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Cavaillon JM, Chousterman BG, Skirecki T. Compartmentalization of the inflammatory response during bacterial sepsis and severe COVID-19. JOURNAL OF INTENSIVE MEDICINE 2024; 4:326-340. [PMID: 39035623 PMCID: PMC11258514 DOI: 10.1016/j.jointm.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/04/2024] [Accepted: 01/06/2024] [Indexed: 07/23/2024]
Abstract
Acute infections cause local and systemic disorders which can lead in the most severe forms to multi-organ failure and eventually to death. The host response to infection encompasses a large spectrum of reactions with a concomitant activation of the so-called inflammatory response aimed at fighting the infectious agent and removing damaged tissues or cells, and the anti-inflammatory response aimed at controlling inflammation and initiating the healing process. Fine-tuning at the local and systemic levels is key to preventing local and remote injury due to immune system activation. Thus, during bacterial sepsis and Coronavirus disease 2019 (COVID-19), concomitant systemic and compartmentalized pro-inflammatory and compensatory anti-inflammatory responses are occurring. Immune cells (e.g., macrophages, neutrophils, natural killer cells, and T-lymphocytes), as well as endothelial cells, differ from one compartment to another and contribute to specific organ responses to sterile and microbial insult. Furthermore, tissue-specific microbiota influences the local and systemic response. A better understanding of the tissue-specific immune status, the organ immunity crosstalk, and the role of specific mediators during sepsis and COVID-19 can foster the development of more accurate biomarkers for better diagnosis and prognosis and help to define appropriate host-targeted treatments and vaccines in the context of precision medicine.
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Affiliation(s)
| | - Benjamin G. Chousterman
- Department of Anesthesia and Critical Care, Lariboisière University Hospital, DMU Parabol, APHP Nord, Paris, France
- Inserm U942, University of Paris, Paris, France
| | - Tomasz Skirecki
- Department of Translational Immunology and Experimental Intensive Care, Centre of Postgraduate Medical Education, Warsaw, Poland
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Sotnikova-Meleshkina ZV, Yatsyk YO, Bobrova OV, Kryvonos KA. The influence of vitamin and mineral consumption on the course of coronavirus disease (COVID-19). WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:1086-1092. [PMID: 39008602 DOI: 10.36740/wlek202405132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
OBJECTIVE Aim: The study of the role of micronutrients in the prevention of the severe course of the coronavirus disease. PATIENTS AND METHODS Materials and Methods: In order to fulfill the task, there was conducted an analytical review of medical and biological publications in English in the electronic databases PubMed Medline of the US National Library of Medicine (NLM), Embase, Cochrane Database of Systematic Reviews for the period from 2015 to November 2023, where included 50 published articles, 28 preprints and 109 trials. In the course of the study, the bibliographic-semantic research method was used according to the "Preferred Reporting Elements for Systematic Reviews and Meta-Analyses" (PRISMA) protocol. According to this protocol, identified literary sources were sequentially analyzed by title, keywords, abstract and full text of articles. Based on the results of 16 searches, 2650 articles from PubMed, Cochrane Database of Systematic Reviews and Embase, 3162 articles from preprint servers and 237 trials were rejected. In the final article synthesis, we included 50 published articles, 28 preprints, and 109 trials. CONCLUSION Conclusions: The most effective in preventing complications of the coronavirus disease are vitamins A, D, E, K, C, B3, B6, B9, B12 and such mineral substances as Mg, Se and Zn. The consumption of appropriate bioactive complexes and source products can be considered a clinically and economically effective strategy for the prevention of a severe course of the coronavirus disease.
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Oud L. Disparities in Palliative Care Among Critically Ill Patients With and Without COVID-19 at the End of Life: A Population-Based Analysis. J Clin Med Res 2023; 15:438-445. [PMID: 38189035 PMCID: PMC10769605 DOI: 10.14740/jocmr5027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/02/2023] [Indexed: 01/09/2024] Open
Abstract
Background The surge in critical illness and associated mortality brought by the coronavirus virus disease 2019 (COVID-19) pandemic, coupled with staff shortages and restrictions of family visitation, may have adversely affected delivery of palliative measures, including at the end of life of affected patients. However, the population-level patterns of palliative care (PC) utilization among septic critically ill patients with and without COVID-19 during end-of-life hospitalizations are unknown. Methods A statewide dataset was used to identify patients aged ≥ 18 years with intensive care unit (ICU) admission and a diagnosis of sepsis in Texas, who died during hospital stay during April 1 to December 31, 2020. COVID-19 was defined by the International Classification of Diseases, 10th Revision (ICD-10) code U07.1, and PC was identified by ICD-10 code Z51.5. Multivariable logistic models were fitted to estimate the association of COVID-19 with use of PC among ICU admissions. A similar approach was used for sensitivity analyses of strata with previously reported lower and higher than reference use of PC. Results There were 20,244 patients with sepsis admitted to ICU during terminal hospitalization, and 9,206 (45.5%) had COVID-19. The frequency of PC among patients with and without COVID-19 was 32.0% vs. 37.1%, respectively. On adjusted analysis, the odds of PC use remained lower among patients with COVID-19 (adjusted odds ratio (aOR): 0.84, 95% confidence interval (CI): 0.78 - 0.90), with similar findings on sensitivity analyses. Conclusions PC was markedly less common among critically ill septic patients with COVID-19 during terminal hospitalization, compared to those without COVID-19. Further studies are needed to determine the factors underlying these findings in order to reduce disparities in use of PC.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, USA.
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de la Fuente-Nunez C, Cesaro A, Hancock REW. Antibiotic failure: Beyond antimicrobial resistance. Drug Resist Updat 2023; 71:101012. [PMID: 37924726 DOI: 10.1016/j.drup.2023.101012] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
Despite significant progress in antibiotic discovery, millions of lives are lost annually to infections. Surprisingly, the failure of antimicrobial treatments to effectively eliminate pathogens frequently cannot be attributed to genetically-encoded antibiotic resistance. This review aims to shed light on the fundamental mechanisms contributing to clinical scenarios where antimicrobial therapies are ineffective (i.e., antibiotic failure), emphasizing critical factors impacting this under-recognized issue. Explored aspects include biofilm formation and sepsis, as well as the underlying microbiome. Therapeutic strategies beyond antibiotics, are examined to address the dimensions and resolution of antibiotic failure, actively contributing to this persistent but escalating crisis. We discuss the clinical relevance of antibiotic failure beyond resistance, limited availability of therapies, potential of new antibiotics to be ineffective, and the urgent need for novel anti-infectives or host-directed therapies directly addressing antibiotic failure. Particularly noteworthy is multidrug adaptive resistance in biofilms that represent 65 % of infections, due to the lack of approved therapies. Sepsis, responsible for 19.7 % of all deaths (as well as severe COVID-19 deaths), is a further manifestation of this issue, since antibiotics are the primary frontline therapy, and yet 23 % of patients succumb to this condition.
