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Robey RC, Logue C, Caird CA, Hansel J, Hellyer TP, Simpson J, Dark P, Mathioudakis AG, Felton T. Immunomodulatory drugs in sepsis: a systematic review and meta-analysis. Anaesthesia 2024. [PMID: 38523060 DOI: 10.1111/anae.16263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/26/2024]
Abstract
Dysregulation of the host immune response has a central role in the pathophysiology of sepsis. There has been much interest in immunomodulatory drugs as potential therapeutic adjuncts in sepsis. We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the safety and clinical effectiveness of immunomodulatory drugs as adjuncts to standard care in the treatment of adults with sepsis. Our primary outcomes were serious adverse events and all-cause mortality. Fifty-six unique, eligible randomised controlled trials were identified, assessing a range of interventions including cytokine inhibitors; anti-inflammatories; immune cell stimulators; platelet pathway inhibitors; and complement inhibitors. At 1-month follow-up, the use of cytokine inhibitors was associated with a decreased risk of serious adverse events, based on 11 studies involving 7138 patients (RR (95%CI) 0.95 (0.90-1.00), I2 = 0%). The only immunomodulatory drugs associated with an increased risk of serious adverse events were toll-like receptor 4 antagonists (RR (95%CI) 1.18 (1.04-1.34), I2 = 0% (two trials, 567 patients)). Based on 18 randomised controlled trials, involving 11,075 patients, cytokine inhibitors reduced 1-month mortality (RR (95%CI) 0.88 (0.78-0.98), I2 = 57%). Mortality reduction was also shown in the subgroup of 13 randomised controlled trials that evaluated anti-tumour necrosis factor α interventions (RR (95%CI) 0.93 (0.87-0.99), I2 = 0%). Anti-inflammatory drugs had the largest apparent effect on mortality at 2 months at any dose (two trials, 228 patients, RR (95%CI) 0.64 (0.51-0.80), I2 = 0%) and at 3 months at any dose (three trials involving 277 patients, RR (95%CI) 0.67 (0.55-0.81), I2 = 0%). These data indicate that, except for toll-like receptor 4 antagonists, there is no evidence of safety concerns for the use of immunomodulatory drugs in sepsis, and they may show some short-term mortality benefit for selected drugs.
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Affiliation(s)
- R C Robey
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - C Logue
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - C A Caird
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Hansel
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - T P Hellyer
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - P Dark
- University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Critical Care Unit, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, UK
| | - A G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - T Felton
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Henley J, Brookes-Howell L, Euden J, Pallmann P, Llewelyn M, Howard P, Powell N, Dark P, Szakmany T, Hellyer TP, Albur M, Hamilton R, Prestwich G, Ogden M, Maboshe W, Sandoe J, Thomas-Jones E, Carrol E. Developing a model for decision-making around antibiotic prescribing for patients with COVID-19 pneumonia in acute NHS hospitals during the first wave of the COVID-19 pandemic: qualitative results from the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients (PEACH Study). BMJ Open 2023; 13:e077117. [PMID: 38114276 DOI: 10.1136/bmjopen-2023-077117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE To explore and model factors affecting antibiotic prescribing decision-making early in the pandemic. DESIGN Semistructured qualitative interview study. SETTING National Health Service (NHS) trusts/health boards in England and Wales. PARTICIPANTS Clinicians from NHS trusts/health boards in England and Wales. METHOD Individual semistructured interviews were conducted with clinicians in six NHS trusts/health boards in England and Wales as part of the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients study, a wider study that included statistical analysis of procalcitonin (PCT) use in hospitals during the first wave of the pandemic. Thematic analysis was used to identify key factors influencing antibiotic prescribing decisions for patients with COVID-19 pneumonia during the first wave of the pandemic (March to May 2020), including how much influence PCT test results had on these decisions. RESULTS During the first wave of the pandemic, recommendations to prescribe antibiotics for patients with COVID-19 pneumonia were based on concerns about secondary bacterial infections. However, as clinicians gained more experience with COVID-19, they reported increasing confidence in their ability to distinguish between symptoms and signs caused by SARS-CoV-2 viral infection alone, and secondary bacterial infections. Antibiotic prescribing decisions were influenced by factors such as clinician experience, confidence, senior support, situational factors and organisational influences. A decision-making model was developed. CONCLUSION This study provides insight into the decision-making process around antibiotic prescribing for patients with COVID-19 pneumonia during the first wave of the pandemic. The importance of clinician experience and of senior review of decisions as factors in optimising antibiotic stewardship is highlighted. In addition, situational and organisational factors were identified that could be optimised. The model presented in the study can be used as a tool to aid understanding of the complexity of the decision-making process around antibiotic prescribing and planning antimicrobial stewardship support in the context of a pandemic. TRIAL REGISTRATION NUMBER ISRCTN66682918.
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Affiliation(s)
- Josie Henley
- School of Social Sciences, Cardiff University, Cardiff, UK
| | | | - Joanne Euden
- College of Biomedical and Life Sciences, Cardiff University Centre for Trials Research, Cardiff, UK
| | - Philip Pallmann
- College of Biomedical and Life Sciences, Cardiff University Centre for Trials Research, Cardiff, UK
| | - Martin Llewelyn
- Brighton and Sussex Medical School, University of Sussex and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, UK
- Pharmacy, Leeds Teaching Hospitals, Leeds, UK
| | - Neil Powell
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Paul Dark
- Intensive Care Unit, University of Manchester, Salford, UK
| | - Tamas Szakmany
- Critical Care Directorate, Aneurin Bevan University Health Board, Newport, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff Univeristy, Cardiff, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Ryan Hamilton
- School of Pharmacy, De Montfort University, Leicester, UK
| | | | - Margaret Ogden
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Jonathan Sandoe
- Department of Microbiology, The General Infirmary at Leeds, Leeds, UK
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | | | - Enitan Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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Elçioğlu ZC, Errington L, Metes B, Sendama W, Powell J, Simpson AJ, Rostron AJ, Hellyer TP. Pooled prevalence of lymphopenia in all-cause hospitalisations and association with infection: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:848. [PMID: 38042792 PMCID: PMC10693046 DOI: 10.1186/s12879-023-08845-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 11/24/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Lymphopenia is defined as a decrease below normal value (often 1.0 x 109 cells/L) of blood circulating lymphocyte count. In the general population, lymphopenia is associated with an increased risk of hospitalisation secondary to infection, independent of traditional clinical risk factors. In hospital, lymphopenia is associated with increased risk of healthcare-associated infection and mortality. By summarising lymphopenia's prevalence and impact on clinical outcomes, we can identify an at-risk population and inform future studies of immune dysfunction following severe illness. METHODS Peer-reviewed search strategy was performed on three databases. Primary objective was to summarise the pooled prevalence of lymphopenia. Primary outcome was infection including pre-existing lymphopenia as a risk factor for admission with infection and as an in-hospital risk factor for healthcare-associated infection. Secondary outcomes were length of stay and mortality. Mortality data extracted included in-hospital, 28/30-day ('early'), and 90-day/1-year ('late') mortality. Meta-analysis was carried out using random-effects models for each outcome measure. Heterogeneity was assessed using I2 statistic. Joanna Briggs Institute checklist for cohort studies was used to assess risk of bias. The protocol was published on PROSPERO. RESULTS Fifteen observational studies were included. The pooled prevalence of lymphopenia in all-cause hospitalisations was 38% (CI 0.34-0.42, I2= 97%, p< 0.01). Lymphopenia was not associated with an infection diagnosis at hospital admission and healthcare associated infection (RR 1.03; 95% CI 0.26-3.99, p=0.97, I2 = 55% and RR 1.31; 95% CI 0.78-2.20, p=0.31, I2=97%, respectively), but was associated with septic shock (RR 2.72; 95% CI 1.02-7.21, p=0.04, I2 =98%). Lymphopenia was associated with higher in-hospital mortality and higher 'early' mortality rates (RR 2.44; 95% CI 1.71-3.47, p < 0.00001, I2 = 89% and RR 2.05; 95% CI 1.64-2.56, p < 0.00001, I2 = 29%, respectively). Lymphopenia was associated with higher 'late' mortality (RR 1.59; 1.33-1.90, p < 0.00001, I2 = 0%). CONCLUSIONS This meta-analysis demonstrates the high prevalence of lymphopenia across all-cause hospitalisations and associated increased risk of septic shock, early and late mortality. Lymphopenia is a readily available marker that may identify immune dysfunctional patients. Greater understanding of immune trajectories following survival may provide insights into longer-term poor clinical outcomes.
