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Chiscano-Camón L, Ruiz-Sanmartin A, Bajaña I, Bastidas J, Lopez-Martinez R, Franco-Jarava C, Gonzalez JJ, Larrosa N, Riera J, Nuvials-Casals X, Ruiz-Rodríguez JC, Ferrer R. Current perspectives in the management of sepsis and septic shock. Front Med (Lausanne) 2024; 11:1431791. [PMID: 39211340 PMCID: PMC11358069 DOI: 10.3389/fmed.2024.1431791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024] Open
Abstract
Within patients with sepsis, there exists significant heterogeneity, and while all patients should receive conventional therapy, there are subgroups of patients who may benefit from specific therapies, often referred to as rescue therapies. Therefore, the identification of these specific patient subgroups is crucial and lays the groundwork for the application of precision medicine based on the development of targeted interventions. Over the years, efforts have been made to categorize sepsis into different subtypes based on clinical characteristics, biomarkers, or underlying mechanisms. For example, sepsis can be stratified into different phenotypes based on the predominant dysregulated host response. These phenotypes can range from hyperinflammatory states to immunosuppressive states and even mixed phenotypes. Each phenotype may require different therapeutic approaches to improve patient outcomes. Rescue strategies for septic shock may encompass various interventions, such as immunomodulatory therapies, extracorporeal support (e.g., ECMO), or therapies targeted at specific molecular or cellular pathways involved in the pathophysiology of sepsis. In recent years, there has been growing interest in precision medicine approaches to sepsis and phenotype identification. Precision medicine aims to tailor treatments to each individual patient based on their unique characteristics and disease mechanisms.
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Affiliation(s)
- Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ivan Bajaña
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juliana Bastidas
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Rocio Lopez-Martinez
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Clara Franco-Jarava
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan José Gonzalez
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Xavier Nuvials-Casals
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
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Nofal MA, Shitawi J, Altarawneh HB, Alrosan S, Alqaisi Y, Al-Harazneh AM, Alamaren AM, Abu-Jeyyab M. Recent trends in septic shock management: a narrative review of current evidence and recommendations. Ann Med Surg (Lond) 2024; 86:4532-4540. [PMID: 39118750 PMCID: PMC11305747 DOI: 10.1097/ms9.0000000000002048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/29/2024] [Indexed: 08/10/2024] Open
Abstract
Septic shock stands for a group of manifestations that will cause a severe hemodynamic and metabolic dysfunction, which leads to a significant increase in the risk of death by a massive response of the immune system to any sort of infection that ends up with refractory hypotension making it responsible for escalating the numbers of hospitalized patients mortality rate, Organisms that are isolated most of the time are Escherichia coli, Klebsiella, Pseudomonas aeruginosa, and Staph aureus. The WHO considers sepsis to be a worldwide health concern; the incidence of sepsis and septic shock have been increasing over the years while being considered to be under-reported at the same time. This review is a quick informative recap of the recent studies regarding diagnostic approaches using lactic acid (Lac), procalcitonin (PCT), Sequential Organ Failure Assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II) score, as well as management recommendations for using vasopressors, fluid resuscitation, corticosteroids and antibiotics that should be considered when dealing with such type of shock.
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Affiliation(s)
| | - Jawad Shitawi
- Internal Medicine, Epsom and St Helier University Hospitals NHS Trust, Sutton, GBR, UK
| | | | - Sallam Alrosan
- Internal Medicine, Saint Luke’s Health System, Kansas City, MO, USA
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Kim MJ, Choi EJ, Choi EJ. Evolving Paradigms in Sepsis Management: A Narrative Review. Cells 2024; 13:1172. [PMID: 39056754 PMCID: PMC11274781 DOI: 10.3390/cells13141172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Sepsis, a condition characterized by life-threatening organ dysfunction due to a dysregulated host response to infection, significantly impacts global health, with mortality rates varying widely across regions. Traditional therapeutic strategies that target hyperinflammation and immunosuppression have largely failed to improve outcomes, underscoring the need for innovative approaches. This review examines the development of therapeutic agents for sepsis, with a focus on clinical trials addressing hyperinflammation and immunosuppression. It highlights the frequent failures of these trials, explores the underlying reasons, and outlines current research efforts aimed at bridging the gap between theoretical advancements and clinical applications. Although personalized medicine and phenotypic categorization present promising directions, this review emphasizes the importance of understanding the complex pathogenesis of sepsis and developing targeted, effective therapies to enhance patient outcomes. By addressing the multifaceted nature of sepsis, future research can pave the way for more precise and individualized treatment strategies, ultimately improving the management and prognosis of sepsis patients.
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Affiliation(s)
- Min-Ji Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu 41404, Republic of Korea;
| | - Eun-Joo Choi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu 42472, Republic of Korea;
| | - Eun-Jung Choi
- Department of Anatomy, School of Medicine, Daegu Catholic University, Duryugongwon-ro 17gil, Nam-gu, Daegu 42472, Republic of Korea
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4
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Lazar A. Recent Data about the Use of Corticosteroids in Sepsis-Review of Recent Literature. Biomedicines 2024; 12:984. [PMID: 38790946 PMCID: PMC11118609 DOI: 10.3390/biomedicines12050984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024] Open
Abstract
Sepsis, characterized by life-threatening organ dysfunction due to a maladaptive host response to infection, and its more severe form, septic shock, pose significant global health challenges. The incidence of these conditions is increasing, highlighting the need for effective treatment strategies. This review explores the complex pathophysiology of sepsis, emphasizing the role of the endothelium and the therapeutic potential of corticosteroids. The endothelial glycocalyx, critical in maintaining vascular integrity, is compromised in sepsis, leading to increased vascular permeability and organ dysfunction. Corticosteroids have been used for over fifty years to treat severe infections, despite ongoing debate about their efficacy. Their immunosuppressive effects and the risk of exacerbating infections are significant concerns. The rationale for corticosteroid use in sepsis is based on their ability to modulate the immune response, promote cardiovascular stability, and potentially facilitate organ restoration. However, the evidence is mixed, with some studies suggesting benefits in terms of microcirculation and shock reversal, while others report no significant impact on mortality or organ dysfunction. The Surviving Sepsis Campaign provides cautious recommendations for their use. Emerging research highlights the importance of genomic and transcriptomic analyses in identifying patient subgroups that may benefit from corticosteroid therapy, suggesting a move toward personalized medicine in sepsis management. Despite potential benefits, the use of corticosteroids in sepsis requires careful consideration of individual patient risk profiles, and further research is needed to optimize their use and integrate genomic insights into clinical practice. This review underscores the complexity of sepsis treatment and the ongoing need for evidence-based approaches to improve patient outcomes.
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Affiliation(s)
- Alexandra Lazar
- Anesthesiology and Intensive Care Department, "George Emil Palade" University of Medicine, Pharmacy, Science and Technology from Tirgu Mures, 540142 Targu Mures, Romania
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Morabito LA, Corica D, Pepe G, Li Pomi A, Aversa T, Wasniewska MG. Critical illness-related corticosteroid insufficiency (CIRCI) in paediatric patients: a diagnostic and therapeutic challenge. Ital J Pediatr 2024; 50:46. [PMID: 38462639 PMCID: PMC10926569 DOI: 10.1186/s13052-024-01616-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/24/2024] [Indexed: 03/12/2024] Open
Abstract
Critical illness-related corticosteroid insufficiency or CIRCI is characterized by acute and life-threatening disfunction of hypothalamic-pituitary-adrenal (HPA) axis observed among intensive care unit- staying patients.It is associated with increased circulating levels of biological markers of inflammation and coagulation, morbidity, length of ICU stay, and mortality.Several mechanisms are involved in CIRCI pathogenesis: reduced CRH-stimulated ACTH release, peripheral resistance to glucocorticoids, altered cortisol synthesis, impaired cortisol-free fraction and bioavailability.Diagnostic and therapeutic management of this condition in children is still debated, probably because of the lack of agreement among intensive care specialists and endocrinologists regarding diagnostic criteria and prevalence of CIRCI in paediatric age.In the present narrative review, we focused on definition of CIRCI in paediatric age and we advise on how to diagnose and treat this poorly understood condition, based on current literature data.
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Affiliation(s)
- Letteria Anna Morabito
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy.
| | - Domenico Corica
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giorgia Pepe
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Alessandra Li Pomi
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Tommaso Aversa
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Malgorzata Gabriela Wasniewska
- Pediatric Unit, Maternal Infant Department, "Gaetano Martino" University Hospital, Via Consolare Valeria, 98122, Messina, Italy
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
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Kommareddy A, Vagha JD, Meshram RJ. Navigating the Landscape of Hydrocortisone Administration in Septic Shock: Current Concepts and Future Directions. Cureus 2023; 15:e49870. [PMID: 38169849 PMCID: PMC10758589 DOI: 10.7759/cureus.49870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/02/2023] [Indexed: 01/05/2024] Open
Abstract
Sepsis remains a formidable challenge in critical care medicine, often culminating in a life-threatening condition known as septic shock. This review article navigates the intricate landscape of hydrocortisone administration in septic shock management, delving into historical perspectives, current evidence, controversies, mechanisms of action, practical considerations, and the importance of precision medicine. Hydrocortisone's role as an adjunctive therapy is explored, highlighting its potential to stabilize hemodynamics, mitigate the inflammatory response, and improve patient outcomes. However, debates persist regarding patient selection, dosing regimens, safety profiles, and long-term consequences. The future of septic shock management lies in emerging therapies, precision medicine approaches, biomarker discovery, and targeted interventions. Moving forward, exploring novel therapeutic avenues, understanding patient-specific responses, and uncovering potential biomarkers will be crucial in advancing septic shock treatment strategies. Clinical guidelines provide a foundation, but individualized patient care, interdisciplinary collaboration, and ongoing research are essential to optimize treatment strategies. This article underscores the call for continued research and evidence-based practice as we strive to enhance the care of septic shock patients and pursue improved outcomes in this critical condition. Embracing future developments in the field will enable us to adapt and refine our approach, ultimately contributing to the advancement of septic shock management.
