José Guerra

Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study

IntroductionSepsis is a leading cause of admission to non-cardiological intensive care units (ICUs) and the second leading cause of death among ICU patients. We present the first extensive dataset on the epidemiology of severe sepsis treated in ICUs in Spain.MethodsWe conducted a prospective, observational, multicentre cohort study, carried out over two 3-month periods in 2002. Our aims were to determine the incidence of severe sepsis among adults in ICUs in a specific area in Spain, to determine the early (48 h) ICU and hospital mortality rates, as well as factors associated with the risk of death.ResultsA total of 4,317 patients were admitted and 2,619 patients were eligible for the study; 311 (11.9%) of these presented at least 1 episode of severe sepsis, and 324 (12.4%) episodes of severe sepsis were recorded. The estimated accumulated incidence for the population was 25 cases of severe sepsis attended in ICUs per 100,000 inhabitants per year. The mean logistic organ dysfunction system (LODS) upon admission was 6.3; the mean sepsis-related organ failure assessment (SOFA) score on the first day was 9.6. Two or more organ failures were present at diagnosis in 78.1% of the patients. A microbiological diagnosis of the infection was reached in 209 episodes of sepsis (64.5%) and the most common clinical diagnosis was pneumonia (42.8%). A total of 169 patients (54.3%) died in hospital, 150 (48.2%) of these in the ICU. The mortality in the first 48 h was 14.8%. Factors associated with early death were haematological failure and liver failure at diagnosis, acquisition of the infection prior to ICU admission, and total LODS score on admission. Factors associated with death in the hospital were age, chronic alcohol abuse, increased McCabe score, higher LODS on admission, ΔSOFA 3-1 (defined as the difference in the total SOFA scores on day 3 and on day 1), and the difference of the area under the curve of the SOFA score throughout the first 15 days.ConclusionsWe found a high incidence of severe sepsis attended in the ICU and high ICU and hospital mortality rates. The high prevalence of multiple organ failure at diagnosis and the high mortality in the first 48 h suggests delays in diagnosis, in initial resuscitation, and/or in initiating appropriate antibiotic treatment.

Search for antiviral activity in higher plant extracts

In the course of our search for plant natural products as antiviral agents, extracts of ten plants from the Iberian Peninsula were tested for antiviral activity against herpes simplex type I (HSV‐ 1), vesicular stomatitis virus (VSV) and poliovirus type 1. Aqueous extracts of five of these medicinal plants, namely Nepeta nepetella (150–500 µg/mL), Nepeta coerulea (150–500 µg/mL), Nepeta tuberosa (150–500 µg/mL), Dittrichia viscosa (50–125 µg/mL) and Sanguisorba minor magnolii (50–125 µg/mL), showed a clear antiviral activity against two different DNA and RNA viruses, i.e. HSV‐1 and VSV. Only the medicinal plant Dittrichia viscosa was active against an additional virus, poliovirus type 1. Copyright

A survey of clinicians addressing the approach to the management of severe sepsis and septic shock in the United States

PURPOSE Mortality in severe sepsis and septic shock (SS/SS) remains high. Surviving Sepsis Campaign (SSC) guidelines were published in 2004 with the goal of improving outcomes in SS/SS. We tested the hypothesis that adherence to SSC guidelines and management of patients with SS/SS were influenced by physician specialty. MATERIALS AND METHODS A survey was mailed to 4998 randomly selected physicians, 1666 each for emergency medicine (EM), critical care medicine (CCM), and internal medicine (IM) from the American Medical Association database. Demographics, compliance with SSC guidelines, and approaches to management of patients with SS/SS were analyzed by specialty. RESULTS Four hundred ninety-nine respondents were included for final analysis. There were no differences between 3 specialties in obtaining blood cultures and in administering intravenous fluids, pressors, and antibiotics. The CCM physicians were more likely to measure serum lactate and central venous pressure, use corticosteroids and drotrecogin α, and aim for normoglycemia and plateau pressures less than 30 cm H(2)O in mechanically ventilated patients (all P < .001). CONCLUSIONS We observe that adherence with SSC guidelines continues to be a challenge for CCM, IM, and EM physicians. Significant differences in management of SS/SS exist for the 3 specialties. Because guideline implementation impacts patient outcomes, further evaluation of these differences is warranted.