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Affiliation(s)
- Z C Elçioğlu
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
| | - L Errington
- Faculty of Medical Sciences Library, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
| | - B Metes
- Faculty of Medical Sciences Library, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
| | - W Sendama
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP, UK
| | - J Powell
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
| | - A J Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP, UK
| | - A J Rostron
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK
- Integrated Critical Care Unit, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, SR4 7TP, UK
| | - T P Hellyer
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, NE2 4HH, UK.
- Department of Critical Care Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP, UK.
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Powell J, Powell S, Mather MW, Beck L, Nelson A, Palmowski P, Porter A, Coxhead J, Hedley A, Scott J, Rostron AJ, Hellyer TP, Zaidi F, Davey T, Garnett JP, Agbeko R, Ward C, Stewart CJ, Taggart CC, Brodlie M, Simpson AJ. Tracheostomy in children is associated with neutrophilic airway inflammation. Thorax 2023; 78:1019-1027. [PMID: 36808087 PMCID: PMC10511973 DOI: 10.1136/thorax-2022-219557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/29/2022] [Indexed: 02/22/2023]
Abstract
BACKGROUND Tracheostomies in children are associated with significant morbidity, poor quality of life, excess healthcare costs and excess mortality. The underlying mechanisms facilitating adverse respiratory outcomes in tracheostomised children are poorly understood. We aimed to characterise airway host defence in tracheostomised children using serial molecular analyses. METHODS Tracheal aspirates, tracheal cytology brushings and nasal swabs were prospectively collected from children with a tracheostomy and controls. Transcriptomic, proteomic and metabolomic methods were applied to characterise the impact of tracheostomy on host immune response and the airway microbiome. RESULTS Children followed up serially from the time of tracheostomy up to 3 months postprocedure (n=9) were studied. A further cohort of children with a long-term tracheostomy were also enrolled (n=24). Controls (n=13) comprised children without a tracheostomy undergoing bronchoscopy. Long-term tracheostomy was associated with airway neutrophilic inflammation, superoxide production and evidence of proteolysis when compared with controls. Reduced airway microbial diversity was established pre-tracheostomy and sustained thereafter. CONCLUSIONS Long-term childhood tracheostomy is associated with a inflammatory tracheal phenotype characterised by neutrophilic inflammation and the ongoing presence of potential respiratory pathogens. These findings suggest neutrophil recruitment and activation as potential exploratory targets in seeking to prevent recurrent airway complications in this vulnerable group of patients.
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Affiliation(s)
- Jason Powell
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Michael W Mather
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lauren Beck
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Nelson
- Department of Applied Science, Northumbria University, Newcastle upon Tyne, UK
| | - Pawel Palmowski
- Protein and Proteome Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Porter
- Protein and Proteome Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Coxhead
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Hedley
- Bioinformatics Support Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fatima Zaidi
- Discovery and Translational Science, Metabolon, Morrisville, North Carolina, USA
| | - Tracey Davey
- Electron Microscopy Research Services, Newcastle University, Newcastle upon Tyne, UK
| | - James P Garnett
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Agbeko
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Intensive Care, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Chris Ward
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J Stewart
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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5
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Conway Morris A, Hellyer TP. Sniffing out pneumonia in the ICU. Anaesthesia 2023; 78:684-687. [PMID: 36947845 DOI: 10.1111/anae.16005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Affiliation(s)
- A Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, UK
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - T P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- Critical Care Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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6
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Thompson S, Pang CY, Sepuru KM, Cambier S, Hellyer TP, Scott J, Simpson AJ, Proost P, Kirby JA, Rajarathnam K, Sheerin NS, Ali S. Nitration of chemokine CXCL8 acts as a natural mechanism to limit acute inflammation. Cell Mol Life Sci 2023; 80:35. [PMID: 36622452 PMCID: PMC9829591 DOI: 10.1007/s00018-022-04663-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/24/2022] [Accepted: 12/09/2022] [Indexed: 01/10/2023]
Abstract
Chemokine CXCL8 is a key facilitator of the human host immune response, mediating neutrophil migration, and activation at the site of infection and injury. The oxidative burst is an important effector mechanism which leads to the generation of reactive nitrogen species (RNS), including peroxynitrite. The current study was performed to determine the potential for nitration to alter the biological properties of CXCL8 and its detection in human disease. Here, we show peroxynitrite nitrates CXCL8 and thereby regulates neutrophil migration and activation. The nitrated chemokine was unable to induce transendothelial neutrophil migration in vitro and failed to promote leukocyte recruitment in vivo. This reduced activity is due to impairment in both G protein-coupled receptor signaling and glycosaminoglycan binding. Using a novel antibody, nitrated CXCL8 was detected in bronchoalveolar lavage samples from patients with pneumonia. These findings were validated by mass spectrometry. Our results provide the first direct evidence of chemokine nitration in human pathophysiology and suggest a natural mechanism that limits acute inflammation.
