Sepsis in Immunocompromised Patients: Current Status in Korea

Kwangha Lee

doi:10.4266/kjccm.2015.30.4.239

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Editorial Sepsis in Immunocompromised Patients: Current Status in Korea: Kwangha Lee, M.D., Ph.D.; Korean Journal of Critical Care Medicine 2015;30(4):239-240.
DOI: https://doi.org/10.4266/kjccm.2015.30.4.239
Published online: November 30, 2015

Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea

Correspondence to: Kwangha Lee, Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7743 Fax: +82-51-245-3127 E-mail: jubilate@pusan.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Severely immunocompromised patients have increased risk of infection by common pathogens, as well as opportunistic infections by less virulent microorganisms of little concern to immunocompetent hosts. This highly developing risk of infection predisposes such individuals to increased risk of sepsis and septic shock.[1,2] The most common cause of severe, prolonged, immune compromise is systemic chemotherapy as a treatment for some forms of hematologic malignancies (e.g., induction chemotherapy for acute leukemia and lymphoreticular malignancies), delayed bone marrow recovery following allogenic hematopoietic stem cell transplantation, and solid organ transplantation. Less intensive chemotherapeutic regimens can cause a low incidence of neutropenia and short duration of bone marrow suppression, such as those regimens used for many solid organ malignancies. Also, the steroids used to treat various rheumatologic diseases and human immunodeficiency virus (HIV) infection contribute to immunosuppressive states. In addition, chronic medical illnesses, such as diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, liver cirrhosis, and heart failure, are often associated with immune abnormalities that increase the susceptibility of affected patients to specific life-threatening infections.[3]

The frequency of community and hospitalized patients with immunocompromised host defenses has increased dramatically over recent decades such that it is common for intensive care unit (ICU) care physicians to routinely encounter immunocompromised hosts. Despite significant advances in the prevention, diagnosis, and treatment of infection in immunocompromised hosts, infection remains a major cause of morbidity, increased hospital stay, and increased total costs.[4] As a result, the mortality of these patients can be higher because of higher incidence of infection severity. However, the superimposition of compromised host defenses and acute catastrophic illness complicates the detection and management of infection in such patients. Moreover, while there is a rapidly increasing evidence base in critical care medicine, there are no documented management guidelines for sepsis in immunocompromised patients.[5]

In Korea, there is no reported data about current status for sepsis in immunocompromised patients. In this issue of the Journal, Oh et al[6] reported the influence of immunosuppressants on in-hospital mortality from sepsis. The authors retrospectively collected data on patients with sepsis from data of Health Insurance Review & Assessment (HIRA) Service over a period of five years (from 2009 to 2013). In their study, in-hospital mortality was 38.9%. When total patients were divided into three groups (immunosuppressant group, steroid-only group, and control group), the steroid-only group and immunosuppressant group received more frequent ICU care, had longer hospital length of stay, and incurred higher medical expenditure. Also, age, male gender, comorbidites (malignancy), and ICU treatment were associated with inhospital mortality based on univariate and multivariate analyses.

The main finding of the present study was that in-hospital mortality was lower in patients taking immunosuppressant drugs compared to those not taking immunosuppressants. Oh et al[6] suggested several considerations of this finding. First, the balance between proinflammatory response and anti-inflammatory response in patients with immunosuppressants and the use of broad-spectrum antibiotics in the early stage of sepsis might be associated with the low mortality rate in these patients. Second, there were differences in the study method compared with previous studies,[4,7,8] which analyzed patients on immunosuppressants rather than immunocompromised hosts (e.g., patients receiving systemic chemotherapy or with HIV infection).

Although, the current study was conducted with a retrospective nature, it is the first to report the epidemiologic status of Korean sepsis patients taking immunosuppressants before admission using data from HIRA. Korean ICUs differ from those in Western countries in many aspects (such as medical expenses, familial support, and social customs); this implies distinct clinical characteristics in patients with sepsis who were immunocompromised before admission. In addition, staffing of nurses and full-time intensivists in Korean ICUs in university and teaching hospitals is poor compared with that in advanced countries,[9,10] which could be associated with poor outcomes. Moreover, there is no universal treatment guideline for sepsis in such patients. Therefore, further investigations are needed to determine the distinct clinical characteristics and prognostic factors of such patients through large-scale studies in Korea.

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No potential conflict of interest relevant to this article was reported.

References

1. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369:840-51.Article PubMed
2. Legrand M, Max A, Peigne V, Mariotte E, Canet E, Debrumetz A, et al. Survival in neutropenic patients with severe sepsis or septic shock. Crit Care Med 2012;40:43-9.Article PubMed
3. Al-Dorzi HM, Khan R, Arabi YM. Life-threatening infections in medically immunocompromised patients. Crit Care Clin 2013;29:807-26.Article PubMed PMC
4. Linden PK. Approach to the immunocompromised host with infection in the intensive care unit. Infect Dis Clin North Am 2009;23:535-56.Article PubMed
5. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.Article PubMed
6. Oh SY, Cho S, Lee H, Chang EJ, Min SH, Ryu HG. Sepsis in patients receiving immunosuppressive drugs in Korea: analysis of the national insurance database from 2009 to 2013. Korean J Crit Care Med 2015;30:249-57.Article
7. Tolsma V, Schwebel C, Azoulay E, Darmon M, Souweine B, Vesin A, et al. Sepsis severe or septic shock: outcome according to immune status and immunodeficiency profile. Chest 2014;146:1205-13.Article PubMed
8. Poutsiaka DD, Davidson LE, Kahn KL, Bates DW, Snydman DR, Hibberd PL. Risk factors for death after sepsis in patients immunosuppressed before the onset of sepsis. Scand J Infect Dis 2009;41:469-79.Article PubMed PMC
9. Kwak SH, Jeong CW, Lee SH, Lee HJ, Koh Y. Current status of intensive care units registered as critical care subspecialty training hospitals in Korea. J Korean Med Sci 2014;29:431-7.Article PubMed PMC
10. Kim JH, Hong SK, Kim KC, Lee MG, Lee KM, Jung SS, et al. Influence of full-time intensivist and the nurse-to-patient ratio on the implementation of severe sepsis bundles in Korean intensive care units. J Crit Care 2012;27:414. e11-21.Article

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Sepsis in Immunocompromised Patients: Current Status in Korea

Korean J Crit Care Med. 2015;30(4):239-240. Published online November 30, 2015

DOI: https://doi.org/10.4266/kjccm.2015.30.4.239

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