Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 176 Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 177 Art of Medicine International Medical Scientific journal Founder and Publisher Pascual Izquierdo-Egea Published science may 2021 year. Issued Quarterly. Internet address: http://artofmedicineimsj.us E-mail: info@artofmedicineimsj.us 11931 Barlow Pl Philadelphia, PA 19116, USA +1 (929) 266-0862 Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 178 The importance of the criteria of systemic inflammatory Responce syndrome of early diagnostics and detection of bloodstream infections 1 Akhmedova D.R., 1 Abdukhalilova G.K., 1 Otamuratova N.Kh., 2 Tadjieva N.U., 1 Bektimirov A.M- T., 1 Akhmedov I.F., Tadjiev B.M. 1 Republican Specialized Scientific and Practical Medical Center of Epidemiology, Microbiology Infectious and Parasitic Diseases, 2 Tashkent Medical Academy Ministry of Health of Republic of Uzbekistan, Tashkent. For Corresponding 1. Akhmedova Dilshoda Rakhmanberdievna, junior researcher, PhD student, RSPMCEMIPD. Tashkent, Uchtepa district, Zakovat st.,2. 100133. Dilyaahmedova85@mail.ru *Corresponding author 2. Abdukhalilova Gulnora Kudratullaevna, Doctor of Medical Sciences, Head of the Center of Antimicrobial Resistance at RSPMCEMIPD, Tashkent, Uchtepa district, Zakovat st., 2. 100133. gula-abd@yandex.ru 3. Otamuratova Nargiza Khasandjanovna, Ph.D., Senior Researcher, Epidemiologist of the Center of Antimicrobial Resistance at RSPMCEMIPD, Tashkent city, Uchtepa district, Zakovat Street, 2. 100133. nargiza.otamuratova@gmail.com 4. Tadjieva Nigora Ubaidullaevna, MD, DSc, Associate Professor of the Department of Infectious and Children's Infectious Diseases of the Tashkent Medical Academy, Olmazor distr ict, st. Farobi, 2. nigora1973@list.ru 5. Bektimirov Amir Mangu-Temirovich, Ph.D., Senior Researcher, Bacteriologist at the Center of Antimicrobial Resistance at RSPMCEMIPD, Tashkent city, Uchtepa district, Zakovat st., 2. 100133. amtbektimirov@gmail.com 6. Akhmedov Ildar Farrukovich, junior researcher, bacteriologist of the Center of Antimicrobial Resistance at RSPMCEMIPD, Tashkent, Uchtepa district, Zakovat str., 2. 100133. a978da@yandex.com 7. Tadjiev Batyr Mirkhashimovich, director of 1 Republican Specialized Scientific and Practical Medical Center of Epidemiology, Microbiology Infectious and Parasitic Diseases. Tashkent, Uchtepa district, Zakovat str., 2. 100133.. infoniiemiz@minzdrav.uz mailto:Dilyaahmedova85@mail.ru mailto:gula-abd@yandex.ru mailto:nargiza.otamuratova@gmail.com mailto:nigora1973@list.ru mailto:amtbektimirov@gmail.com mailto:a978da@yandex.com mailto:infoniiemiz@minzdrav.uz Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 179 Summary Purpose of study Determine the frequency of detection of patients with bloodstream infections (BSI) with applying systemic inflammatory response syndrome (SIRS) criteria, and analyze the clinical characteristics of patients with suspected BSI. Methods In the study were included 1,463 patients hospitalized in various departments according to their primary diagnosis. Indication for study inclusion and hemoculture collection of patients was the detection of at least 2 or more criteria of SIRS (ACCP/SCCM, Atlanta, 1992), in accordance with the protocol of the POP project "Proof-of-principle routine diagnostic project for a Antimicrobial Resistance Surveillance", with technical support from WHO, during the period from 2019-2020. The obtained results The largest number of patients (376) was admitted to the intensive care unit, 293 patients each admitted to the pediatric and infectious disease units and 183 patients admitted to the diagnostic units. All characteristic clinical symptoms of SIRS occurred in the examined patients. Hyperthermia was the most common in all age groups - in 47 patients in 74.60±1.08% of cases in the group of patients under one year of age, significantly more frequent in the group of 1 -5 years (594), 5-12 years (166), 12-18 and over 18 years (60; 486, respectively P<0.05). Tachycardia was also frequently observed in all age