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Affiliation(s)
- Sarah Thompson
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - Chong Yun Pang
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - Krishna Mohan Sepuru
- Department of Biochemistry and Molecular Biology, Sealy Center for Structural Biology and Molecular Biophysics, The University of Texas Medical Branch, Galveston, TX 77555 USA
| | - Seppe Cambier
- Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, 3000 Leuven, Belgium
| | - Thomas P. Hellyer
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Department of Critical Care Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE1 4LP UK
| | - Jonathan Scott
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - A. John Simpson
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK ,Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4L9 UK
| | - Paul Proost
- Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, 3000 Leuven, Belgium
| | - John A. Kirby
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - Krishna Rajarathnam
- Department of Biochemistry and Molecular Biology, Sealy Center for Structural Biology and Molecular Biophysics, The University of Texas Medical Branch, Galveston, TX 77555 USA ,Institute for Human Infections and Immunity, The University of Texas Medical Branch, Galveston, TX 77555 USA
| | - Neil S. Sheerin
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - Simi Ali
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
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Scott J, Trevi L, McNeil H, Ewen T, Mawson P, McDonald D, Filby A, Lall R, Booth K, Boschman G, Melkebeek V, Perkins G, McMullan R, McAuley DF, McCullagh IJ, Walsh T, Rostron A, Shankar-Hari M, Dark P, Simpson AJ, Conway Morris A, Hellyer TP. Role of immunosuppression in an antibiotic stewardship intervention and its association with clinical outcomes and antibiotic use: protocol for an observational study (RISC-sepsis). BMJ Open 2022; 12:e068321. [PMID: 36600326 PMCID: PMC9743405 DOI: 10.1136/bmjopen-2022-068321] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Sepsis is characterised by a dysregulated immune response to infection, with exaggerated pro-inflammatory and anti-inflammatory responses. A predominant immunosuppressive profile affecting both innate and adaptive immune responses is associated with increased hospital-acquired infection and reduced infection-free survival. While hospital-acquired infection leads to additional antibiotic use, the role of the immunosuppressive phenotype in guiding complex decisions, such as those affecting antibiotic stewardship, is uncertain. This study is a mechanistic substudy embedded within a multicentre clinical and cost-effectiveness trial of biomarker-guided antibiotic stewardship. This mechanistic study aims to determine the effect of sepsis-associated immunosuppression on the trial outcome measures. METHODS AND ANALYSIS RISC-sepsis is a prospective, multicentre, exploratory, observational study embedded within the ADAPT-sepsis trial. A subgroup of 180 participants with antibiotics commenced for suspected sepsis, enrolled in the ADAPT-sepsis trial, will be recruited. Blood samples will be collected on alternate days until day 7. At each time point, blood will be collected for flow cytometric analysis into cell preservation tubes. Immunophenotyping will be performed at a central testing hub by flow cytometry. The primary outcome measures are monocyte human leucocyte antigen-DR; neutrophil CD88; programmed cell death-1 on monocytes, neutrophils and T lymphocytes and the percentage of regulatory T cells. Secondary outcome measures will link to trial outcomes from the ADAPT-sepsis trial including antibiotic days; occurrence of hospital-acquired infection and length of ICU-stay and hospital-stay. ETHICS AND DISSEMINATION Ethical approval has been granted (IRAS 209815) and RISC-sepsis is registered with the ISRCTN (86837685). Study results will be disseminated by peer-reviewed publications, presentations at scientific meetings and via patient and public participation groups and social media.
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Affiliation(s)
- Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Loredana Trevi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hannah McNeil
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Tom Ewen
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil Mawson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David McDonald
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Filby
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Katie Booth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | | | - Gavin Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Critical Care Department, Birmingham Heartlands Hospital, Birmingham, UK
| | - Ronan McMullan
- Department of Medical Microbiology, Royal Victoria Hospital, Belfast, UK
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Iain J McCullagh
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Perioperative Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Timothy Walsh
- Intensive Care Unit, Edinburgh Royal Infirmary, Edinburgh, UK
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Integrated Critical Care Unit, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, Edinburgh Royal Infirmary, Edinburgh, UK
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Paul Dark
- Division of Immunology, University of Manchester, Salford, Greater Manchester, UK
- Critical Care Department, Salford Care Organisation, Greater Manchester, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Andrew Conway Morris
- JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
- Division of Immunology, University of Cambridge, Cambridge, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Critical Care Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
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8
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,
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9
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,
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10
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,
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11
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Wilson KJ, Williamson SF, Allen AJ, Williams CJ, Hellyer TP, Lendrem BC. Bayesian sample size determination for diagnostic accuracy studies. Stat Med 2022; 41:2908-2922. [PMID: 35403239 PMCID: PMC9325402 DOI: 10.1002/sim.9393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/21/2022] [Accepted: 03/11/2022] [Indexed: 11/11/2022]
Abstract
The development of a new diagnostic test ideally follows a sequence of stages which, among other aims, evaluate technical performance. This includes an analytical validity study, a diagnostic accuracy study, and an interventional clinical utility study. In this article, we propose a novel Bayesian approach to sample size determination for the diagnostic accuracy study, which takes advantage of information available from the analytical validity stage. We utilize assurance to calculate the required sample size based on the target width of a posterior probability interval and can choose to use or disregard the data from the analytical validity study when subsequently inferring measures of test accuracy. Sensitivity analyses are performed to assess the robustness of the proposed sample size to the choice of prior, and prior‐data conflict is evaluated by comparing the data to the prior predictive distributions. We illustrate the proposed approach using a motivating real‐life application involving a diagnostic test for ventilator associated pneumonia. Finally, we compare the properties of the approach against commonly used alternatives. The results show that, when suitable prior information is available, the assurance‐based approach can reduce the required sample size when compared to alternative approaches.
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Affiliation(s)
- Kevin J. Wilson
- School of Mathematics, Statistics & Physics Newcastle University Tyne and Wear UK
| | - S. Faye Williamson
- Biostatistics Research Group, Population Health Sciences Institute Newcastle University Tyne and Wear UK
| | - A. Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co‐operative Newcastle University Tyne and Wear UK
- Translational and Clinical Research Institute Newcastle University Tyne and Wear UK
| | - Cameron J. Williams
- School of Mathematics, Statistics & Physics Newcastle University Tyne and Wear UK
- NIHR Newcastle In Vitro Diagnostics Co‐operative Newcastle University Tyne and Wear UK
- Translational and Clinical Research Institute Newcastle University Tyne and Wear UK
| | - Thomas P. Hellyer
- Translational and Clinical Research Institute Newcastle University Tyne and Wear UK
| | - B. Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co‐operative Newcastle University Tyne and Wear UK
- Translational and Clinical Research Institute Newcastle University Tyne and Wear UK
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12
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Euden J, Howard P, Powell N, Llewelyn MJ, Szakmany T, Albur M, Bond SE, Brookes-Howell L, Dark P, Hellyer TP, Hopkins S, McCullagh IJ, Ogden M, Pallmann P, Parsons H, Partridge DG, Shaw DE, Shinkins B, Todd S, Thomas-Jones E, West R, Carrol ED, Sandoe JAT. P14 Procalcitonin evaluation of antibiotic use in COVID-19 hospitalized patients during the first wave of COVID-19: the PEACH study. JAC Antimicrob Resist 2022. [PMCID: PMC9040064 DOI: 10.1093/jacamr/dlac004.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background A minority of patients presenting to hospital with COVID-19 have bacterial coinfection. Procalcitonin testing may help identify patients for whom antibiotics should be prescribed or withheld. The PEACH study describes the use of procalcitonin in English and Welsh hospitals during the first wave of the COVID-19 pandemic to help diagnose bacterial infections and guide antibiotic treatment. There is a lack of clear evidence to support its use in lung infections, which means in some hospitals, clinicians have used the procalcitonin test to guide antibiotic decisions in COVID-19, whilst in other hospitals, they have not. Our study is analysing data from hospitals that did and did not use procalcitonin testing during the first wave of the COVID-19 pandemic. It will determine whether and how procalcitonin testing should be used in the NHS in future waves of COVID-19 to protect patients from antibiotic overuse. Methods To assess whether the use of PCT testing, to guide antibiotic prescribing, safely reduced antibiotic use among patients who were hospitalized with COVID-19 during the first wave of the pandemic, we are answering this question through three different, and complimentary, work streams (WS), each with discrete work packages (WP): (i) Work Stream 1: utilization of PCT testing to guide antibiotic prescribing during the first wave of COVID-19 pandemic; (ii) Work Stream 2: patient-level impact of PCT testing on antibiotic exposure and clinical outcome (main work stream currently in analysis); and (iii) Work Stream 3: health economics analysis of PCT testing to guide antibiotics in COVID-19. Results Our first publication from Work Stream 1 (Antibiotics 2021, 10: 516) used a web-based survey to gather data from antimicrobial leads about the use of procalcitonin testing. Responses were received from 148/151 (98%) eligible hospitals. During the first wave of the COVID-19 pandemic, there was widespread introduction and expansion of PCT use in NHS hospitals. The number of hospitals using PCT in emergency/acute admissions rose from 17 (11%) to 74/146 (50.7%) and use in ICU increased from 70 (47.6%) to 124/147 (84.4%). This increase happened predominantly in March and April 2020, preceding NICE guidance. Approximately half of hospitals used PCT as a single test to guide decisions to discontinue antibiotics and half used repeated measurements. There was marked variation in the thresholds used for empirical antibiotic cessation and guidance about interpretation of values. Conclusions Procalcitonin testing has been widely adopted in the NHS during the COVID-19 pandemic in an unevidenced, heterogeneous way and in conflict with relevant NICE guidance. Further research is needed urgently that assesses the impact of this change on antibiotic prescribing and patient safety. Work Stream 2 is ongoing, and results will be published once available.