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Affiliation(s)
- Cesar de la Fuente-Nunez
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA; Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, PA, USA.
| | - Angela Cesaro
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA; Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E W Hancock
- Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, Canada.
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Shapiro L, Scherger S, Franco-Paredes C, Gharamti A, Henao-Martinez AF. Anakinra authorized to treat severe coronavirus disease 2019; Sepsis breakthrough or time to reflect? Front Microbiol 2023; 14:1250483. [PMID: 37928695 PMCID: PMC10620707 DOI: 10.3389/fmicb.2023.1250483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction The European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA) announced conditions for using recombinant human interleukin-1 receptor antagonist (rhIL-1ra) to treat hospitalized patients with Coronavirus disease 2019 (COVID-19) and risk for progression. These decisions followed publication of the suPAR-guided Anakinra treatment for Validation of the risk and early Management OF seveRE respiratory failure by COVID-19 (SAVE- MORE) phase 3 clinical trial that yielded positive results. Methods We conducted a literature review and theoretical analysis of IL-1 blockade as a therapy to treat COVID-19. Using a stepwise analysis, we assessed clinical applicability of the SAVE-MORE results and evaluated conceptual support for interleukin-1 suppression as a suitable approach to COVID-19 treatment. This therapeutic approach was then examined as an example of inflammation-suppressing measures used to treat sepsis. Results Anakinra use as a COVID-19 therapy seems to rely on a view of pathogenesis that incorrectly reflects human disease. Since COVID-19 is an example of sepsis, COVID-19 benefit due to anti-inflammatory therapy contradicts an extensive history of unsuccessful clinical study. Repurposing rhIL-1ra to treat COVID-19 appears to exemplify a cycle followed by inflammation-suppressing sepsis treatments. A landscape of treatment failures is interrupted by a successful clinical trial. However, subsequent confirmatory study fails to replicate the positive data. Discussion We suggest further experimentation is not a promising pathway to discover game-changing sepsis therapies. A different kind of approach may be necessary.
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Affiliation(s)
- Leland Shapiro
- Division of Infectious Diseases, Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, United States
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sias Scherger
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, México City, México
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Collins, CO, United States
| | - Amal Gharamti
- Department of Internal Medicine, Yale University, Waterbury, CT, United States
| | - Andrés F. Henao-Martinez
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Cavaillon JM. During Sepsis and COVID-19, the Pro-Inflammatory and Anti-Inflammatory Responses Are Concomitant. Clin Rev Allergy Immunol 2023; 65:183-187. [PMID: 37395985 DOI: 10.1007/s12016-023-08965-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
The most severe forms of COVID-19 share many features with bacterial sepsis and have thus been considered to be a viral sepsis. Innate immunity and inflammation are closely linked. While the immune response aims to get rid of the infectious agent, the pro-inflammatory host response can result in organ injury including acute respiratory distress syndrome. On its side, a compensatory anti-inflammatory response, aimed to dampen the inflammatory reaction, can lead to immunosuppression. Whether these two key events of the host inflammatory response are consecutive or concomitant has been regularly depicted in schemes. Initially proposed from 2001 to 2013 to be two consecutive steps, the concomitant occurrence has been supported since 2013, although it was proposed for the first time in 2001. Despite a consensus was reached, the two consecutive steps were still recently proposed for COVID-19. We discuss why the concomitance view could have been initiated as early as 1995.
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An AY, Baghela A, Zhang P, Falsafi R, Lee AH, Trahtemberg U, Baker AJ, dos Santos CC, Hancock REW. Persistence is key: unresolved immune dysfunction is lethal in both COVID-19 and non-COVID-19 sepsis. Front Immunol 2023; 14:1254873. [PMID: 37822940 PMCID: PMC10562687 DOI: 10.3389/fimmu.2023.1254873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/04/2023] [Indexed: 10/13/2023] Open
Abstract
Introduction Severe COVID-19 and non-COVID-19 pulmonary sepsis share pathophysiological, immunological, and clinical features, suggesting that severe COVID-19 is a form of viral sepsis. Our objective was to identify shared gene expression trajectories strongly associated with eventual mortality between severe COVID-19 patients and contemporaneous non-COVID-19 sepsis patients in the intensive care unit (ICU) for potential therapeutic implications. Methods Whole blood was drawn from 20 COVID-19 patients and 22 non-COVID-19 adult sepsis patients at two timepoints: ICU admission and approximately a week later. RNA-Seq was performed on whole blood to identify differentially expressed genes and significantly enriched pathways. Using systems biology methods, drug candidates targeting key genes in the pathophysiology of COVID-19 and sepsis were identified. Results When compared to survivors, non-survivors (irrespective of COVID-19 status) had 3.6-fold more "persistent" genes (genes that stayed up/downregulated at both timepoints) (4,289 vs. 1,186 genes); these included persistently downregulated genes in T-cell signaling and persistently upregulated genes in select innate immune and metabolic pathways, indicating unresolved immune dysfunction in non-survivors, while resolution of these processes occurred in survivors. These findings of persistence were further confirmed using two publicly available datasets of COVID-19 and sepsis patients. Systems biology methods identified multiple immunomodulatory drug candidates that could target this persistent immune dysfunction, which could be repurposed for possible therapeutic use in both COVID-19 and sepsis. Discussion Transcriptional evidence of persistent immune dysfunction was associated with 28-day mortality in both COVID-19 and non-COVID-19 septic patients. These findings highlight the opportunity for mitigating common mechanisms of immune dysfunction with immunomodulatory therapies for both diseases.
