Cause Of Severe Sepsis Research Articles

The Value of Next-Generation Sequencing in Diagnosis and Therapy of Critically Ill Patients with Suspected Bloodstream Infections: A Retrospective Cohort Study.

Bloodstream infection (BSI), a frequent cause of severe sepsis, is a life-threatening complication in critically ill patients and still associated with a high mortality rate. Rapid pathogen identification from blood is crucial for an early diagnosis and the treatment of patients with suspected BSI. For this purpose, novel diagnostic tools on the base of genetic analysis have emerged for clinical application. The aim of this study was to assess the diagnostic value of additional next-generation sequencing (NGS) pathogen test for patients with suspected BSI in a surgical ICU and its potential impact on antimicrobial therapy. In this retrospective single-centre study, clinical data and results from blood culture (BC) and NGS pathogen diagnostics were analysed for ICU patients with suspected BSI. Consecutive changes in antimicrobial therapy and diagnostic procedures were evaluated. Results: 41 cases with simultaneous NGS and BC sampling were assessed. NGS showed a statistically non-significant higher positivity rate than BC (NGS: 58.5% (24/41 samples) vs. BC: 21.9% (9/41); p = 0.056). NGS detected eight different potentially relevant bacterial species, one fungus and six different viruses, whereas BC detected four different bacterial species and one fungus. NGS results affected antimicrobial treatment in 7.3% of cases. Conclusions: NGS-based diagnostics have the potential to offer a higher positivity rate than conventional culture-based methods in patients with suspected BSI. Regarding the high cost, their impact on anti-infective therapy is currently limited. Larger randomized prospective clinical multicentre studies are required to assess the clinical benefit of this novel diagnostic technology.

Pyoperitoneum as a consequence of perinephric abscess spontaneous rupture. A case report

Intra-abdominal infections are a common cause of severe sepsis and have a significantly high morbidity and mortality rate. Patients continue to present to hospitals with unacceptable delays in diagnosis or management, resulting in sepsis and organ failure, which lower their survival chances. We reported a rare case of a 64-year-old Syrian woman with a spontaneous rupture of a perinephric abscess that resulted in intra-abdominal infection and ascites, which led to sepsis and multiple organ failure despite resuscitation and antibiotic treatment according to guidelines. Although the recommendations for patients with intra-abdominal infection and hemodynamic instability differ, there is an agreement that surgery should be considered early when other interventional approaches have failed. Rupture of the perinephric abscess rarely produces intra-abdominal infection and ascites; effective care requires early and appropriate infection source identification. To avoid delays, doctors need to use academic methods in developing diagnoses and management.

EFFECTS OF SHENFU INJECTION ON SUBLINGUAL MICROCIRCULATION IN SEPTIC SHOCK PATIENTS: A RANDOMIZED CONTROLLED TRIAL.

Background and Objective: The optimization of macrocirculatory hemodynamics is recommended by current sepsis guidelines. However, microcirculatory dysfunction is considered the cause of severe sepsis. In the present study, we designed to verify whether the application of Shenfu injection (SFI) restores microcirculation, thereby improving tissue perfusion and inhibiting organ dysfunction, resulting in improved outcomes. Design: We conducted a prospective, single-center, randomized, double-blind, placebo-controlled clinical trial. Intervention: Patients were randomly assigned to group receiving SFI (n = 20) or placebo (n = 20) for 5 days. We administered SFI or glucose injection for 5 days and blinded the investigators and clinical staff by applying light-proof infusion equipment that concealed therapy allocation. Measurements and Results: We measured the systemic dynamics and lactate levels, biomarkers of endothelial dysfunction, and inflammatory cytokines in the plasma. The parameters of sublingual microcirculation were assessed using side-stream dark-field imaging. Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) score, total dose, and duration of vasopressor use, emergency intensive care unit (EICU) stay, and 28-day mortality were evaluated. After treatment with SFI, the disturbance of the sublingual microcirculation was considerably alleviated, as indicated by the significant increase in total vessel density, perfused vessel density, and microvascular flow index. Moreover, the plasma biomarker levels of endothelial dysfunction, including Ang-2, Syn-1, and ET-1, were reversed after SFI treatment. Importantly, the SFI group had a more favorable prognosis than the control group in terms of the APACHE-II score, SOFA score, duration of vasopressor administration, and length of EICU stay. However, the difference in mortality at day 28 was not statistically different between the SFI (15%, 3/20) and placebo (25%, 5/20) groups ( P = 0.693). Conclusions : Shenfu injection provided apparent effects in improving sublingual microcirculatory perfusion in patients with septic shock, and this protection may be related with the inhibition of endothelial dysfunction and vasodilatory effects.

