An approach to antibiotic treatment in patients with sepsis

Impact of prolonged versus intermittent infusion of meropenem on mortality and clinical outcomes in patients with severe infection: A systematic review and meta-analysis

OBJECTIVES

To compare the clinical outcomes of patients with severe infection treated with prolonged or intermittent infusion of meropenem.

METHODS

PubMed, Embase, and Cochrane Central databases were searched until July 2023. Randomized controlled trials (RCTs) or observational studies comparing prolonged versus intermittent infusion of meropenem were considered eligible. The primary outcomes included all-cause mortality and clinical improvement, while secondary outcomes encompassed hospital and intensive care unit (ICU) stay duration, microbial eradication rate, and adverse events. A meta-analysis was conducted using a random-effects model. The risk of bias of included studies was assessed using the modified JADAD scale for RCTs and the Newcastle-Ottawa Scale for observational studies.

RESULTS

Fourteen studies were included, with a total of 1,698 patients. Prolonged infusion of meropenem was associated with a significantly lower mortality rate compared to intermittent infusion (RR = 0.81, 95% CI: 0.68-0.98). It also significantly improved clinical improvement rates (RR = 1.35, 95% CI: 1.11-1.64) and microbial eradication rates (RR = 1.19, 95% CI: 1.08-1.32). There were no statistically significant differences in ICU length of stay or hospital length of stay. Subgroup analyses showed that prolonged infusion was significantly associated with lower mortality and better clinical improvement rates in patients with an APACHE II score < 20.

CONCLUSIONS

Prolonged infusion of meropenem is more effective than intermittent infusion in reducing mortality, improving clinical outcomes, and enhancing microbial eradication, without increasing adverse events. These benefits are particularly evident in patients with lower disease severity (APACHE II < 20), emphasizing the importance of patient stratification in optimizing treatment strategies.

REGISTRATION

This systematic review and meta-analysis is registered with PROSPERO (number: CRD42023445360).

Antibiotic Prescription Practice and Resistance Patterns of Bacterial Isolates from a Neonatal Intensive Care Unit: A Retrospective Study from Jordan

Background/Objectives: Neonatal sepsis is a systemic inflammation in neonates caused by bacteria, viruses, or fungi that can progress into severe conditions. In developing countries, neonatal sepsis is a major cause of mortality and a major public health issue with a high prevalence. This study aims to evaluate the antibiotic prescription practice and resistance patterns of bacterial isolates from the neonatal intensive care unit (NICU) at the largest governmental hospital in Amman, Jordan. Methods: This was a retrospective cross-sectional study. The antibiotic prescription practice and resistance patterns of bacterial isolates from the NICU at Al Basheer Government Hospital in Amman, Jordan, were evaluated. The hospital's microbiology lab database and medical records were the sources of the retrospective data collection. Results: A total of 266 neonates treated with antibiotics were assessed. The findings showed that most neonates had late-onset sepsis (LOS) (65.4%). The penicillin group of antibiotics (ampicillin) was the most highly prescribed first empiric antibiotic for LOS and early-onset sepsis (EOS) (61.7%). Aminoglycosides (60.9%) were the most prescribed antibiotics as a second empiric treatment for EOS and LOS. The culture results showed that resistance to antibiotics was as follows: 15.4% of the culture samples were resistant to penicillin (Micrococcus and Viridans streptococci), 13.9% were resistant to cefotaxime (Klebsiella pneumoniae and Viridans streptococci), 13.2% were resistant to cefoxitin (Klebsiella pneumoniae and Staphylococcus epidermidis), and 12.4% were resistant to oxacillin (Klebsiella pneumoniae and Staphylococcus epidermidis). Conclusions: This retrospective study sheds light on the antibiotic prescription practice and resistance patterns of bacterial isolates from newborns with sepsis. The results highlight the high rates of antibiotic resistance. These findings underline the urgent need for improved antibiotic stewardship and infection control strategies to prevent resistance from spreading further.

Metabolic response of Klebsiella oxytoca to ciprofloxacin exposure: a metabolomics approach

INTRODUCTION

Rapid detection and identification of pathogens and antimicrobial susceptibility is essential for guiding appropriate antimicrobial therapy and reducing morbidity and mortality associated with sepsis.

OBJECTIVES

The metabolic response of clinical isolates of Klebsiella oxytoca exposed to different concentrations of ciprofloxacin (the second generation of quinolones antibiotics) were studied in order to investigate underlying mechanisms associated with antimicrobial resistance (AMR).

METHODS

Metabolomics investigations were performed using Fourier-transform infrared (FT-IR) spectroscopy as a metabolic fingerprinting approach combined with gas chromatography-mass spectrometry (GC-MS) for metabolic profiling.

RESULTS

Our findings demonstrated that metabolic fingerprints provided by FT-IR analysis allowed for the differentiation of susceptible and resistant isolates. GC-MS analysis validated these findings, while also providing a deeper understanding of the metabolic alterations caused by exposure to ciprofloxacin. GC-MS metabolic profiling detected 176 metabolic features in the cellular extracts cultivated on BHI broth, and of these, 137 could be identified to Metabolomics Standards Initiative Level 2. Data analysis showed that 40 metabolites (30 Level 2 and 10 unknown) were differentiated between susceptible and resistant isolates. The identified metabolites belonging to central carbon metabolism; arginine and proline metabolism; alanine, aspartate and glutamate metabolism; and pyruvate metabolism. Univariate receiver operating characteristic (ROC) curve analyses revealed that six of these metabolites (glycerol-3-phosphate, O-phosphoethanolamine, asparagine dehydrate, maleimide, tyrosine, and alanine) have a crucial role in distinguishing susceptible from resistant isolates (AUC > 0.84) and contributing to antimicrobial resistance in K. oxtytoca.

CONCLUSION

Our study provides invaluable new insights into the mechanisms underlying development of antimicrobial resistance in K. oxytoca suggests potential therapeutic targets for prevention and identification of AMR in K. oxytoca infections.

Validation and comparison of triage-based screening strategies for sepsis

OBJECTIVE

This study sought to externally validate and compare proposed methods for stratifying sepsis risk at emergency department (ED) triage.

METHODS

This nested case/control study enrolled ED patients from four hospitals in Utah and evaluated the performance of previously-published sepsis risk scores amenable to use at ED triage based on their area under the precision-recall curve (AUPRC, which balances positive predictive value and sensitivity) and area under the receiver operator characteristic curve (AUROC, which balances sensitivity and specificity). Score performance for predicting whether patients met Sepsis-3 criteria in the ED was compared to patients' assigned ED triage score (Canadian Triage Acuity Score [CTAS]) with adjustment for multiple comparisons.

RESULTS

Among 2000 case/control patients, 981 met Sepsis-3 criteria on final adjudication. The best performing sepsis risk scores were the Predict Sepsis version #3 (AUPRC 0.183, 95 % CI 0.148-0.256; AUROC 0.859, 95 % CI 0.843-0.875) and Borelli scores (AUPRC 0.127, 95 % CI 0.107-0.160, AUROC 0.845, 95 % CI 0.829-0.862), which significantly outperformed CTAS (AUPRC 0.038, 95 % CI 0.035-0.042, AUROC 0.650, 95 % CI 0.628-0.671, p < 0.001 for all AUPRC and AUROC comparisons). The Predict Sepsis and Borelli scores exhibited sensitivity of 0.670 and 0.678 and specificity of 0.902 and 0.834, respectively, at their recommended cutoff values and outperformed Systemic Inflammatory Response Syndrome (SIRS) criteria (AUPRC 0.083, 95 % CI 0.070-0.102, p = 0.052 and p = 0.078, respectively; AUROC 0.775, 95 % CI 0.756-0.795, p < 0.001 for both scores).

CONCLUSIONS

The Predict Sepsis and Borelli scores exhibited improved performance including increased specificity and positive predictive values for sepsis identification at ED triage compared to CTAS and SIRS criteria.

