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Adjustment of antimicrobial agents for adults with sepsis, severe sepsis or septic shock

Broad‐spectrum antimicrobial treatment is defined as the use of an antibiotic or a combination of antibiotics which act against a wide range of disease‐causing bacteria. Broad‐spectrum antimicrobial treatment can reduce mortality rates in patients with sepsis, severe sepsis or septic shock. Sepsis is a serious medical condition which is characterized by an inflammatory response to an infection that can affect the whole body. The patient may develop this inflammatory response to microbes in their blood, urine, lungs, skin or other tissues. However, there is a risk that empirical broad‐spectrum antimicrobial treatment can expose patients to overuse of antimicrobials and increase the resistance of micro‐organisms to treatment. De‐escalation has been proposed as a means of adjusting initial, adequate broad‐spectrum treatment by changing the antimicrobial agent or discontinuing an antimicrobial combination according to the patient's culture results (a means of identifying the microbe causing the infection). In this updated Cochrane review we searched the databases until October 2012. We found no published randomized controlled trials (RCTs). We found one ongoing RCT. There is no adequate or direct evidence on whether de‐escalation of antimicrobial agents is effective and safe for adults with sepsis, severe sepsis or septic shock. Appropriate studies are needed to investigate the potential benefits proposed by de‐escalation treatment.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Human recombinant activated protein C for severe sepsis and septic shock in adult and paediatric patients

Sepsis and septic shock are major causes of death. Sepsis is a complex syndrome resulting from a presumed or known infection, and its pathogenesis involves interactions between inflammation and blood clotting pathways. This serious medical condition is characterized by an inflammatory response to an infection which can affect the whole body. Patients with sepsis may have developed the inflammatory response because of microbes in their blood, urine, lungs, skin, or other tissues. Severe sepsis can lead to multiple organ failure due to blood clotting in the finer blood vessels. This reduces the amount of blood reaching the organs and septic shock ensues. Protein C reduces the clotting process and a lack of protein C can lead to an exaggeration of blood clotting. Sepsis and septic shock decrease protein C levels in the body. It has been suggested that human recombinant activated protein C (APC) will increase the levels of protein C and ameliorate or prevent multiple organ failure. In this updated Cochrane review we searched the databases until June 2012. We included six randomized clinical trials which involved 6781 people (6307 adult and 474 paediatric participants) with either a high or low risk of death. All trials had high risk of bias and were sponsored by the pharmaceutical industry (Eli Lilly). We found no evidence suggesting that APC reduced the risk of death in adults or children with severe sepsis or septic shock. On the contrary, APC increased the risk of serious bleeding.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Intravenous immunoglobulins for treating patients with severe sepsis and septic shock

Sepsis is the inflammatory response of the body to severe infection, which can be caused by a variety of micro‐organisms including bacteria, viruses and fungi. Signs of sepsis include fever, hypothermia, rapid heart rate and respiration; and a laboratory finding of increased or decreased white blood cell count. Deaths as a result of sepsis and septic shock remain high despite giving antibiotics, especially if the functions of a persons's vital organs such as the lungs, heart and kidneys are affected. Several studies have looked into other agents than antibiotics to help the body fight the effects of sepsis. Intravenous immunoglobulin preparations contain antibodies that help the body to neutralize bacterial toxins. There are two types of preparations. These are polyclonal immunoglobulins that contain several antibodies directed at endotoxin and inflammatory mediators, and monoclonal immunoglobulins which target a specific inflammatory mediator or antigen. Intravenous immunoglobulins are blood products, specifically pooled sera derived from human donor blood.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

Vasopressors for hypotensive shock

This review seeks unbiased evidence about the effects of different drugs that enhance blood pressure on risk of dying in critically ill patients with impaired blood circulation.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Naloxone may improve blood pressure in people who are in shock but more trials are needed to show whether this reduces deaths

When people go into shock, their blood pressure drops and may be too low to sustain life. One theory about the cause of this is the effect of the opiates that the body produces after major blood loss or trauma. Naloxone is a drug that counteracts the effects of opiates. It has been tried as a treatment to reduce the impact of shock. This review of trials found that giving naloxone to people in shock improves their blood pressure. It is not clear whether or not this improves their overall condition or reduces their chances of dying. More trials are needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Corticosteroids for treating sepsis