The effect of glutathione as adjuvant therapy on levels of TNF-α and IL-10 in wistar rat peritonitis model

BackgroundPeritonitis is the second most common cause of severe sepsis that associated with a significant mortality rate. Due to a large gap of newer antibiotics innovation and antibiotic resistance emergence, the use of antioxidant has a possible alternative as adjuvant therapy in peritonitis management. It has been studied that glutathione as an alternative in the development of new anti-inflammatory effect. Thus, the aim of this study was to evaluate the levels of TNF-α and IL-10 after glutathione administration as adjuvant therapy in rat peritonitis model. Materials and methodsMale wistar rats were divided into four groups (n = 6 per group), Group 1: control group (C), Group 2: peritonitis group (P), Group 3: peritonitis + Ceftriaxone group (P + Cef), Group 4: peritonitis + Ceftriaxone + Glutathione group (P + Cef + Glu). Twenty-four hours after peritonitis induction, the blood samples were taken to evaluate TNF-α and IL-10 levels. ResultsThere was a significantly increase of mean TNF-α level in group 2 (P) 473,86 ± 388,99 pg/ml (p value 0,00) and significantly decrease of mean TNF-α level after glutathione injection in group 4 (P + Cef + Glu) (p value 0,02). No significant changes in IL-10 levels in rats peritonitis model. ConclusionsGlutathione supplementation is significantly decrease the mean level of TNF-α in rats induced peritonitis, however there is no difference compare to antibiotic only. Moreover, there no significant changes level of IL-10 in rats induced peritonitis after glutathione injection.

The role of qSOFA score and biomarkers in assessing severity of community-acquired pneumonia in adults

Abstract Introduction: Community-acquired pneumonia (CAP) is the primary cause of severe sepsis. Severity assessment scores have been created, in order to help physicians decide the proper management of CAP. The purpose of this study was to examine the correlations between different CAP severity scores, including qSOFA, several biomarkers and their predictive value in the 30 day follow-up period, regarding adverse outcome. Materials and methods: One hundred and thirty nine adult patients with CAP, admitted in the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania from December 2015 to February 2017, were enrolled in this study. Pneumonia Severity Index (PSI), CURB-65, SMART-COP and the qSOFA scores were calculated at admittance. Also, C-reactive protein (CRP), procalcitonin (PCT) and albumin levels were used to determine severity. Results: The mean PSI of all patients was 93.30±41.135 points, for CURB-65 it was 1.91±0.928 points, for SMART-COP it was 1.69±1.937 points. The mean qSOFA was 1.06±0.522 points, 21 (14.9%) were at high risk of in-hospital mortality. In the group of patients with qSOFA of ≥2, all pneumonia severity scores and all biomarkers tested were higher than those with scores <2. We found significant correlations between biomarkers and severity scores, but none regarding adverse outcome. Conclusion: The qSOFA score is easier to use and it is able to accurately evaluate the severity of CAP, similar to other scores. Biomarkers are useful in determining the severity of the CAP. Several studies are needed to assess the prediction of these biomarkers and severity scores in pneumonia regarding adverse outcome.

