Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals

Corticosteroid sensitivity detection in sepsis patients using a personalized data mining approach: A clinical investigation

BACKGROUND AND OBJECTIVE

Sepsis is a life-threatening disease with high mortality, incidence, and morbidity. Corticosteroids (CS) are a recommended treatment for sepsis, but some patients respond negatively to CS therapy. Early prediction of corticosteroid responsiveness can help intervene and reduce mortality. In this study, we aim to develop a data mining methodology for predicting CS responsiveness of septic patients.

METHODS

We used data from a randomized controlled trial called APROCCHSS, which recruited 1241 septis patients to study the effectiveness of corticotherapy. We conducted a thorough study of multiple machine learning models to select the most efficient prediction model, called "signature". We evaluated the performance of the signature using precision, sensitivity, and specificity values.

RESULTS

We found that Logistic Regression was the best model with an AUC of 72%. We conducted further experiments to examine the impact of additional features and the model's generalizability to different groups of patients. We also performed a statistical analysis to analyze the effect of the treatment at the individual level and on the population as a whole.

CONCLUSIONS

Our data mining methodology can accurately predict cortico-sensitivity or resistance in septis patients. The signature has been deployed into the Assistance Publique - Hôpitaux de Paris (APHP) information system as a web service, taking patient information as input and providing a prediction of cortico-sensitivity or resistance. Early prediction of corticosteroid responsiveness can help clinicians intervene promptly and improve patient outcomes.

A Clinical Diagnostic Study: Fibulin-2 is a Novel Promising Biomarker for Predicting Infection

Introduction

Infection remains a major cause of morbidity and mortality in hospital. As uncontrolled early infection may develop into systemic infection and eventually progress to sepsis, it is important to address infection at an early stage. Furthermore, early detection and prompt diagnosis of infection are the basis of clinical intervention. However, as a result of the interference of complex aetiologies, including fever and trauma, problems regarding the sensitivity and specificity of current diagnostic indices remain, such as for C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC), neutrophil ratio (NEU%), interleukin-6 (IL-6) and D-dimer. As a result, there is an urgent need to develop new biomarkers to diagnose infection.

Methods

From January to October 2021, consecutive patients in the emergency department (ED) were recruited to investigate the feasibility of fibulin-2 as a diagnostic indicator of early infection. Fibulin-2 concentrations in plasma were determined with enzyme-linked immunosorbent assay (ELISA). The performance of fibulin-2 for predicting infection was analysed by receiver operating characteristic (ROC) curves.

Results

We found that the plasma fibulin-2 level was elevated in patients with infection compared with those without infection. ROC curve analysis showed that the area under the curve (AUC) for fibulin-2 was 0.712. For all patients included, the diagnostic ability of fibulin-2 (AUC 0.712) performed as well as CRP (AUC 0.667) and PCT (AUC 0.632), and better than WBC (AUC 0.620), NEU% (AUC 0.619), IL-6 (AUC 0.561) and D-dimer (AUC 0.630). In patients with fever, fibulin-2 performed as well as PCT and better than the other biomarkers in infection diagnosis. In particular, fibulin-2 performed better than all these biomarkers in patients with trauma.

Conclusion

Fibulin-2 is a novel promising diagnostic biomarker for predicting infection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-022-00622-y.

A Locally Optimized Data-Driven Tool to Predict Sepsis-Associated Vasopressor Use in the ICU

OBJECTIVES

To train a model to predict vasopressor use in ICU patients with sepsis and optimize external performance across hospital systems using domain adaptation, a transfer learning approach.

DESIGN

Observational cohort study.

SETTING

Two academic medical centers from January 2014 to June 2017.

PATIENTS

Data were analyzed from 14,512 patients (9,423 at the development site and 5,089 at the validation site) who were admitted to an ICU and met Center for Medicare and Medicaid Services definition of severe sepsis either before or during the ICU stay. Patients were excluded if they never developed sepsis, if the ICU length of stay was less than 8 hours or more than 20 days or if they developed shock up to the first 4 hours of ICU admission.

