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Background Deciding whether to transfer patients with sepsis from the emergency department (ED) to intensive care units (ICUs) is challenging. We hypothesised that the new biomarker plasma calprotectin (p-calprotectin) could be used to aid the selection of patients for intensive care transfer, since it has been shown to be a promising tool for the determination of sepsis severity in critical care. Methods This prospective study was performed on consecutive sepsis alert patients in the ED of Karolinska University Hospital Huddinge. The sepsis alert mandates clinical assessment and decisions regarding treatment, disposition, and level of care by physicians from the ED, the Department of Infectious Diseases, and the ICU. Blood sample analysis for C-reactive protein, procalcitonin, neutrophils, and lymphocytes was routinely performed. P-calprotectin was analysed from frozen plasma samples, using a specific turbidimetric assay. Results Three-hundred fifty-one patients who triggered the sepsis alert were available for the study. Among 319 patients who were considered to have an infection, 66 patients (26%) were immediately transferred to the ICU or high-dependency unit (HDU), and 253 patients (74%) were transferred to ordinary wards. Median p-calprotectin was 2.2 mg/L (IQR 1.2–3.9 mg/L) for all patients with infection, it was 3.3 (IQR 1.6–5.2) for those transferred to ICU/HDU and 2.1 (IQR 1.1–3.5) for those transferred to ward units ( p  = 0.0001). Receiver operating characteristic curve analysis for transfer to the ICU/HDU showed superiority for p-calprotectin compared with procalcitonin and neutrophil–lymphocyte ratio, regarding both all sepsis alert cases and the patients with infection ( p  < 0.001 for all comparisons). The best p-calprotectin cut-off, 4.0 mg/L, showed a sensitivity of 42.5% and specificity of 83% for transfer to the ICU/HDU among patients with infection. Conclusions In sepsis alert patients, p-calprotectin was significantly elevated in patients who were subject to immediate ICU/HDU transfer after assessment by a multidisciplinary team. P-calprotectin was superior to traditional biomarkers in predicting the need for transfer to the ICU/HDU.

Background COVID-19 remains a major public health challenge, requiring the development of tools to improve diagnosis and inform therapeutic decisions. As dysregulated inflammation and coagulation responses have been implicated in the pathophysiology of COVID-19 and sepsis, we studied their plasma proteome profiles to delineate similarities from specific features. Methods We measured 276 plasma proteins involved in Inflammation, organ damage, immune response and coagulation in healthy controls, COVID-19 patients during acute and convalescence phase, and sepsis patients; the latter included (i) community-acquired pneumonia (CAP) caused by Influenza, (ii) bacterial CAP, (iii) non-pneumonia sepsis, and (iv) septic shock patients. Results We identified a core response to infection consisting of 42 proteins altered in both COVID-19 and sepsis, although higher levels of cytokine storm-associated proteins were evident in sepsis. Furthermore, microbiologic etiology and clinical endotypes were linked to unique signatures. Finally, through machine learning, we identified biomarkers, such as TRIM21, PTN and CASP8, that accurately differentiated COVID-19 from CAP-sepsis with higher accuracy than standard clinical markers. Conclusions This study extends the understanding of host responses underlying sepsis and COVID-19, indicating varying disease mechanisms with unique signatures. These diagnostic and severity signatures are candidates for the development of personalized management of COVID-19 and sepsis.

Background Sepsis was recently redefined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. With this redefinition (Sepsis-3), clinical and microbiological characteristics of patients with sepsis may differ from the patients fulfilling the previous definition (Sepsis-2). Purpose To describe differences in clinical and microbiological characteristics of sepsis episodes between Sepsis-3 and Sepsis-2. The secondary aim was to compare blood culture outcomes between episodes fulfilling Sepsis-3 and Sepsis-2 criteria, respectively. Methods A prospective study design was used to include patients presenting with clinically suspected sepsis in the emergency department. Six blood culture bottles were collected from each patient. Blood cultures were described as having clinically relevant growth, contaminant growth, or no growth. Clinical and laboratory data were collected from medical records and the laboratory information system. Results The analysis included 514 episodes. There were 357/514 (79.5%) Sepsis-3 and 411/514 (80.0%) Sepsis-2 episodes. In total, 341/514 (66.3%) episodes fulfilled both Sepsis-3 and Sepsis-2 criteria. Blood cultures were positive for clinically relevant growth in 130/357 (36.1%) and 145/411 (35.3%) episodes in Sepsis-3 and Sepsis-2, respectively. Other clinical and microbiological characteristics did not differ between Sepsis-3 and Sepsis-2. Conclusions A high proportion of patients included through a sepsis alert system fulfilled both Sepsis-3 and Sepsis-2 criteria. The performance of blood cultures in detection of microorganisms was poor and were similar in Sepsis-3 and Sepsis-2 patients.