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Affiliation(s)
- Joanne Euden
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | | | | | - Tamas Szakmany
- The Grange University Hospital, Aneurin Bevan University Health Board, UK
| | | | | | | | - Paul Dark
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Thomas P. Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Iain J. McCullagh
- The Newcastle upon Tyne hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Helena Parsons
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Dominick E. Shaw
- Division of Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Bethany Shinkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stacy Todd
- Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Enitan D. Carrol
- Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK
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13
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Powell N, Howard P, Llewelyn MJ, Szakmany T, Albur M, Bond SE, Euden J, Brookes-Howell L, Dark P, Hellyer TP, Hopkins S, McCullagh IJ, Ogden M, Pallmann P, Parsons H, Partridge DG, Shaw DE, Shinkins B, Todd S, Thomas-Jones E, West R, Carrol ED, Sandoe JAT. Use of Procalcitonin during the First Wave of COVID-19 in the Acute NHS Hospitals: A Retrospective Observational Study. Antibiotics (Basel) 2021; 10:516. [PMID: 34062898 PMCID: PMC8147337 DOI: 10.3390/antibiotics10050516] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023] Open
Abstract
A minority of patients presenting to hospital with COVID-19 have bacterial co-infection. Procalcitonin testing may help identify patients for whom antibiotics should be prescribed or withheld. This study describes the use of procalcitonin in English and Welsh hospitals during the first wave of the COVID-19 pandemic. A web-based survey of antimicrobial leads gathered data about the use of procalcitonin testing. Responses were received from 148/151 (98%) eligible hospitals. During the first wave of the COVID-19 pandemic, there was widespread introduction and expansion of PCT use in NHS hospitals. The number of hospitals using PCT in emergency/acute admissions rose from 17 (11%) to 74/146 (50.7%) and use in Intensive Care Units (ICU) increased from 70 (47.6%) to 124/147 (84.4%). This increase happened predominantly in March and April 2020, preceding NICE guidance. Approximately half of hospitals used PCT as a single test to guide decisions to discontinue antibiotics and half used repeated measurements. There was marked variation in the thresholds used for empiric antibiotic cessation and guidance about interpretation of values. Procalcitonin testing has been widely adopted in the NHS during the COVID-19 pandemic in an unevidenced, heterogeneous way and in conflict with relevant NICE guidance. Further research is needed urgently that assesses the impact of this change on antibiotic prescribing and patient safety.
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Affiliation(s)
- Neil Powell
- Pharmacy Department, Royal Cornwall Hospital Trust, Truro TR1 3LJ, UK
| | - Philip Howard
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK;
- Department of Medicines Management and Pharmacy, Leeds Teaching Hospitals, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - Martin J. Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PS, UK;
| | - Tamas Szakmany
- Grange University Hospital, Aneurin Bevan University Health Board, Llanyravon, Cwmbran NP44 2XJ, UK;
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff CF14 4XN, UK
| | | | - Stuart E Bond
- Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK;
- School of Applied Sciences, University of Huddersfield, Huddersfield HD13DH, UK
| | - Joanne Euden
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Lucy Brookes-Howell
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Paul Dark
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester M13 9PL, UK;
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK;
| | | | - Iain J McCullagh
- The Newcastle upon Tyne hospitals NHS Foundation Trust, Newcastle Upon Tyne NE7 7DN, UK;
| | - Margaret Ogden
- Patient and Public Involvement Representative, NIHR, London SW1A 2NS, UK;
| | - Philip Pallmann
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Helena Parsons
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; (H.P.); (D.GP.)
| | - David G Partridge
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; (H.P.); (D.GP.)
| | - Dominick E. Shaw
- Division of Respiratory Medicine, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Bethany Shinkins
- Test Evaluation Group, Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK;
| | - Stacy Todd
- Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK;
| | - Emma Thomas-Jones
- Centre for Trials Research, Neuadd Meirionydd, Cardiff University, Heath Park, Cardiff CF14 4YS, UK; (J.E.); (L.B.-H.); (P.P.); (E.T.-J.)
