Empiric Antimicrobial Therapy in Patients with Healthcare-Associated, Hospital-Acquired, or Ventilator-Associated Pneumonia in Septic Shock: Does Antimicrobial Reuse Influence Outcomes?

Appropriate empiric antimicrobial selection is crucial to the survival of septic shock patients. It is suspected that the use of inadequate empiric therapy occurs commonly in practice. The primary objective of this study was to determine if there is a difference in intensive care unit (ICU) length of stay (LOS) among septic shock patients with pneumonia who received adequate versus inadequate empiric antimicrobials. Adequate was defined as a lack of exposure to the same antimicrobial class and absence of previous cultures reporting resistance to the antimicrobial in the last 90 days. This was a retrospective cohort study of adult patients who were diagnosed with septic shock and pneumonia, received IV antimicrobials, and admitted to an ICU at St. Francis Indianapolis between March 1, 2011 and September 30, 2015. Forty-four patients were identified to be included in the study after screening. Of these patients, 13 patients (29.5%) received adequate therapy and 31 patients (70.5%) received inadequate therapy. ICU LOS was found to have a median of 8.5 days (IQR=7) in adequate group and 7 days (IQR=10) in the inadequate group (p=0.776). This study showed that inadequate antimicrobial therapy occurred commonly in this patient sample. A larger sample size is needed to determine the true consequences of inadequate antimicrobial therapy in the septic shock patient population. Enhancements in real time electronic alerts within the electronic medical record may be a method that can be utilized to ensure appropriate empiric antimicrobials are initiated in septic shock patients

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Pneumonia and Septic Shock

CONTEXT: Individuals with type 2 diabetes mellitus (DM) have an increased risk of pneumonia and septic shock. Traditional glucose-lowering drugs have recently been found to be associated with a higher risk of infections. It remains unclear whether sodium-glucose cotransporter 2 inhibitors (SGLT2is), which have pleiotropic/anti-inflammatory effects, may reduce the risk of pneumonia and septic shock in DM. METHODS: MEDLINE, Embase, and ClinicalTrials.gov were searched from inception up to May 19, 2022, for randomized, placebo-controlled trials of SGLT2i that included patients with DM and reported outcomes of interest (pneumonia and/or septic shock). Study selection, data extraction, and quality assessment (using the Cochrane Risk of Bias Assessment Tool) were conducted by independent authors. A fixed-effects model was used to pool the relative risk (RRs) and 95% CI across trials. RESULTS: Out of 4568 citations, 26 trials with a total of 59 264 patients (1.9% developed pneumonia and 0.2% developed septic shock) were included. Compared with placebo, SGLT2is significantly reduced the risk of pneumonia (pooled RR 0.87, 95% CI 0.78-0.98) and septic shock (pooled RR 0.65, 95% CI 0.44-0.95). There was no significant heterogeneity of effect size among trials. Subgroup analyses according to the type of SGLT2i used, baseline comorbidities, glycemic control, duration of DM, and trial follow-up showed consistent results without evidence of significant treatment-by-subgroup heterogeneity (all P(heterogeneity) > .10). CONCLUSION: Among DM patients, SGLT2is reduced the risk of pneumonia and septic shock compared with placebo. Our findings should be viewed as hypothesis generating, with concepts requiring validation in future studies

Notes on some cases of pleural effusion occurring in children

Classification:Class I. Pneumococcab:a. Secondary to lobar Pneumonia: General facts | Family History | Previous Health | Present Illnessb. Secondary to broncho-pneumonia: General facts, etc.Class II. Septic: General Facts, etc.Class III. Tuberculous: General Facts, etcSymptoms and Physical Signs of Effusion in all Classes:a. General Appearance | b. Respiratory System | c. Other SystemsCourse, Treatment and Complications:I. Pneumoniccal | II. Septic | III. TuberculousDiagnosis:Differential Diagnosis with Illustrative Cases:Prognosis:Pathology oft effusion:Tables: i. General History of Cases | ii. Symptoms & Physical Signs | iii. Character of effusion | iv. Analysis of Fatal CasesI. Pneumococcal | Septic | III. Tuberculous: Bacteriology; Of lung and pleura; Cases illustrating pathologyReference

Lower mortality rate in elderly patients with community-onset pneumonia on treatment with aspirin

