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Spaeth B, Taylor S, Shephard M, Reed RL, Omond R, Karnon J, Bonevski B, Rissel C, Ullah S, Noutsos T, Stephens JH, Smith JA, Wilson A, Abbenbroek B, de Courcy-Ireland E, Finfer S. Point-of-care testing for sepsis in remote Australia and for First Nations peoples. Nat Med 2024; 30:2105-2106. [PMID: 38816610 DOI: 10.1038/s41591-024-03034-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
- Brooke Spaeth
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, International Centre for Point-of-Care Testing, Adelaide, South Australia, Australia.
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia.
| | - Sean Taylor
- Northern Territory Government, Department of Health, Darwin, Northern Territory, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Mark Shephard
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, International Centre for Point-of-Care Testing, Adelaide, South Australia, Australia
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Richard L Reed
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Rodney Omond
- Northern Territory Government, Department of Health, Darwin, Northern Territory, Australia
| | - Jonathan Karnon
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Billie Bonevski
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Chris Rissel
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Darwin, Northern Territory, Australia
| | - Shahid Ullah
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Tina Noutsos
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Darwin, Northern Territory, Australia
- Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Jacqueline H Stephens
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - James A Smith
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Darwin, Northern Territory, Australia
| | - Annabelle Wilson
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Brett Abbenbroek
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Emma de Courcy-Ireland
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, International Centre for Point-of-Care Testing, Adelaide, South Australia, Australia
- Flinders University, College of Medicine and Public Health, Flinders Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Faculty of Medicine and Health Sciences, Imperial College London, London, England
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Campbell S, MacGregor K, Smith EL, Kanitkar T, Janson S, Baird RW, Currie BJ, Venkatesan S. Clinical Presentation and Outcomes Following Infection With Vibrio spp, Aeromonas spp, Chromobacterium violaceum, and Shewanella spp Water-Associated Organisms in Tropical Australia, 2015-2022. Open Forum Infect Dis 2024; 11:ofae319. [PMID: 38975250 PMCID: PMC11227229 DOI: 10.1093/ofid/ofae319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024] Open
Abstract
Background Water-associated bacterial infections cause a wide spectrum of disease. Although many of these infections are typically due to human host commensal Staphylococcal or Streptococcal spp, water exposure can result in infections with environmental gram negatives such as Vibrio spp, Aeromonas spp, Chromobacterium violaceum, and Shewanella spp (collectively VACS). Methods We performed a retrospective analysis of the epidemiology, clinical presentation, and outcomes of deep and superficial infections associated with VACS organisms in our health service between 1 January 2015 and 31 December 2023. Results We identified 317 patient episodes of infection with VACS organisms over this period. Of these, Aeromonas spp (63%) was the most common, followed by Vibrio spp (19%), Shewanella spp (13%), and C violaceum (5%). The majority were isolated from males (74.4%) and involved the lower limb (67.5%). Mild infections were more common than severe presentations, with only 15 (4.7%) admissions to the intensive care unit and 8 (2.5%) deaths. Colonization occurred in 6.9% of patients, in contrast to the perceived severity of some of these bacteria. Copathogens were common and included Staphylococcus aureus (48%) and enteric bacteria (57%). The majority of patients (60%) had no documented water exposure. Initial empiric antimicrobial therapy presumptively covered the susceptibilities of the isolated organisms in 47.3% of patients; however, a lack of VACS-covering empirical therapy was not associated with readmission. Conclusions The isolation of a VACS organism in our setting was often not associated with documented water exposure, which has implications for empiric antimicrobial therapy. Severe disease and death were uncommon.
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Affiliation(s)
- Stuart Campbell
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
| | - Kirsten MacGregor
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
- Department of Infection Sciences, North Bristol NHS Trust, Bristol, UK
| | - Emma L Smith
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Tanmay Kanitkar
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
- Department of Infection, Kings College Hospital, London, UK
| | - Sonja Janson
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
| | - Robert W Baird
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
| | - Bart J Currie
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Sudharsan Venkatesan
- Departments of Medicine and Pathology, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Darwin 0810, Australia
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Hargovan S, Groch T, Brooks J, Sivalingam S, Bond T, Carter A. Indigenous Australians critically ill with sepsis: Characteristics, outcomes, and areas for improvement. Aust Crit Care 2024; 37:548-557. [PMID: 38216417 DOI: 10.1016/j.aucc.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 11/13/2023] [Accepted: 11/24/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Aboriginal and Torres Strait Islander Australians have amongst the highest incidence of sepsis globally. OBJECTIVE The objective of this study was to describe the characteristics, short- and long-term outcomes of non-Indigenous, Aboriginal Australian and Torres Strait Islander Australians admitted with sepsis to an intensive care unit (ICU) to inform healthcare outcome improvement. METHODS A retrospective cohort study of 500 consecutive sepsis admissions to the Cairns Hospital ICU compared clinical characteristics, short-term (before ICU discharge) and long-term (2000 days posthospital discharge) outcomes. Cohort stratification was done by voluntary disclosure of Indigenous status. RESULTS Of the 442 individual admissions, 145 (33%) identified as Indigenous Australian. Indigenous and non-Indigenous Australians had similar admission Acute Physiology and Chronic Health Evaluation-3 scores (median [interquartile range]: 70 [52-87] vs. 69 [53-87], P = 0.87), but Indigenous patients were younger (53 [43-60] vs. 62 [52-73] years, P < 0.001) and were more likely to have chronic comorbidities such as type 2 diabetes (58% vs. 23%, P < 0.001), cardiovascular disease (40% vs 28%, P = 0.01), and renal disease (39% vs. 10%, P < 0.001). They also had more hazardous healthcare behaviours such as smoking (61% vs. 45%, P = 0.002) and excess alcohol consumption (40% vs. 18%, P < 0.001). Despite this, the case-fatality rate of Indigenous and non-Indigenous Australians before ICU discharge (13% vs. 12%, P = 0.75) and 2000 days post hospital discharge (25 % vs. 28 %, P = 0.40) was similar. Crucially, however, Indigenous Australians died younger both in the ICU (median [interquartile range] 54 (50-60) vs. 70 [61-76], P < 0.0001) and 2000 days post hospital discharge (58 [53-63] vs. 70 [63-77] years, P < 0.0001). CONCLUSIONS Although Indigenous Australians critically ill with sepsis have similar short and long-term mortality rates, they present to hospital, die in-hospital, and die post-discharge significantly younger. Unique cohort characteristics may explain these outcomes, and assist clinicians, researchers and policy-makers in targeting interventions to these characteristics to best reduce the burden of sepsis in this cohort and improve their healthcare outcomes.
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Affiliation(s)
- Satyen Hargovan
- Department of Medicine, Cairns Hospital and Hinterland Health Service, Cairns, Queensland, Australia; College of Medicine and Dentistry, James Cook University, Queensland, Australia.
| | - Taissa Groch
- Department of Anaesthetics, Cairns Hospital, Cairns, Queensland, Australia
| | - James Brooks
- Department of Anaesthetics, Gloucestershire Royal Hospital, Gloucester, United Kingdom
| | - Sayonne Sivalingam
- Department of Anaesthetics, Cairns Hospital, Cairns, Queensland, Australia
| | - Tatum Bond
- Department of Emergency Medicine, Cairns Hospital and Hinterland Health Service, Cairns, Queensland, Australia
| | - Angus Carter
- Department of Intensive Care Medicine, Bendigo Hospital, Victoria, Australia
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Todorovic Markovic M, Todorovic Mitic M, Ignjatovic A, Gottfredsson M, Gaini S. Mortality in Community-Acquired Sepsis and Infections in the Faroe Islands-A Prospective Observational Study. Infect Dis Rep 2024; 16:448-457. [PMID: 38804443 PMCID: PMC11130956 DOI: 10.3390/idr16030033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024] Open
Abstract
The aim of this study was to collect data and analyze mortality among patients hospitalized with community-acquired infections in the Faroe Islands. A prospective observational study was conducted in the Medical Department of the National Hospital of the Faroe Islands from October 2013 to April 2015. Cumulative all-cause, in-hospital, short-term, intermediate-term and long-term mortality rates were calculated. Kaplan-Meier survival curves comparing infection-free patients with infected patients of all severities and different age groups are presented. A log-rank test was used to compare groups. Mortality hazard ratios were calculated for subgroups using Cox regression multivariable models. There were 1309 patients without infection and 755 patients with infection. There were 51% female and 49% male patients. Mean age was 62.73 ± 19.71. Cumulative all-cause mortality and in-hospital mortality were highest in more severe forms of infection. This pattern remained the same for short-term mortality in the model adjusted for sex and age, while there were no significant differences among the various infection groups in regard to intermediate- or long-term survival after adjustment. Overall and short-term mortality rates were highest among those with severe manifestations of infection and those with infection compared to infection-free patients.
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Affiliation(s)
- Marija Todorovic Markovic
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Infectious Diseases, Odense University Hospital, 5000 Odense, Denmark
- Department of Medicine, Infectious Diseases Division, National Hospital of the Faroe Islands, JC. Svabosgøta 41-49, 100 Torshavn, Faroe Islands
| | | | - Aleksandra Ignjatovic
- Department of Medical Statistics and Informatics, School of Medicine, University of Nis, 18108 Nis, Serbia
| | - Magnús Gottfredsson
- Department of Infectious Diseases, Landspitali University Hospital, 105 Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, 101 Reykjavik, Iceland
| | - Shahin Gaini
- Department of Infectious Diseases, Odense University Hospital, 5000 Odense, Denmark
- Department of Medicine, Infectious Diseases Division, National Hospital of the Faroe Islands, JC. Svabosgøta 41-49, 100 Torshavn, Faroe Islands
- Faculty of Health Sciences, University of the Faroe Islands, 100 Torshavn, Faroe Islands
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Camilleri S, Tsai D, Langham F, Ullah S, Chiong F. Epidemiology, clinical outcomes and risk factors of third-generation cephalosporin-resistant Escherichia coli hospitalized infections in remote Australia-a case-control study. JAC Antimicrob Resist 2023; 5:dlad138. [PMID: 38115858 PMCID: PMC10729849 DOI: 10.1093/jacamr/dlad138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023] Open
Abstract
Background Incidence of third-generation cephalosporin-resistant (3GCR) Escherichia coli infections has increased in remote Australia from 2012 to 2018. Objectives To describe the epidemiology of 3GCR E. coli in Central Australia. Methods A case-control study was conducted in the primary Central Australian hospital. Patient characteristics, antibiotic usage and clinical outcomes were compared between adult hospitalizations with 3GCR and susceptible E. coli isolates in 2018-19. Poisson regression was used to compare the incidence of 3GCR hospitalizations between Indigenous and non-Indigenous individuals. Patient characteristics and antibiotic usage were tested for associations with 3GCR isolates using univariate analysis. Results A total of 889 E. coli isolates were identified, of which 187 (21%) were 3GCR. The incidence of 3GCR E. coli infection was 2.15 per 1000 person-years, with an incidence rate ratio of 6.8 (95% CI 4.6-10.1) between Indigenous and non-Indigenous individuals. When compared with the control group, 3GCR E. coli infections were associated with a higher Charlson comorbidity index (CCI ≥3 in 30.7% versus 15.0%, P < 0.001) and were more commonly healthcare associated (52.4% versus 26.7%, P < 0.001). A higher 1 year mortality was observed in the 3GCR group after adjustment for comorbidity (OR = 4.43, P = 0.002), but not at 30 days (2.4% versus 0.0%, P = 0.2). The 3GCR group used more antibiotics in the past 3 months (OR = 5.75, P < 0.001) and 12 months (OR = 3.65, P < 0.001). Conclusions 3GCR E. coli infections in remote Australia disproportionally affect Indigenous peoples and are associated with a high burden of comorbidities and antibiotic use. Strategies to enhance antimicrobial stewardship should be considered in this remote setting.
