No description available.

Introducción: En febrero del 2016 fueron publicadas las nuevas recomendaciones para identificar al paciente con sepsis con la escala SOFA (Evaluación de la falla orgánica relacionada con la sepsis) y la nueva escala quick SOFA. Objetivo: Evaluar la utilidad de estas escalas como pronóstico de mortalidad en pacientes con sepsis hospitalizados en la unidad de cuidados intensivos (UCI) de la Clínica Good Hope de enero a diciembre del 2015, así como los factores asociados a su mortalidad. Material y métodos: Se revisaron las historias clínicas de los pacientes mayores de 18 años hospitalizados en UCI/UCIN con los diagnósticos de sepsis de acuerdo a su CIE-10. Se recabaron los datos epidemiológicos, clínicos y laboratoriales necesarios para aplicar las escalas SOFA y QSOFA. Se realizó estadística descriptiva, análisis bivariado y análisis del área bajo la curva COR. Resultados: El principal foco infeccioso fue el respiratorio (41.5%). Fallecieron 28.3% de los pacientes. Las variables creatinina y lactato sérico demostraron ser estadísticamente significativos con un OR=11.67(IC 95% 2.58-52.85, p=0.000) y OR=5.78 (IC95% 1.45-23.03, p=0.009), respectivamente. El AUC de SOFA fue 0.698, p=0.026, IC 95% (0.54-0.85), demostrando ser estadísticamente significativa. Se halló un punto de corte de 7.5 con una sensibilidad de 46.7% y 86.8% de especificidad. La escala QSOFA no demostró asociación estadísticamente significativa. Conclusiones: La escala SOFA fue efectiva para identificar aquellos pacientes con probabilidad de fallecer.

ABSTRACT Current guidelines published by the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) recommend empiric antibiotics for all neonates born to mothers with a diagnosis of chorioamnionitis due to the risk of early onset sepsis (EOS). EOS is difficult to diagnose due to nonspecific symptoms and a lack of reliable tests, can progress quickly, and is potentially fatal or have neurodevelopmental consequences for survivors. Antibiotics are frequently prescribed in the hospital and are lifesaving in the setting of a serious infection. Conversely, overuse of antibiotics has potential negative effects to individuals and the population as a whole. Antibiotic resistant infections are a consequence of antibiotic misuse, are costly and difficult to treat, and pose a risk to patients hospitalized. To examine this problem at The University of Vermont Medical Center (UVMMC) a retrospective chart review was preformed. Data on the maternal risk factors associated with EOS were collected in addition to clinical characteristics of their neonates and entered into a neonatal early onset sepsis (NEOS) calculator to determine the specific risk of infection to each infant. Treatment of the infant was compared to the NEOS calculator and CDC recommendations. Using posterior probability to determine a more specific risk profile better targets antibiotic therapy to ensure all infants that need treatment receive it, while reducing the number of infants treated empirically. UVMMC currently treats 78% of infants according to CDC guidelines. Use of the NEOS calculator would reduce antibiotic treatment to 18% of term neonates born to mothers with a diagnosis of chorioamnionitis. Using a new tool to determine risk of EOS may safely reduce the number of infants receiving antibiotic treatment.

Sepsis is the leading cause of death in ICU patients. Patients with sepsis may develop sepsis-related cardiac dysfunction. The presence of this cardiac dysfunction can increase the mortality rate from 40% to 70%. Diabetes is a chronic disease that manifests as an elevation in blood glucose. Patients with diabetes are more susceptible to, and at increasing risk of developing, infections and subsequently sepsis. Activation of the NF-ĸB pathway plays a crucial role in the pathophysiology of sepsis-associated cardiac dysfunction and diabetic cardiomyopathy. The effect of diabetes on outcomes in patients with sepsis is highly controversial and it is still unclear whether pre-existing T2DM augments the cardiac dysfunction associated with sepsis and whether activation of NF-ĸB drives the cardiac dysfunction in T2DM/sepsis patients. In this thesis, I have first developed two models of high fat diet (HFD)-induced diabetes and diabetic cardiomyopathy in mice. Then, I developed two models of sepsis associated cardiac dysfunction using lipopolysaccharide (LPS) or caecumligation and puncture (CLP) in diabetic mice. I have demonstrated that mice with pre-existing T2DM exhibit a significantly greater cardiac (organ) dysfunction after challenge with either (low dose) LPS or mild CLP surgery. The exacerbated cardiac dysfunction was accompanied by an increase in NF-ĸB activation and reduction in Akt phosphorylation in the heart and an increase in the serum levels of proinflammatory cytokines. The increase in cardiac dysfunction, as well as the increase in the activation of NF-ĸB, caused by sepsis in animals with T2DM was largely attenuated by treatment with a selective IĸB kinase inhibitor (IKK-16) or a DPP-4 inhibitor (linagliptin). Thus, excessive activation of NF-ĸB in animals with diabetes/sepsis drives the observed excessive cardiac dysfunction, and that inhibition of NF-ĸB may be a useful target to treat the excessive inflammation and sepsis associated cardiac (organ) dysfunction in patients with T2DM and sepsis.

