Sepsis and septic shock appear to be more common than heart attacks or pulmonary blood clots among patients having general surgery, and the death rate for patients with septic shock is approximately 34% within 30 days of operation.

Prevention of perioperative complications is a major focus in the care of the general-surgery patient. In recent years, attention has been focused on prevention of venous thromboembolism (including post-operative deep vein thrombosis, or blood clots in the deep veins of the pelvis or extremities, and pulmonary embolism, or blood clots that travel to the lungs), myocardial infarction (heart attack) and surgical site infections. These efforts have resulted in awareness and reduction of these complications.

Sepsis, an infection that usually results from bacteria in the bloodstream and can result in failure of multiple organ systems, is another potentially preventable cause of illness and death in general surgery patients. The incidence, mortality rate and risk factors for sepsis in general surgery patients were reviewed using data from the 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program.

Of 363,897 general surgery patients, sepsis occurred in 8,350 (2.3 percent), septic shock or life-threatening low blood pressure due to sepsis occurred in 5,977 (1.6 percent), pulmonary embolism occurred in 1,078 (0.3 percent) and heart attack occurred in 615 (0.2 percent). Death rates within 30 days were 5.4 percent for sepsis, 33.7 percent for septic shock, 9.1 percent for pulmonary embolism and 32 percent for heart attack.

The results suggest that sepsis continues to be a common and serious complication in general surgery patients and occurs more frequently than pulmonary embolism or heart attack. Septic shock occurs 10 times more frequently than myocardial infarction and has the same mortality rate; thus, it kills 10 times more people. Risk factors include age older than 60, the need for emergency surgery and the presence of any co-occurring illness. Having such an illness increased the risk of sepsis and septic shock six-fold and the risk of dying within 30 days 22-fold.

It was concluded that by identifying three major risk factors for the development of and death from sepsis and septic shock in general-surgery patients, we can heighten our awareness for sepsis and septic shock in these at-risk populations. The implementation of mandatory sepsis screening for these high-risk populations has resulted in decreased sepsis-related mortality. Further evaluation of the role of sepsis screening programs in other settings is critical and could significantly reduce sepsis-related mortality in general-surgery patients.

Source: Arch Surg 2010; 145 (7):695-700.

According to a data analysis presented at the 18th International AIDS Conference, several factors have been identified that predict the need for an antiretroviral single drug switch (SDS) and/or a complete regimen change (CRC) because of toxicity or treatment failure in patients co-treated for both HIV and tuberculosis (TB) infections.

A 50 cell/mcL CD4 decrease from the baseline count at antiretroviral initiation may be a predictor for toxicity or treatment failure. Furthermore, the presentation of grade 3 or 4 peripheral neuropathy at baseline was associated with an SDS due to toxicity in the central nervous system.

A retrospective study was conducted to determine how often an antiretroviral SDS and/or a CRC were made and the reasons for these changes in patients receiving combined antiretroviral and TB treatment.

This analysis was performed on data from a randomised trial involving patients coinfected with HIV and TB during the 4-year period from May 2005 to May 2009. Univariate and multivariate regression models were applied to data from 561 patients co-infected with HIV and TB to identify potential predictors for SDS. Patients were followed up for a median of 17 months following treatment initiation with efavirenz (600 mg), lamivudine (300 mg), and didanosine EC (250 or 400 mg administered once daily) together with standard anti-TB treatment.

SDS due to toxicity occurred in 1.8% patients; the most commonly experienced toxicities resulting in SDS were peripheral neuropathy in 23% patients and central nervous system/neuropsychiatric toxicity in 23% patients. These toxicities occurred, on average, 4.6 and 5.9 months into treatment, respectively. Univariate and multivariate analysis found SDS to be significantly associated with 50 cell/mcL CD4 baseline decrease at antiretroviral initiation and/or a grade 3/4 peripheral neuropathy at baseline.

CRC was made because of virological failure or lack of reduction of viral load in 3.9% patients at a median time of 10.4 months. A 50 cell/mcL CD4 decrease from the baseline count at ARV initiation was associated with treatment failure was demonstrated in the univariate analysis only.

Source: Presented at AIDS 2010 [Presentation title: Antiretroviral Drug Switches in an Integrated TB and HIV Treatment Trial. Abstract TUPDB306]

New research shows that individuals with mild H1N1 infection may go undetected using standard diagnostic criteria.

Currently, public health officials rely on body temperature (detecting fever) to screen individuals for potential infection with H1N1. For example, during a pandemic, standard screening at airports relies on body temperature scanners to detect the presence of fever. However, it was found that coughing, not fever, is a more reliable indicator of infection because nearly half of the individuals with mild infection may not have fever.

Confirmed cases of H1N1 who were hospitalized and quarantined during the early stages of the pandemic in 2009 were investigated. The study's results showed only 45.5% of the case subjects had fever. Individuals with mild infection and no fever have the potential to evade detection at airports or medical triage units, thus continuing the chain of infection.

The study found that fever is not reliable for case definition, even though it has been regarded as a key factor in determining influenza infection. The most sensitive indicator is cough. The study concludes that coughing or other respiratory symptoms are more accurate in determining influenza infection than presence of a fever.

Hence screening should take any kind of respiratory manifestation into account.

Source: American Journal of Infection Control 2010; 38 (6)

Several new biomarkers are related to mortality in community acquired pneumonia (CAP). The aim of this study was to compare new biomarkers for the prediction of short and long-term all-cause mortality in CAP.

728 patients (59.0 +/- 18.2 years) with CAP were enrolled. Pro-adrenomedullin (MR-proADM), pro-atrial natriuretic peptide (MR-proANP), pro-arginin-vasopressin (Copeptin,), pro-endothelin-1 (CT-proET-1), procalcitonin (PCT), C-reactive protein (CRP), leukocyte count (WBC) and clinical CRB-65 score (based on confusion, blood pressure, respiratory rate and age) were determined on admission. Patients were followed up for 180 days.

In patients who died of any cause within 28 and 180 days (2.5% and 5.1%, respectively), MR-proADM, MR-proANP, Copeptin, CT-proET-1 and PCT as well as CRB-65 were significantly higher compared to survivors. MR-proADM had the best performance for 28 days (HR 3.67) and 180 days (HR 2.84) survival. C-index of MR-proADM for 28 days survival (0.85) was superior to MR-proANP (0.81), Copeptin (0.78), CT-proET-1 (0.79) and CRB-65 (0.72) for the prediction of mortality. For prediction of mortality at 180 days, C-index of MR-proADM (0.78) was higher than MR-proANP (0.74), Copeptin (0.73), CT-proET-1 (0.76), PCT, CRP and WBC. MR-proADM was independent of CRB-65 and added prognostic information for short- and long-term mortality. MR-proADM was an independent and strong predictor of short- and long-term mortality.

It was concluded that all new biomarkers were good predictors of short- and long-term all-cause mortality, superior to inflammatory markers and at least comparable to CRB-65 score. MRproADM showed the best performance. A combination of CRB-65 with MR-proADM might be the best predictor for mortality.

Source: Am J Respir Crit Care Med. 2010