Table 1 Questions and results of the ballot for hyperinflammatory phenotype

STEROIDS

1. How appropriate is, in selected patients with refractory septic shock and severe hyperinflammatory response, the early (within 4–6 h) use of low-dose steroids (i.e. hydrocortisone 200–300 mg/day)?

APPROPRIATE

Median score 8 (IQR 8–8)

Agreement: YES

2. How appropriate is, in patients with septic shock and severe hyperinflammatory response and with the decision to use low-dose steroids (i.e. hydrocortisone 200–300 mg/day), the continuous infusion as opposed to repeated bolus infusion?

UNCERTAIN

Median score 5 (IQR 5–6)

Agreement: YES

3. How appropriate is, in patients with refractory septic shock and severe hyperinflammatory response, to withdraw (when initially administered) low-dose steroids therapy (i.e. hydrocortisone 200–300 mg/day) when patients no longer need vasopressors?

APPROPRIATE

Median score 8 (IQR 7–9)

Agreement: YES

4. How appropriate is, in patients with severe community-acquired pneumonia, the early use (within 24 h) of steroids (i.e. methylprednisolone 40 mg/day or hydrocortisone 200 mg/day)?

APPROPRIATE

Median score 7 (IQR 6–8)

Agreement: YES

5. How appropriate is, in patients with severe community-acquired pneumonia with diagnosis of influenza, the early (within 24 h) use of steroids (i.e. methylprednisolone 40 mg/day or hydrocortisone 200 mg)?

NOT APPROPRIATE

Median score 2 (IQR 1–3)

Agreement: YES

6. How appropriate is, in patients with suspected community-acquired bacterial meningitis, a very early (before or concomitant to antibiotic administration) therapy with dexamethasone (0.6 mg/kg/day for 4 days)?

APPROPRIATE

Median score 8 (IQR 8–9)

Agreement: YES

BLOOD PURIFICATION

1. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the use of high-volume haemofiltration (HVHF)?

NOT APPROPRIATE

Median score 3 (IQR 1–4)

Agreement: YES

2. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the use of extracorporeal cytokine hemadsorption?

UNCERTAIN

Median score 3 (IQR 3–5)

Agreement: NO

3. How appropriate is, in patients with septic shock with severe hyperinflammatory response and high endotoxin activity (suspected or measured), the use of endotoxin hemadsorption?

UNCERTAIN

Median score 6 (IQR 5–7)

Agreement: NO

4. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the use of Coupled Plasma Filtration Adsorption (CPFA)?

NOT APPROPRIATE

Median score 1 (IQR 1–2)

Agreement: YES

5. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the use of a blood purification technique only when used early (within 6–12 h)?

UNCERTAIN

Median score 5 (IQR 3–6)

Agreement: NO

6. How appropriate is, in patients with septic shock undergoing blood purification, the increase of antibiotic dose?

APPROPRIATE

Median score 8 (IQR 7–8)

Agreement: YES

IMMUNOGLOBULINS

1. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the early (within 6–12 h) therapy with intravenous immunoglobulins?

UNCERTAIN

Median score 6 (IQR 5–7)

Agreement: NO

2. How appropriate is, in patients with septic shock and severe hyperinflammatory response due to toxin-related syndromes (e.g. invasive meningococcal diseases, pneumococcal or meningococcal Purpura fulminans, necrotizing fasciitis/TSST, PVL necrotizing pneumonia), the very early therapy (within 6 h) with intravenous immunoglobulins?

APPROPRIATE

Median score 8 (IQR 7–8)

Agreement: YES

3. How appropriate is, in patients with septic shock and severe hyperinflammatory response and with the decision to use intravenous immunoglobulins, the use of a preparation including also IgM component?

APPROPRIATE

Median score 8 (IQR 7–9)

Agreement: YES

4. How appropriate is, in patients with septic shock and severe hyperinflammatory response due to toxin-related syndromes (e.g. invasive meningococcal diseases, pneumococcal or meningococcal Purpura fulminans, necrotizing fasciitis/TSST, PVL necrotizing pneumonia), the very early therapy (within 1–3 h) with the decision to use intravenous immunoglobulin, the use of a preparation including also IgM component?

APPROPRIATE

Median score 8 (IQR 8–9)

Agreement: YES

OTHER IMMUNOTHERAPEUTIC AGENTS

1. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the use of immunotherapeutic agents as GM-CSF?

NOT APPROPRIATE

Median score 3 (IQR 2–4)

Agreement: YES

2. How appropriate is, in patients with septic shock and severe hyperinflammatory response, the use of immunotherapeutic agents as IL7 or antiPD1-PD-L1 or IFN-g?

NOT APPROPRIATE

Median score 2 (IQR 2–4)

Agreement: YES