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9TJ, UK;
| | - Enitan D Carrol
- Department of Clinical Infection Microbiology and Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK;
| | - Jonathan A. T. Sandoe
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, School of Medicine, University of Leeds, LS2 9JT, UK;
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14
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Affiliation(s)
| | - T Mantle
- Manchester Medical School, Manchester, UK
| | - R McMullan
- Belfast Health & Social Care Trust and Reader, Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - P Dark
- Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
- Northern Care Alliance NHS Group, Greater Manchester, UK
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15
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Loughlin L, Hellyer TP, White PL, McAuley DF, Conway Morris A, Posso RB, Richardson MD, Denning DW, Simpson AJ, McMullan R. Pulmonary Aspergillosis in Patients with Suspected Ventilator-associated Pneumonia in UK ICUs. Am J Respir Crit Care Med 2020; 202:1125-1132. [PMID: 32609533 PMCID: PMC7560800 DOI: 10.1164/rccm.202002-0355oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale:Aspergillus infection in patients with suspected ventilator-associated pneumonia remains uncharacterized because of the absence of a disease definition and limited access to sensitive diagnostic tests.Objectives: To estimate the prevalence and outcomes of Aspergillus infection in adults with suspected ventilator-associated pneumonia.Methods: Two prospective UK studies recruited 360 critically ill adults with new or worsening alveolar shadowing on chest X-ray and clinical/hematological parameters supporting suspected ventilator-associated pneumonia. Stored serum and BAL fluid were available from 194 nonneutropenic patients and underwent mycological testing. Patients were categorized as having probable Aspergillus infection using a definition comprising clinical, radiological, and mycological criteria. Mycological criteria included positive histology or microscopy, positive BAL fluid culture, galactomannan optical index of 1 or more in BAL fluid or 0.5 or more in serum.Measurements and Main Results: Of 194 patients evaluated, 24 met the definition of probable Aspergillus infection, giving an estimated prevalence of 12.4% (95% confidence interval, 8.1-17.8). All 24 patients had positive galactomannan in serum (n = 4), BAL fluid (n = 16), or both (n = 4); three patients cultured Aspergillus sp. in BAL fluid. Patients with probable Aspergillus infection had a significantly longer median duration of critical care stay (25.5 vs. 15.5 d, P = 0.02). ICU mortality was numerically higher in this group, although this was not statistically significant (33.3% vs. 22.8%; P = 0.23).Conclusions: The estimated prevalence for probable Aspergillus infection in this geographically dispersed multicenter UK cohort indicates that this condition should be considered when investigating patients with suspected ventilator-associated pneumonia, including patient groups not previously recognized to be at high risk of aspergillosis.
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Affiliation(s)
- Laura Loughlin
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - P Lewis White
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Raquel B Posso
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Malcolm D Richardson
- UK NHS Mycology Reference Centre, Manchester University NHS Foundation Trust and
| | - David W Denning
- The University of Manchester and Manchester Academic Health Science Centre, National Aspergillosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
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16
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Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, Dark P, Roy AI, Perkins GD, McMullan R, Emerson LM, Blackwood B, Wright SE, Kefala K, O'Kane CM, Baudouin SV, Paterson RL, Rostron AJ, Agus A, Bannard-Smith J, Robin NM, Welters ID, Bassford C, Yates B, Spencer C, Laha SK, Hulme J, Bonner S, Linnett V, Sonksen J, Van Den Broeck T, Boschman G, Keenan DWJ, Scott J, Allen AJ, Phair G, Parker J, Bowett SA, Simpson AJ. More research is required to understand factors influencing antibiotic prescribing in complex conditions like suspected ventilator-associated pneumonia. Ann Transl Med 2020; 8:840. [PMID: 32794522 PMCID: PMC7396250 DOI: 10.21037/atm-20-3701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Thomas P Hellyer
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Daniel F McAuley
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Timothy S Walsh
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Niall Anderson
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Suveer Singh
- Department of Cancer and Surgery, Imperial College, London, UK
| | - Paul Dark
- Manchester National Institute for Health Research Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | | | - Ronan McMullan
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Lydia M Emerson
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Stephen E Wright
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cecilia M O'Kane
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Simon V Baudouin
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Ross L Paterson
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
| | | | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | | | - Nicole M Robin
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Ingeborg D Welters
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Bryan Yates
- Intensive Care Unit, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Craig Spencer
- Intensive Care Unit, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - Jonathan Hulme
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Stephen Bonner
- Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK
| | - Vanessa Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead, UK
| | | | | | - Gert Boschman
- Becton Dickinson Life Sciences, Erembodegem, Belgium
| | | | - Jonathan Scott
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - A Joy Allen
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Jennie Parker
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Susan A Bowett
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - A John Simpson
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
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17
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Hellyer TP, Simpson AJ. Could host response guide VAP treatment? No answer yet - Authors' reply. Lancet Respir Med 2020; 8:e38. [PMID: 32380071 DOI: 10.1016/s2213-2600(20)30133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle NE2 4HH, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle NE2 4HH, UK; National Institute for Health Research Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle, UK; Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
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18
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Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, Dark P, Roy AI, Perkins GD, McMullan R, Emerson LM, Blackwood B, Wright SE, Kefala K, O'Kane CM, Baudouin SV, Paterson RL, Rostron AJ, Agus A, Bannard-Smith J, Robin NM, Welters ID, Bassford C, Yates B, Spencer C, Laha SK, Hulme J, Bonner S, Linnett V, Sonksen J, Van Den Broeck T, Boschman G, Keenan DJ, Scott J, Allen AJ, Phair G, Parker J, Bowett SA, Simpson AJ. Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation. Lancet Respir Med 2020; 8:182-191. [PMID: 31810865 PMCID: PMC7599318 DOI: 10.1016/s2213-2600(19)30367-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia. METHODS VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425. FINDINGS Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes. INTERPRETATION Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect. FUNDING UK Department of Health and the Wellcome Trust.
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Affiliation(s)
- Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Daniel F McAuley
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK; Regional Intensive Care Unit, The Royal Hospitals, Belfast, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK; Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Suveer Singh
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - Paul Dark
- Division of Infection Immunity and Respiratory Medicine, Manchester National Institute for Health Research Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Intensive Care Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ronan McMullan
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lydia M Emerson
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Stephen E Wright
- Integrated Critical Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cecilia M O'Kane
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Simon V Baudouin
- Intensive Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ross L Paterson
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK; Integrated Critical Care Unit, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Jonathan Bannard-Smith
- Intensive Care Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicole M Robin
- Intensive Care Unit, Countess of Chester NHS Foundation Trust, Chester, UK
| | - Ingeborg D Welters
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Christopher Bassford
- Intensive Care Unit, University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Bryan Yates
- Intensive Care Unit, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Craig Spencer
- Intensive Care Unit, Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Shondipon K Laha
- Intensive Care Unit, Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Jonathan Hulme
- Intensive Care Unit, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Stephen Bonner
- Intensive Care Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Vanessa Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | - Julian Sonksen
- Intensive Care Unit, Russells Hall Hospital, Dudley Group NHS Foundation Trust, Dudley, UK
| | | | - Gert Boschman
- Becton Dickinson Biosciences Europe, Erembodegem, Belgium
| | | | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - A Joy Allen
- National Institute for Health Research Newcastle In Vitro Diagnostics Cooperative, Newcastle University, Newcastle, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Jennie Parker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - Susan A Bowett
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK; National Institute for Health Research Newcastle In Vitro Diagnostics Cooperative, Newcastle University, Newcastle, UK.
