Prevalence of Bacterial Codetection and Outcomes for Infants Intubated for Respiratory Infections.

OBJECTIVES: To determine the prevalence of respiratory bacterial codetection in children younger than 2 years intubated for acute lower respiratory tract infection (LRTI), primarily viral bronchiolitis, and identify the association of codetection with mechanical ventilation duration. DESIGN: Prospective observational study evaluating the prevalence of bacterial codetection (moderate/heavy growth of pathogenic bacterial plus moderate/many polymorphonuclear neutrophils) and the impact of codetection on invasive mechanical ventilation (IMV) duration. SETTING: PICUs in 12 high and low/middle-income countries. PATIENTS: Children younger than 2 years old requiring intubation and ICU admission for LRTI and who had a lower respiratory tract culture obtained at the time of intubation between December 1, 2019, and November 30, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 472 analyzed patients (median age 4.5 mo), 55% had a positive respiratory culture and 29% (n = 138) had codetection. 90% received early antibiotics starting at a median of 0.36 hours after respiratory culture. Median (interquartile range) IMV duration was 151 hours (88, 226), and there were 28 deaths (5.3%). Codetection was more common with younger age, a positive respiratory syncytial virus test, and an admission diagnosis of bronchiolitis; it was less common with an admission diagnosis of pneumonia, with admission to a low-/middle-income site, and in those receiving vasopressors. When adjusted for confounders, codetection was not associated with longer IMV duration (adjusted relative risk 0.854 [95% CI 0.684-1.065]). We could not exclude the possibility that codetection might be associated with a 30-hour shorter IMV duration compared with no codetection, although the CI includes the null value. CONCLUSIONS: Bacterial codetection was present in almost a third of children younger than 2 years requiring intubation and ICU admission for LRTI, but this was not associated with prolonged IMV. Further large studies are needed to evaluate if codetection is associated with shorter IMV duration.

Impact of Respiratory Bacterial Codetection on Outcomes in Ventilated Infants With Bronchiolitis.

BACKGROUND: Viral bronchiolitis is a common cause of acute respiratory failure requiring intubation for infants. Bacterial respiratory tract infections can occur with bronchiolitis, although their prevalence and impact on outcomes are unclear, especially with increased use of noninvasive respiratory support. METHODS: This was a single-center retrospective cohort study of children <2 years old requiring intubation in the emergency department for bronchiolitis from 2012 to 2017 who had viral testing plus a lower respiratory culture obtained. We evaluated the impact of bacterial codetection (positive respiratory culture plus moderate or many polymorphonuclear neutrophils on Gram stain) on mechanical ventilation (MV) duration and intensive care unit length of stay using multivariable gamma regression. RESULTS: Of 149 patients enrolled, 52% had bacterial codetection. In adjusted analysis, patients with codetection had shorter MV duration [adjusted relative risk (aRR) 0.819, 95% confidence interval (CI): 0.69-0.98; marginal mean duration of 5.31 days (4.71-5.99) compared to 6.48 days (5.72-7.35) without codetection]. Patients with codetection had a shorter intensive care unit stay [aRR 0.806 (0.69-0.94); marginal mean length of stay 6.9 days (6.21-7.68) vs. 8.57 days (7.68-9.56) without codetection]. The association between codetection and duration of ventilation appears confined to those receiving earlier antibiotics (less than the median time) rather than later antibiotics [aRR 0.738 (0.56-0.95) for earlier vs. aRR 0.92 (0.70-1.18) for later]. CONCLUSIONS: Respiratory bacterial codetection is common and associated with shorter MV duration in infants requiring early intubation for bronchiolitis. Early antibiotics may contribute to these outcomes, but further multicenter studies are needed to understand the role of codetection and antibiotics on bronchiolitis outcomes.

Intensivists' Reported Management of Critical Bronchiolitis: More Data and New Guidelines Needed.