The Therapeutic Potential of Exosome Therapy in Sepsis Management: Addressing Complications and Improving Outcomes"

Infection occurs when pathogens penetrate tissues, reproduce, and trigger a host response to both the infectious agents and their toxins. A diverse array of pathogens, including viruses and bacteria, can cause infections. The host's immune system employs several mechanisms to combat these infections, typically involving an innate inflammatory response. Inflammation is a complex biological reaction that can affect various parts of the body and is a key component of the response to harmful stimuli. Sepsis arises when the body's response to infection leads to widespread damage to tissues and organs, potentially resulting in severe outcomes or death. The initial phase of sepsis involves immune system suppression. Early identification and targeted management are crucial for improving sepsis outcomes. Common treatment approaches include antibiotics, intravenous fluids, blood cultures, and monitoring urine output. This study explores the potential of exosome therapy in enhancing the management and alleviation of sepsis symptoms.

Emergency clinicians' use of adult and paediatric sepsis pathways: An implementation redesign using the behaviour change wheel

AIMS

To identify facilitators and barriers and tailor implementation strategies to optimize emergency clinician's use of adult and paediatric sepsis pathways.

DESIGN

A qualitative descriptive study using focus group methodology.

METHODS

Twenty-two emergency nurses and ten emergency medical officers from four Australian EDs participated in eight virtual focus groups. Participants were asked about their experiences using the New South Wales Clinical Excellence Commission adult and paediatric sepsis pathways using a semi-structured interview template. Facilitators and barriers to use of the sepsis pathways were categorized using the Theoretical Domains Framework. Tailored interventions were selected to address facilitators and barriers, and a re-implementation plan was devised guided by the Behaviour Change Wheel.

RESULTS

Thirty-two facilitators and 58 barriers were identified corresponding to 11 Theoretical Domains Framework domains. Tailored strategies were selected to optimize emergency clinicians' use of the sepsis pathways including refinement of existing education and training programmes, modifications to the electronic medical record system, introduction of an audit and feedback system, staffing strategies and additional resources.

CONCLUSION

The implementation of sepsis pathways in the Emergency Department setting is complex, impacted by a multitude of factors requiring tailored strategies to address facilitators and barriers and optimize uptake.

IMPLICATIONS FOR PATIENT CARE

This study presents a theory-informed systematic approach to successfully implement and embed adult and paediatric sepsis pathways into clinical practice in the Emergency Department.

IMPACT

Optimizing uptake of sepsis pathways has the potential to improve sepsis recognition and management, subsequently improving the outcome of patients with sepsis.

REPORTING METHOD

The Consolidated Criteria for REporting Qualitative research guided the preparation of this report.

PATIENT OR PUBLIC CONTRIBUTION

Nil.

The effect of polyclonal and monoclonal based antibodies as promising potential therapy for treatment of sepsis: A systematic review

While mortality caused by sepsis remains an unsolved problem, studies showed conflicting results about effectiveness of monoclonal and polyclonal antibodies in patients suffering sepsis. For this reason, this current study provides an update of review clinical randomized trial studies until March 2024. The main object of this study is to determine effects of monoclonal and polyclonal antibodies on mortality rate and hospitalization of patients suffering sepsis. Search of Scopus, Web of science, EMBASE, PubMed and Cochrane were performed and randomized controlled trials which conducted in patients with septic shock or bacterial sepsis were included. Two reviewers assessed all searched trials for eligibility according to already defined criteria and did data collection and analyses afterwards. Present study showed monoclonal and polyclonal antibodies are a safe strategy with mild-to-moderate adverse effects. However, most studies indicate no significant change among inter-and intra-group comparison (p > 0.05) and further studies are needed, results showed an increase in survival rate, ventilator-and ICU-free days, resolve organ dysfunction, mediating inflammation related cytokines.

The Role of Mycobacterium indicus pranii in Sepsis Management: A Comprehensive Review of Clinical Outcomes and Therapeutic Potential

Sepsis is a critical condition characterized by a dysregulated immune response to infection, leading to systemic inflammation, multi-organ failure, and high mortality rates. Current treatments primarily involve antibiotics and supportive care, which address the infection and stabilize hemodynamics but do not directly modulate the inflammatory response. This limitation highlights the need for novel therapeutic approaches. This review aims to evaluate the role of Mycobacterium indicus pranii (MIP) in sepsis management, focusing on its clinical outcomes and therapeutic potential. By examining preclinical and clinical evidence, we seek to understand the efficacy, safety, and practical applications of MIP in treating sepsis. A comprehensive review of existing literature was conducted, including preclinical studies, clinical trials, and case reports involving MIP. The review synthesizes findings related to its mechanism of action, therapeutic efficacy, and safety profile. MIP has demonstrated significant immunomodulatory effects, including enhancing innate and adaptive immune responses and reducing excessive inflammation. Clinical trials have shown promising results, with MIP improving clinical outcomes and reducing sepsis-related complications. The agent's unique ability to modulate the cytokine storm associated with sepsis positions it as a potential adjunctive therapy. MIP offers a novel approach to managing sepsis by addressing immune dysregulation and inflammation. The evidence suggests that MIP could be a valuable adjunct to current treatments, improving patient outcomes and addressing some limitations of conventional therapies. Further research is needed to establish its role in clinical practice and to optimize treatment protocols.

Therapeutic Effects of Mesenchymal Stem Cell-Derived Extracellular Vesicles in sepsis: a Systematic Review and Meta-Analysis of Preclinical Studies

BACKGROUND

Sepsis is a life-threatening disorder with no definitive cure. Preclinical studies suggest that extracellular vesicles derived from mesenchymal stromal cells (EV-MSCs) can mitigate inflammatory conditions, potentially leading to increased survival and reduced organ dysfunction during sepsis. Our aim to conduct this systematic review and meta-analysis is assessing the EV-MSCs therapeutic efficacy in sepsis.

METHODS

PubMed, Embase, Scopus, WOS and ProQuest databases and also Google Scholar search engine were searched for published articles. We used hazard ratio (HR) and standardized mean difference (SMD) as effect sizes to evaluate the therapeutic effect of EV-MSCs on survival rate and determine their effect on reducing organ dysfunction, respectively. Finally, we employed GRADE tool for preclinical animal studies to evaluate certainty of the evidence.

RESULTS

30 studies met the inclusion criteria for our article. Our meta-analysis results demonstrate that animals treated with MSC-EVs have better survival rate than untreated animals (HR = 0.33; 95% CI: 0.27-0.41). Our meta-analysis suggests that EV-MSCs can reduce organ dysfunctions in sepsis, such as the lung, kidney, and liver. Additionally, EV-MSCs decrease pro-inflammatory mediators like TNF-α, IL-1β, and IL-6.

CONCLUSION

Our results indicate that EV-MSCs can be as promising therapy for sepsis management in animal models and leading to increased survival rate and reduced organ dysfunction. Furthermore, our study introduces a novel tool for risk of bias assessment and provides recommendations based on various analysis. Future studies with aiming to guide clinical translation can utilize the results of this article to establish stronger evidence for EV-MSC effectiveness.

