Relative tachycardia in patients with sepsis: an independent risk factor for mortality.

BACKGROUND: Excess activation of the sympathetic nervous system may be a risk factor for mortality in patients with the systemic inflammatory response syndrome (SIRS) or sepsis. AIM: To examine whether excessive tachycardia, relative to the degree of fever is an independent risk factor for death in patients with SIRS. DESIGN: Prospective observational study. SETTING: Departments of medicine in three university hospitals in Israel, Germany and Italy. METHODS: We collected data for 3382 patients with SIRS, whether community- or hospital-acquired, 91% with sepsis, as part of an ongoing trial. RESULTS: Overall 30-day mortality was 12% (408/3382). The pulse/temperature ratio was significantly higher in patients who died than in survivors: mean +/- SD 2.55 +/- 0.57 vs. 2.40 +/- 0.48 bpm/ degrees C (p < 0.0001). Excessive tachycardia was significantly associated with a mortality in a logistic model accounting for other strong predictors of mortality (OR 1.54, 95%CI 1.10-2.17). Patients with septic shock were the only group for whom this association did not hold. DISCUSSION: Our data are compatible with the hypothesis that some patients with sepsis experience an excess activation of the sympathetic nervous system, leading to a fatal outcome.

In vitro differentiation and characterization of human peritoneal macrophages from CAPD-peritonitis patients.

Studies on human macrophages are restricted due to difficulties in isolating significant numbers of human macrophages. High numbers of monocytes/macrophages can be obtained from peritonitis effluents of patients treated with peritoneal dialysis. To determine whether these cells might be useful for functional studies, we characterized peritoneal macrophages (PM) immediately after isolation from the dialysate effluents and their subsequent differentiation. During a 10 days culture period they differentiated morphologically and phenotypically (FACS-analysis) from monocyte-like cells to macrophages. Reflecting the intraperitoneal inflammation we found protein- and mRNA-synthesis of IL-8 and monocyte-chemoattractant-protein-1 (MCP-1) to be upregulated in PM after isolation from the effluents. In contrast, TNF-alpha was downregulated and could not be stimulated by LPS and/or IFN-gamma, reflecting the phenomenon of desensitization. After 10 days in culture, cytokine production normalized to a constitutive level and the TNF-alpha responsiveness to LPS was restored. These data suggest the recovery of PM from the inflammatory prestimulation. Therefore PM harvested from peritoneal dialysis effluents might provide a useful tool for further studies on the role of human macrophages in inflammation.

The need for macrolides in hospitalised community-acquired pneumonia: propensity analysis.

The present study compared beta-lactam macrolide ("combination") therapy versus beta-lactam alone ("monotherapy") for hospitalised community-acquired pneumonia, using propensity scores to adjust for the differences between patients. A prospective multinational observational study was carried out. Baseline patient and infection characteristics were used to develop a propensity score for combination therapy. Patients were matched by the propensity score (three decimal point precision) and compared with 30-day mortality and hospital stay. The propensity score was used as a covariate in a logistic model for mortality. Patients treated with monotherapy (n = 169) were older (mean+/-sd age 70.6+/-17.3 versus 65.0+/-19.6 yrs), had a higher chronic diseases score and a different clinical presentation compared with patients treated with combination therapy (n = 282). Unadjusted mortality was significantly higher with monotherapy (37 (22%) out of 169 versus 21 (7%) out of 282). Only 27 patients in the monotherapy group could be matched to 27 patients in the combination group using the propensity score. The mortality in these groups was identical, with three (11%) demises each. The multivariable odds ratio for mortality associated with combination therapy, adjusted for the propensity score and the Pneumonia Severity Index, was 0.69 (95% confidence interval 0.32-1.48). The benefit of combination therapy versus monotherapy cannot be reliably assessed in observational studies, since the propensity to prescribe these regimens differs markedly.

Distinct regulation of IL-8 and MCP-1 by LPS and interferon-gamma-treated human peritoneal macrophages.

BACKGROUND: Interleukin-8 and monocyte chemotactic protein-1 (MCP-1) are major leukocyte chemoattractants during bacterial peritonitis by recruiting neutrophils and monocytes/macrophages respectively. METHODS: Peritoneal macrophages (PM) from 12 different CAPD patients with peritonitis were stimulated with either 10 ng/ml LPS, 10 ng/ml IFN-gamma or LPS+IFN-gamma, and IL-8 and MCP-1 production was determined on protein and mRNA levels by using ELISA technique and Northern blot analysis. To obtain information from two different stages of activation, experiments were done with highly activated PM directly after isolation and with cells after 10 days in culture, each group being stimulated for 4 h. Unstimulated cells served as control. RESULTS: Immediately after isolation IL-8 mRNA-expression and synthesis was high and could be further increased by LPS stimulation, whereas IFN-gamma treatment showed no significant influence. The levels of MCP-1 were also initially high but could not be further stimulated by LPS, whereas addition of IFN-gamma resulted in a significant rise in MCP-1 synthesis. After 10 days in culture LPS-stimulation of cells again revealed a significant increase in IL 8 protein synthesis, whereas IFN-gamma showed no effect. LPS anergy for MCP-1 was still seen in PM after 10 days in culture, and IFN-gamma treatment again induced a significant rise in MCP-1 synthesis. The overall production of both chemokines was far higher on day 1 compared to day 10. CONCLUSION: Our data show differences in LPS/IFN-gamma regulation for IL-8 and MCP-1 in both highly activated and in resting, mature peritoneal macrophages, suggesting distinct pathways for these chemokines that may offer a means of control for the specific recruitment of neutrophils and monocytes/macrophages in bacterial peritonitis.