Introduction The development of resistance by bacterial species is a compelling issue to reconsider indications and administration of antibiotic treatment. Adequate indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care setting. Until recently, no laboratory marker has been available to differentiate bacterial infection from viral or non-infectious inflammatory reaction; however, over the past years, procalcitonin (PCT) is the first among a large array of inflammatory variables that offers this possibility. The present study aimed to investigate the clinical usefulness of PCT for guiding antibiotic therapy in surgical intensive care patients.
Background: Septic shock and SIRS are life-threatening diseases with persistent high mortality.Hemoadsorption with CytoSorb ® offers a possible therapeutic approach, but the optimal timing, dosing and indications are still unclear.Methods: Observational data from 70 patients with septic shock or SIRS, treated in a university hospital with hemoadsorption by CytoSorb ® in addition to renal replacement therapy were analyzed retrospectively. Physiologic parameters and clinical outcomes were extracted from the electronic charts. The predicted mortality was calculated based on APACHE II and SOFA scores and compared with the actual 28-day survival. The total amount of blood puri ed was correlated with outcome.Results: The main origins of septic shock were abdominal (n=29) or pulmonary (n=22). The mean age was 70.6±13.3 years. Hemoadsorption was applied for 85.6±53.8h with 3.2±1.7 cycles lasting 26.75±11.1h each. The severity was characterized by a mean APACHE II score of 30.2±6.3 and SOFA score of 13.8±3.5, which calculated to a predicted mortality of 73.3% and 62.1%, respectively. The observed mortality was signi cantly lower (35/70 patients (50%), p<0.05). Interleukin-6 levels at baseline were high (survivors: 7964±11242pg/ml; nonsurvivors: 8.755±15.800pg/ml, p=0.27) and decreased rapidly within 4-24h. Survival was independently associated with lower IL-6 levels and norepinephrine dosage after 24h. An increase in IL-6 after 48h was predictive of poor outcome.The treatment duration and amount of blood puri ed was higher in survivors than in non-survivors (8.47±4.42 vs. 6.07±3.57l/kg BW, p=0.017). We identi ed 3 clusters of <6l/kg, 6-13l/kg and ≥13l/kg BW with a linear dose-response relation between blood puri cation volume and survival. Although the predicted mortality was comparable among the clusters (p=ns), survival was best in the highest volume cluster (16.7%; p=0.045).Conclusions: The application of CytoSorb ® seems to be safe and effective in various conditions of septic shock and SIRS, although the optimal duration and dosing remain unclear. In a cohort of severely ill patients the observed mortality rate was lower than predicted and decreased linearly with blood puri cation volumes exceeding 6l/kg BW. These results suggest that hemoadsorption with CytoSorb ® improves survival in septic shock or SIRS, provided that the applied dose is high enough.
The “normal” immune response to an insult triggers a highly regulated response determined by the interaction of various immunocompetent cells with pro- and anti-inflammatory cytokines. Under pathologic conditions, the massive elevation of cytokine levels (“cytokine storm”) could not be controlled until the recent development of hemoadsorption devices that are able to extract a variety of different DAMPs, PAMPs, and metabolic products from the blood. CytoSorb® has been approved for adjunctive sepsis therapy since 2011. This review aims to summarize theoretical knowledge, in vitro results, and clinical findings to provide the clinician with pragmatic guidance for daily practice. English-language and peer-reviewed literature identified by a selective literature search in PubMed and published between January 2016 and May 2021 was included. Hemoadsorption can be used successfully as adjunct to a complex therapeutic regimen for various conditions. To the contrary, this nonspecific intervention may potentially worsen patient outcomes in complex immunological processes. CytoSorb® therapy appears to be safe and useful in various diseases (e.g., rhabdomyolysis, liver failure, or intoxications) as well as in septic shock or cytokine release syndrome, although a conclusive assessment of treatment benefit is not possible and no survival benefit has yet been demonstrated in randomized controlled trials.
The development of resistance by infective bacterial species is an incentive to reconsider the indications and administration of available antibiotics. Correct recognition of the indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care situation. There has as yet been no clinical chemical parameter which is capable of specifically distinguishing a bacterial infection from a viral or non-infectious inflammatory reaction, but it now appears that procalcitonin (PCT) offers this possibility. The present study was intended to clarify whether PCT can be used to guide antibiotic therapy in surgical intensive care patients. A total of 110 patients in a surgical intensive care ward receiving antibiotic therapy after confirmed infection or a high grade suspicion of infection were enrolled in this study. In 57 of these patients a new decision was reached each day as to whether the antibiotic therapy should be continued after daily PCT determination and clinical assessment. The control group consisted of 53 patients with a standardized duration of antibiotic therapy over 8 days. Demographic and clinical data were comparable in both groups. However, in the PCT group the duration of antibiotic therapy was significantly shorter compared to controls (5.9+/-1.7 vs. 7.9+/-0.5 days, p<0.001) without unfavorable effects on clinical outcome.
Background The COVID-19 pandemic has taken a toll on health care systems worldwide, which has led to increased mortality of different diseases like myocardial infarction. This is most likely due to three factors. First, an increased workload per nurse ratio, a factor associated with mortality. Second, patients presenting with COVID-19-like symptoms are isolated, which also decreases survival in cases of emergency. And third, patients hesitate to see a doctor or present themselves at a hospital. To assess if this is also true for sepsis patients, we asked whether non-COVID-19 sepsis patients had an increased 30-day mortality during the COVID-19 pandemic. Methods This is a post hoc analysis of the SepsisDataNet.NRW study, a multicentric, prospective study that includes septic patients fulfilling the SEPSIS-3 criteria. Within this study, we compared the 30-day mortality and disease severity of patients recruited pre-pandemic (recruited from March 2018 until February 2020) with non-COVID-19 septic patients recruited during the pandemic (recruited from March 2020 till December 2020). Results Comparing septic patients recruited before the pandemic to those recruited during the pandemic, we found an increased raw 30-day mortality in sepsis-patients recruited during the pandemic (33% vs. 52%, p = 0.004). We also found a significant difference in the severity of disease at recruitment (SOFA score pre-pandemic: 8 (5 - 11) vs. pandemic: 10 (8 - 13); p < 0.001). When adjusted for this, the 30-day mortality rates were not significantly different between the two groups (52% vs. 52% pre-pandemic and pandemic, p = 0.798). Conclusions This led us to believe that the higher mortality of non-COVID19 sepsis patients during the pandemic might be attributed to a more severe septic disease at the time of recruitment. We note that patients may experience a delayed admission, as indicated by elevated SOFA scores. This could explain the higher mortality during the pandemic and we found no evidence for a diminished quality of care for critically ill sepsis patients in German intensive care units.
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