Search

Mitochondria play an essential role in energy metabolism. Oxygen deprivation can poison cells and generate a chain reaction due to the free radical release. In patients with sepsis, the kidneys tend to be the organ primarily affected and the proximal renal tubules are highly susceptible to energy metabolism imbalances. Dynamin-related protein 1 (DRP1) is an essential regulator of mitochondrial fission. Few studies have confirmed the role and mechanism of DRP1 in acute kidney injury (AKI) caused by sepsis. We established animal and cell sepsis-induced AKI (S-AKI) models to keep DRP1 expression high. We found that Mdivi-1, a DRP1 inhibitor, can reduce the activation of the NOD-like receptor pyrin domain-3 (NLRP3) inflammasome-mediated pyroptosis pathway and improve mitochondrial function. Both S-AKI models showed that Mdivi-1 was able to prevent the mitochondrial content release and decrease the expression of NLRP3 inflammasome-related proteins. In addition, silencing NLRP3 gene expression further emphasized the pyroptosis importance in S-AKI occurrence. Our results indicate that the possible mechanism of action of Mdivi-1 is to inhibit mitochondrial fission and protect mitochondrial function, thereby reducing pyroptosis. These data can provide a potential theoretical basis for Mdivi-1 potential use in the S-AKI prevention. [ABSTRACT FROM AUTHOR]

Introduction: Sepsis is one of the most common causes of mortality in postnatal women globally and many other women who develop sepsis are left with severe morbidity. Women's knowledge of postnatal sepsis and how it can be prevented by simple changes to behaviour is lacking. Methods: This paper describes the co-development and feasibility testing of a digital animation intervention called DAISI (digital animation in service improvement). This DAISI is designed to enhance postnatal women's awareness of sepsis and how to reduce their risk of developing the condition. We co-designed the digital animation over a six-month period underpinned by theory, best evidence and key stakeholders, translated it into Urdu then assessed its use, firstly in a focus group with women from different Black, Asian and Minority Ethnic (BAME) groups and secondly with 15 clinical midwives and 15 women (including BAME women). Following exposure to the intervention, midwives completed a questionnaire developed from the COM-B behaviour change model and women participated in individual and focus group interviews using similar questions. Results: The animation was considered acceptable, culturally sensitive and simple to implement and follow. Discussion: DAISI appears to be an innovative solution for use in maternity care to address difficulties with the postnatal hospital discharge process. We could find no evidence of digital animation being used in this context and recommend a study to test it in practice prior to adopting its use more widely. If effective, the DAISI principle could be used in other maternity contexts and other areas of the NHS to communicate health promotion information. [ABSTRACT FROM AUTHOR]

Objective: Infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-PB) can range from asymptomatic bacteriuria and febrile or non-febrile urinary tract infection (UTI) to sepsis. Cleaning of rectal mucosa with topical antiseptics such as povidone iodine or chlorhexidine before the procedure are alternative prophylaxis methods. We aimed to investigate the effects of these two different topical antiseptic agents on infectious complications and their superiority to each other. Material and methods: The study was conducted with 200 patients. Rectal mucosa cleansings were performed in 50 patients with povidone iodine and 49 patients with chlorhexidine. The remaining 101 patients did not receive any antiseptic treatment. The results were examined according to the hospital admissions or hospitalization for the first 30 days after the procedure due to UTI, body temperature >38.5°C, sepsis, hematuria, rectal bleeding, and urinary retention. Results: The mean age of study population was 63.3±7.26 years, and the mean prostate specific antigen value was 13.96±29.5 ng/mL. Acute prostatitis occurred in 14 patients (7%), 9 of whom were hospitalized due to sepsis after TRUS-PB. Statistically significant less acute prostatitis was observed in those patients who were treated with topical rectal antisepsis (topical rectal antisepsis 2% vs. no rectal antisepsis 12.1%, p=0.01). Chlorhexidine and povidone iodine were not superior to each other in terms of inhibiting the development of acute prostatitis (chlorhexidine 2% vs. povidone iodine 2%, p=1.00). Conclusion: Rectal mucosal cleansing with chlorhexidine or povidone iodine before TRUS-PB prevented the development of sepsis due to acute prostatitis. We recommend that this effective method, which is easy to apply, cheap, reliable, easily tolerated should be used in all prostate biopsy practice. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess risk factors of urosepsis after minimally invasive percutaneous nephrolithotomy (MPCNL) for the treatment of upper urinary tract stones in patients with preoperative urinary tract infection (UTI) and to explore preventive measures. Between 2008 and 2016, patients with preoperative UTI who underwent MPCNL for upper urinary tract stones were retrospectively collected. Patients were divided into nonurosepsis and urosepsis groups. Perioperative outcomes of all patients were evaluated and compared between the two groups. Risk factors for post-MPCNL urosepsis were investigated using univariate and multivariate regression analysis. A total of 843 patients including 22 patients with postoperative urosepsis (urosepsis group) and 821 patients without urosepsis (nonurosepsis group) were finally included in this study. All patients with postoperative urosepsis were cured and discharged after treatment. In univariate analysis it was demonstrated that the incidence of urosepsis after MPCNL was significantly correlated with channel size (P = 0.001), surgical time (P = 0.003), as well as the tear of the collection system and percutaneous renal channel crossing the renal papilla (P = 0.004). Moreover, multivariate analysis showed that smaller channel size (OR = 11.192, 95% CI: 2.425–51.650, P = 0.002), longer surgical time (OR = 6.762, 95% CI: 1.712–17.844, P = 0.008), and tear of collection system and percutaneous renal channel crossing the renal papilla (OR = 5.531, 95% CI 1.228–14.469, P = 0.012) were independent risk factors for urosepsis following MPCNL in patients with preoperative UTI. In conclusion, in patients with preoperative UTI undergoing MPCNL for upper urinary tract stones, smaller channel size, prolonged operation time, as well as tear of the collection system and percutaneous renal channel crossing the renal papilla are independent risk factors for postoperative urosepsis. Therefore, it is indicated that, in clinical practice, it is of great significance to choose appropriate channel size and avoid renal injury and control surgical time to prevent the urosepsis after MPCNL in patients with preoperative UTI. [ABSTRACT FROM AUTHOR]

Pediatric sepsis is a major public health concern, and robust surveillance tools are needed to characterize its incidence, outcomes, and trends. The increasing use of electronic health records (EHRs) in the United States creates an opportunity to conduct reliable, pragmatic, and generalizable population-level surveillance using routinely collected clinical data rather than administrative claims or resource-intensive chart review. In 2015, the US Centers for Disease Control and Prevention recruited sepsis investigators and representatives of key professional societies to develop an approach to adult sepsis surveillance using clinical data recorded in EHRs. This led to the creation of the adult sepsis event definition, which was used to estimate the national burden of sepsis in adults and has been adapted into a tool kit to facilitate widespread implementation by hospitals. In July 2018, the Centers for Disease Control and Prevention convened a new multidisciplinary pediatric working group to tailor an EHR-based national sepsis surveillance approach to infants and children. Here, we describe the challenges specific to pediatric sepsis surveillance, including evolving clinical definitions of sepsis, accommodation of agedependent physiologic differences, identifying appropriate EHR markers of infection and organ dysfunction among infants and children, and the need to account for children with medical complexity and the growing regionalization of pediatric care. We propose a preliminary pediatric sepsis event surveillance definition and outline next steps for refining and validating these criteria so that they may be used to estimate the national burden of pediatric sepsis and support site-specific surveillance to complement ongoing initiatives to improve sepsis prevention, recognition, and treatment. [ABSTRACT FROM AUTHOR]

