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Sepsis in Tropical Australia: Epidemiology, Pathophysiology and Adjunctive Therapy

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Sepsis in Tropical Australia: Epidemiology, Pathophysiology and Adjunctive Therapy Sepsis in Tropical Australia: Epidemiology, Pathophysiology and Adjunctive Therapy. by Dr Joshua Saul Davis MBBS (Hons), DTM&H, Grad Cert Pop Health, FRACP A thesis submitted in total fulfilment of the requirements for the degree of Doctor of Philosophy Menzies School of Health Research Darwin, Northern Territory Australia And Institute of Advanced Studies Charles Darwin University March 2010 i Declaration I hereby declare that the work herein, now submitted as a thesis for the degree of Doctor of Philosophy at Charles Darwin University is the result of my own investigations, and all references to ideas and work of other researchers have been specifically acknowledged. I hereby certify that the work embodied in this thesis has not already been accepted in substance for any degree, and is not currently being submitted in candidature for any other degree. ii Abstract Despite substantial advances in its management, severe sepsis remains the most common cause of death in intensive care units, and has a mortality of 30-50%. Within Australia, there are an estimated 15,000 cases of severe sepsis each year. However the epidemiology of sepsis in the tropical Northern Territory, a region with a high incidence of acute infections and chronic diseases, and a high proportion of Indigenous residents, has not been described. The pathophysiology of sepsis is complex and incompletely understood. A pivotal factor in sepsis pathophysiology is dysfunction of the endothelium, a metabolically active organ which lines the entire vascular system Following the literature reviews in section A, this thesis is divided into three parts. In section B, I present a 12-month prospective cohort study based at Royal Darwin Hospital describing the epidemiology of sepsis in the Top End of the Northern Territory. This study found that the incidence of sepsis in this region is five-fold higher than that in temperate Australia and elsewhere, and that most of this burden occurs in Indigenous people. In section C, I undertook an observational study examining endothelial function in patients with sepsis and healthy controls, using a novel technique called peripheral arterial tonometry. This study found that peripheral arterial tonometry is a feasible technique for monitoring endothelial function in sepsis and that endothelial function is impaired in proportion to disease severity. It also identified several potential targets for development of therapeutic intervention to improve the endothelial and microvascular dysfunction of sepsis. One of the most promising potential adjunctive therapies for sepsis is the statins, a class of lipid-lowering drugs. Section D describes the rationale and protocol for a currently recruiting randomised trial of atorvastatin to improve endothelial function in patients with severe sepsis. iii Plain language summary of this thesis The term “sepsis” means an infection which has triggered a widespread response by the infected person’s body. This response may be manifested by fever, increased heart rate and breathing rate, or a raised white blood cell count. Sepsis does not mean local infection (e.g. an abscess of the foot, without fever): it refers to the case where inflammation has spread beyond the original focus of infection to involve the whole body. The term “severe sepsis” means sepsis that results in damage to vital organs, such as the kidneys, liver and heart. Commonly used terms that roughly correspond to sepsis include “blood poisoning” and “septicaemia”. Sepsis is a common and devastating problem, and according to a recent large US study, it causes more deaths each year than heart attacks. Approximately 15,000 cases of severe sepsis occur in Australia and New Zealand every year and around one third of these patients die as a result. However, it is not known how common sepsis is in tropical Northern Australia. This region is different from Australia as a whole, because a high proportion (around 25%) of its residents are Indigenous; many of its residents have chronic diseases such as diabetes or kidney failure; and a different range of bacteria cause infections in this region compared to elsewhere. Following reviews of the relevant literature in Part A, in part B of this thesis I describe a study which aimed to find out how common sepsis is in the Top End of the Northern Territory, who gets it, what are the common responsible germs, and what are the risk factors for dying of sepsis. This study found that sepsis is five times more common in this region than in the rest of Australia, Europe or North America. Most of this difference comes from the figures in Indigenous people, in whom sepsis is twenty times more common than in other regions. However, among patients hospitalised with sepsis, the risk of dying appears to be lower at Royal Darwin Hospital (RDH) than it is in most