Risk factors and outcomes of Candidemia caused by non-albicans Candidain a tertiary hospital in Thailand

Background: Candidemia is an important cause of severe sepsis in critically ill patients. The incidence of candidemia increased dramatically worldwide and the etiologic Candidaspecieshas been shifted from Candida albicans to non- albicans Candida. Candida tropicalisis highly prevalent in Asia. The risk factors and clinical outcomes in patients who had blood stream infection from non-albicans Candida is still unclear. Methods and materials: This is a retrospective review of medical records of patients with candidemia hospitalized at Siriraj Hospital, Thailand, from January 2016 to December 2017. Clinical characteristics, risk factors, treatment outcomes and antifungal susceptibility were analyzed. Results: A total of 156 patients were enrolled, 54.6% were male and the median age was 68 years. The underlying conditions included diabetes mellitus (32.1%), chronic cardiac disease (28.2%), chronic kidney disease (26.9%) and hematologic malignancies (21.2%). Candidaspecies isolated from patients’ blood were C. tropicalis (49.4%), C. albicans (28.8%), C. glabrata (16.7%) and C. parapsilosis (5.1%). Fluconazole resistance was significantly increased in C. tropicalis (37.8%) and C. albicans (14.3%). When compared with C. albicanscandidemia, no independent factor was found to be associated with non-albicans Candida candidemia. There was no significant difference in mortality rate between non-albicans Candida and C. albicanscandidemia [OR=1.35 (0.64–2.85)]. From multivariate analysis, when compared with C. albicanscandidemia, the independent factors associated with C. tropicaliscandidemia were chronic liver disease [OR = 11.39 (1.38–94.02)], neutropenia [OR = 4.31 (1.34–13.87)] and male gender [OR = 2.34 (1.04–5.29)]. Conclusion: In candidemic patients,chronic liver disease, neutropenia and male gender were associated with C. tropicalisrather than C. albicansinfection. Considering a higher fluconazole resistance in C. tropicalis, fluconazole should not be used for empirical antifungal treatment in such patients.

Impact of antibiotic resistance on outcomes of neutropenic cancer patients with Pseudomonas aeruginosa bacteraemia (IRONIC study): study protocol of a retrospective multicentre international study

IntroductionPseudomonas aeruginosa (PA) has historically been one of the major causes of severe sepsis and death among neutropenic cancer patients. There has been a recent increase of multidrug-resistant PA (MDRPA)...

FATAL RASH

SESSION TITLE: Critical Care cases 2 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 03:15 PM - 04:15 PM INTRODUCTION: Vibrio vulnificus is a Gram-negative bacillus found in warm coastal waters. There are three clinical syndromes: primary septicemia, wound infections and gastrointestinal disease. Mortality rates of >50% have been reported in patients who present with primary septicemia. We describe a case of V. vulnificus presenting with septic shock and a violaceous annular rash with hemorrhagic bullae. CASE PRESENTATION: A 52 year old male with chronic alcoholism presented with fever, dyspnea and rash over upper and lower limbs for 2 days. He was febrile, tachypneic, and had a tachycardia of 140 beats/minute, hypotension with a blood pressure of 90/61mmHg, and pulse oximetry of 100% on room air. A violaceous annular rash over face, trunk, and upper limbs and hemorrhagic bullae over lower limbs was observed. There was no overlying cellulitis or necrotizing fasciitis. He was jaundiced, and laboratory data revealed a depressed white cell count, thrombocytopenia, high anion gap metabolic acidosis with hyperlactemia, acute renal failure and disseminated intravascular coagulation. He was intubated and mechanically ventilated and required dual vasopressor support following aggressive fluid resuscitation. Intravenous meropenem and doxycycline were promptly administered. Chest radiograph was normal and computed tomography of the abdomen and pelvis revealed ascites and hepatomegaly. Further history revealed no recent seawater exposure or seafood ingestion. A Gram-negative bacillus which later identified as V. vulnificus was isolated from the initial blood cultures and antibiotics were changed to IV ceftriaxone and doxycycline. Despite appropriate antibiotics and supportive management, he died 20 hours after. DISCUSSION: V. vulnificus infection can have an aggressive clinical course with significant morbidity and mortality. In this case, the patient died of multi-organ failure despite timely and appropriate antibiotics, and maximal supportive treatment. High-risk patients include those with chronic liver disease and chronic alcoholism; usually with a positive history of shellfish consumption or seawater exposure. Hypotension in the first 12 hours of presentation and leukopenia predicts for poorer outcomes. High bacterial densities of V vulnificus are seen with higher water temperatures of tropical seawater. CONCLUSIONS: High clinical suspicion of V. vulnificus infection is warranted in tropical coastline areas for patients presenting with severe sepsis and widespread violaceous annular rash with hemorrhagic bullae. Reference #1: Horseman MA, Surani S. A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection. Int J Infect Dis. 2011 Mar;15(3):e157-66. Reference #2: Klontz KC, Lieb S, Schreiber M, Janowski HT, Baldy LM, Gunn RA. Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987. Ann Intern Med. 1988 Aug 15;109(4):318-23. DISCLOSURES: No relevant relationships by Liesel Fong, source=Web Response No relevant relationships by Pyng Lee, source=Web Response No relevant relationships by Sui An Lie, source=Web Response

