Quality assurance in severe sepsis: an individualised audit/feedback system results in substantial improvements in sepsis care at a large UK teaching hospital
0 P3 Heparin-binding protein improves prediction of severe sepsis in the emergency department Adam Linder
1 Örebro University Hospital , Örebro , Sweden
2 P2 Acute kidney injury decreases long-term survival over a 10-year observation period Adam Linder
3 Cooper University Hospital , Camden, NJ , USA
4 Skåne University Hospital , Lund , Sweden
5 P1 Validation of a novel surveillance paradigm for ventilator-associated events Peter MC Klein Klouwenberg
6 , Bertil Christensson
7 Linköping University Hospital , Linköping , Sweden Critical Care 2013, 17(Suppl 4):P3; doi:10.1186/cc12904
8 Skåne University Hospital , Malmö , Sweden
9 P5 Passive immunotherapy of extended peritonitis as abdominal sepsis prevention Olexandr Butyrsky
10 , Viktor Starosek Department of Surgical Diseases, Crimean State Medical University , Simferopol, Ukraine Critical Care 2013, 17(Suppl 4):P5; doi:10.1186/cc12906
11 Department of Hygiene, Crimean State Medical University , Simferopol, Ukraine Critical Care 2013, 17(Suppl 4):P6; doi:10.1186/cc12907
12 Department of Surgical Diseases, Crimean State Medical University , Simferopol , Ukraine
13 P6 Efficacy of specific immunotherapy of abdominal sepsis Olexandr Butyrsky
14 Hackensack University Medical Center , Hackensack, NJ, USA Critical Care 2013, 17(Suppl 4):P7; doi:10.1186/cc12908
15 Section of Critical Care Medicine, University of Toronto , ON , Canada
16 Laurentian University , Sudbury, ON , Canada
17 Rush University , Chicago, IL , USA
18 Sirtris, A GSK Company , Cambridge, MA, USA Critical Care 2013, 17(Suppl 4):P8; doi:10.1186/cc12909
19 Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam , the Netherlands
20 P8 SRT2379, a small-molecule SIRT1 activator, fails to reduce cytokine release in a human endotoxemia model Maryse A Wiewel
21 Armauer Hansen Research Institute , Addis Ababa , Ethiopia
22 Department of Public Health Officer, Jigjiga University , Jigjiga , Ethiopia
23 Department of Medical Laboratory Science, College of Health Science, Addis Ababa University , Ethiopia
24 P11 Bacteriological profile and antimicrobial sensitivity pattern of blood culture isolates among septicemia-suspected children at Tikur Anbessa Specialized Hospital and Yekatit 12 Hospital , Addis Ababa , Ethiopia Adugna Negussie
25 Tikur Anbessa Specialized Hospital, Department of Pediatrics , Addis Ababa, Ethiopia Critical Care 2013, 17(Suppl 4):P11; doi:10.1186/cc12911
26 Division of Allergy and Clinical Imunology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia , Jakarta , Indonesia
27 Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia , Jakarta, Indonesia Critical Care 2013, 17(Suppl 4):P15; doi:10.1186/cc12915
28 Clinical Hospital, Federal University of Uberlândia , Brazil Critical Care 2013, 17(Suppl 4):P16; doi:10.1186/cc12916
29 Biomedical Sciences Institute, Federal University of Uberlândia , Brazil
30 Genetics and Biochemistry Institute, Federal University of Uberlândia , Brazil
31 P16 Is Strongyloides stercoralis a risk factor for sepsis severity? Patrícia Terra Alves
32 P18 Clinical manifestations, etiology and outcome of sepsis in pediatric patients admitted to the ICU Taís C São Pedro
33 , André M Morcillo, Emilio CE Baracat Department of Pediatrics, State University of Campinas, UNICAMP , Campinas, SP, Brazil Critical Care 2013, 17(Suppl 4):P18; doi:10.1186/cc12918
34 School of Medical Sciences, Rio de Janeiro State Federal University , Rio de Janeiro, Brazil Critical Care 2013, 17(Suppl 4):P19; doi:10.1186/cc12919
35 State University , Rio de Janeiro , Brazil
36 Central Laboratory, Pedro Ernesto University Hospital, Rio de Janeiro State University , Rio de Janeiro , Brazil
37 Bacteriology, Pedro Ernesto University Hospital, Rio de Janeiro State University , Rio de Janeiro , Brazil
38 School of Medical Sciences, Rio de Janeiro State University , Rio de Janeiro , Brazil
39 Pharmacy, Pedro Ernesto University Hospital, Rio de Janeiro State University , Rio de Janeiro , Brazil
40 Research Department of Emergency Medicine, Beth Israel Deaconess Medical Center , Boston, MA , USA
41 P24 Increasing number of organ dysfunctions is an excellent predictor of in-hospital mortality in emergency department patients with suspected infection: an internal and external prospective validation study Marie K Jessen
42 Research Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA Critical Care 2013, 17(Suppl 4):P24; doi:10.1186/cc12924
43 Research Center for Emergency Medicine, Aarhus University Hospital , Aarhus , Denmark
44 P23 Prediction of bacteremia in emergency department patients with suspected infection: an external validation of a clinical decision rule Marie K Jessen
45 Department of Clinical Microbiology, Aalborg University Hospital, Aarhus University Hospital , Aalborg, Denmark Critical Care 2013, 17(Suppl 4):P23; doi:10.1186/cc12923
46 Research Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School , Boston, MA, USA Critical Care 2013, 17(Suppl 4):P25; doi:10.1186/cc12925
47 P25 Lactate levels in emergency department patients across all causes of physiologic instability Kimie Ødorf
48 Central Laboratory Division, University of Sao Paulo Medical School , Sao Paulo, Brazil Critical Care 2013, 17(Suppl 4):P26; doi:10.1186/cc12926
49 Molecular Biology Branch, Central Laboratory Division, University of Sao Paulo Medical School , Sao Paulo , Brazil
50 Infection Control Unit, Heart Institute (InCor), University of Sao Paulo Medical School , Sao Paulo , Brazil
51 P26 Rapid molecular test (SeptiFast®) reduced time for adjustment of antibiotic treatment in comparison with conventional blood cultures in critically ill sepsis patients: a randomized controlled clinical trial (preliminary results) Cristhieni Rodrigues
52 Department of Mathematics and Statistics, University of Canterbury , Christchurch , New Zealand Critical Care 2013, 17(Suppl 4):P67; doi:10.1186/cc12966
53 Department of Intensive Care, Christchurch Hospital , Christchurch , New Zealand
54 Centre for Bioengineering, Department of Mechanical Engineering, University of Canterbury , Christchurch , New Zealand
55 P67 Hourly and accurate severe sepsis classification using kernel density estimates Jacquelyn D Parente
56 Department of Surgery, Federal University of São Paulo , Brazil Critical Care 2013, 17(Suppl 4):P70; doi:10.1186/cc12969
57 P70 Possible variables related to paradoxical findings between PCR and hemoculture assays in rat experimental sepsis Marcello R da Silva
58 Department of Pediatrics, Lusíada University Center , Lisbon , Portugal
59 Department of Pediatrics, Federal University of São Paulo , Brazil
60 P69 Beneficial effects of vigorous fluid resuscitation therapy varied depending on the time of onset and the sepsis stage in rats: preliminary study Ana MA Liberatore
61 Department of Pediatrics, Federal University of São Paulo , Brazil Critical Care 2013, 17(Suppl 4):P73; doi:10.1186/cc12972
62 Institute of Biology of São Paulo State , São Paulo , Brazil
63 Department of Surgery, Federal University of São Paulo , Brazil
64 P73 Effect of sepsis challenge in chronic inflammation state on mortality and long-term pathological findings in rats Roberto Tussi-Junior
65 Department of Veterinary Medicine, Rakuno Gakuen University , Ebetsu, Hokkaido , Japan Critical Care 2013, 17(Suppl 4):P86; doi:10.1186/cc12985
66 P86 Study of the effect of C1-esterase inhibitor administration to the sepsis pig model Hisashi Imahase
67 Department of Veterinary Science, Rakuno Gakuen University , Ebetsu, Hokkaido , Japan
68 Emergency and Critical Care Center, Saga University Hospital , Saga City , Japan
69 P85 Effect of polymicrobial sepsis on the respiratory mechanism of rats previously exposed to cigarette smoking Glauber C Lima
70 Institute of Biomedical Sciences, Federal University of Rio de Janeiro , Brazil Critical Care 2013, 17(Suppl 4):P90; doi:10.1186/cc12989
71 P90 Synaptic deficits in sepsis: role of glial cells Carolina A Moraes
72 Institute Oswaldo Cruz , FIOCRUZ, Rio de Janeiro , Brazil
73 P88 Epigenetic profile in lipopolysaccharide-stimulated macrophages Ester Correia Sarmento Rios
74 , Thais Martins Lima Salgado, Francisco Garcia Soriano Department of Emergency Medicine, University of São Paulo Medical School , Brazil Critical Care 2013, 17(Suppl 4):P88; doi:10.1186/cc12987
75 P92 Feasibility of gene transfer with nonviral vectors in murine models of sepsis Vanessa B Faiotto
76 , Rodolfo ME Hubert, Devanira S Paixao, Gleice R Souza, Maiara ML Fiusa, Carolina Costa-Lima, Sara TO Saad, Joyce M Annichino-Bizzacchi, Erich V De Paula Faculty of Medical Sciences, University of Campinas , SP, Brazil Critical Care 2013, 17(Suppl 4):P92; doi:10.1186/cc12991
77 Innate Immunology Group, National Veterinary Institute, Technical University of Denmark , Frederiksberg , Denmark
78 Department of Food Science, University of Copenhagen , Frederiksberg , Denmark
79 Department of Veterinary Disease Biology, University of Copenhagen , Frederiksberg , Denmark
80 P95 Gene expression patterns in multiple organs in experimentally induced Staphylococcus aureus sepsis in pigs Helle G Olsen
81 Department of Small Animal Clinical Sciences, University of Copenhagen , Frederiksberg, Denmark Critical Care 2013, 17(Suppl 4):P95; doi:10.1186/cc12994
82 Department of Mathematical Sciences, University of Copenhagen , Denmark
83 P99 Modulation of peroxynitrite improves host response to vasopressin in ovine sepsis Osamu Fujiwara
84 Department of Pharmacology, Faculty of Medicine of Ribeirão Preto, University of São Paulo , Ribeirão Preto, SP , Brazil
85 P98 Arginine vasopressin V1a agonist attenuates methicillin-resistant Staphylococcus aureus-induced vascular leakage by inhibiting bradykinin Perenlei Enkhbaatar
86 Shriners Hospital for Children , Galveston, TX, USA Critical Care 2013, 17(Suppl 4):P99; doi:10.1186/cc12998
87 Department of Anesthesiology, University of Texas Medical Branch , Galveston, TX , USA
88 P97 Role of NOX2-derived ROS in the development of cognitive impairment after sepsis Joana C D'Avila
89 Evandro Chagas Clinical Research Institute (IPEC), FIOCRUZ and D'Or Institute for Research and Education (IDOR) , Rio de Janeiro, Brazil Critical Care 2013, 17(Suppl 4):P97; doi:10.1186/cc12996
90 , Sebastian Rehberg, Osamu Fujiwara, Ernesto Lopez, Donald S Prough Department of Anesthesiology, University of Texas Medical Branch , Galveston, TX, USA Critical Care 2013, 17(Suppl 4):P98; doi:10.1186/cc12997
91 Department of Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo , Ribeirão Preto, Brazil Critical Care 2013, 17(Suppl 4):P100; doi:10.1186/cc12999
92 Department of Morphology, Physiology and Basic Pathology, Dental School of Ribeirão Preto, University of São Paulo , Ribeirão Preto , Brazil
93 P100 Effects of solid dispersion of curcumin in metabolic and immunological alterations during experimental sepsis Letycia Silvano da Silva
94 Veterinary Department at AMIB (Brazilian Intensive Care Association) and Intensivet Veterinary Consulting , Brasília, DF, Brazil Critical Care 2013, 17(Suppl 4):P110; doi:10.1186/cc13009
95 Universidade de Brasília - FAV , Brasília, DF , Brazil
96 Universidade Estadual Paulista 'Julio de Mesquita Filho' , FCAV UNESP, Jaboticabal, SP , Brazil
97 P110 Severe sepsis and septic shock survival in a clinical canine model JGMP Isola
P O S T E R P R E S E N T A T I O N S © 2013 various authors, licensee BioMed Central Ltd. All articles published in this supplement are distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Reliable surveillance methods are indispensable for
benchmarking of healthcare-associated infection rates. The National
Healthcare Safety Network (NHSN) recently introduced surveillance of
ventilator-associated events (VAE), including ventilator-associated
conditions (VAC) . This new algorithm is amenable to automated
implementation and strives for more consistent interpretation. We assess
the feasibility and reliability of automated implementation.
Materials and methods: Retrospective analysis of an ICU cohort with
prospective assessment of ventilator-associated pneumonia (VAP) in two
academic medical centers (January 2011 to June 2012). The algorithm
was electronically implemented as specified by the NHSN using
minuteto-minute ventilator data. Two minor modifications were developed to
improve stability and comparability with manual surveillance (10th
percentile and intermittent ventilation). Concordance was assessed
between the algorithms and prospective surveillance. Attributable
mortality of VAC was estimated by multivariable competing-risk survival
Results: Two thousand and eighty patients contributed 2,296 episodes of
mechanical ventilation (MV). VAC incidence was 10.0/1,000 MV days.
Prospective surveillance identified 8 VAP cases/1,000 MV days. The
original VAC algorithm detected 32% (38/115) of patients affected by
VAP; positive predictive value was 25% (38/152). Using the 10th
percentile identified the same number of VAC cases, but only 116 were
identical. VAC incidence was 24.9/1,000 MV days with the intermittent
ventilation modification. Concordance between the original algorithm and
the modified versions was suboptimal. Estimates of attributable mortality
varied by implementation: original VAC subdistribution hazard ratio
(sdHR) = 4.33, 10th percentile sdHR = 6.26 and intermittent ventilation
sdHR = 2.40.
Conclusions: Concordance between manual VAP surveillance and the
VAE algorithm was poor. Although electronic implementation of the VAE
algorithm was feasible, small variations considerably altered the events
detected and their effect on mortality. Using the current specifications,
comparability across institutions using different electronic or manual
implementations remains questionable.
Background: We hypothesized that one single episode of acute kidney
injury (AKI) reduces long-term survival compared with no acute kidney
injury (No AKI) following recovery from critical illness.
Materials and methods: A prospective cohort of 2,010 patients admitted
to the ICU between 2000 and 2009 at a provincial referral hospital was
followed to determine whether AKI influences long-term survival.
Results: Of the 1,844 eligible patients, 18.4% had AKI stage 1, 12.1% had
stage 2, 26.5% had stage 3, and 43.0% had No AKI, using the KDIGO
classification. The mean and median follow-up time was 8.1 and
8.7 years. The 28-day, 1-year, 5-year and 10-year survival rates were
59.6%, 44.9%, 37.4%, and 33.4%, in patients with any AKI (stage 1, stage
2, stage 3), which was significantly worse compared with the critically ill
patients with no AKI at any time (P < 0.01). The adjusted 10-year
mortality risk associated with AKI was 1.44 (95% CI = 1.2 to 1.7) among
28-day survivors. Patients who had mild AKI (stage 1) had significantly
worse survival at 28 days, 1 year, 3 years, 5 years and 10 years compared
with No AKI (P < 0.01) (Figure 1A). Patients with sepsis and AKI who
survived 28 days had significantly poorer 5-year and 10-year survival
compared with nonseptic AKI (P < 0.01) (Figure 1B).
Conclusions: Patients with one episode of mild (stage 1) AKI have
significantly lower survival rates over 10 years than critically ill patients
without AKI. The causes and mechanisms of this association warrant
further careful study. Close medical follow-up of these patients may be
warranted and mechanistic research required understanding how AKI
influences distant events.
Figure 1(abstract P2) A: Bar chart showing that patients with AKI of any stage had significantly poorer mean survival rates compared to
control patients with no AKI, at 28-days, 90-days, 1-year, 3-years, 5-years and 10-years after enrolment. B: Unadjusted Kaplan-Meier curves
showing the10-year survival from ICU admission for patients classified as having any stage of AKI according to the KDIGO classification using serum
creatinine. Time is calculated from 28 days after admission (28-day survivors). Mantel-Cox Log Rank showed a significant difference in mortality between
the two curves with or without AKI.
Background: The early identification of risk of developing severe sepsis
in patients with suspected infection remains a difficult challenge. We
hypothesized that an elevated plasma level of heparin-binding protein
(HBP), a neutrophil-secreted mediator of vascular leakage, would be a
predictor of delayed clinical deterioration and progressive organ
dysfunction in emergency department (ED) sepsis patients.
Materials and methods: A prospective, multicenter study in Sweden and
the US was conducted of 763 patients presenting to an ED with a
suspected infection and signs of systemic inflammation. Based on
recorded clinical and laboratory parameters and final diagnoses, patients
were classified into various groups depending on the severity of the
infection and inflammatory response. Plasma levels of HBP were measured
and compared with levels of other standard sepsis biomarkers including
procalcitonin, lactate, WBC, and C-reactive protein.
Results: The final diagnoses were severe sepsis with organ failure in
338 patients, nonsevere sepsis without organ failure in 340 patients, and
no infection in 85 patients. One-hundred and forty-three patients (19%)
presented without signs of severe sepsis, but developed delayed
circulatory failure and/or organ dysfunction within 72 hours of enrolment.
In this patient group, an elevated HBP level could predict the delayed
development of severe sepsis with an AUC value of 0.86. Elevated HBP
levels (>30 ng/ml) were found in 80% of the patients and elevated
procalcitonin levels (>0.5 ng/ml) were detected in 59%, 10.5 hours
(median) before developing severe sepsis.
Conclusions: Detection of elevated plasma-HBP levels may help to
provide an early risk-stratification of patients with suspected infections in
the ED. An elevated HBP level was independently able to predict delayed
clinical deterioration to overt shock or severe sepsis with organ failure.
Acknowledgements: This project was supported in part by Axis-Shield
Diagnostics and the Swedish Government Funds for Clinical Research
(ALF), the University Hospital, Lund, Sweden.
Clinical trial number: ClinicalTrials.gov NCT01392508 (the IMPRESSED
Potential conflicts of interests: AL, BC, and PÅ are listed as inventors on
a patent filed by Hansa Medical AB.
Impact of the Surviving Sepsis Campaign clinical guideline of in sepsis
mortality in a public health institution in Brazil
Suellen C de Aguiar*, Guilherme F Garcia, Daniela N Ferreira,
Francisco C de Souza, Valda MF Mendonça, Vanuza F Ribeiro, Lívia M Ferreira,
Flávio D Capanema, Luana C de Carvalho, Marina F de Gomes
Comissão Central de Protocolos Clínicos, Fundação Hospitalar do Estado de
Minas Gerais, Belo Horizonte, MG, Brazil
Critical Care 2013, 17(Suppl 4):P4; doi:10.1186/cc12905
Background: Sepsis is the principal cause of mortality in intensive
therapy units (ITUs) around the world . Several international
organizations created in 2002 the Surviving Sepsis Campaign (SSC),
targeting the reduction of sepsis mortality in 25% during 5 years . The
Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Brazil, was
incorporated in this campaign with eight hospitals (four general hospitals,
one trauma hospital, one oncologic center, one infectious diseases center,
one maternity hospital). The aim of this study is to evaluate the impact of
using the SSC sepsis protocol in severe sepsis and sepsis shock lethality
in the FHEMIG net hospitals.
Materials and methods: This is a retrospective cohort study based on
eight ITU public hospitals. The inclusion criteria were patients with severe
sepsis and sepsis shock according to the SSC protocol, from January 2010
to December 2012, aged older than 18 years, which had a final outcome
of hospital discharge or death. The sepsis lethality was compared
annually from 2010 to 2012. Since 2010, the implementation of educative
and managerial measures was based on the SSC guidelines: auditing of
medical charts; education in sepsis care; issue of booklet and posters
about sepsis; inclusion of sepsis information in the medical residence
program; and collaboration of hospital directors in monitoring and giving
information of the sepsis guideline. The study was approved by the
Institutional Ethical and Research Committee. Data were collected and
analyzed on EPIINFO software, using ANOVA test for comparisons with
precision of 95%.
Results: In the period of 3 years, 1,698 severe sepsis and sepsis shock
patients were registered and 1,152 (67.84%) died. We verified a reduction
of 12% (P = 0.0073) on lethality global. Hospitals 2 and 6 had a significant
reduction on lethality, of 35% (P < 0.0001) and 17% (P = 0.0073)
respectively (Table 1).
Conclusions: The sepsis lethality is still high in this institution (64.1%),
compared with the Public Hospitals in Brazil (59.6%) and the world rate
(30.8%) . After the adoption of managerial measures based on the SSC
protocol, there was a significantly reduction in lethality, but only one
hospital reached the target reduction of 25% on lethality. This
heterogeneity could be explained by different engagements of the
professional board and directory and different patient’s profiles. The sepsis
mortality is a major challenge in the world , and application of the SSC
protocol led to a significant reduction in sepsis lethality.
Acknowledgements: The authors would like to acknowledge the
assistance of the staff and local protocol team of the participant hospitals:
Hospital João XXIII, Hospital Alberto Cavalcanti, Hospital Geral de
Barbacena, Hospital Júlia Kubitschek, Hospital Eduardo de Menezes,
Maternidade Odete Valadares, Hospital Regional João Penido and Hospital
Regional Antônio Dias.
1. Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R,
Lipman J, Gomersall C, Sakr Y, et al: International study of the prevalence
and outcomes of infection in intensive care units. JAMA 2009,
2. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM,
Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, et al: Surviving Sepsis
Campaign: international guidelines for management of severe sepsis
and septic shock: 2012. Crit Care Med 2013, 41:580-637.
3. Instituto Latino Americano de Sepse. [http://www.sepsisnet.org].
4. Sales Júnior JAL, David CM, Hatum R, Souza PCSP, Japiassú A, Pinheiro CTS,
Friedman G, Silva OB, Dias MD, Koterba E, et al: Sepse Brasil: estudo
epidemiológico da sepse em Unidades de Terapia Intensiva brasileiras.
Rev Bras Ter Intensiva 2006, 18:9-17.
Background: The outcome of extended peritonitis is determined by
many factors including antimicrobial defense. Microbial invasion, surgery,
and intensive therapy cause secondary immunity deficiency associated
with septic complication incidence and post-surgery lethality. The great
importance in initialization and supporting these processes belongs to
Escherichia coli endotoxin that participates in digestive tract immunity
and general immunoresistance.
Table 1(abstract P4) Severe sepsis and sepsis shock death in the eight FHEMIG hospitals, from 2010 to 2012
Table 1(abstract P5) Indexes of anti-endotoxin immunity in extended peritonitis
Before treatment, opt.un.
5th day of treatment, opt.un.
p1, evidence between donors and day of admission; p2, evidence between day of admission and the 5th day; p3, evidence between patients of different
High immunity level patients (group I, n = 5)
Low immunity level patients (group II, n = 27)
0.276 ± 0.004 (p1 > 0.05)
0.210 ± 0.03 (p1 < 0.01)
0.121 ± 0.01 (p1 < 0.01)
0.084 ± 0.007 (p1 < 0.001, p3 < 0.001)
0.202 ± 0.02 (p1 < 0.05, p3 > 0.05)
0.069 ± 0.008 (p1 < 0.01, p3 < 0.001)
Table 2(abstract P5) Dynamics of anti-LPS-antibodies in
low immunity level patients with peritonitis after
sandoglobulin H injection
Before injection, opt.un.
After injection, opt.un.
Materials and methods: Thirty-two patients ages 15 to 86 (male:female =
24:8) treated for extended peritonitis were investigated. Blood was sampled
after admission and in 5 days to determine anti-lipopolysaccharide
antibodies of different classes (anti-LPS-IgA, anti-LPS-IgG, anti-LPS-IgM,
respectively) by hard-phase immunoenzyme analysis. The control group
included 10 healthy donors (opt.un.): anti-LPS-IgA - 0.348 ± 0.053,
anti-LPSIgM - 0.162 ± 0.01, anti-LPS-IgG - 0.333 ± 0.051.
Results: Patients with high levels of anti-endotoxin immunity were 15.6%
(n = 5) (Table 1); after surgery they had rapid recovery, normalization of
peristalsis and laboratory parameters by the 5th day. Patients of low
immunity level were 84.4% (n = 27); they had a long complicated recovery
period. In group I for standard treatment within 5 days one noticed
evident shifts of all parameters that witnesses its sufficiency. In group II the
parameters are not increased evidently, which testifies to necessity of
additional immunocorrection. Low immunity level patients were
introduced to 3 ml sandoglobulin H on the 5th day after surgery that was
associated with a sharp increase of anti-LPS antibody titer (Table 2).
Growth of anti-LPS antibody titer was associated with positive dynamics of
the post-surgery period.
Conclusions: The majority of peritonitis patients have decreased
competent anti-LPS antibodies, which determines the severity of the
postsurgery period. Low immunity level patients need passive nonspecific
immunotherapy that stimulates protective functions, blocks mechanisms
of inflammation progress, and prevents abdominal sepsis.