Anakinra and tocilizumab are used for severe Covid-19, but only one previous randomized controlled trial (RCT) has studied both. We performed a multi-center RCT comparing anakinra or tocilizumab versus usual care (UC) for adults at high risk of deterioration. The study was conducted June 2020 to March 2021. Eligibility required ≥ 5 liters/minute of Oxygen to maintain peripheral oxygen saturation at ≥ 93%, CRP > 70 mg/L, ferritin > 500 μg/L and at least two points where one point was awarded for lymphocytes < 1x 109/L; D-dimer ≥ 0.5 mg/L and; lactate dehydrogenase ≥ 8 microkatal/L. Patients were randomly assigned 1:1:1 to receive either a single dose of tocilizumab (8 mg/kg) or anakinra 100 mg IV QID for seven days or UC alone. The primary outcome was time to recovery. Recruitment was ended prematurely when tocilizumab became part of usual care. Out of a planned 195 patients, 77 had been randomized, 27 to UC, 28 to anakinra and 22 to tocilizumab. Median time to recovery was 15, 15 and 11 days. Rate ratio for recovery for UC vs anakinra was 0.91, 0.47 to 1.78, 95% [CI], p = 0.8 and for UC vs tocilizumab 1.13, 0.55 to 2.30; p = 0.7. There were non-significant trends favoring tocilizumab (and to limited degree anakinra) vs UC for some secondary outcomes. Safety profiles did not differ significantly. Premature closure of trial precludes firm conclusions. Anakinra or tocilizumab did not significantly shorten time to clinical recovery compared to usual care. (IMMCoVA, NCT04412291, EudraCT: 2020-00174824).

Calprotectin in blood has been identified as a potential biomarker for severe COVID-19 and sepsis. As a knowledge gap remains regarding the biological role of calprotectin, we aimed to investigate the association between serum calprotectin and the circulating proteome in patients with COVID-19 as a model for viral sepsis. In this observational study, serum samples were collected from 160 hospitalized adult patients with COVID-19. The samples were analyzed for calprotectin using a routine turbidimetric assay and for proteomics using the Olink Explore 1536 platform. Patients were classified as having severe or moderate COVID-19 according to oxygen supply on the day of blood sampling. The median calprotectin level was significantly higher in patients with severe compared to moderate COVID-19. In relation to proteomics, calprotectin levels were associated with a neutrophil-centered inflammatory proteomic signature, characterized by upregulation of cytokine and danger-signaling pathways. S100A12 showed the strongest correlation to calprotectin. In conclusion, calprotectin is associated with disease severity in COVID-19, and high levels reflect a neutrophil-driven inflammatory proteomic profile, particularly involving S100A12. These findings support calprotectin as a biomarker of neutrophil-mediated hyperinflammation in viral sepsis.

Objectives Rapid diagnosis and intervention are critical for sepsis patient outcomes. However, diagnosis is challenging because of a heterogenic patient group as well as sometimes vague symptoms when the patient presents at the emergency department. Mucosal‐associated invariant T (MAIT) cells are rapid responders to infection, but their role and characteristics in the early course of sepsis remain unknown. Here, we evaluate the early MAIT cell characteristics in the blood of patients triggering a clinical sepsis alert system at the emergency department. Methods Peripheral blood mononuclear cells were isolated from freshly drawn blood and immediately stained. MAIT cell phenotyping analyses were conducted using multiparameter flow cytometry. All analyses were completed prior to the stratification of patients into sepsis or non‐sepsis groups. Soluble factors in plasma were measured using a multiplex assay. Results Unsupervised high‐dimensional phenotyping identified distinct MAIT cell activation profiles in sepsis and non‐sepsis groups. Among sepsis patients, hierarchical clustering of MAIT cell phenotypes separated clinical endotypes into three groups with different infection focus, severity and aetiology. A prominent characteristic of sepsis severity was high expression of CD69 on MAIT cells, which was associated with organ dysfunction, lymphopenia and poor outcome. Plasma levels of IL‐12, IL‐15, TNF, IFNγ and CXCL10 correlated with the magnitude of MAIT cell activation in sepsis patients. Conclusions These clinical endotype‐specific MAIT cell phenotypes presenting already in the emergency department are of interest for early patient identification and prognostication in sepsis. In this study, mucosal‐associated invariant T (MAIT) cell characteristics were evaluated in blood from patients who triggered a clinical sepsis alert at the emergency department. High‐dimensional phenotyping revealed distinct MAIT cell activation profiles between sepsis and non‐sepsis groups. In sepsis patients, hierarchical clustering identified three clinical endotypes with different infection focuses, severity and aetiology, which are of interest for early patient identification and prognostication.

Anakinra and tocilizumab are used for severe Covid-19, but only one previous randomized controlled trial (RCT) has studied both. We performed a multi-center RCT comparing anakinra or tocilizumab versus usual care (UC) for adults at high risk of deterioration. The study was conducted June 2020 to March 2021. Eligibility required [greater than or equal to] 5 liters/minute of Oxygen to maintain peripheral oxygen saturation at [greater than or equal to] 93%, CRP > 70 mg/L, ferritin > 500 [mu]g/L and at least two points where one point was awarded for lymphocytes < 1x 10.sup.9 /L; D-dimer [greater than or equal to] 0.5 mg/L and; lactate dehydrogenase [greater than or equal to] 8 microkatal/L. Patients were randomly assigned 1:1:1 to receive either a single dose of tocilizumab (8 mg/kg) or anakinra 100 mg IV QID for seven days or UC alone. The primary outcome was time to recovery. Recruitment was ended prematurely when tocilizumab became part of usual care. Out of a planned 195 patients, 77 had been randomized, 27 to UC, 28 to anakinra and 22 to tocilizumab. Median time to recovery was 15, 15 and 11 days. Rate ratio for recovery for UC vs anakinra was 0.91, 0.47 to 1.78, 95% [CI], p = 0.8 and for UC vs tocilizumab 1.13, 0.55 to 2.30; p = 0.7. There were non-significant trends favoring tocilizumab (and to limited degree anakinra) vs UC for some secondary outcomes. Safety profiles did not differ significantly. Premature closure of trial precludes firm conclusions. Anakinra or tocilizumab did not significantly shorten time to clinical recovery compared to usual care. (IMMCoVA, NCT04412291, EudraCT: 2020-00174824).