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Affiliation(s)
- Shayne Camilleri
- Department of Medicine, Alice Springs Hospital, Alice Springs, NT, Australia
- Department of Infectious Diseases, Austin Health, Melbourne, VIC, Australia
| | - Danny Tsai
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
- Pharmacy Department, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Freya Langham
- Department of Medicine, Alice Springs Hospital, Alice Springs, NT, Australia
- Department of Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - Shahid Ullah
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Fabian Chiong
- Department of Medicine, Alice Springs Hospital, Alice Springs, NT, Australia
- Department of Infectious Diseases, Canberra Hospital, Canberra, ACT, Australia
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Prinsloo C, Smith S, Law M, Hanson J. The Epidemiological, Clinical, and Microbiological Features of Patients with Burkholderia pseudomallei Bacteraemia-Implications for Clinical Management. Trop Med Infect Dis 2023; 8:481. [PMID: 37999600 PMCID: PMC10675116 DOI: 10.3390/tropicalmed8110481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023] Open
Abstract
Patients with melioidosis are commonly bacteraemic. However, the epidemiological characteristics, the microbiological findings, and the clinical associations of Burkholderia pseudomallei bacteraemia are incompletely defined. All cases of culture-confirmed melioidosis at Cairns Hospital in tropical Australia between January 1998 and June 2023 were reviewed. The presence of bacteraemia was determined and correlated with patient characteristics and outcomes; 332/477 (70%) individuals in the cohort were bacteraemic. In multivariable analysis, immunosuppression (odds ratio (OR) (95% confidence interval (CI)): (2.76 (1.21-6.27), p = 0.02), a wet season presentation (2.27 (1.44-3.59), p < 0.0001) and male sex (1.69 (1.08-2.63), p = 0.02), increased the likelihood of bacteraemia. Patients with a skin or soft tissue infection (0.32 (0.19-0.57), p < 0.0001) or without predisposing factors for melioidosis (0.53 (0.30-0.93), p = 0.03) were less likely to be bacteraemic. Bacteraemia was associated with intensive care unit admission (OR (95%CI): 4.27 (2.35-7.76), p < 0.0001), and death (2.12 (1.04-4.33), p = 0.04). The median (interquartile range) time to blood culture positivity was 31 (26-39) hours. Patients with positive blood cultures within 24 h were more likely to die than patients whose blood culture flagged positive after this time (OR (95%CI): 11.05 (3.96-30.83), p < 0.0001). Bacteraemia portends a worse outcome in patients with melioidosis. Its presence or absence might be used to help predict outcomes in cases of melioidosis and to inform optimal clinical management.
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Affiliation(s)
- Carmen Prinsloo
- College of Medicine and Dentistry, James Cook University, Cairns Hospital, Cairns, QLD 4870, Australia
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia;
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, NSW 2042, Australia;
| | - Josh Hanson
- Department of Medicine, Cairns Hospital, Cairns, QLD 4870, Australia;
- The Kirby Institute, University of New South Wales, Sydney, NSW 2042, Australia;
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia
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Bowker SL, Williams K, Volk A, Auger L, Lafontaine A, Dumont P, Wingert A, Davis A, Bialy L, Wright E, Oster RT, Bagshaw SM. Incidence and outcomes of critical illness in indigenous peoples: a systematic review and meta-analysis. Crit Care 2023; 27:285. [PMID: 37443118 PMCID: PMC10339531 DOI: 10.1186/s13054-023-04570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/07/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Indigenous Peoples experience health inequities and racism across the continuum of health services. We performed a systematic review and meta-analysis of the incidence and outcomes of critical illness among Indigenous Peoples. METHODS We searched Ovid MEDLINE/PubMed, Ovid EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials (inception to October 2022). Observational studies, case series of > 100 patients, clinical trial arms, and grey literature reports of Indigenous adults were eligible. We assessed risk of bias using the Newcastle-Ottawa Scale and appraised research quality from an Indigenous perspective using the Aboriginal and Torres Strait Islander Quality Assessment Tool. ICU mortality, ICU length of stay, and invasive mechanical ventilation (IMV) were compared using risk ratios and mean difference (MD) for dichotomous and continuous outcomes, respectively. ICU admission was synthesized descriptively. RESULTS Fifteen studies (Australia and/or New Zealand [n = 12] and Canada [n = 3]) were included. Risk of bias was low in 10 studies and moderate in 5, and included studies had minimal incorporation of Indigenous perspectives or consultation. There was no difference in ICU mortality between Indigenous and non-Indigenous (RR 1.14, 95%CI 0.98 to 1.34, I2 = 87%). We observed a shorter ICU length of stay among Indigenous (MD - 0.25; 95%CI, - 0.49 to - 0.00; I2 = 95%) and a higher use for IMV among non-Indigenous (RR 1.10; 95%CI, 1.06 to 1.15; I2 = 81%). CONCLUSION Research on Indigenous Peoples experience with critical care is poorly characterized and has rarely included Indigenous perspectives. ICU mortality between Indigenous and non-Indigenous populations was similar, while there was a shorter ICU length of stay and less mechanical ventilation use among Indigenous patients. Systematic Review Registration PROSPERO CRD42021254661; Registered: 12 June, 2021.
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Affiliation(s)
- Samantha L. Bowker
- Critical Care Strategic Clinical Network™, Alberta Health Services, 2-124 Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, 2-124E Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
| | - Kienan Williams
- Indigenous Wellness Core, Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
| | - Auriele Volk
- Indigenous Medical and Dental Students Association, Faculty of Medicine and Dentistry, University of Alberta, Katz Group Centre for Pharmacy and Health Research, 1-002, Edmonton, AB T6G 2E1 Canada
- Indigenous Peoples and Critical Care in Alberta Advisory Committee, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
| | - Leonard Auger
- Indigenous Peoples and Critical Care in Alberta Advisory Committee, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
| | - Alika Lafontaine
- Indigenous Peoples and Critical Care in Alberta Advisory Committee, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
| | - Paige Dumont
- Indigenous Peoples and Critical Care in Alberta Advisory Committee, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, University of Alberta, Room 4-496A, Edmonton Clinic Health Academic, 11405 – 87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Amanda Davis
- Indigenous Wellness Core, Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, University of Alberta, Room 4-496A, Edmonton Clinic Health Academic, 11405 – 87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Erica Wright
- Alberta Research Centre for Health Evidence, University of Alberta, Room 4-496A, Edmonton Clinic Health Academic, 11405 – 87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Richard T. Oster
- Indigenous Wellness Core, Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
| | - Sean M. Bagshaw
- Critical Care Strategic Clinical Network™, Alberta Health Services, 2-124 Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, 2-124E Clinical Science Building, 8440-112 Street NW, Edmonton, AB T6G 2B7 Canada
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Zhang W, Kedzierski L, Chua BY, Mayo M, Lonzi C, Rigas V, Middleton BF, McQuilten HA, Rowntree LC, Allen LF, Purcell RA, Tan HX, Petersen J, Chaurasia P, Mordant F, Pogorelyy MV, Minervina AA, Crawford JC, Perkins GB, Zhang E, Gras S, Clemens EB, Juno JA, Audsley J, Khoury DS, Holmes NE, Thevarajan I, Subbarao K, Krammer F, Cheng AC, Davenport MP, Grubor-Bauk B, Coates PT, Christensen B, Thomas PG, Wheatley AK, Kent SJ, Rossjohn J, Chung AW, Boffa J, Miller A, Lynar S, Nelson J, Nguyen THO, Davies J, Kedzierska K. Robust and prototypical immune responses toward COVID-19 vaccine in First Nations peoples are impacted by comorbidities. Nat Immunol 2023; 24:966-978. [PMID: 37248417 PMCID: PMC10232372 DOI: 10.1038/s41590-023-01508-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/10/2023] [Indexed: 05/31/2023]
Abstract
High-risk groups, including Indigenous people, are at risk of severe COVID-19. Here we found that Australian First Nations peoples elicit effective immune responses to COVID-19 BNT162b2 vaccination, including neutralizing antibodies, receptor-binding domain (RBD) antibodies, SARS-CoV-2 spike-specific B cells, and CD4+ and CD8+ T cells. In First Nations participants, RBD IgG antibody titers were correlated with body mass index and negatively correlated with age. Reduced RBD antibodies, spike-specific B cells and follicular helper T cells were found in vaccinated participants with chronic conditions (diabetes, renal disease) and were strongly associated with altered glycosylation of IgG and increased interleukin-18 levels in the plasma. These immune perturbations were also found in non-Indigenous people with comorbidities, indicating that they were related to comorbidities rather than ethnicity. However, our study is of a great importance to First Nations peoples who have disproportionate rates of chronic comorbidities and provides evidence of robust immune responses after COVID-19 vaccination in Indigenous people.
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Affiliation(s)
- Wuji Zhang
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Lukasz Kedzierski
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
- Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Brendon Y Chua
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Mark Mayo
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Claire Lonzi
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Vanessa Rigas
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Bianca F Middleton
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Hayley A McQuilten
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Louise C Rowntree
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Lilith F Allen
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Ruth A Purcell
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Hyon-Xhi Tan
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Jan Petersen
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Priyanka Chaurasia
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Francesca Mordant
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Mikhail V Pogorelyy
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Griffith B Perkins
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Eva Zhang
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Macquarie University, Sydney, New South Wales, Australia
| | - Stephanie Gras
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- Department of Biochemistry and Chemistry, La Trobe Institute for Molecular Science, La Trobe University, Bundoora, Victoria, Australia
| | - E Bridie Clemens
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Jennifer A Juno
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Jennifer Audsley
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David S Khoury
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Irani Thevarajan
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Services, Royal Melbourne Hospital and Doherty Department, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Kanta Subbarao
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
- World Health Organization Collaborating Centre for Reference and Research on Influenza, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash Infectious Diseases, Monash Health and School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Miles P Davenport
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Branka Grubor-Bauk
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - P Toby Coates
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Britt Christensen
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Paul G Thomas
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Adam K Wheatley
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - Stephen J Kent
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
- Australian Research Council Centre of Excellence in Convergent Bio-Nano Science and Technology, University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Infectious Diseases Department, Alfred Health, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jamie Rossjohn
- Infection and Immunity Program and Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Amy W Chung
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - John Boffa
- Central Australian Aboriginal Congress, Alice Springs, Northern Territory, Australia
| | - Adrian Miller
- Indigenous Engagement, CQUniversity, Townsville, Queensland, Australia
| | - Sarah Lynar
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, Northern Territory, Australia
| | - Jane Nelson
- Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Thi H O Nguyen
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia.
| | - Jane Davies
- Menzies School of Health Research, Darwin, Northern Territory, Australia.
| | - Katherine Kedzierska
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia.
- Center for Influenza Disease and Emergence Response, Melbourne, Victoria, Australia.
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9
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Tsai D, Secombe P, Chiong F, Ullah S, Lipman J, Hewagama S. Prediction accuracy of commonly used pneumonia severity scores in Aboriginal patients with severe community-acquired pneumonia: a retrospective study. Intern Med J 2023; 53:51-60. [PMID: 34524713 DOI: 10.1111/imj.15534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/18/2021] [Accepted: 09/12/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Severe community-acquired pneumonia (SCAP) is highly prevalent in the Aboriginal population. Few pneumonia severity scores are validated in this population. AIMS To assess the prediction accuracy of pneumonia severity scores in Aboriginal patients with SCAP and to identify risk factors for poor prognosis. METHODS Retrospective cohort study examining Aboriginal patients admitted to the intensive care unit with confirmed SCAP between January 2011 and December 2014. Severity scores were calculated for SMARTCOP (systolic blood pressure, multi-lobar, albumin, respiratory rate, tachycardia, confusion, oxygenation and arterial pH), SMARTACOP (systolic blood pressure, multi-lobar, albumin, respiratory rate, tachycardia, Aboriginal status, confusion, oxygenation and arterial pH), CURB-65 (confusion, urea, respiratory rate, blood pressure and age ≥65 years), pneumonia severity index, Infectious Diseases Society of America and American Thoracic Society SCAP, and Acute Physiology and Chronic Health Evaluation (APACHE) II/III using medical records. Prediction accuracy of 30-day mortality and requirement for intensive respiratory and/or vasoactive support (IRVS) were assessed using logistic regression and the area under the receiver operating characteristic curve (AUROC). Multivariate analysis was used to test associations between poor prognosis and demographic/clinical variables. RESULTS A total of 203 cases (49% women) was identified. Thirty-day mortality was 6.4% (n = 13), and 53% (n = 107) required IRVS. None of the tested pneumonia severity scores accurately predicted mortality. SMARTCOP and SMARTACOP predicted IRVS requirement with the highest diagnostic accuracy, but only achieved acceptable discrimination (P <0.001 and <0.001; AUROC = 0.74 and 0.75 respectively). APACHE II/III predicted both mortality (P = 0.003 and 0.001; AUROC = 0.74 and 0.73 respectively) and IRVS requirement (P <0.001 and <0.001; AUROC = 0.72 and 0.73 respectively). Multivariate analysis associated mortality with male gender, cirrhosis, immunosuppression and acidaemia, and IRVS requirement with multi-lobar pneumonia, hypotension and tachypnoea. Multivariate analysis for mortality and IRVS requirement achieved an AUROC of 0.93 and 0.87 respectively. CONCLUSION None of the pneumonia severity scores accurately predicted mortality. We recommend SMARTACOP to predict IRVS requirement in Aboriginal patients with SCAP. Given Aboriginal patients are over-represented in Australian intensive care units, a new score is warranted for this understudied population.