MEASUREMENTS AND MAIN RESULTS

Forty retrospectively collected features from the electronic medical records of adult ICU patients at the development site (four hospitals) were used as inputs for a neural network Weibull-Cox survival model to derive a prediction tool for future need of vasopressors. Domain adaptation updated parameters to optimize model performance in the validation site (two hospitals), a different healthcare system over 2,000 miles away. The cohorts at both sites were randomly split into training and testing sets (80% and 20%, respectively). When applied to the test set in the development site, the model predicted vasopressor use 4-24 hours in advance with an area under the receiver operator characteristic curve, specificity, and positive predictive value ranging from 0.80 to 0.81, 56.2% to 61.8%, and 5.6% to 12.1%, respectively. Domain adaptation improved performance of the model to predict vasopressor use within 4 hours at the validation site (area under the receiver operator characteristic curve 0.81 [CI, 0.80-0.81] from 0.77 [CI, 0.76-0.77], p < 0.01; specificity 59.7% [CI, 58.9-62.5%] from 49.9% [CI, 49.5-50.7%], p < 0.01; positive predictive value 8.9% [CI, 8.5-9.4%] from 7.3 [7.1-7.4%], p < 0.01).

CONCLUSIONS

Domain adaptation improved performance of a model predicting sepsis-associated vasopressor use during external validation.

Predicting the clinical trajectory in critically ill patients with sepsis: a cohort study

Background

To develop a mathematical model to estimate daily evolution of disease severity using routinely available parameters in patients admitted to the intensive care unit (ICU).

Methods

Over a 3-year period, we prospectively enrolled consecutive adults with sepsis and categorized patients as (1) being at risk for developing (more severe) organ dysfunction, (2) having (potentially still reversible) limited organ failure, or (3) having multiple-organ failure. Daily probabilities for transitions between these disease states, and to death or discharge, during the first 2 weeks in ICU were calculated using a multi-state model that was updated every 2 days using both baseline and time-varying information. The model was validated in independent patients.

Results

We studied 1371 sepsis admissions in 1251 patients. Upon presentation, 53 (4%) were classed at risk, 1151 (84%) had limited organ failure, and 167 (12%) had multiple-organ failure. Among patients with limited organ failure, 197 (17%) evolved to multiple-organ failure or died and 809 (70%) improved or were discharged alive within 14 days. Among patients with multiple-organ failure, 67 (40%) died and 91 (54%) improved or were discharged. Treatment response could be predicted with reasonable accuracy (c-statistic ranging from 0.55 to 0.81 for individual disease states, and 0.67 overall). Model performance in the validation cohort was similar.

Conclusions

This prediction model that estimates daily evolution of disease severity during sepsis may eventually support clinicians in making better informed treatment decisions and could be used to evaluate prognostic biomarkers or perform in silico modeling of novel sepsis therapies during trial design.

Clinical trial registration

ClinicalTrials.gov NCT01905033

Prognostic Value of MMP-9 -1562 C/T Gene Polymorphism in Patients With Sepsis

Introduction:

Matrix metalloproteinase-9 (MMP-9) plays an important role in the pathophysiology of sepsis. A single-nucleotide polymorphism (SNP) at position -1562 (C/T) in the MMP-9 gene has been associated with differential MMP-9 expression, being higher when the -1562 T allele is present. We evaluated the association of the SNP MMP9 -1562 C/T with severity and mortality in patients with sepsis to establish whether the prognosis of the disease is affected.

Materials and Methods:

A case-control study exploratory was carried out in a cohort of infected patients. 540 individuals were selected in total, 270 patients with sepsis and 270 controls (infected but non-septic), classified according to the 2016 consensus (Sepsis-3). The presence of the single-nucleotide polymorphism (SNP; allele T and/or allele C) was determined through analyses of restriction fragment length polymorphism and plasma levels of MMP-9 were determined through enzyme-linked immunosorbent assay immunoassay.

Results:

SNP MMP-9 -1562 has two known alleles (T and C), with predominance of the C over the T allele; in the group of patients with sepsis, T allele was found in 7.2% of cases, while C allele in the rest (92.8%); in comparison, in the group of infected but non-septic patients, frequencies were 9.4% for T allele and 90.6% for the C allele (P = .33). Also, the presence of the polymorphic T allele was not related to the levels of MMP-9 in patients with sepsis in comparison with infected but non-septic patients 780 (397-1375) ng/mL vs 646 (172-1249) ng/mL (P = .64). There was also no association between the SNP and sepsis mortality (P = .78).

Conclusions:

We concluded that there was no association between the SNP MMP9 -1562 C/T and sepsis or between the SNP MMP9 -1562 C/T and sepsis mortality in the Northeastern Colombian septic patient cohort. Further research is needed to clarify the correlation among sepsis, genetic factors with allele T and MMP-9 plasma concentration.