Class of 2006 Abstract / Objectives: To develop and evaluate a data collection form that could be used to assess the influence of heparin administration on the septic severity index score in patients with Candida blood stream infections. Methods: A data collection form was developed to evaluate the influence of heparin administration on the septic severity index score in patients with Candida blood stream infections. This form was assessed using rating scales for ease of use, applicability of data collection items and availability of data in charts. Results: Data from 10 patient charts was used to assess the instrument. Patient demographics were similar. The strengths of the form included applicability of 9 out of 10 items in the instrument. Four out of 10 items were rated low for ease of use. In addition, 7 out of 10 pertinent data items were not documented in the charts. Conclusion: An extensive reworking of the data collection form as described in the discussion section was required. The form is ready to be implemented if the proposed study should be performed.

Sepsis is a severe blood infection caused by bacteria entering the blood stream. Sepsis caused by antibiotic resistant bacteria is very dangerous with a high mortality rate. The current clinical diagnostic methods for sepsis require culturing the blood sample prior to other steps of the diagnosis procedure. Culturing the blood samples is a time-consuming step which increases the time required for the diagnostic procedure. Considering the fact that the mortality rate of the sepsis increases as time passes, it is essential to find methods for sepsis diagnosis that do not require culturing the samples. The first step of a new diagnostic method for antibiotic resistant sepsis, we have developed a new method for rapid separation of the bacteria from whole human blood based on centrifugal force. Density and size differences between blood cells and bacteria lead to different sedimentation velocities for each of these cells and microorganisms in a centrifugal field. Spinning blood inoculated with bacteria in our designed hollow disks at the specified speed for a designated period of time creates fairly well-separated layers of blood cells and plasma. Red and white cells have higher sedimentation velocities due to higher densities or larger sizes compared to bacteria, forming a region of dense cells close to the wall of the spinning disk. Bacteria sediment slower than red and white cells, moving to and remaining in plasma. By carefully slowing the spinning speed after separation, we are able to avoid remixing of the blood cell layer and bacteria, thus keeping the bacteria separated from rest of the blood cells. This thesis involves the experimental methods for increasing the recovery of the bacteria from human blood by mechanical and chemical methods. It also explains the theory behind the separation technique used.

No description available.