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Affiliation(s)
- Danny Tsai
- University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Rural and Remote Health NT, Flinders University, Alice Springs, Northern Territory, Australia.,Pharmacy Department, Alice Springs Hospital, Central Australian Health Service, Alice Springs, Northern Territory, Australia
| | - Paul Secombe
- Department of Intensive Care Medicine, Alice Springs Hospital, Central Australian Health Service, Alice Springs, Northern Territory, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fabian Chiong
- Department of Medicine, Alice Springs Hospital, Central Australian Health Service, Alice Springs, Northern Territory, Australia
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,ICU and Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Saliya Hewagama
- Department of Medicine, Alice Springs Hospital, Central Australian Health Service, Alice Springs, Northern Territory, Australia.,Department of Infectious Diseases, The Northern Hospital, Melbourne, Victoria, Australia
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10
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Barker N, Scott IA, Seaton R, Mehta N, Kalke VR, Redpath L. Recognition and Management of Hospital-Acquired Sepsis Among Older General Medical Inpatients: A Multi-Site Retrospective Study. Int J Gen Med 2023; 16:1039-1046. [PMID: 36987405 PMCID: PMC10039973 DOI: 10.2147/ijgm.s400839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023] Open
Abstract
Purpose To assess accuracy of early diagnosis, appropriateness and timeliness of response, and clinical outcomes of older general medical inpatients with hospital-acquired sepsis. Methods Hospital abstracts of inpatient encounters from seven digital Queensland public hospitals between July 2018 and September 2020 were screened retrospectively for diagnoses of hospital-acquired sepsis. Electronic medical records were retrieved and cases meeting selection criteria and classified as confirmed or probable sepsis using pre-specified criteria were included. Investigations and treatments following the first digitally generated alert of clinical deterioration were compared with a best practice sepsis care bundle. Outcome measures comprised 30-day all-cause mortality after deterioration, and unplanned readmissions at 14 days after discharge. Results Of the 169 screened care episodes, 59 comprised probable or confirmed cases of sepsis treated by general medicine teams at the time of initial deterioration. Of these, 43 (72.9%) had no mention of sepsis in the differential diagnosis on first medical review, and only 38 (64%) were managed as having sepsis. Each care bundle component of blood cultures, serum lactate, and intravenous fluid resuscitation and antibiotics was only delivered in approximately 30% of cases, and antibiotic administration was delayed more than an hour in 28 of 38 (73.7%) cases. Conclusion Early recognition of sepsis and timely implementation of care bundles are challenging in older general medical patients. Education programs in sepsis care standards targeting nurses and junior medical staff, closer patient monitoring, and post-discharge follow-up may improve patient outcomes.
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Affiliation(s)
- Nicholas Barker
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Correspondence: Ian A Scott, Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, 4102, Australia, Tel +61-7-31767355, Fax +61-7-31765214, Email
| | - Robert Seaton
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
| | - Naitik Mehta
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
| | - Vikrant R Kalke
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
| | - Lyndell Redpath
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
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11
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Hilton RS, Hauschildt K, Shah M, Kowalkowski M, Taylor S. The Assessment of Social Determinants of Health in Postsepsis Mortality and Readmission: A Scoping Review. Crit Care Explor 2022; 4:e0722. [PMID: 35928537 PMCID: PMC9345631 DOI: 10.1097/cce.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To summarize knowledge and identify gaps in evidence about the relationship between social determinants of health (SDH) and postsepsis outcomes. DATA SOURCES We conducted a comprehensive search of PubMed/Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, and the Cochrane Library. STUDY SELECTION We identified articles that evaluated SDH as risk factors for mortality or readmission after sepsis hospitalization. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION We dual-extracted study characteristics with specific focus on measurement, reporting, and interpretation of SDH variables. DATA SYNTHESIS Of 2,077 articles screened, 103 articles assessed risk factors for postsepsis mortality or readmission. Of these, 28 (27%) included at least one SDH variable. Inclusion of SDH in studies assessing postsepsis adverse outcomes increased over time. The most common SDH evaluated was race/ethnicity (n = 21, 75%), followed by payer type (n = 10, 36%), and income/wealth (n = 9, 32%). Of the studies including race/ethnicity, nine (32%) evaluated no other SDH. Only one study including race/ethnicity discussed the use of this variable as a surrogate for social disadvantage, and none specifically discussed structural racism. None of the studies specifically addressed methods to validate the accuracy of SDH or handling of missing data. Eight (29%) studies included a general statement that missing data were infrequent. Several studies reported independent associations between SDH and outcomes after sepsis discharge; however, these findings were mixed across studies. CONCLUSIONS Our review suggests that SDH data are underutilized and of uncertain quality in studies evaluating postsepsis adverse events. Transparent and explicit ontogenesis and data models for SDH data are urgently needed to support research and clinical applications with specific attention to advancing our understanding of the role racism and racial health inequities in postsepsis outcomes.
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Affiliation(s)
- Ryan S Hilton
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Katrina Hauschildt
- Center for Clinical Management and Research, VA Ann Arbor Health Care System, Ann Arbor, MI
| | - Milan Shah
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
| | - Stephanie Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine Atrium Health Enterprise, Charlotte, NC
- Critical Illness, Injury, and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, NC
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12
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Brinkworth JF, Shaw JG. On race, human variation, and who gets and dies of sepsis. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2022. [PMCID: PMC9544695 DOI: 10.1002/ajpa.24527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jessica F. Brinkworth
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
- Department of Evolution, Ecology and Behavior University of Illinois Urbana‐Champaign Urbana Illinois USA
| | - J. Grace Shaw
- Department of Anthropology University of Illinois Urbana‐Champaign Urbana Illinois USA
- Carl R. Woese Institute for Genomic Biology University of Illinois at Urbana‐Champaign Urbana Illinois USA
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13
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Xu C, Goh KL, Abeyaratne A, Priyadarshana K. Induction therapy and outcome of proliferative lupus nephritis in the top end of Northern Australia - a single centre study retrospective study. BMC Nephrol 2022; 23:235. [PMID: 35787253 PMCID: PMC9254616 DOI: 10.1186/s12882-022-02849-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 06/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Lupus nephritis is a common manifestation of Systemic Lupus Erythematosus. Mycophenolate is recommended by guidelines for induction therapy in patients with proliferative lupus nephritis and nephrotic range proteinuria Class V lupus nephritis. Indigenous Australians suffer disproportionally from systemic lupus erythematosus compared to non-Indigenous Australians (Anstey et al., Aust N Z J Med 23:646–651, 1993; Segasothy et al., Lupus 10:439–444, 2001; Bossingham, Lupus 12:327–331, 2003; Grennan et al., Aust N Z J Med 25:182–183, 1995). Methods We retrospectively identified patients with newly diagnosed biopsy-proven class III lupus nephritis, class IV lupus nephritis and class V lupus nephritis with nephrotic range proteinuria from 1st Jan 2010 to 31st Dec 2019 in our institution and examined for the patterns of prescribed induction therapy and clinical outcome. The primary efficacy outcome of interest was the incidence of complete response (CR) and partial response (PR) at one-year post diagnosis as defined by the Kidney Disease: Improving Global Outcome (KDIGO) guideline. Secondary efficacy outcome was a composite of renal adverse outcome in the follow-up period. Adverse effect outcome of interest was any hospitalisations secondary to infections in the follow-up period. Continuous variables were compared using Student’s t-test or Mann–Whitney U-test. Categorical variables were summarised using frequencies and percentages and assessed by Fisher’s exact test. Time-to-event data was compared using the Kaplan–Meier method and Log-rank test. Count data were assessed using the Poisson’s regression method and expressed as incident rate ratio. Results Twenty of the 23 patients included in the analysis were managed with mycophenolate induction upfront. Indigenous Australian patients (N = 15), compared to non-Indigenous patients (N = 5) received lower cumulative dose of mycophenolate mofetil over the 24 weeks (375 g vs. 256 g, p < 0.05), had a non-significant lower incidence of complete remission at 12 months (60% vs. 40%, p = 0.617), higher incidence of composite renal adverse outcome (0/5 patients vs. 5/15 patients, p = 0.20) and higher incidence of infection related hospitalisations, (incident rate ratio 3.66, 95% confidence interval 0.89–15.09, p = 0.073). Conclusion Mycophenolate as upfront induction in Indigenous Australian patients were associated with lower incidence of remission and higher incidence of adverse outcomes. These observations bring the safety and efficacy profile of mycophenolate in Indigenous Australians into question.
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Affiliation(s)
- Chi Xu
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia. .,Department of Renal Medicine, Royal Darwin Hospital, Rockland Drive, Tiwi, NT, 0810, Australia.
| | - Kim Ling Goh
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Asanga Abeyaratne
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia.,Flinders University and Northern Territory Medical Program, Royal Darwin Hospital Campus, Darwin, NT, Australia
| | - Kelum Priyadarshana
- Department of Nephrology, Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
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14
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Spoden M, Hartog CS, Schlattmann P, Freytag A, Ostermann M, Wedekind L, Storch J, Reinhart K, Günster C, Fleischmann-Struzek C. Occurrence and Risk Factors for New Dependency on Chronic Care, Respiratory Support, Dialysis and Mortality in the First Year After Sepsis. Front Med (Lausanne) 2022; 9:878337. [PMID: 35665356 PMCID: PMC9162443 DOI: 10.3389/fmed.2022.878337] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/27/2022] [Indexed: 12/14/2022] Open
Abstract
Sepsis survival is associated with adverse outcomes. Knowledge about risk factors for adverse outcomes is lacking. We performed a population-based cohort study of 116,507 survivors of hospital-treated sepsis identified in health claims data of a German health insurance provider. We determined the development and risk factors for long-term adverse events: new dependency on chronic care, chronic dialysis, long-term respiratory support, and 12-month mortality. At-risk patients were defined by absence of these conditions prior to sepsis. Risk factors were identified using simple and multivariable logistic regression analyses. In the first year post-sepsis, 48.9% (56,957) of survivors had one or more adverse outcome, including new dependency on chronic care (31.9%), dialysis (2.8%) or respiratory support (1.6%), and death (30.7%). While pre-existing comorbidities adversely affected all studied outcomes (>4 comorbidities: OR 3.2 for chronic care, OR 4.9 for dialysis, OR 2.7 for respiratory support, OR 4.7 for 12-month mortality), increased age increased the odds for chronic care dependency and 12-month mortality, but not for dialysis or respiratory support. Hospital-acquired and multi-resistant infections were associated with increased risk of chronic care dependency, dialysis, and 12-month mortality. Multi-resistant infections also increased the odds of respiratory support. Urinary or respiratory infections or organ dysfunction increased the odds of new dialysis or respiratory support, respectively. Central nervous system infection and organ dysfunction had the highest OR for chronic care dependency among all infections and organ dysfunctions. Our results imply that patient- and infection-related factors have a differential impact on adverse life changing outcomes after sepsis. There is an urgent need for targeted interventions to reduce the risk.