Enhancing acute inflammatory and sepsis treatment: superiority of membrane receptor blockade

Conditions such as acute pancreatitis, ulcerative colitis, delayed graft function and infections caused by a variety of microorganisms, including gram-positive and gram-negative organisms, increase the risk of sepsis and therefore mortality. Immune dysfunction is a characterization of sepsis, so timely and effective treatment strategies are needed. The conventional approaches, such as antibiotic-based treatments, face challenges such as antibiotic resistance, and cytokine-based treatments have shown limited efficacy. To address these limitations, a novel approach focusing on membrane receptors, the initiators of the inflammatory cascade, is proposed. Membrane receptors such as Toll-like receptors, interleukin-1 receptor, endothelial protein C receptor, μ-opioid receptor, triggering receptor expressed on myeloid cells 1, and G-protein coupled receptors play pivotal roles in the inflammatory response, offering opportunities for rapid regulation. Various membrane receptor blockade strategies have demonstrated efficacy in both preclinical and clinical studies. These membrane receptor blockades act as early stage inflammation modulators, providing faster responses compared to conventional therapies. Importantly, these blockers exhibit immunomodulatory capabilities without inducing complete immunosuppression. Finally, this review underscores the critical need for early intervention in acute inflammatory and infectious diseases, particularly those posing a risk of progressing to sepsis. And, exploring membrane receptor blockade as an adjunctive treatment for acute inflammatory and infectious diseases presents a promising avenue. These novel approaches, when combined with antibiotics, have the potential to enhance patient outcomes, particularly in conditions prone to sepsis, while minimizing risks associated with antibiotic resistance and immune suppression.

Sepsis, Management & Advances in Metabolomics

Though there have been developments in clinical care and management, early and accurate diagnosis and risk stratification are still bottlenecks in septic shock patients. Since septic shock is multifactorial with patient-specific underlying co-morbid conditions, early assessment of sepsis becomes challenging due to variable symptoms and clinical manifestations. Moreover, the treatment strategies are traditionally based on their progression and corresponding clinical symptoms, not personalized. The complex pathophysiology assures that a single biomarker cannot identify, stratify, and describe patients affected by septic shock. Traditional biomarkers like CRP, PCT, and cytokines are not sensitive and specific enough to be used entirely for a patient's diagnosis and prognosis. Thus, the need of the hour is a sensitive and specific biomarker after comprehensive analysis that may facilitate an early diagnosis, prognosis, and drug development. Integration of clinical data with metabolomics would provide means to understand the patient's condition, stratify patients better, and predict the clinical outcome.

Investigation of the protective activity of baicalein on the lungs via regulation of various cellular responses in rats exposed to experimental sepsis

Backgrounds

In the present study, a cecal ligation and puncture (CLP)-induced experimental sepsis rat model was used to explore the effects of baicalein on inflammatory cytokine levels and oxidative stress as well as the possible regulatory role of nuclear factor-kappa B (NF-κB).

Methods

For that purpose, 42 Wistar albino rats were equally divided into control, sham, sepsis, B50 + S, B100 + S, S + B50, and S + B100 groups. The B50 + S and B100 + S groups received baicalein before the induction of sepsis, while the S + B50 and S + B100 groups received baicalein afterwards. Experimental sepsis in related groups is generated through ligation of cecum and a puncture in cecal wall. Serum samples were used for tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) analyses, and tissue Malondialdehyde (MDA), Superoxide dismutase (SOD), Glutathione (GSH), IL-6, and NF-κB levels were measured.

Results

Compared to the control group, there were significantly increases in the serum TNF-α, IL-6, tissue MDA, and NF-κB levels and decreases in the tissue SOD and GSH levels in the septic group (P < 0.05). Compared to the septic group, inflammation and oxidative stress were reduced in the baicalein-treated groups. Although all of the pre- and post-treatment protocols alleviated inflammation and oxidative stress to varying degrees, pre-treatment with 100 mg/kg was the most successful.

Conclusions

Findings of this study indicated that baicalein has the potential to reduce sepsis-related oxidative stress and inflammation in the lungs and that pathological outcomes could be regulated via NF-κB transcription factor activity.

Leptospirosis-Induced Septic Shock and Multi-Organ Dysfunction Syndrome: A Complex Case of Zoonotic Infection in a Young Female Patient

Leptospirosis, a zoonotic infection caused by the Leptospira bacteria, can manifest with varying clinical severities, ranging from subclinical disease to severe multiorgan failure. This progression to severe multiorgan failure, also known as multi-organ dysfunction syndrome (MODS), is a life-threatening condition characterized by the dysfunction of two or more organ systems. Often, MODS is a consequence of events triggered by underlying pathologies, such as severe infections, including those caused by Leptospira. Here, we present a case report of a 29-year-old female patient who initially sought care for increased temperature, fatigue, diarrhea, and vomiting. The patient exhibited signs of septic shock (SS). Her medical history raised suspicion of multiple potential sources of infection. She experienced cat scratch several days before admission, accompanied by an enlarged inguinal lymph node and a history of frequent interaction with animals, as well as freshwater exposure, which prompted investigations into various zoonotic infections. Empiric treatment was started, and, subsequently, after several days, Leptospira titer came back positive. Over the hospitalization course, the patient developed multi-organ failure, which was attributed to the underlying Leptospira infection. The complexity and severity of the patient's condition underscore the far-reaching impact of leptospirosis in precipitating a spectrum of systemic complications culminating in multiorgan failure. The treatment interventions yielded successful outcome, and the patient recovered in one month. This case report highlights the difficulties in diagnosing and treating patients with multiple possible sources of infection. it emphasizes the need for a careful history-taking and high level of suspicion for zoonotic infections in patients with a history of animal exposure and clinical symptoms suggestive of infectious diseases.

Increase in Incidence Rates and Risk Factors for Multidrug Resistant Bacteria in Septic Children: A Nationwide Spanish Cohort Study (2013-2019)

The emergence of multidrug-resistant (MDR) bacteria in children is a growing concern, particularly among septic patients, given the need for first-right dosing. Our aim was to determine the incidence rates and factors associated with MDR-sepsis in the pediatric intensive care unit (PICU), using data from the Spanish ENVIN-HELICS PICU registry between 2013 and 2019. The rate of MDR bacteria among septic children ranged between 5.8 and 16.2% throughout this study period, with a significant increase since 2015 (p = 0.013). MDR-gram-negative bacteria (92%), particularly EBL-Enterobacterales (63.7%), were the most frequent causative microorganisms of MDR-sepsis. During this study period, sixteen MDR-sepsis (32.6%) corresponded to intrahospital infections, and 33 (67.4%) had community-onset sepsis, accounting for 10.5% of the overall community-onset sepsis. Independent risk factors associated with MDR-sepsis were antibiotics 48 h prior to PICU admission (OR 2.38) and PICU onset of sepsis (OR 2.58) in >1 year-old children, and previous malnourishment (OR 4.99) in <1 year-old children. Conclusions: There was an alarming increase in MDR among septic children in Spain, mainly by gram-negative (ESBL-Enterobacterales), mostly coming from the community setting. Malnourished infants and children on antibiotics 48 h prior to PICU are at increased risk and therefore require closer surveillance.

Sepsis Management in the Cardiac Intensive Care Unit

Septic shock management in the cardiac intensive care unit (CICU) is challenging due to the complex interaction of pathophysiology between vasodilatory and cardiogenic shock, complicating how to optimally deploy fluid resuscitation, vasopressors, and mechanical circulatory support devices. Because mixed shock portends high mortality and morbidity, familiarity with quality, contemporary clinical evidence surrounding available therapeutic tools is needed to address the resultant wide range of complications that can arise. This review integrates pathophysiology principles and clinical recommendations to provide an organized, topic-based review of the nuanced intricacies of managing sepsis in the CICU.

Melatonin as a potential treatment for septic cardiomyopathy

Septic cardiomyopathy (SCM) is a common complication of sepsis contributing to high mortality rates. Its pathophysiology involves complex factors, including inflammatory cytokines, mitochondrial dysfunction, oxidative stress, and immune dysregulation. Despite extensive research, no effective pharmacological agent has been established for sepsis-induced cardiomyopathy. Melatonin, a hormone with diverse functions in the body, has emerged as a potential agent for SCM through its anti-oxidant, anti-inflammatory, anti-apoptotic, and cardioprotective roles. Through various molecular levels of its mechanism of action, it counterattacks the adverse event of sepsis. Experimental studies have mentioned that melatonin protects against many cardiovascular diseases and exerts preventive effects on SCM. Moreover, melatonin has been investigated in combination with other drugs such as antibiotics, resveratrol, and anti-oxidants showing synergistic effects in reducing inflammation, anti-oxidant, and improving cardiac function. While preclinical studies have demonstrated positive results, clinical trials are required to establish the optimal dosage, route of administration, and treatment duration for melatonin in SCM. Its safety profile, low toxicity, and natural occurrence in the human body provide a favorable basis for its clinical use. This review aims to provide an overview of the current evidence of the use of melatonin in sepsis-induced cardiomyopathy (SICM). Melatonin appears to be promising as a possible treatment for sepsis-induced cardiomyopathy and demands further investigation.