groups - almost in all patients (91.9±0.99%) in the group less than 1 year old, almost equally often in 75±0.66% and 73.90±0.38% of cases in the group 5 -12 and over 18 years old, respectively. This symptom was noted in more than 50% of cases in patients in the 1-5 (65%) and 12-18 (84%) age group. Tachypnea and leukocytosis were most frequently observed in patients under 1 year of age (47.62±0.87% and 71.43±1.06%, respectively), whereas in the remaining groups (1-5, 5-12, 12-18, and over 18 years of age), leukocytosis was noted in 63%, 50%, 59%, and 58% of cases, respectively, and tachypnea in 23%, 10%, 19%, and 25%, respectively. A combination of 2 symptoms (hyperthermia and tachycardia), a combination of hyperthermia and leukocytosis in 18.1% of cases, a triad of symptoms tachycardia, hyperthermia and leukocytosis in 23.9% of cases was the most common (41.5%) of the criteria for SSRIs. Also often enough (6.8%) were observed 4 symptoms hyperthermia, tachycardia, tachypnoea and leukocytosis. Conclusions The most frequent localization of infection in BSI was the upper respiratory tract, lower respiratory tract infections were detected twice as often. Predominantly, regardless of the Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 180 localization of infection, a combination of the criteria for SIRS of two symptoms was observed. Irrespective of the localization of infection, all patients had fever in various combinations, most frequently with tachycardia (26.8%) and leukocytosis (26.2%). Keywords Bloodstream infections, systemic inflammatory response syndrome, sepsis, hyperthermia, tachycardia, tachypnea, leukocytosis, neutrophilia. Introduction Bloodstream infections (BSIs) are defined as the presence of bacteria in the blood detected by hemoculture testing. This definition includes all clinical manifestations of BSI, including systemic inflammatory response syndrome (SIRS/SIRS, the initial manifestation of BSI), sepsis (life-threatening illness accompanied by organ dysfunction due to dysregulated host response to infection) and septic shock (sepsis accompanied by persistent pressure drop despite rehydration, plus impaired cellular metabolism) 1. Bloodstream infections are among the most common diagnoses treated in intensive care units. According to some author reports, 1.7 million patients develop BSIs each year in the United States, most of whom are over 65 years of age 2. Mortality, which reaches 10% in patients with sepsis and 40% in patients with septic shock, is usually the result of multiple organ dysfunction syndrome (MODS) 3. The introduction of the use of the SIRS criteria proposed at the consensus conference of the American College of Thoracic Surgeons and Society of Emergency Physicians would be an indication for hemoculture testing and would allow identification of patients at risk for sepsis and MODS, and would facilitate early intervention and appropriate management tactics . SIRSs are characterized by a wide range of conditions and may have a severe clinical course. The main clinical and laboratory indicators for the diagnosis of SIRS are body temperature above 38.3°C (fever) or below 36°C (hypothermia), heart rate more than 90 beats per minute (tachycardia), respiratory rate more than 20 breaths per minute (tachypnea), white blood cell count more than 12 × 109/L or less than 4 × 109/L or more than 10% immature neutrophils (stabial forms). SIRS criteria for children are presented in Table 1 according to the age of the child. Table 1. Specific age criteria for SIRS Age group body temperature (°C) heart rate (beats per minute) respiratory rate (breaths per minute) white blood cell count (in 10 9 /L) fever hypothermia tachycardia bradycardia Newborn (0 days to 1 week) >38,3 <36,0 180 100 50 34 Newborn (1 week to 1 month) >38,3 <36,0 180 100 40 19,5 or 5 Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 181 Infant (1 month to 1 year) >38,3 <36,0 180 90 34 17,5 or 5 Pre-school age (from 1 to 5 years) >38,3 <36,0 140 НП 22 15,5 or 6 School age (5 to 12 years old) >38,3 <36,0 130 НП 18 13,5 or 4,5 