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Affiliation(s)
- Melissa Spoden
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - Christiane S. Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
- Klinik Bavaria, Kreischa, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Antje Freytag
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Lisa Wedekind
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Josephine Storch
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Günster
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - Carolin Fleischmann-Struzek
- Center for Sepsis Control and Care, Jena University Hospital/Friedrich Schiller University Jena, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- *Correspondence: Carolin Fleischmann-Struzek
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15
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Donaldson LH, Hammond NE, Agarwal S, Taylor S, Bompoint S, Coombes J, Bennett-Brook K, Bellomo R, Myburgh J, Venkatesh B. Outcomes following severe septic shock in a cohort of Aboriginal and Torres Strait Islander people: a nested cohort study from the ADRENAL trial. CRIT CARE RESUSC 2022; 24:20-28. [PMID: 38046842 PMCID: PMC10692597 DOI: 10.51893/2022.1.oa3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To describe the pattern of acute illness and 6-month mortality and health-related quality-of-life outcomes for a cohort of Aboriginal and Torres Strait Islander patients presenting with septic shock. Design: Nested cohort study of Aboriginal and Torres Strait Islander participants recruited to a large randomised controlled trial of corticosteroid treatment in patients with septic shock. Setting: Royal Darwin Hospital, Northern Territory. Participants: All Aboriginal and Torres Strait Islander patients recruited to the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial at Royal Darwin Hospital were compared with a non-Indigenous cohort drawn from the same site, and a cohort matched for age, sex and severity of disease. Main outcome measures: Mortality at 90 days and 6 months, time to shock resolution, mechanical ventilation requirement, renal replacement therapy requirement, and five-domain, five-level EuroQol questionnaire (EQ-5D-5L) score at 6 months. Results: Aboriginal and Torres Strait Islander patients had significantly reduced risk of death at 90 days when compared with non-Indigenous patients recruited to ADRENAL at Royal Darwin Hospital (12/60 v 23/62; adjusted odds ratio, 0.40 [95% CI, 0.17 to 0.94]) which was robust to additional adjustment for baseline covariates (odds ratio, 0.35 [95% CI, 0.14 to 0.90]). When compared with the matched population drawn from the broader ADRENAL cohort, there was no significant difference in 90-day mortality (12/60 v 16/61; adjusted odds ratio, 1.43 [95% CI, 0.60 to 3.39]; P = 0.42). Only nine Aboriginal and Torres Strait Islander patients provided 6-month health-related quality-of-life data. Conclusions: Aboriginal and Torres Strait Islander patients had reduced risk of death at 90 days when compared with non- Indigenous patients recruited to the ADRENAL trial at Royal Darwin Hospital, which was robust to adjustment for covariates, but similar outcomes when compared with a cohort matched for age, sex and severity of disease.
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Affiliation(s)
- Lachlan H Donaldson
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Naomi E Hammond
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sidharth Agarwal
- Intensive Care Unit, Royal Darwin Hospital, Casuarina, NT, Australia
| | - Sean Taylor
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Severine Bompoint
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Julieann Coombes
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Keziah Bennett-Brook
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - John Myburgh
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Department of Intensive Care Medicine, St George Hospital, Sydney, NSW, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
- The Wesley Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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16
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Thompson KJ, Finfer SR, Coombes J, Eades S, Hunter K, Leong RNF, Lewis E, Liu B. Incidence and outcomes of sepsis in Aboriginal and Torres Strait Islander and non-Indigenous residents of New South Wales: population-based cohort study. CRIT CARE RESUSC 2021; 23:337-345. [PMID: 38046084 PMCID: PMC10692574 DOI: 10.51893/2021.3.oa11] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To estimate the incidence and outcomes of sepsis hospitalisations in Aboriginal and Torres Strait Islander and non-Indigenous residents of New South Wales. Design and participants: Prospective cohort study of residents aged 45 years and older, recruited between 2006 and 2009, and followed for hospitalisation for sepsis. Main outcome measures: Incidence and hazard ratio (HR) of sepsis hospitalisation and intensive care unit (ICU) admission identified using International Classification of Diseases (10th revision) coding on discharge data. Length of stay, readmission and mortality in those admitted for sepsis. Results: Of 264 678 participants, 1928 (0.7%) identified as Aboriginal and/or Torres Strait Islander. Sepsis hospitalisation was higher in Aboriginal and Torres Strait Islander participants (8.67 v 6.12 per 1000 person-years; age- and sex-adjusted HR, 2.35; 95% CI, 1.98-2.80) but was attenuated after adjusting for sociodemographic factors, health behaviour and comorbidities (adjusted HR, 1.56; 95% CI, 1.31-1.86). Among those hospitalised for sepsis, after adjusting for age and sex, there were no differences between the proportions of Aboriginal and Torres Strait Islander and non-Indigenous participants admitted to an ICU (18.0% v 16.1%; P = 0.42) or deceased at 1 year (36.1% v 36.8%; P = 0.92). Aboriginal and Torres Strait Islander participants had shorter lengths of hospital stay (9.98 v 11.72 days; P < 0.001) and ICU stay (4.38 v 6.35 days; P < 0.001) than non-Indigenous participants. Overall, more than 70% of participants were readmitted to hospital within 1 year. Conclusion: We found that the rate of sepsis hospitalisation in NSW was higher for Aboriginal and Torres Strait Islander adults. Culturally appropriate, community-led strategies targeting chronic disease prevention and the social determinants of health may reduce this gap. Preventing readmission following sepsis is a priority for all Australians.
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Affiliation(s)
| | - Simon R. Finfer
- The George Institute for Global Health, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- School of Public Health, Imperial College London, London, UK
| | | | - Sandra Eades
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Asutralia
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Kate Hunter
- The George Institute for Global Health, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Ebony Lewis
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Faculty of Science, University of New South Wales, Sydney, NSW, Australia
| | - Bette Liu
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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Currie BJ, Mayo M, Ward LM, Kaestli M, Meumann EM, Webb JR, Woerle C, Baird RW, Price RN, Marshall CS, Ralph AP, Spencer E, Davies J, Huffam SE, Janson S, Lynar S, Markey P, Krause VL, Anstey NM. The Darwin Prospective Melioidosis Study: a 30-year prospective, observational investigation. THE LANCET. INFECTIOUS DISEASES 2021; 21:1737-1746. [PMID: 34303419 DOI: 10.1016/s1473-3099(21)00022-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 12/14/2020] [Accepted: 01/11/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND The global distribution of melioidosis is under considerable scrutiny, with both unmasking of endemic disease in African and Pacific nations and evidence of more recent dispersal in the Americas. Because of the high incidence of disease in tropical northern Australia, The Darwin Prospective Melioidosis Study commenced in October, 1989. We present epidemiology, clinical features, outcomes, and bacterial genomics from this 30-year study, highlighting changes in the past decade. METHODS The present study was a prospective analysis of epidemiological, clinical, and laboratory data for all culture-confirmed melioidosis cases from the tropical Northern Territory of Australia from Oct 1, 1989, until Sept 30, 2019. Cases were identified on the basis of culture-confirmed melioidosis, a laboratory-notifiable disease in the Northern Territory of Australia. Patients who were culture-positive were included in the study. Multivariable analysis determined predictors of clinical presentations and outcome. Incidence, survival, and cluster analyses were facilitated by population and rainfall data and genotyping of Burkholderia pseudomallei, including multilocus sequence typing and whole-genome sequencing. FINDINGS There were 1148 individuals with culture-confirmed melioidosis, of whom 133 (12%) died. Median age was 50 years (IQR 38-60), 48 (4%) study participants were children younger than 15 years of age, 721 (63%) were male individuals, and 600 (52%) Indigenous Australians. All but 186 (16%) had clinical risk factors, 513 (45%) had diabetes, and 455 (40%) hazardous alcohol use. Only three (2%) of 133 fatalities had no identified risk. Pneumonia was the most common presentation occurring in 595 (52%) patients. Bacteraemia occurred in 633 (56%) of 1135 patients, septic shock in 240 (21%) patients, and 180 (16%) patients required mechanical ventilation. Cases correlated with rainfall, with 80% of infections occurring during the wet season (November to April). Median annual incidence was 20·5 cases per 100 000 people; the highest annual incidence in Indigenous Australians was 103·6 per 100 000 in 2011-12. Over the 30 years, annual incidences increased, as did the proportion of patients with diabetes, although mortality decreased to 17 (6%) of 278 patients over the past 5 years. Genotyping of B pseudomallei confirmed case clusters linked to environmental sources and defined evolving and new sequence types. INTERPRETATION Melioidosis is an opportunistic infection with a diverse spectrum of clinical presentations and severity. With early diagnosis, specific antimicrobial therapy, and state-of-the-art intensive care, mortality can be reduced to less than 10%. However, mortality remains much higher in the many endemic regions where health resources remain scarce. Genotyping of B pseudomallei informs evolving local and global epidemiology. FUNDING The Australian National Health and Medical Research Council.
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Affiliation(s)
- Bart J Currie
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia.
| | - Mark Mayo
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Linda M Ward
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Mirjam Kaestli
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Ella M Meumann
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Jessica R Webb
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Celeste Woerle
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Robert W Baird
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia; Pathology Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Catherine S Marshall
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Anna P Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Emma Spencer
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Jane Davies
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Sarah E Huffam
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Sonja Janson
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Sarah Lynar
- Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
| | - Peter Markey
- Centre for Disease Control, Top End Health Services, Northern Territory Department of Health, Darwin, NT, Australia
| | - Vicki L Krause
- Centre for Disease Control, Top End Health Services, Northern Territory Department of Health, Darwin, NT, Australia
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Infectious Diseases Department, Royal Darwin Hospital and Northern Territory Medical Programme, Darwin, NT, Australia
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Abstract
PURPOSE OF REVIEW The epidemiology of sepsis and septic shock has been challenging to study for multiple reasons. These include changing diagnostic definitions, as well a high concentration of sepsis-related studies published from high-income countries (HICs), despite a large global burden. This section attempts to address the incidence of sepsis throughout the years and worldwide. RECENT FINDINGS The incidence of sepsis and septic shock has continued to increase since the first consensus definitions (Sepsis-1) were established in 1991, and the latest definitions (Sepsis-3) provide a better reflection of mortality risk for a diagnosis of sepsis. Several studies argue that the incidence of sepsis is overreported in HICs, based on billing and coding practices, and may lead to overutilization of resources. However, recent estimates of the true global burden of sepsis, including low-income countries, are likely much higher than reported, with calls for better allocation of resources. SUMMARY The true epidemiology of sepsis worldwide continues to be a highly debated subject, and more research is needed among low-income countries and high-risk subpopulations.
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Evaluating antimicrobial prescribing practice in Australian remote primary healthcare clinics. Infect Dis Health 2021; 26:173-181. [PMID: 33744202 DOI: 10.1016/j.idh.2021.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Inappropriate antimicrobial prescribing contributes to the emergence of antimicrobial resistance. Gaps exist in the understanding of antimicrobial prescribing in the remote setting. We aimed to assess adherence to guidelines and appropriateness of antimicrobial prescribing in Central Australia. METHODS A retrospective study assessing antimicrobial prescriptions in ten Aboriginal clinics (three in remote communities and seven in regional centre) using a validated evaluation tool. Antimicrobials prescribed between 1 January-31 December 2018 were randomly selected for inclusion into the study. The main outcome measures were the rates of guideline adherence and inappropriate prescribing. RESULTS A total of 180 prescriptions were included (96.1% Aboriginal, 32.2% male). Ninety-nine (55.0%) prescriptions were written by general practitioners (GPs), 57 (31.7%) by nurses and 24 (13.3%) by others. Forty-three (25.7%) assessable prescriptions were deemed inappropriate and 75 (44.4%) did not adhere to guidelines. Prescriptions written by GPs were less likely to adhere to guidelines, particularly GPs located in remote communities. The most common reasons for inappropriate prescribing were incorrect dosage/frequency and antimicrobial not indicated. Skin and soft-tissue infection was the commonest indication, with 29 of 41 (70.7%) prescriptions deemed appropriate. Prescriptions for lower respiratory-tract infection had the lowest rate of appropriateness, with one of seven prescriptions deemed appropriate (14.3%). Antimicrobials with the lowest rate of appropriateness were ciprofloxacin, amoxicillin-clavulanate and cefalexin, at 50%, 56%, and 62%, respectively. CONCLUSION A quarter of antimicrobial prescriptions written in select remote central Australian Aboriginal primary healthcare clinics were deemed inappropriate. The implementation of a comprehensive antimicrobial stewardship program is recommended.