OBJECTIVES: Existing bronchiolitis guidelines do not reflect the needs of infants admitted to the PICU. This study aimed to identify PICU providers' reported practice variations and explore the need for critical bronchiolitis clinical guidelines. METHODS: Cross-sectional electronic survey available in English, Spanish, and Portuguese between November 2020 and March 2021, distributed via research networks from North and Latin America, Asia, and Australia/New Zealand. RESULTS: A total of 657 PICU providers responded, including 344 English, 204 Spanish, and 109 Portuguese. PICU providers indicated frequently using (≥25% of time) diagnostic modalities for nonintubated and intubated patients on PICU admission (complete blood count [75%-97%], basic metabolic panel [64%-92%], respiratory viral panel [90%-95%], chest x-ray [83%-98%]). Respondents also reported regularly (≥25% of time) prescribing ß-2 agonists (43%-50%), systemic corticosteroids (23%-33%), antibiotics (24%-41%), and diuretics (13%-41%). Although work of breathing was the most common variable affecting providers' decision to initiate enteral feeds for nonintubated infants, hemodynamic status was the most common variable for intubated infants (82% of providers). Most respondents agreed it would be beneficial to have specific guidelines for infants with critical bronchiolitis who are requiring both noninvasive (91% agreement) and invasive (89% agreement) respiratory support. CONCLUSIONS: PICU providers report performing diagnostic and therapeutic interventions for infants with bronchiolitis more frequently than recommended by current clinical guidelines, with interventions occurring more frequently for infants requiring invasive support. More clinical research is needed to inform the creation of evidence-based guidelines specifically for infants with critical bronchiolitis.

Paediatric critical COVID-19 and mortality in a multinational prospective cohort.

Background: To understand critical paediatric coronavirus disease 2019 (COVID-19) and evaluate factors associated with mortality in children from high and low-middle income countries. Methods: Prospective, observational study of critically ill children hospitalised for COVID-19 in 18 countries throughout North America, Latin America, and Europe between April 1 and December 31, 2020. Associations with mortality were evaluated using logistic regression. Findings: 557 patients (median age, 8 years; 24% <2 years) were enrolled from 55 sites (63% Latin American). Half had comorbidities. Invasive (41%) or non-invasive (20%) ventilation and vasopressors (56%) were the most common support modalities. Hospital mortality was 10% and higher in children <2 years old (15%; odds ratio 1·94, 95%CI 1·08-3·49). Most who died had pulmonary disease. When adjusted for age, sex, region, and illness severity, mortality-associated factors included cardiac (aOR 2·89; 95%CI 1·2-6·94) or pulmonary comorbidities (aOR 4·43; 95%CI 1·70-11·5), admission hypoxemia (aOR 2·44; 95%CI 1·30-4·57), and lower respiratory symptoms (aOR 2·96; 95%CI 1·57-5·59). MIS-C (aOR 0·25; 95%CI 0·1-0·61) and receiving methylprednisolone (aOR 0·5; 95%CI 0·25-0·99), IVIG (aOR 0·32; 95%CI 0·16-0·62), or anticoagulation (aOR 0·49; 95%CI 0·25-0·95) were associated with lower mortality although these associations might be limited to children >2 years old. Interpretation: We identified factors associated with COVID-19 mortality in critically ill children from both high and low-middle income countries, including higher mortality with younger age and COVID-related pulmonary disease but lower mortality in MIS-C. Further research is needed on optimal treatments for younger children and respiratory failure in paediatric COVID-19. Funding: None.

Reducing Avoidable Transfer Delays in the Pediatric Intensive Care Unit for Status Asthmaticus Patients.

INTRODUCTION: Status asthmaticus (acute severe asthma) is one of the most common reasons for Pediatric Intensive Care Unit (PICU) admission. Accordingly, ensuring optimal throughput for patients admitted with status asthmaticus is essential for optimizing PICU capacity. Few studies specifically address effective methods to reduce delays related to PICU discharge. This project aimed to identify and reduce avoidable delays in PICU discharge for status asthmaticus patients. METHODS: This quality improvement project focused on reducing transfer delays for status asthmaticus patients admitted to the PICU at a freestanding academic children's hospital. We standardized the transfer criteria, identified barriers to an efficient transfer, and implemented multidisciplinary interventions. The primary aim was to decrease the average duration from fulfilling the transfer criteria to PICU discharge by 15% from the baseline within 8 months of implementation. The balancing measure was readmissions to the PICU for asthma exacerbations within 24 hours from PICU discharge. RESULTS: The analysis included 623 patients. Following interventions, the time from fulfilling transfer criteria to PICU discharge decreased from 9.8 hours to 6.8 hours, a 30.6% reduction from baseline. Improvements were sustained for 6 months. In the preintervention group, three patients were readmitted to the PICU within 24 hours of transferring out of the PICU, but no patient was readmitted during the postintervention period. CONCLUSIONS: Standardizing transfer criteria and implementing multidisciplinary strategies can reduce avoidable PICU discharge delays for patients with status asthmaticus. The application of a similar approach could potentially reduce avoidable delays for other conditions in the PICU.

