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Vadhan JD, Thoppil J, Vasquez O, Suarez A, Bartels B, McDonald S, Courtney DM, Farrar JD, Thakur B. Primary Infection Site as a Predictor of Sepsis Development in Emergency Department Patients. J Emerg Med 2024; 67:e128-e137. [PMID: 38849253 DOI: 10.1016/j.jemermed.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Sepsis is a life-threatening condition but predicting its development and progression remains a challenge. OBJECTIVE This study aimed to assess the impact of infection site on sepsis development among emergency department (ED) patients. METHODS Data were collected from a single-center ED between January 2016 and December 2019. Patient encounters with documented infections, as defined by the Systematized Nomenclature of Medicine-Clinical Terms for upper respiratory tract (URI), lower respiratory tract (LRI), urinary tract (UTI), or skin or soft-tissue infections were included. Primary outcome was the development of sepsis or septic shock, as defined by Sepsis-1/2 criteria. Secondary outcomes included hospital disposition and length of stay, blood and urine culture positivity, antibiotic administration, vasopressor use, in-hospital mortality, and 30-day mortality. Analysis of variance and various different logistic regression approaches were used for analysis with URI used as the reference variable. RESULTS LRI was most associated with sepsis (relative risk ratio [RRR] 5.63; 95% CI 5.07-6.24) and septic shock (RRR 21.2; 95% CI 17.99-24.98) development, as well as hospital admission rates (odds ratio [OR] 8.23; 95% CI 7.41-9.14), intensive care unit admission (OR 4.27; 95% CI 3.84-4.74), in-hospital mortality (OR 6.93; 95% CI 5.60-8.57), and 30-day mortality (OR 7.34; 95% CI 5.86-9.19). UTIs were also associated with sepsis and septic shock development, but to a lesser degree than LRI. CONCLUSIONS Primary infection sites including LRI and UTI were significantly associated with sepsis development, hospitalization, length of stay, and mortality among patients presenting with infections in the ED.
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Affiliation(s)
- Jason D Vadhan
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joby Thoppil
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ofelia Vasquez
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Arlen Suarez
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brett Bartels
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J David Farrar
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bhaskar Thakur
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Family Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Lee CC, Chen PL, Ho CY, Hong MY, Hung YP, Ko WC. Prompt antimicrobial therapy and source control on survival and defervescence of adults with bacteraemia in the emergency department: the faster, the better. Crit Care 2024; 28:176. [PMID: 38790061 PMCID: PMC11127347 DOI: 10.1186/s13054-024-04963-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Bacteraemia is a critical condition that generally leads to substantial morbidity and mortality. It is unclear whether delayed antimicrobial therapy (and/or source control) has a prognostic or defervescence effect on patients with source-control-required (ScR) or unrequired (ScU) bacteraemia. METHODS The multicenter cohort included treatment-naïve adults with bacteraemia in the emergency department. Clinical information was retrospectively obtained and etiologic pathogens were prospectively restored to accurately determine the time-to-appropriate antibiotic (TtAa). The association between TtAa or time-to-source control (TtSc, for ScR bacteraemia) and 30-day crude mortality or delayed defervescence were respectively studied by adjusting independent determinants of mortality or delayed defervescence, recognised by a logistic regression model. RESULTS Of the total 5477 patients, each hour of TtAa delay was associated with an average increase of 0.2% (adjusted odds ratio [AOR], 1.002; P < 0.001) and 0.3% (AOR 1.003; P < 0.001) in mortality rates for patients having ScU (3953 patients) and ScR (1524) bacteraemia, respectively. Notably, these AORs were augmented to 0.4% and 0.5% for critically ill individuals. For patients experiencing ScR bacteraemia, each hour of TtSc delay was significantly associated with an average increase of 0.31% and 0.33% in mortality rates for overall and critically ill individuals, respectively. For febrile patients, each additional hour of TtAa was significantly associated with an average 0.2% and 0.3% increase in the proportion of delayed defervescence for ScU (3085 patients) and ScR (1266) bacteraemia, respectively, and 0.5% and 0.9% for critically ill individuals. For 1266 febrile patients with ScR bacteraemia, each hour of TtSc delay respectively was significantly associated with an average increase of 0.3% and 0.4% in mortality rates for the overall population and those with critical illness. CONCLUSIONS Regardless of the need for source control in cases of bacteraemia, there seems to be a significant association between the prompt administration of appropriate antimicrobials and both a favourable prognosis and rapid defervescence, particularly among critically ill patients. For ScR bacteraemia, delayed source control has been identified as a determinant of unfavourable prognosis and delayed defervescence. Moreover, this association with patient survival and the speed of defervescence appears to be augmented among critically ill patients.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medical Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
| | - Po-Lin Chen
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, No.57, Sec. 1, Dongmen Road, East Dist., Tainan, 70142, Taiwan
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Ming-Yuan Hong
- Departments of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Yuan-Pin Hung
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
- Department of Medicine, Medical College, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, No. 125, Jhongshan Rd., West Central Dist., Tainan City, Taiwan
| | - Wen-Chien Ko
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
- Department of Medicine, Medical College, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
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Ramasco F, Nieves-Alonso J, García-Villabona E, Vallejo C, Kattan E, Méndez R. Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies. J Pers Med 2024; 14:176. [PMID: 38392609 PMCID: PMC10890552 DOI: 10.3390/jpm14020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Jesús Nieves-Alonso
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Esther García-Villabona
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Vallejo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Eduardo Kattan
- Departamento de Medicina Intensiva del Adulto, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
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Xie N, Lin Y, Li P, Zhao J, Li J, Wang K, Yang L, Jia L, Wang Q, Li P, Song H. Simultaneous identification of DNA and RNA pathogens using metagenomic sequencing in cases of severe acute respiratory infection. J Med Virol 2024; 96:e29406. [PMID: 38373115 DOI: 10.1002/jmv.29406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 02/21/2024]
Abstract
Metagenomic next-generation sequencing (mNGS) is a valuable technique for identifying pathogens. However, conventional mNGS requires the separate processing of DNA and RNA genomes, which can be resource- and time-intensive. To mitigate these impediments, we propose a novel method called DNA/RNA cosequencing that aims to enhance the efficiency of pathogen detection. DNA/RNA cosequencing uses reverse transcription of total nucleic acids extracted from samples by using random primers, without removing DNA, and then employs mNGS. We applied this method to 85 cases of severe acute respiratory infections (SARI). Influenza virus was identified in 13 cases (H1N1: seven cases, H3N2: three cases, unclassified influenza type: three cases) and was not detected in the remaining 72 samples. Bacteria were present in all samples. Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii were detected in four influenza-positive samples, suggesting coinfections. The sensitivity and specificity for detecting influenza A virus were 73.33% and 95.92%, respectively. A κ value of 0.726 indicated a high level of concordance between the results of DNA/RNA cosequencing and SARI influenza virus monitoring. DNA/RNA cosequencing enhanced the efficiency of pathogen detection, providing a novel capability to strengthen surveillance and thereby prevent and control infectious disease outbreaks.
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Affiliation(s)
- Nana Xie
- AnHui Medical University, Hefei, China
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Yanfeng Lin
- Huadong Research Institute for Medicine and Biotechniques, Nanjing, China
| | - Peihan Li
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Jiachen Zhao
- Beijing Center for Disease Prevention and Control, Beijing, China
| | - Jinhui Li
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Kaiying Wang
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Lang Yang
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Leili Jia
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Quanyi Wang
- Beijing Center for Disease Prevention and Control, Beijing, China
- Beijing Research Center for Respiratory Infectious Diseases, Beijing, China
| | - Peng Li
- AnHui Medical University, Hefei, China
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
| | - Hongbin Song
- AnHui Medical University, Hefei, China
- Chinese PLA Center for Disease Control and Prevention of PLA, Beijing, China
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Arumairaj AJ, Habtes I, Park H, Valencia-Manrique JC, Arzu J, Mattana J, Chaudhari S, Trenard N, Newman T. Determining the Association Between the Origin of Sepsis and the Severity of Sepsis in Intensive Care Unit (ICU) Patients Using Acute Physiology and Chronic Health Evaluation (APACHE) IV. Cureus 2024; 16:e54653. [PMID: 38523937 PMCID: PMC10959768 DOI: 10.7759/cureus.54653] [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] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
Objective The objective of this study is to compare the outcomes of hospital mortality, the requirement of invasive ventilation, vasopressor requirement, duration of vasopressor requirement, and duration of intensive care unit (ICU) stay among the different causes of sepsis and to determine which cause of sepsis had the most severe outcomes. Methods A retrospective chart review was done in critically ill adult patients who were admitted with sepsis to the ICU from July 2017 until July 2019. Acute Physiology and Chronic Health Evaluation (APACHE) IV scores were calculated on patients admitted to ICU on day one of ICU admission. Each patient was then evaluated for outcomes of hospital mortality, need for invasive ventilation, requirement of vasopressors, duration of vasopressors, and duration of ICU stay. The outcomes were then compared between the different sources of sepsis to determine which source of sepsis had the highest severity. Results In total, 176 patients were included in the study. Ninety-three patients were admitted with respiratory sepsis, 26 patients were admitted with gastrointestinal sepsis, 31 patients were admitted with urosepsis, and 26 patients were admitted with other miscellaneous causes of sepsis. The hospital mortality was highest in the respiratory sepsis group at 32%, with a trend towards statistical significance with a P value of 0.057. ICU stay duration was highest in patients with respiratory sepsis at six days, with a statistically significant P value of < 0.001. The need for invasive ventilation was highest in patients with respiratory sepsis at 64%, with a statistically significant P value of < 0.001. The requirement of vasopressor support was highest in patients with respiratory sepsis at 47% and the duration of vasopressors was highest in both respiratory and gastrointestinal sepsis at three days, however, there was no statistical significance. Conclusion Among the different origins of sepsis, the patients with respiratory sepsis had the most severe outcomes, with the highest need for invasive ventilation and the highest ICU stay duration.
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Affiliation(s)
- Antony J Arumairaj
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Imnett Habtes
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Hansang Park
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | | | - Jennifer Arzu
- Biostatistics, Physician Affiliate Group of New York (PAGNY), New York, USA
| | - Joseph Mattana
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Shobhana Chaudhari
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
| | - Natoushka Trenard
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New york, USA
| | - Thomas Newman
- Internal Medicine, New York Medical College, Metropolitan Hospital Center, New York, USA
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Ramasco F, Méndez R, Suarez de la Rica A, González de Castro R, Maseda E. Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making. J Pers Med 2024; 14:106. [PMID: 38248807 PMCID: PMC10820263 DOI: 10.3390/jpm14010106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain; (R.M.); (A.S.d.l.R.)