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20
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Tsai D, Chiong F, Secombe P, Hnin KM, Stewart P, Goud R, Woodman R, Lipman J, Roberts J, Hewagama S. Epidemiology and Microbiology of Severe Community-Acquired Pneumonia in Central Australia: A Retrospective Study. Intern Med J 2020; 52:1048-1056. [PMID: 33342052 DOI: 10.1111/imj.15171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/13/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Severe community-acquired pneumonia (SCAP) has high mortality and morbidity. AIMS To describe the epidemiology and microbiology of SCAP in Central Australia. METHODS A retrospective epidemiological study describing the characteristics, incidence rates (IR) and microbiological aetiology of SCAP in Central Australia. Adult patients admitted to Alice Springs Hospital Intensive Care Unit (ICU) between 2011-2014 that fitted the IDSA/ATS definition of SCAP were included. Medical records were reviewed and compared between Indigenous and non-Indigenous patients. Primary outcomes were incidence rate and microbiological aetiology of SCAP. Secondary outcomes were 30-day mortality, and ICU and hospital length of stay (LoS). RESULTS A total of 185 patents were included (156 Indigenous, 29 non-Indigenous). The overall SCAP IR per 1000 person-years was 3.24 (3.75 Indigenous and 1.87 non-Indigenous) with an IR difference of 2.71 after adjustment (p<0.001). Those aged ≥50 had an IR 74.8% higher than those younger. Male IR was 50% higher than females. There was a significant difference between Indigenous and non-Indigenous groups for age (48 vs. 64 years), but not for 30-day mortality (7.7% vs. 10.3%), ICU LoS (4.8 vs. 4.6 days) and hospital LoS (10.9 vs. 15.1 days), respectively. Likely causative pathogen(s) were identified in 117 patients; Streptococcus pneumoniae was the most common pathogen (28.2%), followed by Haemophilus influenzae (19.7%), Influenza A/B (16.2%) and Staphylococcus aureus (14.5%). CONCLUSION A high incidence of SCAP was observed in Central Australia, disproportionately affecting the Indigenous population. Prevention strategies are imperative, as well as early identification of SCAP and appropriate empiric antibiotic regimens. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Danny Tsai
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Centre for Remote Health, Flinders NT, Flinders University, Alice Springs, NT, Australia.,Pharmacy Department, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Fabian Chiong
- Department of Medicine, Alice Springs Hospital, Alice Springs, NT, Australia.,Department of Infectious Diseases, University Hospital Geelong, Geelong, VIC, Australia
| | - Paul Secombe
- Department of Intensive Care Medicine, Alice Springs Hospital, Alice Springs, NT, Australia
| | | | - Penny Stewart
- Department of Intensive Care Medicine, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Rajendra Goud
- Department of Intensive Care Medicine, Cairns Base Hospital, Cairns, QLD, Australia
| | - Richard Woodman
- School of Bioinformatics, Flinders University, Adelaide, SA, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jason Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Saliya Hewagama
- Department of Medicine, Alice Springs Hospital, Alice Springs, NT, Australia.,Department of Infectious Diseases, The Northern Hospital, Epping, Melbourne, VIC, Australia
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21
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Douglas NM, Hennessy JN, Currie BJ, Baird RW. Trends in Bacteremia Over 2 Decades in the Top End of the Northern Territory of Australia. Open Forum Infect Dis 2020; 7:ofaa472. [PMID: 33204758 PMCID: PMC7651056 DOI: 10.1093/ofid/ofaa472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/01/2020] [Indexed: 11/14/2022] Open
Abstract
Background Information on the local distribution of bloodstream pathogens helps to guide empiric antibiotic selection and can generate hypotheses regarding the effectiveness of infection prevention practices. We assessed trends in bacterial blood culture isolates at Royal Darwin Hospital (RDH) in the Northern Territory of Australia between 1999 and 2019. Methods Species identification was extracted for all blood cultures first registered at RDH. Thirteen organisms were selected for focused analysis. Trends were examined graphically and using univariable linear regression. Results Between 1999 and 2019, 189 577 blood cultures from 65 276 patients were processed at RDH. Overall, 6.72% (12 747/189 577) of blood cultures contained a bacterial pathogen. Staphylococcus aureus was the most common cause of bacteremia during the first decade, with an estimated incidence of 96.6 episodes per 100 000 person-years (py; 95% CI, 72.2-121/100 000 py) in 1999. Since 2009, S. aureus bacteremia has declined markedly, whereas there has been an inexorable rise in Escherichia coli bacteremia (30.1 to 74.7/100 000 py between 1999 and 2019; P < .001), particularly in older adults. Since 2017, E. coli has been more common than S. aureus. Rates of Streptococcus pneumoniae bacteremia have reduced dramatically in children, while Burkholderia pseudomallei remained the fourth most common bloodstream isolate overall. Conclusions The incidence of S. aureus bacteremia, though high by international standards, is declining at RDH, possibly in part due to a sustained focus on both community and hospital infection prevention practices. Gram-negative bacteremia, particularly due to E. coli, is becoming more common, and the trend will likely continue given our aging population.
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Affiliation(s)
- Nicholas M Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Territory Pathology, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Jann N Hennessy
- Territory Pathology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Bart J Currie
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Rob W Baird
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Territory Pathology, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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22
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Conigrave JH, Lee KSK, Zheng C, Wilson S, Perry J, Chikritzhs T, Slade T, Morley K, Room R, Callinan S, Hayman N, Conigrave KM. Drinking risk varies within and between Australian Aboriginal and Torres Strait Islander samples: a meta-analysis to identify sources of heterogeneity. Addiction 2020; 115:1817-1830. [PMID: 32057135 DOI: 10.1111/add.15015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/01/2019] [Accepted: 02/05/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS To reduce health and social inequities, it is important to understand how drinking patterns vary within and between Indigenous peoples. We aimed to assess variability in estimates of Indigenous Australian drinking patterns and to identify demographic and methodological factors associated with this. DESIGN A three-level meta-analysis of Australian Aboriginal and Torres Strait Islander ('Indigenous') drinking patterns [International Prospective Register of Systematic Reviews (PROSPERO) no. CRD42018103209]. SETTING Australia. PARTICIPANTS Indigenous Australians. MEASUREMENTS The primary outcomes extracted were drinking status, single-occasion risk and life-time risk. Moderation analysis was performed to identify potential sources of heterogeneity. Moderators included gender, age, socio-economic status, local alcohol restrictions, sample population, remoteness, Australian state or territory, publication year, Indigenous involvement in survey design or delivery and cultural adaptations. FINDINGS A systematic review of the literature revealed 41 eligible studies. For all primary outcomes, considerable heterogeneity was identified within ( I22 = 51.39-68.80%) and between ( I32 = 29.27-47.36%) samples. The pooled proportions (P) of current drinkers [P = 0.59, 95% confidence interval (CI) = 0.53-0.65], single-occasion (P = 0.34, 95% CI = 0.24-0.44) and life-time (P = 0.21, 95% CI = 0.15-0.29) risk were all moderated by gender, age, remoteness and measurement tool. Reference period moderated proportions of participants at single-occasion risk. CONCLUSIONS Indigenous Australian drinking patterns vary within and between communities. Initiatives to reduce high-risk drinking should take account of this variability.
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Affiliation(s)
- James H Conigrave
- Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, Camperdown, NSW, Australia
| | - K S Kylie Lee
- Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, Camperdown, NSW, Australia.,Centre for Alcohol Policy Research, La Trobe University, Bundoora, VIC, Australia
| | - Catherine Zheng
- Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, Camperdown, NSW, Australia
| | - Scott Wilson
- Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, Camperdown, NSW, Australia.,Aboriginal Drug and Alcohol Council Inc South Australia, SA, Australia
| | - Jimmy Perry
- Aboriginal Drug and Alcohol Council Inc South Australia, SA, Australia
| | - Tanya Chikritzhs
- National Drug Research Institute, Curtin University, Health Sciences, WA, Australia
| | - Tim Slade
- The Matilda Centre for Research in Mental Health and Substance Use, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Kirsten Morley
- Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Robin Room
- Centre for Alcohol Policy Research, La Trobe University, Bundoora, VIC, Australia
| | - Sarah Callinan
- Centre for Alcohol Policy Research, La Trobe University, Bundoora, VIC, Australia
| | - Noel Hayman
- Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care, Queensland Health, QLD, Australia.,School of Medicine, Griffith University, QLD, Australia.,School of Medicine, University of Queensland, QLD, Australia
| | - Katherine M Conigrave
- Discipline of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, Camperdown, NSW, Australia.,Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, NSW, Australia
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23
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The applicability of commonly used predictive scoring systems in Indigenous Australians with sepsis: An observational study. PLoS One 2020; 15:e0236339. [PMID: 32697796 PMCID: PMC7375531 DOI: 10.1371/journal.pone.0236339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022] Open
Abstract
Background Indigenous Australians suffer a disproportionate burden of sepsis, however, the performance of scoring systems that predict mortality in Indigenous patients with critical illness is incompletely defined. Materials and methods The study was performed at an Australian tertiary-referral hospital between January 2014 and June 2017, and enrolled consecutive Indigenous and non-Indigenous adults admitted to ICU with sepsis. The ability of the ANZROD, APACHE-II, APACHE-III, SAPS-II, SOFA and qSOFA scores to predict death before ICU discharge in the two populations was compared. Results There were 442 individuals enrolled in the study, 145 (33%) identified as Indigenous. Indigenous patients were younger than non-Indigenous patients (median (interquartile range (IQR) 53 (43–60) versus 65 (52–73) years, p = 0.0001) and comorbidity was more common (118/145 (81%) versus 204/297 (69%), p = 0.005). Comorbidities that were more common in the Indigenous patients included diabetes mellitus (84/145 (58%) versus 67/297 (23%), p<0.0001), renal disease (56/145 (39%) versus 29/297 (10%), p<0.0001) and cardiovascular disease (58/145 (40%) versus 83/297 (28%), p = 0.01). The use of supportive care (including vasopressors, mechanical ventilation and renal replacement therapy) was similar in Indigenous and non-Indigenous patients, and the two populations had an overall case-fatality rate that was comparable (17/145 (12%) and 38/297 (13%) (p = 0.75)), although Indigenous patients died at a younger age (median (IQR): 54 (50–60) versus 70 (61–76) years, p = 0.0001). There was no significant difference in the ability of any the scores to predict mortality in the two populations. Conclusions Although the crude case-fatality rates of Indigenous and non-Indigenous Australians admitted to ICU with sepsis is comparable, Indigenous patients die at a much younger age. Despite this, the ability of commonly used scoring systems to predict outcome in Indigenous Australians is similar to that of non-Indigenous Australians, supporting their use in ICUs with a significant Indigenous patient population and in clinical trials that enrol Indigenous Australians.
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24
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Mitchell WG, Deane A, Brown A, Bihari S, Wong H, Ramadoss R, Finnis M. Long term outcomes for Aboriginal and Torres Strait Islander Australians after hospital intensive care. Med J Aust 2020; 213:16-21. [PMID: 32484925 DOI: 10.5694/mja2.50649] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/10/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess long term outcomes for Aboriginal and Torres Strait Islander (Indigenous) Australians admitted non-electively to intensive care units (ICUs). DESIGN Data linkage cohort study; analysis of ICU patient data (Australian and New Zealand Intensive Care Society Adult Patient Database), prospectively collected during 2007-2016. SETTING All four university-affiliated level 3 ICUs in South Australia. MAIN OUTCOMES Mortality (in-hospital, and 12 months and 8 years after admission to ICU), by Indigenous status. RESULTS 2035 of 39 784 non-elective index ICU admissions (5.1%) were of Indigenous Australians, including 1461 of 37 661 patients with South Australian residential postcodes. The median age of Indigenous patients (45 years; IQR, 34-57 years) was lower than for non-Indigenous ICU patients (64 years; IQR, 47-76 years). For patients with South Australian postcodes, unadjusted mortality at discharge and 12 months and 8 years after admission was lower for Indigenous patients; after adjusting for age, sex, diabetes, severity of illness, and diagnostic group, mortality was similar for both groups at discharge (adjusted odds ratio [aOR], 0.95; 95% CI, 0.81-1.10), but greater for Indigenous patients at 12 months (aOR, 1.14; 95% CI, 1.03-1.26) and 8 years (adjusted hazard ratio, 1.23; 95% CI, 1.13-1.35). The number of potential years of life lost was greater for Indigenous patients (median, 24.0; IQR, 15.8-31.8 v 12.5; IQR, 0-22.3), but, referenced to respective population life expectancies, relative survival at 8 years was similar (proportions: Indigenous, 0.78; 95% CI, 0.75-0.80; non-Indigenous, 0.77; 95% CI, 0.76-0.78). CONCLUSIONS Adjusted long term mortality and median number of potential life years lost are higher for Indigenous than non-Indigenous patients after intensive care in hospital. These differences reflect underlying population survival patterns rather than the effects of ICU admission.