Background Sepsis is a leading cause of neonatal mortality in low-resource settings. As facility-based births become more common, the proportion of neonatal deaths due to hospital-onset sepsis has increased. Methods We conducted a prospective cohort study in a neonatal intensive care unit in Zambia where we implemented a multifaceted infection prevention and control (IPC) bundle consisting of IPC training, text message reminders, alcohol hand rub, enhanced environmental cleaning, and weekly bathing of babies ≥1.5 kg with 2% chlorhexidine gluconate. Hospital-associated sepsis, bloodstream infection (BSI), and mortality (>3 days after admission) outcome data were collected for 6 months prior to and 11 months after bundle implementation. Results Most enrolled neonates had a birth weight ≥1.5 kg (2131/2669 [79.8%]). Hospital-associated mortality was lower during the intervention than baseline period (18.0% vs 23.6%, respectively). Total mortality was lower in the intervention than prior periods. Half of enrolled neonates (50.4%) had suspected sepsis; 40.8% of cultures were positive. Most positive blood cultures yielded a pathogen (409/549 [74.5%]), predominantly Klebsiella pneumoniae (289/409 [70.1%]). The monthly rate and incidence density rate of suspected sepsis were lower in the intervention period for all birth weight categories, except babies weighing <1.0 kg. The rate of BSI with pathogen was also lower in the intervention than baseline period. Conclusions A simple IPC bundle can reduce sepsis and death in neonates hospitalized in high-risk, low-resource settings. Further research is needed to validate these findings in similar settings and to identify optimal implementation strategies for improvement and sustainability. Clinical Trials Registration NCT02386592. [ABSTRACT FROM AUTHOR]

The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required. [ABSTRACT FROM AUTHOR]

Purpose: To determine the epidemiology and outcome of severe sepsis and septic shock after 9 years of the implementation of the Surviving Sepsis Campaign (SSC) and to build a mortality prediction model. Methods: This is a prospective, multicenter, observational study performed during a 5-month period in 2011 in a network of 11 intensive care units (ICUs). We compared our findings with those obtained in the same ICUs in a study conducted in 2002. Results: The current cohort included 262 episodes of severe sepsis and/or septic shock, and the 2002 cohort included 324. The prevalence was 14% (95% confidence interval: 12.5-15.7) with no differences to 2002. The population-based incidence was 31 cases/100 000 inhabitants/year. Patients in 2011 had a significantly lower Acute Physiology and Chronic Health Evaluation II (APACHE II; 21.9 ± 6.6 vs 25.5 ± 7.07), Logistic Organ Dysfunction Score (5.6 ± 3.2 vs 6.3 ± 3.6), and Sequential Organ Failure Assessment (SOFA) scores on day 1 (8 ± 3.5 vs 9.6 ± 3.7; P <.01). The main source of infection was intraabdominal (32.5%) although microbiologic isolation was possible in 56.7% of cases. The 2011 cohort had a marked reduction in 48-hour (7% vs 14.8%), ICU (27.2% vs 48.2%), and in-hospital (36.7% vs 54.3%) mortalities. Most relevant factors associated with death were APACHE II score, age, previous immunosuppression and liver insufficiency, alcoholism, nosocomial infection, and Delta SOFA score. Conclusion: Although the incidence of sepsis/septic shock remained unchanged during a 10-year period, the implementation of the SSC guidelines resulted in a marked decrease in the overall mortality. The lower severity of patients on ICU admission and the reduced early mortality suggest an improvement in early diagnosis, better initial management, and earlier antibiotic treatment. [ABSTRACT FROM AUTHOR]

The timely administration of intrapartum antibiotic prophylaxis (IAP) to eligible pregnant mothers reduces the risk of early onset Group B Streptococcus (GBS) neonatal sepsis. The incidence of neonatal GBS sepsis is increasing, in spite of national guidelines for its prevention. This retrospective cohort study was undertaken to assess the incidence of culture-proven GBS sepsis before and after a change of practice on intrapartum management of GBS sepsis in babies born at Sunderland Royal Hospital between January 1 2008 and December 31 2017. The data regarding the risk factors, the intrapartum antibiotic prophylaxis and the outcomes of the babies were collected. Twenty-nine cases were identified and presented in two epochs-before and after changing guidelines for intrapartum management. There was a statistically significant reduction in early onset sepsis rates and no difference in late-onset sepsis rates. The prolonged rupture of membranes is a significant risk factor at any gestation. Impact statement What is already known on this subject? Appropriate intrapartum administration of antibiotics in mothers reduces 80% of early-onset GBS infections. In the United Kingdom, IAP is given based on risk factors, which fail to accurately identify and treat the woman who harbours GBS in the birth canal in labour and the incidence of GBS neonatal sepsis is increasing. The national guideline on the prevention of GBS sepsis is not consistent and is open to interpretation. What do the results of this study add? This study highlights prolonged rupture of membranes as a significant risk factor at any gestation and there were missed opportunities to prevent GBS sepsis in term babies with the prolonged rupture of membranes. This study also highlights that it is possible to reduce the neonatal GBS sepsis burden by adhering to guidelines and administering timely intrapartum antibiotics. What are the implications of these findings for clinical practice and/or further research? The timely administration of IAP to all eligible women is possible if the national guidelines are consistent and interpreted correctly. Our national guideline on the prolonged rupture of membranes at term is not clear and is interpreted differently. If IAP is provided in all those with risk factors irrespective of gestation, this would involve additional costs to the NHS; but in the long term, it will benefit as it reduces morbidity. [ABSTRACT FROM AUTHOR]

The article discusses the use of an early waning system at Texas Children's Hospital in Houston to prevent sepsis in children. The hospital has participated in a national effort to prevent deaths and organ damage caused by sepsis. The hospital's initiative shows the effect of the lack of any specific diagnostic test and the development of ways to improve the delivery of antibiotics to patients with sepsis.

Enterocutaneous fistula is an abnormal connection between the gastrointestinal tract and skin. Management includes early recognition and treatment of sepsis, reducing fluid and electrolyte homeostasis, nutrition support, wound management and a carefully timed surgical procedure. A multidisciplinary approach is required for successful management of these patients with one of the most challenging and resource-demanding aspects being local control of the effluent, requiring the skill and support of the specialist stoma care nurse. The inability to contain the fistula can be a source of morbidity for the patient, as they will experience pain and severe discomfort from the skin when leakages occur. Enterocutaneous fistula can result in intestinal failure, which is often fatal if not managed correctly. [ABSTRACT FROM AUTHOR]

Highlights • Sepsis is a common and life-threatening syndrome, and a leading cause of morbidity and mortality globally. • We performed a meta-analysis of observational studies to quantify the performance of a machine learning model to predict sepsis. • For machine learning models, the pooled area under receiving operating curve (SAUROC) for predicting sepsis onset 3 to 4 h before, was 0.89 (95%CI: 0.86–0.92); sensitivity 0.81 (95%CI:0.80–0.81), and specificity 0.72 (95%CI:0.72–0.72). Abstract Study objective Sepsis is a common and major health crisis in hospitals globally. An innovative and feasible tool for predicting sepsis remains elusive. However, early and accurate prediction of sepsis could help physicians with proper treatments and minimize the diagnostic uncertainty. Machine learning models could help to identify potential clinical variables and provide higher performance than existing traditional low-performance models. We therefore performed a meta-analysis of observational studies to quantify the performance of a machine learning model to predict sepsis. Methods A comprehensive literature search was conducted through the electronic database (e.g. PubMed, Scopus, Google Scholar, EMBASE, etc.) between January 1, 2000, and March 1, 2018. All the studies published in English and reporting the sepsis prediction using machine learning algorithms were considered in this study. Two authors independently extracted valuable information from the included studies. Inclusion and exclusion of studies were based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Results A total of 7 out of 135 studies met all of our inclusion criteria. For machine learning models, the pooled area under receiving operating curve (SAUROC) for predicting sepsis onset 3 to 4 h before, was 0.89 (95%CI: 0.86–0.92); sensitivity 0.81 (95%CI:0.80–0.81), and specificity 0.72 (95%CI:0.72–0.72) whereas the pooled SAUROC for SIRS, MEWS, and SOFA was 0.70, 0.50, and 0.78. Additionally, diagnostic odd ratio for machine learning, SIRS, MEWS, and SOFA was 15.17 (95%CI: 9.51–24.20), 3.23 (95%CI: 1.52–6.87), 31.99 (95% CI: 1.54–666.74), and 3.75(95%CI: 2.06–6.83). Conclusion Our study findings suggest that the machine learning approach had a better performance than the existing sepsis scoring systems in predicting sepsis. [ABSTRACT FROM AUTHOR]

