Utilidad de la proteína C reactiva sérica en el diagnóstico y tratamiento del adulto inmunocompetente hospitalizado por neumonía adquirida en la comunidad / Immunocompetent adults hospitalized for a community-acquired pneumonia: Serum C-reactive protein as a prognostic marker

Background: C-reactive protein (CRP) is used to monitor patients' response during treatment of infectious diseases. Morbidity and mortality associated with community-acquired pneumonia (CAP) is high, particularly in hospitalized patients. Better risk prediction during hospitalization could improve management and ultimately reduce mortality rates. Aim: To evaluate CRP measured at admission and the third day of hospitalization as a predictor for adverse events in CAP. Material and Methods: A prospective cohort study of adult patients hospitalized with CAP at an academic hospital. Major adverse outcomes were admission to ICU, mechanical ventilation, prolonged hospital length of stay, hospital complications and 30-day mortality. Predictive associations between CRP (as absolute levels and relative decline at third day) and adverse events were analyzed. Results: Eight hundred and twenty-three patients were assessed, 19% were admitted to ICU and 10.6% required mechanical ventilation. The average hospital stay was 8.8 ± 8.2 days, 42% had nosocomial complications and 8.1% died within 30 days. Ninety eight percent of patients had elevated serum CRP on admission to the hospital (18.1 ± 14.1 mg/dL). C-reactive protein measured at admission was associated with the risk of bacterial pneumonia, bacteremic pneumonia, septic shock and use of mechanical ventilation. Lack of CRP decline within three days of hospitalization was associated with high risk of complications, septic shock, mechanical ventilation and prolonged hospital stay. Conclusions: CRP responses at third day of hospital admission was a valuable predictor of adverse events in hospitalized CAP adult patients.

Avaliação da interleucina 3 como marcador prognóstico na sepse / Role of interleukin-3 as a prognostic marker in septic patients

RESUMO Objetivo: Avaliar a acurácia dos níveis de interleucina 3 para predizer prognóstico em pacientes sépticos. Métodos: Conduzimos uma coorte prospectiva que incluiu pacientes adultos internados em unidade de terapia intensiva, que apresentassem sepse ou choque séptico iniciados há até 48 horas. Mediram-se os níveis séricos de interleucina 3 quando da inclusão (dia 1) e nos dias 3 e 7. O desfecho primário analisado foi a mortalidade hospitalar por qualquer causa. Resultados: Foram incluídos 120 pacientes. Os níveis séricos de interleucina 3 dosados à inclusão foram significativamente mais elevados em pacientes que faleceram em comparação aos que sobreviveram à internação hospitalar (91,2pg/mL versus 36pg/mL; p = 0,024). Em modelo de sobrevivência de Cox com inclusão de idade e valores sequenciais de SOFA, os níveis de interleucina 3 mensurados na inclusão mantiveram-se independentemente associados à mortalidade hospitalar (HR 1,032; IC95% 1,010 - 1,055; p = 0,005). Em curva Característica de Operação do Receptor construída para investigação adicional da acurácia da interleucina 3 na predição do prognóstico, encontrou-se área sob a curva de 0,62 (IC95% 0,51 - 0,73; p = 0,024) para mortalidade hospitalar. Valores iniciais de interleucina 3 acima de 127,5pg/mL mostraram-se significativamente associados à mortalidade hospitalar (p = 0,019; OR = 2,97; IC95% 1,27 - 6,97; p = 0,019), entretanto com baixo desempenho (especificidade de 82%, sensibilidade de 39%, valor preditivo positivo de 53%, valor preditivo negativo de 72%, razão de verossimilhança negativa de 0,73 e razão de verossimilhança positiva de 2,16). Conclusão: Níveis elevados de interleucina 3 mostraram-se independentemente associados à mortalidade hospitalar em pacientes sépticos, entretanto com baixo desempenho clínico.