Respiratory Pathogen Detection in Pediatric Patients Intubated for Presumed Infection.

OBJECTIVES: Respiratory syncytial virus (RSV) in pediatric patients has been associated with low risk of concomitant bacterial infection. However, in children with severe disease, it occurs in 22% to 50% of patients. As viral testing becomes routine, bacterial codetections are increasingly identified in patients with non-RSV viruses. We hypothesized, among patients intubated for respiratory failure secondary to suspected infection, there are similar rates of codetection between RSV and non-RSV viral detections. METHODS: This retrospective chart review, conducted over a 5-year period, included all patients younger than 2 years who required intubation secondary to respiratory failure from an infectious etiology in a single pediatric emergency department. Patients intubated for noninfectious causes were excluded. RESULTS: We reviewed 274 patients, of which 181 had positive viral testing. Of these, 48% were RSV-positive and 52% were positive for viruses other than RSV. Codetection of bacteria was found in 76% (n = 65; 95% confidence interval [CI], 66%, 84%) of RSV-positive patients and 66% (n = 63, 95% CI: 57%, 76%) of patients positive with non-RSV viruses. Among patients with negative viral testing, 33% had bacterial growth on lower respiratory culture. Male sex was the only patient-related factor associated with increased odds of codetection (odds ratio [OR], 2.2; 95% CI, 1.08-4.38). The odds of codetection between RSV-positive patients and non-RSV viruses were not significantly different (OR, 1.3; 95% CI, 0.62-2.71). CONCLUSIONS: Bacterial codetection is common and not associated with anticipated patient-related factors or with a specific virus. These results suggest consideration of empiric antibiotics in infants with respiratory illness requiring intubation.

Airway microbiome dynamics and relationship to ventilator-associated infection in intubated pediatric patients.

BACKGROUND: Little is known about the airway microbiome in intubated mechanically ventilated children. We sought to characterize the airway microbiome longitudinally and in association with clinical variables and possible ventilator-associated infection (VAI). METHODS: Serial tracheal aspirate samples were prospectively obtained from mechanically ventilated subjects under 3 years old from eight pediatric intensive care units in the United States from June 2017 to July 2018. Changes in the tracheal microbiome were analyzed by sequencing bacterial 16S ribosomal RNA gene relative to subject demographics, diagnoses, clinical parameters, outcomes, antibiotic treatment, and the Ventilator-Associated InfectioN (VAIN) score. RESULTS: A total of 221 samples from 58 patients were processed and 197 samples met the >1000 reads criteria (89%), with an average of 43,000 reads per sample. The median number of samples per subject was 3 (interquartile range [IQR]: 2-5), with a median VAIN score of 2 (IQR: 1-3). Proteobacteria was the highest observed phyla throughout the intubation period, followed by Firmicutes and Actinobacteria. Alpha diversity was negatively associated with days of intubation (p = .032) and VAIN score (p = .016). High VAIN scores were associated with a decrease of Mycobacterium obuense, and an increase of Streptococcus peroris, Porphyromonadaceae family (unclassified species), Veillonella atypica, and several other taxa. No specific pattern of microbiome composition related to clinically diagnosed VAIs was observed. CONCLUSIONS: Our data demonstrate decreasing alpha diversity with increasing VAIN score and days of intubation. No specific microbiome pattern was associated with clinically diagnosed VAI.

Comparison of Interleukin-6 Plasma Concentration in Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Pediatric Sepsis.