Background: Infections acquired in hospital are an important cause of morbidity and mortality in very preterm infants. Several small trials have suggested that supplementing the enteral diet of very preterm infants with lactoferrin, an antimicrobial protein processed from cow's milk, prevents infections and associated complications. The aim of this large randomised controlled trial was to collect data to enhance the validity and applicability of the evidence from previous trials to inform practice.Methods: In this randomised placebo-controlled trial, we recruited very preterm infants born before 32 weeks' gestation in 37 UK hospitals and younger than 72 h at randomisation. Exclusion criteria were presence of a severe congenital anomaly, anticipated enteral fasting for longer than 14 days, or no realistic prospect of survival. Eligible infants were randomly assigned (1:1) to receive either enteral bovine lactoferrin (150 mg/kg per day; maximum 300 mg/day; lactoferrin group) or sucrose (same dose; control group) once daily until 34 weeks' postmenstrual age. Web-based randomisation minimised for recruitment site, gestation (completed weeks), sex, and single versus multifetal pregnancy. Parents, caregivers, and outcome assessors were unaware of group assignment. The primary outcome was microbiologically confirmed or clinically suspected late-onset infection (occurring >72 h after birth), which was assessed in all participants for whom primary outcome data was available by calculating the relative risk ratio with 95% CI between the two groups. The trial is registered with the International Standard Randomised Controlled Trial Number 88261002.Findings: We recruited 2203 participants between May 7, 2014, and Sept 28, 2017, of whom 1099 were assigned to the lactoferrin group and 1104 to the control group. Four infants had consent withdrawn or unconfirmed, leaving 1098 infants in the lactoferrin group and 1101 in the sucrose group. Primary outcome data for 2182 infants (1093 [99·5%] of 1098 in the lactoferrin group and 1089 [99·0] of 1101 in the control group) were available for inclusion in the modified intention-to-treat analyses. 316 (29%) of 1093 infants in the intervention group acquired a late-onset infection versus 334 (31%) of 1089 in the control group. The risk ratio adjusted for minimisation factors was 0·95 (95% CI 0·86-1·04; p=0·233). During the trial there were 16 serious adverse events for infants in the lactoferrin group and 10 for infants in the control group. Two events in the lactoferrin group (one case of blood in stool and one death after intestinal perforation) were assessed as being possibly related to the trial intervention.Interpretation: Enteral supplementation with bovine lactoferrin does not reduce the risk of late-onset infection in very preterm infants. These data do not support its routine use to prevent late-onset infection and associated morbidity or mortality in very preterm infants.Funding: UK National Institute for Health Research Health Technology Assessment programme (10/57/49). [ABSTRACT FROM AUTHOR]

Background The intestinal microbiota has increasingly been considered to play a role in the etiology of late-onset sepsis (LOS). We hypothesize that early alterations in fecal volatile organic compounds (VOCs), reflecting intestinal microbiota composition and function, allow for discrimination between infants developing LOS and controls in a preclinical stage. Methods In 9 neonatal intensive care units in the Netherlands and Belgium, fecal samples of preterm infants born at a gestational age ≤30 weeks were collected daily, up to the postnatal age of 28 days. Fecal VOC were measured by high-field asymmetric waveform ion mobility spectrometry (FAIMS). VOC profiles of LOS infants, up to 3 days prior to clinical LOS onset, were compared with profiles from matched controls. Results In total, 843 preterm born infants (gestational age ≤30 weeks) were included. From 127 LOS cases and 127 matched controls, fecal samples were analyzed by means of FAIMS. Fecal VOCs allowed for preclinical discrimination between LOS and control infants. Focusing on individual pathogens, fecal VOCs differed significantly between LOS cases and controls at all predefined time points. Highest accuracy rates were obtained for sepsis caused by Escherichia coli, followed by sepsis caused by Staphylococcus aureus and Staphylococcus epidermidis. Conclusions Fecal VOC analysis allowed for preclinical discrimination between infants developing LOS and matched controls. Early detection of LOS may provide clinicians a window of opportunity for timely initiation of individualized therapeutic strategies aimed at prevention of sepsis, possibly improving LOS-related morbidity and mortality. [ABSTRACT FROM AUTHOR]

Although the concept of pre-operative optimisation is traditionally applied to elective surgery, there is ample opportunity to apply similar principles to patients undergoing emergency laparotomy. The key challenge is achieving meaningful improvements in a patient's condition without introducing delays to time-sensitive surgery, which may be required in a matter of hours. Optimisation can be considered in two parts: that of the patient's condition; and that of the care pathway. Optimising the patient's condition is less about improving long-term pathology, and more about correcting physiological derangement, such as electrolyte and fluid balance, blood loss, prompt treatment of sepsis, and ensuring appropriate continuation of medication in the peri-operative period. Optimising the care pathway involves ensuring that the system is designed to deliver reliably the appropriate interventions, such as prompt antibiotics, and access to computed tomography scanning and the operating theatre with minimal delay. [ABSTRACT FROM AUTHOR]

Pelargonidin (PEL) is a well-known red pigment found in plants, and it has been reported to have important biological activities that are potentially beneficial for human health. This study was initiated to determine whether PEL could modulate renal functional damage in a mouse model of sepsis, and to elucidate the underlying mechanisms. The potential of PEL treatment to reduce renal damage induced by cecal ligation and puncture (CLP) surgery in mice was measured by assessment of serum creatinine, blood urea nitrogen (BUN), lipid peroxidation, total glutathione, glutathione peroxidase (GSH-Px) activity, catalase activity, and superoxide dismutase (SOD) activity. Treatment with PEL resulted in elevated plasma levels of BUN and creatinine, and of protein in urine in mice with CLP-induced renal damage. Moreover, PEL inhibited nuclear factor-κB activation and reduced the induction of nitric oxide synthase and excessive production of nitric acid. PEL treatment also reduced the plasma levels of interleukin-6 and tumor necrosis factor-α reduced lethality due to CLP-induced sepsis, increased lipid peroxidation, and markedly enhanced the antioxidant defense system by restoring the levels of SOD, GSH-Px, and catalase in kidney tissues. These results suggested that PEL protects mice against sepsis-triggered renal injury. [ABSTRACT FROM AUTHOR]