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain; (R.M.); (A.S.d.l.R.)
| | - Alejandro Suarez de la Rica
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain; (R.M.); (A.S.d.l.R.)
| | - Rafael González de Castro
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de León, 24071 León, Spain;
| | - Emilio Maseda
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario Quirón Sur Salud, 28922 Madrid, Spain;
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Pereira JG, Fernandes J, Duarte AR, Fernandes SM. β-Lactam Dosing in Critical Patients: A Narrative Review of Optimal Efficacy and the Prevention of Resistance and Toxicity. Antibiotics (Basel) 2022; 11:antibiotics11121839. [PMID: 36551496 PMCID: PMC9774837 DOI: 10.3390/antibiotics11121839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Antimicrobial prescription in critically ill patients represents a complex challenge due to the difficult balance between infection treatment and toxicity prevention. Underexposure to antibiotics and therapeutic failure or, conversely, drug overexposure and toxicity may both contribute to a worse prognosis. Moreover, changes in organ perfusion and dysfunction often lead to unpredictable pharmacokinetics. In critically ill patients, interindividual and intraindividual real-time β-lactam antibiotic dose adjustments according to the patient's condition are critical. The continuous infusion of β-lactams and the therapeutic monitoring of their concentration have both been proposed to improve their efficacy, but strong data to support their use are still lacking. The knowledge of the pharmacokinetic/pharmacodynamic targets is poor and is mostly based on observational data. In patients with renal or hepatic failure, selecting the right dose is even more tricky due to changes in drug clearance, distribution, and the use of extracorporeal circuits. Intermittent usage may further increase the dosing conundrum. Recent data have emerged linking overexposure to β-lactams to central nervous system toxicity, mitochondrial recovery delay, and microbiome changes. In addition, it is well recognized that β-lactam exposure facilitates resistance selection and that correct dosing can help to overcome it. In this review, we discuss recent data regarding real-time β-lactam antibiotic dose adjustment, options in special populations, and the impacts on mitochondria and the microbiome.
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Affiliation(s)
- João Gonçalves Pereira
- Hospital Vila Franca de Xira, 2600-009 Vila Franca de Xira, Portugal
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, 4450-681 Matosinhos, Portugal
- Correspondence: ; Tel.: +351-96-244-1546
| | - Joana Fernandes
- Centro Hospitalar de Trás-os-Montes e Alto Douro, 5000-508 Vila Real, Portugal
| | - Ana Rita Duarte
- Nova Medical School, Universidade NOVA de Lisboa, 1099-085 Lisbon, Portugal
| | - Susana Mendes Fernandes
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, 4450-681 Matosinhos, Portugal
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina, Universidade de Lisboa, 1649-004 Lisboa, Portugal
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Pharmacodynamics of Piperacillin-Tazobactam/Amikacin Combination versus Meropenem against Extended-Spectrum β-Lactamase-Producing Escherichia coli in a Hollow Fiber Infection Model. Antimicrob Agents Chemother 2022; 66:e0016222. [PMID: 35924928 PMCID: PMC9487465 DOI: 10.1128/aac.00162-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Carbapenems are recommended for the treatment of urosepsis caused by extended-spectrum β-lactamase (ESBL)-producing, multidrug-resistant Escherichia coli; however, due to selection of carbapenem resistance, there is an increasing interest in alternative treatment regimens including the use of β-lactam-aminoglycoside combinations. We compared the pharmacodynamic activity of piperacillin-tazobactam and amikacin as mono and combination therapy versus meropenem monotherapy against extended-spectrum β-lactamase (ESBL)-producing, piperacillin-tazobactam resistant E. coli using a dynamic hollow fiber infection model (HFIM) over 7 days. Broth-microdilution was performed to determine the MIC of E. coli isolates. Whole genome sequencing was conducted. Four E. coli isolates were tested in HFIM with an initial inoculum of ~107 CFU/mL. Dosing regimens tested were piperacillin-tazobactam 4.5 g, 6-hourly, plus amikacin 30 mg/kg, 24-hourly, as combination therapy, and piperacillin-tazobactam 4.5 g, 6-hourly, amikacin 30 mg/kg, 24-hourly, and meropenem 1 g, 8-hourly, each as monotherapy. We observed that piperacillin-tazobactam and amikacin monotherapy demonstrated initial rapid bacterial killing but then led to amplification of resistant subpopulations. The piperacillin-tazobactam/amikacin combination and meropenem experiments both attained a rapid bacterial killing (~4-5 log10) within 24 h and did not result in any emergence of resistant subpopulations. Genome sequencing demonstrated that all ESBL-producing E. coli clinical isolates carried multiple antibiotic resistance genes including blaCTX-M-15, blaOXA-1, blaEC, blaTEM-1, and aac(6')-Ib-cr. These results suggest that the combination of piperacillin-tazobactam/amikacin may have a potential role as a carbapenem-sparing regimen, which should be tested in future urosepsis clinical trials.
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Lu J, Liu J, Li A. Roles of neutrophil reactive oxygen species (ROS) generation in organ function impairment in sepsis. J Zhejiang Univ Sci B 2022; 23:437-450. [PMID: 35686524 DOI: 10.1631/jzus.b2101075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sepsis is a condition of severe organ failure caused by the maladaptive response of the host to an infection. It is a severe complication affecting critically ill patients, which can progress to severe sepsis, septic shock, and ultimately death. As a vital part of the human innate immune system, neutrophils are essential in resisting pathogen invasion, infection, and immune surveillance. Neutrophil-produced reactive oxygen species (ROS) play a pivotal role in organ dysfunction related to sepsis. In recent years, ROS have received a lot of attention as a major cause of sepsis, which can progress to severe sepsis and septic shock. This paper reviews the existing knowledge on the production mechanism of neutrophil ROS in human organ function impairment because of sepsis.
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Affiliation(s)
- Jiaqi Lu
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Jingyuan Liu
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Ang Li
- Intensive Care Unit, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China.
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Bedside determination of microcirculatory oxygen delivery and uptake: a prospective observational clinical study for proof of principle. Sci Rep 2021; 11:24516. [PMID: 34972827 PMCID: PMC8720096 DOI: 10.1038/s41598-021-03922-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/06/2021] [Indexed: 11/09/2022] Open
Abstract
Assessment of microcirculatory functional capacity is considered to be of prime importance for therapy guidance and outcome prediction in critically ill intensive care patients. Here, we show determination of skin microcirculatory oxygen delivery and consumption rates to be a feasible approach at the patient’s bedside. Real time laser-doppler flowmetry (LDF) and white light spectrophotometry (WLS) were used for assessment of thenar skin microperfusion, regional Hb and postcapillary venous oxygen saturation before and after forearm ischemia. Adapted Fick’s principle equations allowed for calculation of microcirculatory oxygen delivery and uptake. Patient groups with expected different microcirculatory status were compared [control (n = 20), sepsis-1/2 definition criteria identified SIRS (n = 10) and septic shock patients (n = 20), and the latter group further classified according to sepsis-3 definition criteria in sepsis (n = 10) and septic shock (n = 10)], respectively. In otherwise healthy controls, microcirculatory oxygen delivery and uptake approximately doubled after ischemia with maximum values (mDO2max and mVO2max) significantly lower in SIRS or septic patient groups, respectively. Scatter plots of mVO2max and mDO2max values defined a region of unphysiological low values not observed in control but in critically ill patients with the percentage of dots within this region being highest in septic shock patients. LDF and WLS combined with vasoocclusive testing reveals significant differences in microcirculatory oxygen delivery and uptake capacity between control and critically ill patients. As a clinically feasible technique for bedside determination of microcirculatory oxygen delivery and uptake, LDF and WLS combined with vasoocclusive testing holds promise for monitoring of disease progression and/or guidance of therapy at the microcirculatory level to be tested in further clinical trials. ClinicalTrials.gov: NCT01530932.
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Vallés J, Diaz E, Carles Oliva J, Martínez M, Navas A, Mesquida J, Gruartmoner G, de Haro C, Mestre J, Guía C, Rodriguez A, Ochagavía A. Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control. Med Intensiva 2021; 45:541-551. [PMID: 34839885 DOI: 10.1016/j.medine.2020.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING ICU at a University Hospital in Spain. PATIENTS All consecutive patients admitted to the ICU with CASS. INTERVENTIONS None. MAIN VARIABLES OF INTEREST CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.
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Affiliation(s)
- J Vallés
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain.
| | - E Diaz
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Carles Oliva
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - M Martínez
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Navas
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Mesquida
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - G Gruartmoner
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - C de Haro
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Mestre
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - C Guía
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Rodriguez
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Ochagavía
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
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Analysis of Prognostic Risk Factors of Bloodstream Infections in Beijing Communities: A Retrospective Study from 2015 to 2019. Mediterr J Hematol Infect Dis 2021; 13:e2021060. [PMID: 34804434 PMCID: PMC8577556 DOI: 10.4084/mjhid.2021.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/10/2021] [Indexed: 12/29/2022] Open
Abstract
Objective This study intends to investigate the prognostic risk factors of bloodstream infection in Beijing. Methods This study is a clinical retrospective study. Four hundred forty-six patients with community-onset bloodstream infections (COBSI), admitted to the emergency department and inpatient department of Beijing Jishuitan Hospital from January 1, 2015, to December 31, 2019, were selected as the main research objects. According to whether the patient survives for 100 days or not, 363 cases were in the survival group, and 83 cases were in the death group. By analyzing the clinical data of the two groups of patients, the epidemiology, clinical characteristics, bacterial resistance, and risk factors affecting the prognosis of the patients were analyzed. Results A total of 446 pathogenic bacteria were isolated in this study, including 324 Gram-negative (G-) bacteria (72.6%), 121 Gram-positive (G+) bacteria (27.1%). The results of the study showed that there were significant differences in MDR, initial antibiotic use, solid tumor, CKD, septic shock, acute liver injury, AKI, central venous catheter, urinary catheter, blood replacement therapy, invasive operation, and use of three or more antibiotics between the two groups (p<0.05). The multiple logistic regression analysis showed that solid tumors (OR=3.339, 95% CI: (1.441, 7.734), p=0.005), combined septic shock (OR=20.729, 95% CI: (10.235, 41.982), p<0.001), indwelling catheters (OR=3.556, 95% CI: (1.538, 8.222), p=0.003) and continuous venovenous hemofiltration (CVVH, OR=19.548, 95% CI: (8.724, 35.641), p=0.003) are independent risk factors affecting the prognosis of COBSI patients. Appropriate initial antibiotic therapy is a protective factor affecting the prognosis of COBSI patients. Conclusion Solid tumors, combined septic shock, indwelling catheters, CVVH are independent risk factors affecting the prognosis of COBSI patients.
