Diagnosis and treatment criteria were recently updated based on the Sepsis-3 guidelines, which recommend the sequential organ failure assessment for accurate characterization of organ dysfunction. Large randomized controlled trials have found neutral results with early goal-directed therapy. To improve outcomes, treatment bundles incorporating standards for early sepsis treatment, including antibiotic and steroid treatment, were developed. Thus, future research should address the effects of steroids and immune-modulating agents on refractory septic shock as well as the development of new coagulopathy therapies and dynamic assessment tools.
Diagnosis ; Sepsis ; Shock, Septic ; Steroids ; Systemic Inflammatory Response Syndrome

Introduction: Septic shock is the most common type of shock encountered by internists and is the most common cause of death in non-coronary intensive care units. In the 2012 Surviving Sepsis Campaign, one recommendation is antibiotic administration within three hours from sepsis recognition. Several large-scale studies challenged this recommendation with contrasting results. The researchers aim to determine the impact of early antibiotic therapy (EAT) on mortality and outcome of patients and to determine institutional compliance to current sepsis recommendations. Methods: This retrospective single center study included septic patients at the emergency room from February 2013 to January 2015 and were grouped into the EAT group (lesser than or equal to three hours) and control group (more than three hours) antibiotic initiation from sepsis recognition). Primary outcomes are in-hospital mortality, time-to-antibiotics and extraction of blood culture prior to antibiotics. Secondary outcomes include length of hospital stay, use of vasopressors and mechanical ventilation and development of sepsis-related complications. Results: Two-hundred sixty-one patients were included with 53.26% overall mortality rate. The overall mean timeto-antibiotics is 355.1 minutes and time-to-blood culture is 434.64 minutes. Mean time-to-antibiotics were 115 and 556 minutes in the EAT and control group respectively. Mortality was significantly higher in the control group (43.7% vs. 61.3%, p=0.006). For the sepsis related complications, development of acute kidney injury (p=0.033) was higher in the EAT group and acute respiratory failure (p=0.009) was significantly increased in the control group. Conclusion Antibiotic administration within three hours from sepsis recognition significantly reduced in-hospital mortality. Timing of antibiotics and collection of blood cultures were delayed compared to current recommendations. Among the sepsis-related complications, prolonged time-to-antibiotics (>3 hours) is associated with risk of developing acute respiratory failure and subsequent need for mechanical ventilation.
Early antibiotic therapy ; Shock, Septic ; Sepsis ; Systemic Inflammatory Response Syndrome

The Third International Consensus Definitions for Sepsis and Septic Shock (SEPSIS-3) task force assessed the latest pathophysiological parameters associated with sepsis and septic shock and defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. This SEPSIS-3 definition may be applied using relevant clinical and biological criteria including changes in the Sequential Organ Failure Assessment score and serum lactate levels. The new definition does not include criteria for systemic inflammatory response syndrome or the concept of 'severe sepsis.' The SEPSIS-3 definition aims to devise more precise descriptions of sepsis and to improve clinical care. However, there are important questions relating to the clinical application of the new definition. We review the main characteristics and limitations of previous definitions and discuss some of the potential controversies raised by the new framework.
Advisory Committees ; Consensus ; Lactic Acid ; Organ Dysfunction Scores ; Sepsis* ; Shock, Septic ; Systemic Inflammatory Response Syndrome

Background: Sepsis is a leading cause of mortality both locally and worldwide. Despite this, early diagnosis of sepsis remains challenging, with a significant number not fulfilling SIRS (Systemic Inflammatory Response Syndrome) criteria. In 2016, the Sepsis-3 guidelines modified its definition to include the qSOFA (Quick Sequential Organ Failure Assessment) score in an attempt to include a significant number of SIRS-negative septic patients.

Methods: To compare the two, 295 adult patients in the emergency room with suspected infection were included in the study and simultaneously determined their qSOFA score and SIRS criteria. Three infection specialists adjudicated the presence of sepsis, and outcomes within the first 48 hours were acquired. Sensitivity, specificity, positive predictive and negative predictive values for qSOFA and SIRS were computed using constructed confusion matrices, and overall predictive accuracy was measured by the Area under the Receiver Operating Characteristic (AUROC) curve.

Results: Of the 295 patients included in the study, 95 (32.2%) were deemed sepsis positive via adjudication. The qSOFA score was a specific (95.5%) but a poorly sensitive (46.3%) test compared to the SIRS criteria (sensitivity 73.7% and specificity 60%). Both qSOFA and the SIRS criteria significantly correlated with sepsis positivity, but the qSOFA score had superior overall predictive accuracy at 70.9% compared to the SIRS criteria. The adjudicators had moderate strength in agreement (Fleiss' kappa = 0.39) and a percentage agreement of 60%.

Conclusion: We concluded that the qSOFA score was a more accurate predictor of sepsis and a reliable pre-dictor of in-hospital mortality, but should not be used as a sepsis screening tool due to the low sensitivity. We recommend that the SIRS criteria be maintained as a screening tool and to use the qSOFA score concurrently for time management.