Background: According to the 2004 WHO Annual Report, abdominal
sepsis (AS) is one of the most dangerous diseases of the 21st century. But
the issue of its treatment including immunotherapy is very far from being
completely solved. Our aim was the demonstration of specific
immunotherapy efficacy in AS.
Materials and methods: We investigated activity of immunogenesis
(production of specific antibodies) in AS in 50 patients under impact of
hyperimmune plasma infusion obtained from the donors who recently
0.452 ± 0.02 (p2 < 0.001)
0.286 ± 0.04 (p2 < 0.05)
0.184 ± 0.02 (p2 < 0.01)
0.154 ± 0.015 (p2 < 0.01)
0.213 ± 0.01 (p2 > 0.05)
0.083 ± 0.007 (p2 > 0.05)
Table 1(abstract P6) Dynamics of specific antibody titer
in AS patients after hyperimmune plasma introduction
Before introducing, After introducing,
Anti-E. coli (n = 10)
Anti-P. aeruginosa (n = 10)
Anti-S. aureus (n = 10)
Anti-bacteroids (n = 10)
Anti-peptococci (n = 10)
*Parameters change evidently (P < 0.05).
endured acute inflammatory abdominal diseases. The control group was
made up of 10 healthy people.
Results: Our investigations demonstrated that the donors’ titer of specific
antibodies is evidently more according to indexes of anti-Escherichia coli,
anti-Pseudomonas aeruginosa, anti-Staphylococcus aureus, anti-bacteroids,
anti-peptococci immunity. Introducing hyperimmune plasma obtained
from such donors evidently increases specific antibody titer in AS patients
Our results demonstrated that the titer of specific antibodies to AS main
agents in the dead patients was evidently lower in comparison with the
control group and in recovered people. This trend is observed 7 to
10 days after surgery. For example, at admission the titer of anti-S. aureus
antibodies in dead patients was 11% lower in comparison with the
control group, and the titer of anti-E. coli antibodies 19% lower in
comparison with control group and 32% lower in comparison with
recovered patients; 7 to 10 days after surgery in dead patients in
comparison with recovered patients, the titer of anti-S. aureus antibodies
was lower by 22%, and the titer of anti-E. coli antibodies by 47%.
Conclusions: Introducing hyperimmune plasma (specific immunotherapy)
increases titer of specific antibodies, and increased concentration of
specific antibodies improves forecast of survival in AS.
Characteristics and outcomes of patients with culture negative septic
shock compared with patients with culture positive septic shock: a
retrospective cohort study
Shravan Kethireddy1*, Amanda Bengier2, H Lester Kirchner2, R Bruce Light3,
Yazdan Mirzanejad4, Dennis Maki5, Yaseen Arabi6, Steven Lapinsky7,
David Simon8, Aseem Kumar9, Joseph E Parrillo10, Anand Kumar3,
the Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database
1Section of Critical Care Medicine and Infectious Diseases, Geisinger Medical
Center, Danville, PA, USA; 2Clinical Innovation and Biostatistics, Division of
Internal Medicine, Geisinger Medical Center, Danville, PA, USA; 3Section of
Critical Care, Section of Infectious Diseases, University of Manitoba,
Winnipeg, MB, Canada; 4Surrey Memorial Hospital, Surrey, BC, Canada;
5University of Wisconsin Hospital and Clinics, Madison, WI, USA; 6King Saud
Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia;
Background: Previous studies have identified that nearly 30% of patients
with severe sepsis and septic shock lack a definitive microbial etiology.
The characteristics and outcomes of culture negative septic shock are not
well defined despite large epidemiologic studies on septic shock
Materials and methods: Retrospective nested cohort study of 2,651
patients with culture-negative septic shock and 6,019 culture-positive
septic shock patients derived from a trinational, 8,760-patient database of
patients with septic shock between 1989 and 2008.
Results: In total, 30.6% of cases of septic shock cases were identified as
culture-negative within the database. Patients with culture-negative septic
shock (CNSS) experienced similar ICU mortality as did those with
culturepositive septic shock (CPSS) (41.7% vs. 40.5% P = 0.276) and identical
overall hospital mortality (51.9% vs. 51.9% P = 0.976). Severity of illness
was similar between CNSS and CPSS (median APACHE II 25 (IQR 6 to 54) vs.
25 (IQR 4 to 70) respectively). Initial and 6-hour lactate levels were also
similar among CNSS and CPSS patients (mean 4.4 vs. 4.1, P = 0.237 and
mean 4.0 vs. 4.1, P = 0.221 respectively). Interestingly CNSS patients were
significantly more likely to be hypothermic than CPSS patients (temperature
<36°C 18.9% vs. 15.3%, P < 0.0001). CNSS patients presented significantly
more often from the community (63.3% vs. 58.0%, P < 0.0001), where
patients with CPSS presented more often with nosocomial infections (36.7%
vs. 42.0%, P < 0.0001). Gastrointestinal and respiratory tract infections were
the predominant sources of infection in both groups. However, CNSS
patients with respiratory tract infections experienced lower mortality than
their CPSS counterparts (49.6% vs. 56.3%, P = 0.008) but similar mortality
rates with gastrointestinal infections (61.0% vs. 58.2%, P = 0.289) (Tables 1
Table 1(abstract P7) Comparison of variables of
culture-positive and culture-negative septic shock
Table 1(abstract P7): Comparison of variables of
culture-positive and culture-negative septic shock (Continued)
Days to extubation
Lactate - 6 hours
Lactate - 24 hours
Similar to our previous findings, we identified by the second hour after
onset of persistent/recurrent hypotension that the in-hospital mortality
rate was significantly increased relative to receiving therapy within the first
hour (odds ratio, 1.62; 95% CI, 1.21 to 2.15; P < 0.001) in the CPSS group.
Following increasing delays in the administration of appropriate
antimicrobial therapy over the first 6 hours after the onset of hypotension,
patients in both groups experienced nearly congruent, significant increases
in hospital mortality; at 6 hours the CNSS group (odds ratio, 2.87; 95% CI,
ICU LOS (median, IQR)
15-day survival (n, %)
Hospital survival (n, %)
APACHE (mean, SD)
ICU LOS (median, IQR)
15-day survival (n, %)
Hospital survival (n, %)
APACHE (mean, SD)
1.72 to 4.78; P < 0.0001) and the CPSS group (odds ratio, 3.44; 95% CI, 2.17
to 5.48; P < 0.0001) (Figure 1). Survival differences between these time
intervals are not significantly different in patients with CNSS and CPSS.
Conclusions: Patients with CNSS behave similarly to CPSS patients in
nearly all respects. As with bacterial septic shock, early appropriate
antimicrobial therapy appears to improve mortality. Earlier recognition of
infection is the most obvious effective strategy to improve hospital
survival. Optimal duration of therapy is not well defined among patients
with CNSS. In addition to early, appropriate antimicrobial therapy, use of
de-escalation strategies such as serial procalcitonin levels may be useful
to determine the length of empiric broad-spectrum antimicrobial use in
Background: SRT2379 is a selective small-molecule activator of the
NAD+-dependent deacetylase, Sirtuin 1 (SIRT1), which has broad
antiinflammatory effects in cell cultures and rodents. The aim of the current
Figure 1(abstract P7) Odds ratio of death by antibiotic delay in culture-positive and culture-negative septic shock.
study (EUDRACT # 2011-002266-20) was to determine the effect of
SRT2379 on the inflammatory responses in normal healthy male subjects
after exposure to LPS.
Materials and methods: This single-blind, placebo-controlled study
consisted of four treatment arms (n = 8 per arm): (1) oral SRT2379 50 mg;
(2) oral SRT2379 250 mg; (3) oral SRT2379 1000 mg; and (4) placebo. All
subjects received a single dose of study drug on day 1 followed by
intravenous LPS 4 hours later. Laboratory parameters of inflammation
along with assessment of clinical signs, safety assessments, and
pharmacokinetic measurements were recorded at baseline and after LPS
Results: SRT2379 was well tolerated. Adverse events were similar across all
treatment groups and were predominantly as expected with LPS
administration. Pharmacokinetic exposures increased in a dose-dependent
manner. SRT2379 did not significantly impact cytokine release as
compared with placebo: TNFa (183.52, 177.57, 123.84 vs. 195.30 pg/ml for
groups 1, 2, 3 vs. group 4, respectively, P > 0.05), IL-6 (195.25, 237.51,
180.26 vs. 250.08 pg/ml, respectively, P > 0.05), IL-17 (3.88, 2.59, 6.42 vs. 8.09
pg/ml, respectively, P > 0.05), IL-8 (126.11, 105.25, 110.56 vs. 108.77 pg/ml,
respectively, P > 0.05), and IL-10 (12.61, 13.03, 40.40 vs. 11.90 pg/ml,
respectively, P > 0.05). SRT2379 also had no impact on vital signs, leukocyte
counts, or coagulation activation markers compared with placebo.
Conclusions: Although SRT2379 suppresses inflammatory markers in
preclinical experiments, we were unable to demonstrate a similar impact in
this human model of endotoxemia. This may be due to potency or exposure
issues, with the compound. SRT2379 terminated for further clinical
development. More promising candidates are being identified for future
Pavlo Melnychenko*, Alexander Potapov, Andrey Babanin
Background: One of the perspective directions for the improvement of
surgical patients’ treatment results is a multimodal approach in
perioperative management including wide administration of regional
anesthesia, early enteral feeding and modification of infusion therapy. The
goal of this study is the assessment of the multimodal approach effect on
antiendotoxin immunity and systemic inflammation after major abdominal
Materials and methods: Open nonrandomized research. In the control
group (n = 52), perioperative management was carried out with
perioperative starvation, total intravenous anesthesia and analgesia on the
basis of opiates. In the multimodal approach group (n = 40) we used a
thoracic epidural analgesia in combination with early enteral feeding and
preoperative infusion of HES 130/0.42 of 15 ml/kg body weight. In vein
blood tests we analyzed C-reactive protein (CRP) and antibodies to
lipopolysaccharide of Escherichia coli by IgM (anti-LPS-IgM) class. Data are
submitted in the form of the median and 95% CI. The Mann-Whitney U
criterion is used for comparisons between groups.
Results: The median maintenance of CRP was 135.7 mkg/ml (95% CI =
153.5 to 249.5) in the control group for 3 days after operation but in the
multimodal approach group was significantly lower - 89.0 mkg/ml (95%
CI = 56.9 to 212.4; P < 0.05). The median anti-LPS-IgM level was 0.087 MU
(95% CI, 0.084 to 0.226) in the control group in the same time but in the
multimodal approach group was significantly higher - 0.181 MU (95% CI,
0.153 to 0.241; P < 0.001). The obtained data can mean that the expressed
system inflammatory reaction has negative impact on the postoperative
period. Reduced antiendotoxin immunity increases terms of hospitalization
as an independent factor. This also increases the number of complications
and lethality in surgery.
Conclusions: The multimodal approach that includes thoracic epidural
analgesia, early enteral feeding and preoperative infusion of HES 130/0.42
after volume abdominal operations prevents exhaustion of antiendotoxin
immunity and system inflammatory reaction.
1. Bennet-Guerrero E, Michael HP, Robin GB, et al: Decreased endotoxin
immunity is associated with greater mortality and/or prolonged
hospitalization after surgery. Anesthesiology 2001, 94:992-998.
Background: Septicemia is a systemic disease caused by the spread of
microorganisms and their toxins in the blood. These bloodstream
infections are a major cause of morbidity and mortality in children in
developing country [1-4]. It has been confirmed by culture that is
associated with clinical manifestation and systemic response [5-7]. It is
crucial to continuously monitor any change in the local patterns of
infection and susceptibility to various antibiotics. The aim of this study was
to determine the bacteriological profile and antimicrobial sensitivity
patterns among children suspected of having septicemia.
Materials and methods: A cross-sectional study involved about 201
pediatric patients (≤12 years) was conducted from October 2011 to February
2012 at Tikur Anbessa Specialized Hospital and Yekatit 12 Hospital’s
pediatric units after the proposal of this study was approved by National
Ethics Review Committee. Standard procedure was followed for blood
sample collection. Samples were incubated in the BACTEC 9050 System,
followed by isolate identifications based on standard microbiological
procedures and testing for their susceptibility to antimicrobial agents using
the disc diffusion method. Data were analyzed using the SPSS version
19 software package.
Results: Out of 201 study subjects, 110 (54.7%) were male. The majority
(147, 73.1%) of them were neonates (≤28 days). The mean length of
hospitalization was 11.24 days. Out of the 201 tested blood samples,
blood cultures were positive in 56 (27.9%) cases (Figure 1). Gram-negative
and Gram-positive bacteria constituted 51.8% and 46.4%, respectively.
The most frequent pathogen found was Staphylococcus aureus (23.2%),
followed by Serratia marcescens (21.4%), CoNS (19.6%), Klebsiella spp.
(16%), Salmonella spp. (5.4%) and Enterobacter cloacae (3.6%) (Figure 2).
The majority of bacterial isolates showed high resistance to ampicillin,
penicillin, co-trimoxazole, gentamicin and tetracycline. Ciprofloxacin and
nalidixic acid were the most effective antimicrobial agents for
Gramnegative bacteria, while vancomycin and clindamycin for Gram-positive
bacteria (Table 1). Deaths occurred in 25 (12.4%) children, out of which
13 (23.2%) had bacteremia.
Conclusions: The present study revealed that both Gram-positive and
Gram-negative bacteria were responsible for bloodstream infections
and the majority of the isolates were multidrug resistant. S. aureus and
S. marcescens were the most common isolated bacteria from blood
cultures. The alarmingly higher percentages of multidrug-resistant isolates
urge us to take infection prevention measures and to conduct other large
studies for appropriate empiric antibiotic choice.
Acknowledgements: The authors would like to acknowledge the
technical support provided by the members of the Departments of
Microbiology and Pediatrics of Tikur Anbessa Specialized and Yekatit 12
Hospitals. They also thank Mr Yoseph Kenea for his excellence statistic
support. This work was supported by AHRI/ALERT and AAU.
1. Archibald LK, McDonald LC, Nwanyanwu O, Kazembe P, Dobbie H, Tokars J,
et al: A hospital-based prevalence survey of bloodstream infections in
febrile patients in Malawi: implications for diagnosis and therapy. J Infect
Dis 2000, 181:1414-1420.
2. Ogunleye VO, Ogunleye AO, Ajuwape ATP, Olawole OM, Adetosoye AI:
Childhood septicaemia due to salmonella species in Ibadan, Nigeria.
Afr J Biomed Res 2005, 8:131-134.
Figure 1(abstract P11) Distribution of 56 blood culture isolates by age interval and gender.
Figure 2(abstract P11) Distribution of blood culture isolates in children with suspected of having sepsis.
Table 1(abstract P11) Antimicrobial resistance pattern of bacteria isolated from blood culture
Resistance proportion of bacterial isolates (R%)
ND, not done; SXT, sulphamethaxozol/trimethoprim. aGram-negative bacteria (Acinetobacter baumanii, Escherichia coli, and Pseudomonas leutole). bGram-positive
bacteria (Enterococcus spp. and Streptococcus. spp.).
Development of a new monoclonal antibody-based point-of-care
testing assay for the quantification of procalcitonin in whole blood
for a rapid sepsis diagnostic
Martin Rieger*, Daniela Rascher, Anton Hartmann
Helmholtz Zentrum München, German Research Center for Environmental
Health (GmbH), Department of Environmental Science, Research Unit
Microbe-Plant Interactions, Neuherberg, Germany
Critical Care 2013, 17(Suppl 4):P13; doi:10.1186/cc12913
Background: After recent studies of the BMBF (SepNet), sepsis causes about
150 deaths per day in Germany, making it the third leading cause of death in
Germany. In acute sepsis, rapid diagnosis and rapid medication is crucial. Both
as a reliable parameter for diagnosis of sepsis and for guiding the antibiotic
therapy, procalcitonin (PCT) is a very sensitive available biomarker  and is
recommended in the current guidelines  to be quantified under sepsis
suspicion. Although there are a couple of commercially available fast analytical
devices for the quantification of PCT, none of these devices completely fulfill all
requirements for a point-of-care testing (POCT) device which are: bedside
testing; no sample preparation (whole blood testing); simple handling with
ready-to-use and single-use cartridges; and short turnaround time between
analysis and medical treatment in the clinical necessary concentration range.
Whereas most devices fulfill the latter requirements they are still too big for
bedside testing or cannot handle whole blood.
Materials and methods: Based on newly developed monoclonal antibodies
(mAbs) , a fast and sensitive immunoassay for the quantification of PCT in
whole blood was developed and transferred to a commercially developed
(not available on market) POCT device (respons®IQ) from pes
Results: With the new developed mAbs the achieved limit of detection for
PCT in plasma and whole blood is 0.04 ng/ml and 0.05 ng/ml respectively,
which is within the clinical necessary range (<0.05 ng/ml). The now
established assay shows high reproducibility within 9 minutes, independent
of different plasma samples due to the selection of suitable additive
compounds. In a first set of leftover patient samples, the PCT-POCT assay
showed good correlation (R2 = 0.988, n = 14, m = 2) with the state-of-the-art
technology Kryptor (BRAHMs) (D Rascher, M Rieger, HMGU, AMP,
unpublished data). Moreover, in cooperation with Dr A Geerlof (HMGU),
human recombinant PCT (hrPCT) was produced in two biological and clinical
relevant forms (amino acids 1 to 116 and 3 to 116) in high amounts and
high purity (A Geerlof, D Rascher, M Rieger, unpublished data). This hrPCT
will replace expensive (5 k$/mg) and batch-to-batch varying commercial
available hrPCTs as standard reference material.
Jessamine C Sareno*, Jacinto Blas V Mantaring
Background: Pentoxifylline, a xanthine derivative, has raised new interest
in neonatal research due to its immunomodulatory functions and its
potential role in reducing mortality from sepsis. Two small studies on a
per-protocol analysis have shown promising results. This larger trial on an
intention-to-treat basis will determine whether the use of pentoxifylline
as an adjunctive therapy for sepsis in preterm neonates (≤36 weeks)
weighing <1,500 g will truly result in a reduction in the all-cause
Materials and methods: Preterm infants ≤1,500 g with suspected
infection admitted to the NICU of a large tertiary, training, government
hospital were eligible for inclusion in the study. After informed consent,
they were randomized to receive either pentoxifylline at a dose of
6 mg/kg/hour or placebo. Patients with major congenital malformations,
congenital infections and severe hemorrhage were excluded from the
study. Pentoxifylline was administered as a 6 ml infusion for 6 hours for
6 days. The control group received normal saline in the same manner as
the pentoxifylline infusion. Patients, parents and physicians (outcome
assessors) were blinded to the treatment assignments. The primary
outcome was analyzed on an intention to treat basis. The primary
outcome measured in the study is the occurrence of all-cause mortality
between the two groups. Secondary outcomes measured include
mortality from sepsis, adverse drug reactions and length of hospital stay.
Results: A total of 312 neonates are included in this interim analysis: 156
in the pentoxifylline group and 156 in the control group. Baseline
characteristics were comparable between the two groups. In this analysis,
there is no difference in the occurrence of death among patients in the
pentoxifylline group versus the placebo group (RR: 1.08 (0.83, 1.41)).
There is no statistical difference in the risk of death from septic shock
(RR: 1.03 (0.67, 1.59), P = 1.0). There was also no significant difference in
the length of hospital stay in the two groups (36 days in treatment group vs.
35 days in control group, P = 0.910). No significant adverse drug reactions
were noted with pentoxifylline use.
Conclusions: Pentoxifylline as an adjunct therapy for sepsis did not show
a decrease in the all-cause mortality. There is also no difference in the
occurrence of death from sepsis and length of hospital stay. No adverse
drug reactions were noted with pentoxifylline.
Acknowledgements: The authors thank the neonatology fellows of the
Philippine General Hospital and Ms Carmi Pitajen, RN, research assistant.
Effect of semi-quantitative procalcitonin assay on the adequacy of
empirical antibiotics and mortality in septic patients
Dana Dharaniyadewi1*, Khie Chen Lie2, Nanang Sukmana3,
C Martin Rumende4
1Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia,
Jakarta, Indonesia; 2Division of Tropical Medicine and Infectious Diseases,
Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia,
Background: Sepsis is a serious clinical condition with a considerable
morbidity and mortality. Procalcitonin (PCT) is a good biomarker for early
diagnosis and infection monitoring. A semi-quantitative PCT assay can be
performed at the bedside and has good diagnostic value [1,2]. The
present study aimed to investigate the effect of a semi-quantitative PCT
test on the empirical antibiotic initiation time, the appropriateness of
empirical antibiotics and mortality in septic patients.
Materials and methods: The study design was a randomized diagnostic
trial, which was also a pragmatic trial. Septic patients more than 18 years
old with and without signs of organ hypoperfusion or dysfunction who
were admitted to Cipto Mangunkusomo Hospital emergency department in
the internal medicine unit were eligible. Subjects were randomly assigned
to either a semi-quantitative PCT-examined group (study group) or a
control group. Semi-quantitative PCT test results will be informed to the
physicians taking care of the patients. The primary outcome was 14-day
mortality. Secondary outcomes were the time of initiation and
appropriateness of empirical antibiotics. A Tropical Infection Consultant will assess the
appropriateness of empirical antibiotics based on Pedoman Umum
Penggunaan Antibiotik Departemen Kesehatan Republik Indonesia.
Results: Two hundred and five patients met the inclusion criteria.
Ninetyfive of 100 subjects from the study group and 102 of 105 subjects from
the control group were included in the analysis (Figure 1). Both groups
have equal baseline characteristics (Table 1). The mortality risk was lower
in the study group (RR 0.53; 95% CI 0.36 to 0.77). The study group had
greater probability to have a first dose of empirical antibiotic in less than
6 hours compared with the control group (RR 2.48; 95% CI 1.88 to 3.26).
No effect was seen in appropriateness of empirical antibiotics between
groups (RR 0.99; 95% CI 0.92 to 1.08) (Table 2).
Conclusions: Semi-quantitative PCT examination affects the empirical
antibiotic initiation time and mortality in septic patients, but not the
appropriateness of empirical antibiotics.
Figure 1(abstract P15) Enrollment of patients and completion of the study.
Table 1(abstract P15) Baseline characteristics of the patients
Semi-quantitative PCT-examined group, n (%)
Control group, n (%)
Source of infection
Severe sepsis and septic shock
2.48 (1.88 to 3.26)
0.99 (0.92 to 1.08)
0.53 (0.36 to 0.77)
Table 2(abstract P15) Effect of semi-quantitative procalcitonin assay on adequacy of empirical antibiotics and
mortality in septic patients
Semi-quantitative PCT assay, n (%)
Empirical antibiotic initiation time
Appropriateness of empirical antibiotics
Background: Sepsis is a complex disease with an initial proinflammatory
profile triggered by an infection process, which is typically followed by a
compensatory anti-inflammatory response, leading to immunosuppression.
There are few cases in literature relating sepsis with opportunistic infections,
such as strongyloidiasis, which may lead to severe clinical consequences
due to hyperinfection. Human strongyloidiasis is a neglected tropical disease
of major worldwide distribution, affecting millions of people. Despite of the
fact that infection with Strongyloides stercoralis is usually self-limited and
with low morbidity in immunocompetent individuals, it may become lethal
in cases of immunosuppression, such as AIDS, corticosteroid treatment and
transplantation. Our aim in this work was to investigate the presence of
S. stercoralis antigens and anti-parasitic IgG in sepsis patients in a highly
endemic area of strongyloidiasis.
Materials and methods: Serum samples from 27 individuals with
strongyloidiasis and 27 healthy subjects were used as positive and
negative controls, respectively, according to their parasitological
analyses. Additionally, 27 sepsis patients were also investigated. We
have used ELISA tests to detect S. stercoralis antigens and IgG
antiS. stercoralis in all three groups. The cutoff value was determined by the
ROC curves obtained by Prism 5.0 software.
Results: IgG anti-S. stercoralis was detected in six patients; five under
septic shock and one with sepsis. Among them, four were positive for the
parasite antigen-antibody immune complex; three under septic shock and
one with sepsis, demonstrating that 15% of sepsis patients were infected
by the parasite, which may have significantly contributed with the
hyperinfection presented by septic-shock patients (10%).
Conclusions: There are only two reports of an association between
S. stercoralis infection and immunosuppression, which led to lethal sepsis
cases. However, our preliminary analysis through antigen-antibody
immune complex demonstrated that this parasitic infection might be
more common in sepsis than expected. The correct diagnosis of the
causal infection in sepsis may support the correct therapeutic choice,
which is fundamental to avoid the continuous spread of specific
pathogen/parasite triggers that will eventually lead to hyperinfection, and
consequently to severe sepsis.
Acknowledgements: The authors would like to thank the patients and
their families for the direct collaboration in this work, the medical staff
from the ICU of the university hospital for providing the biological
samples and the clinical parameters, and financial support by CNPq,
CAPES, and FAPEMIG.