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Niu J, Qin B, Wang C, Chen C, Yang J, Shao H. Identification of Key Immune-Related Genes in the Progression of Septic Shock. Front Genet 2021; 12:668527. [PMID: 34804111 PMCID: PMC8595268 DOI: 10.3389/fgene.2021.668527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/25/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Septic shock is the severe complication of sepsis, with a high mortality. The inflammatory response regulates the immune status and mediates the progression of septic shock. In this study, we aim to identify the key immune-related genes (IRGs) of septic shock and explore their potential mechanism. Methods: Gene expression profiles of septic shock blood samples and normal whole blood samples were retrieved from the Gene Expression Omnibus (GEO) and Genotype-Tissue Expression Portal (GTEx). The differential expression genes (DEGs) and septic shock-specific immune-related genes (SSSIRGs) were evaluated and identified, along with the immune components by "cell type identification by estimating relative subsets of RNA transcripts (CIBERSORT, version x)" algorithm. Additionally, in order to explore the key regulatory network, the relationship among SSSIRGs, upstream transcription factors (TFs), and downstream signaling pathways were also identified by Gene Set Variation Analysis (GSVA) and co-expression analysis. Moreover, the Connectivity Map (CMap) analysis was applied to find bioactive small molecules against the members of regulation network while Chromatin Immunoprecipitation sequencing (ChIP-seq) and Assay for Targeting Accessible-Chromatin with high-throughput sequencing (ATAC-seq) data were used to validate the regulation mechanism of the network. Results: A total of 14,843 DEGs were found between 63 septic shock blood samples and 337 normal whole blood samples. Then, we identified septic shock-specific 839 IRGs as the intersection of DEGs and IRGs. Moreover, we uncovered the regulatory networks based on co-expression analysis and found 28 co-expression interaction pairs. In the regulation network, protein phosphatase 3, catalytic subunit, alpha isozyme (PPP3CA) may regulate late estrogen response, glycolysis and TNFα signaling via NFκB and HLA; Kirsten rat sarcoma viral oncogene homolog (KRAS) may be related to late estrogen response and HLA; and Toll-like receptor 8 (TLR8) may be associated with TNFα signaling via NFκB. And the regulation mechanisms between TFs and IRGs (TLR8, PPP3CA, and KRAS) were validated by ChIP-seq and ATAC-seq. Conclusion: Our data identify three SSSIRGs (TLR8, PPP3CA, and KRAS) as candidate therapeutic targets for septic shock and provide constructed regulatory networks in septic shock to explore its potential mechanism.
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Affiliation(s)
- Jingjing Niu
- Department of Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Bingyu Qin
- Department of Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Cunzhen Wang
- Department of Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Chao Chen
- Department of Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Jianxu Yang
- Department of Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Huanzhang Shao
- Department of Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, China
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14
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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Duan LW, Qu JL, Wan J, Xu YH, Shan Y, Wu LX, Zheng JH, Jiang WW, Chen QT, Zhu Y, Zhou J, Yu WB, Pei L, Song X, Li WF, Lin ZF. Effects of viral infection and microbial diversity on patients with sepsis: A retrospective study based on metagenomic next-generation sequencing. World J Emerg Med 2021; 12:29-35. [PMID: 33505547 DOI: 10.5847/wjem.j.1920-8642.2021.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The study aims to investigate the performance of a metagenomic next-generation sequencing (NGS)-based diagnostic technique for the identification of potential bacterial and viral infections and effects of concomitant viral infection on the survival rate of intensive care unit (ICU) sepsis patients. METHODS A total of 74 ICU patients with sepsis who were admitted to our institution from February 1, 2018 to June 30, 2019 were enrolled. Separate blood samples were collected from patients for blood cultures and metagenomic NGS when the patients' body temperature was higher than 38 °C. Patients' demographic data, including gender, age, ICU duration, ICU scores, and laboratory results, were recorded. The correlations between pathogen types and sepsis severity and survival rate were evaluated. RESULTS NGS produced higher positive results (105 of 118; 88.98%) than blood cultures (18 of 118; 15.25%) over the whole study period. Concomitant viral infection correlated closely with sepsis severity and had the negative effect on the survival of patients with sepsis. However, correlation analysis indicated that the bacterial variety did not correlate with the severity of sepsis. CONCLUSIONS Concurrent viral load correlates closely with the severity of sepsis and the survival rate of the ICU sepsis patients. This suggests that prophylactic administration of antiviral drugs combined with antibiotics may be beneficial to ICU sepsis patients.
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Affiliation(s)
- Li-Wei Duan
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Jin-Long Qu
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Jian Wan
- Department of Emergency and Critical Care Medicine, Pudong New Area People's Hospital, Shanghai 201299, China
| | - Yong-Hua Xu
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Yi Shan
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Li-Xue Wu
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Jin-Hao Zheng
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Wei-Wei Jiang
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Qi-Tong Chen
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Yan Zhu
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Jian Zhou
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Wen-Bo Yu
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Lei Pei
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Xi Song
- Department of Emergency and Critical Care Medicine, Pudong New Area People's Hospital, Shanghai 201299, China
| | - Wen-Fang Li
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Zhao-Fen Lin
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, the Second Military Medical University, Shanghai 200003, China
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Lupu F, Kinasewitz G, Dormer K. The role of endothelial shear stress on haemodynamics, inflammation, coagulation and glycocalyx during sepsis. J Cell Mol Med 2020; 24:12258-12271. [PMID: 32951280 PMCID: PMC7687012 DOI: 10.1111/jcmm.15895] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/11/2022] Open
Abstract
Sepsis is a multifactorial syndrome primarily determined by the host response to an invading pathogen. It is common, with over 48 million cases worldwide in 2017, and often lethal. The sequence of events in sepsis begins with the damage of endothelium within the microvasculature, as a consequence of the inflammatory and coagulopathic responses to the pathogen that can progress to multiple organ failure and death. Most therapeutic interventions target the inflammation and coagulation pathways that act as an auto-amplified vicious cycle, which, if unchecked can be fatal. Normal blood flow and shear stress acting on a healthy endothelium and intact glycocalyx have anti-inflammatory, anticoagulant and self-repairing effects. During early stages of sepsis, the vascular endothelium and its glycocalyx become dysfunctional, yet they are essential components of resuscitation and recovery from sepsis. The effects of shear forces on sepsis-induced endothelial dysfunction, including inflammation, coagulation, complement activation and microcirculatory breakdown are reviewed. It is suggested that early therapeutic strategies should prioritize on the restoration of shear forces and endothelial function and on the preservation of the endothelial-glycocalyx barrier.
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Affiliation(s)
- Florea Lupu
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOKUSA
| | - Gary Kinasewitz
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOKUSA
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Vallés J, Diaz E, Carles Oliva J, Martínez M, Navas A, Mesquida J, Gruartmoner G, de Haro C, Mestre J, Guía C, Rodriguez A, Ochagavía A. Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control. Med Intensiva 2020; 45:S0210-5691(20)30175-3. [PMID: 32654923 DOI: 10.1016/j.medin.2020.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/07/2020] [Accepted: 05/16/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING ICU at a University Hospital in Spain. PATIENTS All consecutive patients admitted to the ICU with CASS. INTERVENTIONS None. MAIN VARIABLES OF INTEREST CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.
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Affiliation(s)
- J Vallés
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain.
| | - E Diaz
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Carles Oliva
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - M Martínez
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Navas
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Mesquida
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - G Gruartmoner
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - C de Haro
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Mestre
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - C Guía
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Rodriguez
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Ochagavía
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
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Lertwattanachai T, Montakantikul P, Tangsujaritvijit V, Sanguanwit P, Sueajai J, Auparakkitanon S, Dilokpattanamongkol P. Clinical outcomes of empirical high-dose meropenem in critically ill patients with sepsis and septic shock: a randomized controlled trial. J Intensive Care 2020; 8:26. [PMID: 32318268 PMCID: PMC7158081 DOI: 10.1186/s40560-020-00442-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background Appropriate antimicrobial dosing is challenging because of changes in pharmacokinetics (PK) parameters and an increase in multidrug-resistant (MDR) organisms in critically ill patients. This study aimed to evaluate the effects of an empirical therapy of high-dose versus standard-dose meropenem in sepsis and septic shock patients. Methods We performed a prospective randomized open-label study to compare the changes of modified sequential organ failure assessment (mSOFA) score and other clinical outcomes of the high-dose meropenem (2-g infusion over 3 h every 8 h) versus the standard-dose meropenem (1-g infusion over 3 h every 8 h) in sepsis and septic shock patients. Patients' characteristics, clinical and microbiological outcomes, 14 and 28-day mortality, vasopressor- and ventilator-free days, intensive care unit (ICU) and hospital-free days, percent of the time of antibiotic concentrations above the minimum inhibitory concentration (%T>MIC), and safety were assessed. Results Seventy-eight patients were enrolled. Median delta mSOFA was comparable between two groups (- 1 in the high-dose group vs. - 1 in the standard-dose group; P value = 0.75). There was no difference between the two groups regarding clinical and microbiological cure, 14- and 28-day mortality, vasopressor- and ventilator-free days, and ICU- and hospital-free days. In patients admitted from the emergency department (ED) with a mSOFA score ≥ 7, the high-dose group demonstrated significantly better microbiological cure compared with the standard-dose group (75% (9/12 patients) vs. 20% (2/10 patients); P value = 0.03). Likewise, the high-dose group presented higher microbiological cure rate in patients admitted from ED who had either APACHE II score > 20 (83.3% (10/12) vs. 28.6% (2/7); P value = 0.045) or on mechanical ventilator (87.5% (7/8) vs. 23.1% (3/13); P value = 0.008) than the standard-dose group. Adverse events were comparable between the two groups. Conclusions Empirical therapy with the high-dose meropenem presented comparable clinical outcomes to the standard-dose meropenem in sepsis and septic shock patients. Besides, subgroup analysis manifested superior microbiological cure rate in sepsis or septic shock patients admitted from ED. Trial registration ClinicalTrials.gov, NCT03344627, registered on November 17, 2017.