Background: A novel fecal diverting device (FDD) made for the prevention of sepsis resulting from anastomotic leakage (AL) was tested successfully in an animal study. This study was undertaken to evaluate the clinical safety and effectiveness of the FDD.Methods: A prospective observation trial was implemented in a tertiary referral university hospital. The study enrolled patients who needed a defunctioning stoma to preserve low-lying rectal anastomosis. The FDD was fixed to the proximal colon 15 cm from the anastomosis and scheduled to divert feces for 3 weeks. The duration could be extended for more than 3 weeks if AL was noted. Postoperative evaluations of AL were performed by obtaining a computed tomography (CT) scan after 1 week and a contrast study after 3 weeks. The outcomes were FDD-related complications, and the capacity of the FDD to preserve the anastomosis. The median follow-up period was 10 (range 5-40) months.Results: Thirty-one patients, including 5 benign cases, were evaluated. There was no case of stoma conversion or surgical re-intervention. Evidence of AL was identified in 10 (32%) patients using the CT scan at 1 week after surgery. However, in the contrast study at 3 weeks after surgery, only 5 cases of AL sinus were noted. Conservative treatments including 1-3 weeks prolongation of FDD maintenance were enough to preserve the anastomosis. There were 3 cases of partial colonic wall erosions at the FDD attachment area. All of these patients showed improvement with conservative treatment. The limitations were that the study was performed in a single institute and without a control group.Conclusions: The FDD showed a sufficient capacity of fecal diversion and maintenance duration that prevented aggravation of sepsis in the case of AL without significant complications. [ABSTRACT FROM AUTHOR]

Aim: Late-onset sepsis (LOS) is a frequent and important cause of morbidity and mortality in newborn infants admitted to neonatal intensive care units (NICUs). The objective of this study is to evaluate the impact of various infection control quality measures introduced as a bundle on the trends of the LOS in a NICU.Methods: This was a prospective quality improvement study involving all neonates admitted to a NICU over a 15-year period between 2002 and 2016. The main focus areas of the bundle included collaborative team effort, hand hygiene, education, central line insertion and maintenance bundles and parenteral nutrition. The main outcome measures were LOS and central line-associated bloodstream infections.Results: Yearly admissions increased during study period, from 776 in 2002 to 952 in 2016. There was a progressive decrease in LOS rate, from 4.3 to 1.6 per 1000 patient days (B coefficient -0.17, 95% confidence interval -0.25, -0.09; P < 0.001), and the central line-associated bloodstream infection rate dropped from 25 in 2003 to 5 in 2016 per 1000 central line days (B coefficient -1.20, 95% confidence interval -1.84, -0.56; P = 0.001). Hand hygiene compliance rates remained consistent, over 80%. During the study period, coagulase-negative staphylococcus caused 56% and Gram-negative organisms 18% of the total infections.Conclusion: Multifaceted infection control bundle practices with a concerted team effort in the implementation, with continuing education, feedback and reinforcement of best infection control practices, can sustain the gains achieved by infection control for a long period of time. [ABSTRACT FROM AUTHOR]

Background: Sepsis is a common condition affecting the lives of infants and children worldwide. Although implementation of the surviving sepsis campaign (SSC) care bundles was once believed to be effective in reducing sepsis mortality rates, the approach has recently been questioned. Methods: The study was a prospective, interventional, multicenter trial. Infants and children aged 1 month to 15 years in seven different large academic centers in Thailand who had been diagnosed with severe sepsis or septic shock. They were given treatment based on the SSC care bundles. Results: A total of 519 children with severe sepsis or septic shock were enrolled in the study. Among these, 188 were assigned to the intervention group and 331 were recruited to the historical case–control group. There were no significant differences in the baseline clinical characteristics. The intervention group was administered a significantly higher fluid bolus than was the control group (28.3 ± 17.2 cc/kg vs. 17.7 ± 10.6 cc/kg; P = 0.02) with early vasopressor used (1.5 ± 0.7 h) compared to control group (7.4 ± 2.4 h, P < 0.05). More importantly, our sepsis mortality reduced significantly from 37% ± 20.7% during the preintervention period to 19.4% ± 14.3% during the postintervention period (P < 0.001). Conclusion: Our study demonstrated a significant reduction in sepsis mortality after the implementation of the SSC care bundles. Early diagnosis of the disease, optimum hemodynamic resuscitation, and timely antibiotic administration are the key elements of sepsis management. [ABSTRACT FROM AUTHOR]

Background: Sepsis is a life‐threatening systemic condition that appears to be increasing in the obstetric population. Clinical detection can be difficult and may result in increased morbidity via delays in the continuum of patient care. Aims: To describe the burden of severe maternal morbidity (SMM) caused by sepsis in New Zealand and investigate the potential preventability. Methods: A multidisciplinary expert review panel was established to review cases of obstetric sepsis admitted to intensive care or high‐dependency units over an 18 month span in New Zealand. Cases were then analysed for the characteristics of infection and their preventability. Results: Fifty cases met the inclusion criteria, most commonly due to uterine, respiratory or kidney infection. Fifty per cent (25) of these cases were deemed potentially preventable, predominantly due to delays in diagnosis and treatment. Conclusions: A high index of suspicion, development of early recognition systems and multi‐disciplinary training are recommended to decrease preventable cases of maternal sepsis. [ABSTRACT FROM AUTHOR]

Background/Aims: the pathogenesis of sepsis-associated encephalopathy (SAE) is multifactorial, involving neurotransmitter alterations, inflammatory cytokines, oxidative damage, mitochondrial dysfunction, apoptosis, and other factors. Mitochondria are major producers of reactive oxygen species, resulting in cellular injury. Omi/HtrA2 is a proapoptotic mitochondrial serine protease involved in caspase-dependent cell death; it is translocated from mitochondria to the cytosol after an apoptotic insult. We previously found that UCF-101, a specific inhibitor of Omi/HtrA2, has neuroprotective effects on cerebral oxidative injury and cognitive impairment in septic rats. In this study, the mechanisms and molecular pathways underlying these effects were investigated. Methods: Male Sprague–Dawley rats were subjected to cecal ligation and puncture (CLP) or sham-operated laparotomy and were administered vehicle or UCF-101 (10 µmol/kg). The hippocampus was isolated for subsequent analysis. Omi/HtrA2 expression in the mitochondria or cytosol was evaluated by immunofluorescence or western blotting. Terminal deoxynucleotidyl transferase dUTP nick end labeling staining was utilized to evaluate levels of apoptosis, and western blotting was used to evaluate apoptosis-related proteins, such as cleaved caspase-3, caspase-9, and poly (ADP-ribose) polymerase (PARP). Tight junction expression was assessed by immunofluorescence and western blotting. Mitochondrial function, inflammatory cytokines, and oxidative stress were also assayed. In addition, a wet/dry method was used to evaluate brain edema and Evans blue extravasation was used to evaluate blood–brain barrier (BBB) integrity. Results: After CLP treatment, the hippocampus exhibited a mild increase in Omi/HtrA2 expression; cytosolic Omi/HtrA2 expression increased significantly, whereas mitochondrial Omi/HtrA2 expression was reduced, indicating that CLP-induced oxidative stress resulted in the translocation of Omi/HtrA2 from mitochondria to the cytosol. Hippocampal cleaved caspase-3, caspase-9, and PARP levels were significantly higher in animals treated with CLP than in sham-operated animals, while XIAP expression was lower. Treatment with UCF-101 prevented the mobilization of Omi/HtrA2 from mitochondria to the cytosol, attenuated XIAP degradation, and decreased cleaved caspase-3, caspase-9, and PARP expression as well as apoptosis. UCF-101 also reversed the decreased mitochondrial complex I, II, and III respiration and the reduced ATP caused by CLP. In addition, UCF-101 treatment resulted in a significant improvement in BBB integrity, as demonstrated by increased occludin, claudin-5, and zonula occludens 1 levels and reduced Evans blue extravasation. No significant effects of UCF-101 on brain edema were found. Inflammatory cytokines and oxidative stress were significantly higher in the CLP-treated group than in the sham-operated group. However, the inhibition of Omi/HtrA2 by UCF-101 significantly alleviated these responses. Conclusion: Our data indicated that Omi/ HtrA2 regulates a mitochondria-dependent apoptotic pathway in a murine model of septic encephalopathy. Inhibition of Omi/HtrA2 by UCF-101 leads to neuroprotection by inhibiting the cytosolic translocation of Omi/HtrA2 and antagonizing the caspase-dependent apoptosis pathway. Therapeutic interventions that inhibit Omi/HtrA2 translocation or protease activity may provide a novel method to treat SAE. [ABSTRACT FROM AUTHOR]