Eine intakte Endothelbarriere ist eine unabdingbare Voraussetzung für die uneingeschränkte Funktion sämtlicher Organe. Wird die Barrierefunktion durch entzündliche Prozesse gestört, so kommt es zum Austritt von Gefäßflüssigkeit ins Interstitium. Dies resultiert in Organversagen und ist Mitverursacher der hohen Sterblichkeit bei systemischen Entzündungsreaktionen und Sepsis. Vorangehende Untersuchungen haben bereits wichtige Mechanismen aufgedeckt, die zum Barriereverlust führen (Schlegel et al., 2009). In dieser Studie wurde untersucht, ob die Aktivierung des Transkriptionsfaktors NF ĸB für den LPS-induzierten Zusammenbruch der Endothelbarriere von Bedeutung ist. In der vorliegenden Arbeit wurde gezeigt, dass die Einwirkung von LPS in zwei verschiedenen Endothelzelllinien, den makrovaskulären PSEC sowie den mikrovaskulären HDMEC, zu einer signifikanten Aktivierung von NF ĸB führte. Dies wurde sowohl mittels Kernextraktionsversuchen als auch durch Immunfluoreszenzfärbungen nachgewiesen. Messungen des TER zeigten eine Abnahme des endothelialen Widerstands und folglich der Barrierefunktion nach Applikation von LPS, gefolgt von einer spontanen Regeneration der Barriere nach einer Inkubationszeit von 24 h. Eine Erhöhung des intrazellulären cAMP Spiegels durch Applikation von Forskolin/Rolipram verhinderte zwar die LPS induzierte Bildung interzellulärer Lücken, nicht jedoch die Aktivierung des Transkriptionsfaktors NF ĸB. Vielmehr verstärkte eine cAMP Erhöhung sogar eine NF ĸB Aktivierung in HDMEC nach 4 h, ohne die Morphologie der Endothelzelljunktionen zu schädigen. Der selektive NF ĸB Inhibitor NBD Peptid vermochte im Gegensatz dazu die LPS induzierte NF ĸB Aktivierung deutlich zu hemmen, verhinderte allerdings weder die interzelluläre Lückenbildung noch den Abfall des TER durch LPS. Im Gegenteil – da unter Einwirkung von NBD Peptid die spontane Regeneration des TER nach LPS Applikation ausblieb, schienen barrierekompromittierende Effekte von LPS durch Hemmung der NF ĸB Aktivierung mittels NBD-Peptid sogar verstärkt zu werden. In Übereinstimmung mit diesen Ergebnissen hemmte auch die Repression von NF ĸB p65 durch eine spezifische p65 siRNA den LPS induzierten Zusammenbruch der Endothelbarriere nicht. Weitere NF ĸB abhängige Proteine wie VASP und Caveolin 1, deren Beteiligung am Pathomechanismus von anderen Arbeitsgruppen vorgeschlagen wurde, blieben in unseren Experimenten unter LPS Exposition unverändert. Zusammenfassend scheint die NF ĸB Aktivierung initial nicht entscheidend am LPS induzierten Zusammenbruch der Endothelbarriere beteiligt zu sein. Unsere Ergebnisse legen vielmehr nahe, dass die Aktivierung des Transkriptionsfaktors möglicherweise Teil eines „Rescue“ Mechanismus sein könnte. / An intact endothelial barrier is indispensable for the functioning of all organs. Inflammatory processes like sepsis lead to increased endothelial permability, causing edema which often result in organ failure. Previous studies uncovered important mechanisms leading to endothelial barrier breakdown (Schlegel et al., 2009). This study analyses if activation of NF ĸB is involved in LPS-induced damage to intercellular junctions. It is demonstrated that LPS leads to activation of NF ĸB in two different endothelial cell lines, PSEC and HDMEC, shown by nuclear extraction and immunofluorescence experiments. Measurements of TER visualise reduction of endothelial resistance and thus integrity of the endothelial barrier after application of LPS, followed by spontaneous regeneration after 24 hours. Increase of intracellular cAMP levels by application of Forskolin/Rolipram prevented LPS-induced intercellular gap formation, while activation of NF ĸB was not affected. Rather, increased cAMP levels intensified activation of NF ĸB in HDMEC after 4 h, without damaging morphology of endothelial cell junctions. The selective NF ĸB-inhibitor NBD-peptide prevented LPS-induced NF ĸB activation but not intercellular gap formation and reduction of TER. Because NBD-peptide blocked spontaneous regeneration of TER after LPS application, barrier compromising effects of LPS appeared to be intensified by inhibition of NF ĸB activation. In accordance with these results repression of NF ĸB p65 by siRNA did not prevent LPS-induced barrier breakdown. Other NF ĸB-dependent proteins like VASP and Caveolin-1, both suggested to be involved in the pathomechanism, remained unaffected. In summary, NF ĸB activation appears not to be initially involved in LPS-induced endothelial barrier breakdown. The results of this study suggest activation of NF ĸB might be part of a “rescue” mechanism.