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Affiliation(s)
- Tospon Lertwattanachai
- 1Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, 10400 Thailand
| | - Preecha Montakantikul
- 1Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, 10400 Thailand
| | - Viratch Tangsujaritvijit
- 2Department of Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Piyavate Hospital, Bangkok, Thailand
| | - Pitsucha Sanguanwit
- 4Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jetjamnong Sueajai
- 5Toxicology Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Saranya Auparakkitanon
- 5Toxicology Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Holmbom M, Möller V, Nilsson LE, Giske CG, Rashid MU, Fredrikson M, Hällgren A, Hanberger H, Balkhed ÅÖ. Low incidence of antibiotic-resistant bacteria in south-east Sweden: An epidemiologic study on 9268 cases of bloodstream infection. PLoS One 2020; 15:e0230501. [PMID: 32218575 PMCID: PMC7100936 DOI: 10.1371/journal.pone.0230501] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 03/03/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives The aim of this study was to investigate the epidemiology of bloodstream infections (BSI) in a Swedish setting, with focus on risk factors for BSI-associated mortality. Methods A 9-year (2008–2016) retrospective cohort study from electronic records of episodes of bacteremia amongst hospitalized patients in the county of Östergötland, Sweden was conducted. Data on episodes of BSI including microorganisms, antibiotic susceptibility, gender, age, hospital admissions, comorbidity, mortality and aggregated antimicrobial consumption (DDD /1,000 inhabitants/day) were collected and analyzed. Multidrug resistance (MDR) was defined as resistance to at least three groups of antibiotics. MDR bacteria and MRSA, ESBL-producing Enterobacteriaceae, vancomycin-resistant enterococci not fulfilling the MDR criteria were all defined as antimicrobial-resistant (AMR) bacteria and included in the statistical analysis of risk factors for mortality Results In all, 9,268 cases of BSI were found. The overall 30-day all-cause mortality in the group of patients with BSI was 13%. The incidence of BSI and associated 30-day all-cause mortality per 100,000 hospital admissions increased by 66% and 17% respectively during the nine-year study period. The most common species were Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae and Enterococcus faecalis. Independent risk factors for 30-day mortality were age (RR: 1.02 (CI: 1.02–1.03)) and 1, 2 or ≥3 comorbidities RR: 2.06 (CI: 1.68–2.52), 2.79 (CI: 2.27–3.42) and 2.82 (CI: 2.31–3.45) respectively. Almost 3% (n = 245) of all BSIs were caused by AMR bacteria increasing from 12 to 47 per 100,000 hospital admissions 2008–2016 (p = 0.01), but this was not associated with a corresponding increase in mortality risk (RR: 0.89 (CI: 0.81–0.97)). Conclusion Comorbidity was the predominant risk factor for 30-day all-cause mortality associated with BSI in this study. The burden of AMR was low and not associated with increased mortality. Patients with BSIs caused by AMR bacteria (MDR, MRSA, ESBL and VRE) were younger, had fewer comorbidities, and the 30-day all-cause mortality was lower in this group.
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Affiliation(s)
- Martin Holmbom
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Urology in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Vidar Möller
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lennart E. Nilsson
- Department of Clinical Microbiology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christian G. Giske
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
- Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mamun-Ur Rashid
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Occupational and Environmental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Forum Östergötland, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Anita Hällgren
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Håkan Hanberger
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- * E-mail:
| | - Åse Östholm Balkhed
- Department of Infectious Diseases in Östergötland and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Ewald J, Sieber P, Garde R, Lang SN, Schuster S, Ibrahim B. Trends in mathematical modeling of host-pathogen interactions. Cell Mol Life Sci 2020; 77:467-480. [PMID: 31776589 PMCID: PMC7010650 DOI: 10.1007/s00018-019-03382-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 11/05/2019] [Accepted: 11/12/2019] [Indexed: 12/18/2022]
Abstract
Pathogenic microorganisms entail enormous problems for humans, livestock, and crop plants. A better understanding of the different infection strategies of the pathogens enables us to derive optimal treatments to mitigate infectious diseases or develop vaccinations preventing the occurrence of infections altogether. In this review, we highlight the current trends in mathematical modeling approaches and related methods used for understanding host-pathogen interactions. Since these interactions can be described on vastly different temporal and spatial scales as well as abstraction levels, a variety of computational and mathematical approaches are presented. Particular emphasis is placed on dynamic optimization, game theory, and spatial modeling, as they are attracting more and more interest in systems biology. Furthermore, these approaches are often combined to illuminate the complexities of the interactions between pathogens and their host. We also discuss the phenomena of molecular mimicry and crypsis as well as the interplay between defense and counter defense. As a conclusion, we provide an overview of method characteristics to assist non-experts in their decision for modeling approaches and interdisciplinary understanding.
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Affiliation(s)
- Jan Ewald
- Matthias Schleiden Institute, Bioinformatics, Friedrich Schiller University Jena, Ernst-Abbe-Platz 2, 07743, Jena, Germany
| | - Patricia Sieber
- Matthias Schleiden Institute, Bioinformatics, Friedrich Schiller University Jena, Ernst-Abbe-Platz 2, 07743, Jena, Germany
| | - Ravindra Garde
- Matthias Schleiden Institute, Bioinformatics, Friedrich Schiller University Jena, Ernst-Abbe-Platz 2, 07743, Jena, Germany
- Max Planck Institute for Chemical Ecology, Hans-Knöll-Str. 8, 07745, Jena, Germany
| | - Stefan N Lang
- Matthias Schleiden Institute, Bioinformatics, Friedrich Schiller University Jena, Ernst-Abbe-Platz 2, 07743, Jena, Germany
| | - Stefan Schuster
- Matthias Schleiden Institute, Bioinformatics, Friedrich Schiller University Jena, Ernst-Abbe-Platz 2, 07743, Jena, Germany.
| | - Bashar Ibrahim
- Matthias Schleiden Institute, Bioinformatics, Friedrich Schiller University Jena, Ernst-Abbe-Platz 2, 07743, Jena, Germany.
- Centre for Applied Mathematics and Bioinformatics, Gulf University for Science and Technology, 32093, Hawally, Kuwait.
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21
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Bughrara N, Cha S, Safa R, Pustavoitau A. Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach. Anesthesiol Clin 2020; 38:107-122. [PMID: 32008646 DOI: 10.1016/j.anclin.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Sepsis and septic shock are medical emergencies, with high associated mortality. The Surviving Sepsis Campaign has developed definitions and management guidelines, emphasizing the use of hour-1 care bundle. Anesthesiologists frequently encounter sepsis when source control is required. The authors summarize expected manifestations of organ dysfunction and state-of-the-art management of patients with sepsis and septic shock. They highlight an increasingly vital role point-of-care ultrasound examination in the recognition and management of hemodynamic derangements in this patient population. Supporting the role of anesthesiologists as perioperative physicians, the authors provide a framework for transitions of care between operating room and intensive care units.
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Affiliation(s)
- Nibras Bughrara
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA.
| | - Stephanie Cha
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6216, Baltimore, MD 21287, USA; Division of Critical Care, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 6216, Baltimore, MD 21287, USA
| | - Radwan Safa
- Department of Anesthesiology, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA; Department of Surgery, Albany Medical College, 47 New Scotland Avenue, MC 131, Albany, NY 12208, USA
| | - Aliaksei Pustavoitau
- Division of Adult Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 297, Baltimore, MD 21287, USA
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22
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Augustin P, Tanaka S, Tran-Dinh A, Parenti Ribeiro L, Arapis K, Grall N, Al Qarni A, Montravers P. Outcome and Adequacy of Empirical Antibiotherapy in Post-Operative Peritonitis: A Retrospective Study. Surg Infect (Larchmt) 2019; 21:284-292. [PMID: 31770083 DOI: 10.1089/sur.2019.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Empirical antibiotherapy (EA) should target all bacteria in post-operative peritonitis (PP). Nevertheless, recent studies failed to prove a link between adequacy of EA and prognosis of PP. We sought to confirm this loss of association between adequate EA and prognosis and to analyze the evolution of patients' characteristics and antimicrobial strategies. Methods: This is was retrospective study. Patients with a positive fungal culture were excluded. The cohort was divided into two time periods. Data of survivors and non-survivors were compared within each time period. Differences between the two periods were assessed. A multivariable analysis searched for parameters associated with a higher hospital mortality rate. Results: Two hundred fifty-one patients were included, with 92 patients in the first period (P1) and 152 patients in the second period (P2). Inadequate EA was associated with a worse outcome only in P1. The multivariable analysis in the whole cohort showed that inadequate EA was associated with a higher mortality rate. When the differences noticed between the two periods were entered in the model (presence of resistant gram-positive cocci and EA comprising glycopeptides), inadequate EA was no longer associated with worse outcome. In P1, the most severe patients had more resistant bacteria, hence, had a higher rate of inadequate EA. This artifact disappeared in P2, during which broader antibiotherapies with triple EA were more often prescribed for the most severe patients. Conclusion: This study showed that the link between inadequate EA and outcome of patients with PP was at least partly artifactual in older studies.
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Affiliation(s)
- Pascal Augustin
- Département d'Anesthésie et Réanimation, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Sebastien Tanaka
- Département d'Anesthésie et Réanimation, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexy Tran-Dinh
- Département d'Anesthésie et Réanimation, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Lara Parenti Ribeiro
- Service de Chirurgie digestive, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Kostantinos Arapis
- Service de Chirurgie digestive, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Nathalie Grall
- Laboratoire de Microbiologie, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Adel Al Qarni
- Département d'Anesthésie et Réanimation, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Philippe Montravers
- Département d'Anesthésie et Réanimation, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France.,Université Paris Diderot, Press Sorbonne Cité, Paris, France.,INSERM UMR 1152, Paris, France
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23
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Lee CC, Lee CH, Yang CY, Hsieh CC, Tang HJ, Ko WC. Beneficial effects of early empirical administration of appropriate antimicrobials on survival and defervescence in adults with community-onset bacteremia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:363. [PMID: 31747950 PMCID: PMC6864953 DOI: 10.1186/s13054-019-2632-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/01/2019] [Indexed: 11/20/2022]
Abstract
Background Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. The effects of early administration of appropriate antimicrobials on the prognosis and timing of defervescence of bacteremic patients remain under debate. Methods In a 6-year retrospective, multicenter cohort, adults with community-onset bacteremia at the emergency departments (EDs) were analyzed. The period from ED arrival to appropriate antimicrobial administration and that from appropriate antimicrobial administration to defervescence was regarded as the time-to-appropriate antibiotic (TtAa) and time-to-defervescence (TtD), respectively. The primary study outcome was 30-day mortality after ED arrival. The effects of TtAa on 30-day mortality and delayed defervescence were examined after adjustment for independent predictors of mortality, which were recognized by a multivariate regression analysis. Results Of the total 3194 patients, a TtAa-related trend in the 30-day crude (γ = 0.919, P = 0.01) and sepsis-related (γ = 0.909, P = 0.01) mortality rate was evidenced. Each hour of TtAa delay was associated with an average increase in the 30-day crude mortality rate of 0.3% (adjusted odds ratio [AOR], 1.003; P < 0.001) in the entire cohort and 0.4% (AOR, 1.004; P < 0.001) in critically ill patients, respectively, after adjustment of independent predictors of 30-day crude mortality. Of 2469 febrile patients, a TtAa-related trend in the TtD (γ = 0.965, P = 0.002) was exhibited. Each hour of TtAa delay was associated with an average 0.7% increase (AOR, 1.007; P < 0.001) in delayed defervescence (TtD of ≥ 7 days) after adjustment of independent determinants of delayed defervescence. Notably, the adverse impact of the inappropriateness of empirical antimicrobial therapy (TtAa > 24 h) on the TtD was noted, regardless of bacteremia severity, bacteremia sources, or causative microorganisms. Conclusions The delay in the TtAa was associated with an increasing risk of delayed defervescence and 30-day mortality for adults with community-onset bacteremia, especially for critically ill patients. Thus, for severe bacteremia episodes, early administration of appropriate empirical antimicrobials should be recommended.