Background: A defunctioning stoma is used primarily to protect the anastomosis and prevent pelvic sepsis after bowel surgery. Aim of the work: This study was aimed to compare early stoma closure with conventional stoma closure following defunctioning diversion stoma surgery with respect to the frequency of complications, health-related quality of life (QOL), and length of hospitalization (LOH). Patients and Methods: This study was designed as a prospective parallel-arm randomized controlled trial. 40 patients who underwent temporary stoma following colorectal cancer surgery were enrolled in this study. The rate of complications (medical and surgical) following early (20 patients) and conventional (20 patients) stoma closure was assessed. Health-related QOL and LOH were also measured. Results: Forty patients were included, with 20 cases in each group. Postoperative complications including wound dehiscence (15% vs. 15%; P = 1.00), wound infection (40% vs. 5%; P = 0.023), intra-abdominal collection (15% vs. 30%; P = 0.449), anastomotic leak (15%vs. 30%; P = 0.449) were comparable. The length of hospital stays and overall mortality and morbidity were similar across the two groups. There was a significant reduction in the cost towards stoma care in the early stoma closure group. Furthermore, Patients in the early stoma closure group also had a significantly better QOL. Conclusion: Early stoma closure does not carry an increased risk of postoperative complications, reduces cost towards stoma care, and leads to better a QOL. [ABSTRACT FROM AUTHOR]

Sepsis is a severe clinical syndrome owing to its high mortality. Quick Sequential Organ Failure Assessment (qSOFA) score has been proposed for the prediction of fatal outcomes in sepsis syndrome in emergency departments. Due to the low predictive performance of the qSOFA score, we propose a modification to the score by adding age. We conducted a multicenter, retrospective cohort study among regional referral centers from various regions of the country. Participants recruited data of patients admitted to emergency departments and obtained a diagnosis of sepsis syndrome. Crude in-hospital mortality was the primary endpoint. A generalized mixed-effects model with random intercepts produced estimates for adverse outcomes. Model-based recursive partitioning demonstrated the effects and thresholds of significant covariates. Scores were internally validated. The H measure compared performances of scores. A total of 580 patients from 22 centers were included for further analysis. Stages of sepsis, age, time to antibiotics, and administration of carbapenem for empirical treatment were entered the final model. Among these, severe sepsis (OR, 4.40; CIs, 2.35–8.21), septic shock (OR, 8.78; CIs, 4.37–17.66), age (OR, 1.03; CIs, 1.02–1.05) and time to antibiotics (OR, 1.05; CIs, 1.01–1.10) were significantly associated with fatal outcomes. A decision tree demonstrated the thresholds for age. We modified the quick Sequential Organ Failure Assessment (mod-qSOFA) score by adding age (> 50 years old = one point) and compared this to the conventional score. H-measures for qSOFA and mod-qSOFA were found to be 0.11 and 0.14, respectively, whereas AUCs of both scores were 0.64. We propose the use of the modified qSOFA score for early risk assessment among sepsis patients for improved triage and management of this fatal syndrome. [ABSTRACT FROM AUTHOR]

CONTEXT: Human and bovine colostrum (HBC) administration has been linked to beneficial effects on morbidity and mortality associated with necrotizing enterocolitis (NEC). OBJECTIVES: To determine the effectiveness and safety of HBC for reducing NEC, mortality, sepsis, time to full-feed and feeding intolerance in preterm infants. DATA SOURCES: We conducted searches through Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and gray literature. STUDY SELECTION: Randomized controlled trials comparing human or bovine colostrum to placebo. DATA EXTRACTION: Two reviewers independently did screening, review, and extraction. RESULTS: Eight studies (385 infants) proved eligible. In comparison with placebo, HBC revealed no effect on the incidence of severe NEC (relative risk [RR]: 0.99; 95% confidence interval [CI] 0.48 to 2.02, I² = 2.2%; moderate certainty of evidence), all-cause mortality (RR: 0.88; 95% CI 0.39 to 1.82, I² = 0%; moderate certainty), culture-proven sepsis (RR: 0.78; 95% CI 0.53 to 1.14, I² = 0%; moderate certainty), and feed intolerance (RR: 0.97; 95% CI 0.37 to 2.56, I² = 55%; low certainty). HBC revealed a significant effect on reducing the mean days to reach full enteral feed (mean difference: -3.55; 95% CI 0.33 to 6.77, I² = 41.1%; moderate certainty). The indirect comparison of bovine versus human colostrum revealed no difference in any outcome. LIMITATIONS: The number of patients was modest, whereas the number of NEC-related events was low. CONCLUSIONS: Bovine or human colostrum has no effect on severe NEC, mortality, culture- proven sepsis, feed intolerance, or length of stay. Additional research focused on the impact on enteral feeding may be needed to confirm the findings on this outcome. [ABSTRACT FROM AUTHOR]

Background: Surgical treatment for low rectal cancer septic complications often requires an ileostomy for fecal diversion. Delayed coloanal anastomosis (CAA) has been performed for several years to reduce septic complications and to avoid ileostomy. The aim of this study was to report the technical, functional and oncological results of delayed CAA in patients operated on for low rectal cancer focusing on pelvic septic complications.Methods: All consecutive patients operated on for low rectal cancer suitable for total mesorectal excision and two-step delayed CAA at a single institution between May 2000 and September 2013 were included in the study. Patients’ characteristics, operative and postoperative outcomes, long-term technical, functional and oncological results from a prospectively maintained database, were retrospectively analyzed.Results: A total of 85 consecutive patients (69 men), of median age 63 years (range 42-83 years) were included. Median delay between the first and the second step of the operation was 6 days (range 2-13 days). Twenty-one patients (25%) developed pelvic sepsis, nine of them (10.6%) developed an anastomotic leak. Twenty-three patients had a definitive stoma at the end of follow-up. Seventeen patients (29%) experienced a poor functional result. Thirty-three patients (38%) presented with recurrence at a median follow-up of 59 months (range 12-135 months). Seven (8.2%) developed a local recurrence, 18 a distant metastasis (21.1%) and 8 (9.4%) both a local and distant recurrence.Conclusions: In our series, laparoscopic total mesorectal excision with delayed coloanal anastomosis was associated with septic complications and oncologic results similar to those reported after total mesorectal excision with conventional anastomosis and ileostomy, nearly one-third of patients experience a poor functional result. A randomized trial comparing these two options for low rectal cancer is under way. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to investigate the trend of incidence and outcome of paediatric sepsis in a population-based database.Methods: Children with sepsis were identified from the 23 million nationwide health insurance claims database of Taiwan. Sepsis was defined by the presence of single ICD-9 code for severe sepsis or septic shock or a combination of ICD-9 codes for infection and organ dysfunction. We analysed the trend of incidence, mortality and source of infection in three age groups: infant (28 days to 1 year), child (1-9 years) and adolescent (10-18 years).Results: From 2002 to 2012, we identified 38 582 paediatric patients with sepsis, of which 21.3% were infants, 52.8% were children and 25.8% were adolescents. The incidence of sepsis was 336.4 cases per 100 000 population in infants, 3.3 times higher than in children (101.5/100 000 cases) and 7.3 times higher than in adolescents (46.2/100 000 cases). While sepsis incidence decreased from 598.0 to 336.4 cases per 100 000 people in the infant population, it remained relatively unchanged in children and adolescents. For 90-day mortality, there were significant decreases in all three age groups (absolute decrease of 5.0% for infants, 3.7% for children and 14.4% for the adolescents). In the infant population, we observed a decrease in the incidence of lower respiratory tract infections, while the incidence of urinary tract infections remained unchanged.Conclusions: The incidence and mortality of sepsis among paediatric patients have decreased substantially between 2002 and 2012, especially among infants. The widespread use of Haemophilus influenzae and pneumococcal vaccines in infants could be a possible explanation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Bacterial contamination of platelets remains a major transfusion‐associated risk despite long‐standing safety measures in the United States. We evaluated an approach using secondary bacterial culture (SBC) to contend with residual risk of bacterial contamination. STUDY DESIGN AND METHODS: Phased implementation of SBC was initiated in October 2016 for platelets (all apheresis collected) received at our institution from the blood donor center (Day 3 post collection). Platelet products were sampled aseptically (5 mL inoculated into an aerobic bottle [BacT/ALERT BPA, BioMerieux, Inc.]) by the blood bank staff upon receipt, using a sterile connection device and sampling kit. The platelet sample was inoculated into an aerobic blood culture bottle and incubated at 35°C for 3 days. The cost of SBC was calculated on the basis of consumables and labor costs at time of implementation. RESULTS: In the 13 months following implementation (October 6, 2016, to November 30, 2017), 23,044/24,653 (93.47%) platelet products underwent SBC. A total of eight positive cultures were detected (incidence 1 in 2881 platelet products), seven of which were positive within 24 hours of SBC. Coagulase negative Staphyloccus spp. were identified in four cases. Five of the eight cases were probable true positive (repeat reactive) and interdicted (cost per averted case was US$77,935). The remaining three cases were indeterminate. No septic transfusion reactions were reported during the observation period. CONCLUSION: We demonstrate the feasibility of SBC of apheresis platelets to mitigate bacterial risk. SBC is lower cost than alternative measures (e.g., pathogen reduction and point‐of‐release testing) and can be integrated into workflow at hospital transfusion services. [ABSTRACT FROM AUTHOR]