Procalcitonin, presepsin, pro-adrenomedullin, fibrin degradation
products, and lactate in early diagnosis and prognosis of septic
patients newly admitted to the intermediate care unit from
the emergency department
Filippo Mearelli1*, Nicola Fiotti1, Nicola Altamura1, Irene Paoli1, Chiara Casarsa1,
Maurizio Ruscio2, Gianni Biolo1
1Unit of Clinica Medica Generale e Terapia Medica, Department of Medical
Surgical and Health Sciences, University of Trieste, Italy; 2Laboratory Medicine
Ospedale Sant’ Antonio, San Daniele Del Friuli, Italy
Critical Care 2013, 17(Suppl 4):P17; doi:10.1186/cc12917
Background: More than 50% of all septic patients admitted to intensive
care departments derive from intermediate care units (INCU). Biomarkers
represent the most promising tool for early diagnosis of sepsis; but their
accuracy in INCU has been largely disregarded . Moreover, given the
complexity of the septic pathophysiology, a panel of biomarkers could
be more effective than a single one. For this reason we tested acute
phase protein, cell surface, vasotonous related, coagulation system, and
tissue hypoxia markers in early ruling in/out of sepsis in patients suffering
from systemic inflammatory response syndrome (SIRS) [2-5].
Materials and methods: This prospective observational study included
all SIRS  patients newly admitted to a medical ward from February to
May 2012. Cases were diagnosed as sepsis or non-infective SIRS by
clinical examination, cultures of the biological fluid, and imaging during a
7-day follow-up. Investigators were blinded to biomarker results. Survivors
at 7 and 30 days were also assessed. Samples for procalcitonin (PCT),
presepsin (sCD14-ST), pro-adrenomedullin (PRO-ADM), fibrin degradation
products (FDP) and lactate were collected within 4 hours of admission.
Their role in predicting diagnosis and survival, alone or in combination,
have been investigated by receiver operating characteristic (ROC) curve,
Youden index, relative risk and binary logistic regression.
Results: Among the 60 sepsis patients (microbiological and clinical
sepsis), the most common sites of infection were the lung (67%), urinary
tract (17%), abdomen (5%), and skin (8%). The sepsis group had
significantly higher levels of PCT, sCD14-ST and FDP than the
noninfective SIRS group. The area under the ROC was 0.80, 0.78, and 0.67 for
FDP, PCT, and sCD14-ST respectively. Main results are reported in Table 1:
the combination of FDP and PCT detected correctly 10 more cases,
leaving misdiagnosed only nine out of 80 patients. ROC curves are
reported in Figure 1. sCD14-ST (cutoff 1.317 ng/ml, OR 12.2 (95% CI 2.6 to
55.5) P = 0.0002) and lactate (cutoff 20 mg/dl OR 11.9 (95% CI 2.23 to
62.5) P = 0.001) were comparable in predicting 7-day survival. Mortality
at 30 days was significantly higher in patients with PRO-ADM level
≥4.09 nmol/l (OR 26 (95% CI 4.8 to 143) P = 0.000002). The Kaplan-Meier
curves for PRO-ADM are reported in Figure 2.
Table 1(abstract P17)
180 + 0.1 ng/ml
Background: Sepsis still represents the leading cause of mortality among
children and its etiology changes according to age, immune status and
geographic location [1-4]. Prevention of this disease has key role in
reducing morbidity and mortality and includes development and
application of vaccines [5-7]. In 2010, pneumococcal and meningococcal
C vaccines were introduced in the basic immunization schedule in Brazil.
The application of these may already be influencing the etiologic profile
of sepsis in childhood . The evaluation of this profile, as well as the
clinical manifestations and course of sepsis in the post vaccine, becomes
essential for better clinical decision and effective therapeutic approach in
hospitalized patients. The objective was to determine clinical
manifestations, etiology and outcome of sepsis in patients admitted to a
Materials and methods: A retrospective cohort study, by collecting data
from medical records of patients diagnosed with sepsis admitted to the
pediatric ICU of Hospital Municipal Dr. Mario Gatti, Campinas, SP, from
January 2011 to December 2012. The variables studied were: age, sex,
vaccination schedule, etiologic agent identified in cultures and clinical
Results: Eighty-seven patients were included in the study (56 male,
31 female) with a mean hospital stay of 8.16 days, vasoactive drug use of
2.82 days and 5.33 days of mechanical ventilation. In total, 57/87 cultures
were negative. Among the positive, the majority (21/30) was collected
less than 48 hours after admission and the most frequent etiologies were:
Gram-negative bacteria (10), Staphylococcus aureus (7) and Neisseria
meningitidis (4). Two cultures were positive for Streptococus pyogenes and
only one for Streptococcus pneumoniae. Twenty-four (16.1%) patients died.
Figure 1(abstract P17) ROC curves of PCT, FDP, sCD-14ST, and the
combination of FDP + PCT. Solid thick line, PCT; dashed line, FDP;
dotted line, PCT+FDP; dot-dash line, sCD-14ST; thin solid line, reference
Mortality was higher in patients with incomplete immunization (P =
0.047). Among the cases with meningococcal etiology, 3/4 were not
Conclusions: The clinical group of patients diagnosed with sepsis
showed short time of hospitalization, use of vasoactive drugs and
mechanical ventilation. Mortality was high and higher in the group of
patients with incomplete immunization. Among the causative agents, it
Difficulties in implementation of the project ‘HUPE against sepsis’:
speaking of people who watch
Sérgio da Cunha1*, Mário Castro Álvares Perez1, Elisabete Novello Ferreira2,
Luana Ferreira de Almeida2, Eliane Passos Pereira Assumpção2,
Paulo Vieira Damasco3, Jorge da Silva Motta4, Rogério Marques de Souza5,
Viviane Silva e Silva2, Elizabeth de Andrade Marques6, Vagner Ismerim Lobão7,
Irene de Souza e Silva8, Ana Alice de A Triani8,
Jessica Bernardes Almeida Borges da Silva2, Julio Cesar Delgado Correal9,
Catherine Valdez10, Jessica Oliveira10
1Department of Clinical Medicine, College of Medical Ciences, Rio de Janeiro
State University, Rio de Janeiro, Brazil; 2Nursing Department, Pedro Ernesto
University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil;
3Department of Internal Medicine, College of Medical Ciences, Rio de Janeiro
State University, Rio de Janeiro, Brazil; 4Medical Coordination, Pedro Ernesto
University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil;
5Nursing Coordination, Pedro Ernesto University Hospital, Rio de Janeiro
Figure 2(abstract P17) Thirty-day survival curve (Kaplan-Meier) according to PRO-ADM levels.
Introduction: The project ‘HUPE against sepsis’ seeks to emphasize the
importance of early recognition of sepsis, in order to accelerate the
implementation of measures associated with decreased mortality for
severe sepsis. It is therefore important that the professionals involved in
healthcare are attentive to quick detection of signs and symptoms
associated with the condition. The objective was to identify the
difficulties for the implementation of the protocol advocated by the
Surviving Sepsis Campaign and adopted by the project ‘HUPE against
Materials and methods: The study was conducted in clinical medical
and surgical wards, DIP, general duty, cardiac and ICUs of the Pedro
Ernesto University Hospital (HUPE), totaling 11 inpatient units. In January
2013, a questionnaire was applied to doctors, nurses and nurse
technicians, including effective, contractors and residents. This instrument
contained closed questions, professional profile and was related to the
topic in question.
Results: Fifty-one professionals participated in the study: 22 (43%)
medical staff and 29 (57%) nurses. Of these, 12 were medical residents,
and eight were nursing residents, all in the first year (approximately 78%
of workers investigated). Most physicians (55%), 38% of nurses and
40% of nurses claimed to have greatest difficulty administering the first
dose of antibiotics within up to 1 hour after the diagnosis. About 45% of
doctors and 31% of nurses also reported difficulty in the distribution of
materials to acquire the sepsis kit (which contains materials for deep
venous puncture, invasive hemodynamic monitoring and collecting blood
cultures). Physicians (41%) and nurses (40%) still reported as a problem
going to the pharmacy to get the first dose of the antibiotic. Other
limiting factors were also appointed: obtaining the vesical catheterization
of delay (for hourly diuresis control); rapid identification of severe sepsis;
printed data record of the protocol; samples of blood culture for aerobic;
and peripheral venous access puncture.
Conclusion: The difficulties pointed out by the professionals investigated
are common and include factors that prevent the correct and early
implementation of the protocol, be they of institutional and/or
professional responsibility. Seeking solutions to the problems raised allows
a targeting of future actions to be developed, among them the constant
updating and training of professionals involved in assistance for the
inpatients investigated. This allows, also, the search for better institutional
infrastructure appropriate to meeting the demands of the patient with
Background: Neutrophils as a part of nonspecific immunity factors play a
crucial role in antimicrobial resistance. Reactive oxygen species (ROS) are
an important compound of the neutrophils’ microbicidal action. Analysis
of neutrophils’ ROS production could provide valuable data on a
phagocyte link of immunity . A chemiluminescent (CL) assay being
highly sensitive allows evaluating oxidative output of the cells in
dynamics. Many studies on neutrophil CL in humans with different
diseases have been published [2,3]. However, the results often vary
between authors because of the lack of standardized method of CL
analysis. So we have developed a methodology of neutrophils’ CL
analysis according to the principles of evidence-based medicine.
Materials and methods: One hundred and twenty healthy donors and
17 ICU patients with second-third-degree burns participated in this study.
We held an assay on the 1st, 8th and 15th day after injury and later; 37
observations in total. To dilute blood samples we used Hank’s balanced
salt saline (HBSS) with glucose, pH 7.4. Luminol (Sigma-Aldrich) was
dissolved in double-distilled water at 1 mM.
N-formyl-methionyl-leucylphenylalanine (FMLP; Sigma-Aldrich) and 4-phorbol-12-myristate-13-acetate
(PMA; Sigma-Aldrich) were diluted in dimethyl sulfoxide (MP Biomedicals,
LLC) to make stock solutions that were dissolved in HBSS on the day of
experiment. CL was evaluated by means of a chemiluminometer Lum-12
(Department of Biophysics, Moscow State University) .
Results: We substantiate an optimal experiment design in the context of
obtaining the highest intensity of analytic signal and reproducible
findings. Thus we have developed a method for evaluation of a
neutrophil function, based on a step-by-step stimulation of the cells by
PMA and FMLP. Using our approach, we investigated the distributions of
CL characteristics for the population of 80 healthy donors. We obtained
reproducible kinetic profiles with intensive flash and absent glow phase
of emission in all of the samples. Profiles of ICU patients’ samples showed
high intensity of both flash and glow phase of emission (Figure 1).
Insufficient glow phase indicated subsequent development of severe
Figure 1(abstract P20) Kinetics of CL response in ICU patient and donor.
Conclusions: As a result we suggest a reliable and replicable method for
the evaluation of a neutrophil function. Investigation of the glow phase
of the emission is promising to forecast risks of septic complications; we
constructed a range of values of adjusted CL glow amplitude at different
neutrophil counts that indicates a low probability of SIRS and septic
complications that could be useful for correction of intensive treatment
Acknowledgements: The author would like to express deepest
appreciation to all those who provided the possibility to perform this
research. The author wishes to thank Prof. YA Vladimirov and the team of
Department of Biophysics at Moscow State University (Russia) and Dr MA
Godkov for assistance and guidance with this study and for submitting of
equipment and reagents. Also the author would like to thank Dr EN
Kobzeva and Prof. Dr SV Smirnov for the opportunity to work with blood
donors and ICU patients. Furthermore, the author would also like to
acknowledge with much appreciation Dr VV Kulabukhov and the staff of
the Department of Burn Resuscitation at Vishnevsky Institute of Surgery
(Moscow, Russia) for their suggestions and encouragement.
1. Edwards SW: Biochemistry and Physiology of the Neutrophil Cambridge
University Press 1994.
2. Vladimirov YA, Proscurnina EV: Free radicals and cell chemiluminescence.
Biochemistry 2009, 74:1545-1566.
3. Dahlgren C, Karlsson A, Bylund J: Measurement of respiratory burst
products generated by professional phagocytes. Methods Mol Biol 2007,
4. Obraztsov IV: An evaluation of neutrophil function: a new approach to
the chemiluminescent analysis [abstract]. Immunology 2012,
Background: Bacteremia is a common clinical condition with an incidence
of approximately 140 to 160 per 100,000 person-years. Since sepsis is a
time-critical diagnosis, identification of emergency department (ED)
patients at risk of bacteremia is therefore a priority. The study objective
was to validate a previously published clinical decision rule for predicting a
positive blood culture in ED patients with suspected infection based on
minor criteria, major criteria and a total score .
Table 1(abstract P23) Decision rule
Suspected endocarditis (3 points)
Temperature >39.4°C (103.0°F) (3 points)
Indwelling vascular catheter (2 points)
A blood culture is indicated by the rule if at least one major criterion or two minor criteria are present. Otherwise, cultures may be omitted. Points used to
calculate the total score.
Materials and methods: This was a retrospective matched cohort study,
set in a large urban academic tertiary ED at Aarhus University Hospital,
Aarhus, Denmark with approximately 56,000 patient visits annually. Adult
ED patients with blood cultures obtained from 1 January through
31 December 2011. ED patients with blood culture-confirmed bacteremia
were matched 1:3 to patients with negative cultures. The outcome was
true bacteremia. Features of the clinical history, co-morbid illnesses,
physical observations and laboratory tests were used to evaluate the
performance of the clinical decision rule including calculation of the total
score (Table 1). We report operating characteristics and the summary
c-statistic for the decision rule.
Results: Among 1,526 patients, 105 (6.9%) patients were classified with
true bacteremia. The sensitivity of the prediction rule was 94% (95%
confidence interval (CI) 88 to 98%) and specificity 48% (95% CI 42 to
53%). Positive and negative predictive values were 37% (95% CI 32 to
44%) and 96% (95% CI 92 to 99%), respectively. The area under the
receiver-operating characteristics curve was 0.83 ± 0.02 standard error
Conclusions: The clinical decision rule performed well in our ED setting
and is likely to be a useful supplement to clinical judgment.
Acknowledgements: The CONSIDER Sepsis Network is a collaboration of
clinical researchers with an interest in sepsis at Aarhus University
Hospital, Aarhus, Denmark.
1. Shapiro, et al: Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med 2008, 35:255-264.
Background: Conscious assessment for organ dysfunction in infected
patients is not uniformly performed since the prognostic performance of
organ dysfunction has not been validated. We hypothesize that the
number of organ dysfunctions is a prognostic marker in emergency
department (ED) patients with suspected infection and that an increasing
number of organ dysfunctions correlates with in-hospital mortality.
Materials and methods: A prospective observational study of adult
(18+ years) ED patients with suspected infection presenting to one of
two urban, academic medical center EDs. The inclusion criterion was
clinically suspected infection at ED presentation. At Beth Israel Deaconess
Medical Center (BIDMC), Boston, USA, consecutive patients were enrolled
over a 1-year period (internal validation set) and at Aarhus University Hospital
(AUH), Aarhus, Denmark, a case-control study was performed (external
validation set). Laboratory and clinical data were collected at enrollment
to assess organ dysfunction. Primary outcome was in-hospital mortality.
Minor criteria (1 point each)
Temperature 38.3 to 39.3°C
Hypotension (systolic blood pressure <90 mmHg)
White blood cell count >18,000 cells/mm3
Bands >5% (in our setting, immature cells >0.5%)
Platelets <150,000 cells/mm3
Creatinine >2.0 mg/dl (177 µl/l)
Figure 1(abstract P23) Receiver operating characteristics curve (ROC) for external validation of the bacteremia prediction rule, calculated using
the total score.
Figure 1(abstract P24)
Table 1(abstract P24) Effect of number of organ dysfunctions on in-hospital mortality adjusted for age
and Charlson Comorbidity score
Number of organ dysfunctions
Internal validation set in-hospital mortality
External validation set in-hospital mortality
Data presented as OR (95% CI).
9.3 (4.8 to 18.1)
18.0 (8.8 to 36.9)
50.5 (22.0 to 115.8)
39.0 (8.9 to 170.7)
3.1 (0.9 to 10.4)
7.3 (2.1 to 24.7)
33.6 (8.56 to 127.3)
45.0 (8.56 to 236.2)
285.9 (16.9 to 483.2)
Figure 2(abstract P24)
Logistic regression was performed to determine the independent mortality
Results: Four thousand, nine hundred and fifty-two patients were
enrolled at BIDMC and 483 patients at AUH. Overall mortality rates were
4% and 11% with mean ages of 58 ± 21 and 69 ± 16 years, respectively.
The mortality rate increased with increasing number of organ
dysfunctions: BIDMC: 0 organ dysfunctions, 0.6% mortality; 1 dysfunction,
3.3%; 2 dysfunctions, 7.8%; 3 dysfunctions, 15.9%; and ≥4 dysfunctions,
34.3%; and AUH: 2.2%, 6.7%, 17%, 41%, and 57% mortality (Figure 1). The
number of organ dysfunctions remained an independent predictor after
adjustment for age and Charlson Index (Table 1). The AUCs for the
models were 0.82 and 0.87, respectively (Figure 2). The effect of specific
types of organ dysfunction on mortality was largest for respiratory
dysfunction (OR 3.57 (95% CI 2.5 to 5.1)) in the internal and for
Table 2(abstract P24) Effect of organ dysfunctions on
mortality adjusted for age and Charlson Index
Cardiovascular 3.2 (0.9 to 11.5)
Data presented as OR (95% CI).
29.0 (7.1 to 116.9)
18.5 (7.3 to 46.8)
6.7 (2.9 to 11.2)
8.9 (4.7 to 17.1)
5.4 (2.7 to 10.9)
4.5 (1.1 to 18.2)
hematologic dysfunction (OR 33.57 (8.56 to 127.3)) in the external
validation set (Table 2).
Conclusions: Using readily available criteria in the ED to assess the
number of organ dysfunctions is a reliable tool in predicting in-hospital
mortality in both validation sets and could assist in risk prognostication
and aid with earlier, targeted therapy.
Background: Physiologic instability (PI) is a common, critical problem in the
emergency department (ED) [1,2], and can have different underlying causes.
The ability to determine the underlying cause of instability is paramount for
early treatment and risk stratification . Lactate has been shown to have
prognostic value in some categories of unstable patients [4,5]. The objective
of this study was to investigate how serum lactate concentrations differ
across categories of PI and the association of lactate concentrations with
clinical deterioration for each category.
Materials and methods: A prospective observational study of adult
patients with PI at a university ED. PI was defined as lactate ≥4 mmol/l, or
>5 minutes of heart rate (HR) ≥130, or respiratory rate (RR) ≥24, or shock
index ≥1, or systolic blood pressure ≤90 mmHg. We excluded patients with
no lactate measurements, isolated atrial tachycardia, seizure, intoxication,
psychiatric agitation, or tachycardia due to pain. A physician retrospectively
Figure 1(abstract P25) Lactate levels across groups of physiological instability.
Figure 2(abstract P25) Levels of lactate across groups of physiologic instability stratified by deterioration. no/yes = deterioration present or not.
(*) Significant differences between groups (p < 0.05).
categorized PI cause. Categories were defined as septic, cardiogenic,
hemorrhagic, hypovolemic, or other. The primary outcome was
deterioration, defined as: acute renal failure (elevated creatinine to ≥2× baseline
levels), intubation, vasopressors, or in-hospital mortality.
Results: We identified 1,156 patients with PI and excluded 324. Of the
remaining, 304 did not have lactate measurements, leaving 528 for the
analysis: 302 septic, 46 cardiogenic, 29 hemorrhagic, 57 hypovolemic, and
94 with another cause of instability. The differences in lactate levels
between groups were not statistically significant (Figure 1). The lactate
levels were statistically different between patients who deteriorated when
compared with patients who did not deteriorate in the sepsis group (3.05
mmol/l vs. 1.91 mmol/l, P < 0.0001) and the other group (2.89 mmol/l vs.
1.94 mmol/l, P = 0.002). No statistically significant differences were
demonstrated for the cardiogenic, the hemorrhagic or the hypovolemic
groups (Figure 2).
Conclusions: Lactate levels were not significantly different between the
five groups with PI. However, in patients in the sepsis or other group,
elevated lactate predicted deterioration. This was not demonstrated for
the other causes of PI. This study suggests that in unstable patients
lactate has the same likelihood of elevation between different causes of
instability, but it may not have the same prognostic value for
deterioration across underlying causes.
Acknowledgements: CONSIDER Sepsis Network is a collaboration of
clinical researchers with an interest in sepsis at Aarhus University
Hospital, Aarhus, Denmark.
1. Jones AE, Aborn LS, Kline JA: Severity of emergency department
hypotension predicts adverse hospital outcome. Shock 2004,
2. Jones AE, Stiell IG, Nesbitt LP, Spaite DW, Hasan N, Watts BA, Kline JA:
Nontraumatic out-of-hospital hypotension predicts inhospital mortality.
Ann Emerg Med 2004, 43:106-113.
3. Sebat F, Musthafa Aa, Johnson D, Kramer Aa, Shoffner D, Eliason M,
Henry K, Spurlock B: Effect of a rapid response system for patients in
shock on time to treatment and mortality during 5 years. Crit Care Med
4. Shapiro NI, Howell MD, Talmor D, Nathanson LA, Wolfe RE, Weiss JW:
Serum lactate as a predictor of mortality in emergency department
patients with infection. 2005, 45:524-528.
5. Vermeulen RP, Hoekstra M, Nijsten MW, van der Horst IC, van Pelt LJ,
Jessurun Ga, Jaarsma T, Zijlstra F, van den Heuvel AF: Clinical correlates
of arterial lactate levels in patients with ST-segment elevation
Background: Sepsis is the main cause of death in ICUs all over the world.
Early detection of the pathogen is essential for appropriate antimicrobial
Materials and methods: To evaluate the reduction in time of
antimicrobial adjustment therapy in patients with sepsis comparing a
rapid molecular test (SeptiFast®) with conventional blood cultures, a
randomized controlled clinical trial was conducted between October 2012
and May 2013 in a cardiology hospital. Adult patients staying more than
48 hours in hospital with clinical suspicion of sepsis were included in the
study. Blood samples were collected for cultures (BacT/ALERT®) and
Septifast® test immediately prior to initiation of antibiotic therapy.
Patients were allocated into two groups. In the Intervention Group (GI),
Septifast® results were communicated to the medical researcher and
antimicrobials were adjusted. In the Control Group (GII), Septifast® results
were not informed and therapy adjustment was based on the blood
culture. Registered in Clinical trials.gov (NCT 01450358).
Results: Forty-six patients were included, 17 in GI and 29 in GII. Key data
are shown in Table 1. In GI therapy adjustment was done in 580 minutes
compared with 3,007 minutes in GII (P = 0.004).
Conclusions: The rapid molecular test (SeptiFast®) reduced the time for
adjustment of antibiotic treatment in comparison with conventional
blood cultures in critically ill sepsis patients.
Table 1(abstract P26) Distribution of characteristics in the two groups
Intervention group (n= 17)
Control group (n= 29)
Hospital stay (mean, days)
Ejection fraction <40%
Receiving antibiotics prior to study
Patients with adjustment therapy
based on SeptiFast®
Patients with adjustment therapy
based on blood culture
Pathogens detected in SeptiFast®
Pathogens detected in blood culture
P. aeruginosa (2), K. pneumonia/oxytoca (1), E. aerogenes/cloacae (1),
S. marcescens (1), A. baumanii (1)
Comparison between inflammatory biomarkers procalcitonin, IL-6 and
C-reactive protein for infection diagnosis and fever evolution in
neutropenic patients, submitted to hematopoietic stem cell
Karin Schmidt Rodrigues Massaro1*, Rodrigo Macedo2,
Maria Aparecida Shikanai-Yasuda3, Silvia Figueiredo Costa3
1Department of the School of Medicine of Universidade de São Paulo, Brazil;
2Fanem Ltd, Brazil, São Paulo, Brazil; 3Infectious and Parasitology Diseases,
Department of the School of Medicine of Universidade de São Paulo, Brazil
Critical Care 2013, 17(Suppl 4):P27; doi:10.1186/cc12927
Background: Biomarkers were assessed during neutropenic fever in
hematopoietic stem cell transplantation (HSCT). The objective was to
assess serum values of C-reactive protein (CRP), procalcitonin (PCT) and
IL-6 to identify infection in HSCT and risk factors for death.
Materials and methods: Prospective study with 296 patients submitted
to autologous or allogeneic HSCT. PCT, CRP and IL-6 dosed at the
following moments: afebrile neutropenia, fever, 24 hours upon fever,
72 hours upon fever and long-lasting fever. Patients were classified into
groups (I, afebrile; II, fever of unknown origin; and III, clinically or
microbiologically proven fever). ROC curves, sensitivity, specificity, and
multivariate analysis were used to evaluate factors associated with death.
Results: One hundred and ninety patients had fever. Mean and median
values of IL-6 at fever onset in group I with regard to group II (P = 0.013)
presented significantly higher values. Levels of CRP in group I differed
significantly from those found in group III (P < 0.05). Groups differed in
levels of IL-6 and CRP at fever onset. Group II presented IL-6 and CRP
concentrations significantly lower than group III. Cutoff values of PCT:
fever onset, 24 hours upon fever, 72 hours of fever, and long-standing
fever were: 0.32; 0.47; 0.46 and 0.35 µg/l. At fever onset, sensitivity was
52.3 and specificity 52.6 for infection diagnosis. Best cutoff values of CRP
for fever onset, 24 hours upon fever, 72 hours upon fever and
longstanding fever were: 79, 120, 108 and 72 mg/l. At fever onset, sensitivity
was 55.4 and specificity was 55.1. Best cutoff values of IL-6 for fever
onset, 24 hours upon fever, 72 hours upon fever and long-standing fever
were: 34, 32, 16 and 9 pg/ml. At fever onset, sensitivity and specificity
were: 59.8 and 59.7. In the autologous’ group, IL-6 presents significant
values at initial moments. Independent risk factors identified in the
multivariate analysis were: related donor, unrelated donor, Gram-negative
infection, DHL ≥390 (UI/l), urea ≥25 (mg/dl) and CRP ≥120 (mg/l).