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Affiliation(s)
- Ching-Chi Lee
- Department of Internal Medicine, Madou Sin-Lau Hospital, No. 20, Lingzilin, 72152, Madou Dist., Tainan City, Taiwan.,Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Chao-Yung Yang
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Hung-Jen Tang
- Division of Infectious Disease, Department of Medicine, Chi-Mei Medical Center, No. 901, Chung-Hwa Road, Yung-Kang City, 710, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan. .,Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
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24
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Heffernan AJ, Sime FB, Sun J, Lipman J, Kumar A, Andrews K, Ellwood D, Grimwood K, Roberts J. β-lactam antibiotic versus combined β-lactam antibiotics and single daily dosing regimens of aminoglycosides for treating serious infections: A meta-analysis. Int J Antimicrob Agents 2019; 55:105839. [PMID: 31704215 DOI: 10.1016/j.ijantimicag.2019.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/21/2019] [Accepted: 10/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Combining aminoglycosides with β-lactam antibiotics for treating serious infections has not been associated with reduced mortality in previous meta-analyses. However, the multiple daily aminoglycoside dosing regimen principally used in most of the included studies is inconsistent with current practice. OBJECTIVE To determine if a combination of an aminoglycoside administered as a single daily dose and a β-lactam antibiotic reduces all-cause mortality in patients compared with β-lactam antibiotic monotherapy. METHODS A systematic review and meta-analysis of clinical studies was performed (Prospero registration number #68506). Studies were included if they compared β-lactam antibiotic monotherapy with combined β-lactam and single daily dose aminoglycoside therapy for treating serious infections. Studies investigating multiple daily dosing aminoglycoside regimens, infective endocarditis and febrile neutropaenia were excluded. Study quality was assessed using the PEDro and Newcastle-Ottawa scoring systems. The end points for outcome analyses were 30-day all-cause mortality, clinical cure and nephrotoxicity. RESULTS Four randomised controlled trials and five retrospective cohort studies were analysed. Compared with β-lactam antibiotic monotherapy, single daily aminoglycoside dosing in combination with β-lactam antibiotics was not associated with reduced mortality compared with β-lactam antibiotic monotherapy (n = 3686, OR 0.82, 95% CI 0.63-1.08, P = 0.10, I2 42%). A subgroup analysis of cohort studies suggested reduced mortality with combination therapy (n = 3563, OR 0.79, 95% CI 0.64-0.99, P = 0.04, I2 32%). No increased risk of nephrotoxicity was identified (n = 1110, OR 1.31, 95% CI 0.83-2.09, P = 0.40, I2 0%). CONCLUSIONS The existing evidence suggests no added survival benefit from a single daily dosing regimen of an aminoglycoside when combined with β-lactam antibiotics.
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Affiliation(s)
| | - Fekade Bruck Sime
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jing Sun
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Jeffrey Lipman
- Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anand Kumar
- Sections of Critical Care Medicine and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Katherine Andrews
- Griffith Institute for Drug Discovery, Griffith University, Nathan, Queensland, Australia
| | - David Ellwood
- School of Medicine and Menzies Health Institute Queensland, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia; Department of Maternal-Foetal Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Keith Grimwood
- School of Medicine and Menzies Health Institute Queensland, Gold Coast campus, Griffith University, Gold Coast, Queensland, Australia; Departments of Paediatrics and Infectious Diseases, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Jason Roberts
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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25
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Kim H, Chung SP, Choi SH, Kang GH, Shin TG, Kim K, Park YS, Han KS, Choi HS, Suh GJ, Kim WY, Lim TH, Ko BS. Impact of timing to source control in patients with septic shock: A prospective multi-center observational study. J Crit Care 2019; 53:176-182. [DOI: 10.1016/j.jcrc.2019.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/26/2019] [Accepted: 06/14/2019] [Indexed: 12/17/2022]
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26
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Kethireddy S, Bilgili B, Sees A, Kirchner HL, Ofoma UR, Light RB, Mirzanejad Y, Maki D, Kumar A, Layon AJ, Parrillo JE, Kumar A. Culture-Negative Septic Shock Compared With Culture-Positive Septic Shock: A Retrospective Cohort Study. Crit Care Med 2019; 46:506-512. [PMID: 29293143 DOI: 10.1097/ccm.0000000000002924] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the clinical characteristics and outcomes of culture-negative septic shock in comparison with culture-positive septic shock. DESIGN Retrospective nested cohort study. SETTING ICUs of 28 academic and community hospitals in three countries between 1997 and 2010. SUBJECTS Patients with culture-negative septic shock and culture-positive septic shock derived from a trinational (n = 8,670) database of patients with septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients with culture-negative septic shock (n = 2,651; 30.6%) and culture-positive septic shock (n = 6,019; 69.4%) were identified. Culture-negative septic shock compared with culture-positive septic shock patients experienced similar ICU survival (58.3% vs 59.5%; p = 0.276) and overall hospital survival (47.3% vs 47.1%; p = 0.976). Severity of illness was similar between culture-negative septic shock and culture-positive septic shock groups ([mean and SD Acute Physiology and Chronic Health Evaluation II, 25.7 ± 8.3 vs 25.7 ± 8.1]; p = 0.723) as were serum lactate levels (3.0 [interquartile range, 1.7-6.1] vs 3.2 mmol/L [interquartile range, 1.8-5.9 mmol/L]; p = 0.366). As delays in the administration of appropriate antimicrobial therapy after the onset of hypotension increased, patients in both groups experienced congruent increases in overall hospital mortality: culture-negative septic shock (odds ratio, 1.56; 95% CI [1.47-1.66]; p < 0.0001) and culture-positive septic shock (odds ratio, 1.65; 95% CI [1.59-1.71]; p < 0.0001). CONCLUSIONS Patients with culture-negative septic shock behave similarly to those with culture-positive septic shock in nearly all respects; early appropriate antimicrobial therapy appears to improve mortality. Early recognition and eradication of infection is the most obvious effective strategy to improve hospital survival.
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Affiliation(s)
- Shravan Kethireddy
- The Departments of Critical Care Medicine, Geisinger Medical Center, Danville, PA.,Section of Infectious Diseases, Geisinger Medical Center, Danville, PA
| | - Beliz Bilgili
- Division of Critical Care Medicine, Department of Anesthesiology, Marmara University, Istanbul, Turkey
| | - Amanda Sees
- Department of Biostatistics, Geisinger Medical Center, Danville, PA
| | | | - Uchenna R Ofoma
- The Departments of Critical Care Medicine, Geisinger Medical Center, Danville, PA
| | - R Bruce Light
- Sections of Critical Care and Infectious Diseases, Departments of Medicine and Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - Yazdan Mirzanejad
- Section of Infectious Diseases, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Dennis Maki
- Sections of Infectious Diseases and Critical Care Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Aseem Kumar
- Biomolecular Sciences Program, Department of Chemistry and Biochemistry, Laurentian University, Sudbury, ON, Canada
| | - A Joseph Layon
- The Departments of Critical Care Medicine, Geisinger Medical Center, Danville, PA
| | - Joseph E Parrillo
- Sections of Cardiology and Critical Care Medicine, Hackensack University Medical Center, Hackensack, NJ
| | - Anand Kumar
- Sections of Critical Care and Infectious Diseases, Departments of Medicine and Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
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27
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Patel JJ, Venegas-Borsellino C, Willoughby R, Freed JK. High-Dose Vitamin B12 in Vasodilatory Shock: A Narrative Review. Nutr Clin Pract 2019; 34:514-520. [PMID: 31187494 DOI: 10.1002/ncp.10327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Vasodilatory shock, as observed in postoperative states and sepsis, is hallmarked by low systemic vascular resistance and low blood pressure compensated by increased cardiac output. Gasotransmitters, such as nitric oxide and hydrogen sulfide, are implicated in the development and perpetuation of vasodilatory shock. Established therapies do not target these physiologic drivers of vasodilation. Due to their nontoxic and pleotropic effects, micronutrients are being used as rescue therapy in postoperative vasoplegia and septic shock. Here, we outline the pathophysiology of vasodilatory shock, describe the rationale for vitamin B12 (hydroxocobalamin) in vasodilatory shock, and identify literature evaluating its use in vasoplegic states.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rodney Willoughby
- Division of Pediatric Infectious Disease, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julie K Freed
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Cardiac Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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28
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Shahin NP, Majid E, Amin TBA, Bita B. Host characteristics and virulence typing of Escherichia coli isolated from diabetic patients. GENE REPORTS 2019. [DOI: 10.1016/j.genrep.2019.100371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Li Y, Li Q, Zhang G, Ma H, Wu Y, Yi Q, Jiang L, Wan J, Suo F, Luo Z. Time to positivity of blood culture is a risk factor for clinical outcomes in Staphylococcus aureus bacteremia children: a retrospective study. BMC Infect Dis 2019; 19:437. [PMID: 31101087 PMCID: PMC6525363 DOI: 10.1186/s12879-019-3993-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Staphylococcus aureus (S. aureus) is a common cause of bacteremia, which leads to significant morbidity and mortality. We investigated the relationship between time to positivity (TTP) and clinical outcomes in children with S.aureus bacteremia in the China. METHODS A retrospective study of Staphylococcus aureus bacteremia inpatient was performed in Children's Hospital of Chongqing Medical University in China between 29 January 2014 and 29 August 2017. TTP and clinical parameters were determined and analyzed. The receiver operating characteristic (ROC) curves were plotted for optimal cut-off selection, multivariate logistic regression tests were performed to evaluate the association between TTP and clinical outcomes. RESULTS Overall, 84 cases were enrolled. We stated that in-hospital mortality is significantly higher in the early TTP (≤17 h) than in the late TTP (> 17 h) group (57.14% vs 7.14%, P = 0.000). Septic shock occurred in 57.14% of patients with early TTP and in 18.57% of patients with late TTP (P = 0.002). Detailed multivariate and statistical analysis revealed that early TTP, need for vasoactive agent were independent risk factors of in-hospital mortality; early TTP, need for vasoactive agent and APACHE II score ≥ 15 were independent risk factors of septic shock incidence in S. aureus bacteremia children. CONCLUSIONS Overall, TTP of ≤17 h appeared to correlate with the worse outcomes for S. aureus bacteremia children. These results have important implications in the assessments and management of pediatric S. aureus bacteremia in a clinical setting. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Yuanyuan Li
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Qinyuan Li
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Guangli Zhang
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing, 401122, China
| | - Huan Ma
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Yi Wu
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Qian Yi
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Lili Jiang
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Jiao Wan
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Fengtao Suo
- , Key Laboratory of Pediatrics in Chongqing, Chongqing, China.,Department of Children's Hospital of Chongqing Medical University of Education, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing, China
| | - Zhengxiu Luo
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing, 401122, China.
