Vitamin D status and the risk for hospital-acquired infections in critically ill adults: a prospective cohort study

Positive Effects of Vitamin D Supplementation in Patients Hospitalized for COVID-19: A Randomized, Double-Blind, Placebo-Controlled Trial

Retrospective studies showed a relationship between vitamin D status and COVID-19 severity and mortality, with an inverse relation between SARS-CoV-2 positivity and circulating calcifediol levels. The objective of this pilot study was to investigate the effect of vitamin D supplementation on the length of hospital stay and clinical improvement in patients with vitamin D deficiency hospitalized with COVID-19. The study was randomized, double blind and placebo controlled. A total of 50 subjects were enrolled and received, in addition to the best available COVID therapy, either vitamin D (25,000 IU per day over 4 consecutive days, followed by 25,000 IU per week up to 6 weeks) or placebo. The length of hospital stay decreased significantly in the vitamin D group compared to the placebo group (4 days vs. 8 days; p = 0.003). At Day 7, a significantly lower percentage of patients were still hospitalized in the vitamin D group compared to the placebo group (19% vs. 54%; p = 0.0161), and none of the patients treated with vitamin D were hospitalized after 21 days compared to 14% of the patients treated with placebo. Vitamin D significantly reduced the duration of supplemental oxygen among the patients who needed it (4 days vs. 7 days in the placebo group; p = 0.012) and significantly improved the clinical recovery of the patients, as assessed by the WHO scale (p = 0.0048). In conclusion, this study demonstrated that the clinical outcome of COVID-19 patients requiring hospitalization was improved by administration of vitamin D.

Vitamin D in infectious complications in critically ill patients with or without COVID-19

25-hydroxyvitamin D [25(OH)D] is an important immunomodulator, whose deficiency may aggravate the incidence and outcome of infectious complications in patients admitted to the intensive care unit. The most recognized extra-skeletal action of vitamin D is the regulation of immune function. Host defense against intracellular pathogens depends upon both innate and adaptive immunity. It has been suggested that vitamin D regulates the pro-inflammatory endothelial response to lipopolysaccharide, rendering it a role in the sepsis cascade. Recent studies have indicated that vitamin D deficiency may be associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19), such as more severe disease and higher mortality rates. To this end, clinical trials with vitamin D supplementation are being carried out in an effort to improve COVID-19 outcomes. In this review, we will discuss the role of vitamin D in the immune response, and more specifically its effect on immune cells. Subsequently, we will provide an overview of the studies that have investigated the predictive value of vitamin D in critical illness outcomes, and its therapeutic value as a supplement in critically ill patients. Finally, the emerging role of vitamin D deficiency in COVID-19 infection risk, and worse outcomes will be discussed.

Clinical significance of vitamin D in idiopathic normal pressure hydrocephalus

BACKGROUND

Although recent studies show vitamin D deficiency is associated with cognitive decline, urinary incontinence, and gait instability, there has been no study on the effect of vitamin D on idiopathic normal pressure hydrocephalus (iNPH) characterized by the classic symptom triad of cognitive decline, urinary incontinence, and gait instability. We investigated the clinical significance of vitamin D in patients with iNPH.

METHODS

Between 2017 and 2020, 44 patients who underwent ventriculoperitoneal shunt surgery were divided into low (< 15 ng/mL) and high (≥ 15 ng/mL) vitamin D groups according to the concentration of 25(OH)D, an effective indicator of vitamin D status. They were respectively evaluated according to clinical and radiological findings.

RESULTS

The low vitamin D group (n = 24) showed lower preoperative cognition compared to the high vitamin D group (n = 20) in terms of Korean-Mini Mental Status Examination (K-MMSE) and iNPH grading scale (iNPHGS) (K-MMSE: 20.5 ± 5.4 versus 24.0 ± 4.5, p = 0.041; iNPHGS cognitive score: 2 ± 0.9 versus 1 ± 0.6, p = 0.025). And the low vitamin D group showed pre- and postoperatively more severe urinary incontinence (preoperative iNPHGS urinary score: 1 ± 1.0 versus 0 ± 0.9, p = 0.012; postoperative iNPHGS urinary score:1 ± 1.0 versus 0 ± 0.9, p = 0.014). The score of narrow high-convexity sulci for the low vitamin D group was lower (low vitamin D group: 1 ± 0.7 versus high vitamin D group: 2 ± 0.4, p = 0.031).

CONCLUSION

Lower concentration of vitamin D in iNPH may be related to lower preoperative cognition, pre- and postoperative urinary incontinence, and brain morphological change.