Conclusions: IL-6 and CRP are associated with the early diagnosis of
clinically or microbiologically confirmed infection in post-HSCT febrile
neutropenia. The association of the three biomarkers did not present any
advantage, nor did it improve diagnostic accuracy. IL-6 was the only
biomarker significantly associated at an early stage with infection when
assessed only in patients submitted to autologous HSCT. The independent
variables associated with death were: allogeneic transplantation,
Gramnegative infection, DHL ≥390 UI/l at fever onset and urea ≥25 mg/dl at
fever onset and CRP ≥120 mg/l.
Severe pneumonia in critically ill cancer patients: clinical outcomes and
a comparison between healthcare-associated pneumonia and
Ligia SCF Rabello1*, Luciano CP Azevedo2, Ivens Augusto Oliveira de Souza2,
Viviane Bogado Leite Torres1, Maíra M Rosolem3, Jose Roberto Lapa e Silva11,
Marcio Soares1,4,5, Jorge IF Salluh1,4,5
1Postgraduate Program of Internal Medicine, Universidade Federal do Rio de
Janeiro, Brazil; 2Hospital Sirio-Libanes, São Paulo, Brazil; 3Hospital Barra Dor,
Rio de Janeiro, Brazil; 4D’Or Institute for Research and Education, Rio de
Janeiro, Brazil; 5Postgraduate Program, Instituto Nacional de Câncer, Rio de
Critical Care 2013, 17(Suppl 4):P28; doi:10.1186/cc12928
Background: Pneumonia is the most frequent source of infection in
cancer patients and accounts for 50% of all cases of septic shock.
Frequently cancer patients attend a hospital for several treatments and
an event of pneumonia in this scenario is called healthcare-associated
pneumonia (HCAP) by current ATS/IDSA guidelines. The aims of this study
were to describe a population of cancer patients with severe pneumonia
(not acquired in the hospital setting) who required ICU admission;
identify predictors of hospital mortality; and classify the study population
based on ATS CAP/HCAP definitions providing a comparison of clinical
data, microbiologic variables and outcomes between the two groups.
Materials and methods: A prospective cohort study was performed from
2002 to 2011 at Instituto Nacional de Cancer and Hospital Sirio-Libanes,
Brazil. Adult patients (>18 years) with a definite diagnosis of cancer and
presenting with pneumonia (not acquired in the hospital setting) were
evaluated at ICU admission. Demographic, clinical and laboratory data
were collected during the first day of ICU including the CURB-65, the
SAPS II, the SOFA score, comorbidities, Performance Status and
cancerrelated and treatment-related data.
Results: A total of 268 patients were admitted to the ICU with pneumonia
and classified as CAP (n = 109/40.7%) and HCAP (n = 159/59.3%). There
were 187 (69.8%) patients with solid tumors and 81 (30.2%) patients with
hematological malignancies. One hundred and sixty-seven (62.3%) patients
had septic shock at ICU admission. ICU and hospital mortality rates were
45.5% and 67.9%. When we compared CAP and HCAP populations, we
observed similar characteristics and outcomes in both groups. As expected,
higher severity of illness, organ failures, need for life-sustaining therapies
and failure of NIV were associated with increased mortality. In a multivariate
analysis, mechanical ventilation in the ICU (OR 2.52 (1.19 to 5.32)), dialysis in
the ICU (OR 3.86 (1.23 to 12.10)) and higher severity of illness (SAPS2 per
point OR 1.03 (1.01 to 1.05)) were associated with increased hospital
mortality whereas successful noninvasive ventilation was associated with
lower mortality (OR 0.32 (0.13 to 0.77)). The model showed good
discrimination (AROC 0.832).
Conclusions: We believe that cancer patients are a distinct group of
patients with pneumonia regardless of HCAP or CAP classification. They
have specific characteristics and predictors of outcome, and treatment
should be based on their clinical characteristics and local microbiologic
Background: Delirium is a common occurrence in critically ill patients
and is associated with an increase in morbidity and mortality . Some
evidence suggests that septic patients with delirium may differ from a
general critically ill population. In a subgroup analysis of the MENDS
study, a benefit of dexmedetomidine sedation over lorazepam was only
evident in septic patients . The aim of our study was investigate the
relationship between systemic inflammation and the development of
delirium in septic and nonseptic critically ill patients.
Materials and methods: We performed a cohort study in a 20-bed mixed
ICU that included consecutive patients admitted for more than 24 hours.
Delirium was diagnosed using the Confusion Assessment Method for the
Intensive Care Unit (CAM-ICU). Coma was defined as a Richmond Agitation
Sedation Scale (RASS) score of -4 or -5. Blood samples were collected
within 12 hours of enrollment for determination of TNFa, soluble TNF
receptor (STNFR)-1 and STNFR-2, IL-1b, IL-6, IL-10 and adiponectin.
Results: Seventy-eight patients were included in the study: 26 nonseptic/
nondelirium (control), 13 nonseptic/delirium (delirium), 21 septic/
nondelirium (septic) and 18 septic/delirium (sepsis-associated delirium
(SAD)). From all analyzed biomarkers only STNFR1, STNFR2 and adiponectin
were independently associated with delirium occurrence, but none of these
biomarkers had a significant interaction with sepsis. In contrast, there was
significantly interaction between sepsis and IL-1b suggesting that this
cytokine is differently modulated when comparing septic and nonseptic
patients with delirium.
Burden of mortality related to sepsis in Brazil from 2002 to 2011
Luciano CP Azevedo1,2,3*, Leandro U Taniguchi1,2, Guilherme PP Schettino1,
Cristiana M Toscano1, Ana L Bierrenbach1
1Instituto Sírio-Libanês de Ensino e Pesquisa, São Paulo, Brazil; 2State
University of São Paulo, Brazil; 3Federal University of São Paulo, Brazil
Critical Care 2013, 17(Suppl 4):P65; doi:10.1186/cc12964
Background: Sepsis represents a substantial healthcare burden. Limited
epidemiologic information about the demography of sepsis mortality or
about its temporal changes is available. Few population-based sources of
data have been used to investigate the burden of sepsis-associated
mortality on a national level. We investigated the epidemiology of sepsis
deaths in Brazil from 2002 to 2011 using secondary data from the
Brazilian Mortality Information System (Sistema de Informações de
Materials and methods: A retrospective descriptive study using data
reported to the Brazilian SIM for the years 2002 to 2011. SIM is an
electronic, case-based mortality registry that derives its information almost
entirely from death certificates. Sepsis-associated deaths from 2002 to
2011 were identified based on International Classification of Diseases 10th
Revision codes listed on the underlying and on the contributing
causes-ofdeath. Population-based sepsis-associated mortality rates and trends were
estimated. In addition, age, gender, ethnicity, and outcome variables were
assessed. Considering the cases of sepsis identified during the study
period, annual population-based mortality rates were calculated using as
denominators population estimates provided by the Brazilian Institute of
Geography and Statistics with the 2010 census age-stratified population as
the standard. Trends of mortality rates over time were explored with the
chi-square test for trend. Rate changes were considered significant when
P < 0.05.
Results: The total number of deaths recorded in SIM increased over the
decade. In 2002 there were 982,294 deaths reported and in 2010 this
number was 1,133,761. The number of sepsis deaths increased from
95,972 (9.8%) to 186,712 (16.5%). The average age of sepsis-associated
deaths progressively increased from 60.2 years in 2002 to 2003 to 67.1
years in 2010 to 2011. During the same period the average age of all
deaths increased from 57.8 years to 62.7 years. White individuals were
more frequent (60.4%), as compared with mixed race (24.4%) and blacks
(6.6%). A substantial part of sepsis deaths occurred in the hospital
(94.8%). The age-adjusted rate of sepsis-associated mortality increased
from 69.5 deaths per 100,000 to 97.8 deaths per 100,000 from 2002 to
2010 (P < 0.001).
Conclusions: Between 2002 and 2011, the contribution of sepsis to
allcause mortality increased significantly in Brazil. Moreover, age-adjusted
mortality by sepsis also augmented in the last decade. These numbers
confirm the importance of sepsis as a significant healthcare issue in Brazil
as well as the need for adequate strategies of early recognition and
Joel Passos*, Paulo Pires, Sérgio Curvelo, Decio Netto, Bruna Passos,
Background: Critical patients requiring prolonged intensive care are more
at risk of being colonized by germs acquired in an ICU and present
infections. The factors that contribute to the high rate of infection and
mortality in ICUs are possibly associated with the severity of the
underlying disease, invasive proceedings, the long period of hospitalization
and use of antibiotics, especially the expanded spectrum, so that there are
multidrug-resistant bacteria, which complicates therapy. Approximately 5%
of patients admitted to ICUs will acquire a nosocomial infection, resulting
in increased length of hospitalization, around 5 to 10 days, and will be
considered a consequence of healthcare in 30% of cases. Diagnostic or
therapeutic interventions provide breakdown of the mechanical barrier of
the skin and mucus assigned to invasive, skin lesions caused by
devitalization, trauma or by removing the skin secondary to burns or
debridement. In addition to the mechanical factors that disrupt the natural
barriers of defense, there are others that are inherent in clinical conditions
of patients and promote the acquisition of infections in the hospital
environment; the immune ability is compromised because the natural
defense mechanisms are altered by the very nature base or as a result of
therapeutic interventions. The rate of infection is high among intensive
care patients, especially respiratory infections. Pseudomonas aeruginosa
was the prevalent bacteria in our ICU. That is why the prevalence of
infection acquired in the ICU is high and suggests that preventive
measures are important to reduce the occurrence of infection in critical
Materials and methods: Retrospective study, analyzing culture results
for 1 year in a ICU with 10 beds in the northern of state of Rio de
Janeiro. We considered cultures of urine, blood, cerebrospinal fluid,
tracheal aspirate, nasal swabs and catheter tip, and detected the most
prevalent microorganisms in our ICU.
Results: We analyzed 453 cultures, 178 (39.29%) were positive for some
germ, 240 (52.98%) were negative and 35 (7.72%) had impaired analysis.
Among the cultures were performed 152 blood cultures, 38 (25%)
positive and 114 (75%) negative, 96 urine cultures, 36 (52.17%) positive
and 60 (47.83) negative, 31 samples of tracheal secretions, 20 (64.51%)
positive and 11 negative (35.49%), 141 nasal swabs, 71 (50.35%) positive
and 70 negative (49.65%), and 27 cultures from the catheter tip, six
(22.22%) positive and 21 (77.78%) negative. Among the positive blood
cultures assayed as being prevalent was 31.57% with P. aeruginosa, the
second Staphylococcus aureus and Proteus mirabilis with the same number
of specimens, 15.78%. Among the 36 positive urine cultures, Candida
albicans was the prevalent with 22.22%, second place was 13.88%
Escherichia coli and P. mirabilis was third with 11.11%. The cultures were
tracheal P. aeruginosa as the most prevalent in half of the cases (50%),
and secondly C. albicans and Acinetobacter baumannii at 10%. Among the
cultures of nasal swab taken on admission of patients, the prevalent
germ was P. aeruginosa with 26.76%, in second place with 12.67% was
P. mirabilis and third with the same number of cases were A. baumannii
and Serratia marcescens, 11.26%. Among the catheter tip cultures,
P. aeruginosa was prevalent with 40%, and P. mirabilis second with 20%.
There no was positive cerebrospinal fluid culture in the period.
Conclusions: This study contributes to the knowledge of local resistance
rates, which is one of the basic steps for the establishment of individualized
strategies regarding the use of antimicrobials.
Acknowledgements: We are thankful to the Director, Laboratory and
Committee of the Hospital Infection Control from Hospital Unimed Costa
do Sol, whose contributions have made this study possible.
Background: Sepsis score classifications increase conditionally with
concurrent systemic inflammatory response syndrome (SIRS) score,
Sequential Organ Failure Assessment score, and clinical intervention.
However, hierarchical criteria fail to accurately classify sepsis when related
physiological manifestations are resolved, while the underlying infection
Materials and methods: To enable hour-to-hour sepsis classification, we
examined the diagnostic performance of a continuous sepsis score. We
identified 36 adult patients in the Christchurch Hospital ICU with sepsis
from a patient database. A severe sepsis biomarker was developed from
model-based insulin sensitivity, temperature, heart rate, respiratory rate,
blood pressures, and SIRS score. Sepsis and nonsepsis patient-hours were
categorized by the ACCP/SCCM guidelines, where each category was
scored independently, rather than hierarchically. Kernel density estimates
were used to classify severe sepsis (including septic shock) of 1,690 hours
over 6,550 total hours. Optimal diagnostic performance from the receiver
operating characteristic (ROC) curve was determined for in-sample,
out-ofsample, and overall estimates.
Results: The severe sepsis biomarker achieved 86% sensitivity (81 to
94%), 85% specificity (80 to 95%), 0.93 (0.88 to 0.99) area under the ROC
curve, 8.2 (4.0 to 19.0) positive likelihood ratio, 0.17 (0.06 to 0.23)
negative likelihood ratio, 68% (58 to 87%) positive predictive value, 94%
(92 to 98%) negative predictive value, and a diagnostic odds ratio of
116 (17 to 308) at an optimal probability cutoff value of 0.25.
Conclusions: This clinical biomarker can thus be readily assessed at the
bedside to yield a non-invasive and continuous estimate of the
probability of severe sepsis. The results show high accuracy as a potential
severe sepsis diagnostic and monitoring response to sepsis interventions
in real time.
Potential anti-inflammatory role of 2-chloroadenosine treatment during
acute lung inflammation in BALB/c mice suffering from Klebsiella
pneumoniae B5055-induced acute lung infection
Vijay Kumar*, Kusum Harjai, Sanjay Chhibber
Department of Microbiology, Panjab University, Chandigarh, India
Critical Care 2013, 17(Suppl 4):P68; doi:10.1186/cc12967
Background: Acute lung inflammation (ALI) is a life-threatening pathology
and can develop during the course of several clinical conditions such as
pneumonia, acid aspiration or sepsis. Adenosine plays a significant role in
controlling acute inflammation via binding to A2A receptors on
inflammatory cells; that is, neutrophils or macrophages. The present study
was designed to evaluate the anti-inflammatory and immunomodulatory
effects of 2-chloroadenosine (2-CADO), alone or in combination with
amoxicillin/clavulanic acid (AMC), in Klebsiella pneumoniae B5055-induced
acute lung infection in mice.
Materials and methods: Acute lung infection in mice was induced by
directly instilling the selected dose (104 colony-forming units/ml) of
bacteria intranasally. Histopathological examination of the lungs was
performed to reveal neutrophil infiltration into the lung alveoli. In
addition to the major proinflammatory cytokines TNFa and IL-1a,
levels of the anti-inflammatory cytokine IL-10 were also determined by
Results: Intranasal instillation of bacteria caused profound neutrophil
infiltration into the lung alveoli as well as a significant increase in the
levels of proinflammatory mediators (that is, TNFa and IL-1a). However,
intravenous administration of 2-CADO 10 μg/kg/day, alone or in
combination with an antibiotic (that is, AMC 20 μg/ml/day i.p. 1 day
after establishment of infection), significantly decreased neutrophil
infiltration into the lung alveoli. A significant decrease in TNFa and
IL-1a along with elevation of IL-10 levels in the lung homogenate of
mice with acute lung infection was observed upon treatment with
2CADO alone, with no significant decrease in bacterial counts. Moreover
in combination with AMC, 2-CADO exhibited its immunomodulatory
action in acute lung infection and prevented ALI observed during acute
bacterial pulmonary infection, whilst an antibacterial action was
exhibited by AMC.
Conclusions: 2-CADO proved a potent immunomodulatory agent
during acute Gram-negative bacteria-induced ALI and exhibited its
antiinflammatory and immunomodulatory potential even in the presence of
antibiotics. Thus, it has a potential to be used as an adjunct
immunomodulatory agent during acute inflammatory conditions like ALI or
Background: Fluid replacement has been a usually recommended
maneuver in sepsis; however, growing clinical controversies in the
management of critically ill patients with severe sepsis have questioned its
benefit. Herein, we evaluated the effect of a rapid hyperhydration (HH)
therapy in varying stages of sepsis.
Materials and methods: Wistar-EPM rats, weighing 200 to 250 g, were
submitted to two sepsis models: S8 group, submitted to 2 ml Escherichia
coli 108 CFU/ml intravenous (i.v.) inoculation, LD60, or S9 group, with
E. coli 109 CFU/ml inoculation, LD80. Both groups were treated with HH
(30 ml/kg of Ringer lactate i.v., in 20 minutes) in the early (E30 minute)
and late (L6 hour) phases of sepsis. The mortality was followed up to
30 days (n = 6/group) and the splanchnic microcirculation was monitored
by sidestream dark field imaging (SDF) video microscopy at 6-hour and
24-hour periods (n = 3/group/period).
Results: The HH at the E30 minute phase of S8 improved the survival
rate from 40% to 90%, and L6 hour phase HH promoted an 80%
survival rate. Besides, the survival rate in S9 (LD80), with E30 minute HH,
improved the survival rate from 20% to 50%. However, it was less
effective as compared with the E6H phase HH, which resulted in an
expressive survival rate (from 20% to 70%). These intriguing results
suggested that there is an interdependent and time-dependent
pathophysiology feature within the host response based on sepsis
severity stage and a rapid high-volume reposition. The SDF analysis in
control sepsis groups (S8 and S9), without fluid therapy, showed a
broadly distributed microcirculation dysfunction in the liver lobules and
kidney tubules at 6 hours after sepsis challenge, and such findings were
similar between groups, but after 24 hours the survivors showed an
improved microcirculation hemodynamic pattern and it was more
evident in the S8 group. The survivals of the S8 E30 minute treated
group showed less injury at 6 hours and 24 hours as compared with
nontreated groups and S8 L6 hour treated animals. In S9 treated
groups, both showed a partial repair at 24 hours post sepsis.
Conclusions: The hyperfluid therapy given rapidly in both early and late
phases in sepsis and severe sepsis states showed that its beneficial effect
was more or less effective dependent on the phase and sepsis intensity;
however, the more prominent survival rates were seen at the early phase
of sepsis (S8) and at the later phase of severe sepsis (S9). The underlying
pathophysiology evolved in these paradoxical conditions needs to be
Acknowledgements: Grant number 2012/20841-7, São Paulo Research
Background: A positive blood culture (BC) is considered the gold
standard method for the sepsis diagnosis, although its sensibility is low
(10 to 30%) which demands a better diagnostic tool to limit
broadspectrum antibiotic use in the majority of patients without culture-based
sepsis diagnosis. Besides, after microbial invasion, they can remain live,
dead or fragmented in the bloodstream, thus limiting BC efficiency.
Herein we evaluated the PCR diagnostic efficacy under live, dead and
bacterial DNA contents in the bloodstream.
Materials and methods: Wistar rats were distributed in three groups
(n = 20/group) based on live, dead and DNA inoculations. The LPS+DNA
group (1 mg/kg LPS injection plus 4 hours later DNA injection, n = 10)
was designed for DNA detection under an induced inflammatory state.
Live, Dead and extracted DNA forms of Pseudomonas aeruginosa (ATCC
27853) relative to 2 ml of 107 colony-forming units/ml were injected into
the circulation. Blood samples were collected after 20 minutes and
6 hours (n = 10/group/period), and were submitted to nested PCR assay
using general and specific primers. BC was performed with 200 μl and
3,000 μl only in the Live group.
Results: In the Live group, at 20 minutes the sensibility was 100% by both
BC and PCR and at 6 hours the sensitivity was 60% (with 200 μl) and 90%
(with 3,000 μl) in BC, and 80% in PCR sampled with 50 μl blood volume. In
the Dead group, the PCR sensitivity was 90% at 20 minutes and 50% at
6 hours. In the DNA group, the sensitivity remained at 50% independent of
time. The inflamed condition did not change PCR sensitivity. Overall data
showed that in both techniques the sensitivity dropped with time. In the BC
assay the positivity was dependent on sampled blood volume, and in the
PCR it was related to live or dead condition. These findings suggest that the
live bacteria remain for a short period of time in the bloodstream while DNA
can last for longer periods.
Conclusions: Considering that PCR is performed with 40× less blood
compared with a habitual BC, PCR can be an assay of choice when BC is
negative and in conjunction in a live bacteria circulating condition. Besides,
the PCR assay with specific primers can be a useful method for sepsis
diagnosis in specific bacterial surge events in the ICU, thus improving
antibiotic usage potentials.
Mayara Andrade Ferrari*, Marcelo Eduardo Batalhão, Evelin Capellari Cárnio
Background: Prior exposure to infection, particularly during the neonatal
phase, contributes to individual differences in susceptibility to disease
during adult life. Animal neonates undergoing lipopolysaccharide
administration (LPS) react differently to the front endotoxemia in adulthood.
Ghrelin, a peptide hormone originally found in the stomach, has effects on
the modulation of the inflammatory response. Specific receptors are found
for ghrelin on neutrophils, macrophages and lymphocytes and their
activation by ghrelin inhibits the production of several inflammatory
cytokines, including nitric oxide (NO). Therefore, our objective is to evaluate
the role of ghrelin in the attenuation of fever during endotoxemia in
adulthood induced by neonatal exposure to LPS.
Materials and methods: The study was conducted using rats in the
pregnancy period. After the birth of pups (day 0 of the experiment) we
selected only male rats. All animals were weaned at 21 days and at 14 days
of age received neonatal administration of LPS 100 μg/kg intraperitoneally
(i.p.). Subsequently they were separate in cages until they reached 8 to
12 weeks of age for the experiment (by endotoxemia in adult
administration of 10 mg/kg LPS i.p.). To determine the body temperature,
the animals were anesthetized and a capsule inserted into the peritoneal
cavity biotelemetry. Body temperature was measured for a period of
6 hours after induction of endotoxemia. To verify the effect of ghrelin and
ghrelin antagonist on body temperature during endotoxemia, ghrelin was
administered 0.1 mg/kg ghrelin antagonist or 50 nmol/kg i.p. concomitant
administration of LPS. After decapitation, blood samples were collected
and centrifuged to separate the plasma. The plasma was stored at -70°C
for subsequent determination of NO.
Results: In our preliminary data we observed no significant difference in
fever-induced endotoxemia in animals subjected to LPS administration in
the neonatal period, when compared with their respective controls.
Conclusions: These data do not corroborate the findings of the literature
and we believe it is due to the fact that the animals used until now have
had prior exposure to pathogens. So in our next experiments we will use
experimental animals that are specific pathogen free.
Interruption of the intestinal immune route to the systemic circulation
associated with early hyperhydration minimized splanchnic
microcirculation damage and improved sepsis survival
Fernando M Dulcini1*, Ana MA Liberatore2, Bianca C Zychar1, Ivan HJ Koh1
1Department of Surgery, Federal University of São Paulo, Brazil; 2Department
of Pediatrics, Federal University of São Paulo, Brazil
Critical Care 2013, 17(Suppl 4):P72; doi:10.1186/cc12971
Background: Considering that the communication of the intestinal
immunity with the systemic bloodstream can be a relevant adjuvant
factor in the amplification of the host systemic inflammatory response
and subsequent multiple organ dysfunction in sepsis, we aimed to
evaluate the effect of the obstruction of the mesenteric lymph duct
(OMLD) associated with massive fluid therapy in the early phase of sepsis
and severe sepsis models.
Materials and methods: Adult Wistar-EPM rats were submitted to 108
(S8) or 109 (S9) CFU/ml Escherichia coli inoculum intravenously (i.v.)
(DL80 within 26 hours), and were treated with hyperhydration (HH) with
or without previous OMLD (n = 5/group). Control group were naïve
animals (N) and animals submitted to HH or sepsis only. The mortality
of groups was followed up to 30 days after experiments and
microcirculation monitoring was observed at 6 hours post sepsis induction by
videomicroscopy (sidestream darkfield imaging (SDF)).
Results: The effect of OMLD + HH reduced significantly the sepsis
mortality rate: S8 (60% to 14.5%) and S9 (80% to 60%). Besides, the liver
and kidney microcirculatory features were better preserved as compared
with untreated sepsis groups under video-microscopy (SDF) monitoring.
Conclusions: These preliminary findings showed that both HH and OMLD
have a potential therapeutic application in sepsis by minimizing the
splanchnic organ’s microcirculation dysfunction.
Acknowledgements: Grant number 2011/204014, São Paulo Research
Background: Recent studies from our laboratory showed that animals
subjected to 50% shortening of the small intestine developed bacterial
translocation unleashed chronically. Bacterial translocation has shown the
effect of exacerbation of systemic inflammatory response by crosstalk
between intestinal and systemic immune response. In this sense, the aim
of this study was to evaluate whether a septic challenge in the state of
chronic inflammation resulting from the shortening of the small bowel
can modify the mortality outcome and trigger organ alterations in the
Materials and methods: Wistar-EPM rats were submitted to 50% small
intestine shortening (IS group, n = 20) or sham intestinal anastomosis (IA
group, n = 20), and after 4 months were submitted to sepsis challenge
with 2 ml 108CFU/ml Escherichia coli i.v. The mortality was observed up to
30 days and the survivors of both groups were killed after 6 months for
histological analysis. The other 10 animals were killed after 4 months of
intestinal shortening in order to determine the histological pattern
related to the bowel shortening effect.