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30
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van de Groep K, Verhoeff TL, Verboom DM, Bos LD, Schultz MJ, Bonten MJM, Cremer OL. Epidemiology and outcomes of source control procedures in critically ill patients with intra-abdominal infection. J Crit Care 2019; 52:258-264. [PMID: 31054787 DOI: 10.1016/j.jcrc.2019.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/31/2018] [Accepted: 02/28/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To describe the characteristics and procedural outcomes of source control interventions among Intensive Care Unit (ICU) patients with severe intra-abdominal-infection (IAI). MATERIAL AND METHODS We identified consecutive patients with suspected IAI in whom a source control intervention had been performed in two tertiary ICUs in the Netherlands, and performed retrospective in-depth case reviews to evaluate procedure type, diagnostic yield, and adequacy of source control after 14 days. RESULTS A total of 785 procedures were observed among 353 patients, with initial interventions involving 266 (75%) surgical versus 87 (25%) percutaneous approaches. Surgical index procedures typically involved IAI of (presumed) gastrointestinal origin (72%), whereas percutaneous index procedures were mostly performed for infections of the biliary tract/pancreas (50%) or peritoneal cavity (33%). Overall, 178 (50%) patients required multiple interventions (median 3 (IQR 2-4)). In a subgroup of 236 patients having their first procedure upon ICU admission, effective source control was ultimately achieved for 159 (67%) subjects. Persistence of organ failure was associated with inadequacy of source control at day 14, whereas trends in inflammatory markers were non-predictive. CONCLUSIONS Approximately half of ICU patients with IAI require more than one intervention, yet successful source control is eventually achieved in a majority of cases.
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Affiliation(s)
- Kirsten van de Groep
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Tessa L Verhoeff
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Diana M Verboom
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Lieuwe D Bos
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands
| | - Marc J M Bonten
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, the Netherlands
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31
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Stewart SD, Allen S. Antibiotic use in critical illness. J Vet Emerg Crit Care (San Antonio) 2019; 29:227-238. [PMID: 31021520 DOI: 10.1111/vec.12842] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 05/17/2017] [Accepted: 06/12/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a review on the current use of antimicrobials with a discussion on the pharmacokinetic and pharmacodynamic profiles of antimicrobials in critically ill patients, the challenges of drug resistance, the use of diagnostic testing to direct therapy, and the selection of the most likely efficacious antimicrobial protocol. ETIOLOGY Patients in the intensive care unit often possess profound pathophysiologic changes that can complicate antimicrobial therapy. Although many antimicrobials have known pharmacodynamic profiles, critical illness can cause wide variations in their pharmacokinetics. The two principal factors affecting pharmacokinetics are volume of distribution and drug clearance. Understanding the interplay between critical illness, drug pharmacokinetics, and antimicrobial characteristics (ie, time-dependent vs concentration-dependent) may improve antimicrobial efficacy and patient outcome. DIAGNOSIS Utilizing bacterial culture and susceptibility can aid in identifying drug resistant infections, selecting the most appropriate antimicrobials, and hindering the future development of drug resistance. THERAPY Having a basic knowledge of antimicrobial function and how to use diagnostics to direct therapeutic treatment is paramount in managing this patient population. Diagnostic testing is not always available at the time of initiation of antimicrobial therapy, so empiric selections are often necessary. These empiric choices should be made based on the location of the infection and the most likely infecting bacteria. PROGNOSIS Studies have demonstrated the importance of moving away from a "one dose fits all" approach to antimicrobial therapy. Instead there has been a move toward an individualized approach that takes into consideration the pharmacokinetic and pharmacodynamic variabilities that can occur in critically ill patients.
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Affiliation(s)
- Samuel D Stewart
- Emergency and Critical Care Service, Massachusetts Veterinary Referral Hospital, Woburn, MA
| | - Sarah Allen
- Emergency and Critical Care Service, Massachusetts Veterinary Referral Hospital, Woburn, MA
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Delay of appropriate antibiotic treatment is associated with high mortality in patients with community-onset sepsis in a Swedish setting. Eur J Clin Microbiol Infect Dis 2019; 38:1223-1234. [PMID: 30911928 PMCID: PMC6570779 DOI: 10.1007/s10096-019-03529-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
Abstract
Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important. Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock. A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012–2013. The criterion “early appropriate antibiotic treatment” was defined as administration of the first dose of adequate antibiotics within 1 h, and the second dose given with less than 25% delay after the recommended dose interval. A high-risk patient was defined as a septic patient with either shock within 24 h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality. Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment. Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.
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Nojoomi F, Ghasemian A. The relation of phylogroups, serogroups, virulence factors and resistance pattern of Escherichia coli isolated from children with septicemia. New Microbes New Infect 2019; 29:100517. [PMID: 31080621 PMCID: PMC6501060 DOI: 10.1016/j.nmni.2019.100517] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/02/2019] [Accepted: 02/04/2019] [Indexed: 11/30/2022] Open
Abstract
The characterization of virulent and drug-resistant Escherichia coli strains helps to control and provide more accurate information regarding infection and eradication. The aim of this study was to determine the relationship between antibiotic susceptibility, phylogroups and virulence factors of E. coli isolates from children with septicaemia. One hundred dereplicated E. coli isolates were collected from paediatric patients with septicaemia in five hospitals in Tehran (May 2015 to May 2018). The antibiotic susceptibility of isolates was performed as per the 2016 guidelines of the Clinical and Laboratory Standards Institute. Extended-spectrum β-lactamases and carbapenemase genes, phylogroups, serogroups and virulence encoding genes were detected by PCR. Phylogroup B2 was dominant (40%) among strains, followed by phylogroups D (30%), A (8%) and B1 (7%). CTX-M1 was significantly higher in the B2 group (n = 21, p 0.001). Furthermore, the virulence genes iutA (n = 27, p 0.002), csgA (n = 39, p <0.001), kpsMII (n = 39, p 0.002), ibeA (n = 4, p 0.004), vat (n = 5, p 0.003), traT (n = 24, p <0.001), sat (n = 12, p 0.001) and hlyA (n = 33, p <0.001) showed significantly higher rates in phylogroup B2. Three O25/CTXM1/OXA-48 and cnf, iutA, csgA and traT positive isolates belonged to phylogroup B2. Pulsed-field gel electrophoresis analysis showed 85% similarity among 25% of isolates. More than half of the isolates were multidrug-resistant E. coli. A significant relation was observed among iutA, csgA, kpsMII, ibeA, vat, traT, sat and hlyA genes and phylogroup B2. The characterization of virulent and drug-resistant strains helps control and properly eliminate infections. There was no genetic relation among strains in the pulsed-field gel electrophoresis pattern.
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Affiliation(s)
- F Nojoomi
- Department of Microbiology, Faculty of Medicine, Aja University of Medical Sciences, Tehran, Iran
| | - A Ghasemian
- Department of Microbiology, Faculty of Medicine, Aja University of Medical Sciences, Tehran, Iran
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34
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Analytical and clinical validation of a microbial cell-free DNA sequencing test for infectious disease. Nat Microbiol 2019; 4:663-674. [PMID: 30742071 DOI: 10.1038/s41564-018-0349-6] [Citation(s) in RCA: 470] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/11/2018] [Indexed: 01/05/2023]
Abstract
Thousands of pathogens are known to infect humans, but only a fraction are readily identifiable using current diagnostic methods. Microbial cell-free DNA sequencing offers the potential to non-invasively identify a wide range of infections throughout the body, but the challenges of clinical-grade metagenomic testing must be addressed. Here we describe the analytical and clinical validation of a next-generation sequencing test that identifies and quantifies microbial cell-free DNA in plasma from 1,250 clinically relevant bacteria, DNA viruses, fungi and eukaryotic parasites. Test accuracy, precision, bias and robustness to a number of metagenomics-specific challenges were determined using a panel of 13 microorganisms that model key determinants of performance in 358 contrived plasma samples, as well as 2,625 infections simulated in silico and 580 clinical study samples. The test showed 93.7% agreement with blood culture in a cohort of 350 patients with a sepsis alert and identified an independently adjudicated cause of the sepsis alert more often than all of the microbiological testing combined (169 aetiological determinations versus 132). Among the 166 samples adjudicated to have no sepsis aetiology identified by any of the tested methods, sequencing identified microbial cell-free DNA in 62, likely derived from commensal organisms and incidental findings unrelated to the sepsis alert. Analysis of the first 2,000 patient samples tested in the CLIA laboratory showed that more than 85% of results were delivered the day after sample receipt, with 53.7% of reports identifying one or more microorganisms.