The article presents questions and answers related to large-caliber central access via the subclavian vein, including situations that require inserting a large-caliber central venous line, patient positioning and the benefits of an ultrasound-guided internal jugular or femoral line.

This section offers news briefs pertaining to nursing as of February 1, 2020. Topics discussed include health technology hazards, the benefits of introducing a digital sepsis alert system into a multisite hospital network, and the results of a survey which show that one in five registered nurses holds a second job.

Background: More than a million people a year in the United States experience sepsis or sepsis-related complications, and sepsis remains the leading cause of in-hospital deaths. Unlike many other leading causes of in-hospital mortality, sepsis detection and treatment are not dependent on the presence of any technology or services that differ between tertiary and non-tertiary hospitals.Objective: To compare sepsis mortality rates between tertiary and non-tertiary hospitals in Washington State.Methods: A retrospective longitudinal, observational cohort study of 73 Washington State hospitals for 2010-2015 using data from a standardized state database of hospital abstracts. Abstract records on adult patients (n = 86,378) admitted through the emergency department (ED) from 2010 through 2015 in all tertiary (n = 7) and non-tertiary (n = 66) hospitals in Washington State.Results: The overall mortality rate for all hospitals was 6.5%. In the fully adjusted model, the odds ratio for in-hospital death was higher in non-tertiary hospitals compared with tertiary hospitals (odds ratio 1.25; 95% confidence interval 1.17-1.35; p < 0.001).Conclusions: We observed higher sepsis mortality rates in non-tertiary hospitals, compared with tertiary hospitals. Because most patients who are treated for sepsis are treated outside of tertiary hospitals, and the number of patients treated for sepsis in non-tertiary hospitals seems to be rising, a better understanding of the cause or causes for this differential is crucial. [ABSTRACT FROM AUTHOR]

Objective: To compare 3 prophylactic regimens to assess their impact on postbiopsy sepsis incidence.Methods: Data were reviewed for 829 consecutive patients who underwent prostate biopsy in a community practice setting between January 2013 and October 2017. Group 1 patients received ciprofloxacin 500 mg two times a day orally for 4 days starting the day prior to biopsy and gentamicin 80 mg intramuscularly 20 minutes prior to biopsy. From April 2015 to October 2017, 2 groups of patients were followed in parallel in a randomized manner. Group 2 received ciprofloxacin 500 mg two times a day orally for 4 days starting the day prior to biopsy and ceftriaxone 1 g intramuscularly 20 minutes prior to biopsy. Group 3 received the same antibiotic regimen as group 2 and also underwent isopropyl alcohol needle washing.Results: All study groups were demographically equivalent. Microscopic bacterial counts were substantially decreased after isopropyl alcohol needle washing. Incidence of postbiopsy sepsis in groups 1 (n = 313), 2 (n = 259), and 3 (n = 257) was 3.8%, 2%, and 0%, respectively (analysis of variance; P = .006). Risk factors for sepsis included elevated body mass index, Charlson Comorbidity Score, and presence of type 2 diabetes mellitus.Conclusion: There was a significant reduction in the incidence of sepsis after prostate biopsy using a combination of a ciprofloxacin-ceftriaxone antibiotic regimen and isopropyl alcohol needle washing. The technique for needle washing is inexpensive and quick, and can be easily adopted into current biopsy protocols. [ABSTRACT FROM AUTHOR]

The article provides information on various prospects of sepsis which include recognition, early management, and diagnosis. Topics discussed include recommendations for families having patients of sepsis; use of algorithms for treatment location and remote assessment of risks; and non-malignant disorders.

Background: Women are discharged home from hospital increasingly early, but there is little evidence examining the postnatal hospital discharge process and how this may impact on the health of women and babies. In particular, there is little on sepsis prevention advice, despite it being the biggest direct cause of maternal mortality. Aim: To explore the perceptions of women and senior student midwives related to the postnatal hospital discharge process and maternal sepsis prevention advice. Methods: Three focus group interviews were undertaken, involving 9 senior student midwives and 14 women attending paid or specialist classes for vulnerable migrant women. Findings: All participants believed that the postnatal hospital discharge process was inadequate, rushed and inconsistent. Sepsis advice was patchy and the condition underplayed. Conclusions: Cost effective, time-efficient and innovative ways to impart vital information are required to support the postnatal hospital discharge process. [ABSTRACT FROM AUTHOR]

The aim of this first study was to reveal the new potential biomarkers by a metabolomics approach in severe septic calves. Sepsis is a common cause of morbidity and mortality in newborn dairy calves. The main challenges with the use of biomarkers of sepsis in domestic animals are their availability, cost, and time required to obtain a result. Metabolomics may offer the potential to identify biomarkers that define calf sepsis in terms of combined clinical, physiological, and pathobiological abnormalities. To our knowledge, this is the first study presenting an NMR- (nuclear magnetic resonance-) based plasma metabolomics at set intervals in neonatal septic calves. Twenty neonatal dairy calves with severe sepsis and ten healthy calves were used. Hematological and biochemical health profiles were gathered in plasma samples at set intervals. Similarly, NMR spectra were acquired. All diseased animals (except one) died after 72 hours. Clinical and laboratory results were in accordance with those of severe septic animals. Multivariate analysis on NMR plasma spectra proved to be an excellent tool for faster identification of calves with severe sepsis from healthy animals. The NMR-based metabolomic profile may contribute to the better understanding of severe sepsis in newborn calves. [ABSTRACT FROM AUTHOR]