Inhibition of alveolar macrophages by pentoxifylline.

Background and MethodsPentoxifylline can inhibit blood leukocyte functions in vitro, and some inflammatory processes in the lung in vivo. Therefore, we examined the effects of pentoxifylline on alveolar macrophage functions in vitro. Alveolar macrophages were harvested from normal rat lungs by airway lavage. The dose-response relationship of varying concentrations of pentoxifylline and in vitro cell functions were examined. Macrophage functions studied included adherence to nylon wool, random (unstimulated) and zymosan-activated serum-stimulated migration through 5 um millipore filters, and superoxide generation induced by zymosan-activated serum as assayed by cytochrome c reduction. ResultsPentoxifylline inhibited superoxide generation and stimulated migration (but not random migration or adherence) in a dose-dependent fashion. Statistically significant inhibition was demonstrated at 0.5 mM and 5.0 mM concentrations of pentoxifylline, respectively, for stimulated migration and superoxide generation. ConclusionsPentoxifylline can inhibit some alveolar macrophage functions in vitro. These effects may inhibit some forms of inflammatory lung injury, particularly when iv infusion of high doses of pentoxifylline are utilized. However, potentially adverse effects on inflammatory defense mechanisms must be considered as well.

Active prospective surveillance study with post-discharge surveillance of surgical site infections in Cambodia

Barriers to the implementation of the Centers for Disease Control and Prevention (CDC) guidelines for surgical site infection (SSI) surveillance have been described in resource-limited settings. This study aimed to estimate the SSI incidence rate in a Cambodian hospital and to compare different modalities of SSI surveillance. We performed an active prospective study with post-discharge surveillance. During the hospital stay, trained surveyors collected the CDC criteria to identify SSI by direct examination of the surgical site. After discharge, a card was given to each included patient to be presented to all practitioners examining the surgical site. Among 167 patients, direct examination of the surgical site identified a cumulative incidence rate of 14 infections per 100 patients. An independent review of medical charts presented a sensitivity of 16%. The sensitivity of the purulent drainage criterion to detect SSIs was 83%. After hospital discharge, 87% of the patients provided follow-up data, and nine purulent drainages were reported by a practitioner (cumulative incidence rate: 20%). Overall, the incidence rate was dependent on the surveillance modalities. The review of medical charts to identify SSIs during hospitalization was not effective; the use of a follow-up card with phone calls for post-discharge surveillance was effective.

Antidepressant and Anticonvulsant Drugs as Adjuvant Analgesics in Chronic Pain

Adjuvant analgesics are defined as drugs with a primary indication ther than pain that have analgesic properties in some painful conditions. The group includes numerous drugs in diverse classes. Although the widespread use of these drugs as first-line agents in chronic nonmalignant pain syndromes suggests that the term “adjuvant” is a misnomer, they usually are combined with a less-than-satisfactory opioid regimen when administered for cancer pain. Some adjuvant analgesics are useful in several painful conditions and are described as multipurpose adjuvant analgesics (antidepressants, corticosteroids, α2-adrenergic agonists, neuroleptics), whereas others are specific for neuropathic pain (anticonvulsants, local anesthetics, N-methyl-D-aspartate receptor antagonists), bone pain (calcitonin, bisphosphonates, radiopharmaceuticals), musculoskeletal pain (muscle relaxants), or pain from bowel obstruction (octreotide, anticholinergics). This article reviews the evidence supporting the use of two class of adjuvant analgesic for the treatment of chronic pain, antidepressant ans anticonvulsivants, and provides a comprehensive outline of dosing recommendations, side effects, and drug interactions.