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35
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Ziegler I, Cajander S, Rasmussen G, Ennefors T, Mölling P, Strålin K. High nuc DNA load in whole blood is associated with sepsis, mortality and immune dysregulation in Staphylococcus aureus bacteraemia. Infect Dis (Lond) 2019; 51:216-226. [PMID: 30676833 DOI: 10.1080/23744235.2018.1562205] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Staphylococcus aureus bacteraemia is a disease with varying presentation, ranging from uncomplicated to life-threatening infections. In S. aureus bacteraemia, a high load of bacterial DNA in blood has been linked to mortality. We hypothesized that a high DNA load would also be linked to the presence of sepsis, and to high C-reactive protein (CRP) and lymphopaenia, indicating inflammation and immunosuppression. METHODS Twenty-seven patients with culture-proven S. aureus bacteraemia, 13 (48%) with sepsis and six (22%) non-survivors, were enrolled in a prospective study. Blood samples were collected on days 0, 1-2, 3-4, 6-8, 13-15 and 26-30, and subjected to droplet digital PCR targeting the nuc gene to determine the nuc DNA load. RESULTS nuc DNA was detected on days 0-2 in 22 patients (81%), and on days 6-8 in three patients (all non-survivors). The nuc DNA load on days 1-2 was significantly elevated in patients with sepsis (median 2.69 versus 1.32 log10 copies/mL; p = .014) and in non-survivors (median 2.5 versus 1.0 log10 copies/mL; p = .033). Patients with a high nuc DNA load (>3.0 log10 copies/mL) on days 1-2 had significantly elevated CRP levels at all timepoints, and significantly decreased lymphocyte counts on days 0, 1-2, 13-15 and 26-30. CONCLUSIONS Our results indicate that a high initial load of S. aureus DNA in blood is associated with sepsis, mortality and persistent immune dysregulation in S. aureus bacteraemia patients. Further studies are needed to define the role of bacterial DNA load monitoring in the management of S. aureus bacteraemia.
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Affiliation(s)
- Ingrid Ziegler
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b School of Health and Medical Sciences , Örebro University , Örebro , Sweden
| | - Sara Cajander
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b School of Health and Medical Sciences , Örebro University , Örebro , Sweden
| | - Gunlög Rasmussen
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b School of Health and Medical Sciences , Örebro University , Örebro , Sweden
| | - Theresa Ennefors
- c Department of Laboratory Medicine , Örebro University Hospital , Örebro , Sweden
| | - Paula Mölling
- c Department of Laboratory Medicine , Örebro University Hospital , Örebro , Sweden
| | - Kristoffer Strålin
- b School of Health and Medical Sciences , Örebro University , Örebro , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,e Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
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Abstract
The last two to three years provided several “big steps” regarding our understanding and management of sepsis. The increasing insight into pathomechanisms of post-infectious defense led to some new models of host response. Besides hyper-, hypo-, and anti-inflammation as the traditional approaches to sepsis pathophysiology, tolerance and resilience were described as natural ways that organisms react to microbes. In parallel, huge data analyses confirmed these research insights with a new way to define sepsis and septic shock (called “Sepsis-3”), which led to discussions within the scientific community. In addition to these advances in understanding and defining the disease, follow-up protocols of the initial “sepsis bundles” from the Surviving Sepsis Campaign were created; some of them were part of quality management studies by clinicians, and some were in the form of mandatory procedures. As a result, new “bundles” were initiated with the goal of enabling standardized management of sepsis and septic shock, especially in the very early phase. This short commentary provides a brief overview of these two major fields as recent hallmarks of sepsis research.
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Affiliation(s)
- Daniela Berg
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Berlin, Germany
| | - Herwig Gerlach
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Berlin, Germany
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37
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van Donge T, Pfister M, Bielicki J, Csajka C, Rodieux F, van den Anker J, Fuchs A. Quantitative Analysis of Gentamicin Exposure in Neonates and Infants Calls into Question Its Current Dosing Recommendations. Antimicrob Agents Chemother 2018; 62:e02004-17. [PMID: 29358294 PMCID: PMC5913996 DOI: 10.1128/aac.02004-17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/09/2018] [Indexed: 12/20/2022] Open
Abstract
Optimal dosing of gentamicin in neonates is still a matter of debate despite its common use. We identified gentamicin dosing regimens from eight international guidelines and seven Swiss neonatal intensive care units. The dose per administration, the dosing interval, the total daily dose, and the demographic characteristics between guidelines were compared. There was considerable variability with respect to dose (4 to 6 mg/kg), dosing interval (24 h to 48 h), total daily dose (2.5 to 6 mg/kg/day), and patient demographic characteristics that were used to calculate individualized dosing regimens. A model-based simulation study in 1071 neonates was performed to determine the achievement of efficacious peak gentamicin concentrations according to predefined MICs (Cmax/MIC ≥ 10) and safe trough concentrations (Cmin ≤ 2 mg/liter) with recommended dosing regimens. MIC targets of 0.5 and 1 mg/liter were used. Dosing optimization was performed giving priority to the first day of treatment and with the goal of simplifying dosing. Current gentamicin neonatal guidelines allow to achieve effective peak concentrations for MICs ≤ 0.5 mg/liter but not higher. Model-based simulations indicate that to attain peak gentamicin concentrations of ≥10 mg/liter, a dose of 7.5 mg/kg should be administered using an extended dosing interval regimen. Trough concentrations of ≤2 mg/liter can be maintained with a dosing interval of 36 to 48 h in neonates according to gestational and postnatal age. For treatment beyond 3 days, therapeutic drug monitoring is advised to maintain adequate serum concentrations.
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Affiliation(s)
- Tamara van Donge
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Pfister
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Quantitative Solutions, a Certara Company, London, United Kingdom
| | - Julia Bielicki
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Chantal Csajka
- Service of Clinical Pharmacology, Department of Laboratory, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Frederique Rodieux
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - John van den Anker
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
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Abstract
Since the first edition of Surviving Sepsis Campaign Guidelines, the administration of intravenous antibiotics in the first hours of sepsis is recommend. However, in the last ten years, several studies around importance of early antibiotics in emergency room or in intensive care unit produced disparate results. Therefore, is early administration of antibiotics a life-salver? In this article, we explore studies around this theme and some questions about what does "early antibiotics" mean are addressed.
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39
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Rose WE, Shukla SK, Berti AD, Hayney MS, Henriquez KM, Ranzoni A, Cooper MA, Proctor RA, Nizet V, Sakoulas G. Increased Endovascular Staphylococcus aureus Inoculum Is the Link Between Elevated Serum Interleukin 10 Concentrations and Mortality in Patients With Bacteremia. Clin Infect Dis 2018; 64:1406-1412. [PMID: 28205673 DOI: 10.1093/cid/cix157] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 02/15/2017] [Indexed: 12/12/2022] Open
Abstract
Background Cell wall peptidoglycan stimulates interleukin 10 (IL-10) production in Staphylococcus aureus bacteremia (SaB) animal models, but clinical data are not available. This study evaluates the impact of intravascular bacterial cell numbers (ie, the level of bacteremia), in patients at the time of clinical presentation on IL-10 production and its association with S. aureus bacteremia (SaB) mortality. Methods Blood and isolates were collected in 133 consecutive SaB patients. Serum IL-10 was quantified by an electrochemoluminescence assay. Bacterial inoculum was measured in patient sera with elevated (n = 8) or low (n = 8) IL-10 using a magnetic bacterial capture assay. Staphylococcus aureus from these 2 groups were introduced into whole blood ex vivo to determine IL-10 production with variable inocula. Results IL-10 serum concentration was higher in SaB patient mortality (n = 27) vs survival (n = 106) (median, 36.0 pg/mL vs 10.4 pg/mL, respectively, P < .001). Patients with elevated IL-10 more often had endovascular SaB sources. The inoculum level of SaB was higher in patients with elevated serum IL-10 vs patients with low IL-10 (35.5 vs 0.5 median CFU/mL; P = .044). Ex vivo studies showed that 108 CFU/mL yielded greater IL-10 than did 103 CFU/mL (4.4 ± 1.8 vs 1.0 ± 0.6 pg/mL; P < .01). Conclusions Elevated IL-10 serum concentrations at clinical presentation of SaB were highly associated with mortality. High intravascular peptidoglycan concentration, driven by a higher level of bacteremia, is a key mediator of IL-10 anti-inflammatory response that portends poor clinical outcome. Using IL-10 as an initial biomarker, clinicians may consider more aggressive antimicrobials for rapid bacterial load reduction in high-risk SaB patients.
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Affiliation(s)
- Warren E Rose
- School of Pharmacy, University of Wisconsin-Madison, and
| | | | - Andrew D Berti
- School of Pharmacy, University of Wisconsin-Madison, and
| | - Mary S Hayney
- School of Pharmacy, University of Wisconsin-Madison, and
| | | | - Andrea Ranzoni
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Matthew A Cooper
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia
| | - Richard A Proctor
- Departments of Medicine and Medical Microbiology/Immunology, University of Wisconsin School of Medicine and Public Health, Madison, and
| | - Victor Nizet
- Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla
| | - George Sakoulas
- Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla
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40
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Kumar A, Zarychanski R, Pisipati A, Kumar A, Kethireddy S, Bow EJ. Fungicidal versus fungistatic therapy of invasive Candida infection in non-neutropenic adults: a meta-analysis. Mycology 2018; 9:116-128. [PMID: 30123667 PMCID: PMC6059084 DOI: 10.1080/21501203.2017.1421592] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 12/22/2017] [Indexed: 12/20/2022] Open
Abstract
The purpose of this study was to determine whether fungicidal versus fungistatic pharmacotherapy of invasive candidiasis/candidemia yields superior outcomes. Data sources included MEDLINE (1966-June 2017), EMBASE (1980-June 2017), PubMed (1966-June 2017), Global Health-Ovid (inception to June 2017), LILACS Virtual Health Library (inception to June 2017) and the Cochrane Central Register of Controlled Trials (to 2nd quarter 2017). The ClinicalTrial.gov database, the SCOPUS database, SIGLE (System for Information on Grey Literature) and Google Scholar were also utilised to search for relevant studies. Randomised studies of any pharmacotherapy of invasive candidiasis including candidemia using a fungicidal (amphotericin B or echinocandin compound) versus a fungistatic (triazole) compound in adolescent or adult non-neutropenic patients. Eight studies met the inclusion criteria. Pooled odds ratios demonstrated an advantage of fungicidal therapy with respect to early therapeutic success (OR 1.61, 95% CI 1.27-2.03, p < 0.0001, I2 = 0%) and persistence or recurrence of infection (OR 0.51, 95% CI 0.35-0.74, p = 0.0005, I2 = 0%) but no advantage for late survival (OR 0.97, 95% CI 0.77-1.21, p = 0.77, I2 = 0%). Fungicidal therapy of invasive candidiasis and candidemia is associated with a higher probability of early therapeutic success and decreased probability of persistent or recurrent infection. However, there is no improvement in survival.
