Sepsis: ProCESS shows Progress

The treatment of severe sepsis, colloquially known as blood poisoning, has underwent a real revolution in the last 10+ years largely on the basis of a seminal paper by Emanuel Rivers.

The Rivers study, conducted at one center, demonstrated impressive morality reductions when septic patients were treated to reach specific physiologic goals (that were essentially set to reflect normal physiology). The study protocol required the insertion of a central venous catheter.

Since that paper, early goal-directed therapy (EGDT) has become the paradigm and is the cornerstone to the sepsis management bundle. 

However, some debate has occurred over which goals are most important to achieve and whether the bundle can be de-bundled.

A major study on this topic, known as ProCESS and led by Pitt, was recently published in The New England Journal of Medicine.

The aim of this study was to determine whether EGDT with or without a central venous catheter for sepsis in emergency departments was superior to routine care. The results of the study, somewhat surprisingly, did not demonstrate any difference in mortality amongst the groups. 

The implication, to me, of this study is that early recognition and prompt treatment of severe sepsis is the key step that must be performed. I think part of this result is explained by the widespread diffusion of the general principles exemplified in the Rivers trial. Whether or not a formal protocol or central venous catheter is in place does not matter if one is treating severe sepsis appropriately. However, not everyone can function without a protocol so smaller hospitals may still fare better under a protocol-driven approach--as the accompanying editorial notes. 

Would a Caveman Observe the 5 Second Rule?

I think the recent study regarding the "5 Second Rule", which states that an item of food dropped on the floor is dropped is okay to eat so long as it is picked up within 5 seconds, is really unnecessary.

We literally reside in a world of microbes. They reside everywhere on the planet, including within the body. How are plates and forks immune to bacterial growth? Clearly, they aren't. 

How many seconds does food sit on a bacterial-laden plate?

One caveat, however. If food is visibly soiled after being dropped, say on a farm pasture, it's probably best not to eat it. But, the carpet in your living room or the kitchen floor? What would a caveman do? 

The Needle vs. The Nose

Of vaccine delivery methods, the needle is the one that brings the most apprehension to adults and children alike. Few alternate methods are currently available and include oral (e.g. oral polio vaccine) and, importantly for influenza, nasal mist. 

The nasal mist flu vaccine not only is easier to administer, not only does it mimic the means in which influenza sets up infection, it is a live but weakened--not killed--version of the flu. Data show that this version of the vaccine is preferred for children as it provides the more robust immunity than the ordinary vaccine. 

It was recently reported that the pioneering innovator who developed this vaccine, Hunein Maasab, died.

Commenting on his breakthrough vaccine, Dr. Maasab said: "I feel in a sense that I have accomplished my life’s dream." The secondary consequence of pursuing his life's dream--as it is for all innovators--was the bequest of a life-enhancing augmentation of man's armamenetarium against infectious disease. Thank you, Dr. Maasab.

Syphilis: Got an App for that?

It's often said--not without reason--that technology is the solution to infectious disease.

However, microbes can exploit that very technology to find routes into the body. Witness prosthetic joint infections, for example. 

The fact is that just as we use technology to enhance our lives, so do microbes. 

Case in point: the exploitation of hook-up apps by syphilis. By facilitating sexual encounters such apps also facilitate syphilis transmission. 

Talk about a 21st century problem.

Herpes: Creeping into Everything

A fascinating look at how infectious disease can adversely impact cognitive development was recently published in the Journal of Infectious Diseases. In this study, cognitive function was studied in three age groups: children, adults aged 20-59, and older adults. The study assessed the effect that two herpes viruses (HSV-1 and CMV) had on performance. 

The study found in children that seropositivity for HSV-1 was correlated to lower reading and spatial reasoning schools. In adults aged 20-59, seropositivity to HSV-1 and CMV was correlated to impaired coding speed and seropositivity to CMV was correlated to impaired learning and recall. In older adults, seropositivity to HSV-1 was linked to impaired immediate memory.

The implications of this study are that infection with these pathogens have wide-ranging effects that can substantially alter one's functional capacity. Indeed, both of these pathogens may have roles in Alzheimer's Disease as well. Preventing infection with these ubiquitous pathogens may prove difficult in the absence of a vaccine, however.