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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Severe sepsis and septic shock are frequently encountered conditions in today's hospital environment. The incidence appears to be increasing despite our growing armamentarium of antibiotics and our enhanced knowledge of the pathophysiologic processes at play. The clinical presentation may take a variety of forms, especially in patients at the extremes of age and in the immunocompromised population. A high index of suspicion and prompt institution of appropriate antimicrobial treatment is mandatory for a successful outcome. It is hoped that adoption of uniform definitions will aid in research and in effective communication concerning sepsis and its adverse sequelae.
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PMID:Severe sepsis and septic shock. Definitions, epidemiology, and clinical manifestations. 1076 78

Severe sepsis, defined as sepsis associated with acute organ dysfunction, results from a generalized inflammatory and procoagulant host response to infection. Coagulopathy in severe sepsis is commonly associated with multiple organ dysfunction, and often results in death. The molecule that is central to these effects is thrombin, although it may also have anticoagulant and antithrombotic effects through the activation of Protein C and induction of prostacyclin. In recent years, it has been recognized that chemicals produced by endothelial cells play a key role in the pathogenesis of sepsis. Thrombomodulin on endothelial cells coverts Protein C to Activated Protein C, which has important antithrombotic, profibrinolytic and anti-inflammatory properties. A number of studies have shown that Protein C levels are reduced in patients with severe infection, or even in inflammatory states without infection. Because coagulopathy is associated with high mortality rates, and animal studies have indicated that therapeutic intervention may result in improved outcomes, it was rational to initiate clinical studies.
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PMID:Microvascular endothelial dysfunction: a renewed appreciation of sepsis pathophysiology. 1137 85

Severe sepsis and probably most prolonged critical illnesses reflect a paradox of combined increased activation and depression of the immune apparatus. The increased activation of the inflammatory response is evidenced from the increased levels of circulating proinflammatory cytokines in the blood, increased endothelial activation with increased expression of inducible nitric oxide synthase, and increased de novo CD11b expression on circulating immune effector cells, such as PMNs, monocytes and lymphocytes. However, coexisting with this proinflammatory process is a profound anti-inflammatory state characterized by increased circulating levels of anti-inflammatory species that both directly block the binding of proinflammatory stimuli to their cell surface receptors (IL-1ra, soluble TNF receptors) and also induce an anti-inflammatory state on their own (IL-10, TFG-beta). This humoral anti-inflammatory state is mirrored at the cellular levels by decreased monocyte ability to process antigen, characterized by a reduced HLA-DR expression and impaired PMN upregulation in response to clearly proinflammatory stimuli. Accordingly, severe sepsis reflects a combined pro- and anti-inflammatory state. Both the pro- and anti-inflammatory arms have protective and destructive aspects, making their modulation by treatment less predictable than if their actions were purely beneficial or detrimental.
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PMID:Sepsis: a pro- and anti-inflammatory disequilibrium syndrome. 1139 3

Sepsis remains a major cause of death in hospitalized patients. Despite a massive research effort over the past 2 decades to identify innovative therapies for sepsis, current treatment strategies consist primarily of antiinfective agents and a variety of supportive measures. Activated protein C, an endogenous protein that inhibits thrombosis and inflammation while promoting fibrinolysis, plays an important role in the pathogenesis of sepsis. Recombinant human activated protein C, drotrecogin alfa (activated), when compared with placebo in a randomized, double-blind study of 1690 patients with severe sepsis (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis [PROWESS] trial), decreased the relative risk of death at 28 days by 19.4% (95% confidence interval 6.6-30.5%, p=0.005), although there was a trend for more serious bleeding (3.5% vs 2.0%, p=0.06) with its use. Drotrecogin alfa is the first antisepsis drug found to have a mortality benefit. It should be administered only to patients with severe sepsis who meet the PROWESS study inclusion criteria and should be avoided when risk factors for bleeding are present. Ongoing research will help determine the cost-effectiveness of drotrecogin alfa, as well as its role in critically ill populations not studied in the PROWESS trial.
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PMID:Recombinant human activated protein C, drotrecogin alfa (activated): a novel therapy for severe sepsis. 1171 12

The roles of inflammation and coagulation in the pathophysiology of sepsis are described. Sepsis results when an infectious insult triggers a localized inflammatory reaction that then spills over to cause systemic symptoms of fever or hypothermia, tachycardia, tachypnea, and either leukocytosis or leukopenia. These clinical symptoms are called the systemic inflammatory response syndrome. Severe sepsis is defined by dysfunction of one of the major organ systems or unexplained metabolic acidosis. The inflammatory reaction is mediated by the release of cytokines, including tumor necrosis factor-alpha, interleukins, and prostaglandins, from neutrophils and macrophages. The cytokines activate the extrinsic coagulation cascade and inhibit fibrinolysis. These overlapping processes result in microvascular thrombosis; thrombosis is one potential factor producing organ dysfunction. Activation of the coagulation system leads to consumption of endogenous anticoagulants (e.g., protein C and antithrombin); this may be an important factor in the development of microvascular coagulation. Antiinflammatory mediators as well as inflammatory mediators have a role in sepsis, and an excess of either can result in poor patient outcomes. Sepsis is a complex syndrome involving activation of a variety of systems.
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PMID:Pathophysiology of sepsis. 1188 12