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Affiliation(s)
- Anand Kumar
- Section of Critical Care Medicine, University of Manitoba, Winnipeg, Canada.,Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada.,Department of Pharmacology/Therapeutics, University of Manitoba, Winnipeg, Canada
| | - Ryan Zarychanski
- Section of Critical Care Medicine, University of Manitoba, Winnipeg, Canada.,Department of Medical Oncology and Haematology, CancerCare, Winnipeg, Canada
| | - Amarnath Pisipati
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - Aseem Kumar
- Department of Chemistry and Biochemistry, Laurentian University, Sudbury, Canada
| | - Shravan Kethireddy
- Section of Critical Care Medicine, University of Manitoba, Winnipeg, Canada
| | - Eric J Bow
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada.,Department of Medical Oncology and Haematology, CancerCare, Winnipeg, Canada
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Athlin S, Lidman C, Lundqvist A, Naucler P, Nilsson AC, Spindler C, Strålin K, Hedlund J. Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017. Infect Dis (Lond) 2017; 50:247-272. [PMID: 29119848 DOI: 10.1080/23744235.2017.1399316] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.
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Affiliation(s)
- Simon Athlin
- a Department of Infectious Diseases , Örebro University Hospital , Örebro , Sweden.,b Faculty of Medicin and Health , Örebro University , Örebro , Sweden
| | - Christer Lidman
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anders Lundqvist
- e Department of Infectious Diseases , Södra Älvsborgs Hospital , Borås , Sweden
| | - Pontus Naucler
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Anna C Nilsson
- f Infectious Disease Research Unit, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Carl Spindler
- d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
| | - Kristoffer Strålin
- b Faculty of Medicin and Health , Örebro University , Örebro , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden.,g Unit of Infectious Diseases, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
| | - Jonas Hedlund
- c Unit of Infectious Diseases, Department of Medicine Solna , Karolinska Institutet , Stockholm , Sweden.,d Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
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42
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Xu LY, Xu D. [Changes in blood oxygen metabolism indices and their clinical significance in children with septic shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1124-1128. [PMID: 29046213 PMCID: PMC7389280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/21/2017] [Indexed: 08/01/2024]
Abstract
The key to the treatment of septic shock is to provide adequate oxygen supply and improve tissue perfusion. Lactate and central venous oxygen saturation (ScvO2) are commonly used as the indices of oxygen metabolism, but tissue hypoxia may still exist even when lactate and ScvO2 are within the normal range. Arteriovenous difference in carbon dioxide partial pressure (CO2 gap) can accurately reflect oxygen delivery when ScvO2 is in the normal range. This article reviews the advantages and shortages of lactate, lactate clearance rate, ScvO2, and CO2 gap in evaluating tissue hypoxia, in order to provide a reference for treatment and severity evaluation of septic shock.
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Affiliation(s)
- Ling-Yang Xu
- Department of Pediatrics, Second Hospital of Lanzhou University, Lanzhou 730000, China.
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43
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Xu LY, Xu D. [Changes in blood oxygen metabolism indices and their clinical significance in children with septic shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1124-1128. [PMID: 29046213 PMCID: PMC7389280 DOI: 10.7499/j.issn.1008-8830.2017.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/21/2017] [Indexed: 06/07/2023]
Abstract
The key to the treatment of septic shock is to provide adequate oxygen supply and improve tissue perfusion. Lactate and central venous oxygen saturation (ScvO2) are commonly used as the indices of oxygen metabolism, but tissue hypoxia may still exist even when lactate and ScvO2 are within the normal range. Arteriovenous difference in carbon dioxide partial pressure (CO2 gap) can accurately reflect oxygen delivery when ScvO2 is in the normal range. This article reviews the advantages and shortages of lactate, lactate clearance rate, ScvO2, and CO2 gap in evaluating tissue hypoxia, in order to provide a reference for treatment and severity evaluation of septic shock.
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Affiliation(s)
- Ling-Yang Xu
- Department of Pediatrics, Second Hospital of Lanzhou University, Lanzhou 730000, China.
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44
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Kopitsyna MN, Morozov AS, Bessonov IV, Pisarev VM, Lobakova ES, Bukharin OV. LIGANDS FOR SELECTIVE REMOVAL OF LIPOPOLYSACCHARIDES FROM GRAM NEGATIVE BACTERIA. JOURNAL OF MICROBIOLOGY EPIDEMIOLOGY IMMUNOBIOLOGY 2017. [DOI: 10.36233/0372-9311-2017-3-115-126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bacterial lipopolysaccharides (LPS) are highly toxic molecules released during the lysis of bacterial cells. They play important role in the pathogenesis of sepsis, and can contaminate pharmaceuticals, so removing them from aqueous solutions and biological fluids is an extremely important task. Structure of LPS and its toxicity for various animals are presented in this review. Various low- and high-molecular ligands, suitable for efficient binding and removal LPS from solutions are studied and demonstrated. The main attention is paid to the relationship between the chemical structure of the ligand and its ability to form strong complexes with LPS and the principles of creating selective ligands for the depyrogenation of pharmaceutical substances and the creation of hemoperfusion columns for the sepsis therapy.
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Affiliation(s)
| | - A. S. Morozov
- JSC Advanced Medical Technologies; Lomonosov Moscow State University
| | - I. V. Bessonov
- JSC Advanced Medical Technologies; Lomonosov Moscow State University
| | - V. M. Pisarev
- V.A.Negovsky Research Institute of General Reanimatology
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Lee CC, Lee CH, Hong MY, Tang HJ, Ko WC. Timing of appropriate empirical antimicrobial administration and outcome of adults with community-onset bacteremia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:119. [PMID: 28545484 PMCID: PMC5445436 DOI: 10.1186/s13054-017-1696-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 05/02/2017] [Indexed: 12/29/2022]
Abstract
Background Early administration of appropriate antimicrobials has been correlated with a better prognosis in patients with bacteremia, but the optimum timing of early antibiotic administration as one of the resuscitation strategies for severe bacterial infections remains unclear. Methods In a retrospective cohort study, adults with community-onset bacteremia at the emergency department (ED) were analyzed. Effects of different cutoffs of time to appropriate antibiotic (TtAa) administration after arrival at the ED on 28-day mortality were examined, after adjustment for independent predictors of mortality identified by multivariate regression analysis. Results Among 2349 patients, the mean (interquartile range) TtAa was 2.0 (<1 to 12) hours. All selected cutoffs of TtAa, ranging from 1 to 96 hours, were significantly associated with 28-day mortality (adjusted odds ratio (AOR), 0.54–0.65, all P < 0.001), after adjustment of the following prognostic factors: fatal comorbidities (McCabe classification), critical illness (Pitt bacteremia score (PBS) ≥4) on arrival at the ED, polymicrobial bacteremia, extended-spectrum beta-lactamase-producer bacteremia, underlying malignancies or liver cirrhosis, and bacteremia caused by pneumonia or urinary tract infections. The adverse impact of TtAa on 28-day mortality was most evident at the cutoff of 48 hours, as the lowest AOR was identified (0.54, P < 0.001). In subgroup analyses, the most evident TtAa cutoff (i.e., the lowest AOR) remained at 48 hours in mildly ill (PBS = 0; AOR 0.47; P = 0.04) and moderately ill (PBS = 1–3; AOR 0.55; P = 0.02) patients, but shifted to 1 hour in critically ill patients (PBS ≥4; AOR 0.56; P < 0.001). Conclusions The time from triage to administration of appropriate antimicrobials is one of the primary determinants of mortality. The optimum timing of appropriate antimicrobial administration is the first 48 hours after non-critically ill patients arrive at the ED. As bacteremia severity increases, effective antimicrobial therapy should be empirically prescribed within 1 hour after critically ill patients arrive at the ED.
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Affiliation(s)
- Ching-Chi Lee
- Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, No. 20, Lingzilin, 72152, Madou Dist, Tainan City, Taiwan.,Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Ming-Yuan Hong
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.,Department of Emergency Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi-Mei Medical Center, Tainan, Taiwan. .,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan. .,Division of Infectious Disease, Department of Medicine, Chi-Mei Medical Center, No. 901, Chung-Hwa Road, Yung-Kang City, 710, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan. .,Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan. .,Division of Infectious Disease, Department of Internal Medicine, National Cheng Kung University Hospital, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Abstract
Drugs are key weapons that clinicians have to battle against the profound pathologies encountered in critically ill patients. Antibiotics in particular are commonly used and can improve patient outcomes dramatically. Despite this, there are strong opportunities for further reducing the persisting poor outcomes for infected critically ill patients. However, taking these next steps for improving patient care requires a new approach to antibiotic therapy. Giving the right dose is highly likely to increase the probability of clinical cure from infection and suppress the emergence of resistant pathogens. Furthermore, in some patients with higher levels of sickness severity, reduced mortality from an optimized approach to antibiotic use could also occur. To enable optimized dosing, the use of customized dosing regimens through either evidence-based dosing nomograms or preferably through the use of dosing software supplemented by therapeutic drug monitoring data should be embedded into daily practice. These customized dosing regimens should also be given as soon as practicable as reduced time to initiation of therapy has been shown to improve patient survival, particularly in the presence of septic shock. However, robust data supporting these logical approaches to therapy, which may deliver the next step change improvement for treatment of infections in critically ill patients, are lacking. Large prospective studies of patient survival and health system costs are now required to determine the value of customized antibiotic dosing, that is, giving the right dose at the right time.
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Jeganathan N, Yau S, Ahuja N, Otu D, Stein B, Fogg L, Balk R. The characteristics and impact of source of infection on sepsis-related ICU outcomes. J Crit Care 2017; 41:170-176. [PMID: 28564621 DOI: 10.1016/j.jcrc.2017.05.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/02/2017] [Accepted: 05/20/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Source of infection is an independent predictor of sepsis-related mortality. To date, studies have failed to evaluate differences in septic patients based on the source of infection. METHODS Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12month time period. RESULTS Sepsis due to intravascular device and multiple sources had the highest number of positive blood cultures and microbiology whereas lung and abdominal sepsis had the least. The observed hospital mortality was highest for sepsis due to multiple sources and unknown cause, and was lowest when due to abdominal, genitourinary (GU) or skin/soft tissue. Patients with sepsis due to lungs, unknown and multiple sources had the highest rates of multi-organ failure, whereas those with sepsis due to GU and skin/soft tissue had the lowest rates. Those with multisource sepsis had a significantly higher median ICU length of stay and hospital cost. CONCLUSION There are significant differences in patient characteristics, microbiology positivity, organs affected, mortality, length of stay and cost based on the source of sepsis. These differences should be considered in future studies to be able to deliver personalized care.
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Affiliation(s)
- Niranjan Jeganathan
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Stephen Yau
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Neha Ahuja
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Dara Otu
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Brian Stein
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Rush Medical College, Chicago, IL, USA
| | - Louis Fogg
- College of Nursing, Rush Medical College, Chicago, IL, USA
| | - Robert Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Rush Medical College, Chicago, IL, USA
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3714] [Impact Index Per Article: 530.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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