Importance: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with SARS-CoV-2 infection is thought to be driven by a post-viral dysregulated immune response, where interleukin 6 (IL-6) might have a central role. In this setting, IL-6 inhibitors are prescribed as immunomodulation in cases refractory to standard therapy. Objective: To compare plasma IL-6 concentration between critically ill children with MIS-C and sepsis. Design: A retrospective cohort study from previously collected data. Setting: Individual patient data were gathered from three different international datasets. Participants: Critically ill children between 1 month-old and 18 years old, with an IL-6 level measured within 48 h of admission to intensive care. Septic patients were diagnosed according to Surviving Sepsis Campaign definition and MIS-C cases by CDC criteria. We excluded children with immunodeficiency or immunosuppressive therapy. Exposure: None. Main Outcome(s) and Measure(s): The primary outcome was IL-6 plasma concentration in MIS-C and sepsis group at admission to the intensive care unit. We described demographics, inflammatory biomarkers, and clinical outcomes for both groups. A subgroup analysis for shock in each group was done. Results: We analyzed 66 patients with MIS-C and 44 patients with sepsis. MIS-C cases were older [96 (48, 144) vs. 20 (5, 132) months old, p < 0.01], but no differences in sex (41 vs. 43% female, p = 0.8) compared to septic group. Mechanical ventilation use was 48.5 vs. 93% (p < 0.001), vasoactive drug use 79 vs. 66% (p = 0.13), and mortality 4.6 vs. 34.1% (p < 0.01) in MIS-C group compared to sepsis. IL-6 was 156 (36, 579) ng/dl in MIS-C and 1,432 (122, 6,886) ng/dl in sepsis (p < 0.01), while no significant differences were observed in procalcitonin (PCT) and c-reactive protein (CRP). 52/66 (78.8%) patients had shock in MIS-C group, and 29/44 (65.9%) had septic shock in sepsis group. Septic shock had a significantly higher plasma IL-6 concentration than the three other sub-groups. Differences in IL-6, CRP, and PCT were not statistically different between MIS-C with and without shock. Conclusions and Relevance: IL-6 plasma concentration was elevated in critically ill MIS-C patients but at levels much lower than those of sepsis. Furthermore, IL-6 levels don't discriminate between MIS-C cases with and without shock. These results lead us to question the role of IL-6 in the pathobiology of MIS-C, its diagnosis, clinical outcomes, and, more importantly, the off-label use of IL-6 inhibitors for these cases.

Creation of a Combination Antibiogram for Pseudomonas aeruginosa in a Pediatric Intensive Care Unit.

OBJECTIVE: This study describes the creation of a combination antibiogram directed toward Pseudomonas aeruginosa to determine the most appropriate empiric antimicrobial regimen(s). METHODS: P aeruginosa isolates were collected from all sites between January 2013 and December 2017 for patients admitted to the PICU. Patients with cystic fibrosis and isolates from the same site and susceptibility pattern obtained within 30 days were excluded. ß-Lactam susceptibilities were determined and compared with the addition of an aminoglycoside or fluroquinolone and summarized in a combination antibiogram. RESULTS: One hundred ninety-nine P aeruginosa isolates were included for analysis. The addition of a second agent to piperacillin-tazobactam was shown to have the most significant improvement among the ß-lactams, with 70% susceptibility as monotherapy and increases to above 90% with the addition of an aminoglycoside or fluroquinolone. The addition of an aminoglycoside or fluroquinolone to cefepime and meropenem increased coverage to above 95%. The addition of a second agent was likely to increase susceptibility of a monotherapy backbone; however, as the susceptibility of the first-line agent decreased, the susceptibility of the second agent needed to be higher to achieve a 95% coverage threshold. CONCLUSIONS: Our results support use of a second agent to significantly improve the likelihood of appropriate empiric coverage of P aeruginosa. Use of a combination antibiogram may be more beneficial than a simple antibiogram for units with increasing resistance rates, or for coverage of specific resistant organisms.

Empiric Vancomycin Reduction in a Pediatric Intensive Care Unit.

BACKGROUND: At our institution, empirical vancomycin is overused in children with suspected bacterial community-acquired infections (CAIs) admitted to the PICU because of high community rates of methicillin-resistant Staphylococcus aureus (MRSA). Our goal was to reduce unnecessary vancomycin use for CAIs in the PICU. METHODS: Empirical PICU vancomycin indications for suspected CAIs were developed by using epidemiological risk factors for MRSA. We aimed to reduce empirical PICU vancomycin use in CAIs by 30%. After retrospectively testing, the indications were implemented and monthly PICU empirical vancomycin use during baseline (May 2017-April 2018) and postintervention (May 2018-July 2019) periods. Education was provided to PICU providers, vancomycin indications were posted, and the antibiotic order set was revised. Statistical process control methods tracked improvement over time. Proven S aureus infections for which vancomycin was not empirically prescribed and linezolid or clindamycin use were balancing measures. RESULTS: We identified 1620 PICU patients with suspected bacterial CAIs. Empirical vancomycin decreased from a baseline of 73% to 45%, a 38% relative reduction. No patient not prescribed empirical vancomycin later required the addition of vancomycin or other MRSA-targeted antibiotics. There was no change in nephrotoxicity or in the balancing measures. CONCLUSIONS: Development of clear and concise recommendations, combined with clinician education and decision support via an order set, was an effective and safe strategy to reduce PICU vancomycin use. Retrospective validation of the recommendations with local data were key to obtaining PICU clinician buy in.