Commentary

Commentary

Experience with β-D-Glucan Assay in the Management of Critically ill Patients with High Risk of Invasive Candidiasis: An Observational Study.

Background:The (1,3)-β-D-glucan assay (BDG) is recommended for the early diagnosis of invasive candidiasis (IC).Methods:Records of 154 critically ill adults with suspected IC, on whom BDG was done, were analyzed. Patients were divided into three groups: Group A (confirmed IC), Group B (alternative diagnosis or cause of severe sepsis), and Group C (high candidal score and positive BDG [>80 pg/mL] but without a confirmed diagnosis of IC).Results:Mean BDG levels were significantly higher in Group A (n = 32) as compared to Group B (n = 60) and Group C (n = 62) (448.75 ± 88.30 vs. 144.46 ± 82.49 vs. 292.90 ± 137.0 pg/mL; P < 0.001). Discontinuation of empiric antifungal therapy based on a value <80 resulted in cost savings of 14,000 INR per day per patient.Conclusion:A BDG value of <80 pg/ml facilitates early discontinuation of empirical antifungal therapy, with considerable cost savings.

Disseminated intravascular coagulation in an under-recognised zoonotic infection

A 51 year old man presented with severe sepsis, disseminated intravascular coagulation (DIC) and multiorgan dysfunction after a 24 hour history of diarrhoea and malaise. Despite fluid resuscitation and receiving a platelet transfusion, freshfrozen plasma and intravenous broad-spectrum antibiotics, he remained anuric with a worsening metabolic acidosis. He was transferred to critical care for organ support including renal replacement therapy. He subsequently developed purpura fulminans. Blood cultures were positive for Captocytophaga carnimorsis, a gram-negative canine zoonosis that is an underdiagnosed cause of severe sepsis, for which DIC at presentation is characteristic. Treatment is with penicillins and fluoroquinolones. Identification of risk factors for unusual organisms and recognition of DIC allowing prompt treatment is critical for the acute physician.

High prevalence of Mycobacterium tuberculosis bacteraemia among a cohort of HIV-infected patients with severe sepsis in Lusaka, Zambia.

Tuberculosis is recognised as one of the leading causes of severe sepsis among HIV-infected patients. Most patients with Mycobacterium tuberculosis bacteraemia have advanced HIV disease with CD4 counts less than 100 cells/μl and its presentation is non-specific in most instances. This was a cross-sectional study which was done by analyzing data from 201 adult HIV-infected patients who met the inclusion criteria for severe sepsis. The prevalence of Mycobacterium tuberculosis bactraemia in the study population was 34.8%. Severe sepsis caused by other etiologies was observed in 33 (16.4%) of the participants. Concomitant infection of Mycobacterium tuberculosis bactraemia with other organisms is not uncommon in patients with severe sepsis. This cohort of HIV-infected patients had severe immunosuppression with a median CD4 count of 51 (20-136) cells/μl with moderate anaemia, mean haemoglobin 8.0 (3.0) g/dl, and were generally underweight with a mean mid upper arm circumference (MUAC) of 21.0 (3.4) cm. Mycobacterium tuberculosis bacteraemia is very common in HIV-infected patients with advanced HIV disease who present with severe sepsis. Mycobacterium tuberculosis bacteraemia co-infection with aerobic organisms is not uncommon. Factors that were independently associated with Mycobacterium tuberculosis bacteraemia in our study population were MUAC and sodium level.

