主页 > 医学新闻 >
【文摘发布】脓毒症诊断的对策
Sepsis in the United States has an estimated annual healthcare cost of $16.7 billion and leads to 120 000 deaths. Insufficient development in both medical diagnosis and treatment of sepsis has led to continued growth in reported cases of sepsis over the past two decades with little improvement in mortality statistics. Efforts over the last decade to improve diagnosis have unsuccessfully sought to identify a “magic bullet” proteic biomarker that provides high sensitivity and specificity for infectious inflammation. More recently, genetic methods have made tracking regulation of the genes responsible for these biomarkers possible, giving current research new direction in the search to understand how host immune response combats infection. Despite the breadth of research, inadequate treatment as a result of delayed diagnosis continues to affect approximately one fourth of septic patients. In this report we review past and present diagnostic methods for sepsis and their respective limitations, and discuss the requirements for more timely diagnosis as the next step in curtailing sepsis-related mortality. We also present aproposal toward revision of the current diagnostic paradigm to include real-time immune monitoring.
The clinical definitions of sepsis used in diagnosis extend beyond systemic infection to focus on the symptoms generated by the host response in combating an infection.Despite a broad range of clinical measures, the complexity and heterogeneity of host response to infection, even within distinct populations, frequently lead to delayed diagnosis, which in turn leads to ineffective and belated
antimicrobial treatment (1–4). The necessity of improved diagnosis is evident when considering the 18–29% mortality rates reported in broad epidemiologic studies (5, 6).
Enhanced diagnostics could foster substantial reductions in the 120 000 annual sepsis-related mortalities and associated $16.7 billion annual healthcare cost in the United
States through reduced duration of hospitalization and more efficient pharmaceutical treatment (5, 6). Over the past decade, sepsis has been diagnosed accordingto the consensus guidelines established in 1991 as an infection in addition to the symptoms of systemic inflammatory response syndrome (SIRS)3 (7 ). Amendments
to these criteria were initiated by convening an
international conference in 2001 in response to a survey
revealing that 71% of responding clinicians considered the
existing definitions insufficient (8 ). In addition to the
previous criteria, the 2001 conference added several new
diagnostic criteria for sepsis. Of particular interest was the
inclusion of the biomarkers procalcitonin (PCT) and C-reactive
protein (CRP), despite the overall conclusion that it
was premature to use biomarkers for sepsis diagnosis (8 ).
The primary recommendation of the panel was the implementation
of the Predisposition, insult Infection, Response,
and Organ dysfunction (PIRO) staging system to
determine optimum treatment for individual patients by
stratifying their individual symptoms and risks (Fig. 1)
(8, 9).
The focus of the PIRO system on individualized patient
treatment acknowledges the concerns of authors who
have previously identified the need for individualized
diagnostics and treatment (8–10). However, the PIRO
outline fails to address the necessity of prompt diagnosis.
Given that swift diagnosis is crucial in permitting timely
treatment, it is imperative that diagnostic methods be
rapid enough to provide treatment guidance in corre-
spondence with the progression state of infection. Because
of this need for rapid diagnostics, the majority of current
research has focused on the search for a “magic bullet”
biomarker as a provision for confirmed pathogen presence
[for a listing of studied biomarkers, see Ref. (9 )].
Despite a wealth of case studies correlating sepsis to
specific biomarkers, lack of attention to the timing of
patient sampling in relation to the period elapsed since
infection onset has generated conflicting results for even
the most promising biomarkers. The persistent trend of
increasing rates of septic infection, particularly those
caused by pathogens resistant to antimicrobial agents,
underscores the need to resolve these conflicts or find
alternative methods of rapid sepsis identification and
interim patient monitoring.
To help better understand the challenges in fulfilling
these goals, we will review current diagnostic methodologies
and discuss some of the inherent dilemmas in
resolving sepsis diagnosis, concentrating on the impact of
delayed diagnosis and initiation of antimicrobial treatment.
The focus of the reviewed research on the diagnostic
utility of biomarkers pertains to the differentiation of
sepsis from SIRS in clinical cases, a considerably more
difficult task than is differentiation of severe sepsis or
阅读本文的人还阅读：
作者:admin@医学,生命科学 2011-03-01 17:12
医学,生命科学网