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Affiliation(s)
- Anirudh Kommareddy
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Jayant D Vagha
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Revat J Meshram
- Pediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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7
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Lin Q, Li Z, Lu L, Xu H, Lou E, Chen A, Sun D, Zhang W, Zhu W, Yee EU, Sears PS, Chen X, Kelly CP. Budesonide, an anti-inflammatory drug, exacerbate clostridioides difficile colitis in mice. Biomed Pharmacother 2023; 167:115489. [PMID: 37713991 DOI: 10.1016/j.biopha.2023.115489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND AND AIMS Clostridioides difficile infection (CDI) induces intense acute inflammatory responses through toxin release. A combination of antibiotic and anti-inflammatory agents is sometimes recommended in severe, non-responsive cases, although clinical trials have been inconclusive, raising concerns about potential complications. This study aims to investigate the effect of budesonide and mesalamine in the treatment of CDI in a murine model, by evaluating the combination of fidaxomicin and these anti-inflammatory drugs. METHOD C57BL/6 J female mice pretreated with an antimicrobial mixture were challenged with C. difficile VPI 10463 or culture media by gavage. After the challenge, mice received placebo, fidaxomicin alone (20 mg/kg), or fidaxomicin combined with mesalamine (200, 400 mg/kg) or budesonide (0.2, 1, 10 mg/kg) for 5 days. The mice were monitored for 7 days with weight and survival. Colon and cecum tissues were harvested for histological assessment. RESULTS CDI of mice caused 80% mortality. Fidaxomicin completely protected against CDI in all parameters (weight, survival and pathscores). Mortality rates were up to 90%, 70% in budesonide(10 mg/kg) and mesalamine (400 mg/kg) treatment group, respectively. Budesonide (0.02,0.1 and 1 mg/kg) adjunction to fidaxomicin worsened the disease outcome according to all tested parameters. While mesalamine in combination with fidaxomicin (200, 400 mg/kg) did not lead to any deaths during CDI treatment, it did not provide additional benefits. CONCLUSIONS Anti-inflammatory drugs including corticosteroid therapy may worsen the incidence and severity of CDI in this mouse model. These studies may have important clinical implications for understanding the role of anti-inflammatory/ corticosteroid therapy in CDI and inflammatory bowel disease management.
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Affiliation(s)
- Qianyun Lin
- Department of Gastroenterology, Beijing Friendship Hospital, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, National Clinical Research Center for Digestive Disease, Beijing Digestive Disease Center, Capital Medical University, Beijing, China; Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Zitong Li
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lei Lu
- Section of Neonatology, Department of Paediatrics and Medicine, the University of Chicago, Chicago, IL, USA
| | - Hua Xu
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Eddie Lou
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Alyssa Chen
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Dustin Sun
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Wuyi Zhang
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Weishu Zhu
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Eric U Yee
- Department of Pathology, Beth Israel Deaconess Medical Centre, Boston, MA, USA; Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Xinhua Chen
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA.
| | - Ciaran P Kelly
- Divisions of Gastroenterology, Beth Israel Deaconess Medical Centre, Boston, MA, USA.
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Chemical mimetics of the N-degron pathway alleviate systemic inflammation by activating mitophagy and immunometabolic remodeling. Exp Mol Med 2023; 55:333-346. [PMID: 36720915 PMCID: PMC9981610 DOI: 10.1038/s12276-023-00929-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 02/02/2023] Open
Abstract
The Arg/N-degron pathway, which is involved in the degradation of proteins bearing an N-terminal signal peptide, is connected to p62/SQSTM1-mediated autophagy. However, the impact of the molecular link between the N-degron and autophagy pathways is largely unknown in the context of systemic inflammation. Here, we show that chemical mimetics of the N-degron Nt-Arg pathway (p62 ligands) decreased mortality in sepsis and inhibited pathological inflammation by activating mitophagy and immunometabolic remodeling. The p62 ligands alleviated systemic inflammation in a mouse model of lipopolysaccharide (LPS)-induced septic shock and in the cecal ligation and puncture model of sepsis. In macrophages, the p62 ligand attenuated the production of proinflammatory cytokines and chemokines in response to various innate immune stimuli. Mechanistically, the p62 ligand augmented LPS-induced mitophagy and inhibited the production of mitochondrial reactive oxygen species in macrophages. The p62 ligand-mediated anti-inflammatory, antioxidative, and mitophagy-activating effects depended on p62. In parallel, the p62 ligand significantly downregulated the LPS-induced upregulation of aerobic glycolysis and lactate production. Together, our findings demonstrate that p62 ligands play a critical role in the regulation of inflammatory responses by orchestrating mitophagy and immunometabolic remodeling.
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Wu CH, Guo L, Hao D, Wang Q, Ye X, Ito M, Huang B, Mineo C, Shaul PW, Li XA. Relative adrenal insufficiency is a risk factor and endotype of sepsis - A proof-of-concept study to support a precision medicine approach to guide glucocorticoid therapy for sepsis. Front Immunol 2023; 13:1110516. [PMID: 36713379 PMCID: PMC9878847 DOI: 10.3389/fimmu.2022.1110516] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction 25-60% of septic patients experience relative adrenal insufficiency (RAI) and glucocorticoid (GC) is frequently used in septic patients. However, the efficacy of GC therapy and whether GC therapy should be based on the status of RAI are highly controversial. Our poor understanding about the pathogenesis of RAI and a lack of RAI animal model present significant barriers to address these critical issues. Methods Scavenger receptor BI (SR-BI) regulates stress-induced GC (iGC) production in response to stress. We generated SF1CreSR-BIfl/fl mice and utilized the mice as a RAI model to elucidate the pathogenesis of RAI and GC therapy in sepsis. SF1CreSR-BIfl/fl mice did not express SR-BI in adrenal gland and lacked iGC production upon ACTH stimulation, thus, they are RAI. Results and Discussion RAI mice were susceptible to cecal ligation and puncture (CLP)-induced sepsis (6.7% survival in SF1CreSR-BIfl/fl mice versus 86.4% in SR-BIfl/fl mice; p = 0.0001). Compared to a well-controlled systemic inflammatory response in SR-BIfl/fl mice, SF1CreSR-BIfl/fl mice featured a persistent hyperinflammatory response. Supplementation of a low stress dose of GC to SF1CreSR-BIfl/fl mice kept the inflammatory response under control and rescued the mice. However, SR-BIfl/fl mice receiving GC treatment exhibited significantly less survival compared to SR-BIfl/fl mice without GC treatment. In conclusions, we demonstrated that RAI is a risk factor for death in this mouse model of sepsis. We further demonstrated that RAI is an endotype of sepsis, which features persistent hyperinflammatory response. We found that GC treatment benefits mice with RAI but harms mice without RAI. Our study provides a proof of concept to support a precision medicine approach for sepsis therapy - selectively applying GC therapy for a subgroup of patients with RAI.
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Affiliation(s)
- Chia-Hua Wu
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Ling Guo
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Dan Hao
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Qian Wang
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Xiang Ye
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Misa Ito
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Bin Huang
- Division of Cancer Biostatistics, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Chieko Mineo
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Philip W. Shaul
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Xiang-An Li
- Department of Pharmacology and Nutritional Sciences, University of Kentucky College of Medicine, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, United States
- Lexington Veterans Affairs (VA), Healthcare System, Lexington, KY, United States
- Department of Physiology, University of Kentucky College of Medicine, Lexington, KY, United States
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Ram GK, Shekhar S, Singh RB, Anand R, De RR, Kumar N. Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses versus Continuous Infusion in Septic Shock: A Prospective Randomized Trial. Anesth Essays Res 2022; 16:321-325. [PMID: 36620116 PMCID: PMC9813985 DOI: 10.4103/aer.aer_115_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 12/14/2022] Open
Abstract
Background Hydrocortisone showed an important role in reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the most common side effects associated with corticosteroid treatment. Aims This study aimed to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses versus continuous infusion in septic shock patients. Settings and Design This was a prospective randomized controlled study conducted in a tertiary care teaching hospital. Materials and Methods One hundred and forty patients with septic shock and who received noradrenaline were enrolled in this randomized study. Group 1 was intermittent bolus hydrocortisone group (n = 70) and Group 2 was continuous infusion group (n = 70). All patients who were admitted with septic shock and who received noradrenaline and hydrocortisone were included in the study. Those patients who had exceeded 200 mg per day of hydrocortisone were excluded from the study. The primary outcome of the study was mean blood glucose. Statistical Analysis Used Qualitative variables were compared between the two groups with the Chi-square of the Fisher's exact test and continuous variables were compared using the Student's t-test or the Wilcoxon rank-sum test. Results Out of 112 patients, 54 patients received hydrocortisone as intermittent boluses (48.2%), and 58 patients (51.8%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 154.44 mg.dL-1 (95% confidence interval [CI]: 144.18-166.88) in the bolus group and 160.2 mg.dL-1 (95% CI: 143.82-176.76) in the infusion group with a mean difference of 05.76 mg.dL-1 (95% CI: -13.86-25.38). For the secondary outcomes of the study, no difference was found between the two groups in hyperglycemic or hypoglycemic events, mortality, length of stay in intensive care unit, and reversal of shock. Conclusions The risk of hyperglycemia is almost equal in both intermittent and continuous infusions of hydrocortisone in septic shock patients.
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Affiliation(s)
- Ganesh Kumar Ram
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Saurav Shekhar
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Raj Bahadur Singh
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Ravi Anand
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Ranjeet Rana De
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Nitin Kumar
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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11
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Bhat V, Saini SS, Sachdeva N, Walia R, Sundaram V, Dutta S. Adrenocortical Dysfunctions in Neonatal Septic Shock. Indian J Pediatr 2022; 89:714-716. [PMID: 35091960 DOI: 10.1007/s12098-021-03955-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/20/2021] [Indexed: 11/26/2022]
Abstract
The prevalence of adrenal insufficiency at the onset of neonatal septic shock was estimated. Total serum cortisol and adrenocorticotropin (ACTH) levels were measured at the onset of septic shock in term and preterm neonates. Serum cortisol levels were measured again after 30 min of 1 µg adrenocorticotropin injection. The authors defined Adrenocortical insufficiency as absolute adrenalin sufficiency (baseline serum cortisol < 15 µg/dL, rise in serum cortisol < 9 µg/dL after ACTH injection), or relative adrenal insufficiency (baseline cortisol ≥ 15 µg/dL, rise < 9 µg/dL). Thirty neonates with septic shock were enrolled. Six of them had absolute adrenal insufficiency while 2 neonates had relative adrenal insufficiency. Thus, the prevalence of adrenal insufficiency was 27% at the onset of neonatal septic shock, 95% confidence interval: 12%-46%. Seventeen (57%) neonates with septic shock had cortisol levels (< 15 µg/dL) with adequate rise (≥ 9 µg/dL) after ACTH stimulation indicating depressed baseline levels, which responded to ACTH stimulation.
