Sepsis is the leading cause of death among critically ill patients and the 10th most common cause of death overall in the United States. The mortality rates increase with severity of the disease, ranging from 15% for sepsis to 60% for septic shock. Patient with sepsis can present varied clinical symptoms depending on the personal predisposition, causal microorganism, organ system involved, and disease severity. To facilitate sepsis diagnosis, the first sepsis consensus definitions was published in 1991 and then updated in 2001. Early recognition of a sepsis patient followed with timely and appropriate treatment and management strategies have been shown to significantly reduce sepsis-related mortality, and allows care to be provided at lower costs. Despite the rapid progress in the knowledge of pathophysiological mechanisms of sepsis and its treatment in the last two decades, identifying patient with sepsis and therapeutic approaches to sepsis and its complications remains challenging to critical care clinicians. Hence, the objectives of this thesis were to 1) evaluate the test characteristics of the two sepsis consensus definitions and delineate the differences in patient profile among patients meeting or not meeting sepsis definitions; 2) determine the relationship between the changes in several physiological parameters before sepsis onset and sepsis, and to determine whether these parameters could be used to identify sepsis in critically ill adults; 3) evaluate the effect of corticosteroids therapy on patient mortality. Data used in this thesis were prospectively collected from an electronic medical record system for all the adult patients admitted into the seven critical care units (ICUs) in a tertiary medical center. Besides analyzing data at the ICU stay level, we investigated patient information in various time frames, including 24-hour, 12-hour, and 6-hour time windows. In the first study of this thesis, the 1991 sepsis definition was found to have a high sensitivity of 94.6%, but a low specificity of 61.0%. The 2001 sepsis definition had a slightly increased sensitivity but a decreased specificity, which was 96.9% and 58.3%, respectively. The areas under the ROC curve for the two consensus definitions were similar, but less than optimal. The sensitivity and area under the ROC curve of both definitions were lower at the 24-hour time window level than those of the unit stay level, though the specificity increased slightly. At the time window level, the 1991 definitions performed slightly better than the 2001 definition. In the second study, minimum systolic blood pressure performed the best, followed by maximum respiratory rate in discriminating sepsis patients from SIRS patients. Maximum heart rate and maximum respiratory rate can differentiate sepsis patients from non-SIRS patients fairly well. The area under ROC of the combination of five physiological parameters was 0.74 and 0.90 for comparing sepsis to non-infectious SIRS patients and comparing sepsis to non-SIRS patients, respectively. Parameters typically performed better in 24-hour windows compared to 6-hour or 12-hour windows. In the third study, significantly increased hospital mortality and ICU mortality were observed in the group treated with low-dose corticosteroids than the control group based on the propensity score matched comparisons, and multivariate logistic regression analyses after adjustment for propensity score alone, covariates, or propensity score (in deciles) and covariates. This thesis advances the existing knowledge by systemically evaluating the test characteristics for the 1991 and 2001 sepsis consensus definitions, delineating physiological signs and symptoms of deterioration in the preceding 24 hours prior to sepsis onset, assessing the prediction performances of single or combined physiological parameters, and examining the use of corticosteroids treatment and survival among septic shock patients. In addition, this thesis sets an innovative example on how to use data from electronic medical records as these surveillance systems are becoming increasingly popular. The results of these studies suggest that a more parsimonious set of definitional criteria for sepsis diagnosis are needed to improve sepsis case identification. In addition, continuously monitored physiological parameters could help to identify patients who show signs of deterioration prior to developing sepsis. Last but not least, caution should be used when considering a recommendation on the use of low dose corticosteroids in clinical practice guidelines for the management of sepsis.

Yersinia pestis (Y. pestis), as the causative agent of plague, has caused deaths estimated to more than 200 million people in three historical plague pandemics, including the infamous Black Death in medieval Europe. Although infection with Yersinia pestis can mostly be limited by antibiotics and only 2000-5000 cases are observed worldwide each year, this bacterium is still a concern for bioterrorism and recognized as a category A select agent by the Centers for Disease Control and Prevention (CDC). The investigation into the host-pathogen interactions during Y. pestis infection is important to advance and broaden our knowledge about plague pathogenesis for the development of better vaccines and treatments. Y. pestis is an expert at evading innate immune surveillance through multiple strategies, several mediated by its type three secretion system (T3SS). It is known that the bacterium induces rapid and robust cell death in host macrophages and dendritic cells. Although the T3SS effector YopJ has been determined to be the factor inducing cytotoxicity, the specific host cellular pathways which are targeted by YopJ and responsible for cell death remain poorly defined. This thesis research has established the critical roles of caspase-8 and RIP kinases in Y. pestis-induced macrophage cell death. Y. pestis-induced cytotoxicity is completely inhibited in RIP1-/- or RIP3-/-caspase-8-/- macrophages or by specific chemical inhibitors. Strikingly, this work also indicates that macrophages deficient in either RIP1, or caspase-8 and RIP3, have significantly reduced infection-induced production of IL-1β, IL-18, TNFα and IL-6 cytokines; impaired activation of NF-κB signaling pathway and greatly compromised caspase-1 processing; all of which are critical for innate immune responses and contribute to fight against pathogen infection. Y. pestis infection causes severe and often rapid fatal disease before the development of adaptive immunity to the V bacterium, thus the innate immune responses are critical to control Y. pestis infection. Our group has previously established the important roles of key molecules of the innate immune system: TLR4, MyD88, NLRP12, NLRP3, IL-18 and IL-1β, in host responses against Y. pestis and attenuated strains. Yersinia has proven to be a good model for evaluating the innate immune responses during bacterial infection. Using this model, the role of caspase-8 and RIP3 in counteracting bacterial infection has been determined in this thesis work. Mice deficient in caspase-8 and RIP3 are very susceptible to Y. pestis infection and display reduced levels of pro-inflammatory cytokines in spleen and serum, and decreased myeloid cell death. Thus, both in vitro and in vivo results indicate that caspase-8 and RIP kinases are key regulators of macrophage cell death, NF-κB and caspase-1 activation in Yersinia infection. This thesis work defines novel roles for caspase-8 and RIP kinases as the central components in innate immune responses against Y. pestis infection, and provides further insights to the host-pathogen interaction during bacterial challenge.