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Affiliation(s)
| | | | - Alex Brown
- South Australian Health and Medical Research Institute, Adelaide, SA.,University of Adelaide, Adelaide, SA
| | - Shailesh Bihari
- Flinders Medical Centre, Adelaide, SA.,College of Medicine and Public Health, Flinders University, Adelaide, SA
| | - Hao Wong
- University of Adelaide, Adelaide, SA.,Queen Elizabeth Hospital, Adelaide, SA
| | | | - Mark Finnis
- University of Adelaide, Adelaide, SA.,Royal Adelaide Hospital, Adelaide, SA
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25
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Jacups SP, Carter AW, Murray A. Acute kidney injury in Indigenous intensive care patients. Aust Crit Care 2020; 33:452-457. [PMID: 32305150 DOI: 10.1016/j.aucc.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 10/09/2019] [Accepted: 10/20/2019] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Patients presenting to intensive care units (ICUs) report high rates of acute kidney injury (AKI) requiring renal replacement therapy (RRT). Globally, Indigenous populations report higher rates of renal disease than their non-Indigenous counterparts. OBJECTIVES This study reports the prevalence, presenting features, and outcomes of Indigenous ICU admissions with AKI (who require RRT) within an Australian ICU setting and compares these with those of Indigenous patients without AKI. METHOD A retrospective database review examined all Indigenous patients older than 18 years admitted to a regional Australian ICU between June 2013 and June 2016, excluding patients with chronic kidney disease requiring dialysis. We report patient demography, presenting clinical and physiological characteristics, ICU length of stay, hospital outcome, and renal requirements at three months after discharge, on Indigenous patients with AKI requiring RRT. RESULTS AKI requiring RRT was identified in 15.9% of ICU Indigenous patients. On univariate analysis, it was found that these patients were older and had a higher body mass index, lower urine output, and higher levels of creatinine and urea upon presentation than patients who did not have AKI. Patients with AKI reported longer ICU stays and a higher mortality rate (30%, p < 0.05), and 10% of these required ongoing RRT at 3 months. Multivariate analysis found significant associations with AKI were only found for presenting urine outputs, urea and creatinine levels. CONCLUSIONS This study reports higher rates of AKI requiring RRT for Indigenous adults than non-Indigenous adults, as has been previously published. Benefits arising from this study are as follows: these reported findings may initiate early targeted clinical management and can assist managing expectations, as some patients may require ongoing RRT after discharge.
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Affiliation(s)
- Susan P Jacups
- Apunipima Cape York Health Council, 186 McCoombe St Bungalow, 4870, Cairns, Australia; The Cairns Institute, James Cook University, Australia.
| | - Angus W Carter
- Intensive Care Department, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Queensland, Australia.
| | - Andrew Murray
- Intensive Care Department, Cairns Hospital, Cairns and Hinterland Hospital and Health Service, Queensland, Australia
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Kissoon N, Ansermino JM. Exploring vulnerabilities to sepsis in Canada. Can J Anaesth 2020; 67:399-402. [PMID: 31768788 DOI: 10.1007/s12630-019-01537-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/02/2019] [Accepted: 10/18/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Niranjan Kissoon
- Critical Care - Global Child Health, Department of Pediatrics and Emergency Medicine, University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.
| | - John Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
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27
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Hennessy DA, Soo A, Niven DJ, Jolley RJ, Posadas-Calleja J, Stelfox HT, Doig CJ. Socio-demographic characteristics associated with hospitalization for sepsis among adults in Canada: a Census-linked cohort study. Can J Anaesth 2020; 67:408-420. [PMID: 31792835 DOI: 10.1007/s12630-019-01536-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Sepsis is a considerable health system burden. Population-based epidemiological surveillance of sepsis is limited to basic data available in administrative databases. We sought to determine if routinely collected Census data, linked to hospitalization data, can provide a broad socio-demographic profile of patients admitted to Canadian hospitals with sepsis. METHODS Linking the 2006 long-form Canadian Census (most recent available for linkage) to the Discharge Abstract Data from 2006/2007 to 2008/2009, we created a population-based cohort of approximately 3,433,900 Canadians. Patients admitted to hospital with sepsis were identified using the Canadian Institute for Health Information administrative data definition. Age-standardized hospital admission rates for sepsis were calculated. Multivariable modelling was used to examine the relationship between Census characteristics and hospitalization with sepsis. RESULTS Of those individuals successfully linked to the 2006 long-form Canadian Census, 10,400 patients of 18 yr and older were admitted to hospital with sepsis between the fiscal years 2006/2007 and 2008/2009. These individuals represented a weighted count of approximately 49,000 Canadians from all provinces and territories, excluding Quebec. The age-standardized rate of sepsis hospitalization was 96 cases/100,000 population. Of these, 37/100,000 cases were classified as severe sepsis. The association of Census characteristics with sepsis hospitalization varied with age. In all age-specific models, male sex, never being married, visible minority status, having functional limitations, and not being in the labour force were associated with an increased odds of hospital admission. CONCLUSIONS Census data identified broad socio-demographic risk factors for admission to hospital with sepsis. Consideration should be given to incorporating Census data linked to administrative hospital data in population-based epidemiologic surveillance.
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Affiliation(s)
- Deirdre A Hennessy
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, ON, K1A 0T6, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Rachel J Jolley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Juan Posadas-Calleja
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Christopher J Doig
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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Źródłowski T, Sobońska J, Salamon D, McFarlane IM, Ziętkiewicz M, Gosiewski T. Classical Microbiological Diagnostics of Bacteremia: Are the Negative Results Really Negative? What is the Laboratory Result Telling Us About the "Gold Standard"? Microorganisms 2020; 8:microorganisms8030346. [PMID: 32121353 PMCID: PMC7143506 DOI: 10.3390/microorganisms8030346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 12/29/2022] Open
Abstract
Standard blood cultures require at least 24–120 h to be reported as preliminary positive. The objective of this study was to compare the reliability of Gram staining and fluorescent in-situ hybridization (FISH) for detecting bacteria in otherwise negative blood culture bottles. Ninety-six sets were taken from patients with a diagnosis of sepsis. Six incomplete blood culture sets and eight blood cultures sets demonstrating positive growth were excluded. We performed Gram stain and FISH on 82 sets taken from post-operative septic patients: 82 negative aerobic blood cultures, 82 anaerobic blood cultures, and 82 blood samples, as well as 57 blood samples taken from healthy volunteers. From the eighty-two blood sets analyzed from the septic patients, Gram stain visualized bacteria in 62.2% of blood samples, 35.4% of the negative aerobic bottles, and in 31.7% of the negative anaerobic bottles. Utilizing FISH, we detected bacteria in 75.6%, 56.1%, and 64.6% respectively. Among the blood samples from healthy volunteers, FISH detected bacteria in 64.9%, while Gram stain detected bacteria in only 38.6%. The time needed to obtain the study results using Gram stain was 1 h, for FISH 4 h, and for the culture method, considering the duration of growth, 5 days. Gram stain and FISH allow quick detection of bacteria in the blood taken directly from a patient. Finding phagocytosed bacteria, which were also detected among healthy individuals, confirms the hypothesis that blood microbiome exists.
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Affiliation(s)
- Tomasz Źródłowski
- Thoracic Anesthesia and Respiratory Intensive Care Unit, John Paul II Hospital, 31- 202 Kraków, Poland;
- Department of Internal Medicine, St. John’s Episcopal Hospital, Far Rockaway, NY 11691, USA
| | - Joanna Sobońska
- Department of Molecular Medical Microbiology, Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, 31-121 Krakow, Poland
| | - Dominika Salamon
- Department of Molecular Medical Microbiology, Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, 31-121 Krakow, Poland
| | - Isabel M. McFarlane
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Mirosław Ziętkiewicz
- Thoracic Anesthesia and Respiratory Intensive Care Unit, John Paul II Hospital, 31- 202 Kraków, Poland;
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Krakow, Poland
- Correspondence: (M.Z.); (T.G.)
| | - Tomasz Gosiewski
- Department of Molecular Medical Microbiology, Chair of Microbiology, Faculty of Medicine, Jagiellonian University Medical College, 31-121 Krakow, Poland
- Correspondence: (M.Z.); (T.G.)
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29
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Ye Lynn KL, Hanson J, Mon NCN, Yin KN, Nyein ML, Thant KZ, Kyi MM, Oo TZC, Aung NM. The clinical characteristics of patients with sepsis in a tertiary referral hospital in Yangon, Myanmar. Trans R Soc Trop Med Hyg 2020; 113:81-90. [PMID: 30412257 DOI: 10.1093/trstmh/try115] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/31/2018] [Indexed: 01/08/2023] Open
Abstract
Background The clinical characteristics and course of patients hospitalised with sepsis in Myanmar and the responsible pathogens remain poorly defined. Methods We performed an observational study of adults admitted from the community to a tertiary referral hospital in Yangon with fever and dysfunction of at least two organ systems. Results The 120 patients had a median age of 47 y (interquartile range 28-63); 11 (9%) were human immunodeficiency virus positive. Limited laboratory support meant that a microbiological diagnosis was possible in only 35 (29%) patients, but 18 (13%) had pathogens in blood cultures, including 9 (50%) organisms that were multidrug resistant (4 Escherichia coli, 4 Pseudomonas aeruginosa, 1 Burkholderia pseudomallei). Tuberculosis was confirmed in six patients, with two being rifampicin resistant, and dengue infection was confirmed in five patients. Without access to comprehensive intensive care support, 34 (28%) patients died. An admission National Early Warning Score ≥7 (odds ratio [OR] 8.6 [95% confidence interval {CI} 2.6 to 28.2], p=0.001) and quick sequential (sepsis-related) organ failure assessment score ≥2 (OR 3.2 [95% CI 1.3 to 8.0], p=0.02) were helpful in predicting death. Conclusions Tropical pathogens are a common cause of sepsis in Myanmar. The frequent identification of multidrug-resistant organisms and limited diagnostic and intensive care support hinder patient care significantly. However, simple clinical assessment on admission has prognostic utility.