Teenagers (12 to 18 years old) >38,3 <36,0 110 НП 14 11 or 4,5 The presence of two or more of the above signs against the background of infection and bacteremia is interpreted as a systemic inflammatory response to the infection, i.e., SIRS 4,5,6. The purpose of our study is to determine the frequency of detection of patients with bloodstream infections when applying the criteria of systemic inflammatory response syndrome, and to analyze the clinical characteristics of patients with suspected bloodstream infections. Materials and Methods In the study were included 1,463 patients hospitalized in various departments according to their primary diagnosis. Indication for study inclusion and hemoculture collection of patients was the detection of at least 2 or more criteria of SIRS (ACCP/SCCM, Atlanta, 1992), in accordance with the protocol of the POP project "Proof-of-principle routine diagnostic project for a Antimicrobial Resistance Surveillance", with technical support from WHO, during the period from 2019-2020. From the total number of patients, 42% were female (615) and 58% male (848). The age of the patients ranged from a few months to 90 years (up to 1 year - 5%, 1-5 years - 45%, 5-12 years - 12%, 12-18 years - 4%, and over 18 years - 34%). In the selected patients we analyzed medical history data, clinical parameters in accordance with SIRS criteria, the fact of taking antibiotics at the time of blood sampling, empirical therapy before the bacteriological test result of hemoculture, and the tactics of antibiotic therapy after a positive result from the bacteriological laboratory. Obtained results All patients were hospitalized in different departments of huge multidisciplinary hospitals of Tashkent, Uzbekistan (Table 2). Table 2. Distribution of patients according to departments Departments n % 1. Adults ICU 376 25,7±0,13 2. Pediatric/Newborn 296 20,23±0,12 3. Infectious Diseases 293 20,03±0,12 4. Diagnostic 183 12,51±0,09 Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 182 5. Pediatric/Newborn ICU 95 6,49±0,07 6. Therapeutic 92 6,29±0,07 7. Surgical 91 6,22±0,07 8. Urologic 34 2,32±0,07 9. Rehabilitation 3 0,21±0,04 Comparative analysis of the obtained data showed that the largest number of patients (376) were hospitalized in the intensive care unit (p 0.05)/ Between the number of patients hospitalized in pediatric (293), infectious diseases (293) and diagnostic (183) departments significance was not noted. Hospitalization of the examined patients in the neonatal intensive care unit, therapeutic and surgical departments was equally frequent (p0.05). Hospitalization of patients at the urologic department and rehabilitation department was significantly less frequent, and showed only in 2.32±0.07%, 0.21±0.04% cases, respectively (p0.05). The distribution of patients according to SIRS clinical criteria at the time of hospitalization is shown in Table 3. Table 3. Clinical parameters of the whole group of patients according to age Clinical parameters Under 1 year old 1 - 5 years old 6-12 years old 13 – 18 years old Older than 18 years old hyperthermia 74,60±1,08 90,69±0,37* 96,51±0,75*° 80,00±1,03*°˄ 97,597±0,44*° hypothermia 3,17±0,22 2,9±0,07 3,49±0,14° - 1,20±0,05*°˄ tachycardia 91,9±0,99 50,84±0,28* 75±0,66*° 61,33±0,90°˄ 73,90±0,38*° bradycardia - 0,46±0,03* 0,58±0,06* - 1,41±1,08*°˄ tachypnea 47,62±0,87 20,15±0,18* 8,72±0,23*° 16,00±0,46*°˄ 21,08±0,21*°˄ leukocytosis 71,43±1,06 59,69±0,30* 46,51±0,52*° 49,33±0,81*°˄ 55,02±0,33*°˄ leukopenia 4,76±0,27 1,37±0,05* 1,74±0,10*° 1,33±0,13* 1,20±0,05* neutrophilia 3,17±0,22 0,76±0,03* 1,16±0,08*° - 0,80±0,04*˄ Note: * Comparison of indicators with the group of patients under 1 year of age (p0.05) ° Comparison of indicators with the group of 1-5 years, (p0.05) ˄ Comparison of indicators with the group of 5-12 years, (p0.05) - Comparison of indicators with the group of 12-18 years, (p0.05) The examined patients had all clinical symptoms of SIRS. The most common in all age groups was hyperthermia: in the 1-5 years group and in over 18 year’s group it amounted significantly