March 29, 2018

Background: There have now been several trials published on the use of steroids in sepsis.  In 2002, we had the Annane Trial, with 299 patients showing mortality and shock reversal benefit in sepsis with hydrocortisone.  Then in 2008 we had the CORTICUS trial, with 499 patients, which found a faster reversal of shock, but no benefit in mortality.  Next the HYPRESS trial published in 2016 with 380 patients, with severe sepsis, not septic shock,  showed no difference in mortality or time to reversal of shock.  And finally the ADRENAL Trial published this year with 3800 patients show no difference in mortality, but a small benefit in reversal of shock.  Due to these mixed results, many physicians have variable practice patterns with the use of steroids in sepsis/septic shock.  Now, we have the APROCCHSS trial looking at hydrocortisone plus fludrocortisone for adults with septic shock (By the way the lead author is the same author that published the 2002 steroids in sepsis trial…Annane).

January 22, 2018

Background: Randomized clinical trials evaluating the efficacy of adjunctive corticosteroids in septic shock have shown conflicting evidence of clinical relevance. Two trials in particular [2][3] looked at lower dose hydrocortisone (200mg/day) and its effect on mortality in patients with septic shock resulting in conflicting results in regards to mortality, but both showing earlier reversal of shock in patients treated with hydrocortisone. The current surviving sepsis guidelines recommend the use of hydrocortisone in patients with septic shock after adequate fluid resuscitation and use of vasopressors who have not achieved hemodynamic stability, but this recommendation is classified as weak evidence (Level 2C). Due to these weak recommendations there has been a variability in use of corticosteroids in septic shock. On Jan 19th, 2018 the ADRENAL Trial results were published trying to once and for all answer the question of adjunctive steroids in septic shock.

January 18, 2018

Background: A Cochrane review was published in 2015 evaluating 33 trials with 4,268 participants to evaluate the effects of corticosteroids on death at one month in patients with sepsis.  In that meta-analysis the authors concluded that despite the overall low quality of evidence, corticosteroids still reduced mortality among patients with sepsis. Corticosteroids in sepsis/septic shock has been a controversial topic as the exact dose, which steroid to use, which patients will benefit and when to start them have all been debated. 

December 4, 2017

Background:

  • Definition
    • Infective Endocarditis (IE) = Inflammation of the endothelium of the heart, heart valves (or both) (Osman 2013)
  • Epidemiology
    • Annual incidence = 5-7 cases per 100,000 (Fraimow 2013)
    • 40,000 to 50,000 new cases in the US per year. Average hospital charges in excess of $120,000 per patient (Bor 2013)
    • Slightly higher male predominance (1.5:1 - 2:1) (Moreillon 2010)
    • In-hospital mortality of 14–22% and 1-year mortality of 20-40% (Gomes 2017, (Habib 2006)
    • Before antibiotics and surgery it was almost universally fatal  (Aretz 2010, Osman 2013)
  • Pathophysiology (Moreillon 2010, Faza 2013, Tan 2014, Osman 2013, Kokowski 2018)
    • The normal, undamaged valve endothelium is very resistant to colonization and infection by circulating bacteria
    • Micro-trauma (caused by turbulent flow, intracardiac devices, etc) or chronic diseases (rheumatic heart disease, congenital heart disease, prosthetic valves, previous IE) can cause damage to the endothelium
    • Damage to endothelium produces a fibin and platelet sterile thrombus.  Microbes can seed that thrombus during transient episodes of bacteremia, fungemia and viremia
  • Risk factors –  (Faza 2013, Moreillon 2010).
    • Diseased/damaged heart (highest risk)
    • IV drug use (IVDU)
    • Low immune function –
    • Poor oral hygiene. (Faza 2013)
    • Nosocomial