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Affiliation(s)
- Vivek Bhat
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shiv Sajan Saini
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Naresh Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkataseshan Sundaram
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sourabh Dutta
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Lin HC, Chiang HP, Jiang WP, Lan YH, Huang GJ, Hsieh MT, Kuo SC, Lo CL, Chiang YT. Exploitation of a rod-shaped, acid-labile curcumin-loaded polymeric nanogel system in the treatment of systemic inflammation. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 133:112597. [DOI: 10.1016/j.msec.2021.112597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
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13
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Nedel W, Lisboa T, Salluh JIF. What Is the Role of Steroids for Septic Shock in 2021? Semin Respir Crit Care Med 2021; 42:726-734. [PMID: 34544190 DOI: 10.1055/s-0041-1733900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.
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Affiliation(s)
- Wagner Nedel
- Programa de Pós-Graduação em Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Programa de Pós-Graduação em Ciencias Pneumologicas, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Universidade Unilasalle, Canoas, Brazil
- Instituto de Pesquisa, HCOR, São Paulo, Brazil
| | - Jorge I F Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Cetin G, Tras B, Uney K. The Effects of P‐glycoprotein Modulators on the Transition of Levofloxacin to Rat Brain, Testicle, and Plasma: In Vivo and In Silico Studies. ChemistrySelect 2021. [DOI: 10.1002/slct.202102122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Gul Cetin
- Department of Pharmacology Faculty of Pharmacy Erzincan Binali Yıldırım University Erzincan 24100 Turkey
| | - Bunyamin Tras
- Department of Pharmacology and Toxicology Faculty of Veterinary Medicine Selcuk University Konya 42031 Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology Faculty of Veterinary Medicine Selcuk University Konya 42031 Turkey
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Sacha GL, Chen AY, Palm NM, Duggal A. Evaluation of the Initiation Timing of Hydrocortisone in Adult Patients With Septic Shock. Shock 2021; 55:488-494. [PMID: 32890314 DOI: 10.1097/shk.0000000000001651] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Clinical studies evaluating the use of hydrocortisone in patients with septic shock are heterogeneous in design with conflicting results. The appropriate time in which to initiate hydrocortisone after shock onset is unknown. This study sought to compare clinical outcomes including vasopressor duration and mortality in patients with septic shock who received hydrocortisone based on timing of initiation after shock onset. METHODS Retrospective cohort study of patients between 2011 and 2017 admitted to 10 medical, surgical, and neurosciences intensive care units (ICUs) at a large, tertiary care academic medical center. Adult patients with vasopressor-dependent septic shock who received hydrocortisone were included. Patients were divided into five timing cohorts based on time after shock onset: 0-6, 6-12, 12-24, 24-48, or >48 h. The primary outcome was days alive and free from vasopressors. RESULTS One thousand four hundred seventy patients were included: 567 (38.6%) received hydrocortisone between 0 and 6 h, 231 (15.7%) 6 and 12 h, 260 (17.7%) 12 and 24 h, 195 (13.3%) 24 and 48 h, and 217 (14.8%) >48 h after shock onset. Patients who received hydrocortisone earlier were sicker at baseline with higher APACHE III scores, lactate concentrations, and norepinephrine requirements. On univariate analysis, days alive and free from vasopressors did not significantly differ amongst the timing groups (median 3.3 days for 0-6 h; 1.9 for 6-12 h; 1.9 for 12-24 h; 0 for 24-48 h; 0 for >48 h; P = 0.39); similarly, ICU mortality did not differ. On multivariable linear regression, timing of hydrocortisone was independently associated with more days alive and free from vasopressors when comparing initiation within 0 to 6 h with >48 h (beta-coefficient 2.8 days [95% CI 0.8-4.7]), 6-12 h with >48 h (2.5 days [95% CI 0.2-4.7]), and 12-24 h with >48 h (2.3 days [95% CI 0.2-4.5]). On multivariable logistic regression, timing of hydrocortisone was associated with reduced ICU mortality when comparing receipt within 0 to 6 h of shock onset to >48 h after shock onset (OR 0.6, 95% CI 0.4-0.8). CONCLUSIONS In patients in whom hydrocortisone is prescribed for vasopressor-dependent septic shock, timing is crucial and hydrocortisone should be started within the first 12 h after shock onset.
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Affiliation(s)
| | - Alyssa Y Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Nicole M Palm
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Abhijit Duggal
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Mitwally H, Saad MO, Mahmoud S, Mohamed A. Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses vs Continuous Infusion in Septic Shock: A Retrospective Study. Indian J Crit Care Med 2021; 25:29-33. [PMID: 33603298 PMCID: PMC7874298 DOI: 10.5005/jp-journals-10071-23501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Hydrocortisone showed to be effective in reducing the time until reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the common adverse effects associated with corticosteroid treatment. However, the difference in hyperglycemia risk with different methods of hydrocortisone administration is not clear. The objective of this study was to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses vs continuous infusion in septic shock patients. Materials and methods This was a retrospective observational study. Data were collected from the electronic medical records of eligible patients admitted to intensive care units. All patients admitted with septic shock who received noradrenaline and hydrocortisone were included. Only patients who exceeded 200 mg/day of hydrocortisone were excluded. The primary outcome was mean blood glucose. Results A total of 108 patients (with 3,021 blood glucose readings) were included in the final analysis. Seventy-six patients received hydrocortisone as intermittent boluses (70.3%), and 32 patients (29.7%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 8.58 mmol/L (95% confidence interval [CI]; 8.01-9.16) in the bolus group and 8.9 mmol/L (95% CI; 7.99-9.82) in the infusion group with a mean difference of 0.32 mmol/L (95% CI; -0.77 to 1.41). For secondary outcomes, no difference was found between the two groups in mortality, length of stay, reversal of shock, or hypoglycemic events. Conclusion Intermittent boluses of hydrocortisone were not associated with a higher risk of hyperglycemia than continuous infusion in septic shock patients. How to cite this article Mitwally H, Saad MO, Mahmoud S, Mohamed A. Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses vs Continuous Infusion in Septic Shock: A Retrospective Study. Indian J Crit Care Med 2021;25(1):29-33.
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Affiliation(s)
- Hassan Mitwally
- Pharmacy Department, Al-Wakra Hospital, Hamad Medical Corporation, Al-Wakra, Qatar
| | - Mohamed O Saad
- Pharmacy Department, Al-Wakra Hospital, Hamad Medical Corporation, Al-Wakra, Qatar
| | - Sara Mahmoud
- Pharmacy Department, Al-Wakra Hospital, Hamad Medical Corporation, Al-Wakra, Qatar
| | - Adham Mohamed
- Pharmacy Department, Saint Luke's Hospital of Kansas City, Kansas City, Missouri, USA
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Kittle H, Ormseth A, Patetta MJ, Sood A, Gonzalez MH. Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000001. [PMID: 32672719 PMCID: PMC7366416 DOI: 10.5435/jaaosglobal-d-20-00001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/22/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Osteoarthritis may be caused by or concurrent with diseases such as rheumatoid arthritis or systemic lupus erythematosus, which rely on chronic corticosteroids regimens for treatment. If a total knee or hip arthroplasty is needed, this chronic treatment method has been associated with poorer surgical outcomes. METHODS A retrospective analysis of data collected by the American College of Surgeons National Surgical Quality Improvement Program was conducted. The Current Procedural Terminology codes were used to identify 403,566 total knee arthroplasty and total hip arthroplasty patients who were then stratified by the use of chronic corticosteroids for univariate analysis. RESULTS Forteen thousand seven hundred seventy-four of the patients identified were prescribed chronic corticosteroid regimens. A statistically significant difference was observed in perioperative complications for patients prescribed with corticosteroids, including higher rates of surgical site infection (P = 0.0001), occurrence of deep incisional surgical site infection (P < 0.0001), occurrences of organ space surgical site infection (P < 0.0001), wound dehiscence (P < 0.0001), general would infection (P < 0.0001), pneumonia (P < 0.0001), occurrences of unplanned intubation (P = 0.0002), urinary tract infection (P < 0.0001), and readmission (P < 0.0001). No statistically significant difference was observed in the 30-day mortality between the 2 groups (0.63), venous thromboembolic event (0.42), cerebrovascular accident (0.12), myocardial infarction (0.49), cardiac arrest (0.098), deep vein thrombosis (0.17), or sepsis (0.52). CONCLUSION Many of the notable differences in complications may be directly attributed to the immunosuppressive nature of corticosteroids. With increased knowledge of which perioperative complications to monitor, surgeons can tailor treatment strategies to this population that reduce morbidity and improve outcomes.
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Affiliation(s)
- Haley Kittle
- From the Department of Orthopaedics, University of Illinois College of Medicine (Ms. Kittle and Dr. Ormseth), and the Department of Orthopaedics, University of Illinois College of Medicine (Dr. Patetta, Dr. Sood, and Dr. Gonzalez), Chicago, IL
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Pourmand A, Whiteside T, Yamane D, Rashed A, Mazer-Amirshahi M. The controversial role of corticosteroids in septic shock. Am J Emerg Med 2019; 37:1353-1361. [PMID: 31056383 DOI: 10.1016/j.ajem.2019.04.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/13/2019] [Accepted: 04/25/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Several clinical trials and literature reviews have been conducted to evaluate the impact of corticosteroids on the physiological markers and clinical outcomes of patients in septic shock. While the findings have been somewhat contradictory, there is evidence of moderate benefit from the administration of low-dose corticosteroids to patients in septic shock. In this review, we discuss recent studies evaluating the impact of corticosteroids on morbidity and mortality in septic shock and explore future directions to fully elucidate when and how the administration of corticosteroid therapies can be beneficial. METHODS A literature review was performed using the Mesh database of PubMed with the term "septic shock" and subheadings "therapeutic use", "drug therapy", "pharmacology", and "therapy" followed by the addition of "steroid". Filters were added to restrict the search to 18+ age, English and human studies, and articles published within the last 10 years. One hundred sixty-five articles were examined and twenty-five were deemed relevant to this review. RESULTS The twenty-five articles reviewed here provide conflicting evidence as to the usefulness of corticosteroid treatments during septic shock. Several showed improved physiological outcomes, including rates of organ failure, need for life supporting interventions, adverse effects, inflammatory markers, and perfusion during the course of septic shock, as well as decreased mortality for a statistically significant number of patients. CONCLUSIONS There remains a need for improved therapy for patients in septic shock. Corticosteroids have shown some potential in improving mortality rates and clinical markers. Additional studies are needed to determine the optimal role of corticosteroids in septic shock.