Urinary obstruction is an important complicating factor in patients with septic shock due to urinary infection

ObjectiveUrinary tract infection (UTI) is a common cause of severe sepsis, and anatomic urologic obstruction is a recognized factor for complicated disease. We aimed to identify the incidence of urinary obstruction complicating acute septic shock and determine the characteristics and outcomes of this group. MethodsPatients prospectively enrolled in a sepsis treatment pathway registry between October 2013 and July 2014 were reviewed for the diagnosis of UTI. Standardized medical record review was performed to confirm sepsis due to UTI and determine clinical variables including the presence of anatomic urinary obstruction. Patients with septic shock due to UTI with obstruction were compared with those without obstruction. The primary outcomes were incidence of urinary obstruction and hospital mortality. ResultsAmong 1084 registry enrollees, 209 (19.2%) met inclusion criteria for the study. Acute anatomic obstruction was identified in 22 (10.5%) patients. Hospital mortality in patients with obstruction was 27.3% compared with 11.2% in patients without obstruction (absolute difference of 16.1%; P = .03; 95% confidence interval [CI], 1.2%-30.9%). Hospital length of stay among survivors was 12.8 days compared with 8.3 days (absolute difference of 4.5 days; P = .04; 95% CI, 0.2-8.8 days). History of urinary stone disease was independently associated with obstruction (odds ratio, 5.6; 95% CI, 2.2-14.3). ConclusionsApproximately 1 in 10 patients presenting with septic shock due to a urinary source is complicated by anatomic urinary obstruction. These patients have significantly higher mortality compared with patients without obstruction. Early imaging of patients with septic shock due to suspected urinary source should be considered to identify obstruction requiring emergency intervention.

Overwhelming Postsplenectomy Infection: A Prospective Multicenter Cohort Study.

Recent population-based cohort studies have questioned the role of pneumococci as the most frequent pathogen causing severe infection in patients after splenectomy. The aim of the study was to define the causative pathogens and clinical presentation of patients with overwhelming postsplenectomy infection (OPSI). In a prospective cohort study in 173 German intensive care units, we searched for patients with and without asplenia and community-acquired severe sepsis/septic shock. Clinical and laboratory variables and survival of patients were assessed. Fifty-two patients with severe sepsis or septic shock with asplenia and 52 without asplenia were included. OPSI patients more often had a history of malignancy (38% vs 17%; P = .016) and had a lower body mass index (24 kg/m(2) vs 28 kg/m(2); P = .004). Streptococcus pneumoniae was detected more frequently in OPSI patients (42% vs 12% without asplenia; P < .001) and more frequently manifested as bloodstream infection (31% vs 6%; P = .002). Gram-negative infection was similar in both groups (12% vs 19%; P = .157). Pneumococcal vaccine coverage of OPSI patients was low overall (42% vs 8% among patients without asplenia; P < .001). Purpura fulminans was a frequent complication, developing in 19% of OPSI patients vs 5% of patients without asplenia (P = .038). The interval between splenectomy and OPSI was 6 years (range, 1 month-50 years). On multivariable Poisson regression, asplenia was the only predictive variable independently associated with pneumococcal sepsis (adjusted relative risk, 2.53 [95% confidence interval, 1.06-6.08]). Pneumococcal infections remain the most important cause of severe sepsis and septic shock following splenectomy.