The Effects of High-volume Hemofiltration by Different Ultrasound Directing on Extra Vascular Lung Water Index in Patients with Septic Shock

BACKGROUND

We explored the effects of high-volume hemofiltration(HVHF) by different ultrasound directing on the plasma N-terminal pro-B-type natriuretic peptide(NT-Pro-BNP), extra vascular lung water index (EVLWI), liquid net balance quantity and prognosis in patients with septic shock.

METHODS

Overall, 107 intensive patients with septic shock were enrolled by retrospective analysis from Department of Intensive Care Unit (ICU) of the Shandong Provincial Hospital affiliated to Shandong University from 2014-2017. According to HVHF by different ultrasound directing, all the patients were divided into two groups ((ultrasonic cardiac output monitor (USCOM), group A, n=51cases)) and ((critical bedside ultrasound (CBU), group B, n=56cases)).

RESULTS

The value of CI in group A had a significant positive correlation with the value of PCCI by the PiCCO₂ monitoring (P<0.05). The lung ultrasound water B lines in group B also had a significant positive correlation with the value of EVLWI by the PiCCO₂ monitoring. The cumulative liquid net balance quantity in group B had a more significant elevation than group A after treatment 7th d. The level of EVLWI after treatment 48 h and 72 h, the level of plasma NT-Pro-BNP, the levels of P(A-a)DO2,OI and blood lactic after treatment 72 h, and the APACHE II scores and SOFA scores after treatment 7thd were reduced more significantly in group B than group A (P<0.001). The mortality at 28th day had a more significant decrease in group B than group A.

CONCLUSION

It could decrease the level of NT-Pro-BNP, EVLWI, P(A-a)DO2, which then improves pulmonary oxygenation. Consequently, it decreased the APACHE II and SOFA scores and improved the 28th survival rate of patients.

Attenuation of the physiological response to infection on adults over 65 years old admitted to the emergency room (ER)

It has been considered that the elderly have clinical manifestations different from the ones observed in middle-age adults during an injury event. This hypothesis has not been extensively explored in sepsis and bacterial infections. Secondary analysis of two prospective studies including 2611 patients over 18 years of age admitted to the emergency room with confirmed or probable bacterial infections and sepsis. The outcome measures were heart rate, respiratory rate, systolic blood pressure, temperature, Glasgow Coma Scale, creatinine, PaO₂/FiO₂ and platelets daily during the first week. Compared to survivors younger than 65, the deceased under 65 had an average heart rate of 12.5 beats per minute per day higher (95% CI 9.32; 15.61), while patients over 65 who died barely had an average 5.7 beats per minute per day higher than the same reference group (95% CI 3.45; 8.06). The systolic blood pressure had a significant decreased in those who died younger than 65, compared to survivors with the same age, in both cohorts (-5.2 mmHg, 95% CI -8.17; -2.23 and -8.5 mmHg, 95% CI -13.48; -3.54, respectively), while those older than 65 who died had a nonsignificant increase (+1.6 mmHg, 95% CI -1.33; 4.62 and +0.1, 95% CI -6.48; 6.72, respectively) compared to the same reference group. The behavior of most clinical and laboratory variables suggests a less pronounced response of subjects above 65 years of age who died 28 days after being diagnosed with sepsis.

Predictive Value of Matrix Metalloproteinases and Their Inhibitors for Mortality in Septic Patients: A Cohort Study

Purpose:

Over 170 biomarkers are being investigated regarding their prognostic and diagnostic accuracy in sepsis in order to find new tools to reduce morbidity and mortality. Matrix metalloproteinases (MMPs) and their inhibitors have been recently studied as promising new prognostic biomarkers in patients with sepsis. This study is aimed at determining the utility of several cutoff points of these biomarkers to predict mortality in patients with sepsis.

Materials and Methods:

A multicenter, prospective, analytic cohort study was performed in the metropolitan area of Bucaramanga, Colombia. A total of 289 patients with sepsis and septic shock were included. MMP-9, MMP-2, tissue inhibitor of metalloproteinase 1 (TIMP-1), TIMP-2, TIMP-1/MMP-9 ratio, and TIMP-2/MMP-2 ratio were determined in blood samples. Value ranges were correlated with mortality to estimate sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiving operating characteristic curve.