Four Assessment Tools for Predicting Mortality and Adverse Events in Surgical Patients With Sepsis and Septic Shock: A Comparative Study

BACKGROUND

The mortality rate for sepsis and septic shock in surgical patients is approximately 36%, which is higher than that of other medical patients. Predisposition, infection/injury, response, and organ dysfunction (PIRO) is currently the most widely used tool for assessing patients with surgical sepsis. However, it is not a standardized assessment tool for surgical patients in general.

PURPOSE

The purposes of this study were to (a) create a modified PIRO (mPIRO) that adds a count of platelets and does not include a body temperature reading; (b) test the sensitivity and specificity of the mPIRO for predicting mortality and adverse events among patients with surgical sepsis; and (c) compare the predictive accuracy of the mPIRO, sequential organ failure assessment (SOFA), quick SOFA, and PIRO tools.

METHODS

A retrospective observational cohort study was conducted. Two thousand fifty-five patient medical records were reviewed, with 103 identified as meeting the inclusion criteria.

RESULTS

Compared with the other tools, mPIRO ≥ 4 achieved better sensitivity (90.5%) in predicting mortality and high sensitivity (72%) and specificity (80%) in predicting adverse events. mPIRO was the most accurate predictor of mortality (area under the receiver operating characteristic curve [AUC] = 0.83) among the tools considered. SOFA and mPIRO were the first and second most accurate predictor of adverse events, respectively, with respective AUC values of 0.86 and 0.82.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

mPIRO, which employs an easy-to-use scoring system, is a valid assessment tool with good sensitivity and AUC for predicting both mortality and adverse events in patients with surgical sepsis. We recommend using mPIRO ≥ 3 as an indicator of potential adverse events.

Less Severe Sepsis in Cecal Ligation and Puncture Models with and without Lipopolysaccharide in Mice with Conditional Ezh2-Deleted Macrophages (LysM-Cre System)

Despite a previous report on less inflammatory responses in mice with an absence of the enhancer of zeste homologue 2 (Ezh2), a histone lysine methyltransferase of epigenetic regulation, using a lipopolysaccharide (LPS) injection model, proteomic analysis and cecal ligation and puncture (CLP), a sepsis model that more resembles human conditions was devised. As such, analysis of cellular and secreted protein (proteome and secretome) after a single LPS activation and LPS tolerance in macrophages from Ezh2 null (Ezh2^flox/flox; LysM-Cre^cre/-) mice (Ezh2 null) and the littermate control mice (Ezh2^fl/fl; LysM-Cre^-/-) (Ezh2 control) compared with the unstimulated cells from each group indicated fewer activities in Ezh2 null macrophages, especially by the volcano plot analysis. Indeed, supernatant IL-1β and expression of genes in pro-inflammatory M1 macrophage polarization (IL-1β and iNOS), TNF-α, and NF-κB (a transcription factor) were lower in Ezh2 null macrophages compared with the control. In LPS tolerance, downregulated NF-κB compared with the control was also demonstrated in Ezh2 null cells. In CLP sepsis mice, those with CLP alone and CLP at 2 days after twice receiving LPS injection, representing sepsis and sepsis after endotoxemia, respectively, symptoms were less severe in Ezh2 null mice, as indicated by survival analysis and other biomarkers. However, the Ezh2 inhibitor improved survival only in CLP, but not LPS with CLP. In conclusion, an absence of Ezh2 in macrophages resulted in less severe sepsis, and the use of an Ezh2 inhibitor might be beneficial in sepsis.

Use of C-reactive protein to guide the antibiotic therapy in hospitalized patients: a systematic review and meta-analysis

BACKGROUND

C-reactive protein (CRP) is an inflammatory protein used in clinical practice to identify and monitor inflammatory and infectious processes. Recent data suggest CRP might be useful in guiding antibiotic therapy discontinuation among critical care patients. This meta-analysis analyzed the benefits and risks of CRP-guided protocols to guide antibiotic therapy in hospitalized patients in comparison with standard treatment.

METHODS

Studies were searched in four databases: CENTRAL, Medline, Embase and LILACS. The search was performed until Jan 25th, 2023. The reference lists of the articles retrieved and related review studies were hand-screened to find eligible trials that might have been missed. Primary endpoints included the duration of antibiotic therapy for the index episode of infection. The secondary endpoint was the all-cause hospital mortality and infection relapses. The risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool. Random effects were used to pool the mean differences and odds ratio of individual studies. The protocol was registered in PROSPERO (CRD42021259977).

RESULTS

The search strategy retrieved 5209 titles, out of which three studies met the eligibility criteria and were included in this meta-analysis. 727 adult patients were analyzed, of whom 278 were included in the intervention group and 449 were included in the control group. 55,7% of all patients were women. Meta-analysis indicated that experimental groups (CRP-guided) had a lower duration of antibiotic therapy (days) [MMD = -1.82, 95%IC -3.23; -0.40]; with no difference in mortality [OR = 1.19 95%IC 0.67-2.12] or in the occurrence of infection relapse [OR = 3.21 95%IC 0.85-12.05].

CONCLUSION

The use of CRP-guided protocol reduces the total amount of time required for antibiotic therapy when compared to standard protocols of treatment in hospitalized patients with acute bacterial infection. We did not observe statistical differences regarding mortality and infection relapse rates.

Implementing Alfred60AST in a clinical lab: Clinical impact on the management of septic patients and financial analysis

INTRODUCTION

Sepsis is an important cause of morbidity and mortality. An accelerated microbiology diagnosis is crucial in order to reduce the time to initiate targeted antibiotic therapy. The Alfred60AST system is able to provide phenotypic Antimicrobial Susceptibility Testing (AST) results within hours. This study has two objectives: assess the clinical impact of this technology and determine its cost-effectiveness.

METHODS

During a ten-week period, all new enterobacterial or enterococcal bloodstream infection was analyzed with the Alfred60AST system, in parallel with routine methods. Its impact on the clinician's therapeutic strategy was studied. In order to assess the financial and practical aspects of the method, an analysis of the extracosts and a survey of the technical staff were conducted.

RESULTS

Fifty-three cases of bacteriemia were included. For the Enterobacteriaceae bacteriemias, a clinical impact was shown in 18.9% of the cases (e.g, treatment modification). The financial analysis highlighted an increase in costs (+38% for Enterobacteriaceae, +50% for Enterococci), compared to the theoretical costs reported by the firm, due to the workflow and the volumes of samples used. Finally, results of the technical staff survey were favorable in terms of ease of use of the system.

CONCLUSION

In addition to its ease of use, the Alfred60AST system is able to provide an AST in a record time. This study shows a real interest of the technique in the therapeutic management of patients with enterobacterial sepsis. However, its routine implementation requires an increase of the analyzed volumes as well as a 24/7 organization of the laboratory in order to be profitable.