Severe sepsis and sepsis shock secondary to non ventilator associated nosocomial pneumonia. principal features and predictors of outcome

Non ventilator associated nosocomial pneumonia (NVANP) is considered as a rare cause of severe sepsis and septic shock. However its real impact is unknown.

Recombinant soluble thrombomodulin: coagulation takes another chance to reduce sepsis mortality

The striking coagulopathy in patients with severe sepsis and the increasing insight into the intricate link between inflammation and coagulation has been an inspiration for many researchers and pharmaceutical companies to explore potential therapeutic interventions for severe sepsis [1]. Indeed, in view of the high incidence of severe sepsis and sepsis mortality ranging from 20 to 50%, there is a urgent need for better treatment options [2]. As dysfunctional physiological anticoagulant regulators, such as antithrombin, activated protein C, and tissue factor pathway inhibitor, were shown to be key players in the sepsis-associated activation of coagulation, and animal studies supported the hypothesis that restoration of these pathways resulted in attenuation of coagulopathy and organ dysfunction and reduced mortality, large clinical studies were performed to establish the beneficial effect of these interventions in patients with severe sepsis [2-5]. Although some of these studies demonstrated some advantage in subgroups of patients with most extreme coagulopathies an overall reduction in mortality was not confirmed. This article is protected by copyright. All rights reserved

Results of the severe sepsis registry in intensive care units in Poland from 2003-2009.

Severe sepsis remains the most common cause of death in intensive care units (ICUs) according to many epidemiological studies. There are no data in Poland on the extent of severe sepsis cases treated in ICUs. The aim of the study was to analyse the course and outcome of severe sepsis patients treated in Polish ICUs. In 2003, the internet-based severe sepsis registry was created as a multicentre observational research project. An online questionnaire was made accessible to ICUs participating in the study. Questionnaires were completed after the discharge of patients and included demographic data, clinical and microbiological information about the cause, course, treatment and outcome of septic patients. All data were given voluntarily and anonymously. During the 7-year period (2003-2009), 4999 cases of severe sepsis were registered for analysis. The mean age of septic patients was 57 years, and the majority of the patients were men (58%). The mean length of stay in the ICU was 10 days. A significant decrease in the mortality rate was observed from 54% in 2003 and 56% in 2004 to 46% in 2009 (P < 0.05). Most of the patients were admitted to the ICU for surgical reasons (56%), and intra-abdominal infections predominated (49%). Severe sepsis patients were admitted to ICUs in critical condition, and the majority of them (89%) had 3 or more organs dysfunction. The APACHE II score on admission was 26 points. Community acquired infections were the most frequent cause of severe sepsis (53%). Most of the pathogens responsible for infection were Gram-negative bacteria (58%). Gram-positive bacteria were identified in 34% of patients and fungi in 16%. A positive blood culture was detected in 41% of patients. Vasopressors were administered to most of the patients (86%). There was a marked increase in the frequency of administering noradrenaline and a decrease in administering dopamine. Renal replacement therapy was applied in 22% of the patients, and there was a marked increase in this type of therapy in the last two years of the study period. Patients with severe sepsis involved in the 7-year registry were critically ill in half of the cases because of intra-abdominal infections, and the majority of them had multi-organ dysfunction. The mortality of registered patients was high, but it significantly decreased during the observation time. Based on the results obtained from this voluntary registry, the authors conclude that mandated sepsis registries should be established in Polish hospitals to improve the strategy of diagnosing and managing this syndrome.

Variations in organism-specific severe sepsis mortality in the United States: 1999-2008.