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19
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Pinder EM, Rostron AJ, Hellyer TP, Ruchaud-Sparagano MH, Scott J, Macfarlane JG, Wiscombe S, Widdrington JD, Roy AI, Linnett VC, Baudouin SV, Wright SE, Chadwick T, Fouweather T, Juss JK, Chilvers ER, Bowett SA, Parker J, McAuley DF, Conway Morris A, Simpson AJ. Randomised controlled trial of GM-CSF in critically ill patients with impaired neutrophil phagocytosis. Thorax 2018; 73:918-925. [PMID: 30064991 PMCID: PMC6166597 DOI: 10.1136/thoraxjnl-2017-211323] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/10/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Critically ill patients with impaired neutrophil phagocytosis have significantly increased risk of nosocomial infection. Granulocyte-macrophage colony-stimulating factor (GM-CSF) improves phagocytosis by neutrophils ex vivo. This study tested the hypothesis that GM-CSF improves neutrophil phagocytosis in critically ill patients in whom phagocytosis is known to be impaired. METHODS This was a multicentre, phase IIa randomised, placebo-controlled clinical trial. Using a personalised medicine approach, only critically ill patients with impaired neutrophil phagocytosis were included. Patients were randomised 1:1 to subcutaneous GM-CSF (3 μg/kg/day) or placebo, once daily for 4 days. The primary outcome measure was neutrophil phagocytosis 2 days after initiation of GM-CSF. Secondary outcomes included neutrophil phagocytosis over time, neutrophil functions other than phagocytosis, monocyte HLA-DR expression and safety. RESULTS Thirty-eight patients were recruited from five intensive care units (17 randomised to GM-CSF). Mean neutrophil phagocytosis at day 2 was 57.2% (SD 13.2%) in the GM-CSF group and 49.8% (13.4%) in the placebo group, p=0.73. The proportion of patients with neutrophil phagocytosis≥50% at day 2, and monocyte HLA-DR, appeared significantly higher in the GM-CSF group. Neutrophil functions other than phagocytosis did not appear significantly different between the groups. The most common adverse event associated with GM-CSF was fever. CONCLUSIONS GM-CSF did not improve mean neutrophil phagocytosis at day 2, but was safe and appeared to increase the proportion of patients with adequate phagocytosis. The study suggests proof of principle for a pharmacological effect on neutrophil function in a subset of critically ill patients.
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Affiliation(s)
- Emma M Pinder
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony J Rostron
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | - Jonathan Scott
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - James G Macfarlane
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Wiscombe
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - John D Widdrington
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | | | - Simon V Baudouin
- Intensive Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Thomas Chadwick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jatinder K Juss
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Susan A Bowett
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jennie Parker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | | | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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20
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Conway Morris A, Gadsby N, McKenna JP, Hellyer TP, Dark P, Singh S, Walsh TS, McAuley DF, Templeton K, Simpson AJ, McMullan R. 16S pan-bacterial PCR can accurately identify patients with ventilator-associated pneumonia. Thorax 2016; 72:1046-1048. [PMID: 27974525 PMCID: PMC5738539 DOI: 10.1136/thoraxjnl-2016-209065] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/10/2016] [Accepted: 10/01/2016] [Indexed: 11/23/2022]
Abstract
Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >104 colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (Ct) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for Ct in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics.
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Affiliation(s)
- Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Naomi Gadsby
- Department of Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - James P McKenna
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Intensive Care Unit, Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | - Suveer Singh
- Intensive Care Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | - Timothy S Walsh
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast, UK.,Intensive Care Unit, Royal Victoria Infirmary, Belfast, UK
| | - Kate Templeton
- Department of Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Ronan McMullan
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK.,Centre for Infection and Immunity, Queen's University Belfast, UK
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21
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Hellyer TP, Anderson NH, Parker J, Dark P, Van Den Broeck T, Singh S, McMullan R, Agus AM, Emerson LM, Blackwood B, Gossain S, Walsh TS, Perkins GD, Morris AC, McAuley DF, Simpson AJ. Erratum to: 'Effectiveness of biomarker-based exclusion of ventilator-acquired pneumonia to reduce antibiotic use (VAPrapid-2): study protocol for a randomised controlled trial'. Trials 2016; 17:465. [PMID: 27669981 PMCID: PMC5037580 DOI: 10.1186/s13063-016-1594-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/13/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
| | - Niall H Anderson
- Centre for Population Health Sciences, University of Edinburgh, Medical School, Edinburgh, UK
| | - Jennie Parker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre & Intensive Care Unit, Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | | | - Suveer Singh
- Intensive Care Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | - Ronan McMullan
- Department of Medical Microbiology, Kelvin Building, The Royal Hospitals, Belfast, UK
| | - Ashley M Agus
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Belfast, UK
| | - Lydia M Emerson
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Savita Gossain
- Public Health Laboratory, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Tim S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Gavin D Perkins
- University of Warwick and Heart of England NHS Foundation Trust, Coventry, UK
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Daniel F McAuley
- Centre for Population Health Sciences, University of Edinburgh, Medical School, Edinburgh, UK.,Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Hellyer TP, Anderson NH, Parker J, Dark P, Van Den Broeck T, Singh S, McMullan R, Agus AM, Emerson LM, Blackwood B, Gossain S, Walsh TS, Perkins GD, Conway Morris A, McAuley DF, Simpson AJ. Effectiveness of biomarker-based exclusion of ventilator-acquired pneumonia to reduce antibiotic use (VAPrapid-2): study protocol for a randomised controlled trial. Trials 2016; 17:318. [PMID: 27422026 PMCID: PMC4947254 DOI: 10.1186/s13063-016-1442-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 06/24/2016] [Indexed: 02/21/2023] Open
Abstract
Background Ventilator-acquired pneumonia (VAP) is a common reason for antimicrobial therapy in the intensive care unit (ICU). Biomarker-based diagnostics could improve antimicrobial stewardship through rapid exclusion of VAP. Bronchoalveloar lavage (BAL) fluid biomarkers have previously been shown to allow the exclusion of VAP with high confidence. Methods/Design This is a prospective, multi-centre, randomised, controlled trial to determine whether a rapid biomarker-based exclusion of VAP results in fewer antibiotics and improved antimicrobial management. Patients with clinically suspected VAP undergo BAL, and VAP is confirmed by growth of a potential pathogen at > 104 colony-forming units per millilitre (CFU/ml). Patients are randomised 1:1, to either a ‘biomarker-guided recommendation on antibiotics’ in which BAL fluid is tested for IL-1β and IL-8 in addition to routine microbiology testing, or to ‘routine use of antibiotics’ in which BAL undergoes routine microbiology testing only. Clinical teams are blinded to intervention until 6 hours after randomisation, when biomarker results are reported to the clinician. The primary outcome is a change in the frequency distribution of antibiotic-free days (AFD) in the 7 days following BAL. Secondary outcome measures include antibiotic use at 14 and 28 days; ventilator-free days; 28-day mortality and ICU mortality; sequential organ failure assessment (SOFA) at days 3, 7 and 14; duration of stay in critical care and the hospital; antibiotic-associated infections; and antibiotic-resistant pathogen cultures up to hospital discharge, death or 56 days. A healthcare-resource-utilisation analysis will be calculated from the duration of critical care and hospital stay. In addition, safety data will be collected with respect to performing BAL. A sample size of 210 will be required to detect a clinically significant shift in the distribution of AFD towards more patients having fewer antibiotics and therefore more AFD. Discussion This trial will test whether a rapid biomarker-based exclusion of VAP results in rapid discontinuation of antibiotics and therefore improves antibiotic management in patients with suspected VAP. Trial registration ISRCTN65937227. Registered on 22 August 2013. ClinicalTrials.gov, NCT01972425. Registered on 24 October 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1442-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