Results: The mortality rate after sepsis was 80% in the IS group and 35%
in the IA group. The bowel shortening without sepsis challenge showed
hepatic mild steatosis with inflammation similar to acute hepatitis, vascular
congestion and focal necrosis. The distal ileum showed shortening and
broadening of villus, focal cryptic necrosis and mild macrophages and
eosinophil infiltration in the lamina propria. In the IS group was seen a
generalized steatosis and vascular congestion in the liver; alveolar
atelectasis, BALT hyperplasia, a large number of macrophages, mast cells,
foam cells, lymphocytes, eosinophil and plasmocyte infiltration and
alveolar edema, plus vascular congestion and sclerosis in the lung; villus
apical necrosis, intense inflammatory cell infiltration and vascular
congestion in the lamina propria of the ileum; and the kidney with tubular
nephrosis, tubular obstruction, vascular congestion with interstitium
hemorrhage and tubular hyaline material deposition. In the IA group was
seen moderate liver steatosis, intestinal lamina propria cellular infiltrations,
glomerulonephritis, kidney tubular edema, parenchymal hemorrhage and
Figure 1(abstract P72) Splanchnic organ’s microcirculation following 6 hours after sepsis or HH procedures by SDF monitoring: (a) HH; (b) S8 +
OMLD + HH; (c) S9 + OMLD + HH.
Bowman capsule thickness. However, the alterations were less compared
with the IS group.
Conclusions: The chronic inflammatory state, in combination with
sepsis, might be an important aggravating factor related to sepsis
Cholecystokinin inhibits inducible nitric oxide synthase expression in
Evelin C Carnio1*, Luiz GS Branco2, Rafael S Saia3
1Escola de Enfermagem de Ribeirão Preto - USP, Brazil; 2Faculdade de
Odontologia de Ribeirão Preto - USP, Brazil; 3Faculdade de Medicina de
Ribeirão Preto - USP, Brazil
Critical Care 2013, 17(Suppl 4):P74; doi:10.1186/cc12973
Background: Cholecystokinin (CCK) receptors are expressed in
macrophages and are upregulated by inflammatory stimulus. In vitro and in vivo
studies have demonstrated the ability of CCK to decrease the production
of various proinflammatory cytokines. This study investigates the role of
CCK on iNOS expression in lipopolysaccharide (LPS)-activated peritoneal
macrophages, as well as the intracellular signaling pathways involved in
affecting iNOS synthesis.
Materials and methods: Experimental procedures were approved by the
Comitê de Ética em Experimentação Animal - FMRP (protocol number 152/
2009). Thioglicollate-elicited macrophages were obtained by peritoneal
lavage and cultured in RPMI 1640 medium, 10% fetal bovine serum and
antibiotics. Nuclear p65, cAMP and iNOS levels were determined using
ELISA kits, CCK receptors and I Ba expression by western blot and nitrite
by the Griess method. Data were compared by one-way ANOVA and
significant differences obtained using the Tukey multiple variances post
Results: CCK reduced NO production attenuating iNOS mRNA expression
(15.49 ± 10.80 vs. 113.16 ± 0.23 AU; P < 0.05) and protein formation.
Furthermore, CCK inhibited the NF- B pathway reducing I Ba degradation
and minor p65-dependent translocation to the nucleus (543.78 ± 84.57 vs.
90.42 ± 9.13%, P < 0.05). Moreover, CCK restored the intracellular cAMP
content activating the cAMP-protein kinase A (PKA) pathway, which resulted
in a negative modulatory role on iNOS expression and nitrite production. In
peritoneal macrophages, the CCK-1R expression was predominant and
upregulated by LPS (0.61 ± 0.08 vs. 0.30 ± 0.09 AU; P < 0.05). The
pharmacological studies confirmed that CCK-1R subtype is the major
receptor responsible for the biological effects of CCK.
Conclusions: These data suggest an anti-inflammatory role for the
peptide CCK in modulating iNOS-derived NO synthesis, possibly
controlling the macrophage hyper-activation through NF- B, cAMP-PKA
and CCK-1R pathways.
Acknowledgements: Fapesp and CNPq.
CD11b and TLR4 in human neutrophil priming by endotoxins from
Isabella Prokhorenko*, Dimitry Kabanov, Svetlana Zubova, Sergay Grachev
Institute of Basic Biological Problems, Pushchino, Moscow Region, Russia
Critical Care 2013, 17(Suppl 4):P75; doi:10.1186/cc12974
Background: The interaction of endotoxins (lipopolysaccharides (LPS)) from
Gram-negative bacteria with peripheral blood mononuclear cells leads to
the assembly of a receptor cluster composed from mCD14, CD11b/CD18,
TLR4, CD16A and CD36 [1,2]. It is well known that the main signal
transducing receptor complex is TLR4/MD-2 while mCD14 is involved in the
recognition of S or R endotoxin’s glycoforms [3,4]. A growing body of
evidence indicates that the CD11b/CD18 receptor plays the significant role
in the endotoxin signaling machinery because it can influence
TLR4mediated cell activation . So, using mAbs, we carried out experiments to
elucidate the influence of CD11b inhibition on neutrophil priming by
endotoxins for N-formyl-methionyl-leucyl-phenylalanine (fMLP)-induced
Materials and methods: Human neutrophils were isolated from
heparinized blood of healthy volunteers by standard procedure and
incubated with or without anti-TLR4 mAbs (HTA125, IgG2a) or anti-CD11b
mAbs (clone 44, IgG1) or isotypic immunoglobulin controls, respectively, for
30 minutes before stimulation with S-LPS or Re-LPS from Escherichia coli O55:
B5 or JM103, respectively. The cells (2 × 105), 2% of autologous serum,
glucose and luminol in Ca2+-PBS buffer (pH 7.3), were placed in the
chemiluminometer’s chambers (37°C) and primed by S-LPS or Re-LPS
(100 ng/ml) for 30 minutes (37°C). Reactive oxygen species (ROS) production
was triggered by addition of fMLP (1 µM). The chemiluminescence reaction
was monitored continuously for 7 minutes. Total ROS production by control
Introduction: Attention has been paid in recent years to studies showing
immune cell death mechanisms during the course of sepsis in response
to proinflammatory and anti-inflammatory mediators that are involved in
its pathophysiology. Taurine (Tau) is an abundant amino acid in
polymorphonuclear leucocytes that reacts with hypochlorous acid to form
taurine chloramine (TauCl) under inflammatory conditions. In this context,
we investigated potential interactions between lymphocytes and TauCl in
rats submitted to cecal ligation and perforation (CLP), analyzing cell
viability and cytokine secretion profile (TNFa, IFNg, IL-6, IL-17A, IL-23 and
Materials and methods: Adult male rats were divided in two groups:
sham and CLP that were killed 24 or 120 hours after sepsis induction to
isolate lymphocytes from the blood and spleen. Lymphocytes (>95.0%
purity determined by differentiation with Giemsa staining) were cultured
Figure 1(abstract P75)
for 24 hours at a concentration of 1 × 106 cells/ml and activated by
2 mg/ml concanavalin A. After 24 hours, Tau and TauCl were added
at concentrations of 0.1, 0.2, 0.3, 0.4 and 0.5 mM for 1 hour. After this
time, cells were incubated with MTT (500 μg/ml) for 3 hours to evaluate
cell viability and supernatants were used to determine cytokine
Results: Tau-treated cells exhibited better viability than those treated
with TauCl, in both time and organs. TauCl, in a time and
dosedependent ratio, decreased cytokines secretion when compared with
untreated cells. See Figures 1 to 7.
Conclusion: These findings show a possible impairment in lymphocyte
function promoted by TauCl, correlated with immunosuppression and cell
death characteristic of the late stages of sepsis.
Figure 1(abstract P76) Cell viability by MTT assay. Viability of lymphocytes treated with Tau and TauCl in different molar concentrations. Rats were
submitted to CLP or Sham, and 24 or 120 hours after the surgery their blood and spleens were collected, the lymphocytes were isolated, cultured and
the cell viability was measured by MTT assay. (A) blood, 24 hours; (B) blood, 120 hours; (C) spleen, 24 hours; (D) spleen, 120 hours. *P < 0.05, compared
with sham group (Tau-treated); #P < 0.05, compared with sham group (TauCl-treated), n = 5.
Figure 2(abstract P76) Cytokine secretion. Effect of TauCl on production of proinflammatory mediator IL-17A by Th17 lymphocytes. Activated
lymphocytes (1 × 106 cells/ml) were preincubated with TauCl (0.1 or 0.5 mM) for 1 hour. After this, supernatants were collected and IL-17A was
measured by ELISA. (A) blood; (B) spleen. Results are expressed as means ± SD. *Compared with sham control 24 hours; #compared with Clp control
24 hours; &compared with sham control 120 hours; $compared with Clp control 120 hours, all with P < 0.05 significant (n = 5).
Figure 3(abstract P76) Effect of TauCl on production of proinflammatory mediator IL-23 by Th17 lymphocytes. Activated lymphocytes (1 × 106
cells/ml) were preincubated with TauCl (0.1 or 0.5 mM) for 1 hour. After this, supernatants were collected and IL-23 was measured by ELISA. (A) blood;
(B) spleen. Results are expressed as means ± SD. *Compared with sham control 24 hours; #compared with Clp control 24 hours; &compared with sham
control 120 hours; $compared with Clp control 120 hours, all with P < 0.05 significant (n = 5).
Figure 4(abstract P76) Effect of TauCl on production of proinflammatory mediator IFNg by Th1 lymphocytes. Activated lymphocytes (1 × 106
cells/ml) were preincubated with TauCl (0.1 or 0.5 mM) for 1 hour. After this, supernatants were collected and IFNg was measured by ELISA. (A) blood;
(B) spleen. Results are expressed as means ± SD. *Compared with sham control 24 hours; #compared with Clp control 24 hours; &compared with sham
control 120 hours; $compared with Clp control 120 hours, all with P < 0.05 significant (n = 5).
Figure 5(abstract P76) Effect of TauCl on production of proinflammatory mediator TNFa by Th1 lymphocytes. Activated lymphocytes (1 × 106
cells/ml) were preincubated with TauCl (0.1 or 0.5 mM) for 1 hour. After this, supernatants were collected and TNFa was measured by ELISA. (A) blood;
(B) spleen. Results are expressed as means ± SD. *Compared with sham control 24 hours; #compared with Clp control 24 hours; &compared with sham
control 120 hours; $compared with Clp control 120 hours, all with P < 0.05 significant (n = 5).
Figure 6(abstract P76) Effect of TauCl on production of proinflammatory mediator IL-6 by Th2 lymphocytes. Activated lymphocytes (1 × 106 cells/ml)
were preincubated with TauCl (0.1 or 0.5 mM) for 1 hour. After this, supernatants were collected and IL-6 was measured by ELISA. (A) blood; (B) spleen. Results
are expressed as means ± SD. *Compared with sham control 24 hours; #compared with Clp control 24 hours; &compared with sham control 120 hours;
$compared with Clp control 120 hours, all with P < 0.05 significant (n = 5).
Background: Sepsis is a clinical condition resulting from the excessive
inflammatory response of the host against an infectious agent and is
associated with high morbidity and mortality in patients in ICUs. In sepsis
the brain can be targeted, associated with mental damage and decline,
impaired attention, disorientation, delirium and coma. It has been seen that
the permeability of the blood-brain barrier (BBB) is associated with septic
encephalopathy, allowing cell infiltration and increased oxidative stress.
Accordingly, such events can be potentiated through the involvement of
molecules that when activated perpetuate the inflammatory response and
the breaking of the BBB, and it is possible to postulate that the CD40
molecule may be involved by being under increased expression in microglia
in inflammatory events occurring systemically. The aim of this study
therefore is to evaluate the role of CD40 in the breakdown of the BBB, cell
infiltration and oxidative damage in the brain of rats with sepsis.
Materials and methods: Male Wistar rats were subjected to cecal
ligation and puncture (CLP) to induce sepsis. The animals (n = 10) were
Figure 7(abstract P76) Effect of TauCl on production of anti-inflammatory mediator IL-10 by Th2 lymphocytes. Activated lymphocytes (1 × 106
cells/ml) were preincubated with TauCl (0.1 or 0.5 mM) for 1 hour. After this, supernatants were collected and IL-10 was measured by ELISA. (A) blood;
(B) spleen. Results are expressed as means ± SD. *Compared with sham control 24 hours; #compared with Clp control 24 hours; &compared with sham
control 120 hours; $compared with Clp control 120 hours, all with P < 0.05 significant (n = 5).
divided into sham, CLP, CLP + 1 ng, CLP + 10 ng and CLP + 100 ng
antiCD40 antibody administered intracerebroventricularly. The rats were killed
at 24 hours for assessment of oxidative damage in lipids (TBARS),
damage to proteins by protein carbonylation, nitrite/nitrate concentration
(NO), myeloperoxidase (MPO) and breakdown of the BBB. The other
group was subjected to CLP and after 24 hours they were killed and the
hippocampus removed to analyse expression of CD40 and CD40L by
western blotting. Data were evaluated by ANOVA and post-hoc Tukey test
with significance P < 0.05.
Results: Our results show that in the most effective dose of 100 ng/kg
anti-CD40 showed a decrease in the breakdown of the BBB, MPO, nitrite/
nitrate concentration and TBARS. A dose of 1 ng/kg was effective only in
the reduction of nitrite/nitrate concentration and 10 ng/kg was not
effective in TBARS and carbonyl. Western blotting analysis showed
increased expression of CD40 and CD40L in CLP animals when compared
Conclusions: Modulation of the levels of CD40 may represent a potential
therapeutic target in sepsis.
Acknowledgements: CAPES, CNPq, UNESC and UNISUL.
Endotoxin induces conversion of endothelial cells into activated
César Echeverría1*, Ignacio Montorfano1, Daniela Sarmiento1, Alvaro Becerra1,
Claudio Cabello-Verrugio1, Felipe Simon1,2
1Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, Chile;
2Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
Critical Care 2013, 17(Suppl 4):P78; doi:10.1186/cc12977
Background: Endothelial dysfunction is a key step in
endotoxemiaderived sepsis syndrome pathogenesis. It is well accepted that the
bacterial endotoxin lipopolysaccharide (LPS) induces endothelial cell (EC)
dysfunction through immune system overactivation [1-3]. However, LPS
can also affect ECs in the absence of participation by immune cells [4-6].
Although interactions between LPS and ECs evoke endothelial death, a
significant portion of ECs are resistant to LPS challenge [6-8]. However, the
mechanism that confers endothelial resistance to LPS is not known.
Considering that LPS-resistant ECs exhibit a fibroblast-like morphology,
suggesting that these ECs enter in a fibrotic program in response to LPS,
our aim was to investigate whether LPS induces endothelial fibrosis and
explore the underlying mechanism.
Materials and methods: We used two different models: primary ECs, and
intact blood vessels (IBV). Both preparations were freshly obtained from
umbilical cord veins from normal pregnancies, after patients’ informed
consent. The investigation conforms with the principles outlined in the
Declaration of Helsinki. The Commission of Bioethics and Biosafety of
Universidad Andres Bello approved all experimental protocols. Once the
preparation was established they were cultured with or without LPS as a
Sandra Crestani*, Jose Eduardo da Silva Santos, Jamil Assreuy
Background: Calcium activity is essential to vascular smooth muscle
contraction. Although it is well established that arteries from rats in septic
shock present hyporesponsiveness to vasoconstrictor drugs, the role of
calcium mobilization in this contractile dysfunction is far less investigated.
We hypothesized that during septic shock calcium dynamics is changed
and may have a role in the vascular dysfunction in sepsis.
Materials and methods: Female Wistar rats (3 months old) were
anesthetized by oxygen-isoflurane (3%) inhalation and subjected to cecal
ligature and puncture surgery (CLP). Immediately after and every 12 hours
rats received physiological saline solution (PBS 30 ml/kg, subcutaneously)
and tramadol (5 mg/kg, subcutaneously). After 6 hours (CLP-6) or 24 hours
(CLP-24) rats were killed, the aorta was harvested and cut in rings, the
endothelium was removed and rings were mounted in baths. Rings were
exposed to KCl 120 mM and phenylephrine (PE 1 µM). Aorta rings were
kept in a modified depolarizing Krebs solution nominally Ca2+ free and
contracted by CaCl2 (1 to 100 mM). The same protocol were repeated in
presence of thapsigargin (3 µM), DTNB (100 µM) or PTIO (100 µM).
Different vessels were exposed to single concentrations of PE (1 μM) or
caffeine (20 mM) in Ca2+-free solution, in the presence or absence of
Results: Maximal contraction (Emax) induced by KCl or PE was reduced,
especially in the CLP-24 group. Similarly, CaCl2-induced contraction was
reduced (60%) in the CLP-24 group. Thapsigargin (sarcoplasmatic calcium
reuptake blocker) and DTNB (sulphydryl oxidation) restored the
contraction elicited by CaCl2 in septic rings, but without effect in control
rings. PE-induced contraction in calcium-free solution was significantly
reduced in CLP-24 rings (Emax 1.6 ± 0.4 g control vs. 0.3 ± 0.1 g CLP-24
rings). Thapsigargin did not change the hyporesponsiveness to PE but
PTIO (nitric oxide scavenger) restored it partially. Caffeine-induced
contraction in Ca2+-free solution was reduced in CLP-24 rings (0.2 ± 0.06 g
control vs. 0.03 ± 0.01 g in CLP-24). Thapsigargin or PTIO restored the
contraction induced by caffeine.
Conclusions: These data suggest that in septic shock septic calcium
mobilization is strongly impaired. Although preliminary, our results
suggest that calcium channel nitrosylation and calcium reuptake may be
reasons for the vascular hyporesponsiveness of septic shock.
Acknowledgements: Financial support: CNPq. FINEP. FAPESC and CAPES.
Background: Hypotension and cardiac dysfunction are frequently found in
severe sepsis and septic shock. Vasoactive and inotropic drugs are largely
used to reverse hypotension, but its effects on heart function have been
scarcely investigated . We thus evaluated the influence of both
norepinephrine and dobutamine on the cardiovascular function of rats
subjected to cecal ligation and puncture (CLP).
Materials and methods: The measurement of the cardiac function was
performed in male Wistar rats (3 to 4 months old), kept under
isofluraneinduced anesthesia (1 to 3%), using a pressure-volume catheter, which was
inserted into the left ventricle through the carotid artery. Blood samples
were collected from all animals for hematological analyses. The
experiments were conducted at 24 and 48 hours after CLP. For this, the cecum
was ligated with a ratio of 50% and perforated with a needle (18 G, four
holes; mortality rate ~50% after 48 hours), followed by four subcutaneous
injections (12/12 hours) of sterile saline (30 ml/kg) and tramadol (5 mg/kg),
for fluid resuscitation and analgesia, respectively. Data were recorded at
baseline and after single bolus administration of norepinephrine (1, 3 and
10 nmol/kg, i.v.) or dobutamine (3, 10 and 30 nmol/kg, i.v.). The results
obtained in CLP groups were compared with control (CT) animals, which did
not undergo any manipulation.
Results: Both CLP 24 and 48 hour groups presented thrombocytopenia
(~40% reduction), lymphopenia, hypoglycemia and leukopenia (P < 0.05),
a clear indication of severe sepsis. However, only CLP 48 hour animals
displayed refractory hypotension (MAP = 59 mmHg, vs. 78 mmHg in CT;
P < 0.05) in spite of volume resuscitation. The highest doses of
norepinephrine and dobutamine increased the MAP to 133.8 ± 8.1 and
97.8 ± 3.1 mmHg in CT, and to 120.6 ± 6.7 and 77.3 ± 4.4 mmHg in CLP
48 hour animals, respectively. The heart rate was significantly increased
by norepinephrine and dobutamine in control, but not in CLP 48 hour
animals. In addition, the basal values of both dP/dtmax and dP/dtmin, as
well as after 1 nmol/kg dobutamine, were reduced in CLP 48 hour
Conclusions: Using a pressure-volume catheter in a closed-chest
approach we demonstrated that, in spite of the ability to increase blood
pressure, the chronotropic effects of norepinephrine and dobutamine are
reduced at 48 hours after CLP in rats subjected to CLP. In addition, all
doses of norepinephrine, but only by the highest doses of dobutamine,
improved systolic and diastolic function in these animals.
Acknowledgements: CNPq and FAPESC (2012000367 and 2012000078).
1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM,
Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME,
Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS,
Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R:
Surviving Sepsis Campaign: international guidelines for management of
severe sepsis and septic shock, 2012. Intensive Care Med 2013, 39:165-228.
Increased sympathetic tone contributes to cardiovascular dysfunction
Ana Maria Favero1*, Regina Sordi1, Geisson Nardi2, Jamil Assreuy1
1Department of Pharmacology, Universidade Federal de Santa Catarina,
Florianópolis, Brazil; 2Department of Biological Sciences and Health,
Universidade do Oeste de Santa Catarina, Joaçaba, Brazil
Critical Care 2013, 17(Suppl 4):P81; doi:10.1186/cc12980
Background: The cardiovascular dysfunction of sepsis/septic shock is
characterized by hypotension, tachycardia/bradycardia, endothelial
dysfunction and hyporesponsiveness to vasoconstrictors. Hypotension and
low tissue perfusion trigger an increase in sympathetic tone probably as an
attempt to restore blood pressure to normal levels. The persistently higher
sympathetic stimulation may lead to the exhaustion of the capacity of
vascular response and thus create a vicious circle contributing to vascular
hyporesponsiveness and higher adrenergic stimulation. In addition, in
septic shock patients, increased arterial levels of norepinephrine (NE) were
significantly associated with mortality. The aim of this work was to
evaluate the vascular response to an adrenergic agonist during severe
sepsis and the effects of the early inhibition of sympathetic tone in
sepsisinduced cardiovascular dysfunction.
Materials and methods: Sepsis was induced by cecal ligation and puncture
(CLP) surgery in female Wistar rats. Septic animals and controls (CT) were
treated with the ganglionic blockers pentolinium (PENT; 5 mg/kg, s.c.) or
hexamethonium (HEX, 15 mg/kg, s.c.) or vehicle (saline) 1 hour after surgery.
The vascular response to the administration of NE was assessed 6 hours
or 24 hours after CLP surgery. The survival rate was also evaluated. All
procedures were approved by our Institutional Ethics Committee (PP00631/
CEUA-UFSC) and are in accordance with NIH Animal Care Guidelines.
Results: Six hours after CLP surgery, septic animals were hypotensive.
Treatment with hexamethonium or pentolinium prevented the
development of hypotension (control 84.8 ± 2.6; CLP 60.7 ± 4.5*; CLP +
HEX 72.7 ± 3.1; CLP + PENT 78.1 ± 2.7 mmHg; *P < 0.05 compared with
control group). However, 24 hours after surgery, the ganglionic blockers
failed to prevent hypotension (control 88.5 ± 1.7; CLP 62.7 ± 1.7*; CLP +
HEX 68.8 ± 2.7*; CLP + PENT 70.9 ± 3.4* mmHg; *P < 0.05 compared with
control group). The vascular hyporesponsiveness to NE observed both
6 hours and 24 hours after CLP was completely blocked by the early
treatment with both ganglionic blockers (NE 10 nmol/kg, expressed as
increase in blood pressure compared with baseline: control 54.2 ± 4.5;
CLP 6 hours 21.9 ± 3.1*; CLP 6 hours + HEX 52.6 ± 7.0; CLP 6 hours +
PENT 54.1 ± 4.9; CLP 24 hours 31.1 ± 5.6*; CLP 24 hours + HEX 74.6 ±
3.0; CLP 24 hours + PENT 64.4 ± 7.8 mmHg; *P < 0.05 compared with
control group). The early ganglionic blockade with PENT decreased the
mortality observed after 96 hours.
Conclusions: Our data indicate that increased sympathetic tone in sepsis
contributes, at least in part, to the development of hypotension,
hyporesponsiveness to vasoactive agents and mortality. Blockade of
increased sympathetic tone thus may be considered as an adjuvant
therapy for the treatment of septic cardiovascular dysfunction.
Acknowledgements: Financial support: CAPES, CNPq, FAPESC and FINEP.
Vascular smooth muscle cell activation depends on NOS-1-derived NO
and consequent peroxynitrite generation
Karin Scheschowitsch1*, Regina de Sordi1, João Alfredo de Moraes2,
Christina Barja-Fidalgo2, Jamil Assreuy1
1Department of Pharmacology, UFSC, Florianópolis, SC, Brazil; 2Department
of Pharmacology, UERJ, Rio de Janeiro, RJ, Brazil
Critical Care 2013, 17(Suppl 4):P82; doi:10.1186/cc12981
Background: Low levels of nitric oxide (NO) play a key role in vascular
tonus maintenance. Previous results from our laboratory show that
hypotension and mortality during sepsis are prevented by the early
administration of NOS-1 inhibitors. The aim of this study was thus to
investigate the role of NOS-1 and NOS-3-derived NO and of other
reactive oxygen species (ROS) in smooth muscle cell activation.
Materials and methods: Smooth muscle cell line of rat aorta (A7r5) was
used. Control cells and NOS-1 or NOS-3 silenced cells (siNOS-1 and siNOS-3,
respectively) were stimulated with LPS 1 µg/ml and IFN 200 U/ml (LPS/IFN).