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Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Tess Whiteside
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Amir Rashed
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States
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Sacha GL, Bauer SR, Lat I. Vasoactive Agent Use in Septic Shock: Beyond First-Line Recommendations. Pharmacotherapy 2019; 39:369-381. [PMID: 30644586 DOI: 10.1002/phar.2220] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Septic shock is a life-threatening disorder associated with high mortality rates requiring rapid identification and intervention. Vasoactive agents are often required to maintain goal hemodynamics and preserve tissue perfusion. However, guidance regarding the proper administration of adjunct agents for the management of septic shock is limited in patients who are refractory to norepinephrine. This review summarizes vasopressor agents and describes the nuanced application of these agents in patients with septic shock, specifically focusing on clinical scenarios with limited guidance including patients who are nonresponsive to first-line agents and individuals with mixed shock states, tachyarrhythmias, obesity, valvular abnormalities, or other comorbid conditions.
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Affiliation(s)
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Ishaq Lat
- Department of Pharmacy, Shirley Ryan Ability Lab, Chicago, Illinois
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Buckley MS, Barletta JF, Smithburger PL, Radosevich JJ, Kane-Gill SL. Catecholamine Vasopressor Support Sparing Strategies in Vasodilatory Shock. Pharmacotherapy 2019; 39:382-398. [PMID: 30506565 DOI: 10.1002/phar.2199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Shock syndromes are associated with unacceptably high rates of mortality in critically ill patients despite advances in therapeutic options. Vasodilatory shock is the most common type encountered in the intensive care unit. It is manifested by cardiovascular failure, peripheral vasodilatation, and arterial hypotension leading to tissue hypoperfusion and organ failure. Hemodynamic support is typically initiated with fluid resuscitation strategies and administration of adrenergic vasopressor agents in nonresponsive patients to restore arterial pressure with subsequent adequate organ reperfusion. Unfortunately, high catecholamine dosing requirements may be necessary to achieve targeted hemodynamic goals that may increase the risk of vasopressor-induced adverse events. The purpose of this article is to review the clinical efficacy and safety data and potential role in therapy for catecholamine-sparing agents in vasodilatory shock. Adjunctive therapeutic options to reduce vasoactive support requirements without compromising arterial pressure include arginine vasopressin and analogs, corticosteroids, midodrine, methylene blue, and angiotensin II. Although concomitant vasopressin and corticosteroids have a more defined role in evidence-based guidelines for managing shock, clinicians may consider other potential catecholamine-sparing agents.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy - Glendale, Midwestern University, Glendale, Arizona
| | - Pamela L Smithburger
- Department of Pharmacy Practice, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - John J Radosevich
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sandra L Kane-Gill
- Department of Pharmacy Practice, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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Li R, Kowalski PS, Morselt HWM, Schepel I, Jongman RM, Aslan A, Ruiters MHJ, Zijlstra JG, Molema G, van Meurs M, Kamps JAAM. Endothelium-targeted delivery of dexamethasone by anti-VCAM-1 SAINT-O-Somes in mouse endotoxemia. PLoS One 2018; 13:e0196976. [PMID: 29763440 PMCID: PMC5953446 DOI: 10.1371/journal.pone.0196976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/24/2018] [Indexed: 01/19/2023] Open
Abstract
Microvascular endothelial cells play a pivotal role in the pathogenesis of sepsis-induced inflammatory responses and multiple organ failure. Therefore, they represent an important target for pharmacological intervention in the treatment of sepsis. Glucocorticosteroids were widely used in the treatment of sepsis but vast evidence to support their systemic use is lacking. The limited effects of glucocorticoids in the treatment of sepsis may be explained by differential effects of drug initiated NF-κB inhibition in different cell types and insufficient drug delivery in target cells. The current study aimed therefore to investigate the effects of an endothelial targeted delivery of dexamethasone in a mouse model of endotoxemia induced by two consecutive i.p. injections of lipopolysaccharide (LPS). To achieve endothelial cell specific delivery of dexamethasone, we modified SAINT-O-Somes, a new generation of liposomes that contain the cationic amphiphile SAINT-C18 (1-methyl-4-(cis-9-dioleyl) methyl-pyridinium chloride, with antibodies against vascular cell adhesion molecule-1 (VCAM-1). In LPS challenged mice, the systemic administration of free dexamethasone had negligible effects on the microvascular inflammatory endothelial responses. Dexamethasone-loaded anti-VCAM-1 SAINT-O-Somes specifically localized at VCAM-1 expressing endothelial cells in the microvasculature of inflamed organs. This was associated with a marginal attenuation of the expression of a few pro-inflammatory genes in kidney and liver, while no effects in the lung were observed. This study reveals that, although local accumulation of the targeted drug was achieved, endothelial targeted dexamethasone containing anti-VCAM-1 SAINT-O-Somes exhibited marginal effects on inflammatory endothelial cell activation in a model of endotoxemia. Studies with more potent drugs encapsulated into anti-VCAM-1 SAINT-O-Somes will in the future reveal whether this delivery system can be further developed for efficacious endothelial directed delivery of drugs in the treatment of sepsis.
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Affiliation(s)
- Ranran Li
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Piotr S Kowalski
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henriëtte W M Morselt
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ilona Schepel
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rianne M Jongman
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Dept. of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Dept. of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adnan Aslan
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Dept. of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marcel H J Ruiters
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Dept. of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Grietje Molema
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Matijs van Meurs
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Dept. of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan A A M Kamps
- Dept. of Pathology & Medical Biology, Medical Biology Section, Laboratory for Endothelial Biomedicine & Vascular Drug Targeting Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Praveen RV, Fernando ME, Ishwarya A. Modulation of maintenance immunosuppression during infection in renal transplant recipients. INDIAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4103/ijot.ijot_25_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sewal RK, Modi M, Saikia UN, Chakrabarti A, Medhi B. Increase in seizure susceptibility in sepsis like condition explained by spiking cytokines and altered adhesion molecules level with impaired blood brain barrier integrity in experimental model of rats treated with lipopolysaccharides. Epilepsy Res 2017; 135:176-186. [DOI: 10.1016/j.eplepsyres.2017.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/07/2017] [Accepted: 05/19/2017] [Indexed: 02/02/2023]
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Li Q, Feng Y, He W, Wang L, Wang R, Dong L, Wang C. Post-screening characterisation and in vivo evaluation of an anti-inflammatory polysaccharide fraction from Eucommia ulmoides. Carbohydr Polym 2017; 169:304-314. [DOI: 10.1016/j.carbpol.2017.04.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/28/2017] [Accepted: 04/14/2017] [Indexed: 12/18/2022]
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D’Aoust J, Battat R, Bessissow T. Management of inflammatory bowel disease with Clostridium difficile infection. World J Gastroenterol 2017; 23:4986-5003. [PMID: 28785153 PMCID: PMC5526769 DOI: 10.3748/wjg.v23.i27.4986] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/16/2017] [Accepted: 06/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To address the management of Clostridium difficile (C. difficile) infection (CDI) in the setting of suspected inflammatory bowel disease (IBD)-flare.
METHODS A systematic search of the Ovid MEDLINE and EMBASE databases by independent reviewers identified 70 articles including a total of 932141 IBD patients or IBD-related hospitalizations.
RESULTS In those with IBD, CDI is associated with increased morbidity, including subsequent escalation in IBD medical therapy, urgent colectomy and increased hospitalization, as well as excess mortality. Vancomycin-containing regimens are effective first-line therapies for CDI in IBD inpatients. No prospective data exists with regards to the safety or efficacy of initiating or maintaining corticosteroid, immunomodulator, or biologic therapy to treat IBD in the setting of CDI. Corticosteroid use is a risk factor for the development of CDI, while immunomodulators and biologics are not.
CONCLUSION Strong recommendations regarding when to initiate IBD specific therapy in those with CDI are precluded by a lack of evidence. However, based on expert opinion and observational data, initiation or resumption of immunosuppressive therapy after 48-72 h of targeted antibiotic treatment for CDI may be considered.
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Ngo Ndjom CG, Kantor LV, Jones HP. CRH Affects the Phenotypic Expression of Sepsis-Associated Virulence Factors by Streptococcus pneumoniae Serotype 1 In vitro. Front Cell Infect Microbiol 2017; 7:263. [PMID: 28690980 PMCID: PMC5479890 DOI: 10.3389/fcimb.2017.00263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/02/2017] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a life-threatening health condition caused by infectious pathogens of the respiratory tract, and accounts for 28–50% of annual deaths in the US alone. Current treatment regimen advocates the use of corticosteroids as adjunct treatment with antibiotics, for their broad inhibitory effect on the activity and production of pro-inflammatory mediators. However, despite their use, corticosteroids have not proven to be able to reverse the death incidence among septic patients. We have previously demonstrated the potential for neuroendocrine factors to directly influence Streptococcus pneumoniae virulence, which may in turn mediate disease outcome leading to sepsis and septic shock. The current study investigated the role of Corticotropin-releasing hormone (CRH) in mediating key markers of pneumococcal virulence as important phenotypic determinants of sepsis and septic shock risks. In vitro cultures of serotype 1 pneumococcal strain with CRH promoted growth rate, increased capsule thickness and penicillin resistance, as well as induced pneumolysin gene expression. These results thus provide significant insights of CRH–pathogen interactions useful in understanding the underlying mechanisms of neuroendocrine factor's role in the onset of community acquired pneumonias (CAP), sepsis and septic shock.
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Affiliation(s)
- Colette G Ngo Ndjom
- Department of Molecular and Medical Genetics, University of North Texas Health Science CenterFort Worth, TX, United States
| | - Lindsay V Kantor
- Graduate School of Biomedical Sciences, University of North Texas Health Science CenterFort Worth, TX, United States
| | - Harlan P Jones
- Department of Molecular and Medical Genetics, University of North Texas Health Science CenterFort Worth, TX, United States
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Hoang H, Wang S, Islam S, Hanna A, Axelrad A, Brathwaite C. Evaluation of Hydrocortisone Continuous Infusion Versus Intermittent Boluses in Resolution of Septic Shock. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2017; 42:252-255. [PMID: 28381918 PMCID: PMC5358683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To compare the effectiveness of continuous infusion of hydrocortisone versus intermittent boluses in the resolution of septic shock. METHODS A retrospective chart review was performed to investigate the effects of low-dose hydrocortisone continuous infusion (200 mg per day) versus intermittent boluses (50 mg every six hours) in septic shock patients who did not respond to fluid resuscitation and vasopressors. The primary outcome was time to resolution of shock, defined by time from the initiation of hydrocortisone to time of vasopressor withdrawal when mean arterial pressure was greater than 65 mm Hg. Hospital length of stay, intensive care unit (ICU) length of stay, 28-day all-cause in-hospital mortality, and hyperglycemia were secondary outcomes. RESULTS Of the 51 patients in the study, 33 received intermittent boluses of hydrocortisone. The median time to resolution of shock in the continuous group was three days, compared with a mean time of two days in the bolus group (P = 0.41). Mean hospital length of stay was 18.7 ± 19.4 days in the continuous group versus 18.6 ± 17.4 days in the bolus group (P = 0.77). Mean ICU length of stay was 10.4 ± 12.5 days in the continuous group versus 11.1 ± 9.2 days in the bolus group (P = 0.31). Thirteen patients (72%) in the continuous group died within 28 days, compared with 20 (60%) in the bolus group (P = 0.76). Five patients (28%) had hyperglycemic episodes after being given hydrocortisone in the continuous infusion group, compared with 20 patients (60%) in the bolus group (P = 0.04). CONCLUSION There was no significant difference in time to resolution of septic shock between continuous infusion (200 mg per day) and intermittent boluses (50 mg every six hours) of hydrocortisone. There were also no statistically significant differences in overall hospital length of stay, ICU length of stay, and 28-day all-cause in-hospital mortality. However, there was a significant difference in the incidence of hyperglycemia between the two groups, with patients in the bolus group experiencing more hyperglycemia than those in the continuous infusion group.