| | - Niall H Anderson
- Centre for Population Health Sciences, University of Edinburgh, Medical School, Edinburgh, UK
| | - Jennie Parker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre & Intensive Care Unit, Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | | | - Suveer Singh
- Intensive Care Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | - Ronan McMullan
- Department of Medical Microbiology, Kelvin Building, The Royal Hospitals, Belfast, UK
| | - Ashley M Agus
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Belfast, UK
| | - Lydia M Emerson
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Savita Gossain
- Public Health Laboratory, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Tim S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Gavin D Perkins
- University of Warwick and Heart of England NHS Foundation Trust, Coventry, UK
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Daniel F McAuley
- Northern Ireland Clinical Trials Unit, Elliot Dynes Building, The Royal Hospitals, Belfast, UK.,Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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23
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Nolan TJ, Gadsby NJ, Hellyer TP, Templeton KE, McMullan R, McKenna JP, Rennie J, Robb CT, Walsh TS, Rossi AG, Conway Morris A, Simpson AJ. Low-pathogenicity Mycoplasma spp. alter human monocyte and macrophage function and are highly prevalent among patients with ventilator-acquired pneumonia. Thorax 2016; 71:594-600. [PMID: 27071419 PMCID: PMC4941152 DOI: 10.1136/thoraxjnl-2015-208050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/12/2016] [Accepted: 02/04/2016] [Indexed: 12/02/2022]
Abstract
BACKGROUND Ventilator-acquired pneumonia (VAP) remains a significant problem within intensive care units (ICUs). There is a growing recognition of the impact of critical-illness-induced immunoparesis on the pathogenesis of VAP, but the mechanisms remain incompletely understood. We hypothesised that, because of limitations in their routine detection, Mycoplasmataceae are more prevalent among patients with VAP than previously recognised, and that these organisms potentially impair immune cell function. METHODS AND SETTING 159 patients were recruited from 12 UK ICUs. All patients had suspected VAP and underwent bronchoscopy and bronchoalveolar lavage (BAL). VAP was defined as growth of organisms at >10(4) colony forming units per ml of BAL fluid on conventional culture. Samples were tested for Mycoplasmataceae (Mycoplasma and Ureaplasma spp.) by PCR, and positive samples underwent sequencing for speciation. 36 healthy donors underwent BAL for comparison. Additionally, healthy donor monocytes and macrophages were exposed to Mycoplasma salivarium and their ability to respond to lipopolysaccharide and undertake phagocytosis was assessed. RESULTS Mycoplasmataceae were found in 49% (95% CI 33% to 65%) of patients with VAP, compared with 14% (95% CI 9% to 25%) of patients without VAP. Patients with sterile BAL fluid had a similar prevalence to healthy donor BAL fluid (10% (95% CI 4% to 20%) vs 8% (95% CI 2% to 22%)). The most common organism identified was M. salivarium. Blood monocytes from healthy volunteers incubated with M. salivarium displayed an impaired TNF-α response to lipopolysaccharide (p=0.0003), as did monocyte-derived macrophages (MDMs) (p=0.024). MDM exposed to M. salivarium demonstrated impaired phagocytosis (p=0.005). DISCUSSION AND CONCLUSIONS This study demonstrates a high prevalence of Mycoplasmataceae among patients with VAP, with a markedly lower prevalence among patients with suspected VAP in whom subsequent cultures refuted the diagnosis. The most common organism found, M. salivarium, is able to alter the functions of key immune cells. Mycoplasmataceae may contribute to VAP pathogenesis.
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Affiliation(s)
- T J Nolan
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - N J Gadsby
- Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - T P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | | | - R McMullan
- Centre for Infection and Immunity, Queen's University, Belfast, UK
| | - J P McKenna
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK
| | - J Rennie
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - C T Robb
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - T S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - A G Rossi
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - A Conway Morris
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - A J Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
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Hellyer TP, Ewan V, Wilson P, Simpson AJ. The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. J Intensive Care Soc 2016; 17:238-243. [PMID: 28979497 DOI: 10.1177/1751143716644461] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ventilator-associated pneumonia is an important healthcare-associated infection. Interventions for the prevention of ventilator-associated pneumonia are often used within bundles of care. Recent evidence has challenged widespread practices mandating a review of subject. This article outlines guidance for ventilator-associated pneumonia prevention.
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Affiliation(s)
- Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Victoria Ewan
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Wilson
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Scott J, Harris GJ, Pinder EM, Macfarlane JG, Hellyer TP, Rostron AJ, Conway Morris A, Thickett DR, Perkins GD, McAuley DF, Widdrington JD, Wiscombe S, Baudouin SV, Roy AI, Linnett VC, Wright SE, Ruchaud-Sparagano MH, Simpson AJ. Exchange protein directly activated by cyclic AMP (EPAC) activation reverses neutrophil dysfunction induced by β2-agonists, corticosteroids, and critical illness. J Allergy Clin Immunol 2015; 137:535-44. [PMID: 26388312 DOI: 10.1016/j.jaci.2015.07.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 06/20/2015] [Accepted: 07/14/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neutrophils play a role in the pathogenesis of asthma, chronic obstructive pulmonary disease, and pulmonary infection. Impaired neutrophil phagocytosis predicts hospital-acquired infection. Despite this, remarkably few neutrophil-specific treatments exist. OBJECTIVES We sought to identify novel pathways for the restoration of effective neutrophil phagocytosis and to activate such pathways effectively in neutrophils from patients with impaired neutrophil phagocytosis. METHODS Blood neutrophils were isolated from healthy volunteers and patients with impaired neutrophil function. In healthy neutrophils phagocytic impairment was induced experimentally by using β2-agonists. Inhibitors and activators of cyclic AMP (cAMP)-dependent pathways were used to assess the influence on neutrophil phagocytosis in vitro. RESULTS β2-Agonists and corticosteroids inhibited neutrophil phagocytosis. Impairment of neutrophil phagocytosis by β2-agonists was associated with significantly reduced RhoA activity. Inhibition of protein kinase A (PKA) restored phagocytosis and RhoA activity, suggesting that cAMP signals through PKA to drive phagocytic impairment. However, cAMP can signal through effectors other than PKA, such as exchange protein directly activated by cyclic AMP (EPAC). An EPAC-activating analog of cAMP (8CPT-2Me-cAMP) reversed neutrophil dysfunction induced by β2-agonists or corticosteroids but did not increase RhoA activity. 8CPT-2Me-cAMP reversed phagocytic impairment induced by Rho kinase inhibition but was ineffective in the presence of Rap-1 GTPase inhibitors. 8CPT-2Me-cAMP restored function to neutrophils from patients with known acquired impairment of neutrophil phagocytosis. CONCLUSIONS EPAC activation consistently reverses clinical and experimental impairment of neutrophil phagocytosis. EPAC signals through Rap-1 and bypasses RhoA. EPAC activation represents a novel potential means by which to reverse impaired neutrophil phagocytosis.