Results:

Sensitivity ranged from 33.3% (MMP-9/TIMP-1 ratio) to 60.6% (TIMP-1) and specificity varied from 38.8% (MMP-2/TIMP-2 ratio) to 58.5% (TIMP-1). As for predictive values, positive predictive value range was from 17.5% (MMP-9/TIMP-1 ratio) to 70.4% (MMP-2/TIMP-2 ratio), whereas negative predictive values were between 23.2% (MMP-2/TIMP-2 ratio) and 80.9% (TIMP-1). Finally, area under the curve scores ranged from 0.31 (MMP-9/TIMP-1 ratio) to 0.623 (TIMP-1).

Conclusion:

Although TIMP-1 showed higher sensitivity, specificity, and negative predictive value, with a representative population sample, we conclude that none of the evaluated biomarkers had significant predictive value for mortality.

Perspectives on aetiology, pathophysiology and management of shock in African children

Paediatric shock is still a common emergency of public health importance with an estimated 400,000–500,000 reported cases annually. Mortality due to paediatric shock has varied over the years. Data in 1980s show that mortality rates due to septic shock in children were over 50%; but by the end of the year 2000 data indicated that though a marked decline in mortality rates had been achieved, it had stagnated at about 20%. Descriptions of paediatric shock reveal the lack of a common definition and there are important gaps in evidence-based management in different settings. In well-resourced healthcare systems with well-functioning intensive care facilities, the widespread implementation of shock management guidelines based on the Paediatric Advanced Life Support and European Paediatric Advanced Life Support courses have reduced mortality. In resource limited settings with diverse infectious causative agents, the Emergency Triage Assessment and Treatment (ETAT) approach is more pragmatic, but its impact remains circumscribed to centres where ETAT has been implemented and sustained. Advocacy for common management pathways irrespective of underlying cause have been suggested. However, in sub Saharan Africa, the diversity of underlying causative organisms and patient phenotypes may limit a single approach to shock management.

Data from a large fluid trial (the FEAST trial) in East Africa have provided vital insight to shock management. In this trial febrile children with clinical features of impaired perfusion were studied. Rapid infusion of fluid boluses, irrespective of whether the fluid was colloid or crystalloid, when compared to maintenance fluids alone had an increased risk of mortality at 48 h. All study participants were promptly managed for underlying conditions and comorbidity such as malaria, bacteraemia, severe anaemia, meningitis, pneumonia, convulsions, hypoglycaemia and others. The overall low mortality in the trial suggests the potential contribution of ETAT, the improved standard of care and supportive treatment across the subgroups in the trial. Strengthening systems that enable rapid identification of shock, prompt treatment of children with correct antimicrobials and supportive care such as oxygen administration and blood transfusion may contribute to better survival outcomes in resources limited settings.

Sepsis in Buraidah Central Hospital, Qassim, Kingdom of Saudi Arabia

OBJECTIVES

Severe sepsis is a major public health concern and a frequent cause of intensive care unit (ICU) admission with a high fatality rate. Higher (Sequential Organ Failure Assessment score) SOFA score and co-morbidity of acute renal failure (ARF) are risk factors contributing to fatal outcome. This work was meant to study the epidemiology of sepsis in Buraidah central hospital.

METHODS

This is a descriptive study conducted in the period from January 1, 2012, to June 29, 2012 to determine the epidemiology (incidence, clinical characteristics) and the outcome of sepsis in Buraidah hospital, Saudi Arabia.

RESULTS

Out of 387 patients admitted to ICU, 62 (16%) patients had sepsis, their mean (SD) age was 62.7 (21.3) years. Three quarters of them 47 (75.8%) presented with septic shock. The median APACHE II score was 26.5 (8 to 48) and SOFA score 11 (5 to 21). The mean of duration of hospital stay was 11.95 days. The most frequent infection site was the pulmonary (69.5%). There were 37 isolated organism, gram-negative organisms (13; 35.13%) were the predominant isolates. There were 25 (40.3%) deaths; the majority of the deaths were due to septic shock 20(80%). There was a significant difference between deaths and the survivors, in the APACHI II score, SOFA score), and whether ventilated or not.

CONCLUSIONS

There was a high incidence of septic shock (and higher mortality) among the patients admitted to the ICU of Buraidah central hospital, especially among the elderly patients with respiratory infections.