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Affiliation(s)
- Andy Y. An
- Center for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
| | - Arjun Baghela
- Center for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
| | - Peter Zhang
- Center for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
| | - Reza Falsafi
- Center for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
| | - Amy H. Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Uriel Trahtemberg
- Keenan Research Center for Biomedical Science and the Department of Critical Care, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
- Department of Critical Care, Galilee Medical Center, Nahariya, Israel
| | - Andrew J. Baker
- Keenan Research Center for Biomedical Science and the Department of Critical Care, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Claudia C. dos Santos
- Keenan Research Center for Biomedical Science and the Department of Critical Care, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Robert E. W. Hancock
- Center for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
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Shappell CN, Klompas M, Chan C, Chen T, Kanjilal S, McKenna C, Rhee C. Use of Electronic Clinical Data to Track Incidence and Mortality for SARS-CoV-2-Associated Sepsis. JAMA Netw Open 2023; 6:e2335728. [PMID: 37773495 PMCID: PMC10543118 DOI: 10.1001/jamanetworkopen.2023.35728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/21/2023] [Indexed: 10/01/2023] Open
Abstract
Importance Efforts to quantify the burden of SARS-CoV-2-associated sepsis have been limited by inconsistent definitions and underrecognition of viral sepsis. Objective To describe the incidence and outcomes of SARS-CoV-2-associated sepsis vs presumed bacterial sepsis using objective electronic clinical criteria. Design, Setting, and Participants This retrospective cohort study included adults hospitalized at 5 Massachusetts hospitals between March 2020 and November 2022. Exposures SARS-CoV-2-associated sepsis was defined as a positive SARS-CoV-2 polymerase chain reaction test and concurrent organ dysfunction (ie, oxygen support above simple nasal cannula, vasopressors, elevated lactate level, rise in creatine or bilirubin level, and/or decline in platelets). Presumed bacterial sepsis was defined by modified US Centers for Disease Control and Prevention adult sepsis event criteria (ie, blood culture order, sustained treatment with antibiotics, and organ dysfunction using identical thresholds as for SARS-CoV-2-associated sepsis). Main Outcomes and Measures Trends in the quarterly incidence (ie, proportion of hospitalizations) and in-hospital mortality for SARS-CoV-2-associated and presumed bacterial sepsis were assessed using negative binomial and logistic regression models. Results This study included 431 017 hospital encounters from 261 595 individuals (mean [SD] age 57.9 [19.8] years, 241 131 (55.9%) females, 286 397 [66.5%] from academic hospital site). Of these encounters, 23 276 (5.4%) were from SARS-CoV-2, 6558 (1.5%) had SARS-CoV-2-associated sepsis, and 30 604 patients (7.1%) had presumed bacterial sepsis without SARS-CoV-2 infection. Crude in-hospital mortality for SARS-CoV-2-associated sepsis declined from 490 of 1469 (33.4%) in the first quarter to 67 of 450 (14.9%) in the last (adjusted odds ratio [aOR], 0.88 [95% CI, 0.85-0.90] per quarter). Crude mortality for presumed bacterial sepsis was 4451 of 30 604 patients (14.5%) and stable across quarters (aOR, 1.00 [95% CI, 0.99-1.01]). Medical record reviews of 200 SARS-CoV-2-positive hospitalizations confirmed electronic health record (EHR)-based SARS-CoV-2-associated sepsis criteria performed well relative to sepsis-3 criteria (90.6% [95% CI, 80.7%-96.5%] sensitivity; 91.2% [95% CI, 85.1%-95.4%] specificity). Conclusions and Relevance In this retrospective cohort study of hospitalized adults, SARS-CoV-2 accounted for approximately 1 in 6 cases of sepsis during the first 33 months of the COVID-19 pandemic. In-hospital mortality rates for SARS-CoV-2-associated sepsis were high but declined over time and ultimately were similar to presumed bacterial sepsis. These findings highlight the high burden of SARS-CoV-2-associated sepsis and demonstrate the utility of EHR-based algorithms to conduct surveillance for viral and bacterial sepsis.
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Affiliation(s)
- Claire N. Shappell
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Christina Chan
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Tom Chen
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sanjat Kanjilal
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Caroline McKenna
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Oud L, Garza J. The Impact of COVID-19 on Sepsis-Related Mortality in the United States. J Clin Med Res 2023; 15:328-331. [PMID: 37434769 PMCID: PMC10332882 DOI: 10.14740/jocmr4937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19)-related organ dysfunction is increasingly considered as sepsis of viral origin. In recent clinical and autopsy studies, sepsis has been present in the majority of decedents with COVID-19. Given the high mortality toll of COVID-19, sepsis epidemiology would be expected to be substantially transformed. However, the impact of COVID-19 on sepsis-related mortality at the national level has not been quantified. We aimed to estimate the contribution of COVID-19 to sepsis-related mortality in the USA during the first year of the pandemic. Methods We used the Centers for Disease Control Wide-Ranging Online Data for Epidemiological Research (CDC WONDER) Multiple Cause of Death dataset to identify decedents with sepsis during 2015 - 2019, and those with a diagnosis of sepsis, COVID-19, or both in 2020. Negative binomial regression was used on the 2015 - 2019 data to forecast the number of sepsis-related deaths in 2020. We then compared the observed vs. predicted number of sepsis-related deaths in 2020. In addition, we examined the frequency of a diagnosis of COVID-19 among decedents with sepsis and the proportion of a diagnosis of sepsis among decedents with COVID-19. The latter analysis was repeated within each of the Department of Health and Human Services (HHS) regions. Results In 2020, there were 242,630 sepsis-related deaths, 384,536 COVID-19-related deaths, and 35,807 deaths with both in the USA. The predicted number of sepsis-related deaths for 2020 was 206,549 (95% confidence interval (CI): 201,550 - 211,671). COVID-19 was reported in 14.7% of decedents with sepsis, while a diagnosis of sepsis was reported in 9.3% of all COVID-19-related deaths, ranging from 6.7% to 12.8% across HHS regions. Conclusions A diagnosis of COVID-19 was reported in less than one in six of decedents with sepsis in 2020, with corresponding less than one in 10 diagnoses of sepsis among decedents with COVID-19. These findings suggest that death certificate-based data may have substantially underestimated the toll of sepsis-related deaths in the USA during the first year of the pandemic.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, USA
| | - John Garza
- Department of Mathematics, The University of Texas of the Permian Basin, Odessa, TX, USA
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Marques A, Torre C, Pinto R, Sepodes B, Rocha J. Treatment Advances in Sepsis and Septic Shock: Modulating Pro- and Anti-Inflammatory Mechanisms. J Clin Med 2023; 12:jcm12082892. [PMID: 37109229 PMCID: PMC10142733 DOI: 10.3390/jcm12082892] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Sepsis is currently defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection, and it affects over 25 million people every year. Even more severe, septic shock is a subset of sepsis defined by persistent hypotension, and hospital mortality rates are higher than 40%. Although early sepsis mortality has greatly improved in the past few years, sepsis patients who survive the hyperinflammation and subsequent organ damage often die from long-term complications, such as secondary infection, and despite decades of clinical trials targeting this stage of the disease, currently, no sepsis-specific therapies exist. As new pathophysiological mechanisms have been uncovered, immunostimulatory therapy has emerged as a promising path forward. Highly investigated treatment strategies include cytokines and growth factors, immune checkpoint inhibitors, and even cellular therapies. There is much to be learned from related illnesses, and immunotherapy trials in oncology, as well as the recent COVID-19 pandemic, have greatly informed sepsis research. Although the journey ahead is a long one, the stratification of patients according to their immune status and the employment of combination therapies represent a hopeful way forward.