The effects of flavonoids in experimental sepsis: A systematic review and meta-analysis

Sepsis is a host's dysregulated immune response to an infection associated with systemic inflammation and excessive oxidative stress, which can cause multiple organ failure and death. The literature suggests that flavonoids, a broad class of secondary plant metabolites, have numerous biological activities which can be valuable in the treatment of sepsis. This study aimed to review the effects of flavonoids on experimental sepsis, focusing mainly on survival rate, and also summarizing information on its mechanisms of action. We searched in the main databases up to November 2022 using relevant keywords, and data were extracted and analyzed qualitatively and quantitatively. Thirty-two articles met the study criteria for review and 29 for meta-analysis. Overall, 30 different flavonoids were used in the studies. The flavonoids were able to strongly inhibit inflammatory response by reducing the levels of important pro-inflammatory mediators, for example, tumor necrosis factor-alpha and interleukin-1β, oxidative stress, and showed antibacterial and anti-apoptotic actions. The meta-analysis found an increase of 50% in survival rate of the animals treated with flavonoids. They appear to act as multi-target drugs and may be an excellent therapeutic alternative to reduce a number of the complications caused by sepsis, and consequently, to improve survival rate.

Clinical evaluation of polymerase chain reaction coupled with quantum dot fluorescence analysis in the identification of bacteria and yeasts in patients with suspected bloodstream infections

Bloodstream infections are serious and complex infectious diseases that often require a rapid diagnosis. Polymerase chain reaction coupled with quantum dot fluorescence analysis (PCR-QDFA) is a novel diagnostic technique. This study aimed to evaluate the diagnostic performance of PCR-QDFA for pathogen detection in patients with suspected bloodstream infections (BSIs). It evaluates 29 kinds of common pathogens (24 bacteria and 5 yeasts) from blood culture bottles. The results of PCR-QDFA identification and traditional microbial laboratory identification were compared, and the latter was used as the 'gold standard' to analyse the diagnostic performance of the PCR-QDFA. In total, 517 blood culture bottles were included in this study. The PCR-QDFA identified microorganisms in 368/422 (87.2%) samples with monomicrobial growth. For the pathogens on the PCR-QDFA list, the assay showed a higher sensitivity of 97.4% (368/378). When polymicrobial growth was analysed, the PCR-QDFA successfully detected 19/25 (76%) microorganisms on the PCR-QDFA list. In addition, 82/82 negative blood culture bottles also showed no pathogens by PCR-QDFA with a specificity of 100%. In conclusion, the PCR-QDFA assay could identify a majority of the common pathogens encountered in clinical practice, showing excellent diagnostic performance for pathogen detection in patients with suspected BSIs.

Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial

Background

In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients.

Materials and methods

Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients.

Results

In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33).

Conclusions

In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.

Coleus Amboinicus Lour. Leaf Extract as an Antioxidant in Sepsis

Background

As broad-spectrum antibiotics can cause antimicrobial resistance in sepsis, there is the need for a complementary therapy to combat sepsis. Oxidative stress causes an increased severity and mortality in sepsis, whereas herbal medicines have been considered as an option due to its antioxidant potential. Coleus amboinicus Lour. has been documented for its therapeutic value due to the presence of flavonoid, an antioxidant compound.

Objective

To study the effect of Coleus amboinicus Lour. leaf extract on total antioxidant capacity (TAC) and hepatic catalase (CAT) levels in septic rat model.

Methods

Twenty-eight male Rattus norvegicus rats were divided into four groups: control (rats without sepsis induction and treatment), group 1 (septic rats treated with antibiotics), group 2 (septic rats treated with antibiotics and 250 mg/kg body weight of Coleus amboinicus Lour. leaf extract), and group 3 (septic rats treated with antibiotics and 500 mg/kg body weight of Coleus amboinicus Lour. leaf extract). The rats were sacrificed at the end of the eighth day of observation, and blood and liver tissues were gathered for examination.

Results

Compared to the septic rat groups treated with only antibiotics, there was an increase in the TAC levels and CAT expression levels in septic rat groups given antibiotics and Coleus amboinicus Lour. leaf extract. However, the increase was not significant.

Conclusion

Administering Coleus amboinicus Lour. leaf extract increases TAC levels and CAT expression levels in sepsis, decreasing oxidative stress. This will exert protective effects in the cells and therefore alleviate sepsis.

Overcoming Antibiotic Resistance with Novel Paradigms of Antibiotic Selection

Conventional antimicrobial susceptibility tests, including phenotypic and genotypic methods, are insufficiently accurate and frequently fail to identify effective antibiotics. These methods predominantly select therapies based on the antibiotic response of only the lead bacterial pathogen within pure bacterial culture. However, this neglects the fact that, in the majority of human infections, the lead bacterial pathogens are present as a part of multispecies communities that modulate the response of these lead pathogens to antibiotics and that multiple pathogens can contribute to the infection simultaneously. This discrepancy is a major cause of the failure of antimicrobial susceptibility tests to detect antibiotics that are effective in vivo. This review article provides a comprehensive overview of the factors that are missed by conventional antimicrobial susceptibility tests and it explains how accounting for these methods can aid the development of novel diagnostic approaches.

Early and Appropriate Use of Ceftazidime-Avibactam in the Management of Multidrug-Resistant Gram-Negative Bacterial Infections in the Indian Scenario

The increasing prevalence of antibiotic-resistant pathogens exerts a substantial burden on the healthcare infrastructure worldwide. The World Health Organization (WHO) has declared that multidrug-resistant (MDR) Gram-negative pathogens, especially, carbapenem-resistant Enterobacterales (CRE), Acinetobacter baumannii, and Pseudomonas aeruginosa as the topmost priority while developing newer antimicrobials. The increasing prevalence of infectious diseases caused by MDR Gram-negative bacteria also poses a challenge when choosing the empiric antimicrobial therapy for seriously ill hospitalized patients. The infections caused by MDR Gram-negative organisms ultimately result in increased mortality, morbidity, prolonged hospital stay, and increased cost of management. To tackle these challenges, newer antimicrobials like ceftazidime-avibactam were explored. The article also discusses the in vitro activity and therapeutic efficacy of ceftazidime-avibactam along with its pharmacokinetic properties and the role it will play in the management of MDR Gram-negative organisms in the Indian setting. Several studies have highlighted the role of early and appropriate antibiotic use in the reduction of mortality in patients with Gram-negative infections. Timely initiation of appropriate antibiotic therapy for serious infections leads to favorable clinical outcomes. Early and appropriate use of ceftazidime-avibactam while treating MDR Gram-negative infections has been associated with improved clinical outcomes. The aim of this review is to highlight the efficacy of ceftazidime-avibactam in the treatment of MDR Gram-negative infections. We have also summarized the information on outcomes achieved by early and appropriate use of ceftazidime-avibactam.

Identifying infected patients using semi-supervised and transfer learning

Objectives

Early identification of infection improves outcomes, but developing models for early identification requires determining infection status with manual chart review, limiting sample size. Therefore, we aimed to compare semi-supervised and transfer learning algorithms with algorithms based solely on manual chart review for identifying infection in hospitalized patients.

Materials and Methods

This multicenter retrospective study of admissions to 6 hospitals included “gold-standard” labels of infection from manual chart review and “silver-standard” labels from nonchart-reviewed patients using the Sepsis-3 infection criteria based on antibiotic and culture orders. “Gold-standard” labeled admissions were randomly allocated to training (70%) and testing (30%) datasets. Using patient characteristics, vital signs, and laboratory data from the first 24 hours of admission, we derived deep learning and non-deep learning models using transfer learning and semi-supervised methods. Performance was compared in the gold-standard test set using discrimination and calibration metrics.

Results

The study comprised 432 965 admissions, of which 2724 underwent chart review. In the test set, deep learning and non-deep learning approaches had similar discrimination (area under the receiver operating characteristic curve of 0.82). Semi-supervised and transfer learning approaches did not improve discrimination over models fit using only silver- or gold-standard data. Transfer learning had the best calibration (unreliability index P value: .997, Brier score: 0.173), followed by self-learning gradient boosted machine (P value: .67, Brier score: 0.170).

Discussion

Deep learning and non-deep learning models performed similarly for identifying infection, as did models developed using Sepsis-3 and manual chart review labels.