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Affiliation(s)
- Kyi Lai Ye Lynn
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Josh Hanson
- Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar.,Kirby Institute, Level 6, Wallace Wurth Building High Street, UNSW, Kensington, NSW, Australia
| | - Nan Cho Nwe Mon
- Department of Medical Research, Ministry of Health and Sports, Ziwaka Road, Dagon Township, Yangon, Myanmar
| | - Kyi Nyein Yin
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar
| | - Myo Lwin Nyein
- Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar.,Department of Medicine, North Okkalapa General Hospital, May Darwi Road, North Okkalapa Township, Yangon, Myanmar
| | - Kyaw Zin Thant
- Department of Medical Research, Ministry of Health and Sports, Ziwaka Road, Dagon Township, Yangon, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Thin Zar Cho Oo
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
| | - Ne Myo Aung
- Department of Medicine, Insein General Hospital, Min Gyi Road, Insein Township, Yangon, Myanmar.,Department of Medicine, University of Medicine 2, Khaymar Thi Road, North Okkalapa Township, Yangon, Myanmar
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30
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Thompson K, Venkatesh B, Finfer S. Sepsis and septic shock: current approaches to management. Intern Med J 2019; 49:160-170. [PMID: 30754087 DOI: 10.1111/imj.14199] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/28/2018] [Accepted: 09/28/2018] [Indexed: 12/15/2022]
Abstract
Sepsis, defined as life-threatening organ dysfunction due to a dysregulated host response to infection, is recognised by the World Health Organization as a global health priority. Each year, 5000 of the 18 000 adults with sepsis treated in Australian intensive care units die, with survivors suffering long-term physical, cognitive and psychological dysfunction, which is poorly recognised and frequently untreated. There are currently no effective pharmacological treatments for sepsis, making early recognition, resuscitation and immediate treatment with appropriate antibiotics the key to reducing the burden of resulting disease. The majority of sepsis, around 70-80%, is community acquired making emergency departments and primary care key targets to improve recognition and early management. Case fatality rates for sepsis are decreasing in many countries with the reduction attributed to national or regional screening and quality improvement programmes focused on early identification and immediate treatment. The optimum approach to treating established sepsis has been informed by high-quality, multicentre investigator initiated randomised trials with much of the valuable data coming from National Health and Medical Research Council-funded trials run from Australia. While early recognition and improved management of the acute episode are important steps in reducing death and disability from sepsis, a substantial reduction in the burden of sepsis-related disease requires action across the entire healthcare system. In this narrative review, we provide a summary of current knowledge on epidemiology of sepsis and septic shock and recommendations on the optimum approach to the management of these conditions in adults.
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Affiliation(s)
- Kelly Thompson
- The George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia.,The Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia.,The Wesley Hospital, Brisbane, Queensland, Australia
| | - Simon Finfer
- The George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
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31
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Impact of point-of-care testing for white blood cell count on triage of patients with infection in the remote Northern Territory of Australia. Pathology 2019; 51:512-517. [PMID: 31262564 DOI: 10.1016/j.pathol.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 11/23/2022]
Abstract
In Australia's Northern Territory (NT), acute infections are highly prevalent within Indigenous remote communities and difficulties in diagnosing the aetiology of infection are exacerbated by limited access to diagnostic tests. The objective of this study was to investigate the clinical effectiveness of point-of-care (POC) testing for total and 5-part differential white blood cell (WBC DIFF) counts for the triage of patients with possible acute infection. The HemoCue WBC DIFF POC device was introduced into 13 remote health clinics over a 6 month period. A retrospective clinical audit of patient cases meeting the selection criteria for three acute infections (sepsis, respiratory infection and appendicitis) were examined by four registrars in duplicate; one with POC test results available and the other with POC test results removed to determine if WBC DIFF results changed or assisted in patient triage. The number of changed outcomes provided a preliminary cost-benefit analysis. Sixty (23%) patient cases met the selection criteria for the clinical effectiveness analysis. POC test results changed the triage decision for 24 (41%) patients, of which 20 (34%) led to the prevention of an unnecessary medical retrieval and four (7%) indicated the patient had an acute infection which required a medical retrieval. POC test results assisted decision making for a further 13 (22%) patients. Cost savings related to avoiding unnecessary medical retrievals were estimated to be AU$481,440. Extrapolated NT-wide cost savings are projected to be AU$5.33 million per annum. POC testing for WBC DIFF counts aided clinical decision making for triaging patients with three common acute infections.
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32
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Bowen AC, Daveson K, Anderson L, Tong SYC. An urgent need for antimicrobial stewardship in Indigenous rural and remote primary health care. Med J Aust 2019; 211:9-11.e1. [DOI: 10.5694/mja2.50216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Asha C Bowen
- Perth Children's Hospital Perth WA
- Wesfarmers Centre for Vaccines and Infectious DiseasesTelethon Kids Institute Perth WA
| | - Kathryn Daveson
- Canberra Hospital Canberra ACT
- Queensland Statewide Antimicrobial Stewardship ProgramMetro North Hospital and Health Services Brisbane QLD
| | | | - Steven YC Tong
- Victorian Infectious Disease ServiceRoyal Melbourne Hospital, and Peter Doherty Institute for Infection and Immunity Melbourne VIC
- Menzies School of Health Research Darwin NT
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33
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Aung NM, Nyein PP, Htut TY, Htet ZW, Kyi TT, Anstey NM, Kyi MM, Hanson J. Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria. Am J Trop Med Hyg 2018; 99:688-696. [PMID: 30014826 DOI: 10.4269/ajtmh.18-0378] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
It has been believed that concomitant bacteremia is uncommon in adults hospitalized with falciparum malaria. Accordingly, the World Health Organization treatment guidelines presently only recommended additional antibacterial therapy in these patients if they have a clinical syndrome compatible with serious bacterial infection. Admission blood cultures were collected from 20 consecutive adults in Myanmar, hospitalized with a positive immunochromatographic test and blood film, suggesting a diagnosis of falciparum malaria; four (20%) had bacteremia with a clinically significant pathogen. These case series' data were pooled with a previously published multicenter study from Myanmar which had also collected blood cultures in adults hospitalized with a diagnosis of falciparum malaria. Among 87 patients in the two studies, 13 (15%) had clinically significant bacteremia on admission, with Gram-negative organisms in 10 (77%) and Staphylococcus aureus in the remaining three (23%). Bacteremic patients had more severe disease than non-bacteremic patients (median [interquartile range] respiratory coma acidosis malaria score 2 [1-4] versus 1 [1-2], P = 0.02) and were more likely to die (2/13 [15%] versus 1/74 [1%], P = 0.01). However, bacterial coinfection was suspected clinically in a minority of bacteremic patients (5/13 [38%] compared with 13/70 [19%] of non-bacteremic patients, P = 0.11). Concomitant bacteremia in adults diagnosed with falciparum malaria may be more common than previously believed and is difficult to identify clinically in resource-poor settings. Death is more common in these patients, suggesting that clinicians should have a lower threshold for commencing empirical antibacterial therapy in adults diagnosed with falciparum malaria in these locations than is presently recommended.
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Affiliation(s)
- Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | | | | | - Tint Tint Kyi
- Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Kirby Institute, University of New South Wales, Sydney, Australia.,University of Medicine 2, Yangon, Myanmar
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Abstract
Sepsis is one of the oldest and complex syndromes in medicine that has been in debate for over two millennia. Valid and comparable data on the population burden of sepsis constitute an essential resource for guiding health policy and resource allocation. Despite current epidemiological data suggesting that the global burden of sepsis is huge, the knowledge of its incidence, prevalence, mortality, and case-fatality rates is subject to several flaws. The objective of this narrative review is to assess how sepsis incidence and mortality can be estimated, providing examples on how it has been done so far in medical literature and discussing its possible biases. Results of recent studies suggest that sepsis incidence rates are increasing consistently during the last decades. Although estimates might be biased, this probably reflects a real increase in incidence over time. Nevertheless, case fatality rates have decreased, which is a probable reflex of advances in critical care provision to this very sick population at high risk of death. This conclusion can only be drawn with a reasonable degree of certainty for high-income countries. Conversely, adequately designed studies from middle- and low-income countries are urgently needed. In these countries, sepsis incidence and case-fatality rates could be disproportionally higher due to health care provision constraints and ineffective preventive measures.
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35
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Ostrowski JA, MacLaren G, Alexander J, Stewart P, Gune S, Francis JR, Ganu S, Festa M, Erickson SJ, Straney L, Schlapbach LJ. The burden of invasive infections in critically ill Indigenous children in Australia. Med J Aust 2017; 206:78-84. [PMID: 28152345 DOI: 10.5694/mja16.00595] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/08/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To describe the incidence and mortality of invasive infections in Indigenous children admitted to paediatric and general intensive care units (ICUs) in Australia. DESIGN Retrospective multi-centre cohort study of Australian and New Zealand Paediatric Intensive Care Registry data. PARTICIPANTS All children under 16 years of age admitted to an ICU in Australia, 1 January 2002 - 31 December 2013. Indigenous children were defined as those identified as Aboriginal and/or Torres Strait Islander in a mandatory admissions dataset. MAIN OUTCOMES Population-based ICU mortality and admission rates. RESULTS Invasive infections accounted for 23.0% of non-elective ICU admissions of Indigenous children (726 of 3150), resulting in an admission rate of 47.6 per 100 000 children per year. Staphylococcus aureus was the leading pathogen identified in children with sepsis/septic shock (incidence, 4.42 per 100 000 Indigenous children per year; 0.57 per 100 000 non-Indigenous children per year; incidence rate ratio 7.7; 95% CI, 5.8-10.1; P < 0.001). While crude and risk-adjusted ICU mortality related to invasive infections was not significantly different for Indigenous and non-Indigenous children (odds ratio, 0.75; 95% CI, 0.53-1.07; P = 0.12), the estimated population-based age-standardised mortality rate for invasive infections was significantly higher for Indigenous children (2.67 per 100 000 per year v 1.04 per 100 000 per year; crude incidence rate ratio, 2.65; 95% CI, 1.88-3.64; P < 0.001). CONCLUSIONS The ICU admission rate for severe infections was several times higher for Indigenous than for non-Indigenous children, particularly for S. aureus infections. While ICU case fatality rates were similar, the population-based mortality was more than twice as high for Indigenous children. Our study highlights an important area of inequality in health care for Indigenous children in a high income country that needs urgent attention.
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Affiliation(s)
| | | | - Janet Alexander
- Australian and New Zealand Paediatric Intensive Care Registry (CORE), Brisbane, QLD
| | | | | | | | - Subodh Ganu
- Women's and Children's Hospital Adelaide, Adelaide, SA
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Buntsma D, Lithgow A, O'Neill E, Palmer D, Morris P, Acworth J, Babl FE. Patterns of paediatric emergency presentations to a tertiary referral centre in the Northern Territory. Emerg Med Australas 2017; 29:678-685. [PMID: 29115723 DOI: 10.1111/1742-6723.12853] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 07/25/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe epidemiological data concerning paediatric attendances at the ED of Royal Darwin Hospital (RDH). METHODS We conducted a retrospective cohort study of paediatric emergency presentations to the RDH ED during 2004 and 2013. Epidemiological data, including demographics, admission rates and diagnostic grouping, were analysed using descriptive and comparative statistical methods. We compared data with findings from a baseline epidemiological study by the Paediatric Research in Emergency Departments International Collaborative (PREDICT) conducted in 2004. RESULTS A total of 12 745 and 15 378 paediatric presentations (age 0-18 years) to the RDH ED were analysed for the years 2004 and 2013 respectively. In 2004, the mean age of children presenting to RDH was 7.1 years, and 56.0% were female. Indigenous patients accounted for 31.2% of presentations at RDH and were significantly more likely to be admitted than non-Indigenous patients (31.6% vs 12.8%, OR 3.24, 95% CI 2.95-3.55). Children <5 years old accounted for the highest number of presentations (45.2%) and admissions (51.2%), and there was a high proportion of adolescent presentations (18.0%). Similar to the PREDICT study, viral infectious conditions (bronchiolitis, gastroenteritis, upper respiratory tract infections) were the most common cause for presentations. Key differences included a higher proportion of patients presenting with cellulitis and head injury at RDH and an increasing proportion of adolescent psychiatric presentations at RDH from 2004 to 2013. CONCLUSION This study provides important information regarding paediatric presentations to a major referral hospital in the Northern Territory. Overall, there was a disproportionate rate of presentation and admission among Indigenous children. Other key findings were higher proportions of cellulitis, head injury and adolescent presentations. These findings can assist in service planning and in directing future research specific to children in the Northern Territory.