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Affiliation(s)
- Adriana Marques
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, 1649-003 Lisbon, Portugal
| | - Carla Torre
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, 1649-003 Lisbon, Portugal
| | - Rui Pinto
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, 1649-003 Lisbon, Portugal
- Joaquim Chaves Saúde, Joaquim Chaves Laboratório de Análises Clínicas, Miraflores, 1495-069 Algés, Portugal
| | - Bruno Sepodes
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, 1649-003 Lisbon, Portugal
| | - João Rocha
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, 1649-003 Lisbon, Portugal
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Zahid S, Ali Y, Rashid S. Structural-based design of HD-TAC7 PROteolysis TArgeting chimeras (PROTACs) candidate transformations to abrogate SARS-CoV-2 infection. J Biomol Struct Dyn 2023; 41:14566-14581. [PMID: 36841549 DOI: 10.1080/07391102.2023.2183037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for about 672 million infections and 6.85 million deaths worldwide. Upon SARS-CoV-2 infection, Histone deacetylases (HDACs) hyperactivate the pro-inflammatory response resulting in stimulation of Acetyl-Coenzyme A and cholesterol for viral entry. HDAC3 inhibition results in the anti-inflammatory activity and reduction of pro-inflammatory cytokines that may restrict COVID-19 progression. Here, we have designed 44 conformational ensembles of previously known HD-TAC7 by enumerating torsions of dihedral angles tested for their binding preferences against HDAC3. Through scrutinizing their placements at active site and binding affinities, three hits were isolated. Cereblon (CRBN) is a well-known E3 ligase that facilitates Proteolysis Targeting Chimeras (PROTACs) targeting. Three entities, including HDAC3-binding moiety (4-acetamido-N-(2-amino-4 fluorophenyl) benzamide), a 6-carbon linker, and CRBN binding ligand (pomalidomide) were assembled to design 4 PROTACs followed by energy minimization and docking against HDAC3 and CRBN, respectively. Subsequent molecular dynamics (MD) and free energy analyses corroborated similar binding trends and favorable energy values. Among all cases, Met88, GLu106, Pro352, Trp380 and Trp388 residues of CRBN, and Pro23, Arg28, Lys194, Phe199, Leu266, Thr299 and Ile346 residues of HDAC3 were engaged in PROTAC binding. Thus, conformational dynamics of both HDAC3 and CRBN moieties are essential for the placement of PROTAC, resulting in target degradation. Overall, the proposed bifunctional small molecules may effectively target HDAC3, stimulating innate immune response to restrict COVID-19 hyperinflammation. This study supports the basis for designing new PROTACs by limiting the conformational search space that may prove more efficient for targeting the protein of interest.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Sana Zahid
- National Center for Bioinformatics, Quaid-i-Azam University, Islamabad, Pakistan
| | - Yasir Ali
- National Center for Bioinformatics, Quaid-i-Azam University, Islamabad, Pakistan
| | - Sajid Rashid
- National Center for Bioinformatics, Quaid-i-Azam University, Islamabad, Pakistan
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Chehayeb RJ, Ilagan-Ying YC, Sankey C. Addressing Cognitive Biases in Interpreting an Elevated Lactate in a Patient with Type 1 Diabetes and Thiamine Deficiency. J Gen Intern Med 2023; 38:1547-1551. [PMID: 36814053 PMCID: PMC9946700 DOI: 10.1007/s11606-023-08091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
We present the case of a young woman admitted for diabetic ketoacidosis with persistent, asymptomatic lactic acid (LA) elevation during the evolving COVID-19 pandemic. Cognitive biases in interpreting an elevated LA in this patient's care resulted in an extensive infectious workup instead of the low-cost and potentially diagnostic provision of empiric thiamine. We discuss clinical patterns and etiologies of LA elevation and the role of thiamine deficiency. We also address cognitive biases potentially affecting the interpretation of elevated lactate levels and provide guidance for clinicians to determine appropriate patients for empiric thiamine administration.
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Affiliation(s)
| | | | - Christopher Sankey
- General Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
- Yale New Haven Hospital, New Haven, CT, USA.
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13
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Gravrand V, Mellot F, Ackermann F, Ballester MC, Zuber B, Kirk JT, Navalkar K, Yager TD, Petit F, Pascreau T, Farfour E, Vasse M. Stratification of COVID-19 Severity Using SeptiCyte RAPID, a Novel Host Immune Response Test. Viruses 2023; 15:419. [PMID: 36851633 PMCID: PMC9960895 DOI: 10.3390/v15020419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
SeptiCyte® RAPID is a gene expression assay measuring the relative expression levels of host response genes PLA2G7 and PLAC8, indicative of a dysregulated immune response during sepsis. As severe forms of COVID-19 may be considered viral sepsis, we evaluated SeptiCyte RAPID in a series of 94 patients admitted to Foch Hospital (Suresnes, France) with proven SARS-CoV-2 infection. EDTA blood was collected in the emergency department (ED) in 67 cases, in the intensive care unit (ICU) in 23 cases and in conventional units in 4 cases. SeptiScore (0-15 scale) increased with COVID-19 severity. Patients in ICU had the highest SeptiScores, producing values comparable to 8 patients with culture-confirmed bacterial sepsis. Receiver operating characteristic (ROC) curve analysis had an area under the curve (AUC) of 0.81 for discriminating patients requiring ICU admission from patients who were immediately discharged or from patients requiring hospitalization in conventional units. SeptiScores increased with the extent of the lung injury. For 68 patients, a chest computed tomography (CT) scan was performed within 24 h of COVID-19 diagnosis. SeptiScore >7 suggested lung injury ≥50% (AUC = 0.86). SeptiCyte RAPID was compared to other biomarkers for discriminating Critical + Severe COVID-19 in ICU, versus Moderate + Mild COVID-19 not in ICU. The mean AUC for SeptiCyte RAPID was superior to that of any individual biomarker or combination thereof. In contrast to C-reactive protein (CRP), correlation of SeptiScore with lung injury was not impacted by treatment with anti-inflammatory agents. SeptiCyte RAPID can be a useful tool to identify patients with severe forms of COVID-19 in ED, as well as during follow-up.
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Affiliation(s)
| | | | - Felix Ackermann
- Internal Medicine Department, Foch Hospital, 92150 Suresnes, France
| | | | - Benjamin Zuber
- Intensive Care Unit, Foch Hospital, 92150 Suresnes, France
| | | | | | | | - Fabien Petit
- Biology Department, Foch Hospital, 92150 Suresnes, France
| | - Tiffany Pascreau
- Biology Department, Foch Hospital, 92150 Suresnes, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR-S1176, 94270 Le Kremlin-Bicêtre, France
| | - Eric Farfour
- Biology Department, Foch Hospital, 92150 Suresnes, France
| | - Marc Vasse
- Biology Department, Foch Hospital, 92150 Suresnes, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR-S1176, 94270 Le Kremlin-Bicêtre, France
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14
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Shappell C, Rhee C, Klompas M. Update on Sepsis Epidemiology in the Era of COVID-19. Semin Respir Crit Care Med 2023; 44:173-184. [PMID: 36646093 DOI: 10.1055/s-0042-1759880] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Timely and accurate data on the epidemiology of sepsis is essential to inform public policy, clinical practice, and research priorities. Recent studies have illuminated several ongoing questions about sepsis epidemiology, including the incidence and outcomes of sepsis in non-Western countries and in specialized populations such as surgical patients, patients with cancer, and the elderly. There have also been new insights into the limitations of current surveillance methods using administrative data and increasing experience tracking sepsis incidence and outcomes using "big data" approaches that take advantage of detailed electronic health record data. The COVID-19 pandemic, however, has fundamentally changed the landscape of sepsis epidemiology. It has increased sepsis rates, helped highlight ongoing controversies about how to define sepsis, and intensified debate about the possible unintended consequences of overly rigid sepsis care bundles. Despite these controversies, there is a growing consensus that severe COVID-19 causing organ dysfunction is appropriate to label as sepsis, even though it is treated very differently from bacterial sepsis, and that surveillance strategies need to be modified to reliably identify these cases to fully capture and delineate the current burden of sepsis. This review will summarize recent insights into the epidemiology of sepsis and highlight several urgent questions and priorities catalyzed by COVID-19.
