Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients
ABSTRACT Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been introduced to reduce the high risk of death associated with severe sepsis or septic shock. This systematic review is an update of a Cochrane review originally published in 2007.
We assessed the benefits and harms of APC for patients with severe sepsis or septic shock.
We searched CENTRAL (The Cochrane Library 2012, Issue 6); MEDLINE (2010 to June 2012); EMBASE (2010 to June 2012); BIOSIS (1965 to June 2012); CINAHL (1982 to June 2012) and LILACS (1982 to June 2012). There was no language restriction.
We included randomized clinical trials assessing the effects of APC for severe sepsis or septic shock in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28 and at the end of study follow up, and hospital mortality as the primary outcomes.
We independently performed trial selection, risk of bias assessment, and data extraction in duplicate. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.
We identified one new randomized clinical trial in this update which includes six randomized clinical trials involving 6781 participants in total, five randomized clinical trials in adult (N = 6307) and one randomized clinical trial in paediatric (N = 474) participants. All trials had high risk of bias and were sponsored by the pharmaceutical industry. APC compared with placebo did not significantly affect all-cause mortality at day 28 compared with placebo (780/3435 (22.7%) versus 767/3346 (22.9%); RR 1.00, 95% confidence interval (CI) 0.86 to 1.16; I(2) = 56%). APC did not significantly affect in-hospital mortality (393/1767 (22.2%) versus 379/1710 (22.1%); RR 1.01, 95% CI 0.87 to 1.16; I(2) = 20%). APC was associated with an increased risk of serious bleeding (113/3424 (3.3%) versus 74/3343 (2.2%); RR 1.45, 95% CI 1.08 to 1.94; I(2) = 0%). APC did not significantly affect serious adverse events (463/3334 (13.9%) versus 439/3302 (13.2%); RR 1.04, 95% CI 0.92 to 1.18; I(2) = 0%). Trial sequential analyses showed that more trials do not seem to be needed for reliable conclusions regarding these outcomes.
This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. APC seems to be associated with a higher risk of bleeding. The drug company behind APC, Eli Lilly, has announced the discontinuation of all ongoing clinical trials using this drug for treating patients with severe sepsis or septic shock. APC should not be used for sepsis or septic shock outside randomized clinical trials.
- SourceAvailable from: Zhongheng Zhang
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- "Interventions RCTs or meta-analysis No. of component studies No. of patients Sequence generation Allocation concealment Blindness ITT APC Marti-Carvajal et al (2012)  "
ABSTRACT: Background and objectives sepsis is a leading cause of mortality and morbidity in intensive care unit and many studies have been conducted aiming to improve its outcome. Randomized controlled trials (RCT) and observational studies using propensity score (PS) method are commonly employed for this purpose. However, the agreement between these two major methodological designs has never been investigated in this specific area. The present study aimed to compare the effect sizes between RCTs and PS-based studies. Methods Electronic databases including Pubmed, SCOPUS and EBSCO were searched to obtain PS-based studies in the area of sepsis. The studies were matched to RCTs or systematic reviews and meta-analysis in terms of population, intervention, control and outcome. When there were multiple PS-based studies or RCTs in one area, the effect sizes were pooled by using random-effects model and inverse variance method. The comparisons were performed by using differences in the effect size. Results A total of 8 topics were identified fulfilling the criterion that at least one pair of RCT and PS-based study could be matched. The interventions included activated protein C, low dose steroid, antithrombin III, combination antibiotic therapy, fish oil supplementation, statin, etomidate for intubation, recombinant human soluble thrombomodulin. The effect sizes were statistically different between RCTs and PS-based studies in most circumstances (6/8). The pooled mean difference in effect sizes was -0.16 (95% CI: -0.33-0.01), indicating a trend towards larger treatment effect in PS studies than that in RCTs. The result remains unaltered by restricting to RCTs and PS studies with the largest sample sizes. Conclusion Our study shows that PS studies tend to report larger treatment effect than RCTs in the field of sepsis, indicating the difference between efficacy trials and effectiveness studies.Journal of Critical Care 10/2014; 29(5). DOI:10.1016/j.jcrc.2014.05.023 · 2.00 Impact Factor
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- "Taking into account these contradictory results, the fact that DrotAA patients clearly improved regional oxygenation, as previously shown by others [23,24], but DrootAA has failed repeatedly to prove effectiveness on prognosis [29,30], lead us to the next questions: Are microcirculation-targeted therapies futile? Despite our results support the DrotAA effect on regional tissue perfusion, the degree of regional improvement derived from this therapy might not be associated to better prognosis. "
ABSTRACT: Sepsis is a leading cause of death despite appropriate management. There is increasing evidence that microcirculatory alterations might persist independently from macrohemodynamic improvement and are related to clinical evolution. Future efforts need to be directed towards microperfusion monitoring and treatment. This study explored the utility of thenar muscle oxygen saturation (StO2) and its changes during a transient vascular occlusion test (VOT) to measure the microcirculatory response to drotrecogin alfa (activated) (DrotAA) in septic patients. A prospective, observational study was performed in three general intensive care units at three university hospitals. We studied 58 patients with recent onset of severe sepsis or septic shock and at least two organ dysfunctions. Thirty-two patients were treated with DrotAA and 26 were not treated because of formal contraindication. StO2 was monitored using near-infrared spectroscopy (NIRS), and VOT was performed to obtain deoxygenation (DeOx) and reoxygenation (ReOx) slopes. Measurements were obtained before DrotAA was started and were repeated daily for a 96-hour period. Patients' characteristics, outcome, severity, and baseline values of StO2, DeOx, and ReOx did not differ between groups. Treated patients significantly improved DeOx and ReOx values over time, whereas control patients did not. In treated patients, ReOx improvements were correlated to norepinephrine dose reductions. Early clinical response (SOFA improvement after 48 hours of treatment) was not associated to changes in VOT-derived slopes. In the treated group, the relative improvement of DeOx within 48 hours was able to predict mortality (AUC 0.91, p < 0.01). In patients with severe sepsis or septic shock, DrotAA infusion was associated with improvement in regional tissue oxygenation. The degree of DeOx amelioration after 2 days in treated patients predicted mortality with high sensitivity and specificity. Thus, StO2 derived variables might be useful to evaluate the microcirculatory response to treatment of septic shock.Annals of Intensive Care 09/2013; 3(1):30. DOI:10.1186/2110-5820-3-30 · 3.31 Impact Factor
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ABSTRACT: Sepsis is the leading cause of death in most intensive care units, and the death of septic patients usually does not result from the initial septic event but rather from subsequent nosocomial infections. Patients who survive severe sepsis often display severely compromised immune function. Not only is there significant apoptosis of lymphoid and myeloid cells that depletes critical components of the immune system during sepsis, there is also decreased function of the remaining immune cells. Studies of animals and humans suggest the immune defects that occur during sepsis may be critical to pathogenesis and subsequent mortality. This review focuses on sepsis-induced alterations with the cluster differentiation (CD) 8 T-cell compartment that can affect the control of secondary heterologous infections. Understanding how a septic event directly influences CD8 T-cell populations through apoptotic death and homeostatic proliferation and indirectly by immune-mediated suppression will provide valuable starting points for developing new treatment options.Critical Reviews in Immunology 03/2013; 33(1):23-40. DOI:10.1615/CritRevImmunol.2013006721 · 3.70 Impact Factor