NO and ROS production was assessed with fluorescent probes. NOS content
was evaluated by western blot and NOS-2 activity was indirectly measured
by Griess reaction. Further, control cells were treated for 30 minutes with a
NO scavenger (c-PTIO), a NOS inhibitor (7-NI) or a NADPH oxidase inhibitor
(DPI) before stimulation. Immunofluorescence was used to evaluate protein
nitration and NF- B nuclear translocation. To confirm the role of
peroxynitrite in cell activation, control cells were stimulated with a sub-effective
amount of LPS/IFN together with a NO donor and a superoxide anion
generator and treated with a NOS-2 inhibitor 4 hours after stimulation. Griess
reaction was performed 48 hours after. Statistical comparisons were
performed by two-way ANOVA followed by the Bonferroni test.
Results: A7r5 control cells stimulated with LPS/IFN presented a rapid
increase in intracellular NO and ROS content. These increases were
prevented by c-PTIO, 7-NI and DPI, as well as in siNOS-1 and siNOS-3
cells. NOS-2 was only expressed after cell stimulation. Control cells
incubated with c-PTIO or 7-NI and stimulated with LPS/IFN presented a
diminished NOS-2 expression and activity. Only in siNOS-1 cells was
NOS2 expression and activity also reduced. Nuclear translocation of NF- B
and positive nitrotyrosine reaction were reduced in c-PTIO or 7-NI treated
groups. Sub-effective concentrations of LPS/IFN did not induce significant
nitrite production. However, when sub-effective LPS/IFN was associated with
the production of low concentrations of peroxynitrite, nitrite accumulation
was as high as in cells stimulated with activating concentrations of LPS/IFN.
Conclusions: We show for the first time the importance of NOS-1-derived
NO and peroxynitrite for smooth muscle cell activation. Cell stimulation
with LPS/IFN causes an early NOS-1-derived NO pulse and a ROS pulse
that forms peroxynitrite. The interplay between these species seems to
be key events for NF- B nuclear translocation and NOS-2 expression.
Acknowledgements: CNPQ, CAPES and FAPESC.
Estradiol cypionate modulates immunological response during sepsis
Luiz E da Silva*, Angelita M Stabile, Marcel E Batalhão, Evelin C Cárnio
College of Nursing at Ribeirão Preto, São Paulo, Brazil
Critical Care 2013, 17(Suppl 4):P83; doi:10.1186/cc12982
Background: Sepsis and its common complication septic shock are
generally induced by the action of lipopolysaccharide (LPS) and characterized
by peripheral arteriolar vasodilatation that results in hypotension and
inadequate tissue perfusion. During sepsis, secretion occurs of large amounts
of inflammatory mediators such as nitric oxide (NO), interleukin 1 (IL-1) and
TNFa that will modulate the inflammatory response. One significant finding
in clinics is that men and women respond differently to sepsis, with better
prognosis related to women .
Materials and methods: Male and female (ovariectomized and sham
surgery) rats were injected intraperitoneally (i.p.) for three consecutive
days with ECP 40 µg/kg or vehicle. On the third day, after ECP injection,
rats receive i.p. injection of 10 mg/kg bacterial LPS or saline solution.
Plasma was collected 2, 4 and 6 hours after LPS for NO and cytokine
Results: Administration of LPS increased the NO plasma concentration in
males and females (2, 4 and 6 hours). ECP pretreatment decreased the NO
concentration in sham females at 4 and 6 hours; conversely, it increased
nitrate levels in ovariectomized and in males at 4 and 6 hours. IL-1 plasma
concentration was increased in the three groups after LPS administration
at 2 and 4 hours and in Sham at 6 hours; ECP pretreatment decreased IL-1
plasma concentration in all groups at 2 hours. LPS administration also
increased TNFa plasma concentration at 2, 4 and 6 hours in the three
groups; ECP pretreatment inhibited the increase of TNFa at 2 hours in
Conclusions: Our results indicate that estradiol may have
proinflammatory or anti-inflammatory actions depending on the gender
and the mediator evaluated; this balance in mediator secretion may be
protective and explain in part the better outcomes of woman during
1. Martin GS, Mannino DM, Eaton S, Moss M: The epidemiology of sepsis in
the United States from 1979 through 2000. N Engl J Med 2003,
Patrícia de Oliveira Benedet*, Gustavo Campos Ramos, Ana Maria Favero,
Background: The profound decrease in vasomotor tone accompanied by
hyporesponsiveness to vasoconstrictors is an important contributor to
morbidity and mortality in septic shock. Overproduction of nitric oxide
(NO) has been shown to play a relevant role in septic shock vascular
dysfunction. One of the mechanisms whereby NO exerts some of its
effects is the reaction with thiol groups of cysteine residues in a process
called S-nitrosylation, producing S-nitrosothiols. The aim of the present
study is to show that modification in S-nitrosylation has an important
impact in sepsis-induced vascular dysfunction and mortality.
Materials and methods: Wistar female rats were anesthetized and
submitted to cecal ligation and puncture (CLP) for induction of sepsis.
Thirty minutes before and 4 hours after surgery, animals received
5,5’dithio-bis-(2-nitrobenzoic acid) (DTNB), an oxidizing agent of sulfhydryl
groups or vehicle. Eight hours after CLP the rats were prepared for
invasive blood pressure measurements and vascular reactivity to
phenylephrine was assessed. The effect of DTNB on survival was also
evaluated. All of the procedures were approved by the institutional
Animal Ethics Committee (protocol number PP00790/CEUA/UFSC).
Results: Eight hours after sepsis induction, rats displayed a pronounced
hyporesponsiveness to phenylephrine (10 nmol/kg; 21.3 ± 1.1 mmHg CLP
group compared with 42.3 ± 0.8 mmHg in control group; P < 0.05, n = 6).
When DTNB was injected 30 minutes before and 4 hours after CLP
surgery, the response to phenylephrine was completely normalized
(10 nmol/kg; 46.2 ± 2.2 mmHg; P < 0.05, n = 6). DTNB also reduced the
mortality of septic rats by 40%.
Conclusions: Our results suggest that NO overproduction during septic
shock may cause nitrosylation of critical proteins important for
alphaadrenergic contractile response. Oxidation of protein sulfhydryls by DTNB
prevents nytrosylation and restores the response to phenylephrine in
septic animals. Another important finding is that DTNB restored the
alpha-adrenergic response even after sepsis is installed. Understanding
the role of S-nitrosylation may help to develop strategies to prevent or
reverse the vascular dysfunction of sepsis.
Acknowledgements: Financial support: CNPq, CAPES, FAPESC and FINEP.
Background: The objective was to evaluate the profile of respiratory
mechanism of septic female rats previously submitted to exposure of
Materials and methods: Initially, female rats (230 to 300 g) were
randomly divided into a control group (NS) kept with no manipulation and
a cigarette smoking-induced respiratory disorders group (S). A rat model
used to induce respiratory disorders was established by exposure to
cigarette smoking (8 units/15 minutes) daily for 6 weeks. Twenty-four
hours after the last cigarette smoking exposure session, each group
underwent cecal ligation and puncture procedures to induce polymicrobial
sepsis (CLP group) or only underwent a laparotomy (sham group),
resulting in the following four experimental groups: Sham-NS (n = 11),
Sham-S (n = 11), CLP-NS (n = 6) and CLP-S (n = 9). The profile of
respiratory mechanism was evaluated by forced oscillation measurements
using a computer-controlled piston ventilator (flexiVent; SCIREQ Inc.) at
24 hours CLP or Sham procedures. The respiratory system parameters
evaluated were calculated in flexiWare7 software. All experimental
procedures used in our study were approved by the Institutional Animal
Ethics Committee (nº 11221971-3/47).
Results: Among the experimental groups, no significant difference in
airway resistance was verified, while prior exposure to cigarette smoking
decreased the tissue resistance of sham-operated rats (0.77 ± 0.03 vs.
0.55 ± 0.01 cmH2O.second/ml, Sham-NF and Sham-F, respectively) as well
as inhibiting the increase in tissue resistance induced by sepsis (1.11 ±
0.11 vs. 0.76 ± 0.03 cmH2O.second/ml, CLP-NS and CLP-S, respectively).
The prior exposure to cigarette smoking did not alter the lung
compliance of sham-operated rats, but it blocked the CLP-induced
reduction of lung compliance (0.82 ± 0.04, 0.21 ± 0.11 and 0.57 ± 0.07
cmH2O.second/ml, Sham-NS, CLP-NS and CLP-S, respectively). Similarly,
cigarette smoking blocked the CLP-induced decrease of inspiratory
capacity (7.85 ± 0.25, 4.96 ± 1.49 and 7.00 ± 0.41 cmH2O.second/ml,
Sham-NS, CLP-NS and CLP-S, respectively) but did not alter the inspiratory
capacity from sham-operated rats (8.68 ± 0.2 cmH2O.second/ml, Sham-S)
compared with Sham-NS.
Conclusions: In contrast to sham-operated rats, cigarette smoking
inhibited changes in the resistance, compliance and inspiratory capacity
of the respiratory system of CLP-operated rats.
Background: New therapy is required that improves the prognosis of
patients suffering from severe sepsis or septic shock. C1-esterase inhibitor
(C1-Inh) was introduced in clinical medicine for patients with hereditary
angioedema. Some studies show that C1-Inh administration may also
have a beneficial effect in other clinical conditions such as sepsis [1,2].
We examined the effect of C1-Inh administration to the sepsis pig model.
Materials and methods: The experiments were performed divided into
two groups: the treatment group and the control group. We administered
LPS (40 μg/kg) to pigs of about 10 kg over 30 minutes. At the same time,
we administered C1-Inh in the control group (500 U, n = 3; 1,000 U,
n = 3), and saline in the control group (n = 3). We examined the effect of
C1-Inh for the outcome of the two groups, physiological indicators such
as heart rates (HR) and mean arterial pressure (MAP), and autopsy results
such as pleural effusion and ascites.
Results: The outcome of the two groups was that 5/6 in the treatment
group and 2/3 in the control group survived at 240 minutes from the
end of LPS administration. HR (/minute) at 180 minutes from the end of
LPS administration was 157.5 ± 12.3 in the treatment group and 205.3 ±
42.6 in the control group, and MAP (mmHg) at the same time was 60.0 ±
8.2 in the treatment group and 58.3 ± 5.6 in the control group. As for the
autopsy results, pleural effusion (ml) was 13.28 ± 3.13 in the treatment
group and 9.87 ± 4.33 in the control group, and ascites (ml) was 165.8 ±
32.99 in the treatment group and 210.0 ± 60.8 in the control group.
Seeing each individual, the individual showing a large effect of C1-inh
Conclusions: C1-Inh tended to stabilize the hemodynamics of the sepsis
pig model, but was not able to reduce significantly the amount of pleural
effusion and ascites.
Acknowledgements: This is a collaborative study of Emergency and
Critical Care Center, Saga University Hospital and the Department of
Veterinary Medicine, Rakuno Gakuen University.
1. Caliezi C, Wuillemin WA, Zeerleder S, Redondo M, Eisele B, Hack CE: C1
esterase inhibitor: an anti-inflammatory agent and its potential use in
the treatment of diseases other than hereditary angioedema. Pharmacol
Rev 2000, 52:91-112.
2. Igonin AA, Protsenko DN, Galstyan GM, Vlasenko AV, Khachatryan NN,
Nekhaev IV, Shlyapnikov SA, Lazareva NB, Herscu P: C1-esterase inhibitor
infusion increases survival rates for patients with sepsis. Crit Care Med
Brain markers of neurodegeneration in sepsis survivor rats
Larissa de Souza Constantino1*, Cristiane Damiani Tomasi1, Matheus Pasquali2,
Samantha Pereira Miguel3, João Paulo Almeida dos Santos2, Francieli Vuolo1,
Clarissa Martinelo Comim1, Fabrícia Petronilho3, João Quevedo1,
Daniel Pens Gelain2, José Cláudio Fonseca Moreira2, Felipe Dal-Pizzol1
1University of the Extreme-South Catarinense, Criciúma, Brazil; 2Federal
University of the Rio Grande do Sul (UFRGS), Porto Alegre, Brazil; 3University
of Southern Santa Catarina, Tubarão, Brazil
Critical Care 2013, 17(Suppl 4):P87; doi:10.1186/cc12986
Background: Several preclinical and clinical reports indicate a significant
role for systemic inflammation in chronic neurodegenerative diseases ,
with commitment of different brain regions. Several studies have
demonstrated hippocampal atrophy, EEG changes , profound glial
activation, the generation of nitric oxide and changes in expression of
mediator apoptosis . The release of these mediators and oxidative
stress occur mainly in acute phase inflammation in sepsis survivor rats
and are associated with long-term cognitive impairment . These
cognitive deficits have been associated with decreased quality of life and
increased long-term morbidity. Some of these alterations resembled the
pathophysiological mechanisms of neurodegenerative diseases. For this
reason, we analyzed parameters related to neurodegeneration in rats that
survived sepsis, and their relation to cognitive dysfunction.
Materials and methods: Wistar rats were subjected to sepsis by cecal
ligation and puncture and 30 days after surgery the hippocampus and
prefrontal cortex were isolated just after cognitive evaluation by the
inhibitory avoidance test. The immunocontent of b-amyloid peptide (Ab),
receptor for advanced glycation endproducts (RAGE) and synaptophysin
were analyzed by western blot.
Results: Ab was increased in septic animals in the hippocampus, but
not in the prefrontal cortex. RAGE was upregulated in both structures
after sepsis, and the immunocontent of synaptophysin was decreased
only in the prefrontal, and inversely correlated to Ab levels. Prefrontal
levels of synaptophysin correlated with performance in the inhibitory
Background: Sepsis remains a clinical challenge for the ICUs. However, it is
known that the tolerance mechanism using low doses of lipopolysaccharide
(LPS) reduces the expression of proinflammatory genes and involves
epigenetic regulation. The chromatin openness is regulated by histone
acetyltransferases (HATs) and these enzymes could be modulated by nitric
oxide (NO) interaction. In the present work, we demonstrate the pathway of
tolerance to LPS from HAT activity and level of histone openness to
production of cytokines as well as the influence of NO inhibition.
Materials and methods: THP1 differentiated into macrophages (with
2.5 nM PMA treatment) were cultivated in RPMI medium (Control group),
submitted to tolerance (500 ng/ml LPS 24 hours before challenge with
1,000 ng/ml LPS - Tolerant group) and challenge (1,000 ng/ml LPS - D group)
during 24 hours. NO production was inhibited by addition of 100 μM LNAME.
The HAT activity and cytokine production (IL-6) were measured with
biochemistry kits. Histone acetylated H3 and H4 were analyzed by western
Results: Tolerance reduced HAT activity compared with the group directly
challenged (P < 0.05). Acetylated H4 was maintained at basal levels in the
tolerant group and increased in the D group (P < 0.05). However, the
tolerance increases the acetylation of histone H3 in a NO-dependent
response. Similarly, the IL-6 release was reduced by induction of tolerance
(P < 0.05 vs. D group). However, this effect was abolished by inhibition of
Conclusions: The induction of tolerance diminishes HAT activity and
cytokine production. The tolerance triggers a complex epigenetic
modulation dependent of NO.
Acknowledgements: FAPESP 09/15530-0.
Histone acetyltransferase and DNA methyltransferase expression in
response to LPS stimulation
Ester Correia Sarmento Rios*, Francisco Garcia Soriano
Departamento de Clínica Médica da Universidade de São Paulo, SP, Brazil
Critical Care 2013, 17(Suppl 4):P89; doi:10.1186/cc12988
Background: Tolerance is a defense strategy capable of reducing the
proinflammatory impact of infection. Tolerance capacity differs among the
different tissues. It is known that epigenetic regulation is cell type specific.
The cell machinery regulates the expression and activity of the enzymes
that regulate chromatin openness. Understanding the epigenetic
mechanism activated by different doses of LPS is important to define new
approaches for the treatment of systemic infections. The objective of this
work was to study the LPS-induced epigenetic response, analyzing the
expression of histone acetyltransferases (HAT) and DNA methyltransferases
Materials and methods: THP-1 human promonocytes were cultivated in
RPMI (C group), submitted to different doses of LPS (T group - tolerance
with 500 ng/ml during 24 hours and challenge with 1 µg/ml during
24 hours; D group - 1 µg/ml during 24 hours). The inhibition of nitric oxide
production was performed with LNAME (100 µM). Male Balb C mice
(8 weeks old) were divided into two groups: C group - without
manipulation; D group - received 5 mg/kg LPS. The spleens were collected
48 hours after. The HAT, DNMTs, lysine acetylated and histone H3 acetylated
amounts were determinate by western blot. The results represent three
similar experiments. The statistical analysis was performed by ANOVA.
Research protocol number 0950/09 was approved by the ethics committee.
Results: The challenge with LPS reduced the expression of DNMT1 in
THP1 cells. However, the tolerance increased the amount of this enzyme
(25%). Challenge with LPS reduces DNTM3a production (50%) in mice
spleen. The expression of HAT was reduced (50%) in the T group and this
event was NO dependent. The LPS addition to THP1 culture decreases
the production of acetylated lysine (P < 0.05) in a dose-dependent way
(68% and 33% with 0, 1 and 5 µg/ml LPS respectively). Low doses of LPS
reduce the acetylation of histone H3 (30% and 60% with 500 ng and
1 µg/ml LPS respectively).
Conclusions: Different concentrations of LPS are required for selective
regulation of subsequent LPS-stimulated epigenetic mechanisms.
Acknowledgements: FAPESP 09/15530-0.
Background: Recent clinical studies have shown that sepsis survivors can
develop long-term cognitive impairment. The cellular and molecular
mechanisms involved in these events are not yet completely understood.
In this study, we investigate the synaptic deficits in sepsis and the
involvement of glial cells in this process.
Materials and methods: Using a clinically relevant model of sepsis (cecal
ligation and puncture), we observed a decrease of recognition memory
9 days after sepsis. At the same time, by colocalization between
presynaptic and post-synaptic protein, synaptophysin and PSD-95, we
observed a reduction of structural synapses in the hippocampus and
cerebral cortex of septic mice. To define the molecular mechanisms
accountable for synaptic loss in sepsis, we used an in vitro approach
treating neuronal cultures with conditioned medium from astrocyte
(ACM) and microglial (MCM) cultures stimulated with LPS.
Results: We observed that the MCM reduced the synapse number and
the ACM increased the number of synapses. The analysis of conditioned
medium composition showed that MCM had increased levels of IL-1b
while the ACM had increased levels of TGF-b1, as compared with
medium from the non-LPS-stimulated cultures. The increased levels of
IL-1b, from microglial activated with LPS, accompanied by an increase of
TGF-b1, from LPS-activated astrocytes, suggests an anti-synaptic activity
in IL-1b and pro-synaptic actions in TGF-b1. Inhibition assays with the
addition of soluble IL-1b receptor (IL-1 Ra) prevented the MCM-induced
synapsis loss. To understand whether the loss in synapse density would
have functional outcomes we performed patch clamp experiments in
neurons treated with microglia conditioned medium (MCM) and MCM of
LPS-stimulated cultures. Patch-clamp recordings in the MCM-treated
neurons showed a reduction in postsynaptic current frequency, while an
increase in current amplitudes suggests a functional synaptic deficit.
Conclusions: These findings show, for the first time, a correlation
between synaptic deficits and memory dysfunction, suggesting a possible
mechanism for cognitive impairment after sepsis as well as a glial-derived
molecule mediating synapse reduction.
Association of the immature platelet fraction with the diagnosis and
severity of sepsis: an observational study
Melina V Rodrigues*, Bruna D Andreguetto, Thiago M Santos,
Maria de Fátima P Gilberti, Joyce M Annichino-Bizzacchi, Desanka Dragosavac,
Marco A Carvalho-Filho, Erich V De Paula
Faculty of Medical Sciences, University of Campinas, SP, Brazil
Critical Care 2013, 17(Suppl 4):P91; doi:10.1186/cc12990
Background: An ideal sepsis biomarker should be able to segregate
infected patients from other causes of SIRS, and also to allow some kind of
risk stratification. Furthermore, it should be capable of identifying
subgroups of patients with specific sepsis complications, enabling
targetspecific preventive and therapeutic measures. Finally, access to this
biomarker should not depend on complex and high-cost equipments and
reagents, allowing access to more patients. New hematologic automated
analyzers used for evaluation of the complete blood count provide a series
of advanced analytical parameters that permit more detailed evaluations
of circulating blood cells. Parameters such as the immature reticulocyte
fraction (IRF) and immature platelet fraction (IPF) identify early signs of
hematopoietic recovery, and have been studied in several inflammatory
conditions. Recently, a study performed in critically ill patients suggested
that the IPF could be a more accurate biomarker of sepsis development
than C-reactive protein (CRP) and procalcitonin. The aim of this study was
to evaluate whether IPF and IRF levels presented any association with
clinical and laboratory parameters of sepsis severity.
Materials and methods: During 30 days the IPF and IRF were obtained
using an automated hematologic analyzer (Sysmex XE5000) within
24 hours from admission for consecutive patients with sepsis.
Results: In total, 23 patients with sepsis were enrolled in the study, of which
12 (52%) presented severe sepsis or septic shock. The median APACHE II and
SOFA scores at admission were 15 (6 to 37) and 6 (1 to 17). Median IPF and
IRF levels at admission were 4% (1.1 to 11.0%) and 14% (1.6 to 47.1%)
respectively, and were significantly higher than in a population of healthy
individuals (IPF = 2.1% and IRF = 2.9%; both P < 0.001). As opposed to the
CRP, both IPF and IRF were significantly correlated with the SOFA at
admission (Rs = 0.52 and 0.45; P = 0.01 and 0.02 respectively). However,
when patients were stratified by the median SOFA score at admission, only
the IPF was significantly higher in patients with SOFA ≥6 (IPF = 6.2% vs.
2.9%; P = 0.01). Similar results were observed when patients were stratified
by the presence of severe sepsis. The IPF presented a significant correlation
with the platelet count (Rs = -0.71; P < 0.001), but with not with PT, aPTT
Conclusions: In patients with sepsis, both IPF and IRF were higher than
in healthy individuals, and the IPF was associated with increased sepsis
severity. Larger studies are warranted to define and validate the precise
role of the IPF as a sepsis biomarker.
Background: Although several target-specific therapies for sepsis failed to
translate into clinical benefits during the last decades, the increasing
knowledge about sepsis pathogenesis continues to reveal new therapeutic
targets that could be explored in the future. One of the challenges of
previous target-specific treatments for sepsis was the short half-life of
agents, some in the range of minutes. Gene transfer strategies can
overcome this limitation, by providing a platform for longer expression of
secreted therapeutic proteins. On the other hand, the transient nature of
sepsis precludes the use of gene transfer strategies leading to long-term
expression such as viral vectors. In this context, the use of nonviral vectors
emerges as an attractive strategy for the treatment of sepsis, provided that
sufficient expression of any therapeutic gene can be obtained.
Materials and methods: Two gene constructs were used to evaluate the
feasibility of gene transfer in the endotoxemia model: a lacZ expression
plasmid driven by the CMV promoter, and a coagulation factor IX expression
plasmid with the hAAT liver-specific promoter. The latter was used as a
reporter gene for secreted proteins. C57Bl/6 mice were challenged with LPS
and gene transfer was performed 6 hours thereafter, so as to mimic the
timepoint when sepsis treatments would be initiated. Fifty micrograms of
plasmid were injected into the tail vein using hydrodynamic transfection.
A less aggressive protocol, which could in principle be translatable to the
clinical setting, was also tested. Gene expression was evaluated 72 hours
after gene transfer by a blinded investigator.
Results: Factor IX activity levels (FIX:C) were significantly lower in
nontransfected LPS-challenged mice (n = 12) compared with
nontransfected controls (n = 14), suggesting that endotoxemia decreases baseline
FIX:C levels. Higher FIX:C levels (twofold higher than controls) were
observed in control mice submitted to hydrodynamic transfection (n = 5),
as expected. When gene transfer was evaluated in the context of sepsis,
LPS-challenged mice (n = 9) presented 1.7-fold higher FIX:C levels than
control mice (n = 12) (P < 0.01). Moreover, mice that were exposed to a
less aggressive intravenous transfection protocol (n = 8) presented FIX:C
levels that were 1.4-fold higher than controls (P = 0.04). Liver-expression
of b-galactosidase also demonstrated the feasibility of gene transfer in
Conclusions: Our results suggest that the cellular and molecular events of
sepsis reproduced in the endotoxemia model could facilitate gene transfer,
thus offering a unique opportunity for gene therapy with nonviral vectors,
without the need for traumatic gene transfer protocols that would be
required in other pathological conditions.
Effect of IL-1 receptor antagonist on the cerebrospinal fluid nitric
oxide concentrations during experimental polymicrobial sepsis in rats
Fazal Wahab1*, Lucas F Tazinafo1, Marcelo Eduardo Batalhão2,
Evelin Capellari Carnio2, Maria Jose Alves da Rocha1
1Department of Morphology, Physiology and Basic Pathology, FORP,
University of São Paulo Campus de Ribeirão Preto, São Paulo, Brazil;
2Department of General and Specialized Nursing, EERP, University of São
Paulo Campus de Ribeirão Preto, São Paulo, Brazil
Critical Care 2013, 17(Suppl 4):P93; doi:10.1186/cc12992
Background: Recently, we observed that blocking the IL-1-IL-1r signaling
pathway by central administration of IL-1ra (an IL-1 receptor antagonist)
can result in increased AVP secretion and survival rate in the late phase
of sepsis . The mechanism of this effect of IL-1ra on AVP concentration
and survival rate remains elusive. Many studies have implicated excessive
production of nitric oxide (NO) as one of the important factors
responsible for decreased AVP secretion during the late phase of sepsis
. Currently, the effect of IL-1ra on the central NO production and
release during sepsis is not known.