Compliance With an Antibiotic Guideline for Suspected Ventilator-Associated Infection: The Ventilator-Associated INfection (VAIN2) Study.

OBJECTIVES: To evaluate a guideline for antibiotic decisions in children with suspected ventilator-associated infection. DESIGN: Prospective, observational cohort study conducted in 22 PICUs in the United States and Canada. SETTING: PICUs in 22 hospitals from April 2017 to January 2019. SUBJECTS: Children less than 3 years old on mechanical ventilation greater than 48 hours who had respiratory secretions cultured and antibiotics initiated for suspected ventilator-associated infection. INTERVENTIONS: After baseline data collection in children with suspected ventilator-associated infection (Phase 1), a consensus guideline was developed for advising antibiotic continuation or stopping at 48-72 hours (Phase 2) and implemented (Phase 3). Guideline-based antibiotic recommendations were provided to the treating clinicians once clinical and microbiologic data were available. Demographic and outcome data were collected, and guideline compliance and antibiotic utilization evaluated for Phase 1 and Phase 3. MEASUREMENTS AND MAIN RESULTS: Despite education and implementation efforts, guideline-concordant antibiotic management occurred in 158 of 227 (70%) Phase 3 subjects compared with 213 of 281 (76%) in Phase 1. Illness severity and positive respiratory cultures were the primary determinants of antibiotic continuation. For subjects with a positive respiratory culture but a score for which antibiotic discontinuation was recommended (score ≤ 2), only 27% of Phase 3 subjects had antibiotics discontinued. Antibiotic continuation was not associated with improved outcomes in these subjects and was associated with significantly longer duration of ventilation (median 5.5 d longer) and PICU stay (5 d longer) in the overall study population. Positive respiratory cultures were not associated with outcomes irrespective of antibiotic treatment. CONCLUSIONS: Antibiotic guideline efficacy and safety remain uncertain due to clinician failure to follow the guideline, instead primarily relying on respiratory culture results. Strategies to overcome clinician perceptions of respiratory cultures and other barriers will be vital for improving guideline adherence and antibiotic use in suspected ventilator-associated infection in future studies.

Relationship of Viral Detection with Duration of Ventilation in Critically Ill Infants with Lower Respiratory Tract Infection.

Rationale: Although respiratory virus testing is frequently done for critically ill infants with bronchiolitis, the prognostic value of this testing is unknown for those requiring positive-pressure ventilation (PPV). Objectives: To determine the differences in PPV use according to viral detection and to explore the association between viral detection and duration of PPV in critically ill children with presumed respiratory infection. Methods: This is a retrospective cohort study in a quaternary pediatric intensive care unit from February 2014 until February 2017. We evaluated 984 children less than 1 year of age who received PPV for presumed respiratory infection without significant congenital heart disease, care limitations, baseline PPV usage, or tracheostomy. Respiratory viruses were identified using a PCR panel. Analyses of duration of PPV according to viral etiology were performed using univariate and multivariable logistic regression and truncated negative binomial regression with calculated mean marginal effects (MME). Results: Overall, 85 (9%) infants had no viruses identified, 629 (64%) had a single virus detected, most commonly respiratory syncytial virus (417, 42%) followed by rhinovirus/enterovirus (145, 15%), 230 (23%) had two viruses detected, and 40 (4%) had three viruses detected. Compared with those with one or no virus detected, infants with ⩾2 viruses received longer total PPV duration in adjusted analysis (relative risk [RR], 1.4; 95% confidence interval [CI], 1.2-1.6; P < 0.001; MME = 29 h). Detection of rhinovirus/enterovirus alone, compared with respiratory syncytial virus alone, was associated with significantly shorter duration of total PPV (RR, 0.7; 95% CI, 0.62-0.87; P = <0.001; MME = -23 h), noninvasive PPV (RR, 0.7; 95% CI, 0.60-0.85; P < 0.001; MME = -15 h), and invasive PPV (RR, 0.7; 95% CI, 0.54-0.83; P < 0.001; MME = -54 h) when adjusted for weight, prematurity, and administration of early antibiotic therapy. Conclusions: Identification of viral type and number in severe bronchiolitis is an important predictor of duration of PPV.