Acute intestinal ischemic injury (i3) is a life-threatening condition with disastrous prognosis, which is currently difficult to diagnose at the early stages of the disease; a rapid diagnosis is mandatory to avoid irreversible ischemia, extensive bowel resection, sepsis and death. The overlapping protein expression of liver and gut related to the complex physiopathology of the disease, the heterogeneity of the disease and its relative rarity could explain the lack of a useful early biochemical marker of i3. Apart from non-specific biological markers of thrombosis, hypoxia inflammation, and infection, several more specific biomarkers in relation with the gut barrier dysfunction, the villi injury and the enterocyte mass have been used in the diagnosis of acute i3. It includes particularly D-lactate, intestinal fatty acid-binding protein (FABP) and citrulline. Herein, we will discuss leading publications concerning these historical markers that point out the main limitations reagrding their use in routine clinical practice. We will also introduce the first and limited results arising from omic studies, underlying the remaining effort that needs to be done in the field of acute i3 biological diagnosis, which remains a challenge. [ABSTRACT FROM AUTHOR]

BACKGROUND: Septic shock is characterized by dysregulation of the host response to infection, with circulatory, cellular, and metabolic abnormalities. We hypothesized that therapy with hydrocortisone plus fludrocortisone or with drotrecogin alfa (activated), which can modulate the host response, would improve the clinical outcomes of patients with septic shock. METHODS: In this multicenter, double-blind, randomized trial with a 2-by-2 factorial design, we evaluated the effect of hydrocortisone-plus-fludrocortisone therapy, drotrecogin alfa (activated), the combination of the three drugs, or their respective placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included mortality at intensive care unit (ICU) discharge and hospital discharge and at day 28 and day 180 and the number of days alive and free of vasopressors, mechanical ventilation, or organ failure. After drotrecogin alfa (activated) was withdrawn from the market, the trial continued with a two-group parallel design. The analysis compared patients who received hydrocortisone plus fludrocortisone with those who did not (placebo group). RESULTS: Among the 1241 patients included in the trial, the 90-day mortality was 43.0% (264 of 614 patients) in the hydrocortisone-plus-fludrocortisone group and 49.1% (308 of 627 patients) in the placebo group (P = 0.03). The relative risk of death in the hydrocortisoneplus- fludrocortisone group was 0.88 (95% confidence interval, 0.78 to 0.99). Mortality was significantly lower in the hydrocortisone-plus-fludrocortisone group than in the placebo group at ICU discharge (35.4% vs. 41.0%, P = 0.04), hospital discharge (39.0% vs. 45.3%, P = 0.02), and day 180 (46.6% vs. 52.5%, P = 0.04) but not at day 28 (33.7% and 38.9%, respectively; P = 0.06). The number of vasopressor-free days to day 28 was significantly higher in the hydrocortisone-plus-fludrocortisone group than in the placebo group (17 vs. 15 days, P<0.001), as was the number of organ-failure-free days (14 vs. 12 days, P = 0.003). The number of ventilator-free days was similar in the two groups (11 days in the hydrocortisone-plus-fludrocortisone group and 10 in the placebo group, P = 0.07). The rate of serious adverse events did not differ significantly between the two groups, but hyperglycemia was more common in hydrocortisone-plus-fludrocortisone group. CONCLUSIONS: In this trial involving patients with septic shock, 90-day all-cause mortality was lower among those who received hydrocortisone plus fludrocortisone than among those who received placebo. [ABSTRACT FROM AUTHOR]

Background: Whether hydrocortisone reduces mortality among patients with septic shock is unclear.Methods: We randomly assigned patients with septic shock who were undergoing mechanical ventilation to receive hydrocortisone (at a dose of 200 mg per day) or placebo for 7 days or until death or discharge from the intensive care unit (ICU), whichever came first. The primary outcome was death from any cause at 90 days.Results: From March 2013 through April 2017, a total of 3800 patients underwent randomization. Status with respect to the primary outcome was ascertained in 3658 patients (1832 of whom had been assigned to the hydrocortisone group and 1826 to the placebo group). At 90 days, 511 patients (27.9%) in the hydrocortisone group and 526 (28.8%) in the placebo group had died (odds ratio, 0.95; 95% confidence interval [CI], 0.82 to 1.10; P=0.50). The effect of the trial regimen was similar in six prespecified subgroups. Patients who had been assigned to receive hydrocortisone had faster resolution of shock than those assigned to the placebo group (median duration, 3 days [interquartile range, 2 to 5] vs. 4 days [interquartile range, 2 to 9]; hazard ratio, 1.32; 95% CI, 1.23 to 1.41; P<0.001). Patients in the hydrocortisone group had a shorter duration of the initial episode of mechanical ventilation than those in the placebo group (median, 6 days [interquartile range, 3 to 18] vs. 7 days [interquartile range, 3 to 24]; hazard ratio, 1.13; 95% CI, 1.05 to 1.22; P<0.001), but taking into account episodes of recurrence of ventilation, there were no significant differences in the number of days alive and free from mechanical ventilation. Fewer patients in the hydrocortisone group than in the placebo group received a blood transfusion (37.0% vs. 41.7%; odds ratio, 0.82; 95% CI, 0.72 to 0.94; P=0.004). There were no significant between-group differences with respect to mortality at 28 days, the rate of recurrence of shock, the number of days alive and out of the ICU, the number of days alive and out of the hospital, the recurrence of mechanical ventilation, the rate of renal-replacement therapy, and the incidence of new-onset bacteremia or fungemia.Conclusions: Among patients with septic shock undergoing mechanical ventilation, a continuous infusion of hydrocortisone did not result in lower 90-day mortality than placebo. (Funded by the National Health and Medical Research Council of Australia and others; ADRENAL ClinicalTrials.gov number, NCT01448109 .). [ABSTRACT FROM AUTHOR]

Sepsis is a common and often devastating medical emergency with a high mortality rate and, in many survivors, long-term morbidity. It is defi ned as the dysregulated host response to infection resulting in organ dysfunction, and its incidence is increasing as the population ages. However, it is a treatable and potentially reversible condition, especially if identifi ed and treated promptly. A sound understanding of sepsis is crucial for optimal care. Although general guidelines are available for management, here we provide a foundation of understanding to encourage thoughtful, personalised management of sepsis during the acute phase. We provide an overview of the epidemiology, the new Sepsis-3 defi nitions, pathophysiology, clinical presentations, and investigation and management of sepsis for the non-expert. [ABSTRACT FROM AUTHOR]

Viral hemorrhagic septicemia is a serious disease that can assume epidemic proportions in cultivated olive flounders in Korea. The causal agent of this disease is viral hemorrhagic septicemia virus (VHSV), and it leads to vast economic losses in the olive flounder aquaculture industry. Therefore, the rapid and accurate detection of VHSV is paramount. At present, the manual of the World Organization for Animal Health's Office International des Epizooties (OIE) for pathogen detection is being followed for VHSV detection in Korea. However, in that manual, the primers for VHSV detection are based on the European VHSV genotype Ia. In this study, we identified 5 VHSV strains from olive flounders in Korea, and the nucleotide and amino acid sequences of VHSV genes (N, P, M, and G) were compared to investigate the genetic variation of VHSV genotypes. As expected, VHSV isolates from Korea were highly related to genotype IVa, clearly differing from the 3 European genotypes. In addition, the N gene showed low genetic variation and therefore might be considered a useful marker for VHSV detection, regardless of genotype. In contrast, the other VHSV genes (P, M, and G) had different nucleotides within genotypes. They might be suitable for designing specific primers for distinguishing between various VHSV genotypes. Duplex RT-PCR using the newly designed primers successfully detected all VHSV isolates and validated the genotype (I and IV) without sequence analysis. According to the results, all the VHSV isolates were successfully detected, and their genotypes were validated by duplex RT-PCR using the newly designed primers. Collectively, our findings suggest that duplex PCR is a convenient and appropriate method for the diagnosis of VHSV isolates in Korean aquaculture systems. [ABSTRACT FROM AUTHOR]