BACKGROUND: Pneumonia is complicated by high rate of mortality and cardiovascular events (CVEs). The potential benefit of aspirin, which lowers platelet aggregation by inhibition of thromboxane A2 production, is still unclear. The aim of the study was to assess the impact of aspirin on mortality in patients with pneumonia. METHODS AND RESULTS: Consecutive patients admitted to the University-Hospital Policlinico Umberto I (Rome, Italy) with community-onset pneumonia were recruited and prospectively followed up until discharge or death. The primary end point was the occurrence of death up to 30 days after admission; the secondary end point was the intrahospital incidence of nonfatal myocardial infarction and ischemic stroke. One thousand and five patients (age, 74.7±15.1 years) were included in the study: 390 were receiving aspirin (100 mg/day) at the time of hospitalization, whereas 615 patients were aspirin free. During the follow-up, 16.2% of patients died; among these, 19 (4.9%) were aspirin users and 144 (23.4%; P<0.001) were aspirin nonusers. Overall, nonfatal CVEs occurred in 7% of patients, 8.3% in nonaspirin users, and 4.9% in aspirin users (odds ratio, 1.77; 95% confidence interval, 1.03 to 3.04; P=0.040). The Cox regression analysis showed that pneumonia severity index (PSI), severe sepsis, pleural effusion, and PaO(2)/FiO(2) ratio <300 negatively influenced survival, whereas aspirin therapy was associated with improved survival. Compared to patients receiving aspirin, the propensity score adjusted analysis confirmed that patients not taking aspirin had a hazard ratio of 2.07 (1.08 to 3.98; P=0.029) for total mortality. CONCLUSIONS: This study shows that chronic aspirin use is associated with lower mortality rate within 30 days after hospital admission in a large cohort of patients with pneumonia

Causes of pleural effusions in horses resident in the UK

Pleural effusions (PE) reportedly occur most commonly secondary to bacterial pneumonia with neoplastic effusions contributing a minority of cases. The majority of reports originate from the USA and Australia, where long distance transport of horses, a recognised risk factor, may occur more frequently than in the UK. Anecdotally, a greater proportion of horses with PE are diagnosed with neoplasia in the UK than has been reported. The aim of this retrospective study was to describe the causes of PE in horses in the UK, and to identify markers that can help differentiate between septic and neoplastic causes of PE. Medical records from 4 equine hospitals in the UK were searched for horses diagnosed with PE. Information recorded included case background, admission physical examination and biochemical findings, and characteristics of the effusion (volume, cell count, total protein [TP] concentration). A total of 69 horses were identified, with 26 (38%) diagnosed with a neoplastic effusion. The remainder were categorised as septic, including 14/43 (32.5%) that had a history of international transport. Horses with septic effusions were significantly younger (8 vs. 13 years; P = 0.001) and had significantly smaller volumes of pleural fluid drained at admission (9.8 l vs. 32.2 l; P<0.001). Horses with septic PE had a significantly higher rectal temperature (38.6°C vs. 38.2°C; P = 0.03), fibrinogen concentration (7.8 g/l vs. 5.3 g/l; P = 0.01) and serum amyloid A concentration (230 mg/l vs. 59 mg/l; P = 0.02) than those with neoplastic effusions. Significantly higher pleural fluid cell count and TP concentration were identified in horses with septic PE (63.9 × 109/l vs. 8.6 × 109/l; P<0.001; 57.5 g/l vs. 35.9 g/l; P = 0.04). These results suggest that in the UK, neoplastic effusions account for a greater proportion of PE than previously reported. A large volume of PE in an older horse with a low cell count and relatively low TP concentration should increase the index of suspicion of neoplasia

An immunohistochemical study of the diagnostic value of TREM-1 as marker for fatal sepsis cases

Triggering receptor expressed on myeloid cells-1 (TREM-1) is produced and up-regulated by exposure of myeloid cells to lipopolysaccharides or other components of either bacterial or fungal origin, which causes it to be strongly expressed on phagocytes that accumulate in inflamed areas. Because TREM-1 participates in septic shock and in amplifying the inflammatory response to bacterial and fungal infections, we believe it could be an immunohistochemical marker for postmortem diagnosis of sepsis. We tested the anti-TREM-1 antibody in 28 cases of death by septic shock and divided them into two groups. The diagnosis was made according to the criteria of the Surviving Sepsis Campaign. In all cases, blood cultures were positive. The first group was comprised subjects that presented high ante-mortem serum procalcitonin and the soluble form of TREM-1 (s-TREM-1) values. The second group comprised subjects in which s-TREM-1 was not measured ante-mortem. We used samples of brain, heart, lung, liver and kidney for each case to test the anti-TREM-1 antibody. A semiquantitative evaluation of the immunohistochemical findings was made. In lung samples, we found immunostaining in the cells of the monocyte line in 24 of 28 cases, which suggests that TREM-1 is produced principally by cells of the monocyte line. In liver tissue, we found low TREM-staining in the hepatocyte cytoplasm, duct epithelium, the portal-biliary space and blood vessel. In kidney tissue samples, we found the TREM-1 antibody immunostaining in glomeruli and renal tubules. We also found TREM-1 staining in the lumen of blood vessels. Immunohistochemical staining using the anti-TREM-1 antibody can be useful for postmortem diagnosis of sepsis

Septic Arthritis Caused by Legionella dumoffii in a Patient with Systemic Lupus Erythematosus-Like Disease

We describe a patient with systemic lupus erythematosus (SLE)-like disease on immunosuppressive treatment who developed septic arthritis of the knee involving Legionella dumoffii. Cultures initially remained negative. A broad-range 16S PCR using synovial fluid revealed L. dumoffii rRNA genes, a finding that was subsequently confirmed by positive Legionella culture results