Key Words: Sepsis, qSOFA, SIRS

BACKGROUND: The burden of sepsis is global despite measures to improve its prompt recognition. However, there is no single reliable parameter for its early detection. Heparin-binding protein (HBP) is a new and promising biomarker for sepsis. Presently, there are no published reports in children apart from a limited study on UTI.

OBJECTIVE: To evaluate the role of HBP as a diagnostic tool and prognostic marker of sepsis syndrome among pediatric patients.

METHODS: This prospective cohort study enrolled pediatric patients who were categorized as SIRS or sepsis syndrome. HBP assay was determined on Day1. Likewise, blood culture was taken. A 7-day observation period using PELOD scoring was done. Final category as SIRS or sepsis syndrome was done on Day7. Statistical analysis was done to know relationship of HBP level to SIRS and sepsis.

RESULTS: 106 patients were included in this study. There was statistical significance in the correlation of HBP assay with presence of growth in blood culture and toxic granulations, length of ventilator support, and development of complications including mortality. The cutoff point was >125ng/mL. Sensitivity and specificity for HBP in sepsis syndrome were 98.31% and 97.87% respectively. Positive predictive value was 98.3%. Negative predictive value was 97.9%. Positive likelihood ratio was 46.2. Negative likelihood ratio was 0.017. Risk ratio was 47.6. Subjects with HBP level of >125 ng/mL had 47.6 times the risk of having sepsis syndrome as compared to those with level

CONCLUSION & RECOMMENDATIONS: Elevated HBP level is a useful diagnostic and prognostic marker for childhood sepsis syndrome. Determination of HBP levels at different time intervals within a longer observation period may give a more accurate description of subject's clinical improvement or progression to MODS or mortality.

BACKGROUND: We evaluated the clinical usefulness of the quick Sepsis-Related Organ Failure Assessment (qSOFA) score (based on the 2016 definition of sepsis) at intensive care unit admission in Korean patients with bacteremia. METHODS: We retrospectively analyzed clinical data from 236 patients between March 2011 and February 2016. In addition to the qSOFA, the Modified Early Warning score (MEWS) and systemic inflammatory response syndrome (SIRS) criteria were calculated. RESULTS: The patients' median age was 69 years, and 61.0% were male. Of the patients, 127 (53.8%) had a qSOFA score ≥2 points. They had significantly higher rates of septic shock, thrombocytopenia, and hyperlactatemia, and increased requirements for ventilator care, neuromuscular blocking agents, vasopressors, and hemodialysis within 72 hours after intensive care unit admission. They also had a significantly higher 28-day mortality rate. When analyzed using common thresholds (MEWS ≥5 and ≥2 SIRS criteria), patients with a MEWS ≥5 had the same results as those with a qSOFA score ≥2 (P < 0.05). However, patients with ≥2 SIRS criteria showed no significant differences. CONCLUSIONS: Our results show that a qSOFA score ≥2 at admission is a useful screening tool for predicting disease severity and medical resource usage within 72 hours after admission, and for predicting 28-day mortality rates in patients with bacteremia. In addition, qSOFA scores may be more useful than SIRS criteria in terms of prognostic utility.
Bacteremia* ; Critical Care* ; Humans ; Hyperlactatemia ; Intensive Care Units* ; Korea* ; Male ; Mass Screening ; Mortality ; Neuromuscular Blocking Agents ; Prognosis ; Renal Dialysis ; Retrospective Studies ; Sepsis ; Shock, Septic ; Systemic Inflammatory Response Syndrome ; Thrombocytopenia ; Ventilators, Mechanical

BACKGROUND: We evaluated the clinical usefulness of the quick Sepsis-Related Organ Failure Assessment (qSOFA) score (based on the 2016 definition of sepsis) at intensive care unit admission in Korean patients with bacteremia. METHODS: We retrospectively analyzed clinical data from 236 patients between March 2011 and February 2016. In addition to the qSOFA, the Modified Early Warning score (MEWS) and systemic inflammatory response syndrome (SIRS) criteria were calculated. RESULTS: The patients' median age was 69 years, and 61.0% were male. Of the patients, 127 (53.8%) had a qSOFA score ≥2 points. They had significantly higher rates of septic shock, thrombocytopenia, and hyperlactatemia, and increased requirements for ventilator care, neuromuscular blocking agents, vasopressors, and hemodialysis within 72 hours after intensive care unit admission. They also had a significantly higher 28-day mortality rate. When analyzed using common thresholds (MEWS ≥5 and ≥2 SIRS criteria), patients with a MEWS ≥5 had the same results as those with a qSOFA score ≥2 (P < 0.05). However, patients with ≥2 SIRS criteria showed no significant differences. CONCLUSIONS: Our results show that a qSOFA score ≥2 at admission is a useful screening tool for predicting disease severity and medical resource usage within 72 hours after admission, and for predicting 28-day mortality rates in patients with bacteremia. In addition, qSOFA scores may be more useful than SIRS criteria in terms of prognostic utility.
Bacteremia ; Critical Care ; Humans ; Hyperlactatemia ; Intensive Care Units ; Korea ; Male ; Mass Screening ; Mortality ; Neuromuscular Blocking Agents ; Prognosis ; Renal Dialysis ; Retrospective Studies ; Sepsis ; Shock, Septic ; Systemic Inflammatory Response Syndrome ; Thrombocytopenia ; Ventilators, Mechanical