This discussion article focuses on the literature surrounding early warning scoring systems and their use in primary care, specifically within district nursing. Patient deterioration is a global concern, associated with high mortality rates and avoidable deaths. Early recognition and response by nursing and other health care staff has been attributed to early warning scoring systems (EWSS) and tools. However, the use of equivalent tools in the community appears to be lacking. This review concludes that there is no consensus over the use of EWSS in district nursing and culture of practice is varied, rather than standardised. [ABSTRACT FROM AUTHOR]

Sepsis is a leading cause of critical illness and hospital mortality. Early recognition and intervention are essential for the survival of patients with this syndrome. In 2002, the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) launched the Surviving Sepsis Campaign (SSC) to reduce overall patient morbidity and mortality from sepsis and septic shock by driving practice initiatives based on current best evidence. The SSC guidelines have been updated every four years, with the most recent update completed in 2016. The new guidelines have increased the focus on early identification of infection, risks for sepsis and septic shock, rapid antibiotic administration, and aggressive fluid resuscitation to restore tissue perfusion. In 2014, the SCCM and the ESICM convened a task force of specialists to reexamine the definitions of terms used to identify patients along the sepsis continuum. In 2016, this task force published the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The new definitions and recommendations included tools, based on an updated understanding of the pathobiology of sepsis, that can be used to predict adverse outcomes in patients with infection. This article discusses the new SSC treatment guidelines, changes in the sepsis bundle interventions, and the Sepsis-3 definitions and tools, all of which enable nurses to improve patient outcomes through timely collaborative action. [ABSTRACT FROM AUTHOR]

Cerebral blood flow (CBF) autoregulation maintains consistent blood flow across a range of blood pressures (BPs). Sepsis is a common cause of systemic hypotension and cerebral dysfunction. Guidelines for BP management in sepsis are based on historical concepts of CBF autoregulation that have now evolved with the availability of more precise technology for its measurement. In this article, we provide a narrative review of methods of monitoring CBF autoregulation, the cerebral effects of sepsis, and the current knowledge of CBF autoregulation in sepsis. Current guidelines for BP management in sepsis are based on a goal of maintaining mean arterial pressure (MAP) above the lower limit of CBF autoregulation. Bedside tools are now available to monitor CBF autoregulation continuously. These data reveal that individual BP goals determined from CBF autoregulation monitoring are more variable than previously expected. In patients undergoing cardiac surgery with cardiopulmonary bypass, for example, the lower limit of autoregulation varied between a MAP of 40 to 90 mm Hg. Studies of CBF autoregulation in sepsis suggest patients frequently manifest impaired CBF autoregulation, possibly a result of BP below the lower limit of autoregulation, particularly in early sepsis or with sepsis-associated encephalopathy. This suggests that the present consensus guidelines for BP management in sepsis may expose some patients to both cerebral hypoperfusion and cerebral hyperperfusion, potentially resulting in damage to brain parenchyma. The future use of novel techniques to study and clinically monitor CBF autoregulation could provide insight into the cerebral pathophysiology of sepsis and offer more precise treatments that may improve functional and cognitive outcomes for survivors of sepsis. [ABSTRACT FROM AUTHOR]

Background: Maternal sepsis is the underlying cause of 11% of all maternal deaths and a significant contributor to many deaths attributed to other underlying conditions. The effective prevention, early identification and adequate management of maternal and neonatal infections and sepsis can contribute to reducing the burden of infection as an underlying and contributing cause of morbidity and mortality. The objectives of the Global Maternal Sepsis Study (GLOSS) include: the development and validation of identification criteria for possible severe maternal infection and maternal sepsis; assessment of the frequency of use of a core set of practices recommended for prevention, early identification and management of maternal sepsis; further understanding of mother-to-child transmission of bacterial infection; assessment of the level of awareness about maternal and neonatal sepsis among health care providers; and establishment of a network of health care facilities to implement quality improvement strategies for better identification and management of maternal and early neonatal sepsis. Methods: This is a facility-based, prospective, one-week inception cohort study. This study will be implemented in health care facilities located in pre-specified geographical areas of participating countries across the WHO regions of Africa, Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific. During a seven-day period, all women admitted to or already hospitalised in participating facilities with suspected or confirmed infection during any stage of pregnancy through the 42nd day after abortion or childbirth will be included in the study. Included women will be followed during their stay in the facilities until hospital discharge, death or transfer to another health facility. The maximum intra-hospital follow-up period will be 42 days. Discussion: GLOSS will provide a set of actionable criteria for identification of women with possible severe maternal infection and maternal sepsis. This study will provide data on the frequency of maternal sepsis and uptake of effective diagnostic and therapeutic interventions in obstetrics in different hospitals and countries. We will also be able to explore links between interventions and maternal and perinatal outcomes and identify priority areas for action. [ABSTRACT FROM AUTHOR]

The latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths, the fourth in the new annual report format, and the first to repeat the 3‐yearly thematic cycle, was published in December,1 and includes surveillance and Confidential Enquiries covering the period 2013–15. Once again the report includes reviews into the care of women who died during or after pregnancy in the Republic of Ireland as well as the UK. Following the annual topic‐specific format, this report includes topic‐specific reviews into the care of women who died from neurological conditions, other medical and surgical conditions, sepsis, anaesthetic complications, haemorrhage and amniotic fluid embolism, as well as Confidential Enquiries into the care of women with morbidity due to uncontrolled epilepsy in pregnancy and those with severe postpartum mental illness. [ABSTRACT FROM AUTHOR]

Background. Infection is the most important cause of treatment-related morbidity and mortality in pediatric patients treated for acute lymphoblastic leukemia (ALL). Although routine in adults with leukemia, antibacterial prophylaxis is controversial in pediatrics because of insufficient evidence for its efficacy or antibiotic choice and concerns about promoting antibiotic resistance and Clostridium difficile infection. Methods. This was a single-center, observational cohort study of patients with newly diagnosed ALL, comparing prospectively collected infection-related outcomes in patients who received no prophylaxis, levofloxacin prophylaxis, or other prophylaxis during induction therapy on the total XVI study. A propensity score-weighted logistic regression model was used to adjust for confounders. Results. Of 344 included patients, 173 received no prophylaxis, 69 received levofloxacin prophylaxis, and 102 received other prophylaxis regimens. Patients receiving prophylaxis had longer duration of neutropenia. Prophylaxis reduced the odds of febrile neutropenia, likely bacterial infection, and bloodstream infection by ≥70%. Levofloxacin prophylaxis alone reduced these infections, but it also reduced cephalosporin, aminoglycoside, and vancomycin exposure and reduced the odds of C. difficile infection by >95%. No increase in breakthrough infections with antibiotic-resistant organisms was seen, but this cannot be excluded. Conclusions. This is the largest study to date of antibacterial prophylaxis during induction therapy for pediatric ALL and the first to include a broad-spectrum fluoroquinolone. Prophylaxis prevented febrile neutropenia and systemic infection. Levofloxacin prophylaxis also minimized the use of treatment antibiotics and drastically reduced C. difficile infection. Although long-term antibiotic-resistance monitoring is needed, these data support using targeted prophylaxis with levofloxacin in children undergoing induction chemotherapy for ALL. [ABSTRACT FROM AUTHOR]