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Affiliation(s)
- Claire Shappell
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Baghela A, An A, Zhang P, Acton E, Gauthier J, Brunet-Ratnasingham E, Blimkie T, Freue GC, Kaufmann D, Lee AHY, Levesque RC, Hancock REW. Predicting severity in COVID-19 disease using sepsis blood gene expression signatures. Sci Rep 2023; 13:1247. [PMID: 36690713 PMCID: PMC9868505 DOI: 10.1038/s41598-023-28259-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
Severely-afflicted COVID-19 patients can exhibit disease manifestations representative of sepsis, including acute respiratory distress syndrome and multiple organ failure. We hypothesized that diagnostic tools used in managing all-cause sepsis, such as clinical criteria, biomarkers, and gene expression signatures, should extend to COVID-19 patients. Here we analyzed the whole blood transcriptome of 124 early (1-5 days post-hospital admission) and late (6-20 days post-admission) sampled patients with confirmed COVID-19 infections from hospitals in Quebec, Canada. Mechanisms associated with COVID-19 severity were identified between severity groups (ranging from mild disease to the requirement for mechanical ventilation and mortality), and established sepsis signatures were assessed for dysregulation. Specifically, gene expression signatures representing pathophysiological events, namely cellular reprogramming, organ dysfunction, and mortality, were significantly enriched and predictive of severity and lethality in COVID-19 patients. Mechanistic endotypes reflective of distinct sepsis aetiologies and therapeutic opportunities were also identified in subsets of patients, enabling prediction of potentially-effective repurposed drugs. The expression of sepsis gene expression signatures in severely-afflicted COVID-19 patients indicates that these patients should be classified as having severe sepsis. Accordingly, in severe COVID-19 patients, these signatures should be strongly considered for the mechanistic characterization, diagnosis, and guidance of treatment using repurposed drugs.
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Affiliation(s)
- Arjun Baghela
- Department of Microbiology and Immunology, University of British Columbia (UBC), Vancouver, Canada
| | - Andy An
- Department of Microbiology and Immunology, University of British Columbia (UBC), Vancouver, Canada
| | | | - Erica Acton
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, Canada
| | - Jeff Gauthier
- Institut de Biologie Intégrative et des Systèmes (IBIS), Département de Microbiologie-Infectiologie et d'immunologie, Université Laval, Quebec, QC, Canada
| | - Elsa Brunet-Ratnasingham
- Département de Microbiologie, Infectiologie Et Immunologie, Université de Montréal, Montreal, Canada
- Centre de Recherche du CHUM, Montreal, QC, Canada
| | - Travis Blimkie
- Department of Microbiology and Immunology, University of British Columbia (UBC), Vancouver, Canada
| | | | - Daniel Kaufmann
- Centre de Recherche du CHUM, Montreal, QC, Canada
- Département de Médecine, Université de Montréal, Montreal, Canada
| | - Amy H Y Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, Canada
| | - Roger C Levesque
- Institut de Biologie Intégrative et des Systèmes (IBIS), Département de Microbiologie-Infectiologie et d'immunologie, Université Laval, Quebec, QC, Canada
| | - Robert E W Hancock
- Department of Microbiology and Immunology, University of British Columbia (UBC), Vancouver, Canada.
- Asep Medical, Vancouver, Canada.
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16
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An AY, Baghela A, Zhang P, Falsafi R, Lee AH, Trahtemberg U, Baker AJ, dos Santos CC, Hancock REW. Severe COVID-19 and non-COVID-19 severe sepsis converge transcriptionally after a week in the intensive care unit, indicating common disease mechanisms. Front Immunol 2023; 14:1167917. [PMID: 37090709 PMCID: PMC10115984 DOI: 10.3389/fimmu.2023.1167917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Severe COVID-19 and non-COVID-19 pulmonary sepsis share pathophysiological, immunological, and clinical features. To what extent they share mechanistically-based gene expression trajectories throughout hospitalization was unknown. Our objective was to compare gene expression trajectories between severe COVID-19 patients and contemporaneous non-COVID-19 severe sepsis patients in the intensive care unit (ICU). Methods In this prospective single-center observational cohort study, whole blood was drawn from 20 COVID-19 patients and 22 non-COVID-19 adult sepsis patients at two timepoints: ICU admission and approximately a week later. RNA-Seq was performed on whole blood to identify differentially expressed genes and significantly enriched pathways. Results At ICU admission, despite COVID-19 patients being almost clinically indistinguishable from non-COVID-19 sepsis patients, COVID-19 patients had 1,215 differentially expressed genes compared to non-COVID-19 sepsis patients. After one week in the ICU, the number of differentially expressed genes dropped to just 9 genes. This drop coincided with decreased expression of antiviral genes and relatively increased expression of heme metabolism genes over time in COVID-19 patients, eventually reaching expression levels seen in non-COVID-19 sepsis patients. Both groups also had similar underlying immune dysfunction, with upregulation of immune processes such as "Interleukin-1 signaling" and "Interleukin-6/JAK/STAT3 signaling" throughout disease compared to healthy controls. Discussion Early on, COVID-19 patients had elevated antiviral responses and suppressed heme metabolism processes compared to non-COVID-19 severe sepsis patients, although both had similar underlying immune dysfunction. However, after one week in the ICU, these diseases became indistinguishable on a gene expression level. These findings highlight the importance of early antiviral treatment for COVID-19, the potential for heme-related therapeutics, and consideration of immunomodulatory therapies for both diseases to treat shared immune dysfunction.
