Septic shock from descending necrotizing mediastinitis - combined treatment with IgM-enriched immunoglobulin preparation and direct polymyxin B hemoperfusion: a case report

Background

Descending necrotizing mediastinitis is a common and progressive polymicrobial infection involving the neck and chest with a high death rate (10 to 40%). From a microbiological point of view, descending necrotizing mediastinitis is sustained by Gram-positive bacteria (43–62%), anaerobes (46–78%), and, rarely, Gram-negative bacteria. Data collected during the Antibiotic Resistance-Istituto Superiore di Sanità project confirmed that Italy is positioned among the countries with the highest levels of resistance in most pathogenic species under surveillance. In particular, 32.9% of Klebsiella pneumoniae isolates were resistant to carbapenem, 33.6% of Staphylococcus aureus to methicillin, and 28.7% and 43.9% of Escherichia coli isolates to third-generation cephalosporins and fluoroquinolones, respectively.

Case presentation

We describe the case of a 38-year-old white man with septic shock due to descending necrotizing mediastinitis sustained by multidrug-resistant Gram-negative and Gram-positive bacteria treated after surgery with an IgM-enriched immunoglobulin preparation and polymyxin B hemoperfusion therapy.

Conclusion

Despite the contrasting data on the use of immunoglobulins and polymyxin B hemoperfusion in septic shock and the lack of literature in cases of acute mediastinitis caused by both Gram-negative and Gram-positive multidrug-resistant bacteria, we obtained an improvement in clinical conditions and the survival of our patient, against all odds.

A pilot study of selective lipopolysaccharide adsorption and coupled plasma filtration and adsorption in adult patients with severe sepsis

AIM

To evaluate the safety and effectiveness of combined extracorporeal therapy in patients with severe sepsis after cardiac surgery.

MATERIALS AND METHODS

Twenty patients received combined extracorporeal therapy (LPS-adsorption with Toraymyxin columns + CPFA). The inclusion criteria were clinical signs of severe sepsis, EAA = 0.6, and PCT >2 ng/ml. 20 comparable patients in the control group received only standard therapy.

RESULTS

Each patient in the study group received 2 daily treatments of combined extracorporeal therapy. In contrast to controls, we noted an increase in the values of MAP from 73 to 82 mm Hg, (p < 0.001) and the mean oxygenation index (from 180 to 246, p < 0.001), decrease of EAA from 0.77 to 0.55, p < 0.001, and PCT (from 6.23 to 2.83 ng/ml, p < 0.001). The 28-day survival rate was 65 and 35% in the study and control groups respectively, p = 0.11.

CONCLUSION

The combined use of LPS-adsorption and CPFA in a single circuit with standard therapy is a safe and possibly effective adjunctive method for treating severe sepsis.

Endotoxin adsorption using polymyxin B immobilized fiber cartridges in severe sepsis patients following cardiac surgery

INTRODUCTION

Sepsis still represents an obstacle in modern medicine. The purpose of this study was to evaluate the safety and effectiveness of selective lipopolysaccharide (LPS)-adsorption therapy using polymyxin B immobilized fiber cartridges in adult patients complicated with severe sepsis after cardiac surgery.

METHODS

65 patients received extracorporeal LPS-adsorption procedures using Toraymyxin columns (PMX; Toray, Tokyo, Japan) in addition to the standard treatment according to the Surviving Sepsis Campaign guidelines. The inclusion criteria were clinical signs of severe sepsis, endotoxin activity assay (EAA)≥0.6, and blood plasma procalcitonin (PCT)>2 ng/ml. For the control group, we selected 40 patients who were comparable with the study group but who received only the standard therapy.

RESULTS

Each patient received 2 standard LPS-adsorption procedures (lasting for 120 min each). After the LPS-adsorption course, we noted any indices of hemodynamic improvements, including an increase in mean arterial pressure from 73 to 89 mmHg (p<0.001), mean oxygenation index (213-265, p<0.001. We observed a decrease in LPS concentrations by the EAA (0.71-0.55, p<0.001) and by the LAL test (1.44-0.36 EU/ml, p<0.001). In the control group, there were no significant changes in any of the studied parameters. Moreover, the 28-day mortality was 42% in the study group and 65% in the control group (p=0.032). The endotoxin adsorption procedures were not associated with any adverse reactions, and specifically, no extracorporeal circuit thrombosis cases were noted.

CONCLUSIONS

Selective LPS-adsorption is a safe and possibly effective adjunctive treatment method for severe sepsis patients.

Intraoperative direct hemoperfusion with a polymyxin-B immobilized fiber column for treatment of infective endocarditis

PURPOSE

Endotoxin adsorption treatment (direct hemoperfusion using a polymyxin-B immobilized fiber column, or PMX-DHP) is now considered a useful option for treating severe sepsis. However, the efficacy of PMX-DHP for infective endocarditis (IE), in which the causative microorganisms are usually gram-positive cocci, remains unclear. In the present study, we investigated the impact of intraoperative PMX-DHP on clinical parameters during the treatment of IE.

METHODS

From November 2006 to December 2009, a total of 11 patients with active IE underwent emergent surgery using intraoperative PMX-DHP. The perioperative courses of these patients were compared with those of seven patients who underwent emergent surgery for active IE with the conventional method from January 2003 to October 2006.

RESULTS

PMX-DHP was associated with a significant decrease in the postoperative catecholamine dose and duration. Intubation time and intensive care unit length of stay for the PMX-DHP group was significantly shorter than that for the conventional therapy group. There was also a significant difference in the number of failed organs postoperatively between the two groups.

CONCLUSION

Intraoperative PMX-DHP demonstrated several positive effects, such as a drastic decrease in the doses of inotropic agents and shortening of the duration of mechanical ventilation, in patients who underwent emergent surgery for active IE. Intraoperative PMX-DHP can be a useful option for the treatment of critically ill patients with IE.

[Preparation of bovine serum albumin immobilized adsorbent for specific adsorption of bilirubin]

Serum bilirubin concentration is greatly elevated in certain diseases such as hyperbilirubinemia and severe hepatitis. Lowering the level of bilirubin is one of the major targets of many therapies such as plasma exchange and hemoperfusion. In this study, a bilirubin specific adsorbent was prepared by covalently immobilizing bovine serum albumin (BSA) onto macroporous poly (glycidyl methacrylate-co-trimethylolpropane trimethacrylate) microspheres. The resulting BSA immobilized adsorbent (BIA) demonstrated good performance in adsorption of bilirubin with an adsorption capacity of 48.7 mg/g. Presence of BSA in bilirubin solution significantly lowered the adsorption capacity of the adsorbent due to the tight binding of bilirubin onto BSA. Adsorption performance of the adsorbent for bilirubin was improved with the elevation of temperature. The adsorbent demonstrated good stability even after 31 d of storage at - 80 degrees C in that there was almost no change in adsorption capacity for bilirubin. These results indicated that the prepared BSA immobilized adsorbent could be an alternative choice for specific adsorption of bilirubin.