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Similar but not the same: Differential diagnosis of HLH and sepsis. Crit Rev Oncol Hematol 2017; 114:1-12. [PMID: 28477737 DOI: 10.1016/j.critrevonc.2017.03.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/12/2022] Open
Abstract
Differential diagnosis of hemophagocytic lymphohistiocytosis (HLH; hemophagocytic syndrome) and sepsis is critically important because the life-saving aggressive immunosuppressive treatment, required in the effective HLH therapy, is absent in sepsis guidelines. Moreover, HLH may be complicated by sepsis. Hyperinflammation, present in both states, gives an overlapping clinical picture including fever and performance status deterioration. The aim of this review is to provide aid in this challenging diagnostic process. Analysis of clinical features and laboratory results in multiple groups of patients (both adult and pediatric) with either HLH or sepsis allows to propose criteria differentiating these two conditions. The diagnosis of HLH is supported by hyperferritinemia, splenomegaly, marked cytopenias, hypofibrinogenemia, low CRP, characteristic cytokine profile and, only in adults, hypertriglyceridemia. In the presence of these parameters (especially the most characteristic hyperferritinemia), the other HLH criteria should be assessed. Genetic analyses can reveal familial HLH. Hemophagocytosis is neither specific nor sensitive for HLH.
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Evaluation of Early Corticosteroid Therapy in Management of Pediatric Septic Shock in Pediatric Intensive Care Patients: A Randomized Clinical Study. Pediatr Infect Dis J 2017; 36:155-159. [PMID: 27798546 DOI: 10.1097/inf.0000000000001380] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Septic shock is a major healthcare problem. Adrenal insufficiency (AI) in children with septic shock is a recognized complication, yet is controversial regarding its management and effect on mortality. According to the current guidelines, children with risk factors for AI should receive a stress dose of steroids in step 3 of treatment. This study aimed to evaluate and compare early corticosteroid therapy with the traditional use of steroids among pediatric septic shock patients. METHODS This prospective randomized interventional clinical study included 3 groups of patients (32 each) and was conducted in Alexandria University pediatric intensive care unit. By protocol, the first group received steroids in step 3 of the treatment according to the current international guidelines (group A), and the second group was managed as group A and was tested for AI by adrenal stimulation test using intramuscular adrenocorticotropic hormone (cosyntropin) (group B). The third group received steroids at the start of fluid therapy (group C). A fourth group (group D) was created by adding patients from groups A and B who needed corticosteroids in the third stage of therapy according to the international protocol in 1 group. All patients were evaluated for basal serum cortisol and plasma adrenocorticotropic hormone concentrations. RESULTS The data showed a statistically significant shorter shock reversal time among patients receiving corticosteroids at the start of treatment compared with those who received it at the third step of treatment (P = 0.046); however, mortality was not statistically different among the groups. In addition, there was no superinfection in cases receiving early steroid therapy. CONCLUSIONS Early use of corticosteroid in patients with septic shock might shorten the shock reversal time without increase in mortality or superinfection.
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Hamitouche N, Comets E, Ribot M, Alvarez JC, Bellissant E, Laviolle B. Population Pharmacokinetic-Pharmacodynamic Model of Oral Fludrocortisone and Intravenous Hydrocortisone in Healthy Volunteers. AAPS JOURNAL 2017; 19:727-735. [DOI: 10.1208/s12248-016-0041-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/30/2016] [Indexed: 01/10/2023]
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Honore PM, Jacobs R, De Waele E, Hendrickx I, Spapen HD. Vasopressin versus noradrenaline as initial therapy in septic shock. Is vasopressin-related renal protection doomed to "vanish" in the haze? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S47. [PMID: 27868015 PMCID: PMC5104637 DOI: 10.21037/atm.2016.10.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/18/2016] [Indexed: 09/20/2023]
Affiliation(s)
- Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rita Jacobs
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elisabeth De Waele
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Inne Hendrickx
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herbert D Spapen
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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de Leeuw K, Niemeijer AS, Eshuis J, Nieuwenhuis MK, Beerthuizen GIJM, Janssen WMT. Effect and mechanism of hydrocortisone on organ function in patients with severe burns. J Crit Care 2016; 36:200-206. [PMID: 27546772 DOI: 10.1016/j.jcrc.2016.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/06/2016] [Accepted: 06/12/2016] [Indexed: 01/12/2023]
Abstract
INTRODUCTION In patients with severe burns, resuscitation with large volumes of fluid is needed, partly because of an increase in capillary leakage. Corticosteroids might be beneficial by diminishing capillary leakage. This study aimed to assess in severely burned nonseptic patients whether hydrocortisone (HC) improved outcome and diminished capillary leakage. METHODS Retrospective analyses of a prospectively collected database were performed, including 39 patients (age 52 [35-62] years, 72% male). Patients were divided based on HC therapy. First, in patients in whom HC was started late, that is when deteriorating (late; 5-12 days postburn) data before and after start of HC were compared. Second, patients in whom HC was started day 0 or 1 postburn (upfront; within 48 hours) were compared with patients who did not receive HC (control). Outcome was assessed as organ dysfunction by Denver Multiple Organ Failure (MOF) score and Sequential Organ Failure Assessment (SOFA) score. As markers for capillary leakage and hydration state, proteinuria, B-type natriuretic peptide (BNP), and fluid administration were assessed. Follow-up was 20 days postburn. Possible adverse effects including mortality were recorded. Repeated measurement regression analyses were performed using MLwiN. RESULTS In the late group, Denver MOF and SOFA scores significantly decreased after HC (P<.001). Proteinuria tended to decrease (P=.13), BNP increased on the days HC was used (P<.001), and amounts of fluids diminished (P<.001). In the upfront vs control group, Denver MOF and SOFA scores (P<.001) decreased more quickly. Proteinuria (P=.006) and administered fluids decreased more rapidly (P<.001). Mortality rate, numbers of positive blood cultures, incidence of pneumonia, and graft loss were similar in all groups. CONCLUSIONS Hydrocortisone treatment in severe burned patients without sepsis might improve organ dysfunction possibly because of a reduction in capillary leakage, as reflected by a decrease of proteinuria, an increase of BNP, and diminished fluid resuscitation volumes.
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Affiliation(s)
- K de Leeuw
- Department of Internal Medicine and Rheumatology, Martini Hospital, Groningen, The Netherlands; Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands.
| | - A S Niemeijer
- Association of Dutch Burn Centers, Burn centre, Martini Hospital, Groningen, The Netherlands
| | - J Eshuis
- Association of Dutch Burn Centers, Burn centre, Martini Hospital, Groningen, The Netherlands
| | - M K Nieuwenhuis
- Association of Dutch Burn Centers, Burn centre, Martini Hospital, Groningen, The Netherlands
| | - G I J M Beerthuizen
- Association of Dutch Burn Centers, Burn centre, Martini Hospital, Groningen, The Netherlands
| | - W M T Janssen
- Department of Internal Medicine and Rheumatology, Martini Hospital, Groningen, The Netherlands
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Annane D, Buisson CB, Cariou A, Martin C, Misset B, Renault A, Lehmann B, Millul V, Maxime V, Bellissant E. Design and conduct of the activated protein C and corticosteroids for human septic shock (APROCCHSS) trial. Ann Intensive Care 2016; 6:43. [PMID: 27154719 PMCID: PMC4859323 DOI: 10.1186/s13613-016-0147-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/22/2016] [Indexed: 01/10/2023] Open
Abstract
Background We aimed at assessing the benefit-to-risk ratio of activated protein C (drotrecogin-alfa activated, DAA) and corticosteroids, given alone or in combination, in patients with septic shock. Methods We implemented an investigator-led, publicly funded, multicenter, randomized according to a 2 × 2 factorial design, placebo-controlled, double-blind trial in four parallel groups in which adults with persistent septic shock and no contraindication to DAA were assigned to either DAA alone (24 mg/kg/h for 96 h), or hydrocortisone (50 mg intravenous bolus q6 for 7 days) and fludrocortisone (50 µg once daily through the nasogastric tube for 7 days) alone, or their respective combinations, or their respective placebos. Primary endpoint was 90-day mortality rate. Follow-up duration was 6 months. Statistical analysis was planned to be performed in intent-to-treat once after all participants completed 180-day follow-up and according to the 2 × 2 factorial design. Results The first patient was recruited in September 2008. The trial was suspended on October 25, 2011, owing to the withdrawal from the market of DAA. At this time, 411 patients had been enrolled. On May 17, 2012, the continuation of the trial on two parallel groups was approved by all legal authorities with the aim of investigating the benefit-to-risk ratio of corticosteroids. On June 30, 2014, the trial was suspended again by the study sponsor upon request of the independent data and safety monitoring board. Recruitment restarted on October 7, 2014, after any safety concern was ruled out. Finally, the trial was completed on June 23, 2015, with the recruitment of 1241 patients. Conclusions This report details the design, statistical plan and conduct of a randomized controlled trial of hydrocortisone and fludrocortisone in septic shock. Trial registration The trial was registered at ClinicalTrials.gov under NCT00625209
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Affiliation(s)
- Djillali Annane
- General ICU, Service de Réanimation, Hôpital Raymond Poincaré, Laboratory of Infection and Inflammation, U1173, AP-HP, University of Versailles SQY and INSERM, 104 Boulevard Raymond Poincaré, 92380, Garches, France.