Therapeutic Value of Vitamin D as an Adjuvant Therapy in Neonates with Sepsis

Sepsis is unusual systemic reaction to an ordinary infection, and it probably represents a pattern of response by the immune system to the injury. Vitamin D is a fat-soluble steroid hormone that contributes to the maintenance of normal calcium homeostasis and skeletal mineralization. Vitamin D has an important role in the regulation of both innate and adaptive immune systems.

AIM OF THE WORK

The current study aimed to evaluate the therapeutic value of vitamin D supplementation as an adjuvant therapy in neonates with sepsis.

SUBJECTS AND METHOD

This study included 60 neonates with sepsis who were randomly divided into 2 equal groups; group I: 30 neonates with sepsis who received antibiotic only, Group II: 30 neonates with sepsis who received antibiotic therapy and vitamin D. This study also included 30 healthy neonates as a control group. For all patients and controls, serum level of 25 (OH) vitamin D and highly sensitive C reactive protein (hs-CRP) were immunoassayed.

RESULTS

There is no significant difference between groups I, II and controls regarding weight, gestational age, sex and mode of delivery. There were significant differences between groups I and II in sepsis score and hs-CRP after 3, 7, 10 days of treatment (p values for sepsis score were 0.009, 0.006, 0.004 respectively and for hs-CRP were 0.015, 0.001, 0.001 respectively). There was a significant difference in immature /total (I/T) ratio after 7, and 10 days of treatment (p value= 0.045, 0.025, respectively,) while there was no significant difference in immature /total (I/T) ratio after 3 days of treatment (p value = 0.624).Serum 25(OH) vitamin D levels were significantly lower in neonates with sepsis (group I and II) than the controls (p value < 0.05, while there were no significant differences between the three groups considering serum calcium and phosphorus levels (P =1.000, 1.000, respectively). Isolated organisms from blood culture in neonates with sepsis (group I and group II) were most commonly B- hemolytic streptococci, E-coli, hemophilus influenza and staphylococcus aurous. There was a significant negative correlation between hs-CRP and serum 25 (OH) vitamin in group II on entry (r = - 0.832 and P value = 0.001) and after 2 weeks (r = - 0.590 and P value = 0.021). ROC curve of specificity and sensitivity of 25 (OH) vitamin D level in prediction of early-onset neonatal sepsis showed that cutoff value of vitamin D was ≤20 ng/ml, sensitivity was 100%, specificity was 73%, positive predictive value was 73%, negative predictive value was 100% and accuracy was 87.

CONCLUSION AND RECOMMENDATION

Serum 25 (OH) vitamin D levels of neonates with the early onset neonatal sepsis were significantly lower than the healthy controls. Vitamin D supplementation improved sepsis score and decrease high levels of hs-CRP; this reflects the role of vitamin D as a target therapy for neonatal sepsis. Further studies are warranted to confirm the therapeutic value of vitamin D in neonatal sepsis.

Uremic pruritus and long-term morbidities in the dialysis population

Background

Uremic pruritus (UP) is a multifactorial problem that contributes to low quality of life in dialysis patients. The long-term influences of UP on dialysis patients are still poorly understood. This study aims to elucidate the contribution of UP to long-term outcomes.

Materials and method

We used the Taiwan National Health Insurance Research Database to conduct this study. Patients on chronic dialysis were included and divided into UP and non-UP groups according to the long-term prescription of antihistamine in the absence of other indications. The outcomes include infection-related hospitalization, catheter-related infection, major adverse cardiac and cerebrovascular events (MACCE) and parathyroidectomy.

Results

After propensity score matching, 14,760 patients with UP and 29,520 patients without UP were eligible for analysis. After a mean follow-up of 5 years, we found that infection-related hospitalization, MACCE, catheter-related infection, heart failure and parathyroidectomy were all slightly higher in the UP than non-UP group (hazard ratio: 1.18 [1.16–1.21], 1.05 [1.01–1.09], 1.16 [1.12–1.21], 1.08 [1.01–1.16] and 1.10 [1.01–1.20], respectively). Subgroup analysis revealed that the increased risk of adverse events by UP was generally more apparent in younger patients and patients who underwent peritoneal dialysis.

Conclusion

UP may be significantly associated with an increased risk of long-term morbidities.

Serum Admission 25-Hydroxyvitamin D Levels and Outcomes in Initially Non-Septic Critically Ill Patients

INTRODUCTION

To examine whether very low levels of 25-hydroxyvitamin D {25(OH)D} upon admission to the intensive care unit (ICU) are associated with worse outcomes.