Materials and methods: In this study, we checked the effect of IL-1ra on
sepsis-induced increased release of NO in cerebrospinal fluid (CSF). Sepsis
was induced by cecal ligation and puncture (CLP). IL-1ra (9 nmol/animal)
and vehicle (PBS: 2 μl/animal) were injected intracerebroventricularly to
separate groups of CLP (n = 8/group) and control (n = 8/group) animals.
CSF and blood samples were collected from different groups of rats (n =
6 to 8/group) after 1, 2, 4, 6 and 24 hours. The NO concentration in CSF
was determined by chemiluminescence assay. Specific ELISA was used for
AVP analysis. All experiments were carried out according to an
institutional ethic committee-approved protocol (CEUA protocol number
Results: NO levels were significantly (P < 0.05 to 0.005) increased in
postCLP 6-hour and 24-hour as compared with control, post-CLP 1-hour,
2-hour, and 4-hour animals. IL-1ra administration did not significantly
alter the NO concentration in CSF after 1, 2, 4 and 6 hours as compared
with vehicle treatment in CLP animals as well as in control. In contrast,
after 24 hours NO levels were significantly (P < 0.02) lowered in
IL-1ratreated animals (22.36 ± 2.07 μM) as compared with vehicle-treated
animals (31.97 ± 2.88 μM). The AVP concentration in IL-1ra-treated rats
was significantly higher in IL-1ra-treated animals in comparison with
vehicle treatment. Moreover, the survival rate of IL-1ra-treated rats was
>80% while that of vehicle-treated rats was 47%.
Conclusions: Our results have demonstrated that blocking the IL-1-IL-1r
signaling pathway by central administration of IL-1ra increases AVP
secretion in the late phase of sepsis, which may be beneficial for survival.
We believe that one of the mechanisms for this effect of IL-1ra is through
reduction of NO concentration in CSF of the septic rats.
Acknowledgements: This research work was funded by FAPESP. FW is
supported by a postdoctoral fellowship of FAPESP.
1. Wahab F, Tazinafo LF, Rocha MJA: Study of the effect of IL-1 receptor
antagonist on vasopressin secretion during experimental polymicrobial
sepsis in rats. Covian Symposium. University of Sao Paulo, Brazil 1913.
2. Corrêa PB, Pancoto JA, de Oliveira-Pelegrin GR, Cárnio EC, Rocha MJ:
Participation of iNOS-derived NO in hypothalamic activation and
vasopressin release during polymicrobial sepsis. J Neuroimmunol 2007,
Background: Since its discovery by Kojima and colleagues in 1999 , the
hormone ghrelin has been studied in different contexts, since this peptide
has the ability to promote hormonal, vascular and immune changes. His
well-established functions are the release of growth hormone, by a
mechanism distinct from the growth hormone release factor, and
stimulation of hunger, by activating hippothalamic neurons, leading to
release of neuropeptide Y, thus promoting orexigenic effects . Because of
its ability to release hormones, including vasopressin , and by possessing
immunomodulatory properties, ghrelin has been studied in different
contexts of inflammatory states, as present in endotoxemia and sepsis .
The infusion of lipopolysaccharide (LPS) is capable of generating an
inflammatory state, with augmenting of TNFa, IL-1b and nitric oxide, which
in turn leads to cardiac depression and systemic vasodilation and
hypotension . Due to its properties to modulate the inflammatory
response, in a way of diminishing the levels of TNFa, IL-1b and nitric oxide,
which are augmented in the endotoxemic state, as well the ability to
augment the plasma levels of vasopressin, ghrelin emerges as a potential
neuro-immunomodulator in hypotension caused by endotoxemia. We
speculate that ghrelin, mediating the inflammatory response and by
augmenting vasopressin blood levels, could attenuate the hypotension
caused by endotoxin.
Materials and methods: Male Wistar rats (250 to 300 g) had their
jugular vein and/or their right cerebral ventricle cannulated for drug
administration, and the femoral artery cannulated for mean arterial
pressure (MAP) and heart rate (HR) records, respectively. All experimental
procedures were approved by the Comitê de Ética em Experimentação
Animal-campus de Ribeirão Preto (protocol number 12.1.1441.53.5). The
endotoxemia model was induced by endovenous injection of
lipopolysaccharide (LPS; 1.5 mg/kg). Data were compared using two-way
analyses of variance and significant differences were obtained using the
Bonferroni post test.
Results: LPS administration leads to a drop in MAP in the first 2 hours,
followed by a partial recovery of the MAP, and then a second drop in MAP,
with a peak in 6 hours. The HR was augmented in this group. Systemic
administration of ghrelin alone, through a bolus followed by subcutaneous
implantation of an osmotic pump, did not alter the response, in
comparison with the saline-treated group. The icv administration of
ghrelin, however, diminished the HR in some intervals, although did not
present a difference in MAP, in comparison with the saline-treated group.
The administration of ghrelin, centrally and peripherally, when given at the
same time as the LPS bolus, attenuated the first drop in MAP and
completely restored the second drop present in the LPS group.
Conclusions: Ghrelin is capable of attenuating the hypotension caused
by endotoxin, and we speculate that the improvement is due to
Background: Animal research in sepsis needs analytical tools that can
capture and exploit the complexity of the condition. To summarise the
disease progression in a porcine model of severe Staphylococcus aureus
sepsis, we used principal component analysis (PCA) as a multivariate
approach to identify early dynamic expression patterns of 34 selected
genes in the liver, lung, and spleen tissue.
Materials and methods: We combined data from two related
experimental studies in pigs haematogenously infected with a porcine
pathogenic strain of S. aureus [1,2]. Seventeen infected pigs were
euthanised at the following time points post infection (p.i.): 6 hours (n =
3), 12 hours (n = 3), 24 hours (n = 3), 30 hours (n = 1), 36 hours (n = 2),
and 48 hours (n = 5). Five healthy controls were managed in parallel.
Gene expression of 34 genes related to acute inflammation and
haemostasis was measured in the liver, lung, and spleen by quantitative
real-time PCR. The data matrix of 22 samples and 102 (34 × 3) variables
were log-transformed, scaled to unit variance, and subjected to PCA.
Results: Three (PC1 to PC3) distinct dynamic response patterns were
identified. PC1: hepatic positive and negative acute-phase genes were
the main influencers of a protracted pattern induced between 12 and
48 hours of infection, which explained 23% of the total variation in the
dataset (Figure 1A, C). PC2: an acute pattern distinguished infected pigs
from controls already after 6 hours and peaked around 12 hours p.i.
After 30 to 48 hours, pigs had either reverted back to basal levels (n =
7) or below basal levels (n = 2) (Figure 1A). This pattern explained 14%
of the total variation and was influenced by a systemic
(nonorganspecific) mixture of proinflammatory, anti-inflammatory and haemostatic
genes (Figure 1C). The two pigs with low PC2 levels had suffered from
overt disseminated intravascular coagulation when euthanised , and
this outcome was clearly reflected by PC2. PC3: a per-acute pattern,
influenced mainly by pulmonary proinflammatory genes (explaining
11% of the total variation), was induced in infected pigs at 6 hours p.i.,
while at later time points most pigs had moved towards basal levels
(Figure 1B, D).
Conclusions: Multivariate analysis (PCA) identified three temporally
distinct patterns in gene expression data from the liver, lung, and spleen
tissue: pulmonary inflammation was rapidly induced, followed by
transient induction of a generalised inflammatory and haemostatic
response, and initiation of the hepatic acute-phase response.
Figure 1(abstract P95) Pigs (scores) and genes (loadings) in PC1-PC2 (A, C) and PC1-PC3 space (B, D). (A) Increased PC1 scores are seen in infected
pigs from 12 hours until the end of the study (48 hours), with a peak around 24 hours. PC2 scores are increased after 6 hours of infection, with a peak at
12 hours. Thereafter, scores decline towards basal levels, or below. (B) PC3 scores are increased mainly in infected pigs at 6 hours p.i. (C) Genes with
largest influence on the PC1 axis are mainly hepatic positive and negative acute phase genes (for example, SAA, ITIH4, TTR, TRF). Genes with largest
influence on the PC2 axis are not specifically related to a single tissue. (D) The main influencers of the PC3 axis are inflammatory genes measured in lung
tissue. Gene symbols are used according to the National Center for Biotechnology Information (NCBI).
Background: Previous studies demonstrated the presence of microparticles
(exosomes) in plasma of septic patients. These are cell-derived vesicles
containing specific collections of proteins, lipids and genetic material that
participate in the intercellular communication, changing the function and
physiology of their target cells. The role of exosomes in sepsis, however,
remains deeply unexplored. This study aimed to investigate the composition
of microRNAs and messenger RNAs related to inflammatory response in
circulating microparticles of septic shock patients.
Materials and methods: Fourteen patients had 30 ml blood collected in
the first 48 hours of sepsis and 7 days after for those who survived. Five
healthy volunteers served as controls. Exosomes were isolated from
plasma by filtration (0.22 μM) and ultracentrifugation. Thirty nanograms of
the total RNA were reversely transcribed and the expression profile of 754
human miRNAs and 91 mRNAs from immune response was evaluated by
real-time quantitative PCR using the Taqman Low Density Array (Applied
Biosystems). The raw data were processed in Expression Suite v1.0.1
software and analyzed in StatMiner v3.0 software considering the global
expression level for normalization. The fold-change was calculated based
on the estimated mean difference (2(-ΔCT)).
Results: Different miRNA expression was observed in the exosomes from
septic patients in comparison with healthy donors. In the first 48 hours of
septic shock, three miRNAs were differentially expressed: miR-1290
(2.78fold, P = 0.02), miR-1298 (4.02-fold, P = 0.03) and miR-146a (-2.51-fold,
P = 0.02). In the recovery phase of sepsis, five miRNAs were differently
expressed as compared with controls: miR-1260 (2.29-fold, P = 0.02),
miR1274A (2.83-fold, P = 0.02), miR-1274B (3.31-fold, P = 0.02), miR-192
(1.83fold, P = 0.02) and miR-604 (-6.41-fold, P = 0.02). The miRNA expression
profiles in different stages of sepsis were similar. Moreover, exosomes
from patients after 1 week of sepsis carry less CCL5 mRNA than in the
beginning of the disease (-2.49-fold, P = 0.02).
Conclusions: Exosomes from septic shock patients carry different miRNA
expression profiles at different stages of the disease, as compared with
healthy individuals. CCL5 mRNA is less expressed in the recovery phase of
sepsis. The composition of these vesicles may help to understand the
underlying mechanisms involved in their role in the pathogenesis of sepsis.
Acknowledgements: Financial support from Fundação de Amparo à
Pesquisa do Estado de São Paulo (FAPESP).
Background: Septic encephalopathy (SE) is a frequent complication in
severe sepsis. Here we have explored the role of NADPH oxidase in
different aspects of SE pathophysiology. We investigated the involvement
of NADPH oxidase in neuroinflammation and in the long-term cognitive
impairment of sepsis survivors.
Materials and methods: Our approach included pharmacological
inhibition of NADPH oxidase activity with apocynin and the use of
genetically deficient (knockout) mice for gp91phox (gp91phox-/-), the
catalytic subunit of Nox2. Sepsis was induced by cecal ligation and puncture
and fecal peritonitis. We measured the hippocampal oxidative stress, Nox2
and Nox4 gene expression and neuroinflammation in WT and
gp91phox-/mice at 6 hours, 24 hours and 5 days post sepsis. Behavioral outcomes were
evaluated 15 days after sepsis with the inhibitory avoidance and the Morris
water maze tests.
Results: The data show progressive oxidative damage to the hippocampus,
identified by increased 4-hydroxynonenal expression, associated with
an increase in Nox2 gene expression in the first days after sepsis.
Pharmacological inhibition of Nox2 with apocynin completely inhibits
hippocampal oxidative damage in septic animals as well as the development
of long-term cognitive impairment in the survivors. Pharmacologic inhibition
or the absence of Nox2 in gp91phox-/- mice prevents glial cells activation, one
of the central mechanisms associated with SE and other neurodegenerative
Conclusions: We identified Nox2 activation as a necessary step for glial cell
activation in SE. Our data indicate that Nox2 is as a major source of
oxidative stress in the brain and consequently has a central role in the
development of cognitive impairments observed in sepsis survivors.
Background: Previously, we have shown that methicillin-resistant
Staphylococcus aureus (MRSA) sepsis was associated with more severely
pronounced vascular leakage compared with Pseudomonas aeruginosa
sepsis. We have also demonstrated that the arginine vasopressin V1a
receptor (V1aR) agonist significantly attenuated the severity of
MRSAinduced vascular leakage . The goal of the present study was to explore
mechanistic aspects of V1aR agonist’s action.
Materials and methods: Twelve adult female sheep were operatively
prepared for chronic study. After 5 days of recovery, tracheostomy was
performed under anesthesia and injury was given. The injury consisted of
insufflation of cooled cotton smoke (48 breaths) and instillation of 2.5 × 106
CFU MRSA into the lungs by bronchoscope under maintenance isoflurane
anesthesia. Following the injury, sheep were awakened, placed on
mechanical ventilation and randomly allocated into two groups: control
group, saline treated, n = 6; and POV group, treated with intravenous V1aR
agonist, Phe2-Orn8-Vasotocin (POV) (Ferring Research Institute, Inc., San
Diego, CA, USA), n = 6. The titration of POV was started when mean arterial
blood pressure (MAP) dropped by 10 mmHg from the baseline with the
initial dose of 30 pmol/minute, which was further adjusted to maintain MAP
close to baseline. All sheep were resuscitated with lactated Ringer’s solution
with initial rate of 2 ml/kg/hour that was further adjusted according to
hematocrit. The experiment lasted 24 hours. Plasma levels of nitric oxide
(NO; Grease reaction), asymmetric dymethylarginine (ADMA; mass
spectrometry) and bradykinin (mass spectrometry) were determined at
0 hours and every 3 hours after the injury.
Results: MRSA-induced plasma levels of NO (nitrite/nitrate) as well as
cumulative body fluid were significantly inhibited by V1aR agonist. The
treatment with POV also attenuated the MRSA-induced hypotension. The
plasma levels of ADMA were higher in the treated group compared with the
control at 24 hours after the injury (0.93 ± 0.14 in control, n = 3 vs. 1.23 ±
0.08 in POV, n = 6). In addition, the treatment with POV significantly
inhibited the MRSA-induced bradykinin increases at 3 hours after the injury
(1.14 ± 0.4 in control vs. 0.52 ± 0.001 in POV, P < 0.05).
Conclusions: Arginine vasopressin V1aR agonist attenuates the severity
of MRSA-induced vascular leakage by inhibiting potent permeability
factor bradykinin and excessive NO. The V1aR agonist may modulate NO
production by promoting the release of endogenous NO synthase
1. Rehberg S, et al: Selective V(1a) agonism attenuates vascular dysfunction and fluid accumulation in ovine severe sepsis. Am J Physiol Heart Circ Physiol 2012, 303:H1245-H1254.
Background: The standard therapy for sepsis is becoming less effective due
to increasing microorganism resistance to antibiotics and cardiovascular
collapse refractory to fluid resuscitation and vasopressors. In this study, we
demonstrate a critical role of peroxynitrite in vascular hyporesponsiveness to
vasopressin (VP) in methicillin-resistant Staphylococcus aureus
(MRSA)induced ovine sepsis.
Materials and methods: Sheep were instrumented with Swan Ganz
(common jugular vein), femoral artery, and left atrium catheters to monitor
hemodynamics for 24 hours. Sepsis was induced by instillation of live MRSA
(2.5 to 3.5 × 1011 CFU) into the lungs by bronchoscope under anesthesia.
Sheep were then awakened, placed on a ventilator, and fluid resuscitated.
Urine output was measured via a Foley catheter. Groups: MRSA, received
MRSA, n = 4; MRSA + peroxynitrite decomposition catalyst (PDC), received
MRSA and were treated with PDC starting 6 hours post injury (0.1 mg/kg
bolus followed by 0.02 mg/kg/hour), n = 4; MRSA + VP, received MRSA and
were titrated with VP when mean arterial pressure fell by 10 mmHg, n = 4;
and MRSA + VP + PDC, received MRSA, treated with VP and PDC, n = 4.
Results: MRSA induced severe hypotension refractory to aggressive fluid
and AVP. PDC and AVP alone partially attenuated the severe hypotension.
When combined they more effectively reversed the hypotension. Inhibition
of peroxynitrite formation by PDC also markedly reduced AVP requirement.
In addition, the in vitro effects of AVP (5 nM) on isolated arterial ring tone
were abolished with co-incubation with peroxynitrite (50 μM).
Conclusions: Peroxynitrite modulation may be a novel treatment option
for management of sepsis-induced cardiovascular collapse refractory to
vasopressors. These findings are especially provocative since peroxynitrite
is the product of excessive nitric oxide regardless of which NOS isoform
is involved and the major debate of whether the use of NOS inhibitors in
management of sepsis is beneficial still remains.
Background: Studies suggest that curcumin, found in the tropical plant
Curcuma longa, has anti-inflammatory and antioxidant properties and can
act in sepsis, decreasing the release of proinflammatory mediators and free
radicals. In the search to increase curcumin’s bioavailability a fitotecnologic
process was developed that generated a solid dispersion of curcumin
named DS17. This dispersion is water soluble and seems to increase the
curcumin absorption by the gastrointestinal tract. The aim of our study
was to assess the biological activity of the solid dispersion of curcumin
(DS17) in immunological and metabolic alterations observed in a model of
sepsis in rats induced by CLP.
Materials and methods: Male Wistar rats (250 to 300 g) were divided into
two groups: polymicrobial sepsis model by cecal ligation and puncture
(CLP) and sham operation (OF). The animals were pretreated with DS17
(100 mg/kg) orally for 7 days prior to CLP and treated 2 hours after
surgery. The animals were used to analyze curcumin absorption through
HPLC, plasma glucose, cytokines, nitric oxide (NO) and HSP70. Another
group had the survival rate assessed for 48 hours.
Results: Our results showed that curcumin is present in the plasma at
4 and 6 hours but absent 24 hours following the DS17 administration.
The dispersion decreased IL-6 in plasma and peritoneal fluid at 6 and
24 hours, and IL-1b 6 hours after sepsis stimulus. Moreover, we observed
an increase in the hematocrit and a decrease in plasma glucose in the
same animals. Paradoxically, plasma IL-10 and serum HSP70 decreased in
24 hours while plasma NO increased in the same period. These changes
were not sufficient to increase significantly the survival although we
observed a biological improvement of 20% 24 hours following CLP.
Conclusions: Our results suggest that despite a significant decrease in
proinflammatory cytokines (IL-1b and IL-6), treatment with curcumin solid
dispersion produced no beneficial biological effect in septic animals.
Further studies are necessary to better clarify the suggested antioxidant
and anti-inflammatory effect of curcumin.
Effects of PPARg in dendritic cells during severe sepsis and
Raphael Molinaro1*, Roberta Navarro-Xavier1, Papp Attila2,
Adriana Vieira-de-Abreu1, Adriana Ribeiro Silva1, Hugo Caire Castro-Faria-Neto1,
Claudia Farias Benjamim3, Laszlo Nagy2, Patrícia Torres Bozza1
1Immunopharmacology Laboratory, IOC/FIOCRUZ, RJ, Brazil; 2Nuclear
Hormone Receptors Laboratory, Debrecen, Hungary; 3Inflammation
Laboratory, UFRJ, Brazil
Critical Care 2013, 17(Suppl 4):P101; doi:10.1186/cc13000
Background: Sepsis is a systemic inflammatory response syndrome against
infection, which can develop in sepsis-associated immunosuppression.
Actually, several inflammatory dysfunctions have been described in dendritic
cells (DCs) that could be responsible for impairing the immune response
towards the secondary infection. PPARg is a lipid-activated nuclear
receptor, which participates in inflammation, lipid metabolism and cellular
differentiation. Previous studies have shown the role of PPARg in acute
sepsis besides its effects in sepsis-induced immunosuppression still being
unclear. Our aims were to evaluate the phenotypic changes in DCs in lungs
from post-septic mice and to assess the effects of PPARg on DC functions.
Materials and methods: Mice were subjected to cecum ligation and
puncture (CLP) or Sham and, 6 hours after, all groups were treated with
antibiotics. Fourteen post-septic and Sham mice were infected with BCG
and 24 hours after challenge the lungs were collected, minced and
digested to investigate the cytokine production, gene expression and
phenotype analysis. To evaluate the effects of PPARg, post-septic derived
BMDC were pretreated with PPARg agonist (rosiglitazone) before BCG
infection. After 24 hours, lipid droplet formation, phagocytosis, cytokines
and oxide nitric production were analyzed.
Results: Post-septic mice were susceptible against Mycobacterium bovis,
BCG and exhibited higher cellular infiltration. Lungs from post-septic mice
showed increased IL-10 level and COX2, CCR2 and IL-1b expression.
When post-septic and Sham mice were infected with BCG, we observed
higher increased COX2, CCR2 and IL-1b expression in lungs from
postseptic mice as compared with lungs from Sham mice but the IL-10 level
was reduced. In addition, lungs from post-septic mice showed higher
Ly6G cells compared with lungs from Sham mice. Infected BMDC
exhibited an immature profile (lower expression of CD80 and CD40) and
a positive shift to anti-inflammatory cytokine production (increased IL-10
and reduced TNFa, CCL2 and IL-1b levels). PPARg flanked mice in CD11c
cells were more susceptible to severe sepsis. Activation of PPARg in
infected BMDC from post-septic mice reduced lipid droplet formation,
phagocytosis and oxide nitric production but not cytokine production
when compared with infected BMDC from Sham mice.
Conclusions: After severe sepsis, phenotypic changes modulate DC
functions and may contribute to sepsis-induced immunosuppression. The
understanding of PPARg could be important for development of new therapy
in sepsis-associated immunosuppression and long-term inflammatory
Raphael Molinaro1*, Papp Attila2, Adriana Ribeiro Silva1,
Hugo Caire Castro-Faria-Neto1, Claudia Farias Benjamim3, Laszlo Nagy2, Patrícia Torres Bozza1
Background: Sepsis is a systemic inflammatory response syndrome against
infection, which can develop in sepsis-associated immunosuppression.
Actually, several inflammatory dysfunctions have been described in dendritic
cells (DCs), which could be responsible for impairing the immune response
towards the secondary infection, although how these stable modifications
maintain is still unknown. Our hypothesis is that DCs from post-septic mice
have chromatin alteration and differential microRNA expression.
Materials and methods: To investigate the global gene expression,
postseptic and Sham-derived BMDC were infected or not with BCG for 24 hours.
Total RNA were collected and the gene expression profile was assessed by
Affymetrix GeneChip technology. The gene expression profiles were
classified by Gene Ontology (GEO). Also, the microRNA analysis was
obtained from Affymetrix microarray. To investigate the chromatin
modifications, post-septic and Sham BMDC were performed to Chip-Seq
Results: Supervised analysis identified a set of 2,755 genes that
distinguished very accurately between post-septic BMDC and Sham BMDC.
The gene expression signature showed 1,805 stimulated genes and 950
inhibited genes in post-septic BMDC compared with Sham BMDC. The gene
expression signature of post-septic BMDC provided a molecular and
functional profile based in GEO. It is noteworthy that post-septic BMDC were
mostly found in the downregulated genes to encode proteins involved in
the biological pathways of the inflammatory process (IL-1a, IL-12, CD28,
TLR2, Hmgb1, CCL2), lipid metabolism (FABP4, Elovl2, PTGS1, PPARδ) and
histone modifications (ACAT3, CBx2, Oip5, Hist2hX). When post-septic and
Sham BMDC were infected with BCG, downregulated gene sets were
classified in 130 significant GEO terms (mainly involved in inflammatory and
lipid metabolism process) while surprisingly upregulated gene sets were
classified in 10 significant GEO terms (nine inflammatory processes of
10 terms). In microRNA expression, we observed higher microRNA
expression in post-septic compared with Sham BMDC. When BMDC were
infected with BCG, post-septic BMDC exhibited higher numbers of microRNA
compared with Sham BMDC. Furthermore, we assessed the presence of
H3K27ac and H3K4me3 in inflammatory (IL-10, TNFa, IL-6 and TGF-b) and
lipid metabolism genes (ABCA1, PLIN2, CD36 and FABP4). Both H3K4me3
and H3K27ac on PLIN2, CD36 and FABP4 gene bodies were reduced and the
presence of H3K4me3/H3K27ac was increased on TNFa and TGF-b gene
Conclusions: These results demonstrate the global gene expression
signature, higher microRNA expression and H3K4me3/H3K27ac profile on
chromatin structure in post-septic BMDC. The present study suggests
epigenetic changes may play a role in transcriptional regulation in
Vasopressin secretion in sepsis-surviving animals following dehydration
Lucas Favaretto Tazinafo*, Tatiana Tocchini Felippotti,
Maria José Alves da Rocha
Department of Morphology, Physiology and Basic Pathology, Faculty of
Dentistry of Ribeirão Preto - USP, Ribeirão Preto, Brazil
Critical Care 2013, 17(Suppl 4):P103; doi:10.1186/cc13002
Background: Vasopressin (AVP) plasma levels increase in the early phase
of sepsis but remain at basal levels in the late phase of sepsis . It is
also known that one-half of septic patients do not properly respond to
an osmotic challenge, one of the strongest stimuli for AVP secretion .