Conclusion

In a multicenter study of almost 3000 chart-reviewed patients, semi-supervised and transfer learning models showed similar performance for model discrimination as baseline XGBoost, while transfer learning improved calibration.

Beneficial Immune Regulation by Biological Response Modifier Glucans in COVID-19 and Their Envisaged Potentials in the Management of Sepsis

Sepsis is a life-threatening condition caused by an abnormal immune response induced by infection with no approved or specific therapeutic options. We present our perspectives for the therapeutic management of sepsis through a four-way approach: (1) infection control through immune enhancement; (2) immune suppression during the initial hyper-inflammatory phase; (3) balanced immune-modulation to counter the later immune-paralysis phase; and (4) advantageous effects on metabolic and coagulation parameters throughout. COVID-19 is a virus-triggered, accelerated sepsis-like reaction that is associated with the rapid progress of an inflammatory cascade involving a cytokine storm and multiorgan failure. Here, we discuss the potential of the biological response modifiers, β-glucans (BRMGs), in the management of sepsis based on their beneficial effects on inflammatory-immune events in COVID-19 clinical studies. In COVID-19 patients, apart from metabolic regulation, BRMGs, derived from a black yeast, Aureobasidium pullulans strain AFO-202, have been reported to stimulate immune responses. BRMGs, produced by another strain (N-163) of A. pullulans, have been implicated in the beneficial regulation of inflammatory markers and immunity, namely IL-6, C-reactive protein (CRP), D-Dimer, ferritin, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-C-reactive protein ratio (LCR), leucocyte-to-C-reactive protein ratio (LeCR), and leukocyte-to-IL-6 ratio (LeIR). Agents such as these β-glucans, which are safe as they have been widely consumed by humans for decades, have potential as adjuncts for the prevention and management of sepsis as they exert their beneficial effects across the spectrum of processes and factors involved in sepsis pathology, including, but not limited to, metabolism, infection, inflammation, immune modulation, immune enhancement, and gut microbiota.

Physicians' knowledge and sepsis guide implementation in tertiary care hospitals in China

BACKGROUND

This study was designed to investigate the extent to which physicians involved in sepsis management understand and adopt sepsis guidelines in clinical practice. The overarching aim of this study was to generate ideas for developing more effective training methods to help physicians apply the guidelines in patient management.

METHODS

Physicians working in a tertiary care hospital, primarily in the emergency and critical care departments, were recruited into the survey. They were asked to fill questionnaires which were designed to collect sepsis score, diagnostic indicators, fluid resuscitation, antibiotics choice, access to knowledge and training, as well as implementation of sepsis guidelines in clinical diagnosis and treatment.

RESULTS

Overall, the response rate was 625/661 (94.5%). The investigate shows the basic information of all physicians who participated in the answer sheet, including their work department, professional title and whether their hospital was a teaching hospital. Significant differences were identified among the physicians in terms of method of acquiring sepsis guidelines, the impact of study guidelines on clinical diagnosis and treatment, efficiency of training methods, cognition of fluid resuscitation in patients with sepsis, the cognition of sepsis rehydration principles, selection of antibiotics for patients with sepsis, the basis for antibiotic selection, among other variables.

CONCLUSION

Although majority of physicians involved in tertiary care hospital understand the contents of sepsis-3 guidelines, the clinical implementation of the guidelines in the diagnosis and treatment of patients with sepsis is highly heterogeneous. Thus, there is need to develop standardized training for physicians involved in sepsis diagnosis and treatment.

Neonatal hyperleukocytosis and regenerative anemia in a septic puppy

This paper reports a case of neonatal hyperleukocytosis in a dog due to a bacterial infection. A 3-week-old, mixed-breed dog was brought to a veterinary college referral center with a history of weight loss despite a good appetite. Clinical and laboratory examinations included: physical examination, complete blood (cell) count (CBC), serum biochemistry profile, abdominal ultrasound examination, and cytology of liver and bone marrow aspirates. The CBC showed hyperleukocytosis of 158.0 × 10⁹/L (RI: 2.1 to 21.2 × 10⁹/L) and hematocrit of 0.19 L/L (RI: 0.21 to 0.34 L/L). The strong leukemoid reaction was comprised of neutrophils, monocytes, and lymphocytes. The dog was diagnosed with Staphylococcus pseudointermedius liver infection based on liver aspirates and culture. Amoxicillin-clavulanic acid was prescribed. A recheck abdominal ultrasound and CBC repeated 4 wk after initial examination were unremarkable. Neonatal hyperleukocytosis is well-described in human medicine but veterinary studies in small animal neonates are scarce. Key clinical message: Hyperleukocytosis in adult dogs may be caused by leukemia or leukemoid reactions. Generalized sepsis is a leading cause of leukemoid reactions in adult dogs and cats. In puppies, neoplasia is less likely, and other causes should be investigated. Similar to human neonates, puppies can mount a strong leukemoid reaction during an infection, even if it is not a generalized septic process.

Coagulation factor protein abundance in the pre-septic state predicts coagulopathic activities that arise during late-stage murine sepsis

BACKGROUND

Although sepsis accounts for 1 in 5 deaths globally, few molecular therapies exist for this condition. The development of effective biomarkers and treatments for sepsis requires a more complete understanding of host responses and pathogenic mechanisms at early stages of disease to minimize host-driven pathology.

METHODS

An alternative to the current symptom-based approach used to diagnose sepsis is a precise assessment of blood proteomic changes during the onset and progression of Salmonella Typhimurium (ST) murine sepsis.

FINDINGS

A distinct pattern of coagulation factor protein abundance was identified in the pre-septic state- prior to overt disease symptoms or bacteremia- that was predictive of the dysregulation of fibrinolytic and anti-coagulant activities and resultant consumptive coagulopathy during ST murine sepsis. Moreover, the changes in protein abundance observed generally have the same directionality (increased or decreased abundance) reported for human sepsis. Significant overlap of ST coagulopathic activities was observed in Gram-negative Escherichia coli- but not in Gram-positive staphylococcal or pneumococcal murine sepsis models. Treatment with matrix metalloprotease inhibitors prevented aberrant inflammatory and coagulopathic activities post-ST infection and increased survival. Antibiotic treatment regimens initiated after specific changes arise in the plasma proteome post-ST infection were predictive of an increase in disease relapse and death after cessation of antibiotic treatment.

INTERPRETATION

Altered blood proteomics provides a platform to develop rapid and easy-to-perform tests to predict sepsis for early intervention via biomarker incorporation into existing blood tests prompted by patient presentation with general malaise, and to stratify Gram-negative and Gram-positive infections for appropriate treatment. Antibiotics are less effective in microbial clearance when initiated after the onset of altered blood proteomics as evidenced by increased disease relapse and death after termination of antibiotic therapy. Treatment failure is potentially due to altered bacterial / host-responses and associated increased host-driven pathology, providing insight into why delays in antibiotic administration in human sepsis are associated with increased risk for death. Delayed treatment may thus require prolonged therapy for microbial clearance despite the prevailing notion of antibiotic de-escalation and shortened courses of antibiotics to improve drug stewardship.

FUNDING

National Institutes of Health, U.S. Army.