more frequent 594 (p<0.05) and 486 of cases (p<0.05), respectively. In the 6-12 years group – in 166 of cases, in the 13-18 – in 60 of cases, and in the group of patients under one year of age it amounted 47 patients (74.60±1.08% of cases), which shows that it was not had significant difference. Tachycardia were also frequently observed in all age groups - nearly all patients (91.9±0.99%, p0.05) in the group less than 1 year old, almost equally often in 75±0.66% and Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 183 73.90±0.38% of cases in the group 5-12 and over 18 years old, respectively. In more than 50% of cases this symptom was observed in patients in the age group of 1-5 (65%) and 12-18 (84%) years old. Such symptoms as tachypnoea and leukocytosis were most frequently observed in patients under 1 year of age (47.62±0.87% and 71.43±1.06%, respectively), whereas in the remaining groups (1-5, 5-12, 12-18 and over 18 years old), leukocytosis was noted in 63%, 50%, 59% and 58%, respectively, and tachypnoea in 23%, 10%, 19% and 25%, respectively. We divided all the examined patients into groups according to combinations of symptom occurrence. The results showed that the most common combination of 2 characteristic clinical symptoms was registered in 758 patients (51.8%), in 590 patients (40.3%) of 3 symptoms, and in 115 cases (7.9%) 4 symptoms were encountered. But there was no statistical reliability in the distribution of patients into groups. (p0.05). Table 4. Distribution of patients into groups according to combinations of SIRS criteria Groups Combinations of SIRS criteria Quantity (n, %) 1 group 2 symptoms 758 (51,8%) 2 group 3 symptoms 590 (40,3%) 3 group 4 symptoms 115 (7,9%) Table 5. Combination of SIRS criteria Combination of SIRS criteria Quantity (%) Quantity (n) Hyperthermia + tachycardia 26,8% 392 hyperthermia + tachycardia + leucocytosis 26,2% 384 hyperthermia+leukocytosis 20,6% 301 hyperthermia+tachycardia+tachypnoea 9,0% 132 hyperthermia+tachycardia+tachypnoea+leukocytosis 6,7% 98 tachycardia+tachypnoea+leukocytosis 3,3% 48 hyperthermia+tachycardia+leukocytosis+neutrophilia 1,0% 15 hyperthermia+tachypnoea 1,0% 15 tachycardia+tachypnea 0,6% 9 leukocytosis+tachypnea 0,5% 8 tachycardia+tachypnoea+hypothermia 0,5% 7 Combinations of SIRS criteria depending on the presumed localization of infection are shown in Fig.1a, and Fig.1b Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 184 Analysis of the occurrence of various combinations of SIRS criteria in the surveyed group of patients showed that the most frequent was a combination of two symptoms: in 62.2% for localization on the skin and soft tissues, in 61.7% in the upper respiratory tract, and in 52.5% for a source of infection in the gastrointestinal tract. The greatest combination of three SSRI criteria was observed in the lower respiratory tract (53.1%) and gastrointestinal tract (42.4%). Combinations of SSRS criteria of hyperthermia, tachycardia and tachypnoea were observed in 26.6% of cases with localization of infection in the lower respiratory tract (301), 22.6% of hyperthermia, tachycardia and leucocytosis, 9.6% of hyperthermia, tachypnoea and leucocytosis, in 20.3% of cases there was a combination of 2 symptoms - hyperthermia and leucocytosis, and in 14.3% of hyperthermia and tachycardia. Figure 1a - Combinations of SIRS Figure 1b - Combinations of SIRS When we analyzed the localization of infection in our patients with suspected BSI, the most frequent was in the upper respiratory tract (703), accounting for 48.1%; in the lower respiratory tract - 301 patients, accounting for 20.6%. Gastrointestinal diseases accounted for 10.8% (158) of the cases (p≥0,05) Fig.2a, 2b, 2c. 0,0% 50,0% 100,0% 6,8% 3,8% 4,2% 20,0% 3,5% 5,7% 9,3% 33,3% 5,3% 5,0% 4,4% 3,2% 1,8% 11,4% 25,6% 3,2% 23,5% 9,5% 28,4% 66,7% 50,9% 8,6% 22,6% 100,0% 69,5% 0,4% 22,2% 1,1% 2,3% 0,3% 4,4% 1,8% 2,9% 1,3% Hyperthermia, tachycardia, leukocytosis, neutrophilia hyperthermia, tachycardia tachypnoea, leukocytosis hyperthermia, tachycardia tachypnoea Hyperthermia, tachycardia, leucocytosis 