ABSTRACT Objective: To evaluate the accuracy of IL-3 to predict the outcome of septic patients. Methods: Prospective cohort study with adult patients in an intensive care unit with sepsis or septic shock diagnosed within the previous 48 hours. Circulating IL-3 levels were measured upon inclusion (day 1) and on days 3 and 7. The primary outcome was hospital mortality. Results: One hundred and twenty patients were included. Serum levels of IL-3 on day 1 were significantly higher among patients who died than among patients who survived the hospital stay (91.2pg/mL versus 36pg/mL, p = 0.024). In a Cox survival model considering the IL-3 levels at inclusion, age and sequential SOFA, IL-3 values remained independently associated with mortality (HR 1.032; 95%CI 1.010 - 1.055; p = 0.005). An receiver operating characteristic curve was built to further investigate the accuracy of IL-3, with an area under the curve of 0.62 (95%CI 0.51 - 0.73; p = 0.024) for hospital mortality. A cutoff initial IL-3 value above 127.5pg/mL was associated with hospital mortality (OR 2.97; 95%CI: 1.27 - 6.97; p = 0.0019) but with a low performance (82% for specificity, 39% for sensibility, 53% for the positive predictive value, 72% for the negative predictive value, 0.73 for the negative likelihood and 2.16 for the positive likelihood ratio). Conclusion: Higher levels of IL-3 are shown to be independently associated with hospital mortality in septic patients but with poor clinical performance.

Procalcitonin determined at emergency department as an early indicator of progression to septic shock in patient with sepsis associated with ureteral calculi

ABSTRACT Introduction: To investigate the role of initial procalcitonin (PCT) level as an early predictor of septic shock for the patient with sepsis induced by acute pyelonephritis (APN) secondary to ureteral calculi. Materials and Methods: The data from 49 consecutive patients who met criteria of sepsis due to APN following ureteral stone were collected and divided into two groups: with (n=15) or without (n=34) septic shock. The clinical variables including PCT level for this outcome were retrospectively compared by univariate analysis, followed by multivariable logistic regression model. Results: All subjects had hydronephrosis, and were hospitalized with the mean of 11.8 days (3–42 days). The mean size of the ureteral stones was 7.5mm (3–30mm), and 57% were located in upper ureter. At univariate analysis, patients with septic shock were significantly older, a higher proportion had hypertension, lower platelet count and serum albumin level, higher CRP and PCT level, and higher positive blood culture rate. Multivariate models indicated that lower platelet count and higher PCT level are independent risk factors (p=0.043 and 0.046, respectively). In ROC curve, the AUC was significantly wider in PCT (0.929), compared with the platelet count (0.822, p=0.004). At the cut-off of 0.52ng/mL, the sensitivity and specificity were 86.7% and 85.3%. Conclusion: Our study demonstrated elevated initial PCT levels as an early independent predictor to progress into septic shock in patients with sepsis associated with ureteral calculi.

Observancia de las guías internacionales de manejo temprano en sepsis grave y choque séptico / Adherence to international guidelines on early management in severe sepsis and septic shock