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Affiliation(s)
- Jonathan Scott
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graham J Harris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma M Pinder
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - James G Macfarlane
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anthony J Rostron
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew Conway Morris
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - David R Thickett
- Centre for Translational Inflammation Research, University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Gavin D Perkins
- Warwick Medical School Clinical Trials Unit and Heart of England Foundation Trust, University of Warwick, Coventry, United Kingdom
| | - Daniel F McAuley
- Centre for Infection and Immunity, Health Sciences Building, Queen's University Belfast, Belfast, United Kingdom; Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - John D Widdrington
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sarah Wiscombe
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simon V Baudouin
- Department of Anaesthetics, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Vanessa C Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead, United Kingdom
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | | | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Nolan TJ, Gadsby N, Hellyer TP, Templeton K, McMullan R, McKenna J, Rennie J, Robb CT, Walsh TS, Rossi AG, Simpson AJ, Morris A. Low-pathogenicity mycoplasma species induce immunoparesis and are highly prevalent amongst patients with ventilator-associated pneumonia. Crit Care 2015. [PMCID: PMC4470596 DOI: 10.1186/cc14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Browne E, Hellyer TP, Baudouin SV, Conway Morris A, Linnett V, McAuley DF, Perkins GD, Simpson AJ. A national survey of the diagnosis and management of suspected ventilator-associated pneumonia. BMJ Open Respir Res 2014; 1:e000066. [PMID: 25553248 PMCID: PMC4275666 DOI: 10.1136/bmjresp-2014-000066] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/10/2014] [Accepted: 11/12/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) affects up to 20% of patients admitted to intensive care units (ICU). It is associated with increased morbidity, mortality and healthcare costs. Despite published guidelines, variability in diagnosis and management exists, the extent of which remains unclear. We sought to characterise consultant opinions surrounding diagnostic and management practice for VAP in the UK. METHODS An online survey was sent to all consultant members of the UK Intensive Care Society (n=∼1500). Data were collected regarding respondents' individual practice in the investigation and management of suspected VAP including use of diagnostic criteria, microbiological sampling, chest X-ray (CXR), bronchoscopy and antibiotic treatments. RESULTS 339 (23%) responses were received from a broadly representative spectrum of ICU consultants. All respondents indicated that microbiological confirmation should be sought, the majority (57.8%) stating they would take an endotracheal aspirate prior to starting empirical antibiotics. Microbiology reporting services were described as qualitative only by 29.7%. Only 17% of respondents had access to routine reporting of CXRs by a radiologist. Little consensus exists regarding technique for bronchoalveolar lavage (BAL) with the reported volume of saline used ranging from 5 to 500 mL. 24.5% of consultants felt inadequately trained in bronchoscopy. CONCLUSIONS There is wide variability in the approach to diagnosis and management of VAP among UK consultants. Such variability challenges the reliability of the diagnosis of VAP and its reported incidence as a performance indicator in healthcare systems. The data presented suggest increased radiological and microbiological support, and standardisation of BAL technique, might improve this situation.
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Affiliation(s)
- Emma Browne
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Simon V Baudouin
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Andrew Conway Morris
- MRC Centre for Inflammation Research, University of Edinburgh, and Critical Care NHS Lothian , Edinburgh , UK
| | - Vanessa Linnett
- Queen Elizabeth Hospital, Gateshead Health NHS Trust , Gateshead , UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast and Regional Intensive Care Unit, Royal Victoria Hospital Belfast , Belfast , Northern Ireland
| | - Gavin D Perkins
- Warwick Medical School and Heart of England NHS Foundation Trust , Birmingham , UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
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28
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Hellyer TP, Morris AC, McAuley DF, Walsh TS, Anderson NH, Singh S, Dark P, Roy AI, Baudouin SV, Wright SE, Perkins GD, Kefala K, Jeffels M, McMullan R, O'Kane CM, Spencer C, Laha S, Robin N, Gossain S, Gould K, Ruchaud-Sparagano MH, Scott J, Browne EM, MacFarlane JG, Wiscombe S, Widdrington JD, Dimmick I, Laurenson IF, Nauwelaers F, Simpson AJ. Diagnostic accuracy of pulmonary host inflammatory mediators in the exclusion of ventilator-acquired pneumonia. Thorax 2014; 70:41-7. [PMID: 25298325 PMCID: PMC4992819 DOI: 10.1136/thoraxjnl-2014-205766] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Excessive use of empirical antibiotics is common in critically ill patients. Rapid biomarker-based exclusion of infection may improve antibiotic stewardship in ventilator-acquired pneumonia (VAP). However, successful validation of the usefulness of potential markers in this setting is exceptionally rare. OBJECTIVES We sought to validate the capacity for specific host inflammatory mediators to exclude pneumonia in patients with suspected VAP. METHODS A prospective, multicentre, validation study of patients with suspected VAP was conducted in 12 intensive care units. VAP was confirmed following bronchoscopy by culture of a potential pathogen in bronchoalveolar lavage fluid (BALF) at >10(4) colony forming units per millilitre (cfu/mL). Interleukin-1 beta (IL-1β), IL-8, matrix metalloproteinase-8 (MMP-8), MMP-9 and human neutrophil elastase (HNE) were quantified in BALF. Diagnostic utility was determined for biomarkers individually and in combination. RESULTS Paired BALF culture and biomarker results were available for 150 patients. 53 patients (35%) had VAP and 97 (65%) patients formed the non-VAP group. All biomarkers were significantly higher in the VAP group (p<0.001). The area under the receiver operator characteristic curve for IL-1β was 0.81; IL-8, 0.74; MMP-8, 0.76; MMP-9, 0.79 and HNE, 0.78. A combination of IL-1β and IL-8, at the optimal cut-point, excluded VAP with a sensitivity of 100%, a specificity of 44.3% and a post-test probability of 0% (95% CI 0% to 9.2%). CONCLUSIONS Low BALF IL-1β in combination with IL-8 confidently excludes VAP and could form a rapid biomarker-based rule-out test, with the potential to improve antibiotic stewardship.
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Affiliation(s)
- Thomas P Hellyer
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Conway Morris
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK Department of Anaesthesia, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Daniel F McAuley
- Centre for Infection and Immunity, Health Sciences Building, Queen's University Belfast, Belfast, UK Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
| | - Timothy S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Niall H Anderson
- Centre for Population Health Sciences, University of Edinburgh, Medical School, Edinburgh, UK
| | - Suveer Singh
- Intensive Care Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre & Intensive Care Unit, Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Simon V Baudouin
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK Intensive Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Gavin D Perkins
- University of Warwick and Heart of England NHS Foundation Trust, Coventry, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Melinda Jeffels
- Newcastle Clinical Trials Unit, William Leech Building, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ronan McMullan
- Department of Medical Microbiology, Kelvin Building, The Royal Hospitals, Belfast, UK
| | - Cecilia M O'Kane
- Centre for Infection and Immunity, Health Sciences Building, Queen's University Belfast, Belfast, UK
| | - Craig Spencer
- Intensive Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Shondipon Laha
- Intensive Care Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Nicole Robin
- Intensive Care Unit, Countess of Chester NHS Trust, Chester, UK
| | - Savita Gossain
- Public Health Laboratory, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Kate Gould
- Public Health England & Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | | | - Jonathan Scott
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Emma M Browne
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - James G MacFarlane
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Wiscombe
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - John D Widdrington
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Dimmick
- Bioscience Centre (West Wing), International Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Ian F Laurenson
- Department of Clinical Microbiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - A John Simpson
- Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK
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