Reduced PICU respiratory admissions during COVID-19.

BACKGROUND: The COVID-19 pandemic reached the Southern Hemisphere in the autumn of 2020, thus coinciding with its expected annual viral respiratory season. The potential impact of national strategies aimed at mitigating COVID-19 during the pandemic on the incidence of other critical viral lower respiratory tract infections (LRTIs) in children is unknown. METHODS: We analysed admission data for LRTIs from 22 paediatric intensive care units (PICUs) in four countries, part of a large international Latin American registry of children with acute respiratory failure (Red Colaborativa Pediátrica de Latinoamérica [LARed Network]). RESULTS: Between January and August, there were 83% fewer PICU admissions for LRTIs in 2020 compared to the 2018/2019 average over the same period. Similar decreases were noted for PICU admissions due to respiratory syncytial virus and influenza (92% and 78%, respectively). CONCLUSION: We observed a striking reduction in PICU admissions due to viral LRTIs over winter, during the COVID-19 pandemic in South America.

Comparison of two continuous nebulized albuterol doses in critically ill children with status asthmaticus.

Objectives: Continuous nebulized albuterol is frequently used to treat children with status asthmaticus in the pediatric intensive care unit (PICU) but can have cardiovascular side effects. Limited data exist comparing different dosages. The purpose of this study was to compare hemodynamic side effects of two continuous albuterol doses (10 vs. 25 mg/h). Our hypothesis was that lower dose albuterol would be associated with lower toxicity without increased need for adjunctive therapies.Methods: We conducted a retrospective cohort study of all children over 2 years old receiving continuous nebulized albuterol for status asthmaticus in our PICU from 2011 to 2013. Standard initial therapy was intravenous steroids and continuous nebulized albuterol. Patients receiving 10 mg/h albuterol were compared to those receiving 25 mg/h. Clinical outcomes, including the need for additional asthma therapies as well as hypotension requiring fluid resuscitation, were evaluated.Results: About 632 patients were studied (342 received 10 mg/h, 290 received 25 mg/h). Children in the lower-dose group received less fluid resuscitation without increased adjunctive therapies when adjusted for confounders. Those in the 25 mg/h group receiving 17% higher bolus volume. Those receiving lower-dose albuterol had shorter adjusted PICU and hospital lengths of stay.Conclusions: In our PICU cohort of children with status asthmaticus, use of 10 mg/h continuous albuterol was associated with lower fluid bolus resuscitation without more adjunctive therapies. These findings support the safety of lower doses in this population. Prospective studies evaluating the efficacy and toxicity of specific continuous albuterol dosages in critically ill children with status asthmaticus are warranted.

Circulating extracellular vesicle content reveals de novo DNA methyltransferase expression as a molecular method to predict septic shock.

Extracellular vesicles (EVs) are mRNA-containing cell fragments shed into circulation during pathophysiological events. DNA methyltransferases (DNMT1, DNMT3A, and DNMT3B) regulate gene expression by modifying DNA methylation and altering transcription. Sepsis is a systemic insult resulting in vascular dysfunction, which can lead to shock and death. We analysed plasma from ICU patients for circulating EV numbers, defined as particles isolated from 1 mL plasma at 21,000xg, and DNMTs mRNA content as prognostic markers of septic shock. Compared to plasma from critically ill patients with or without sepsis, plasma from septic shock patients contained more EVs per mL, expressed as total DNMTs mRNAs over 5 days, and more individual DNMT mRNAs at each day. A comparison of EV-DNMT1 (maintenance methylation) with EV-DNMT3A+DNMT3B (de novo methylation) expression correlated highly with severity, and EVs from septic shock patients carried more total DNMT mRNAs and more DNMT3A+DNMT3B mRNAs than control or sepsis EVs. Total plasma EVs also correlated with sepsis severity. EV-DNMT mRNAs load, when coupled with total plasma EV number, may be a novel method to diagnose septic shock upon ICU admittance and offer opportunities to more precisely intervene with standard therapy or other targeted interventions to regulate EV release and/or specific DNMT activity.