| | | | - Alain Cariou
- Service de Réanimation Médicale, Hôpital Cochin, AP-HP, Paris, France
| | - Claude Martin
- Service d'Anesthésie Réanimation, Hôpital Nord, AP-HM, Marseille, France
| | - Benoit Misset
- Service de Médecine Intensive et Réanimation, Hôpital Saint-Joseph, AP-HP, Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Alain Renault
- Service de Pharmacologie, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université de Rennes 1, Rennes, France
| | | | - Valérie Millul
- Délégation à la Recherche Clinique, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Virginie Maxime
- General ICU, Service de Réanimation, Hôpital Raymond Poincaré, Laboratory of Infection and Inflammation, U1173, AP-HP, University of Versailles SQY and INSERM, 104 Boulevard Raymond Poincaré, 92380, Garches, France
| | - Eric Bellissant
- Service de Pharmacologie, Centre d'Investigation Clinique INSERM 1414, CHU de Rennes, Université de Rennes 1, Rennes, France
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A novel nitro-dexamethasone inhibits agr system activity and improves therapeutic effects in MRSA sepsis models without antibiotics. Sci Rep 2016; 6:20307. [PMID: 26839286 PMCID: PMC4738243 DOI: 10.1038/srep20307] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/30/2015] [Indexed: 12/13/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) sepsis is a life-threatening medical condition that involves systemic inflammation throughout the body. Glucocorticoids are widely used in combination with antibiotics in the treatment of MRSA sepsis to fight the overwhelming inflammation. Here, we describe the improved anti-inflammatory properties of a nitric oxide (NO)-releasing derivative of dexamethasone, ND8008. ND8008 affected MRSA biofilm formation, caused biofilm cell death, and reduced the effects of virulence factors, such as α-toxin, by inhibiting the activity of the Staphylococcus aureus accessory gene regulator (agr) system. Dosing of mice with ND8008 (127.4 nmol/kg, i.p.) alone greatly reduced the inflammatory response caused by MRSA blood stream infection and considerably increased the survival rate of septic mice. These findings suggest that this novel NO-releasing derivative of dexamethasone ND8008 could be helpful in the treatment of MRSA sepsis.
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Annane D. The Role of ACTH and Corticosteroids for Sepsis and Septic Shock: An Update. Front Endocrinol (Lausanne) 2016; 7:70. [PMID: 27379022 PMCID: PMC4913096 DOI: 10.3389/fendo.2016.00070] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 06/08/2016] [Indexed: 02/05/2023] Open
Abstract
Sepsis is a common disorder associated with high morbidity and mortality. It is now defined as an abnormal host response to infection, resulting in life-threatening dysfunction of organs. There is evidence from in vitro and in vivo experiments in various animal models and in patients that endotoxin or sepsis may directly and indirectly alter the hypothalamic-pituitary-adrenal response to severe infection. These alterations may include necrosis or hemorrhage or inflammatory mediator-mediated decreased ACTH synthesis, steroidogenesis, cortisol delivery to tissues, clearance from plasma, and decreased sensitivity of tissues to cortisol. Disruption of the hypothalamic-pituitary-adrenal axis may translate in patients with sepsis into cardiovascular and other organ dysfunction, and eventually an increase in the risk of death. Exogenous administration of corticosteroids at moderate dose, i.e., <400 mg of hydrocortisone or equivalent for >96 h, may help reversing sepsis-associated shock and organ dysfunction. Corticosteroids may also shorten the duration of stay in the ICU. Except for increased blood glucose and sodium levels, treatment with corticosteroids was rather well tolerated in the context of clinical trials. The benefit of treatment on survival remains controversial. Based on available randomized controlled trials, the likelihood of survival benefit is greater in septic shock versus sepsis patients, in sepsis with acute respiratory distress syndrome or with community-acquired pneumonia versus patients without these conditions, and in patients with a blunted cortisol response to 250 μg of ACTH test versus those with normal response.
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Affiliation(s)
- Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Garches, France
- Laboratory of Infection and Inflammation, U1173, University of Versailles Saint-Quentin-en-Yvelines University, INSERM, Garches, France
- *Correspondence: Djillali Annane,
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Kinin B1 receptor antagonist BI113823 reduces allergen-induced airway inflammation and mucus secretion in mice. Pharmacol Res 2015; 104:132-9. [PMID: 26747401 DOI: 10.1016/j.phrs.2015.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 12/30/2022]
Abstract
Kinin B1 receptors are implicated in asthmatic airway inflammation. Here we tested this hypothesis by examining the anti-inflammatory effects of BI113823, a novel non-peptide orally active kinin B1 receptor antagonist in mice sensitized to ovalbumin (OVA). Male Balb-c mice were randomly assigned to four study groups: (1) control, (2) OVA+vehicle, (3) OVA+BI113823, (4) OVA+dexamethasone. Mice were sensitized intraperitoneally with 75μg ovalbumin on days 1 and 8. On days 15-17, mice were challenged intranasally with 50μg of ovalbumin. Mice received vehicle, BI113823, or dexamethasone (positive control) on days 16-18. On day 19, bronchoalveolar lavage (BAL) and lung tissue were collected for biochemical and immuno-histological analysis. Compared to controls treatment with BI113823 significantly reduced the numbers of BAL eosinophils, macrophages, neutrophils and lymphocytes by 58.3%, 61.1%, 66.4% and 56.0%, respectively. Mice treated with dexamethasone showed similar reductions in BAL cells. Treatment with BI113823 and dexamethasone also significantly reduced total protein content, IgE, TNF-α and IL-1β in lavage fluid, reduced myeloperoxidase activity, mucus secretion in lung tissues, and reduced the expression of B1 receptors, matrix metalloproteinase (MMP)-2 and cyclooxygenase (COX)-2 compared to vehicle-treated mice. Only BI113823 reduced MMP-9 and inducible nitric oxide synthase (iNOS). BI113823 effectively reduced OVA-induced inflammatory cell, mediator and signaling pathways equal to or greater than that seen with steroids in a mouse asthma model. BI113823 might be useful in modulating inflammation in asthma.
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Low-dose corticosteroid treatment and mortality in refractory abdominal septic shock after emergency laparotomy. Ann Intensive Care 2015; 5:32. [PMID: 26514125 PMCID: PMC4626466 DOI: 10.1186/s13613-015-0074-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/19/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of low-dose corticosteroid as an adjunctive treatment for abdominal septic shock remains controversial. METHODS We identified refractory septic shock patients who required noradrenaline and at least one of other vasopressor/inotropic (dopamine, dobutamine or vasopressin) following emergency open laparotomy for perforation of the lower intestinal tract between July 2010 and March 2013 using the Japanese Diagnosis Procedure Combination inpatient database. In-hospital mortality was compared between the low-dose corticosteroid and control groups. RESULTS There were 2164 eligible patients (155 in the corticosteroid group, 2009 in the control group). We observed no significant difference between the groups in terms of in-hospital mortality in the unadjusted analysis [corticosteroid vs. control groups, 19.4 and 25.1 %, respectively; difference, -5.7 %; 95 % confidence interval (CI), -12.8 to 1.3]; however, a significant difference in in-hospital mortality was evident in the propensity score-weighted analysis (17.6 and 25.0 %, respectively; difference, -7.4 %; 95 % CI -9.9 to -5.0). An instrumental variable analysis with the hospital low-dose corticosteroid prescription proportion showed that receipt of low-dose corticosteroid was significantly associated with reduction in in-hospital mortality (differences, -13.5 %; 95 % CI -24.6 to -2.3). CONCLUSIONS Low-dose corticosteroid administration may be associated with reduced in-hospital mortality in patients with refractory septic shock following emergency laparotomy for lower intestinal perforation.
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Affiliation(s)
- Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8555, Japan. .,Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, 206-8512, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8555, Japan.
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8555, Japan.
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Levy M, Antunes A, Fiette L, Deghmane AE, Taha MK. Impact of corticosteroids on experimental meningococcal sepsis in mice. Steroids 2015; 101:96-102. [PMID: 26066898 DOI: 10.1016/j.steroids.2015.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/21/2015] [Accepted: 05/25/2015] [Indexed: 11/17/2022]
Abstract
Neisseria meningitidis is responsible for septicemia and meningitis with high fatality that is associated with an excessive inflammatory reaction particularly with hyperinvasive isolates of the clonal complex ST-11 (cc11). However, anti-inflammatory adjuvant treatment remains controversial and difficult to assess in patients. We addressed this topic in a well-defined experimental meningococcal infection in transgenic mice expressing the human transferrin. Mice were infected by intra-peritoneal challenge with bioluminescent serogroup C/cc11 strain. After 3h of infection mice were differentially treated every 6h by saline, amoxicillin alone or amoxicillin and dexamethasone (DXM). Infected mice were scored for clinical status, temperature and weight. Biological markers of inflammation were also quantified. Significant clinical improvement was observed in mice treated with amoxicillin and DXM compared to the two other groups. A significant reduction of the inflammatory reaction assessed by CRP and Lipocalin 2 (two acute phase proteins) was also observed with this treatment. DXM significantly increased blood levels of IL-10 at 6h post-infection. DXM/amoxicillin treated mice, compared to the two other groups, also showed lower levels of TNF-α and lower bacterial blood load assessed by serial dilutions of blood and bioluminescence dynamic imaging. Our results suggest that DXM, added to an appropriate antibiotic therapy, has a beneficial effect on experimental sepsis with a hyperinvasive meningococcal strain in transgenic mice expressing human transferrin. This is most likely due to the reduction of inflammatory response by an early induction of IL-10 cytokine. These data may allow better decision-making to use or not corticotherapy during meningococcal sepsis.
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Affiliation(s)
- Michaël Levy
- Institut Pasteur, Unité des Infections Bactériennes Invasives, 28 rue du Dr Roux, 75724 Paris Cedex 15, France; Institut Pasteur, Université Paris Descartes, Sorbonne Paris, Cité, France
| | - Ana Antunes
- Institut Pasteur, Unité des Infections Bactériennes Invasives, 28 rue du Dr Roux, 75724 Paris Cedex 15, France; Institut Pasteur, Université Paris Descartes, Sorbonne Paris, Cité, France
| | - Laurence Fiette
- Institut Pasteur, Unité Histopathologie Humaine et Modèles Animaux, 28 rue du Dr Roux, 75724 Paris Cedex 15, France; Institut Pasteur, Université Paris Descartes, Sorbonne Paris, Cité, France
| | - Ala-Eddine Deghmane
- Institut Pasteur, Unité des Infections Bactériennes Invasives, 28 rue du Dr Roux, 75724 Paris Cedex 15, France; Institut Pasteur, Université Paris Descartes, Sorbonne Paris, Cité, France
| | - Muhamed-Kheir Taha
- Institut Pasteur, Unité des Infections Bactériennes Invasives, 28 rue du Dr Roux, 75724 Paris Cedex 15, France; Institut Pasteur, Université Paris Descartes, Sorbonne Paris, Cité, France.