METHODS

Retrospective observational cohort study of critically ill patients treated in a multidisciplinary ICU. Two hundred twenty seven initially non-septic, critically ill patients, in whom 25-hydroxyvitamin D was measured at ICU admission. An additional group of 192 healthy subjects was also used. Patients were categorized according to their vitamin D levels at admission; the two patient groups were those with severely low 25-hydroxyvitamin D levels (<7 ng/mL, N = 101) and those with vitamin D levels ≥7 ng/mL, N = 126.

RESULTS

ICU admission 25-hydroxyvitamin D levels of critically ill patients were much lower than those of healthy subjects (P < 0.0001). The median time to sepsis for the two patient groups did not differ, nor did the length of ICU stay (days). Both groups exhibited similar hospital mortality rates. However, among the fraction of patients who eventually became septic (N = 145), the odds ratio (OR) for developing respiratory infections in patients with admission vitamin levels < 7 ng/mL compared with patients with admission vitamin D levels ≥7 ng/mL was 5.25 {95% confidence interval (CI) 1.5-18.32, P = 0.009}.

CONCLUSIONS

Initially non-septic critically ill patients appear to have very low ICU admission 25-hydroxyvitamin D levels. Among critically ill patients, severely low vitamin D levels (<7 ng/mL) at ICU admission do not predict sepsis development, increased risk of in-hospital mortality, or longer stay in the ICU. However, these severely low admission vitamin D levels in patients who will eventually develop sepsis are associated with development of respiratory tract infections.

Importance of vitamin D in acute and critically ill children with subgroup analyses of sepsis and respiratory tract infections: a systematic review and meta-analysis

OBJECTIVES

To estimate the prevalence of 25-hydroxyvitamin D (25(OH)D) deficiency and investigate its association with mortality in children with acute or critical conditions.

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

PubMed, OVID, Google Scholar and the Cochrane Library searched until 21 December 2018.

ELIGIBILITY CRITERIA

Studies of children hospitalised with acute or critical conditions who had blood 25(OH)D levels measured.

DATA EXTRACTION AND SYNTHESIS

We obtained pooled prevalence estimates of 25(OH)D deficiency and ORs for mortality. We calculated 95% CI and prediction intervals and investigated heterogeneity and evidence of small-study effects.

RESULTS

Fifty-two studies were included. Of 7434 children, 3473 (47.0%) were 25(OH)D deficient (<50 nmol/L). The pooled prevalence estimate of 25(OH)D deficiency was 54.6% (95% CI 48.5% to 60.6%, I²=95.3%, p<0.0001). Prevalence was similar after excluding smaller studies (51.5%). In children with sepsis (18 studies, 889 total individuals) prevalence was 64.0% (95% CI 52.0% to 74.4%, I²=89.3%, p<0.0001) and 48.7% (95% CI 38.2% to 59.3%; I²=94.3%, p<0.0001) in those with respiratory tract infections (RTI) (25 studies, 2699 total individuals). Overall, meta-analysis of mortality (18 cohort studies, 2463 total individuals) showed increased risk of death in 25(OH)D deficient children (OR 1.81, 95% CI 1.24 to 2.64, p=0.002, I²=25.7%, p=0.153). Four (22.0%) of the 18 studies statistically adjusted for confounders. There were insufficient studies to meta-analyse sepsis and RTI-related mortality.

CONCLUSIONS

Our results suggest that 25(OH)D deficiency in acute and critically ill children is high and associated with increased mortality. Small-study effects, reverse causation and other biases may have confounded results. Larger, carefully designed studies in homogeneous populations with confounder adjustment are needed to clarify the association between 25(OH)D levels with mortality and other outcomes.

PROSPERO REGISTRATION NUMBER

CRD42016050638.

Effect of High-Dose Vitamin D on Duration of Mechanical Ventilation in ICU Patients