BACKGROUND: Selenium is an essential trace-element with antioxidant and immunological function. We studied the relationship between blood selenium concentrations, systemic inflammatory response syndrome (SIRS) and organ dysfunctions in critically ill children. METHODS: This was a retrospective, observational study of the blood selenium concentrations of critically ill children at the time of a pediatric intensive care unit admission. RESULTS: A total of 62 patients with a median age of 18 (5-180) months were included in this study. The mean of blood selenium concentration (microg/dl) was 8.49 +/- 2.42. The platelet count (r = -0.378) and PaCO2 (r = -0.403) showed negative correlations with blood selenium concentration, while PaO2/FiO2 (r = 0.359) and PaO2 (r = 0.355) showed positive correlations (p < 0.05, for all variables). Blood selenium concentrations were significantly lower in patients with SIRS than in those patients without SIRS (8.08 +/- 2.42 vs. 9.45 +/- 2.02, p = 0.011). Patients with severe sepsis and septic shock had showed significantly lower blood selenium concentrations than those without SIRS (7.03 +/- 2.73 vs. 9.45 +/- 2.02, p = 0.042). Patients with PaO2/FiO2 < or = 300 had lower blood selenium concentrations than those with PaO2/FiO2 > 300 (7.90 +/- 2.43 vs. 9.54 +/- 2.17, p = 0.018). Blood selenium concentrations were significantly lower in patient with PaO2/FiO2 < or = 200 than in those with PaO2/FiO2 > 300 (7.64 +/- 2.76 vs. 9.54 +/- 2.17, p = 0.018). CONCLUSIONS: Patients with systemic inflammatory response syndrome or respiratory dysfunction showed significantly low blood selenium concentrations.
Child ; Critical Illness ; Humans ; Intensive Care Units ; Platelet Count ; Retrospective Studies ; Selenium ; Sepsis ; Shock, Septic ; Systemic Inflammatory Response Syndrome

Despite the development of modern intensive care and new antimicrobial agents, the mortality of the patients with severe sepsis and septic shock remains high. The poor outcome is considered to be a consequence of an overactive systemic inflammatory response. Sepsis is now defined as systemic inflammatory response syndrome (SIRS) in which there is an identifiable focus of infection. As a consequence of the overactive SIRS response, the function of various organ systems may be compromised, resulting in multiple organ dysfunction syndrome (MODS) and death. Systemic inflammation is a consequence of activation of the innate immune system. It is characterized by intravascular release of pro-inflammatory cytokines and other vasoactive mediators, and the concurrent activation of the innate immune cells. In addition to the pro-inflammatory reactions, the host's anti-inflammatory mechanisms are also activated and aimed at counteracting the inflammatory response. The balance between pro- and anti-inflammatory reactions is critical for the outcome of the patient. Understanding the mechanisms of acute inflammatory responses in critical ill patients is necessary for the development of urgently needed therapeutics. The aim of this review is to provide a description of the key components and mechanisms involved in the inflammatory response in patients with SIRS and sepsis.
Anti-Infective Agents ; Cytokines ; Humans ; Immune System ; Inflammation ; Critical Care ; Multiple Organ Failure ; Sepsis ; Shock, Septic ; Systemic Inflammatory Response Syndrome

PURPOSE: Procalcitonin (PCT) is a good marker of infection but is still not routinely used. Here, we assessed the usefulness of a semi-quantitative procalcitonin test kit (PCT-Q(R)), a rapid and simple test for evaluating sepsis in the emergency department. METHODS: We recruited 80 patients who visited the emergency center and with systemic inflammatory response syndrome (SIRS). Patients were classified into 4 groups according to PCT levels using PCT-Q[Ed-Trademark signs only have to be given one time in a document]. Mortality rate, bacteremia, severity score, and severity of sepsis (SIRS/sepsis/severe sepsis/septic shock) were assessed with the criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. We calculated a receiver operating characteristic curve (ROC curve), cut-off value, and the related diagnostic parameters of each cut-off value. RESULTS: Higher PCT levels were significantly associated with increased mortality, bacteremia, and severity scores. PCT levels could discriminate between sepsis and severe sepsis at a threshold of 2 ng/ml. CONCLUSION: PCT-Q is a prognostic marker of infectious disease, but low levels do not always indicate a good prognosis. PCT levels increase with aggravation of sepsis, especially at values greater than 2 ng/ml for severe sepsis.
Bacteremia ; Calcitonin ; Communicable Diseases ; Consensus ; Critical Care ; Emergencies ; Emergency Medicine ; Humans ; Prognosis ; Protein Precursors ; Reagent Strips ; ROC Curve ; Sepsis ; Systemic Inflammatory Response Syndrome ; Thorax