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Affiliation(s)
- Andy Y. An
- Centre for Microbial Diseases and Immunity Research, Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Arjun Baghela
- Centre for Microbial Diseases and Immunity Research, Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Peter Zhang
- Centre for Microbial Diseases and Immunity Research, Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Reza Falsafi
- Centre for Microbial Diseases and Immunity Research, Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Amy H. Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, Burnaby, BC, Canada
| | - Uriel Trahtemberg
- The Department of Critical Care, Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
- Department of Critical Care, Galilee Medical Center, Nahariya, Israel
| | - Andrew J. Baker
- The Department of Critical Care, Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Claudia C. dos Santos
- The Department of Critical Care, Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Robert E. W. Hancock
- Centre for Microbial Diseases and Immunity Research, Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
- *Correspondence: Robert E. W. Hancock,
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17
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Walsh TJ, Bright RA, Ahuja A, McCarthy MW, Marfuggi RA, Simpson SQ. Meeting the Challenges of Sepsis in Severe Coronavirus Disease 2019: A Call to Arms. Open Forum Infect Dis 2022; 10:ofac645. [PMID: 36686626 PMCID: PMC9850274 DOI: 10.1093/ofid/ofac645] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction that is caused by a dysregulated host response to infection. Sepsis may be caused by bacterial, fungal, or viral pathogens. The clinical manifestations exhibited by patients with severe coronavirus disease 2019 (COVID-19)-related sepsis overlap with those exhibited by patients with sepsis from secondary bacterial or fungal infections and can include an altered mental status, dyspnea, reduced urine output, tachycardia, and hypotension. Critically ill patients hospitalized with severe acute respiratory syndrome coronavirus 2 infections have increased risk for secondary bacterial and fungal infections. The same risk factors that may predispose to sepsis and poor outcome from bloodstream infections (BSIs) converge in patients with severe COVID-19. Current diagnostic standards for distinguishing between (1) patients who are critically ill, septic, and have COVID-19 and (2) patients with sepsis from other causes leave healthcare providers with 2 suboptimal choices. The first choice is to empirically administer broad-spectrum, antimicrobial therapy for what may or may not be sepsis. Such treatment may not only be ineffective and inappropriate, but it also has the potential to cause harm. The development of better methods to identify and characterize antimicrobial susceptibility will guide more accurate therapeutic interventions and reduce the evolution of new antibiotic-resistant strains. The ideal diagnostic test should (1) be rapid and reliable, (2) have a lower limit of detection than blood culture, and (3) be able to detect a specific organism and drug sensitivity directly from a clinical specimen. Rapid direct detection of antimicrobial-resistant pathogens would allow targeted therapy and result in improved outcomes in patients with severe COVID-19 and sepsis.
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Affiliation(s)
- Thomas J Walsh
- Correspondence: Thomas J. Walsh MD, PhD, Center for Innovative Therapeutics and Diagnostics, 6641 West Broad Street, Room 100, Richmond, Virginia 23220 ()
| | - Rick A Bright
- The Rockefeller Foundation, Pandemic Prevention Institute, New York, New York, USA
| | | | - Matthew W McCarthy
- Weill Cornell Medicine and New York Presbyterian Hospital, New York, New York, USA
| | - Richard A Marfuggi
- American Medical Association Foundation, Chicago, Illinois, USA,WBB Research Institute, Cranford, New Jersey, USA
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18
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Forceville X, Van Antwerpen P, Annane D, Vincent JL. Selenocompounds and Sepsis-Redox Bypass Hypothesis: Part B-Selenocompounds in the Management of Early Sepsis. Antioxid Redox Signal 2022; 37:998-1029. [PMID: 35287478 DOI: 10.1089/ars.2020.8062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Significance: Endothelial barrier damage, which is in part caused by excess production of reactive oxygen, halogen and nitrogen species (ROHNS), especially peroxynitrite (ONOO-), is a major event in early sepsis and, with leukocyte hyperactivation, part of the generalized dysregulated immune response to infection, which may even become a complex maladaptive state. Selenoenzymes have major antioxidant functions. Their synthesis is related to the need to limit deleterious oxidant redox cycling by small selenocompounds, which may be of therapeutic cytotoxic interest. Plasma selenoprotein-P is crucial for selenium transport from the liver to the tissues and for antioxidant endothelial protection, especially against ONOO-. Above micromolar concentrations, sodium selenite (Na2SeO3) becomes cytotoxic, with a lower cytotoxicity threshold in activated cells, which has led to cancer research. Recent Advances: Plasma selenium (<2% of total body selenium) is mainly contained in selenoprotein-P, and concentrations decrease rapidly in the early phase of sepsis, because of increased selenoprotein-P binding and downregulation of hepatic synthesis and excretion. At low concentrations, Na2SeO3 acts as a selenium donor, favoring selenoprotein-P synthesis in physiology, but probably not in the acute phase of sepsis. Critical Issues: The cytotoxic effects of Na2SeO3 against hyperactivated leukocytes, especially the most immature forms that liberate ROHNS, may be beneficial, but they may also be harmful for activated endothelial cells. Endothelial protection against ROHNS by selenoprotein-P may reduce Na2SeO3 toxicity, which is increased in sepsis. Future Direction: The combination of selenoprotein-P for endothelial protection and the cytotoxic effects of Na2SeO3 against hyperactivated leukocytes may be a promising intervention for early sepsis. Antioxid. Redox Signal. 37, 998-1029.
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Affiliation(s)
- Xavier Forceville
- Medico-surgical Intensive Care Unit, Great Hospital of East Francilien - Meaux site, Meaux, France.,Clinical Investigation Centre (CIC Inserm1414) CHU de Rennes - Université de Rennes 1, Rennes, France
| | - Pierre Van Antwerpen
- Pharmacognosy, Bioanalysis and Drug Discovery and Analytical Platform of the Faculty of Pharmacy, Univesité libre de Bruxelles (ULB), Bruxelles, Belgium
| | - Djillali Annane
- Service de Réanimation Médicale, Hôpital Raymond Poincaré (APHP), Garches, France.,U1173 Lab. of Inflammation & Infection, (Fédération Hospitalo-Universitaire) FHU SEPSIS, Université Paris Saclay-campus (Université de Versailles Saint-Quentin-en-Yvelines) UVSQ, Versailles, France
| | - Jean Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
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19
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Rondovic G, Djordjevic D, Udovicic I, Stanojevic I, Zeba S, Abazovic T, Vojvodic D, Abazovic D, Khan W, Surbatovic M. From Cytokine Storm to Cytokine Breeze: Did Lessons Learned from Immunopathogenesis Improve Immunomodulatory Treatment of Moderate-to-Severe COVID-19? Biomedicines 2022; 10:2620. [PMID: 36289881 PMCID: PMC9599155 DOI: 10.3390/biomedicines10102620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
Complex immune response to infection has been highlighted, more than ever, during the COVID-19 pandemic. This review explores the immunomodulatory treatment of moderate-to-severe forms of this viral sepsis in the context of specific immunopathogenesis. Our objective is to analyze in detail the existing strategies for the use of immunomodulators in COVID-19. Immunomodulating therapy is very challenging; there are still underpowered or, in other ways, insufficient studies with inconclusive or conflicting results regarding a rationale for adding a second immunomodulatory drug to dexamethasone. Bearing in mind that a "cytokine storm" is not present in the majority of COVID-19 patients, it is to be expected that the path to the adequate choice of a second immunomodulatory drug is paved with uncertainty. Anakinra, a recombinant human IL-1 receptor antagonist, is a good choice in this setting. Yet, the latest update of the COVID-19 Treatment Guidelines Panel (31 May 2022) claims that there is insufficient evidence to recommend either for or against the use of anakinra for the treatment of COVID-19. EMA's human medicines committee recommended extending the indication of anakinra to include treatment of COVID-19 in adult patients only recently (17 December 2021). It is obvious that this is still a work in progress, with few ongoing clinical trials. With over 6 million deaths from COVID-19, this is the right time to speed up this process. Our conclusion is that, during the course of COVID-19, the immune response is changing from the early phase to the late phase in individual patients, so immunomodulating therapy should be guided by individual responses at different time points.