Recent studies have reported decreased overall severe sepsis mortality, but associations with organism trends have not yet been investigated. This study explored organism-specific severe sepsis mortality trends from 1999 to 2008 in a large hospital-based administrative database. Secondary data analysis using the Nationwide Inpatient Sample. United States hospitals sampled in the Nationwide Inpatient Sample dataset. This sample approximates a stratified 20% sample of all nonfederal, short-term, general, and specialty hospitals serving adults in the United States. Severe sepsis hospitalizations and organism-specific causes were identified using predetermined International Classification of Diseases, 9th Revision, Clinical Modification codes. None. Analysis was conducted using descriptive Cox proportional hazards and linear regression trend analysis. Adjustments were made for the influence of demographics, comorbidities, number of organisms, and number of organ failures on hospital mortality. The data for 5,033,257 severe sepsis hospitalizations were examined and revealed decreased in-hospital mortality from 40.0% to 27.8% during the study period. The leading cause of severe sepsis was 51.5% Gram-negative bacteria, followed by 45.6% Gram-positive, 1.7% anaerobic, and 1.2% fungal species. The most common Gram-negative organisms were 39.9% Escherichia coli and 17.6% Pseudomonas. Staphylococcus species (62.2% methicillin-sensitive Staphylococcus aureus and 22.6% Streptococcus) were the most commonly reported Gram-positive organisms. Crude mortality estimates were higher for anaerobic and fungal organisms, 34.5% and 31.4%, respectively. Among Gram-positive bacteria, mortality was highest for methicillin-sensitive S. aureus, 30.9%, whereas Pseudomonas was associated with the highest mortality for Gram-negative septicemia cases, 29.5%. After adjusting for covariates, anaerobes were associated with the highest mortality hazard of 1.31 (95% CI, 1.23-1.40). Methicillin-resistant S. aureus had the highest mortality hazard of 1.38 (1.33-1.44) for Gram-positive organisms, whereas all Gram-negative bacteria had decreased mortality hazards. We not only confirmed an overall decline in severe sepsis mortality from 1999 to 2008 but also identified previously unreported variations in organism-specific severe sepsis mortality. Gram-negative organisms predominate, whereas anaerobes and methicillin-resistant S. aureus are significant predictors of mortality. Future clinical trials exploring new treatments in severe sepsis should incorporate individual organism trends to elucidate potential effect on mortality.

Chromobacterium violaceum sepsis in Minas Gerais, Brazil

Infection by Chromobacterium violaceum , known as chromobacte riosis, is a rare cause of severe sepsis with rapid spread and high mortality. In February 2009, a 14-year-old male patient was admitted t o Santa Casa of Misericordia of Juiz de Fora Hospital, and he dete riorated rapidly with severe sepsis and death by chromobacteriosis. In t his article we discuss the main clinical fidings, sensitivity profie, and antimicrobial therapy of this case.

Escherichia coli bacteremia in children: age and portal of entry are the main predictors of severity.

Escherichia coli bacteremia is a major cause of severe sepsis in children. Little is known about predictors of severity. We analyzed 84 children ≤ 18 years of age with E. coli bacteremia from the prospective COLIBAFI study performed during 2005-2007. The severity of bacteremia was defined as occurrence of death or transfer to intensive care unit. Studied characteristics included age, gender, birth weight, history of prematurity, immunodepression, nosocomial infection, portal of entry, phylogenetic group and subgroup belonging, O-type, virulence gene content and antimicrobial susceptibility. We compared bacterial characteristics in urinary- versus digestive-source bacteremia, in children ≤ 3 versus >3 month of age, and in children versus adults. We also searched for risk factors of severity. Median age was 2.4 months, 57% males. Most frequent portals of entry were urinary (66.2%) and digestive (19.5%) tracts. Most isolates (63.1%) belonged to B2 phylogroup. Strains in children ≤ 3 months of age exhibited more virulence genes, especially neuC and fyuA/irp2, and were less resistant to antibiotics than in children >3 months of age. Comparing community-acquired urinary-source bacteremia between children and adults, we found that bacteremia were less severe in children, whose strains exhibited a specific virulence gene repertoire and had a higher resistance score than in adults. Seventeen children (20.2%) had a severe bacteremia and 8 died. Non-urinary portal of entry and age ≤ 3 months of age were the only risk factors associated with severity. E. coli strains responsible for bacteremia exhibit specific characteristics according to age of children. However, host characteristics and portal of entry are the main determinants of severity of E. coli bacteremia in children, as observed in adults.