However, whether these AVP secretion changes persist in sepsis survivors
is not known. This study investigated the possible alterations in plasma
AVP levels in sepsis-surviving animals.
Materials and methods: Male Wistar rats were separated into two
groups: sepsis induced by cecal ligation and puncture (CLP), or sham
animals. They received saline solution (50 mg/ml; s.c) immediately and
12 hours after CLP, and also ceftriaxone (30 mg/kg; s.c.) and clyndamicin
(25 mg/kg; s.c.) after every 6 hours for 3 days. Sham animals received
the volume of saline corresponding to antibiotic administration. After
10 days, the animals were dehydrated or left as control. After 2 days, the
animals were decapitated, and the serum and plasma collected for
sodium, hematocrit and hormone determination. The posterior pituitary
glands were removed for hormone stock analysis.
Results: Sepsis-surviving animals presented a higher serum sodium even
without the osmotic stimulus (147.8 ± 0.97 SEM vs. 151.4 ± 0.6 SEM mmol/l
CLP; P < 0.001). Following dehydration, as expected, there was an increase
of serum sodium in CLP animals (151.4 ± 0.6 SEM vs. 155.71 ± 0.47 SEM
mmol/l; P < 0.001) and sham animals (147.8 ± 0.97 SEM vs. 154 ± 0.26 SEM
mmol/l dehydrated; P < 0.001) with difference between the groups (154 ±
0.26 SEM vs. 155.71 ± 0.47 SEM mmol/l CLP; P < 0.041). Hematocrit also
increased in both CLP (42.63 ± 1.58 SEM vs. 50.17 ± 1.67% SEM
dehydrated; P = 0.002) and sham (mean: 41.8 ± 1.43 SEM vs. 49.5 ± 1.0%
SEM; P = 0.003) groups but without difference between the groups. The
animals responded with an increase in the AVP plasma levels (6.12 ± 0.68
SEM vs. 6.16 ± 0.94 SEM pg/ml CLP, P > 0.05), and a decrease in AVP
neurohypophysis stocks (4.0 ± 1.02 SEM vs. 1.91 ± 0.67 SEM ng/μg CLP;
P = 0.107), with no difference between the groups.
Conclusions: The results suggest that sepsis-surviving animals do not
present alterations in secretion of AVP in relation to volemia. However,
serum sodium results suggest that AVP secretion is impaired in
Acknowledgements: Fazal Wahab, Nilton Nascimento dos Santos Junior,
Nadir Martins Fernandes, José Antunes Rodrigues and Milene M. Lopes.
1. Correa PB, Pancoto JA, De Oliveira-Pelegrin GR, Carnio EC, Rocha MJ:
Participation of iNOS-derived NO in hypothalamic activation and
vasopressin release during polymicrobial sepsis. J Neuroimmunol 2007,
2. Siami S, Bailly-Salin J, Polito A, Porcher R, Blanchard A, Haymann JP,
Laborde K, Maxime V, Boucly C, Carlier R, Annane D, Sharshar T:
Osmoregulation of vasopressin secretion is altered in the postacute
phase of septic shock. Crit Care Med 2010, 38:1962-1969.
Evaluation of inflammatory parameters and cognitive impairment in a
murine model of Pseudomonas aeruginosa pneumosepsis
Flora Magno*, Danielle O Nascimento, Pedro CB Alexandre, Patrícia A Reis,
Patrícia T Bozza, Hugo C Castro-Faria-Neto, Fernando A Bozza
Immunopharmacology Laboratory, IOC/FIOCRUZ, RJ, Brazil
Critical Care 2013, 17(Suppl 4):P104; doi:10.1186/cc13003
Background: Sepsis is a severe medical condition characterized by
systemic inflammatory response secondary to infection, which frequently
progresses to multiple organ dysfunction and death. It is currently the
leading cause of death in ICUs worldwide. The most frequent source of
infection in sepsis is the lung with a high lethality rate. Pseudomonas
aeruginosa is one of the most common pathogens found in sepsis
patients. Cognitive impairment is a significant consequence of sepsis
reported among survivors. The encephalopathy associated with systemic
inflammation is not well understood so the development of new clinical
relevant models to help understand this sequelae is important. In this
study we aimed to evaluate acute inflammatory markers and establish a
long-term consequence in a murine model of pneumosepsis.
Materials and methods: C57/BL6 mice were submitted to intratracheal
instillation of 105 colony-forming units of P. aeruginosa. Six hours later
the bronchoalveolar lavage fluid was collected for cell migration, protein
(BCA method) and cytokine (ELISA) analysis. Caudal vein blood samples
were collected for cell counting. Another group of animals had their
lungs perfused for myeloperoxidase quantification and histological
analysis. Evan’s blue dye method was used for the assessment of lung
permeability. The survival rate of animals submitted to P. aeruginosa
instillation was observed daily during 7 days. This group of animals
received a single dose of antibiotic meropenem (30 mg/kg), 6 hours after
pneumonia induction. Cognitive damage was evaluated through the
Results: Our results showed that P. aeruginosa infection caused an
expressive recruitment of leukocytes, mainly neutrophils to the lung.
Myeloperoxidase, a marker for neutrophil migration, was significantly
increased in the lungs of animals instilled with P. aeruginosa. The animals
instilled with P. aeruginosa also showed a significant increase in IL-6, KC
and protein levels. Histological analysis showed an intense cell infiltrate in
the lung tissue and the survival rate was extensively lower in P. aeruginosa
infected mice. Additionally, the animals submitted to pneumosepsis had a
loss of aversive memory 13 days after pneumonia induction and this loss
remained 50 days later.
Conclusions: Our study demonstrates the acute inflammatory response
to P. aeruginosa lung infection and indicates that possibly this pneumonia
model can cause irreversible cognitive impairment. Our results reveal a
possible experimental model for the study of encephalopathy associated
with systemic inflammation.
Acknowledgements: Financial support: CNPq, FAPERJ and FIOCRUZ.
Role of inflammatory caspases in a murine two-hit model of sepsis:
analysis of immunosuppression and cognitive impairment
Mariana Gisely Amarante Teixeira da Cunha1*,
Danielle Bastos de Albuquerque1, Daiane Chaves1,
Silvio Caetano Alves Júnior1, Flora Magno1, Patrícia Torres Bozza1,
Fernando Augusto Bozza2, Hugo Caire Castro-Faria-Neto1,
Rachel Novaes Gomes1,2
1Laboratório de Imunofarmacologia, Fiocruz, RJ, Brazil; 2Instituto de Pesquisa
Evandro Chagas (IPEC), Fiocruz, RJ, Brazil
Critical Care 2013, 17(Suppl 4):P105; doi:10.1186/cc13004
Background: Morbidities associated with severe sepsis are serious
problems for surviving patients, such as cognitive impairment and
immunosuppression. The immunosuppression predisposes the patients to
a second infection, which generally is fatal. Several studies have been
made to understand the mediators involved with this immunosuppression
associated with sepsis. Some data from the literature show that caspase-1
promotes activation of cytokines, such as IL-1b, and actions are inhibited
by caspase-12. This study proposes to analyze the role of inflammatory
caspases in immunosuppression and cognitive damage associated with a
two-hit model of sepsis.
Materials and methods: We submitted Swiss animals to the model of
two hits of infection. The first hit was the CLP model and the second hit
was intratracheal instillation of Pseudomonas aeruginosa. We analyze the
mortality rate and the inflammatory profile of the animals submitted to
the CLP model and the two-hit sepsis model. The cognition of the
animals was tested by the passive avoidance test 15 and 21 days after
the CLP and 21 days until 96 days after the two-hit sepsis model.
Results: First we characterize the model and we observed a 30% survival
rate of the CLP group in comparison with a 100% survival rate in the SHAM
group. The high mortality of the CLP group was associated with
hypoglycemia in the first 72 hours after the infection, increased neutrophil
accumulation in the peritoneal cavity 6 and 24 hours after the CLP and an
increase of inflammatory cytokines 6 hours after the CLP, such as CCL2, IL-1b
and IL-10. The CLP group had a cognitive impairment 15 days after the CLP,
but the memory was recovered 21 days after the infection. The CLP group
was more susceptible to P. aeruginosa infection 21 days after the CLP, when
we compare with the SHAM group. The CLP + P. aeruginosa group had a
low count of neutrophils in BAL when compared with the SHAM +
P. aeruginosa group. We observed a decrease in caspase-1 expression and
an increased expression of caspase-12 in the lungs of the CLP +
P. aeruginosa group. When we look to cognition, both the SHAM +
P. aeruginosa and CLP + P. aeruginosa groups had cognitive impairment
21 days after the infection, and the cognitive impairment remained until
96 days in the SHAM + P. aeruginosa group after the infection, but the
CLP + P. aeruginosa recovered the memory 96 days after the infection.
Conclusions: Our preliminary results suggest that the immunosuppression
associated with the CLP model (first hit) led to more susceptibility for
survivor animals, which succumbed to a pneumonia model (second hit). We
observed the involvement of inflammatory caspases in this
immunosuppression phenomenon with a decrease of caspase-1 and an increase in
caspase-12 expression. When we observed the cognitive function, we
observed that the animals submitted to CLP had a cognitive impairment
15 days after the infection and the infection with P. aeruginosa induced a
cognitive impairment until 96 days in both in groups. However, further
studies should be made to confirm these results.
Involvement of CC-chemokine receptor 2 in sepsis: focus on cognitive
Mariana Gisely Amarante Teixeira da Cunha1*, Rachel Novaes Gomes1,2,
Daniele Bastos de Albuquerque1, Daiane Chaves1, Silvio Caetano Alves Júnior1,
Patrícia Reis1, Rosália Mendez Otero3, Patrícia Torres Bozza1,
Fernando Augusto Bozza2, Hugo Caire Castro-Faria-Neto1
1Laboratório Imunofarmacologia, Fiocruz-IOC, Rio de Janeiro, Brazil;
2FiocruzIPEC, Rio de Janeiro, Brazil; 3Lab. Neurobiologia Cellular e Molecular - CCS,
Rio de Janeiro, Brazil
Critical Care 2013, 17(Suppl 4):P106; doi:10.1186/cc13005
Background: Sepsis is a major disease entity with important clinical
implications. Critical illness survivors present long-term cognitive
impairment, including problems with memory and learning. Chemokines
are important to the recruitment of leukocytes to infectious tissue, but a
few studies described the role of the CC-chemokine receptor 2 (CCL2) in
the cognitive process. In this study, we analyze the involvement of CCR2
in the physiopathology of sepsis, especially in development of cognitive
Materials and methods: The CCR2-deficient mice (CCR2-/-) were
submitted to a CLP model and we analyzed the survival rate, the severity
score of the animals during 144 hours and 15 days after the CLP, and we
analyzed the memory of the animals. To analyze the contextual memory,
the mice were submitted to the open field method and the water maze
procedure. To evaluate the aversive memory, the passive avoidance test
Results: First, we observed that the CLP group had cognitive impairment,
but the CCR2-/- group submitted to CLP had more severe cognitive
impairment in comparison with the WT-CLP group. Interesting, the
CCR2-/- Sham group presented cognitive impairment, suggesting that
CCR2 is important to the physiological process of cognition. We then
submitted CCR2-/- naive mice to water maze and passive avoidance tests.
We found that CCR2-/- naive mice have an impairment of aversive and
contextual memory. The cognitive impairment was associated with a
decrease of BDNF expression in the hippocampus. When we analyze the
expression of b-amyloid protein in the brain of CCR2-/- naive mice, we
observed the increased in b-amyloid protein expression in the cortex and
hippocampus of these animals, accompanied by increased cell
proliferation in the dentate girus, and increased caspase-3 and caspase-12
expression in the hippocampus and cortex. We did not observe a
difference in the numbers of neurons in the brain from CCR2-/- naïve
mice, as well the numbers of microglial cells. But, surprisingly, there was
an increase of astrocytes in the hippocampus of CCR2-/- mice.
Conclusions: CCR2 is involved with the physiology of cognition, with the
important role arising in the amyloid accumulation in the brain and
induction of the caspase-3 pathway.
Evaluation of compound NXY-059 on cognitive impairment caused
Nathália S Oliveira1*, Monica F Pereira1, Mariana GAT Cunha1, Silvio CA Júnior1,
Rachel N Gomes1, Patrícia A Reis1, Robert Floyd2, Hugo CCF Neto1
1Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, RJ, Brazil; 2Oklahoma
Medical Research Foundation, Oklahoma City, OK, USA
Critical Care 2013, 17(Suppl 4):P107; doi:10.1186/cc13006
Background: Nitrones are a class of molecules whose main effect on
biological systems is their antioxidant action. Some studies showed a
neuroprotective effect in ischemia models and neurodegenerative
diseases. Those diseases presented an inflammatory profile that leads the
production of reactive oxygen species. This characteristic can generate
brain injuries, which can affect areas related to memory consolidation.
Sepsis is a pathology that forms an inflammatory response, which causes
encephalopathy creating cognitive impairment. Therefore, the present
study has the aim to evaluate the effect of the compound NXY-059 on the
cognitive impairment caused by encephalopathy like sepsis.
Materials and methods: For the assays, mice Swiss Webster male (22 to
28 g, n = 15 per group) were submitted to the CLP method and treated
with antibiotics (10 mg/kg, i.p.) for three consecutive days (6, 24 and
48 hours) and with NXY-059 (50 mg/kg, i.p.) for five consecutive days (6,
24, 48, 72 and 96 hours after the surgery). At 24 and 48 hours, a gravity
score was made to determine the level of sepsis and the percent of
survival was assessed until 144 hours. After 4 hours fast, the glucose
levels were also measured 24 and 48 hours after CLP performance. The
cognitive impairment was evaluated through the open field method on
the 15th (training) and 16th (test) day after the surgery.
Results: Our results show that treatment with NXY-059 did not offer a
protective effect on mortality and the animals developed moderated
sepsis according to the gravity score at 24 hours (4 to 6). At 48 hours, the
animals recovered for slight sepsis (2 to 3). The glucose levels were
slightly restored at 48 hours for the animals treated with the compound.
In the cognitive impairment analysis, we observed a as reduction (P <
0.05) in the numbers of crossing and rearings for the animals treated
with NXY-059 when compared with animals treated with vehicle (saline).
Conclusions: According to these results, we can suggest that treatment
with NXY-059 offered protection against cognitive impairment generated
Atorvastatin and simvastatin protects cognitive impairment in an
animal model of sepsis
Pedro CB Alexandre1*, Patricia A Reis1, Joana D’Ávila1, Flora M de J Oliveira1,
Fabricio A Pamplona2, Luciana D Siqueira1, Hugo CC Faria Neto1,
Fernando A Bozza3
1Laboratorio de Imunofarmacologia, IOC/FIOCRUZ, Rio de Janeiro, Brazil;
2Instituto D’Or de Pesquisa e Ensina - IDOR, Rio de Janeiro, Brazil; 3Instituto
de Pesquisa Clinica Evandro Chagas - IPEC/FIOCRUZ, Rio de Janeiro, Brazil
Critical Care 2013, 17(Suppl 4):P108; doi:10.1186/cc13007
Background: Recently it was shown that a significant proportion of
sepsis survivors can develop a transitory or permanent cognitive
impairment. Statins have the ability to block the cascade of cholesterol
formation by acting on HMG-CoA reductase, reducing the synthesis of
endogenous cholesterol. Recently it has been observed that statins have
anti-inflammatory properties preventing brain dysfunction in malaria
models, reducing the production of brain cytokines, oxidative stress and
alterations in the blood-brain barrier. The aim of the present study was to
evaluate the ability of statins to reduce neuroinflammation and protect
septic animals from neurocognitive damage.
Materials and methods: Feces were extracted (5 mg/g b.w.) from the
large intestine of SW mice and diluted in saline, centrifuged and the
supernatant collected and injected into the animals (n = 5 to 8/group).
Control animals received 0.5 ml saline. Animals were treated at 6, 24 and
48 hours after sepsis induction with imipenem (30 mg/kg b.w., 0.2 ml s.c.)
and 1.0 ml saline (s.c.). Statins (Ator and Sinv) were administrated 1 hour
before and 6, 24 and 48 hours after the infection (20 mg/kg b.w., p.o.).
Mortality was observed for 96 hours and a score of severity evaluated.
The inflammatory profile and oxidative damage was determined at 6 and
24 hours. In addition, mice brains were evaluated for microglial activation
and BBB dysfunction. After 15 days we analyzed the cognitive damage
using the inhibitory avoidance task and Morris water maze.
Results: No significant difference in survival was observed comparing
septic animals treated with antibiotics plus atorvastatin or simvastatin
(56%; 53%) with septic animals with only antibiotics (37%). We observed
lower levels of proinflammatory cytokines (IL-1, IL-6) and chemokines (KC
and MCP-1) when comparing statin-treated animals and nontreated. We
also observed a decreased in the oxidative damage in brains 6 hours
after sepsis in the treated groups. Finally, statin treatment was able to
protect septic animals from cognitive damage including avoidance and
spatial memory, both affected in untreated infected mice.
Conclusions: We can conclude that statins protected septic animals from
cognitive damage, reducing neuroinflammation, and adjuvant therapies
with statins can be interesting targets for future clinical trials focused on
the prevention of long-term cognitive decline in sepsis.
Dasatinib has a dual effect on sepsis
Cassiano F Gonçalves-deAlbuquerque*, Alessandra F Silveira, Cristina L Nagae,
Carlos André M Silva, Mirian Priscila L Lima, Raysa Captivo, Larissa Camisão,
Caroline L Hildebrandt, Patrícia T Bozza, Adriana R Silva,
Hugo C Castro-Faria-Neto
Laboratório de Imunofarmacologia, IOC/Fiocruz, Rio de Janeiro, Brazil
Critical Care 2013, 17(Suppl 4):P109; doi:10.1186/cc13008
Background: Sepsis occurs as a result of a systemic inflammatory response
to an infection. In this context, homeostasis of biological systems depends
on regulatory mechanisms to modulate the amplitude of the immune
response to stimuli, such as infection, preventing damage resulting from this
imbalance of immune response. The exacerbated immune response can
cause serious tissue or systemic damage, as occurs in autoimmune and
chronic inflammatory diseases. The main aim of our study is to investigate
the effect of dasatinib in polymicrobial sepsis.
Materials and methods: Swiss mice were subjected to cecal ligation and
puncture and treated with dasatinib 1, 5 and 10 mg/kg 30 minutes before
and 6 and 24 hours after the surgery. Survival rate and clinical signs were
assayed; cell accumulation, bacterial load were measured in peritoneal
lavage and inflammatory mediators were measured in plasma.
Results: Animals receiving dasatinib 5 and 10 mg/kg showed the worst
clinical score and an increased mortality rate. Animals receiving dasatinib
1 mg/kg showed an increase in survival, a decrease in clinical score, in
cell migration, in colony-forming units and cytokine production.
Conclusions: Dasatinib has a dual effect in polymicrobial sepsis, where
higher doses had deleterious effects but lower doses had beneficial
effects, probably because lower doses may downregulate the immune
response, avoiding extensive tissue damage.
Acknowledgements: Financial support: Fiocruz, CNPq, Faperj, Vichem
Chemie and TARKINAID.
Background: Sepsis is a major cause of death in veterinary medicine, as
in the human field, but there are no survival data described for this
syndrome in the veterinary clinical field. This aspect challenges
experimental medicine, may alter the baseline data to be applied in the
human setting and could explain in part why most results obtained from
laboratory research are not completely useful in the human clinical field.
The purpose of this prospective observational study was to investigate
the 24-hour and 30-day survival from severe sepsis and septic shock in
canine septic patients that were approached with the Surviving Sepsis
Campaign (SSC) bundles.
Materials and methods: Nineteen client-owned puppies with naturally
acquired parvovirus haemorrhagic gastroenteritis were classified as severe
sepsis and septic shock patients and received medical care according to
the guidelines proposed by the SSC. Subsequently, the 24-hour and
30-day survival was evaluated for each case. The results were statistically
analysed by Fisher’s exact test at a significance level of 5%.
Results: Fifteen patients (78.9%) were admitted to the emergency
department and classified as severe sepsis subjects. The mortality rate in
the severe sepsis group was 33.33% (five animals), of which four animals
died in the first 24 hours of admission and the other on the following
day. Four dogs (21.1%) were classified as septic shock patients. The
mortality rate in the septic shock group was 100%, of which two animals
died in the first 24 hours of admission and two on the day after (Table 1).
Conclusions: The observation of clinical outcomes in this clinical canine
sepsis model showed that the majority of deaths in both severe sepsis
and septic shock occur within the first 24 hours. However, after 30 days
there is a significant difference between both groups, showing no
survival in septic shock animals. Therefore, this preliminary study suggests
a new veterinary database to be applied for future human research.
Peroxisome proliferator-activated receptor agonist rosiglitazone
improves host defense against Pseudomonas aeruginosa in a murine
model of pneumonia
Crisitina Lyra Nagae*, Cassiano Felippe Gonçalves-de-Albuquerque,
Alessandra Silveira Ferreira, Raysa Captivo, Larissa Camisão,
Carlos André Mandarino Silva, Mirian Priscila Lins de Lima,
Caroline Loureiro Hildebrandt, Patricia Torres Bozza,
Hugo Caire de Castro-Faria-Neto, Adriana Ribeiro Silva
Laboratório de Imunofarmacologia, IOC/FIOCRUZ, Rio de Janeiro, RJ, Brazil
Critical Care 2013, 17(Suppl 4):P111; doi:10.1186/cc13010
Table 1(abstract P110) Severe sepsis and septic shock animals classified as nonsurvivors and survivors 24 hours and
30 days after admission
Nonsurvivors 24 hours
Survivors 24 hours
Nonsurvivors 30 days
Survivors 30 days
Background: Pseudomonas aeruginosa is a Gram-negative bacterium
regarded as an opportunistic pathogen. It infects immunocompromised
patients, and is the second leading cause of nosocomial diseases. This
bacterium has numerous virulence factors, adapts quickly to new
environments, and requires a few nutrients to survive. All of these
mechanisms will generate a host response. The fastest immune response is
neutrophil recruitment, followed by phagocytosis and degranulation. There
is another mechanism to fight bacteria called NET formation, which is the
formation of a neutrophil extracellular network. NET is formed through a
process called NETosis where the release of the cell nuclear material can
hold and destroy pathogens. The nuclear receptor peroxisome
proliferatoractivated receptor PPARg, besides lipid and glucose metabolism, is
involved in the inflammatory response modulation, being considered a
potential target for the study of new therapies for inflammatory and
infectious diseases. We therefore aim to investigate the involvement of
PPARg in lung injury caused by P. aeruginosa using an agonist of this
Materials and methods: For this purpose, Swiss mice were instilled
intratracheally with bacteria and treated with rosiglitazone 5 hours after
the operation. We analysed clinical signs using 10 physical parameters,
cellularity and DNA measurement to assess NET formation.
Results: We found that the animals stimulated with Pseudomonas showed
an increase in inflammatory parameters, while the animals treated with
rosiglitazone showed improvement in clinical signs and increased NET
Conclusions: We can conclude that rosiglitazone has an
antiinflammatory role during lung infection, suggesting that PPARg activation
may improve the host defense against bacteria.
Acknowledgements: Financial support: FIOCRUZ, CNPq and FAPERJ.
1. Leifsson PS , Iburg T , Jensen HE , Agerholm JS , Kjelgaard-Hansen M , Wiinberg B , Heegaard PMH , Astrup LB , Olsson AE , Skov MG , et al: Intravenous inoculation of Staphylococcus aureus in pigs induces severe sepsis as indicated by increased hypercoagulability and hepatic dysfunction . FEMS Microbiol Lett 2010 , 309 : 208 - 216 .
2. Soerensen KE , Nielsen OL , Birck MM , Soerensen DB , Leifsson PS , Jensen HE , Aalbaek B , Kristensen AT , Wiinberg B , Kjelgaard-Hansen M , et al: The use of sequential organ failure assessment parameters in an awake porcine model of severe Staphylococcus aureus sepsis . APMIS 2012 , 120 : 909 - 921 .
3. Soerensen KE , Olsen HG , Skovgaard K , Wiinberg B , Nielsen OL , Leifsson PS , Jensen HE , Kristensen AT , Iburg TM : Disseminated intravascular coagulation in a novel porcine model of severe Staphylococcus aureus sepsis fulfills human clinical criteria . J Comp Pathol 2013 in press.
P96 Microparticles from septic shock patients contain microRNA and messenger RNA: new players in the pathogenesis of sepsis? Luciano CP Azevedo1 , 2 , 3 *, Juliana M Real1 , João E Bezerra2 , Flavia R Machado3 , Reinaldo Salomao3 1Instituto Sírio-Libanês de Ensino e Pesquisa , São Paulo , Brazil; 2State University of São Paulo, Brazil; 3Federal University of São Paulo, Brazil Critical Care 2013 , 17 (Suppl 4):P96; doi:10.1186/cc12995