We reviewed the evidence on effects on survival at one month and on tolerance of systemic corticosteroids in people with sepsis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

High‐volume haemofiltration for sepsis

Severe sepsis and septic shock are among the most common causes of death in adults who are sufficiently ill to be admitted to an intensive care unit (ICU). Sepsis often arises following an infection. The organisms causing the infection can be bacterial, viral or fungal. If sepsis develops, the body responds by producing chemicals which cause massive inflammation in the whole body. (Inflammation is how body tissues react to infection, irritation or other injury). This inflammation can cause individual organs to fail e.g. the kidneys, heart, circulation and lungs. It is these organ failures, as a result of the inflammation, which lead to the high death rates associated with sepsis.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

To assess the optimal of timing of administering antibiotics to sepsis patients in the emergency department

Sepsis is a serious medical condition characterized by an inflammatory response to an infection that can affect the whole body. The patient may develop an inflammatory response to microbes in their blood, urine, lungs, skin, or other tissues. Sepsis is a serious condition with a very high death rate if left untreated. Most sepsis patients require antibiotics and admission to an intensive care unit (ICU). How soon broad spectrum antibiotics should be delivered is as yet unclear. Broad spectrum antimicrobial treatment is defined as a combination of antibiotics which act against a wide range of disease‐causing bacteria, used to reduce mortality rates in patients with sepsis, severe sepsis or septic shock. We carried out a systematic review of the literature by searching key databases for high quality published and unpublished material on the timing of antibiotics in the emergency department prior to ICU admission. Our searches revealed no randomized controlled trials (RCTs) on the timing of broad spectrum antibiotic treatment in this population. We conclude that there is a need to carry out observational cohort studies, in the absence of RCTs, even if they lack the precision of RCTs. We also conclude that the earlier the antibiotics are administered the better. It is important to realize that the clock starts ticking when the patient arrives in the ED and stops once the antibiotic is started. The pre‐intensive care unit period is the time spent in the ward or ED prior to being admitted to the ICU, where most patients with severe sepsis are admitted. The review was purposefully very specific as it is focused only on patients with severe sepsis and in finding only RCTs. The absence of these may imply, in itself, the complicated nature of the study question as it may be ethically wrong to randomize such patients to a seemingly inferior treatment arm.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Intravenous N‐acetylcysteine compared to placebo for treatment of systemic inflammatory response syndrome and sepsis in seriously ill adults

Systemic inflammatory response syndrome (SIRS) is a complex response to an insult such as major surgery or trauma. It is called sepsis syndrome, or simply sepsis, when infection is present. The generalized inflammatory reaction involves activation of leukocytes and endothelial cells and the release of inflammatory mediators and toxic oxygen free radicals. Diffuse microthrombosis can result in localized tissue perfusion abnormalities and low oxygenation (hypoxia). Both SIRS and sepsis can be difficult to treat and are major causes of multiple organ failure and the death of patients in the intensive care unit. SIRS and sepsis both lead to a drop in the level of antioxidants normally present in the body.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Surgical versus nonsurgical interventions for flail chest (ribs with more than one fracture)

Flail chest is a medical term describing multiple rib fractures, when ribs are broken or dislocated in more than one place and are no longer completely connected to the other rib bones. When a person injured in this way breathes, the broken segment may move in a different way compared to the rest of the chest wall. Flail chest can cause a person to have difficulty breathing, in which case they may be given mechanical ventilation (machine‐assisted breathing). Surgery is sometimes performed in order to reconnect the broken ribs.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Etomidate for sedating critically ill people during emergency endotracheal intubation

People who are critically ill often need help breathing. One way to do this is called endotracheal intubation. This involves placing a tube into the windpipe (trachea) and having a ventilator (breathing machine) help the patient breathe.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Medications to prevent post‐traumatic stress disorder (PTSD): a review of the evidence

‐ People affected by PTSD and their families.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Using antibiotics to treat intra‐amniotic infection in pregnant women

Review question: Cochrane authors reviewed available evidence from randomized controlled trials on the use of antibiotics for the treatment of pregnant women with intra‐amniotic infection (chorioamnionitis).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Systematic Reviews in PubMed

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Systematic Review Methods in PubMed

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