0,0% 50,0% 100,0% 42,1% 8,9% 25,3% 6,7% 8,8% 28,6% 14,0% 33,3% 9,5% 17,6% 30,4% 34,7% 28,1% 31,4% 19,6% 33,3% 7,4% 0,3% 3,8% 1,1% 1,8% 8,6% 2,0% 0,0% 2,1% 0,1% 4,4% 2,9% Hyperthermia + tachycardia Hyperthermia+leukocytosis Hyperthermia+tachypnoea Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 185 Fig. 2a, 2b, 2c Combinations of SIRS criteria depending on the presumed localization of infection In this group of patients, a combination of 2 symptoms (hyperthermia and tachycardia), in 18.1% of cases a combination of hyperthermia and leukocytosis, and in 23.9% of cases a triad of symptoms - tachycardia, hyperthermia and leukocytosis - was observed most frequently. The 4 symptoms of hyperthermia, tachycardia, tachypnoea and leucocytosis were also common (6.8%). In the gastrointestinal tract, a combination of hyperthermia and leucocytosis (30.4%) was more frequent, hyperthermia, tachycardia with leucocytosis was shown in 9.5% of cases, and less frequent were the criteria of SIRS such as hyperthermia with tachycardia, in 8.9% (p≤0.05). Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 186 Fig.3a, 3b, 3c. Combinations of SIRS criteria depending on the presumed localization of infection More than half of the cases (51.8%) showed a combination of three symptoms: hyperthermia, tachycardia and leucocytosis, and 28.6% showed a combination of 2 symptoms: hyperthermia and leucocytosis, if the infection was localized in the urogenital tract (Fig. 3b). A comparative analysis of the results showed that irrespective of the localisation of infection, all patients had fever in various combinations, most frequently with tachycardia (26.8%) and leucocytosis (26.2%). Thus, all the characteristic clinical symptoms of SIRS were mostly present. Hyperthermia was the most common in all age groups. The most frequent localization of infection in BSI was in the upper respiratory tract (702), accounting for 48.1%, (p0.05); almost half as many were in the lower respiratory tract, 301 patients, accounting for 20.6%, (p0.05). In 10.8% (158) of cases, the development of septic conditions was observed in gastrointestinal diseases. Analysis of the occurrence of various combinations of SIRS criteria in the examined group of patients showed that the most frequent was a combination of two symptoms: in 62.2% for localization in the skin and soft tissues, in 61.7% in the upper respiratory tract, and in 52.5% for a source of infection in the gastrointestinal tract (p<0.05). The most frequent combination of three SIRS criteria was observed in the lower respiratory tract (53.1%) and gastrointestinal tract (42.4%). A comparative analysis of the findings showed that irrespective of the localisation of infection, all patients had fever in varying combinations, most frequently with tachycardia (26.8%) and leucocytosis (26.2%), p0.05. Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 187 Conclusions. 1. The upper respiratory tract, lower respiratory tract infections was the most frequent localization of infection in BSI. 2. Predominantly, irrespective of the localization of infection, a combination of the criteria for SIRSs of two symptoms was observed. 3. Irrespective of the localization of infection, all patients present with fever in varying combinations, most commonly with tachycardia (26.8%) and leucocytosis (26.2%). Conflict of interest The authors declare no conflict of interest. Financial support The study was conducted by the "Proof-of-principle routine diagnostic project for a Antimicrobial Resistance Surveillance" with technical and financial support of WHO. WHO was involved in the development of the POP-project protocol. WHO was not involved in the conduct of the study; data collection, management, analysis and interpretation, or in the preparation, review or approval of the manuscript. Art of Medicine Volume-1 International Medical Scientific Journal Issue-2 10.5281/zenodo.5558714 188 References 1. Singer M., Deutchman C.S., Seymour C.W., Shankar-Hari M., Annane D., Bauer M. 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