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Vettorazzi S, Bode C, Dejager L, Frappart L, Shelest E, Klaßen C, Tasdogan A, Reichardt HM, Libert C, Schneider M, Weih F, Henriette Uhlenhaut N, David JP, Gräler M, Kleiman A, Tuckermann JP. Glucocorticoids limit acute lung inflammation in concert with inflammatory stimuli by induction of SphK1. Nat Commun 2015; 6:7796. [PMID: 26183376 PMCID: PMC4518295 DOI: 10.1038/ncomms8796] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/11/2015] [Indexed: 12/18/2022] Open
Abstract
Acute lung injury (ALI) is a severe inflammatory disease for which no specific treatment exists. As glucocorticoids have potent immunosuppressive effects, their application in ALI is currently being tested in clinical trials. However, the benefits of this type of regimen remain unclear. Here we identify a mechanism of glucocorticoid action that challenges the long-standing dogma of cytokine repression by the glucocorticoid receptor. Contrarily, synergistic gene induction of sphingosine kinase 1 (SphK1) by glucocorticoids and pro-inflammatory stimuli via the glucocorticoid receptor in macrophages increases circulating sphingosine 1-phosphate levels, which proves essential for the inhibition of inflammation. Chemical or genetic inhibition of SphK1 abrogates the therapeutic effects of glucocorticoids. Inflammatory p38 MAPK- and mitogen- and stress-activated protein kinase 1 (MSK1)-dependent pathways cooperate with glucocorticoids to upregulate SphK1 expression. Our findings support a critical role for SphK1 induction in the suppression of lung inflammation by glucocorticoids, and therefore provide rationales for effective anti-inflammatory therapies. Endothelial damage is a major component of acute lung injury pathogenesis. Here the authors show that in a mouse model of acute lung injury, glucocorticoids induce sphingosine kinase 1 production in macrophages, promoting endothelial barrier function and ameliorating the disease.
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Affiliation(s)
- Sabine Vettorazzi
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, 89081 Ulm, Germany.,Leibniz Institute for Age Research - Fritz Lipmann Institute, 07745 Jena, Germany
| | - Constantin Bode
- Molecular Cancer Research Centre (MKFZ), Charité - University Medical School (CVK), 13353 Berlin, Germany
| | - Lien Dejager
- Inflammation Research Center, Mouse Genetics in Inflammation group, VIB and University Ghent, B9052 Ghent, Belgium
| | - Lucien Frappart
- Department of Pathology, Bat 10, HCL-Edouard Herriot Hospital, INSERM U590, 69437 Lyon, France
| | - Ekaterina Shelest
- Leibniz Institute for Natural Product Research and Infection Biology Hans Knöll Institute (HKI), 07745 Jena, Germany
| | - Carina Klaßen
- Institute for Cellular and Molecular Immunology, University of Göttingen Medical School, 37073 Göttingen, Germany
| | | | - Holger M Reichardt
- Institute for Cellular and Molecular Immunology, University of Göttingen Medical School, 37073 Göttingen, Germany
| | - Claude Libert
- Inflammation Research Center, Mouse Genetics in Inflammation group, VIB and University Ghent, B9052 Ghent, Belgium
| | - Marion Schneider
- Section of Experimental Anesthesiology, University Clinic Ulm, 89081 Ulm, Germany
| | - Falk Weih
- Leibniz Institute for Age Research - Fritz Lipmann Institute, 07745 Jena, Germany
| | - N Henriette Uhlenhaut
- Institute for Diabetes and Obesity, Helmholtz Zentrum München, 85748 Garching, Germany
| | - Jean-Pierre David
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Markus Gräler
- Molecular Cancer Research Centre (MKFZ), Charité - University Medical School (CVK), 13353 Berlin, Germany.,Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care (CSCC) and Center for Molecular Biomedicine (CMB), University Hospital Jena, 07740 Jena, Germany
| | - Anna Kleiman
- Leibniz Institute for Age Research - Fritz Lipmann Institute, 07745 Jena, Germany.,Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care (CSCC) and Center for Molecular Biomedicine (CMB), University Hospital Jena, 07740 Jena, Germany
| | - Jan P Tuckermann
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, 89081 Ulm, Germany.,Leibniz Institute for Age Research - Fritz Lipmann Institute, 07745 Jena, Germany
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Kadova Z, Dolezelova E, Cermanova J, Hroch M, Laho T, Muchova L, Staud F, Vitek L, Mokry J, Chladek J, Havlinova Z, Holecek M, Micuda S. IL-1 receptor blockade alleviates endotoxin-mediated impairment of renal drug excretory functions in rats. Am J Physiol Renal Physiol 2015; 308:F388-99. [DOI: 10.1152/ajprenal.00266.2014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of our study was to investigate whether two potent anti-inflammatory agents, dexamethasone and anakinra, an IL-1 receptor antagonist, may influence acute kidney injury (AKI) and associated drug excretory functions during endotoxemia (LPS) in rats. Ten hours after LPS administration, untreated endotoxemic rats developed typical symptoms of AKI, with reduced GFR, impaired tubular excretion of urea and sodium, and decreased urinary excretion of azithromycin, an anionic substrate for multidrug resistance-transporting proteins. Administration of both immunosuppressants attenuated the inflammatory response, liver damage, AKI, and increased renal clearance of azithromycin mainly by restoration of GFR, without significant influence on its tubular secretion. The lack of such an effect was related to the differential effect of both agents on the renal expression of individual drug transporters. Only dexamethasone increased the urinary clearance of bile acids, in accordance with the reduction of the apical transporter (Asbt) for their tubular reabsorption. In summary, our data demonstrated the potency of both agents used for the prevention of AKI, imposed by endotoxins, and for the restoration of renal drug elimination, mainly by the improvement of GFR. The influence of both drugs on altered tubular functions and the expression of drug transporters was differential, emphasizing the necessity of knowledge of transporting pathways for individual drugs applied during sepsis. The effect of anakinra suggests a significant contribution of IL-1 signaling to the pathogenesis of LPS-induced AKI.
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Affiliation(s)
- Zuzana Kadova
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
- Department of Pharmacology and Toxicology, Charles University in Prague, Faculty of Pharmacy in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Eva Dolezelova
- Department of Biological and Medical Sciences, Charles University in Prague, Faculty of Pharmacy in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jolana Cermanova
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Milos Hroch
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
- Department of Medical Biochemistry, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Tomas Laho
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Lucie Muchova
- Institute of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; and
| | - Frantisek Staud
- Department of Pharmacology and Toxicology, Charles University in Prague, Faculty of Pharmacy in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Libor Vitek
- Institute of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; and
- 4th Department of Internal Medicine, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jaroslav Mokry
- Department of Histology and Embryology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jaroslav Chladek
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Zuzana Havlinova
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Milan Holecek
- Department of Physiology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Stanislav Micuda
- Department of Pharmacology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
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Chelazzi C, Villa G, Mancinelli P, De Gaudio AR, Adembri C. Glycocalyx and sepsis-induced alterations in vascular permeability. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:26. [PMID: 25887223 PMCID: PMC4308932 DOI: 10.1186/s13054-015-0741-z] [Citation(s) in RCA: 240] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Endothelial cells line the inner portion of the heart, blood vessels, and lymphatic vessels; a basal membrane of extracellular matrix lines the extraluminal side of endothelial cells. The apical side of endothelial cells is the site for the glycocalyx, which is a complex network of macromolecules, including cell-bound proteoglycans and sialoproteins. Sepsis-associated alterations of this structure may compromise endothelial permeability with associated interstitial fluid shift and generalized edema. Indeed, in sepsis, the glycocalyx acts as a target for inflammatory mediators and leukocytes, and its ubiquitous nature explains the damage of tissues that occurs distant from the original site of infection. Inflammatory-mediated injury to glycocalyx can be responsible for a number of specific clinical effects of sepsis, including acute kidney injury, respiratory failure, and hepatic dysfunction. Moreover, some markers of glycocalyx degradation, such as circulating levels of syndecan or selectins, may be used as markers of endothelial dysfunction and sepsis severity. Although a great deal of experimental evidence shows that alteration of glycocalyx is widely involved in endothelial damage caused by sepsis, therapeutic strategies aiming at preserving its integrity did not significantly improve the outcome of these patients.
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Affiliation(s)
- Cosimo Chelazzi
- Department of Health Sciences, University of Florence, Section of Anesthesiology, Intensive Care and Pain Medicine, Viale Pieraccini, 6, 50139, Florence, Italy.
| | - Gianluca Villa
- Department of Health Sciences, University of Florence, Section of Anesthesiology, Intensive Care and Pain Medicine, Viale Pieraccini, 6, 50139, Florence, Italy.
| | - Paola Mancinelli
- Department of Health Sciences, University of Florence, Section of Anesthesiology, Intensive Care and Pain Medicine, Viale Pieraccini, 6, 50139, Florence, Italy.
| | - A Raffaele De Gaudio
- Department of Health Sciences, University of Florence, Section of Anesthesiology, Intensive Care and Pain Medicine, Viale Pieraccini, 6, 50139, Florence, Italy.
| | - Chiara Adembri
- Department of Health Sciences, University of Florence, Section of Anesthesiology, Intensive Care and Pain Medicine, Viale Pieraccini, 6, 50139, Florence, Italy.
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Ordonez AA, Maiga M, Gupta S, Weinstein EA, Bishai WR, Jain SK. Novel adjunctive therapies for the treatment of tuberculosis. Curr Mol Med 2014; 14:385-95. [PMID: 24236454 DOI: 10.2174/1566524013666131118112431] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 07/07/2013] [Accepted: 08/05/2013] [Indexed: 11/22/2022]
Abstract
Despite significant efforts to control tuberculosis (TB), the disease remains a major global threat, with an estimated 8.6 million new cases and 1.3 million deaths in 2012 alone. Significant treatment challenges include HIV co-infection, the dramatic rise of multidrug-resistant TB and the vast reservoir of latently infected individuals, who will develop active disease years after the initial infection. The long duration of chemotherapy also remains a major barrier to effective large scale treatment of TB. Significant advances are being made in the development of shorter and effective TB drug regimens and there is growing evidence that host-directed and "non-antimicrobial" pathogen-directed therapies, could serve as novel approaches to enhance TB treatments. This review highlights the rationale for using these therapies and summarizes some of the progress in this field.
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Affiliation(s)
| | | | | | | | | | - S K Jain
- Center for Infection and Inflammation Imaging Research, 1550 Orleans Street, Rm 1.09, Baltimore, MD 21287, USA.