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Affiliation(s)
- Goran Rondovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
| | - Dragan Djordjevic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
| | - Ivo Udovicic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
| | - Ivan Stanojevic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
- Institute for Medical Research, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Snjezana Zeba
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
| | - Tanja Abazovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Danilo Vojvodic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
- Institute for Medical Research, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Dzihan Abazovic
- Biocell Hospital, Omladinskih Brigada 86a, 11000 Belgrade, Serbia
| | - Wasim Khan
- Division of Trauma & Orthopaedic Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK
| | - Maja Surbatovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia
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20
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Forceville X, Laviolle B, Gromadzinska J, Boutten A, Van Antwerpen P, Plouvier E, Annane D, Bellissant E. Delayed increase of plasma selenoproteins and absence of side effect induced by infusion of pharmacological dose of sodium selenite in septic shock: Secondary analysis of a multicenter, randomized controlled trial. J Trace Elem Med Biol 2022; 73:127031. [PMID: 35793609 DOI: 10.1016/j.jtemb.2022.127031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND In sepsis, neutrophil respiratory bursts participate in endothelium damage, the first step to multiple organ failure. In plasma two antioxidant selenoenzymes, which protect the endothelium, decrease: selenoprotein-P, and to a lesser extent glutathione peroxidase (GPX3). Sodium selenite (Na2SeO3) is a Se donor, but also an oxidant chemotherapy drug depending on its concentration. In a previous published study, Na2SeO3 continuous infusion in septic shock patients at a pharmacological dose of 4 mg1 Se/day on day-1, followed by a high nutritional dose of 1 mg Se/day during 9 days, showed no beneficial effect on weaning of catecholamine nor on survival. In this ancillary study, we report clinical and biological effects of such continuous infusion of Na2SeO3. METHODS: This was a multicenter, placebo-controlled, double-blind study on 60 patients. Na2SeO3 or placebo in continuous infusion as described above. Evolution with time of plasma Se, selenoprotein-P, GPX3, Organ dysfunction (sequential organ failure assessment SOFA scores, including PaO2/FiO2, for respiratory failure, and plasma lactate) and quality of life at 6 months (by SF36 scores) were analyzed using two-way (time, treatment) non-parametric repeated-measures analysis of variance (Friedman test). MAIN RESULTS At baseline, plasma Se was about a quarter of reference values. From baseline to day-4 plasma Se, selenoprotein-P and GPX3 significantly increased by 3.9, 2.7 and 1.8 respectively in the Na2SeO3 group as compared with placebo and remained elevated by 2.3, 2.7 and 2.1 at day-14 respectively (p < 0.001). Na2SeO3 did not affect global and organ by organ SOFA Scores and plasma lactate concentration at day-1 and later up to day-14. The evolution of PaO2/FiO2 until day-14 was similar in the two groups. Quality of life in the surviving patients at 6 months was similar between the two groups. CONCLUSION Continuous infusion of Na2SeO3 at 4 mg Se at day-1 seems to have neither beneficial nor toxic effect at day-1 or later and induces a late increase of selenoprotein-P at day-4. Preclinical studies are required to confirm the use of Na2SeO3 as a cytotoxic drug against neutrophils and protection of the endothelium by selenoprotein-P.
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Affiliation(s)
- Xavier Forceville
- Service de Réanimation Médico-Chirurgicale-USC, Grand Hôpital de l'Est Francilien, site de Meaux, Hôpital Saint Faron, 6-8 rue Saint Fiacre, 77104 Meaux, France; Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France.
| | - Bruno Laviolle
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France.
| | - Jolanta Gromadzinska
- Biological and Environmental Monitoring Department, Nofer Institute of Occupational Medicine, 8 Teresy St., 90-950 Lodz, Poland.
| | - Anne Boutten
- Laboratoire de biochimie, Hôpital Bichat-Claude Bernard, APHP, 46 rue Henri Huchard, 75877 Paris cedex 18, France.
| | - Pierre Van Antwerpen
- Pharmacognosy, Bioanalysis and Drug Discovery and Analytical Platform of the Faculty of Pharmacy, Université libre de Bruxelles (ULB), Bld du Triomphe Campus Plaine 205/05, 1050 Bruxelles, Belgium.
| | - Elisabeth Plouvier
- Laboratoire de Biochimie, Grand Hôpital de l'Est Francilien, site de Meaux, Hôpital Saint Faron, 6-8 rue Saint Fiacre, 77104 Meaux, France.
| | - Djillali Annane
- Service de Réanimation Médicale, Hôpital Raymond Poincaré, 104 boulevard Raymond Poincaré, 92380 Garches, France; U1173 Lab. of Inflammation & Infection, (Fédération Hospitalo-Universitaire) FHU SEPSIS, Université Paris Saclay-campus (Université de Versailles Saint-Quentin-en-Yvelines) UVSQ, France.
| | - Eric Bellissant
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France.
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21
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Ripamonti C, Spadotto V, Pozzi P, Stevenazzi A, Vergani B, Marchini M, Sandrone G, Bonetti E, Mazzarella L, Minucci S, Steinkühler C, Fossati G. HDAC Inhibition as Potential Therapeutic Strategy to Restore the Deregulated Immune Response in Severe COVID-19. Front Immunol 2022; 13:841716. [PMID: 35592335 PMCID: PMC9111747 DOI: 10.3389/fimmu.2022.841716] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/01/2022] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic has had a devastating impact worldwide and has been a great challenge for the scientific community. Vaccines against SARS-CoV-2 are now efficiently lessening COVID-19 mortality, although finding a cure for this infection is still a priority. An unbalanced immune response and the uncontrolled release of proinflammatory cytokines are features of COVID-19 pathophysiology and contribute to disease progression and worsening. Histone deacetylases (HDACs) have gained interest in immunology, as they regulate the innate and adaptative immune response at different levels. Inhibitors of these enzymes have already proven therapeutic potential in cancer and are currently being investigated for the treatment of autoimmune diseases. We thus tested the effects of different HDAC inhibitors, with a focus on a selective HDAC6 inhibitor, on immune and epithelial cells in in vitro models that mimic cells activation after viral infection. Our data indicate that HDAC inhibitors reduce cytokines release by airway epithelial cells, monocytes and macrophages. This anti-inflammatory effect occurs together with the reduction of monocytes activation and T cell exhaustion and with an increase of T cell differentiation towards a T central memory phenotype. Moreover, HDAC inhibitors hinder IFN-I expression and downstream effects in both airway epithelial cells and immune cells, thus potentially counteracting the negative effects promoted in critical COVID-19 patients by the late or persistent IFN-I pathway activation. All these data suggest that an epigenetic therapeutic approach based on HDAC inhibitors represents a promising pharmacological treatment for severe COVID-19 patients.
