Alba Luz León

Immunological characterization of compensatory anti-inflammatory response syndrome in patients with severe sepsis: a longitudinal study*.

Objectives:To perform a complete immunological characterization of compensatory anti-inflammatory response syndrome in patients with sepsis and to explore the relationship between these changes and clinical outcomes of 28-day mortality and secondary infections. Design:Prospective single-center study conducted between April 2011 and December 2012. Setting:ICUs from Hospital Universitario San Vicente Fundación at Medellin, Colombia. Patients:One hundred forty-eight patients with severe sepsis. Interventions:None. Measurements and Main Results:At days 0, 1, 3, 5, 10, and 28, we determined the expression of HLA-DR in monocytes and the apoptosis and the proliferation index in T lymphocytes, as well as the levels of tumor necrosis factor-&agr;, interleukin-6, interleukin-1&bgr;, interleukin-10, and transforming growth factor-&bgr; in both plasma and cell culture supernatants of peripheral blood mononuclear cells. The mean percentage of HLA-DR+ was 60.7 at enrollment and increased by 0.9% (95% CI, 0.7–1.2%) per day. The mean percentage of CD4 T cells and CD8 T cells AV+/7-AAD– at enrollment was 37.2% and 20.4%, respectively, but it diminished at a rate of –0.5% (95% CI, –0.7% to –0.3%) and –0.3% (95% CI, –0.4% to –0.2%) per day, respectively. Plasma levels of interleukin-6 and interleukin-10 were 290 and 166 pg/mL and decreased at a rate of –7.8 pg/mL (95% CI, –9.5 to –6.1 pg/mL) and –4 pg/mL (95% CI, –5.1 to –2.8 pg/mL) per day, respectively. After controlling for confounders, only sustained plasma levels of interleukin-6 increase the risk of death (hazard ratio 1.003; 95% CI, 1.001–1.006). Conclusions:We found no evidence to support a two-phase model of sepsis pathophysiology. However, immunological variables did behave in a mixed and time-dependent manner. Further studies should evaluate changes over time of interleukin-6 plasma levels as a prognostic biomarker for critically ill patients.

Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals

BackgroundSepsis has several clinical stages, and mortality rates are different for each stage. Our goal was to establish the evolution and the determinants of the progression of clinical stages, from infection to septic shock, over the first week, as well as their relationship to 7-day and 28-day mortality.MethodsThis is a secondary analysis of a multicenter cohort of inpatients hospitalized in general wards or intensive care units (ICUs). The general estimating equations (GEE) model was used to estimate the risk of progression and the determinants of stages of infection over the first week. Cox regression with time-dependent covariates and fixed covariates was used to determine the factors related with 7-day and 28-day mortality, respectively.ResultsIn 2681 patients we show that progression to severe sepsis and septic shock increases with intraabdominal and respiratory sources of infection [OR = 1,32; 95%IC = 1,20-1,46 and OR = 1.21, 95%CI = 1,11-1,33 respectively], as well as according to Acute Physiology and Chronic Health Evaluation II (APACHE II) [OR = 1,03; 95%CI = 1,02-1,03] and Sequential Organ Failure Assessment (SOFA) [OR = 1,16; 95%CI = 1,14-1,17] scores. The variables related with first-week mortality were progression to severe sepsis [HR = 2,13; 95%CI = 1,13-4,03] and septic shock [HR = 3,00; 95%CI = 1,50-5.98], respiratory source of infection [HR = 1,76; 95%IC = 1,12-2,77], APACHE II [HR = 1,07; 95% CI = 1,04-1,10] and SOFA [HR = 1,09; 95%IC = 1,04-1,15] scores.ConclusionsIntraabdominal and respiratory sources of infection, independently of SOFA and APACHE II scores, increase the risk of clinical progression to more severe stages of sepsis; and these factors, together with progression of the infection itself, are the main determinants of 7-day and 28-day mortality.

Desarrollo y validación de un modelo predictor para bacteriemia en pacientes hospitalizados por el servicio de urgencias con sospecha de infección

BACKGROUND Positive blood cultures usually indicate disseminated infection that is associated with a poor prognosis and higher mortality. We seek to develop and validate a predictive model to identify factors associated with positive blood cultures in emergency patients. METHODS Secondary analysis of data from two prospective cohorts (EPISEPSIS: developing cohort, and DISEPSIS: validation cohort) of patients with suspected or confirmed infection, assembled in emergency services in 10 hospitals in four cities in Colombia between September 2007 and February 2008. A logistic multivariable model was fitted to identify clinical and laboratory variables predictive of positive blood culture. RESULTS We analyzed 719 patients in developing and 467 in validation cohort with 32% and 21% positive blood cultures, respectively. The final predictive model included variables with significant coefficients for both cohorts: temperature > 38° C, Glasgow < 15 and platelet < 150.000 cells/mm³, with calibration (goodness-of-fit H-L) p = 0.0907 and p = 0.7003 and discrimination AUC = 0.68 (95% CI = 0.65-0.72) and 0.65 (95% CI = 0.61-0.70) in EPISEPSIS and DISEPSIS, respectively. Specifically, temperature > 38 °C and platelets < 150.000 cells/mm³ and normal Glasgow; or Glasgow < 15 with normal temperature and platelets exhibit a LR between 1,9 (CI 95% = 1,2-3,1) and 2,3 (CI 95% = 1,7-3,1). Glasgow < 15 with any of low platelets or high temperature shows a LR between 2,2 (CI 95% = 1,1-4,4) and 2,6 (CI 95% = 1,7-4,3). DISCUSSION Temperature > 38° C, platelet count < 150,000 cells/mm³ and GCS < 15 are variables associated with increased likelihood of having a positive blood culture.

