-fit models associated with sepsis. Using cutoff values of CTpr >500 pg/mL and interleukin-8 >20 pg/mL produced a screening test for sepsis with 94% sensitivity and 90% specificity. CONCLUSIONS Our data show the utility of a rapid and sensitive assay for CTpr combined with interleukin-8 as a highly sensitive and specific diagnostic marker of bacterial sepsis in febrile, neutropenic children. The use of these markers as a clinical tool may allow for better prognostication for clinicians and may eventually lead to more targeted therapies for this heterogeneous population.
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Affiliation(s)
- Glenn R Stryjewski
- Department of Pediatrics and Critical Care Medicine, Children's National Medical Center, Washington, DC, USA.
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26
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Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: An evidence-based review. Crit Care Med 2004; 32:S466-94. [PMID: 15542957 DOI: 10.1097/01.ccm.0000145917.89975.f5] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for the diagnosis of infection in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSIONS Obtaining a precise bacteriological diagnosis before starting antibiotic therapy is, when possible, of paramount importance for the success of therapeutic strategy during sepsis. Two to three blood cultures should be performed, preferably from a peripheral vein, without interval between samples to avoid delaying therapy. A quantitative approach is preferred in most cases when possible, in particular for catheter-related infections and ventilator-associated pneumonia. Diagnosing community-acquired pneumonia is complex, and a diagnostic algorithm is proposed. Appropriate samples are indicated during soft tissue and intraabdominal infections, but cultures obtained through the drains are discouraged.
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Affiliation(s)
- Jonathan Cohen
- Department of Medicine, Brighton & Sussex Medical School, Brighton, UK
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Brooks WA, Yunus M, Santosham M, Wahed MA, Nahar K, Yeasmin S, Black RE. Zinc for severe pneumonia in very young children: double-blind placebo-controlled trial. Lancet 2004; 363:1683-8. [PMID: 15158629 DOI: 10.1016/s0140-6736(04)16252-1] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pneumonia is a leading cause of morbidity and mortality in young children. Early reversal of severity signs--chest indrawing, hypoxia, and tachypnoea--improves outcome. We postulated that zinc, an acute phase reactant, would shorten duration of severe pneumonia and time in hospital. METHODS In a double-blind placebo-controlled clinical trial in Matlab Hospital, Bangladesh, 270 children aged 2-23 months were randomised to receive elemental zinc (20 mg per day) or placebo, plus the hospital's standard antimicrobial management, until discharge. The outcomes were time to cessation of severe pneumonia (no chest indrawing, respiratory rate 50 per min or less, oxygen saturation at least 95% on room air) and discharge from hospital. Discharge was allowed when respiratory rate was 40 per minute or less for 24 consecutive hours while patients were maintained only on oral antibiotics. FINDINGS The group receiving zinc had reduced duration of severe pneumonia (relative hazard [RH]=0.70, 95% CI 0.51-0.98), including duration of chest indrawing (0.80, 0.61-1.05), respiratory rate more than 50 per min (0.74, 0.57-0.98), and hypoxia (0.79, 0.61-1.04), and overall hospital duration (0.75, 0.57-0.99). The mean reduction is equivalent to 1 hospital day for both severe pneumonia and time in hospital. All effects were greater when children with wheezing were omitted from the analysis. INTERPRETATION Adjuvant treatment with 20 mg zinc per day accelerates recovery from severe pneumonia in children, and could help reduce antimicrobial resistance by decreasing multiple antibiotic exposures, and lessen complications and deaths where second line drugs are unavailable.
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Affiliation(s)
- W Abdullah Brooks
- Centre for Health and Population Research, International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128 Mohakhali, Dhaka 1000, Bangladesh.
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Jaimes F, Arango C, Ruiz G, Cuervo J, Botero J, Vélez G, Upegui N, Machado F. Predicting Bacteremia at the Bedside. Clin Infect Dis 2004; 38:357-62. [PMID: 14727205 DOI: 10.1086/380967] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2003] [Accepted: 09/17/2003] [Indexed: 11/03/2022] Open
Abstract
Our aim was to develop a clinical prediction rule for detection of bacteremia in a cohort of patients observed prospectively at a reference center in Medellín, Colombia. The significant predictors of bacteremia were an age of >or=30 years (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.19-3.60), a heart rate of >or=90 beats/min (OR, 1.90; 95% CI, 1.13-3.17), a temperature of >or=37.8 degrees C (OR, 2.42; 95% CI, 1.41-4.14), a leukocyte count of >or=12,000 cells/microL (OR, 2.40; 95% CI, 1.41-4.10), use of a central venous catheter (OR, 1.89; 95% CI, 1.02-3.50), and a length of hospitalization of >or=10 days (OR, 2.02; 95% CI, 1.25-3.24). The Hosmer-Lemeshow test revealed a goodness-of-fit of 2.99 (P=.981), and the area under the receiver operating characteristics curve was 0.7186. Simple variables obtained from the clinical history of patients are associated with bloodstream infection in a reproducible fashion and should be instrumental for prioritizing the requests for blood cultures by clinicians.
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Affiliation(s)
- Fabián Jaimes
- Department of Internal Medicine and Escuela de Investigaciones Médicas Aplicadas, School of Medicine, University of Antioquia, Medellín, Colombia.