The effects of magainin 2-derived and rationally designed antimicrobial peptides on Mycoplasma pneumoniae

Combating the spread of antimicrobial resistance (AMR) among bacteria requires a new class of antimicrobials, which desirably have a narrow spectrum because of their low propensity for the spread of AMR. Antimicrobial peptides (AMPs), which target the bacterial cell membrane, are promising seeds for novel antimicrobials because the cell membrane is essential for all cells. Previously, we reported the antimicrobial and haemolytic effects of a natural AMP, magainin 2 (Mag2), isolated from the skin of Xenopus laevis (the African clawed frog), four types of synthesised Mag2 derivatives, and three types of rationally designed AMPs on gram-positive and gram-negative bacteria. To identify novel antimicrobial seeds, we evaluated the effect of AMPs on Mycoplasma pneumoniae, which also exhibits AMR. We also evaluated the antimicrobial effects of an AMP, NK2A, which has been reported to have antimicrobial effects on Mycoplasma bovis, in addition to Mag2 and previously synthesised seven AMPs, on four strains of M. pneumoniae using colorimetric, biofilm, and killing assays. We found that three synthesised AMPs, namely 17base-Ac6c, 17base-Hybrid, and Block, had anti-M. pneumoniae (anti-Mp) effect at 8–30 μM, whereas others, including NK2A, did not have any such effect. For the further analysis, the membrane disruption activities of AMPs were measured by propidium iodide (PI) uptake assays, which suggested the direct interaction of AMPs to the cell membrane basically following the colorimetric, biofilm, and killing assay results. PI uptake assay, however, also showed the NK2A strong interaction to cell membrane, indicating unknown anti-Mp determinant factors related to the peptide sequences. Finally, we conclude that anti-Mp effect was not simply determined by the membrane disruption activities of AMPs, but also that the sequence of AMPs were important for killing of M. pneumoniae. These findings would be helpful for the development of AMPs for M. pneumoniae.

Simultaneous Raman and infrared spectroscopy: a novel combination for studying bacterial infections at the single cell level

Sepsis is a life-threatening clinical condition responsible for approximately 11 million deaths worldwide. Rapid and accurate identification of pathogenic bacteria and its antimicrobial susceptibility play a critical role in reducing the morbidity and mortality rates related to sepsis. Raman and infrared spectroscopies have great potential to be used as diagnostic tools for rapid and culture-free detection of bacterial infections. Despite numerous reports using both methods to analyse bacterial samples, there is to date no study collecting both Raman and infrared signatures from clinical samples simultaneously due to instrument incompatibilities. Here, we report for the first time the use of an emerging technology that provides infrared signatures via optical photothermal infrared (O-PTIR) spectroscopy and Raman spectra simultaneously. We use this approach to analyse 12 bacterial clinical isolates including six isolates of Gram-negative and six Gram-positive bacteria commonly associated with bloodstream infection in humans. To benchmark the single cell spectra obtained by O-PTIR spectroscopy, infrared signatures were also collected from bulk samples via both FTIR and O-PTIR spectroscopies. Our findings showed significant similarity and high reproducibility in the infrared signatures obtained by all three approaches, including similar discrimination patterns when subjected to clustering algorithms. Principal component analysis (PCA) showed that O-PTIR and Raman data acquired simultaneously from bulk bacterial isolates displayed different clustering patterns due to the ability of both methods to probe metabolites produced by bacteria. By contrast, signatures of microbial pigments were identified in Raman spectra, providing complementary and orthogonal information compared to infrared, which may be advantageous as it has been demonstrated that certain pigments play an important role in bacterial virulence. We found that infrared spectroscopy showed higher sensitivity than Raman for the analysis of individual cells. Despite the different patterns obtained by using Raman and infrared spectral data as input for clustering algorithms, our findings showed high data reproducibility in both approaches as the biological replicates from each bacterial strain clustered together. Overall, we show that Raman and infrared spectroscopy offer both advantages and disadvantages and, therefore, having both techniques combined in one single technology is a powerful tool with promising applications in clinical microbiology.

O-PTIR was used for simultaneous collection of infrared and Raman spectra from clinical pathogens associated with bloodstream infections.

A pentaplex real-time PCR assay for rapid identification of major beta-lactamase genes KPC, NDM, CTX, CMY, and OXA-48 directly from bacteria in blood

Introduction. Antibiotic resistance, particularly in cases of sepsis, has emerged as a growing global public health concern and economic burden. Current methods of blood culture and antimicrobial susceptibility testing of agents involved in sepsis can take as long as 3-5 days. It is vital to rapidly identify which antimicrobials can be used to effectively treat sepsis cases on an individual basis. Here, we present a pentaplex, real-time PCR-based assay that can quickly identify the most common beta-lactamase genes (Klebsiella pneumoniae carbapenemase (KPC); New Delhi metallo-beta-lactamase (NDM); cefotaximase-Munich (CTX-M); cephamycin AmpC beta-lactamases (CMY); and Oxacillinase-48 (OXA-48)) from pathogens derived directly from the blood of patients presenting with bacterial septicemia.Aim. To develop an assay which can rapidly identify the most common beta-lactamase genes in Carbapenem-resistant Enterobacteriaceae bacteria (CREs) from the United States.Hypothesis/Gap Statement. Septicemia caused by carbapenem-resistant bacteria has a death rate of 40-60 %. Rapid diagnosis of antibiotic susceptibility directly from bacteria in blood by identification of beta-lactamase genes will greatly improve survival rates. In this work, we develop an assay capable of concurrently identifying the five most common beta-lactamase and carbapenemase genes.Methodology. Primers and probes were created which can identify all subtypes of Klebsiella pneumoniae carbapenemase (KPC); New Delhi metallo-beta-lactamase (NDM); cefotaximase-Munich (CTX); cephamycin AmpC beta-lactamase (CMY); and oxacillinase-48 (OXA-48). The assay was validated using 13 isolates containing various PCR targets from the Centre for Disease Control Antimicrobial Resistance Isolate Bank Enterobacterales Carbapenemase Diversity Panel. Blood obtained from volunteers was spiked with CREs and bacteria were separated, lysed, and subjected to analysis via the pentaplex assay.Results. This pentaplex assay successfully identified beta-lactamase genes derived from bacteria separated from blood at concentrations of 4-8 c.f.u. ml-1.Conclusion. This assay will improve patient outcomes by supplying physicians with critical drug resistance information within 2 h of septicemia onset, allowing them to prescribe effective antimicrobials corresponding to the resistance gene(s) present in the pathogen. In addition, information supplied by this assay will lessen the inappropriate use of broad-spectrum antimicrobials and prevent the evolution of further antibiotic resistance.

Evaluation of the BioFire Blood Culture Identification 2 panel and impact on patient management and antimicrobial stewardship

Bloodstream infection survival is linked to timely administration of optimal antimicrobial therapy. Commercial multiplex polymerase chain reaction (PCR) assays, such as the BioFire Blood Culture Identification Panel (BCID) used for the rapid diagnosis of bloodstream infections, have significantly improved the turnaround time for optimisation of antimicrobial therapy. Reported concordance with culture-based methods and multiplex PCR analysis is high and only limited by (1) the range of targets available on the multiplex panel; and (2) the complexity of microorganisms present in the blood culture specimen. In this study, we evaluated the use of the BioFire Blood Culture Identification 2 panel (BCID2), including an expanded repertoire of targets for Gram-positive and Gram-negative bacteria, yeast and antimicrobial resistance genes compared to the BCID panel. The BCID2 panel identified microorganisms in 39/42 (92.9%) blood cultures where monomicrobial growth was detected; the three unidentified blood cultures contained organisms not included in the BCID2 panel. Polymicrobial blood culture analysis revealed a lower degree of concordance (28.6%); however, most disagreement was due to the culture-based identification of off-panel microorganisms of low clinical significance. Turnaround time, from blood culture collection to organism identification on the blood cultures correctly identified by BCID2, was 24.6 (±16.8) hours for the BCID2 panel versus 38.2 (±21.9) hours for conventional methods. Analysis of the theoretical impact of the BCID2 identification on clinical management found therapy would be altered in 45.1% (23/51) of patients. The BCID2 panel is anticipated to improve the diagnosis and antimicrobial management of patients with serious bloodstream infections.

Comparison of 5% human albumin and normal saline for fluid resuscitation in sepsis induced hypotension among patients with cirrhosis (FRISC study): a randomized controlled trial

AIMS

Sepsis and septic shock are common causes of hospitalization and mortality in patients with cirrhosis. There is no data on the choice of fluid and resuscitation protocols in sepsis-induced hypotension in cirrhosis.