The relationship of vitamin D3 with the duration of mechanical ventilation and mortality is still unknown. Therefore, this study aimed to determine the effect of using high-dose vitamin D on the duration of mechanical ventilation among the patients admitted to the intensive care unit. The current double-blinded clinical trial was performed on 44 mechanically ventilated, adult patients. Using permuted block randomization, the patients were recruited in intervention and placebo arms. In the placebo group, four patients were excluded due to death before 72 h. The vitamin D level was measured in both groups on entrance and 7^th day of the study. The intervention and placebo groups received intramuscular injection of 300000 IU vitamin D and identical placebo, respectively. SOFA and CPIS score were evaluated daily for 7 days and on 14^th and 28^th days of the study. Also duration of mechanical ventilation and mortality rate were recorded. Fourteen males and 8 females were recruited in the intervention group, as well as 13 males and 5 females in the control group. There was no significant difference in baseline characteristics of the patients including gender and age. The mean duration of the mechanical ventilation was 17.63 ± 14 days in the intervention group versus 27.72 ± 22.48 days in the control group (p = 0.06). Mortality rate in control and intervention groups was 61.1% versus 36.3% (p = 0.00), respectively. Administration of high-dose vitamin D could reduce mortality in mechanically ventilated patients. Despite decrease of 10 days in duration of mechanical ventilation, the difference was not statistically significant. Larger studies are recommended.

High-Dose Vitamin D3 Administration Is Associated With Increases in Hemoglobin Concentrations in Mechanically Ventilated Critically Ill Adults: A Pilot Double-Blind, Randomized, Placebo-Controlled Trial

BACKGROUND

Anemia and vitamin D deficiency are highly prevalent in critical illness, and vitamin D status has been associated with hemoglobin concentrations in epidemiologic studies. We examined the effect of high-dose vitamin D therapy on hemoglobin and hepcidin concentrations in critically ill adults.

MATERIALS AND METHODS

Mechanically ventilated critically ill adults (N = 30) enrolled in a pilot double-blind, randomized, placebo-controlled trial of high-dose vitamin D3 (D3 ) were included in this analysis. Participants were randomized to receive placebo, 50,000 IU D3 , or 100,000 IU D3 daily for 5 days (totaling 250,000 IU D3 and 500,000 IU D3 , respectively). Blood was drawn weekly throughout hospitalization for up to 4 weeks. Linear mixed-effects models were used to assess change in hemoglobin and hepcidin concentrations by treatment group over time.

RESULTS

At enrollment, >75% of participants in all groups had plasma 25-hydroxyvitamin D (25(OH)D) concentrations <30 ng/mL, and >85% of participants across groups were anemic. In the 500,000-IU D3 group, hemoglobin concentrations increased significantly over time (Pgroup × time = .01) compared with placebo but did not change in the 250,000-IU D3 group (Pgroup × time = 0.59). Hepcidin concentrations decreased acutely in the 500,000-IU D3 group relative to placebo after 1 week (P = .007). Hepcidin did not change significantly in the 250,000-IU D3 group.

CONCLUSION

In these critically ill adults, treatment with 500,000 IU D3 was associated with increased hemoglobin concentrations over time and acutely reduced serum hepcidin concentrations. These findings suggest that high-dose vitamin D may improve iron metabolism in critical illness and should be confirmed in larger studies.

Impact of high-dose vitamin D3 on plasma free 25-hydroxyvitamin D concentrations and antimicrobial peptides in critically ill mechanically ventilated adults

OBJECTIVES

High-dose vitamin D₃ increases plasma total 25-hydroxyvitamin D [25(OH)D] in critically ill, ventilated patients; however, to our knowledge, the effect on plasma levels of free (nonprotein-bound) 25(OH)D has not been investigated in critical illness. Moreover, the relationship of free 25(OH)D and the regulation of endogenous antimicrobial peptides (AMPs) remains unknown. The aims of this study were to determine in critically ill adults with respiratory failure the effect of previous high-dose regimens of vitamin D₃ on free 25(OH)D concentrations, the relationship of free 25(OH)D with circulating cathelicidin (LL-37) and human beta-defensin-2 (hBD-2), and the associations between plasma levels of free 25(OH)D and these AMPs to alveolar macrophage phagocytosis function.

METHODS

In a double blind, randomized controlled trial, critically ill ventilator-dependent adults (N = 30) received enteral vitamin D₃ (250,000 or 500,000 IU total over 5 d) or placebo. Plasma was obtained serially for concentrations of free 25(OH)D, LL-37, hBD-2, and expression of peripheral blood mononuclear cell human cationic antimicrobial protein (hCAP18) mRNA. Total 25(OH)D and LL-37 concentrations and alveolar macrophage phagocytosis were determined in bronchoalveolar lavage fluid.

RESULTS

Plasma concentrations of free 25(OH)D over time were correlated with total 25(OH)D levels (r= 0.82; P < 0.001). The increase in free 25(OH)D was greater with the 500 000 IU vitamin D₃ dose than with the lower dose. The percent change in mRNA expression of hCAP18 was positively associated with percent change in free 25(OH)D at days 7 and 14 (ρ = 0.48; P = 0.04 and ρ = 0.59; P = 0.03, respectively). Additionally, plasma LL-37 levels correlated with the percentage of alveolar macrophages exhibiting phagocytosis (ρ = 0.51; P = 0.04).