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Tacx AN, Groeneveld ABJ, Hart MH, Aarden LA, Hack CE. Mannan binding lectin in febrile adults: no correlation with microbial infection and complement activation. J Clin Pathol 2004; 56:956-9. [PMID: 14645358 PMCID: PMC1770136 DOI: 10.1136/jcp.56.12.956] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To study the role of the mannan binding lectin (MBL) pathway of complement activation in the host defence to microbial infection in vivo, and the role of MBL in infectious mortality in non-selected patients. METHODS A prospective observational study on 177 hospitalised medical patients with new onset fever. The presence, origin, and microbial cause of infection, the circulating MBL and complement activation product 3a (C3a), and the 28 day hospital course were determined. RESULTS The patients had median MBL values similar to healthy blood donors: 18% of the patients and 14% of the blood donors had MBL deficiency, with values below 0.1 microg/ml. Median C3a was higher in patients with microbiologically confirmed infection than in those without, whereas there was no difference in MBL values or frequency of deficiency among patient groups with or without positive local cultures or bacteraemia. The mortality rate was 8% and the outcome groups did not differ in MBL. In febrile adults hospitalised in internal medicine wards, microbial infection induces complement activation, independently of MBL. CONCLUSIONS The results argue against a predominant role for the MBL pathway of complement activation and a deficiency of MBL predisposing to serious and invasive microbial infection in non-selected adults.
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Affiliation(s)
- A N Tacx
- Department of Intensive Care, Vrije Universiteit Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Predictive Value of Leukocytosis and Neutrophilia for Bloodstream Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2004. [DOI: 10.1097/01.idc.0000104893.16995.0a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ansari-Lari MA, Kickler TS, Borowitz MJ. Immature granulocyte measurement using the Sysmex XE-2100. Relationship to infection and sepsis. Am J Clin Pathol 2003; 120:795-9. [PMID: 14608908 DOI: 10.1309/lt30-bv9u-jjv9-cfhq] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
We determined the usefulness of immature granulocyte measurement as a predictor of infection or positive blood culture and compared the results with total WBC count and absolute neutrophil count (ANC). Blood samples from 102 infected and 69 noninfected patients were analyzed using the Sysmex XE-2100 automated blood cell counter (Sysmex, Kobe, Japan). The percentage of immature granulocytes was significantly higher in infected than in noninfected patients and in patients with positive than patients with negative blood cultures. Receiver operating characteristic curves showed that the percentage of immature granulocytes was a better predictor of infection than the WBC count and comparable to the ANC. Automated immature granulocyte measurements reflect a biologically and clinically relevant phenomenon but are not sensitive enough to be used as screening assays for prediction of infection or bacteremia. However, although infrequently encountered, a percentage of immature granulocytes of more than 3 was a very specific predictor of sepsis and might help expedite microbiologic laboratory evaluation of a subset of patients.
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Affiliation(s)
- M Ali Ansari-Lari
- Department of Pathology, Johns Hopkins Medical Institutions, 401 N Broadway, Room Weinberg 2335, Baltimore, MD 21231-2410, USA
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Groeneveld ABJ, Tacx AN, Bossink AWJ, van Mierlo GJ, Hack CE. Circulating inflammatory mediators predict shock and mortality in febrile patients with microbial infection. Clin Immunol 2003; 106:106-15. [PMID: 12672401 DOI: 10.1016/s1521-6616(02)00025-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The host response to microbial infection is associated with the release of inflammatory mediators. We hypothesized that the type and degree of the systemic response as reflected by levels of circulating mediators predict morbidity and mortality, according to the invasiveness of microbial infection. We prospectively studied 133 medical patients with fever and culture-proven microbial infection. For 3 days after inclusion, the circulating levels of activated complement C3a, interleukin (IL)-6, and secretory phospholipase A(2) (sPLA(2)) were determined daily. Based on results of microbiological studies performed for up to 7 days, patients were classified as having local infections (Group 1, n = 80 positive local cultures or specific stains for fungal or tuberculous infections) or bacteremia (Group 2, n = 52 plus 1 patient with malaria parasitemia). Outcome was assessed as the development of septic shock and as mortality up to 28 days after inclusion. Fifteen patients (11%) developed septic shock and overall mortality was 18% (n = 24). Bacteremia was associated with shock and shock predisposed to death. Circulating mediator levels were generally higher in Group 2 than in Group 1. Circulating levels of IL-6 and sPLA(2) were higher in patients developing septic shock and in nonsurvivors, particularly in Group 1. High C3a was particularly associated with nonsurvival in Group 2. In Group 1, the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for the peak sPLA(2) for shock development was 0.79 (P < 0.05). The AUC of the ROC curve of the peak IL-6 and sPLA(2) for mortality was 0.69 and 0.68 (P < 0.05), respectively. In Group 2, the AUC of the ROC for peak C3a predicting mortality was 0.73 (P < 0.05). In conclusion, in medical patients with fever and microbial infection, the systemic inflammatory host response predicts shock and death, at an early stage, dependent on the invasiveness of microbial infection. The results suggest a differential pathogenetic role of complement activation on the one hand and release of cytokine and lipid mediators on the other in bacteremic and local microbial infections, respectively. They may partly explain the failure of strategies blocking proinflammatory cytokines or sPLA(2) in human sepsis and may extend the basis for attempts to inhibit complement activation at an early stage in patients at risk of dying from invasive microbial infections.
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Affiliation(s)
- A B J Groeneveld
- Department of Internal Medicine and Intensive Care Unit, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands.
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