The innate immune system is in the vanguard of host defenses against infection. Recognition of invasive microbial pathogens is mediated by pattern recognition receptors on the surface of immune cells that recognize pathogen-associated molecular motifs. Considerable progress has been made in recent years in understanding how bacterial products initiate sepsis. In gram-negative sepsis, the LPS-binding protein (LBP), CD14 and the recently identified Toll-like receptor 4 (TLR4) are key molecules for the recognition of endotoxin (lipopolysaccharide, LPS) by cells of the myelomonocytic lineage. In gram-positive sepsis, components of the bacterial cell wall (peptidoglycan, PGN; lipoteichoic acids, LTA) have been shown to activate myeloid cells through an interaction with a receptor complex composed of CD14, TLR2 and perhaps also TLR6 (PGN) or CD14 and TLR4 (LTA). By contrast, gram-positive exotoxins act as superantigens and directly stimulate T lymphocytes by cross-linking the MHC class II of antigen presenting cells to specific chains of the T cell receptor. Immune cells activated by microbial pathogens release numerous effector molecules, which orchestrate the innate and adaptive host defenses. Furthermore, bacteria and microbial toxins directly activate the complement and coagulation systems, which play an important part in the host defensive response. Severe sepsis and septic shock can be viewed as clinical manifestations of a failing innate immune response that ultimately results in an overstimulation of the physiological host response. The pathogenesis of sepsis is far more complex that was initially anticipated. However, combined research efforts of basic scientists and clinical investigators continue to provide critical information for the identification of novel therapeutic targets. The exciting results obtained recently with treatment strategies designed to correct coagulation abnormalities occurring during sepsis are an example of how research may ultimately translate into improved patient care.
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PMID:Pathogenesis of septic shock: implications for prevention and treatment. 1193 63

Severe sepsis is a systemic inflammatory response to infection involving organ dysfunction. Severe sepsis is a common cause of death and is associated with a 20% to 56% mortality rate. Drotrecogin alpha (activated) is a recombinant human activated protein C(rhAPC) approved in the U.S. for the reduction of mortality in adult patients with severe sepsis who have a high risk of death. Drotrecogin alpha (activated), when administered to adult patients with clinically defined severe sepsis, demonstrated a 6.1% absolute reduction (p=0.005) in 28-day all-cause mortality in one published, randomized, double-blind study of 1,690 patients (PROWESS). Drotrecogin alpha (activated) is used as an adjunct to standard therapy and is therefore and "add-on" cost. Close attention must be paid to proper patient selection for treatment with drotrecogin alpha (activated). Certain individuals, such as those at a greater risk of bleeding, could be harmed from therapy. The benefit or harm in individuals not meeting the trial selection criteria is uncertain.
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PMID:Activated protein C for severe sepsis. 1198 65

Activated protein C (APC) reduced all-cause 28-day mortality by 19% in patients with severe sepsis (sepsis associated with acute organ dysfunction) in the Protein C Evaluation in Severe Sepsis (PROWESS) trial, leading to recent approval of recombinant APC for treatment of this condition in adults. This review summarizes current knowledge derived from studies of a variety of animal models in which infused human APC demonstrated beneficial activities. Based on in vivo and also in vitro data, APC manifests antithrombotic, profibrinolytic, anti-inflammatory, and antiapoptotic activities. APC is a normal circulating component of plasma, derived from the protein C zymogen, and is thus a natural endogenous protective homeostatic factor. Because of its multiple activities, APC has a potential role in the treatment of complex and challenging medical disorders, including thrombosis and stroke.
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PMID:Activated protein C: potential therapy for severe sepsis, thrombosis, and stroke. 1212 82

Severe sepsis with multiple organ failure after hematopoietic stem cell transplantation (HSCT) results in extremely high morbidity and mortality. Recent studies have highlighted the importance of sepsis-induced activation of the coagulation system in the pathophysiology of severe sepsis. Activated protein C is an important modulator of coagulation and inflammatory derangements during severe sepsis. Low levels of protein C occur in severe sepsis and are predictive of poor outcome. Recombinant human activated protein C (drotrecogin alfa (activated)) was recently approved by the Food and Drug Administration (FDA) for severe sepsis. The phase III trial that resulted in the approval of this agent, however, enrolled a general sepsis population and excluded patients undergoing HSCT. We report a case of fulminant septic shock and multiple organ failure after HSCT that was treated with drotrecogin alfa (activated) in addition to standard therapy, and recovered. The high mortality rates of patients who develop severe sepsis after HSCT demand that new avenues of treatment be considered for this very high-risk patient population. This case illustrates the potential application of a novel therapeutic approach. Clinical trials are warranted to further investigate the safety and efficacy of drotrecogin alfa (activated) in patients with severe sepsis after HSCT.
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PMID:Septic shock and multiple organ failure after hematopoietic stem cell transplantation: treatment with recombinant human activated protein C. 1213 53

Severe sepsis is a common and frequently fatal condition. Evidence showing a link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alfa (activated) as an agent in the treatment of sepsis. This recombinant form of the natural protein, activated protein C (Xigris, Eli Lilly Co.), has been shown to significantly reduce mortality in a large randomised, controlled Phase III study involving 1690 patients. The exact mode of action of drotrecogin alfa (activated) remains uncertain, although it clearly combines anticoagulant and anti-inflammatory properties. Although associated with an increased risk of bleeding, this is usually procedure-related rather than spontaneous. Although costly, this is a drug that effectively reduces mortality rates in patients with severe sepsis.
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PMID:Drotrecogin alfa: a new approach in the treatment of severe sepsis. 1217 9


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