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Atkinson SJ, Cvijanovich NZ, Thomas NJ, Allen GL, Anas N, Bigham MT, Hall M, Freishtat RJ, Sen A, Meyer K, Checchia PA, Shanley TP, Nowak J, Quasney M, Weiss SL, Banschbach S, Beckman E, Howard K, Frank E, Harmon K, Lahni P, Lindsell CJ, Wong HR. Corticosteroids and pediatric septic shock outcomes: a risk stratified analysis. PLoS One 2014; 9:e112702. [PMID: 25386653 PMCID: PMC4227847 DOI: 10.1371/journal.pone.0112702] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/09/2014] [Indexed: 12/17/2022] Open
Abstract
Background The potential benefits of corticosteroids for septic shock may depend on initial mortality risk. Objective We determined associations between corticosteroids and outcomes in children with septic shock who were stratified by initial mortality risk. Methods We conducted a retrospective analysis of an ongoing, multi-center pediatric septic shock clinical and biological database. Using a validated biomarker-based stratification tool (PERSEVERE), 496 subjects were stratified into three initial mortality risk strata (low, intermediate, and high). Subjects receiving corticosteroids during the initial 7 days of admission (n = 252) were compared to subjects who did not receive corticosteroids (n = 244). Logistic regression was used to model the effects of corticosteroids on 28-day mortality and complicated course, defined as death within 28 days or persistence of two or more organ failures at 7 days. Results Subjects who received corticosteroids had greater organ failure burden, higher illness severity, higher mortality, and a greater requirement for vasoactive medications, compared to subjects who did not receive corticosteroids. PERSEVERE-based mortality risk did not differ between the two groups. For the entire cohort, corticosteroids were associated with increased risk of mortality (OR 2.3, 95% CI 1.3–4.0, p = 0.004) and a complicated course (OR 1.7, 95% CI 1.1–2.5, p = 0.012). Within each PERSEVERE-based stratum, corticosteroid administration was not associated with improved outcomes. Similarly, corticosteroid administration was not associated with improved outcomes among patients with no comorbidities, nor in groups of patients stratified by PRISM. Conclusions Risk stratified analysis failed to demonstrate any benefit from corticosteroids in this pediatric septic shock cohort.
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Affiliation(s)
- Sarah J. Atkinson
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Department of Surgery, University of Cincinnati, Cincinnati, OH, United States of America
| | | | - Neal J. Thomas
- Penn State Hershey Children’s Hospital, Hershey, PA, United States of America
| | - Geoffrey L. Allen
- Children’s Mercy Hospital, Kansas City, MO, United States of America
| | - Nick Anas
- Children’s Hospital of Orange County, Orange, CA, United States of America
| | | | - Mark Hall
- Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Robert J. Freishtat
- Children’s National Medical Center, Washington, DC, United States of America
| | - Anita Sen
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY, United States of America
| | - Keith Meyer
- Miami Children’s Hospital, Miami, FL, United States of America
| | - Paul A. Checchia
- Texas Children’s Hospital, Houston, TX, United States of America
| | - Thomas P. Shanley
- C. S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI, United States of America
| | - Jeffrey Nowak
- Children’s Hospital and Clinics of Minnesota, Minneapolis, MN, United States of America
| | - Michael Quasney
- C. S. Mott Children’s Hospital at the University of Michigan, Ann Arbor, MI, United States of America
| | - Scott L. Weiss
- The Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Sharon Banschbach
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Eileen Beckman
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Kelli Howard
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Erin Frank
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Kelli Harmon
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Patrick Lahni
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
| | - Christopher J. Lindsell
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Hector R. Wong
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center and Cincinnati Children’s Research Foundation, Cincinnati, OH, United States of America
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- * E-mail:
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Cao Z, Robinson RAS. The role of proteomics in understanding biological mechanisms of sepsis. Proteomics Clin Appl 2014; 8:35-52. [PMID: 24339042 DOI: 10.1002/prca.201300101] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/27/2013] [Accepted: 11/29/2013] [Indexed: 11/10/2022]
Abstract
Sepsis is a systemic inflammatory state caused by infection. Complications of this infection with multiple organ failure lead to more lethal conditions, such as severe sepsis and septic shock. Sepsis is one of the leading causes of US deaths. Novel biomarkers with high sensitivity and specificity may be helpful for early diagnosis of sepsis and for improvement of patient outcomes through the development of new therapies. Mass spectrometry-based proteomics offers powerful tools to identify such biomarkers and furthermore to give insight to fundamental mechanisms of this clinical condition. In this review, we summarize findings from proteomics studies of sepsis and how their applications have provided more understanding into the pathogenesis of septic infection. Literatures related to "proteomics", "sepsis", "systemic inflammatory response syndrome", "severe sepsis", "septic infection", and "multiple organ dysfunction syndrome" were searched using PubMed. Findings about neonatal and adult sepsis are discussed separately. Within the adult sepsis studies, results are grouped based on the models (e.g., human or animal). Across investigations in clinical populations and in rodent and mammalian animal models, biological pathways, such as inflammatory and acute phase response, coagulation, complement, mitochondrial energy metabolism, chaperones, and oxidative stress, are altered at the protein level. These proteomics studies have discovered many novel biomarker candidates of septic infection. Validation the clinical use of these biomarker candidates may significantly impact the diagnosis and prognosis of sepsis. In addition, the molecular mechanisms revealed by these studies may also guide the development of more effective treatments.
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Affiliation(s)
- Zhiyun Cao
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA
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Levy-Shraga Y, Pinhas-Hamiel O. Critical illness-related corticosteroid insufficiency in children. Horm Res Paediatr 2014; 80:309-17. [PMID: 24217117 DOI: 10.1159/000354759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 07/31/2013] [Indexed: 02/05/2023] Open
Abstract
Adequate adrenocortical function is essential for survival in critical illness. Most critically ill patients display elevated plasma cortisol concentrations, which reflects activation of the hypothalamic-pituitary-adrenal axis and is considered to be a homeostatic adaptation. However, many critically ill patients have 'relative' or 'functional' adrenal insufficiency, which is characterized by an inadequate production of cortisol in relation to an increased demand during periods of severe stress. Recently, the term 'critical illness-related corticosteroid insufficiency' (CIRCI) was coined. CIRCI occurs as a result of a decrease in adrenal steroid production or tissue resistance to glucocorticoids. An international task force of the American College of Critical Care Medicine issued recommendations for the diagnosis and management of this condition in adult patients. We review the prevalence, diagnosis, and therapeutic approach to adrenal insufficiency in critically ill children. We found a lack of consensus within the pediatric field as to the optimal approach to CIRCI, and call for an international task force to establish unified guidelines.
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Affiliation(s)
- Yael Levy-Shraga
- Pediatric Endocrine and Diabetes Unit, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
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Corticosteroid treatment for community-acquired pneumonia--the STEP trial: study protocol for a randomized controlled trial. Trials 2014; 15:257. [PMID: 24974155 PMCID: PMC4083867 DOI: 10.1186/1745-6215-15-257] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 06/16/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is the third-leading infectious cause of death worldwide. The standard treatment of CAP has not changed for the past fifty years and its mortality and morbidity remain high despite adequate antimicrobial treatment. Systemic corticosteroids have anti-inflammatory effects and are therefore discussed as adjunct treatment for CAP. Available studies show controversial results, and the question about benefits and harms of adjunct corticosteroid therapy has not been conclusively resolved, particularly in the non-critical care setting. METHODS/DESIGN This randomized multicenter study compares a treatment with 7 days of prednisone 50 mg with placebo in adult patients hospitalized with CAP independent of severity. Patients are screened and enrolled within the first 36 hours of presentation after written informed consent is obtained. The primary endpoint will be time to clinical stability, which is assessed every 12 hours during hospitalization. Secondary endpoints will be, among others, all-cause mortality within 30 and 180 days, ICU stay, duration of antibiotic treatment, disease activity scores, side effects and complications, value of adrenal function testing and prognostic hormonal and inflammatory biomarkers to predict outcome and treatment response to corticosteroids. Eight hundred included patients will provide an 85% power for the intention-to-treat analysis of the primary endpoint. DISCUSSION This largest to date double-blind placebo-controlled multicenter trial investigates the effect of adjunct glucocorticoids in 800 patients with CAP requiring hospitalization. It aims to give conclusive answers about benefits and risks of corticosteroid treatment in CAP. The inclusion of less severe CAP patients will be expected to lead to a relatively low mortality rate and survival benefit might not be shown. However, our study has adequate power for the clinically relevant endpoint of clinical stability. Due to discontinuing glucocorticoids without tapering after seven days, we limit duration of glucocorticoid exposition, which may reduce possible side effects. TRIAL REGISTRATION 7 September 2009 on ClinicalTrials.gov: NCT00973154.
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Wong HR, Cvijanovich NZ, Allen GL, Thomas NJ, Freishtat RJ, Anas N, Meyer K, Checchia PA, Weiss SL, Shanley TP, Bigham MT, Banschbach S, Beckman E, Harmon K, Zimmerman JJ. Corticosteroids are associated with repression of adaptive immunity gene programs in pediatric septic shock. Am J Respir Crit Care Med 2014; 189:940-6. [PMID: 24650276 DOI: 10.1164/rccm.201401-0171oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Corticosteroids are prescribed commonly for patients with septic shock, but their use remains controversial and concerns remain regarding side effects. OBJECTIVES To determine the effect of adjunctive corticosteroids on the genomic response of pediatric septic shock. METHODS We retrospectively analyzed an existing transcriptomic database of pediatric septic shock. Subjects receiving any formulation of systemic corticosteroids at the time of blood draw for microarray analysis were classified in the septic shock corticosteroid group. We compared normal control subjects (n = 52), a septic shock no corticosteroid group (n = 110), and a septic shock corticosteroid group (n = 70) using analysis of variance. Genes differentially regulated between the no corticosteroid group and the corticosteroid group were analyzed using Ingenuity Pathway Analysis. MEASUREMENTS AND MAIN RESULTS The two study groups did not differ with respect to illness severity, organ failure burden, mortality, or mortality risk. There were 319 gene probes differentially regulated between the no corticosteroid group and the corticosteroid group. These genes corresponded predominately to adaptive immunity-related signaling pathways, and were down-regulated relative to control subjects. Notably, the degree of down-regulation was significantly greater in the corticosteroid group, compared with the no corticosteroid group. A similar pattern was observed for genes corresponding to the glucocorticoid receptor signaling pathway. CONCLUSIONS Administration of corticosteroids in pediatric septic shock is associated with additional repression of genes corresponding to adaptive immunity. These data should be taken into account when considering the benefit to risk ratio of adjunctive corticosteroids for septic shock.
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Affiliation(s)
- Hector R Wong
- 1 Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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