other studies. For example, of those with severe sepsis who went to the intensive care unit, 21% died, compared with 38% in a study from the rest of Australia and 36% in a large European study. This is true despite the sepsis being just as severe at RDH as in other studies. The reasons for this are unclear, but one possible explanation is that patients here are, on average, younger than those reported from elsewhere. Even though a low proportion of patients die from sepsis in the Top End, a high number of patients die, because sepsis is so much more common here than elsewhere. Therefore, sepsis is an important problem in the Top End. Most of the burden is shouldered by Indigenous Australians, particularly those with poor iv nutrition and kidney disease. The results of this study can be used to design strategies to prevent sepsis, and to decrease the number of people dying from sepsis. Chapters 6 and 7 of part B both evaluate scoring systems to estimate the severity of sepsis, and help to predict who will die or develop more severe illness. Both of these chapters describe new uses for these scoring systems to help in developing local treatment guidelines to improve outcomes from sepsis. Part C of the thesis concerns “endothelial function” in patients with sepsis. The “endothelium” is a group of cells which form the lining of all the blood vessels in the human body, ranging from the largest (the aorta for example) to the smallest (the capillaries, which need a microscope to be seen). There are more than 100 trillion endothelial cells in the human body, and if they were all laid out, they would cover an area of approximately twenty-seven tennis courts, or 27,000 Monopoly boards. The endothelium was once thought to be simply a passive cell layer which kept the blood vessels smooth and prevented blood clotting – akin to a layer of Teflon. However it is now known that endothelial cells are very active; they sense changes in their environment, and can respond to these changes in multiple ways (usually by releasing messenger chemicals into the blood stream). The function of endothelial cells is to keep the blood flowing (i.e. to prevent it from clotting); to stop the blood cells and fluid from leaking out into the tissues; to regulate how big or small individual blood vessels are; and to act as part of the immune system, responding to foreign material such as bacteria. Together these jobs are known as “endothelial function”. So what does this have to do with sepsis? During sepsis, the endothelium becomes activated and damaged, and starts not to do its job properly. It stops being able to control the tightness and size of blood vessels (causing blood pressure to become too low, and meaning that not enough blood flows to vital organs); It allows cells and fluid to leak out into the tissues (causing the patient to swell up); it allows the blood to clot in small blood vessels (also depriving some organs of proper blood flow); it amplifies the body’s response to infection, making sepsis worse (instead of damping it down, as it is meant to do). Many of these effects have only been measured in laboratory animals with sepsis. It is difficult to measure endothelial function in people with sepsis. A few previous studies have done so using complicated or invasive techniques which require highly trained staff and a very co-operative patient. We used a relatively new technology, peripheral arterial v tonometry (or PAT) to measure endothelial function in patients with sepsis. PAT is easy to perform, requires no needles, and the results are generated by a computer. It uses a thimble-like device to record the pulse in the fingertips. PAT has been used in many studies to measure endothelial function in people who have or are at risk of heart disease, but it has never been used in sepsis before. Because people with sepsis often have poor blood supply to their fingertips, it was unclear if PAT would work in this setting. The aim of the study described in Chapter 9 was to determine the feasibility of PAT to measure endothelial function in sepsis, to determine if endothelial function is impaired in sepsis patients compared with healthy patients, and to explore the correlations of the PAT results. This study found that PAT was indeed a feasible technique in sepsis patients (i.e. it worked in the majority of patients). Endothelial function was impaired in sepsis patients compared with healthy people, and this impairment correlated with disease severity; in other words the sicker a patient was, the worse their endothelial function. Chapters 11-13 present further results from this study, identifying several biochemical targets for potential treatments aiming to improve endothelial function in people with sepsis. Finally, in part D of the thesis, I present the detailed plans for a clinical trial of a drug called atorvastatin (Lipitor – a member of a family of cholesterol medications called the “statin” family) to try to improve endothelial function and thus decrease organ failure and death in patients with severe sepsis.
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