Introducción. La observancia completa del tratamiento temprano dirigido por objetivos, disminuye significativamente la mortalidad a 28 días, mientras que la observancia parcial no tiene ningún beneficio. Objetivos. Determinar la observancia de las guías internacionales en sepsis grave y choque séptico, mediante el conjunto de medidas (bundle) de reanimación de las primeras seis horas en pacientes mayores de 16 años de edad, en un centro de referencia de alta complejidad. Materiales y métodos. Se presenta un estudio de cohorte, prospectivo y descriptivo, llevado a cabo durante un período de seis meses, en pacientes con sepsis grave o choque séptico admitidos a los servicios de urgencias, unidades de cuidados intensivos y cuidados especiales. Se midió la observancia del conjunto de medidas mediante ocho intervenciones: 1) medición del lactato sérico, 2) inicio temprano de antibióticos, 3) toma de hemocultivos, 4) infusión de líquidos intravenosos, 5) uso de medicamentos vasopresores, 6) inserción de catéter venoso central, 7) presión venosa central mayor de 8 mm Hg, y 8) saturación venosa central de oxígeno mayor de 70 %. Resultados. Se tamizaron 723 pacientes; 16 % (n=116) cumplieron los criterios de inclusión, 92,2 % (n=107) cumplieron los criterios para sepsis grave y 37,9 % (n=44) para choque séptico. El 62,9 % (n=73) fue subdiagnosticado. La observancia completa de las 8 intervenciones del conjunto de medidas fue de 0 %; de 6 a 7, 19 % (n=22); de 3 a 5, 67,2 % (n=78), y de 0 a 2, 98,3 % (n=114). Conclusión. La completa observancia de las guías internacionales de manejo en sepsis grave y choque séptico en las primeras seis horas es nula y solo se cumple de manera parcial.

Introduction. Complete adherence to early goal-directed therapy has shown a significant reduction in 28-day mortality rate, whereas partial adherence has not shown beneficial effect. Objectives. The effect of adherence to 6 hour sepsis bundle treatment was evaluated on patients with severe sepsis and septic shock. Materials and methods. A prospective cohort study was conducted during a six-month period. The patients were limited to those 16 years or older and included admissions to intensive care units, special care units or emergency departments with severe sepsis or septic shock. The adherence to the 6-hour sepsis bundle was evaluated through 8 interventions as follows: (1) serum lactate measure,( 2) early antibiotic administration, (3) blood culture samples, (4) infusion of intravenous fluids, (5) vasopressor use, (6) central venous catheter, (7) central venous pressure >8 mm Hg, and (8) central venous oxygen saturation >70%. Results. Seven hundred and twenty three patients were screened; 16% (n=116) met the inclusion criteria; 92.2% (n=107) met the criteria for severe sepsis and 37.9% (44) for septic shock; 62.9% (n=73) were subdiagnosed. Complete adherence to the 8 interventions of 6-hour sepsis bundle was 0%; 6 to 7 (19%, n=22), 3 to 5 (67.2%, n=78), and 0 to 2 (98.3%, n=114). Conclusion. Adherence to 6-hour sepsis bundle treatment for severe sepsis and septic shock was not done for the full 8 interventions and only partial accomplishment of the first 4 interventions.

Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal-directed therapy: still outcome markers?

OBJETIVO: Comparar a evolução do "standard base excess" e o nível de lactato sérico entre pacientes sobreviventes e não sobreviventes com sepse grave ou choque séptico reanimados com o "early goal directed therapy". MÉTODOS: Estudo retrospectivo em uma unidade de terapia intensiva de um hospital escola onde sessenta e cinco pacientes com sepse grave e choque séptico foram observados sem intervenções. RESULTADOS: Em nosso estudo, a mortalidade na sepse grave e choque séptico foi de 38%. A saturação venosa central de oxigênio nos dois grupos foi maior que 70% depois da reanimação, exceto no segundo dia no grupo dos pacientes não sobreviventes (69,8%). Depois do segundo dia, a saturação venosa central foi significantemente maior no grupo dos sobreviventes (p<0.001). O "standard base excess" foi inicialmente baixo em ambos os grupos, mas a partir do segundo dia a recuperação do "standard base excess" foi significantemente mais importante e linear no grupo dos sobreviventes (p<0.001). Os níveis de lactato foram similares na evolução dos dois grupos. DISCUSSÃO: O "standard base excess" e o lactato são ainda considerados como marcadores prognósticos em pacientes com sepse grave ou choque séptico reanimados de acordo com o "early goal directed therapy". Outros estudos devem ser realizados com a intenção de demonstrar se intervenções hemodinâmicas baseadas no "standard base excess" e nos níveis de lactato podem ser úteis em melhorar desfechos clínicos em pacientes com sepse grave ou choque séptico.