Indiana University-Purdue University Indianapolis (IUPUI)

Human body lice, Pediculus humanus humanus, and head lice, Pediculus humanus capitis, have been hematophagous ectoparasites of humans for thousands of years. Despite being ecotypes, only body lice are known to transmit bacterial diseases to humans, and it appears that lower humoral and cellular immune responses allow body lice to possess a higher vector competence. We previously observed that the transcription level of the defensin 1 gene was up-regulated only in head lice following oral challenge of Bartonella quintana, a causative agent of trench fever, and also that body lice excreted more viable B. quintana in their feces. In this study, we first investigated this differential immune response by performing RNAi to knockdown defensin 1 by dsRNA injection. B. quintana was orally infected 72 h after injection and proliferation was compared at 2 hours (day 0) and day 4 post-infection. At day 0, bacterial cell numbers increased 1.5-fold in defensin 1 (Def1(-)) knocked down head lice compared with non-knocked down, pQE30-dsRNA injected, head lice control. At day 4, Def1(-) knocked down head lice had 2.55-fold more bacterial cells than control head lice and 1.65-fold greater than body lice, indicating that defensin 1 was active in reducing B. quintana cell number in non-knocked down head lice. Second, the levels of cytotoxic reactive oxygen species (ROS) generated by the epithelial cells of the alimentary tract were measured using two general indictors of ROS in both body and head lice at day 1 and day 4 following B. quintana challenge. Challenged body lice showed a 42% and 34% increase in ROS, whereas head lice showed a 70% and 22% increase at day 1 using CM-H2DCFDA and HPF as general indicators, respectively. On day 4, all challenged lice showed similar ROS levels except for body lice which maintained their ROS levels (40% increase using CM-H2DCFDA). Head lice are likely to have multiple immune and/or non-immune factors that suppress B. quintana proliferation, and the production of sustained ROS levels and/or the single knockdown of Defensin 1 is not enough to increase B. quintana proliferation in head lice to that seen in body lice.

In der vorliegenden Arbeit wurde anhand der im Rahmen des Vermont-Oxford-Neonatal-Networks erhobenen Daten an der Berliner Klinik für Neonatologie der Charité Campus Mitte und der Abteilung für neonatologische Intensivmedizin der Universitätskinderklinik in Innsbruck ein Benchmarking-Projekt für die Jahre 1997 bis 2001 durchgeführt. Nach der Analyse des Outcomes wurde eine Analyse der externen Evidenz anhand von Literatursuche in PubMed und der Cochrane Datenbank für systematische Reviews durchgeführt. Danach wurde ein Fragebogen entworfen, der gezielt Handlungsstrategien und -richtlinien bezüglich der relevanten Outcome-Parameter erfragt. Für das Benchmarking-Projekt wurden das Atemnotsyndrom, die nekrotisierende Enterokolitis und die bakteriellen Infektionen ausgewählt. Die Analyse der Handlungsstrategien durch den Fragebogen zeigte, dass in den drei Bereichen respiratorische Interventionen, Nahrung und Ernährung sowie im Infektionsmanagement Unterschiede vorlagen. In der Diskussion zeigte sich, dass in vielen Bereichen noch Bedarf nach guter externer Evidenz und weiterer Forschung besteht. / This dissertation presents the results of a 1997 - 2001 benchmark project in co-operation with the "Berliner Klinik für Neonatologie der Charité Campus Mitte" and the "Abteilung für neonatologische Intensivmedizin der Universitätskinderklinik" in Innsbruck. The study is based on the Vermont-Oxford-Neonatal-Network''s data. After analysing the results, further evidence was analysed by way of literary research in PubMed and the Cochrane Database of Systematic Reviews. Afterwards, a questionnaire was created, lining out the clinical guidelines of the relevant outcome parameters. The respiratory distress syndrom, the necrotising enterocolitis and the bacterial infections were selected for the benchmark. The internal guidelines'' analysis showed that there were differences between the two clinics'' results in respiratory interventions, feeding and the management of infections. The discussion made clear that research based on further evidence is necessary in many fields.