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Affiliation(s)
- Chiara Ripamonti
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Valeria Spadotto
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Pietro Pozzi
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Andrea Stevenazzi
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Barbara Vergani
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Mattia Marchini
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Giovanni Sandrone
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
| | - Emanuele Bonetti
- Department of Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Luca Mazzarella
- Department of Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Saverio Minucci
- Department of Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | | | - Gianluca Fossati
- New Drug Incubator Department, Italfarmaco Group, Cinisello Balsamo, Italy
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22
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Vincent JL, Levi M, Hunt BJ. Prevention and management of thrombosis in hospitalised patients with COVID-19 pneumonia. THE LANCET. RESPIRATORY MEDICINE 2022; 10:214-220. [PMID: 34838161 PMCID: PMC8616572 DOI: 10.1016/s2213-2600(21)00455-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/28/2021] [Accepted: 10/07/2021] [Indexed: 12/13/2022]
Abstract
A proportion of people infected with SARS-CoV-2 develop moderate or severe COVID-19, with an increased risk of thromboembolic complications. The inflammatory response to SARS-CoV-2 infection can cause an acute-phase response and endothelial dysfunction, which contribute to COVID-19-associated coagulopathy, the clinical and laboratory features of which differ in some respects from those of classic disseminated intravascular coagulation. Understanding of the pathophysiology of thrombosis in COVID-19 is needed to develop approaches to management and prevention, with implications for short-term and long-term health outcomes. Evidence is emerging to support treatment decisions in patients with COVID-19, but many questions remain about the optimum approach to management. In this Viewpoint, we provide a summary of the pathophysiology of thrombosis and associated laboratory and clinical findings, and highlight key considerations in the management of coagulopathy in hospitalised patients with severe COVID-19, including coagulation assessment, identification of thromboembolic complications, and use of antithrombotic prophylaxis and therapeutic anticoagulation. We await the results of trials that are underway to establish the safety and benefits of prolonged thromboprophylaxis after hospital discharge.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Marcel Levi
- Department of Medicine and Cardiometabolic Programme-National Institute for Health Research UCLH/UCL Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK; Department of Vascular Medicine, Amsterdam University Medical Center (location Academic Medical Center), Amsterdam, Netherlands
| | - Beverley J Hunt
- Kings Healthcare Partners and Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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23
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Henry A. Welcome to the 17th volume of Future Microbiology. Future Microbiol 2021; 17:1-3. [PMID: 34932418 DOI: 10.2217/fmb-2021-0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Atiya Henry
- Commissioning Department, Future Science Group, Unitec House, 2 Albert Place, Finchley, London, N3 1QB, UK
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24
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Zhou Y, Liao X, Song X, He M, Xiao F, Jin X, Xie X, Zhang Z, Wang B, Zhou C, Kang Y, Zhang W. Severe Adaptive Immune Suppression May Be Why Patients With Severe COVID-19 Cannot Be Discharged From the ICU Even After Negative Viral Tests. Front Immunol 2021; 12:755579. [PMID: 34867988 PMCID: PMC8640185 DOI: 10.3389/fimmu.2021.755579] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/01/2021] [Indexed: 02/05/2023] Open
Abstract
During the COVID-19 pandemic, a phenomenon emerged in which some patients with severe disease were critically ill and could not be discharged from the ICU even though they exhibited negative viral tests. To explore the underlying mechanism, we collected blood samples from these patients and analyzed the gene expression profiles of peripheral immune cells. We found that all enrolled patients, regardless of changes in genes related to different symptoms and inflammatory responses, showed universally and severely decreased expression of adaptive immunity-related genes, especially those related to T/B cell arms and HLA molecules, and that these patients exhibited long-term secondary infections. In addition, no significant change was found in the expression of classic immunosuppression molecules including PD-1, PD-L1, and CTLA-4, suggesting that the adaptive immune suppression may not be due to the change of these genes. According to the published literatures and our data, this adaptive immunosuppression is likely to be caused by the "dysregulated host response" to severe infection, similar to the immunosuppression that exists in other severely infected patients with sepsis.
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Affiliation(s)
- Yue Zhou
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Xuelian Liao
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Xiangrong Song
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Min He
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Fei Xiao
- Department of Intensive Care Unit of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaodong Jin
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Xiaoqi Xie
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Zhongwei Zhang
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Bo Wang
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Chenliang Zhou
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yan Kang
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Wei Zhang
- Department of Critical Care Medicine, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
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25
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Mazzoni A, Salvati L, Maggi L, Annunziato F, Cosmi L. Hallmarks of immune response in COVID-19: Exploring dysregulation and exhaustion. Semin Immunol 2021; 55:101508. [PMID: 34728121 PMCID: PMC8547971 DOI: 10.1016/j.smim.2021.101508] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/11/2021] [Accepted: 10/15/2021] [Indexed: 01/08/2023]
Abstract
One and half year following the occurrence of COVID-19 pandemic, significant efforts from laboratories all over the world generated a huge amount of data describing the prototypical features of immunity in the course of SARS-CoV-2 infection. In this Review, we rationalize and organize the main observations, trying to define a “core” signature of immunity in COVID-19. We identified six hallmarks describing the main alterations occurring in the early infection phase and in the course of the disease, which predispose to severe illness. The six hallmarks are dysregulated type I IFN activity, hyperinflammation, lymphopenia, lymphocyte impairment, dysregulated myeloid response, and heterogeneous adaptive immunity to SARS-CoV-2. Dysregulation and exhaustion came out as the trait d’union, connecting abnormalities affecting both innate and adaptive immunity, humoral and cellular responses.
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Affiliation(s)
- Alessio Mazzoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorenzo Salvati
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Laura Maggi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Annunziato
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Lorenzo Cosmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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26
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da Silva Ramos FJ, de Freitas FGR, Machado FR. Sepsis in patients hospitalized with coronavirus disease 2019: how often and how severe? Curr Opin Crit Care 2021; 27:474-479. [PMID: 34292175 PMCID: PMC8452249 DOI: 10.1097/mcc.0000000000000861] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW To discuss why severe COVID-19 should be considered sepsis and how co-infection and secondary infection can aggravate this condition and perpetuate organ dysfunction leading to high mortality rates. RECENT FINDINGS In severe COVID-19, there is both direct viral toxicity and dysregulated host response to infection. Although both coinfection and/or secondary infection are present, the latest is of greater concern mainly in resource-poor settings. Patients with severe COVID-19 present a phenotype of multiorgan dysfunction that leads to death in an unacceptable high percentage of the patients, with wide variability around the world. Similarly to endemic sepsis, the mortality of COVID-19 critically ill patients is higher in low-income and middle-income countries as compared with high-income countries. Disparities, including hospital strain, resources limitations, higher incidence of healthcare-associated infections (HAI), and staffing issues could in part explain this variability. SUMMARY The high mortality rates of critically ill patients with severe COVID-19 disease are not only related to the severity of patient disease but also to modifiable factors, such as the ICU strain, HAI incidence, and organizational aspects. Therefore, HAI prevention and the delivery of best evidence-based care for these patients to avoid additional damage is important. Quality improvement interventions might help in improving outcomes mainly in resource-limited settings.
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