CONCLUSIONS

The present study found a dose-related increase in plasma free-25(OH)D levels, which was associated with increasing circulating mRNA expression of hCAP18 over time. There were no correlations between changes in total and free 25(OH)D against plasma LL-37 and hBD-2 concentrations. Larger studies appear warranted to determine the impact of high-dose vitamin D₃ administration on endogenous AMPs.

Associations Between Vitamin D Level and Hospitalizations With and Without an Infection in a National Cohort of Medicare Beneficiaries

Research has implicated low 25-hydroxyvitamin D (25(OH)D) level as a risk factor for infection; however, results have not been consistent. To further determine the nature of this relationship, we conducted a cohort study using Medicare beneficiaries participating in the 2001-2002 and 2003-2004 cycles of the National Health and Nutrition Examination Survey with data individually linked to hospital records from the Centers for Medicare and Medicaid Services. The primary exposure was a 25(OH)D level of <15 ng/mL versus ≥15 ng/mL. The outcomes were a hospitalization with or without an infection within 1 year of participation in the National Health and Nutrition Examination Survey, as determined from the final hospital discharge codes (International Classification of Diseases, Ninth Revision, Clinical Modification). Of 1,713 individuals, 348 had a baseline serum 25(OH)D level of <15 ng/mL, 77 experienced a hospitalization with an infection, and 287 experienced a hospitalization without an infection. In multivariable analyses, a serum 25(OH)D level of <15 ng/mL was associated with a higher risk of hospitalization with an infection (risk ratio = 2.8, 95% confidence interval: 1.3, 5.9, P < 0.01) but not of hospitalization without an infection (risk ratio = 1.4, 95% confidence interval: 0.9, 2.1, P = 0.1). In this study, we found an association between a serum 25(OH)D concentration of <15 ng/mL and a higher subsequent risk for hospitalization with an infection among Medicare beneficiaries.

High Dose Vitamin D Administration in Ventilated Intensive Care Unit Patients: A Pilot Double Blind Randomized Controlled Trial

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First double blind RCT of vitamin D therapy in mechanically ventilated patients.

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Treatment with placebo, 250,000 IU or 500,000 IU enteral vitamin D3 was well tolerated.

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Significant increase in plasma 25(OH)D from baseline to day 7.

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Significant decrease in hospital length of stay for vitamin D3 treated subjects.

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No change in plasma LL-37 according to treatment group.

Background

There is a high prevalence of vitamin D deficiency in the critically ill patient population. Several intensive care unit studies have demonstrated an association between vitamin D deficiency [25-hydroxyvitamin D (25(OH)D) < 20 ng/mL] and increased hospital length of stay (LOS), readmission rate, sepsis and mortality.

Material and Methods

Pilot, double blind randomized control trial conducted on mechanically ventilated adult ICU patients. Subjects were administered either placebo, 50,000 IU vitamin D₃ or 100,000 IU vitamin D₃ daily for 5 consecutive days enterally (total vitamin D₃ dose = 250,000 IU or 500,000 IU, respectively). The primary outcome was plasma 25(OH)D concentration 7 days after oral administration of study drug. Secondary outcomes were plasma levels of the antimicrobial peptide cathelicidin (LL37), hospital LOS, SOFA score, duration of mechanical ventilation, hospital mortality, mortality at 12 weeks, and hospital acquired infection.

Results

A total of 31 subjects were enrolled with 13 (43%) being vitamin D deficient at entry (25(OH)D levels < 20 ng/mL). The 250,000 IU and 500,000 IU vitamin D₃ regimens each resulted in a significant increase in mean plasma 25(OH)D concentrations from baseline to day 7; values rose to 45.7 ± 19.6 ng/mL and 55.2 ± 14.4 ng/mL, respectively, compared to essentially no change in the placebo group (21 ± 11.2 ng/mL), p < 0.001. There was a significant decrease in hospital length of stay over time in the 250,000 IU and the 500,000 IU vitamin D₃ group, compared to the placebo group (25 ± 14 and 18 ± 11 days compared to 36 ± 19 days, respectively; p = 0.03). There was no statically significant change in plasma LL-37 concentrations or other clinical outcomes by group over time.

Conclusions

In this pilot study, high-dose vitamin D3 safely increased plasma 25(OH)D concentrations into the sufficient range and was associated with decreased hospital length of stay without altering other clinical outcomes.