Das grampositive Bakterium Staphylococcus epidermidis ist ein wesentlicher Bestandteil der kommensalen Flora der Haut und der Schleimhäute des Menschen. Jedoch stellen diese Bakterien eine häufige Ursache nosokomialer Katheter-assozierter Infektionen bei immunsupprimierten Patienten dar. Dies liegt zum einen an der Fähigkeit von S. epidermidis, Biofilm zu bilden. Diese physikalische Barriere schützt die Bakterien vor dem Immunsystem sowie vor Antibiotika. Dabei zählen sie zu den häufigsten Erregern von Infektionen an implantierten Fremdkörpern mit Plastikoberflächen, wie z. B. Venenkathetern, künstlichen Herzklappen oder Gefäßprothesen. Zum anderen stellt die Antibiotikaresistenzentwicklung unter S. epidermidis ein zunehmendes Problem dar. Vor allem die late-onset Sepsis, die durch S. epidermidis als Erreger verursacht werden kann, stellt für Frühgeborene eine Gefahr dar. Ziel der vorliegenden Arbeit war, für S. epidermidis als häufigsten und klinisch bedeutsamen KoNS zu eruieren, ob die zunehmende Dauer des stationären Krankenhausaufenthaltes von sehr kleinen Frühgeborenen mit einer höheren Rate an ica-Präsenz, Biofilmbildung und Antibiotikaresistenz assoziiert ist, sowie die Verbreitungswege und das Reservoir für diese S. epidermidis-Stämme zu identifizieren. Hierzu wurden sequenzielle Isolate von S. epidermidis bei Müttern, Kindern und vom Krankenhauspersonal gewonnen und mittels MLST (Multilocus-Sequence-Typing) klonal typisiert. Sie wurden auf Antibiotikaresistenzen, Biofilmbildung und Präsenz des icaA-Gens, das eine Rolle bei der Biofilmbildung spielt, sowie des mecA-Gens untersucht und mit Isolaten, die aus Blutkulturen oder Venenkatheter des Kindes isoliert wurden, verglichen. Es fiel auf, dass die Isolate der sehr kleinen Frühgeborenen deutlich mehr Virulenzfaktoren, wie z.B. Biofilmbildung, hohe Antibiotikaresistenzraten sowie die Präsenz des mecA- und des icaA- Gens, als die maternalen Stämme besaßen. Im Vergleich mit den Ergebnissen der untersuchten Personalstämme liegt der Verdacht nahe, dass oftmals auch das Personal als Transmitter, vor allem von Klonen mit mehreren Virulenzfaktoren, dient. Das Krankenhaus-Milieu scheint dabei ein ideales Reservoir für die Ausbreitung solcher gefährlichen S. epidermidis-Stämme zu sein. / Staphylococcus epidermidis is usually a commensal inhabitant of the human skin and mucosa. However, they are a common cause of nosocomial infections, especially in context with medical devices and catheters in immunocompromised patients. This is due to the ability of Staphylococcus epidermidis to form biofilms on inert surfaces of medical devices, like intravenous catheters or artificial arthroplastics. Furthermore the development of antibiotic resistances among Staphylococcus epidermidis is another problem. Especially the late-onset-sepsis is a danger for very low birth weight premature infants. The aim of the study was to identify for S. epidermidis isolates in very preterm infants, if a longer stay in the hospital is associated with a higher carriage of the ica-operon, a higher antibiotic resistance and the ability to form biofilms. The reservoir and the means of distribution of these nosocomial isolates should be idendified. Therefore sequential isolates were taken from mothers, their children and from the hospital staff. They were clonally typified by MLST (Multilocus-Sequence-Typing) and tested for antibiotic resistances, biofilm formation and the presence of the icaA- and mecA gene. Then they were compared with isolates from blood cultures or venous catheters from the preterm infants. Herby it was remarkable that the isolates of the very premature infants had more virulence factors, e.g. formation of biofilm, antibiotic resistances and the presence of the icaA- and mecA gene, as the maternal isolates. Compared to the results of the isolates from the medical staff it could be suggested that the staff transmits these opportunistic pathogens. The hospital environment seems to be an ideal reservoir for these dangerous S. epidermidis isolates.

Objectives: The objectives of this thesis were to: 1) develop and validate a coding algorithm to identify true cases of neonatal bacterial sepsis, and 2) apply the algorithm to calculate incidence rates and estimate temporal trends of neonatal bacterial sepsis. Methods: For Objective 1, the reference cohorts were assembled among neonates born in 2012-2017 using patient-level health care encounter data. Any neonates who met both the Diagnostic Criterion Ⅰ (microbiological confirmation) and Criterion Ⅱ (sepsis-related antibiotic administration) were included in the true-positive cohort. Potential coding algorithms were developed based on different combinations of ICD-10-CA codes on the hospitalization discharge abstract. For Objective 2, the coding algorithm with the most optimal characteristics was applied to provincial data to calculate incidence rates in Ontario during 2003-2017. Recent temporal trends were estimated by Poisson regression analysis. Results: In Objective 1, since all true-positive cases identified were born at preterm gestation, the study population in Objective 2 was limited to preterm infants. The final coding algorithm selected had sensitivity of 75.3% (95% CI, 66.8%-83.7%), specificity of 98.2% (95% CI, 97.8%-98.6%) and PPV of 50.0% (95% CI, 42.1%-58.0%). Using this algorithm, the annual incidence declined over time from 50.2 (95% CI, 45.4-55.4) per 1000 preterm infants in 2003 to 27.5 (95% CI, 20.4-36.9) per 1000 preterm infants in 2017. The trend over time was statistically significant with P-value <0.0001. Significant variation in bacterial sepsis incidence rates was noted across infant sex and gestational age. Conclusion: The coding algorithm developed in this study could not accurately identify neonates with bacterial sepsis from within health administrative database using the data available to us now. For the purpose of demonstrating the application of the algorithm, we carried out Objective 2; however, it is important to cautiously interpret the provincial rates given the the poor performance of the case-finding algorithm.