Positive Culture and Prognosis in Patients With Sepsis: A Prospective Cohort Study

Purpose: To analyze the prognostic role of positive cultures in patients with sepsis. Methods: A prospective cohort study in a tertiary referral hospital in Medellín, Colombia. Adults older than 18 years of age with a bacterial infection diagnosis according to Centers for Disease Control criteria and sepsis (evidence of organ dysfunction) were included. A logistic regression model was used to determine the association between positive cultures and hospital mortality, and a Cox regression with a competing risk modeling approach was used to determine the association between positive cultures and hospital stay as well as secondary infections. Results: Overall, 408 patients had positive cultures, of which 257 were blood culture, and 153 had negative cultures. Patients with positive cultures had a lower risk of mortality (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.27-0.68), but this association was not maintained after adjusting for confounding factors (OR, 0.56; 95% CI, 0.31-1.01). No association was found with the hospital stay (adjusted subhazard ratio [SHR], 1.06; 95% CI, 0.83-1.35). There was no association between positive cultures and the presence of secondary infections (adjusted SHR, 0.99; 95% CI, 0.58-1.71). Conclusion: Positive cultures are not associated with prognosis in patients with sepsis.

Antibiotics has more impact on mortality than other early goal-directed therapy components in patients with sepsis: An instrumental variable analysis

Purpose: To estimate the effect of each of the EGDT components, as well as of the antibiotics, on length‐of‐stay and mortality. Methods: Prospective cohort in three hospitals. Adult patients admitted by the Emergency Rooms (ER) with infection and any of systolic blood pressure < 90 mmHg or lactate >4 mmol/L. An instrumental analysis with hospital of admission as the instrumental variable was performed to estimate the effect of each intervention on hospital mortality and secondary outcomes. Results: Among 2587 patients evaluated 884 met inclusion criteria, with a hospital mortality rate of 17% (n = 150). In the instrumental analysis, the only intervention associated with an absolute reduction in mortality (21%) was the use of antibiotics in the first 3 h. In patients with lactate values ≥4 mmol/L in the ER, a non‐decrease of at least 10% at six hours was independently associated with mortality (OR = 3.1; 95%CI = 1.5–6.2). Conclusions: Among patients entering ER with infection and shock or hypoperfusion criteria, the use of appropriate antibiotics in the first 3 h is the measure that has the greatest impact on survival. In addition, among patients with hyperlactatemia >4 mmol/L, the clearance of >10% of lactate during resuscitation is associated with better outcomes.

Epidemiología y pronóstico de pacientes con infección del torrente sanguíneo en 10 hospitales de Colombia

BACKGROUND Knowing the local epidemiology and etiology of bloodstream infections allows tailoring the empirical initial antimicrobial therapy to obtain a better outcome for these episodes. AIM To describe the epidemiological and microbiological aspects as well as the factors associated with mortality in patients with bloodstream infection in Colombian hospitals. METHODS Sub-analysis of a prospective cohort study of 375 consecutive patients with bloodstream infection in 10 hospitals in Colombia, admitted between September first 2007 and Febrnary 29, 2008. RESULTS The most frequently isolated bacteria were Gram-negative bacilli in 54% of patients, followed by Gram-positive cocci in 38.4%. The source of infection was known in 67%, unknown in 24% and associated with intravascular catheter in 9%. The most frequently isolated bacteria were Escherichia coli (46%), coagulase-negative Staphylococci (16%), Klebsiella pneumoniae (8.9%) and Staphylococcus aureus (7.8%). Staphylococcus aureus was methicillin sensitive in 82% of patients (46/56). Overall 28-day mortality was 25% and their independent associated factors were age, SOFA score and APACHE II score. CONCLUSIONS In our study the most frequently isolated bacteria in bloodstream infections were Gram-negative bacilli, contrasting those reported in developed countries. The overall mortality rate was high and the factors associated with mortality were age and severity scores.

Variables associated with pacemaker implantation in postoperative patients of cardiac surgery in a university hospital

In postoperative cardiac patients, the incidence of conduction disturbances is between 1 to 4% depending on the complexity of the surgical procedure, the intraoperatory complications and the need for reintervention. These disorders lead to the need for electrical support, transient or permanent by a pacemaker. So far, there are few data in the literature regarding the potential factors related to the need for a pacemaker in postoperative cardiac surgery.