METHODS

In this open-label trial conducted at a single center, we enrolled 308 cirrhotics with sepsis-induced hypotension and randomized them to receive either 5% albumin or normal saline. The primary endpoint was a reversal of hypotension [mean arterial pressure, MAP, ≥ 65 mmHg] at 3 h. Secondary endpoints included serial effects on heart rate, arterial lactate and urine output.

RESULTS

154 patients each received 5% albumin (males, 79.8%, mean MAP 52.9 ± 7.0 mm Hg) or 0.9% saline (85.1%, 53.4 ± 6.3 mm Hg) with comparable baseline parameters and liver disease severity. Reversal of hypotension was higher in patients receiving 5% albumin than saline at the end of one hour [25.3% and 11.7%, p = 0.03, Odds ratio (95% CI)-1.9 (1.08-3.42)] and at the end of three hours [11.7% and 3.2%, p = 0.008, 3.9 (1.42-10.9)]. Sustained reduction in heart rate and hyperlactatemia (p < 0.001) was better in the albumin group. At one week, the proportion of patients surviving was higher in the albumin group than those receiving saline (43.5% vs 38.3%, p = 0.03). Female gender and SOFA ≥ 11 were predictors of non-response to fluid.

CONCLUSIONS

5% human albumin is safe and beneficial in reversing sepsis-induced hypotension compared to normal saline in patients with cirrhosis improving clinically assessable parameters of systemic hemodynamics, tissue perfusion and in-hospital short-term survival of cirrhosis patients with sepsis.

Antibiotic therapy in sepsis: No next time for a second chance!

WHAT IS KNOWN AND OBJECTIVE

Sepsis is a life-threatening organ dysfunction associated with a high rate of morbidity and mortality. Appropriate antibiotic therapy remains the cornerstone of sepsis and septic shock management.

COMMENT

Although the early initiation of antimicrobial agents in the treatment of sepsis is widely acknowledged, the selection and adjustment to optimal dosage can be equally important. Since significant pathophysiological changes in the critically ill patients lead to altered pharmacokinetics of antibiotics, early consideration of pharmacokinetic/pharmacodynamic (PK/PD) properties is necessary for optimal antibiotic dosing in sepsis and should be integrated in practice.

WHAT IS NEW AND CONCLUSION

Where possible, an individualized antibiotic dosing approach through the application of therapeutic drug monitoring (TDM) service should replace the conventional dosing in critically ill patients with sepsis. Finally, antimicrobial stewardship can help improve clinical outcomes.

A fast and high-sensitivity liquid chromatography-tandem mass spectrometry method combined with in vivo microdialysis for quantification of meropenem in rabbits with sepsis under the simultaneous infusion of total parenteral nutrition: Application to a pharmacokinetic study

A fast and high-sensitivity liquid chromatography-tandem mass spectrometry (LC-MS/MS) method assisted by microdialysis was established for the determination of meropenem in total parenteral nutrition (TPN) infused plasma. A 10-times dilution was arranged for sample preparation to overcome the severe matrix effect caused by the high salt content in dialysate and complex composition of TPN. This quantification method was proved to be satisfied in selectivity, accuracy, precision, linearity (R²  > 0.998), recovery, matrix effect and stability. In the optimized conditions, the calibration curve range was set from 2 to 2000 ng/ml. This validated method was applied to pharmacokinetics study of meropenem in rabbits with sepsis (induced by cecal ligation and punctures) under simultaneous infusion of TPN to simulate the clinical practice. The results demonstrated that the LC-MS/MS method assisted by microdialysis can be used successfully for the determination of meropenem in TPN-infused plasma. Moreover, the area under the curve and the maximum concentrations in the plasma of meropenem in control rabbits were significantly smaller (P < 0.05), while clearance and distribution volumes were significantly greater (P < 0.05) than in those with sepsis. It could be speculated that drug monitoring in patients with sepsis may be necessary.

Feasibility of De-Escalation Implementation for Positive Blood Cultures in Patients With Sepsis: A Prospective Cohort Study

Purpose: The aim of the present study was to determine whether de-escalation guided by blood cultures for patients with a diagnosis of sepsis, severe sepsis or septic shock reduces mortality, and antimicrobial drug resistance (ADR).

Methods: A prospective, single-center, cohort study was conducted with adults admitted to the ICU with a diagnosis of sepsis, severe sepsis, or septic shock at a public hospital in Sorocaba, State of São Paulo, Brazil, from January 2013 to December 2013. We excluded patients who had negative blood cultures. Patients who had replaced the initial empirical broad-spectrum antibiotic therapy (EAT) by the antibiotic therapy guided by blood cultures were compared with those who continued receiving EAT. The outcome included mortality and antimicrobial drug resistance. We used the Cox regression (proportional hazards regression) and the Poisson regression to analyze the association between antibiotic therapy guided by blood cultures (ATGBC) and outcomes. The statistical adjustment in all models included the following variables: sex, age, APACHE II (Acute Physiology And Chronic Health Evaluation II) score and SOFA (Sequential Organ Failure Assessment) score.

Results: Among the 686 patients who were admitted to the intensive care unit, 91 were included in this study. The mean age of the patients was 52.7 years (standard deviation = 18.5 years) and 70.3% were male. EAT was replaced by ATGBC in 33 patients (36.3%) while 58 patients (63.7%) continued receiving EAT. Overall hospital mortality decreased from 56.9% in patients who received EAT to 48.5% in patients who received ATGBC [Hazard ratio- HR 0.44 (95% CI 0.24–0.82), p = 0.009]. There was no association between ATGBC and ADR [HR 0.90 (95% CI 0.78 – 1.03) p = 0.15].

Conclusions: Although the early and appropriate empirical EAT is undoubtedly an important factor prognostic, ATGBC can reduce the mortality in these patients.

SARS-CoV-2 Bound Human Serum Albumin and Systemic Septic Shock

The emergence of the COVID-19 virus and the subsequent pandemic have driven a great deal of research activity. The effects of COVID-19 are caused by the severe respiratory syndrome coronavirus 2 (SARS-CoV-2) and it is the underlying actions of SARs-CoV-2 virions on the endothelial glycocalyx that we consider here. One of the key factors in COVID-19 infection is its almost unique age-related profile, with a doubling in mortality every 10 years after the age of 50. The endothelial glycocalyx layer is essential in maintaining normal fluid homeostasis, but is fragile and prone to pathophysiological damage. It is physiologically significant in capillary microcirculation and in fluid distribution to the tissues. Human serum albumin (HSA), the most abundant protein in plasma, is created in the liver which also maintains its concentration, but this reduces by 10-15% after 50 years of age. HSA transports hormones, free fatty acids and maintains oncotic pressure, but SARS-CoV-2 virions bind competitively to HSA diminishing its normal transport function. Furthermore, hypoalbuminemia is frequently observed in patients with such conditions as diabetes, hypertension, and chronic heart failure, i.e., those most vulnerable to SARS-CoV-2 infection. Hypoalbuminemia, coagulopathy, and vascular disease have been linked in COVID-19 and have been shown to predict outcome independent of age and morbidity. Hypoalbuminemia is also known factor in sepsis and Acute respiratory distress syndrome (ARDS) occurs when fluids build-up in the alveoli and it is associated with sepsis, whose mechanism is systemic, being associated with the fluid and logistic mechanisms of the circulation. Glycocalyx damage is associated with changes plasma protein concentration, particularly HSA and blockage of albumin transport can produce the systemic symptoms seen in SARS-CoV-2 infection and sepsis. We therefore conclude that albumin binding to SARS-CoV-2 virions may inhibit the formation of the endothelial glycocalyx by inhibition of albumin transport binding sites. We postulate that albumin therapy to replace bound albumin might alleviate some of the symptoms leading to sepsis and that clinical trials to test this postulation should be initiated as a matter of urgency.