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Affiliation(s)
- Davina Buntsma
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Anna Lithgow
- Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Evan O'Neill
- Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Didier Palmer
- Emergency Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Peter Morris
- Menzies School of Health Research Institute, Darwin, Northern Territory, Australia
| | - Jason Acworth
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Franz E Babl
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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Preadmission Use of Calcium Channel Blocking Agents Is Associated With Improved Outcomes in Patients With Sepsis: A Population-Based Propensity Score-Matched Cohort Study. Crit Care Med 2017; 45:1500-1508. [PMID: 28658023 DOI: 10.1097/ccm.0000000000002550] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Use of calcium channel blockers has been found to improve sepsis outcomes in animal studies and one clinical study. This study determines whether the use of calcium channel blockers is associated with a decreased risk of mortality in patients with sepsis. DESIGN Population-based matched cohort study. SETTING National Health Insurance Research Database of Taiwan. PATIENTS Hospitalized severe sepsis patients identified from National Health Insurance Research Database by International Classification of Diseases, Ninth Revision, Clinical Modification codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The association between calcium channel blocker use and sepsis outcome was determined by multivariate-adjusted Cox proportional hazard models and propensity score analysis. To examine the influence of healthy user bias, beta-blocker was used as an active comparator. Our study identified 51,078 patients with sepsis, of which, 19,742 received calcium channel blocker treatments prior to the admission. Use of calcium channel blocker was associated with a reduced 30-day mortality after propensity score adjustment (hazard ratio, 0.94; 95% CI, 0.89-0.99), and the beneficial effect could extend to 90-day mortality (hazard ratio, 0.95; 95% CI, 0.89-1.00). In contrast, use of beta-blocker was not associated with an improved 30-day (hazard ratio, 1.06; 95% CI, 0.97-1.15) or 90-day mortality (hazard ratio, 1.00; 95% CI, 0.90-1.11). On subgroup analysis, calcium channel blockers tend to be more beneficial to patients with male gender, between 40 and 79 years old, with a low comorbidity burden, and to patients with cardiovascular diseases, diabetes, or renal diseases. CONCLUSIONS In this national cohort study, preadmission calcium channel blocker therapy before sepsis development was associated with a 6% reduction in mortality when compared with patients who have never received calcium channel blockers.
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Wongseelashote S, Tayal V, Bourke PF. Off-label use of rituximab in autoimmune disease in the Top End of the Northern Territory, 2008-2016. Intern Med J 2017; 48:165-172. [PMID: 28742259 DOI: 10.1111/imj.13554] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/18/2017] [Accepted: 07/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Rituximab, an anti-CD20 B-cell depleting monoclonal antibody, is increasingly prescribed off-label for a range of autoimmune diseases. There has not previously been an audit of off-label rituximab use in the Northern Territory, where the majority of patients are Aboriginal. AIMS To evaluate retrospectively off-label rituximab use in autoimmune diseases in the Top End of the Northern Territory. METHODS We performed a retrospective audit of 8 years of off-label rituximab use at the Royal Darwin Hospital, the sole tertiary referral centre for the Darwin, Katherine and East Arnhem regions. Electronic and paper records were reviewed for demographic information, diagnosis/indication for rituximab, doses, previous/concomitant immunosuppression, clinical outcomes and specific adverse events. RESULTS Rituximab was prescribed off-label to 66 patients for 24 autoimmune diseases. The majority of patients (62.1%) were Aboriginal and 60.6% female. The most common indications were refractory/relapsing disease despite standard therapies (68.7%) or severe disease with rituximab incorporated into an induction immunosuppressive regimen (19.4%). Systemic lupus erythematosus was the underlying diagnosis in 28.8% of cases. A clinically significant response was demonstrated in 74.2% of cases overall. There were 18 clinically significant infections; however, 13 were in patients receiving concurrent immunosuppressive therapy. There was a total of nine deaths from any cause. CONCLUSION Rituximab has been used off-label for a range of autoimmune diseases in this population with a high proportion of Aboriginal patients successfully and safely in the majority of cases.
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Affiliation(s)
- Sarah Wongseelashote
- General and Acute Care Medicine, Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Vipin Tayal
- Division of Medicine (Rheumatology), Royal Darwin Hospital, Tiwi, Northern Territory, Australia
| | - Peter Francis Bourke
- Division of Medicine (Rheumatology), Royal Darwin Hospital, Tiwi, Northern Territory, Australia.,Division of Integrated Medicine and Emergency Services (Clinical Immunology), Cairns Hospital, Cairns, Queensland, Australia
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High mortality due to sepsis in Native Hawaiians and African Americans: The Multiethnic Cohort. PLoS One 2017; 12:e0178374. [PMID: 28558016 PMCID: PMC5448766 DOI: 10.1371/journal.pone.0178374] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/11/2017] [Indexed: 01/21/2023] Open
Abstract
Background/Objectives Sepsis is a severe systemic response to infection with a high mortality rate. A higher incidence has been reported for older people, in persons with a compromised immune system including cancer patients, and in ethnic minorities. We analyzed sepsis mortality and its predictors by ethnicity in the Multiethnic Cohort (MEC). Subjects/Methods Among 191,561 white, African American, Native Hawaiian, Japanese American, and Latino cohort members, 49,347 deaths due to all causes and 345 deaths due to sepsis were recorded during follow-up from 1993–96 until 2010. Cox proportional hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated and adjusted for relevant confounders. In addition, national death rates were analyzed to compare mortality by state. Results Age-adjusted rates of sepsis death were 5-times higher for Hawaii than Los Angeles (14.4 vs. 2.7 per 100,000). By ethnicity, Native Hawaiians had the highest rate in Hawaii (29.0 per 100,000) and African Americans in Los Angeles (5.2 per 100,000). In fully adjusted models, place of residence was the most important predictor of sepsis mortality (HR = 7.18; 95%CI: 4.37–11.81 Hawaii vs. Los Angeles). African Americans showed the highest risk (HR = 2.08; 95% CI: 1.16–3.75) followed by Native Hawaiians (HR = 1.88; 95% CI: 1.34–2.65) as compared to whites. Among cohort members with cancer (N = 49,794), the 2-fold higher sepsis mortality remained significant in Native Hawaiians only. The geographic and ethnic differences in the MEC agreed with results for national death data. Conclusions The finding that African Americans and Native Hawaiians experience a higher mortality risk due to sepsis than other ethnic groups suggest ethnicity-related biological factors in the predisposition of cancer patients and other immune-compromising conditions to develop sepsis, but regional differences in health care access and death coding may also be important.
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Pharmacokinetics of Piperacillin in Critically Ill Australian Indigenous Patients with Severe Sepsis. Antimicrob Agents Chemother 2016; 60:7402-7406. [PMID: 27736759 DOI: 10.1128/aac.01657-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/24/2016] [Indexed: 01/24/2023] Open
Abstract
There are no available pharmacokinetic data to guide piperacillin dosing in critically ill Australian Indigenous patients despite numerous reported physiological differences. This study aimed to describe the population pharmacokinetics of piperacillin in critically ill Australian Indigenous patients with severe sepsis. A population pharmacokinetic study of Indigenous patients with severe sepsis was conducted in a remote hospital intensive care unit. Plasma samples were collected over two dosing intervals and assayed by validated chromatography. Population pharmacokinetic modeling was conducted using Pmetrics. Nine patients were recruited, and a two-compartment model adequately described the data. The piperacillin clearance (CL), volume of distribution of the central compartment (Vc), and distribution rate constants from the central to the peripheral compartment and from the peripheral to the central compartment were 5.6 ± 3.2 liters/h, 14.5 ± 6.6 liters, 1.5 ± 0.4 h-1, and 1.8 ± 0.9 h-1, respectively, where CL and Vc were found to be described by creatinine clearance (CLCR) and total body weight, respectively. In this patient population, piperacillin demonstrated high interindividual pharmacokinetic variability. CLCR was found to be the most important determinant of piperacillin pharmacokinetics.
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Total and unbound ceftriaxone pharmacokinetics in critically ill Australian Indigenous patients with severe sepsis. Int J Antimicrob Agents 2016; 48:748-752. [PMID: 27838278 DOI: 10.1016/j.ijantimicag.2016.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/04/2016] [Accepted: 09/15/2016] [Indexed: 11/21/2022]
Abstract
In the absence of specific data to guide optimal dosing, this study aimed to describe the pharmacokinetics of ceftriaxone in severely septic Australian Indigenous patients and to assess achievement of the pharmacodynamic target of the regimens prescribed. A pharmacokinetic study was conducted in a remote hospital intensive care unit in patients receiving ceftriaxone dosing of 1 g every 12 h (q12h). Serial blood and urine samples were collected over one dosing interval on two consecutive days. Samples were assayed using a validated chromatography method for total and unbound concentrations. Concentration-time data collected were analysed with a non-compartmental approach. A total of 100 plasma samples were collected from five subjects. Ceftriaxone clearance, volume of distribution at steady-state, elimination half-life and elimination rate constant estimates were 0.9 (0.6-1.5) L/h, 11.2 (7.6-13.4) L, 9.5 (3.2-10.2) h and 0.07 (0.07-0.21) h-1, respectively. The unbound fraction of ceftriaxone ranged between 14% and 43%, with a higher unbound fraction present at higher total concentrations. The unbound concentrations at 720 min from the initiation of infusion for the first and second dosing intervals were 7.2 (4.8-10.7) mg/L and 7.8 (4.7-12.1) mg/L respectively, which exceeds the minimum inhibitory concentration of all typical target pathogens. In conclusion, the regimen of ceftriaxone 1 g q12h is adequate for critically ill Australian Indigenous patients with severe sepsis caused by non-resistant pathogens.
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Mariansdatter SE, Eiset AH, Søgaard KK, Christiansen CF. Differences in reported sepsis incidence according to study design: a literature review. BMC Med Res Methodol 2016; 16:137. [PMID: 27733132 PMCID: PMC5062833 DOI: 10.1186/s12874-016-0237-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/29/2016] [Indexed: 11/30/2022] Open
Abstract
Background Sepsis and severe sepsis are common conditions in hospital settings, and are associated with high rates of morbidity and mortality, but reported incidences vary considerably. In this literature review, we describe the variation in reported population-based incidences of sepsis and severe sepsis. We also examine methodological and demographic differences between studies that may explain this variation. Methods We carried out a literature review searching three major databases and reference lists of relevant articles, to identify all original studies reporting the incidence of sepsis or severe sepsis in the general population. Two authors independently assessed all articles, and the final decision to exclude an article was reached by consensus. We extracted data according to predetermined variables, including study country, sepsis definition, and data source. We then calculated descriptive statistics for the reported incidences of sepsis and severe sepsis. The studies were classified according to the method used to identify cases of sepsis or severe sepsis: chart-based (i.e. review of patient charts) or code-based (i.e. predetermined International Classification of Diseases [ICD] codes). Results Among 482 articles initially screened, we identified 23 primary publications reporting incidence of sepsis and/or severe sepsis in the general population. The reported incidences ranged from 74 to 1180 per 100,000 person-years and 3 to 1074 per 100,000 person-years for sepsis and severe sepsis, respectively. Most chart-based studies used the Bone criteria (or a modification hereof) and Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study criteria to identify cases of sepsis and severe sepsis. Most code-based studies used ICD-9 codes, but the number of codes used ranged from 1 to more than 1200. We found that the incidence varied according to how sepsis was identified (chart-based vs. code-based), calendar year, data source, and world region. Conclusion The reported incidences of sepsis and severe sepsis in the general population varied greatly between studies. Such differences may be attributable to differences in the methods used to collect the data, the study period, or the world region where the study was undertaken. This finding highlights the importance of standardised definitions and acquisition of data regarding sepsis and severe sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s12874-016-0237-9) contains supplementary material, which is available to authorized users.
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McGuinness SL, Whiting SE, Baird R, Currie BJ, Ralph AP, Anstey NM, Price RN, Davis JS, Tong SYC. Nocardiosis in the Tropical Northern Territory of Australia, 1997-2014. Open Forum Infect Dis 2016; 3:ofw208. [PMID: 27942539 PMCID: PMC5144655 DOI: 10.1093/ofid/ofw208] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nocardia is an opportunistic pathogen that can cause life-threatening disease. We aimed to characterize the epidemiological, microbiological, and clinical features of nocardiosis in the tropical north of Australia. METHODS We conducted a retrospective cohort study of nocardiosis diagnosed between 1997 and 2014. Population-based incidences were calculated using district population data. RESULTS Clinically significant nocardiosis was identified in 61 patients. The unadjusted population-based annual incidence of nocardiosis was 2.02 (95% confidence interval [CI], 1.55-2.60) per 100000 people and was 1.7 (95% CI, .96-2.90) fold higher in Indigenous compared with non-Indigenous persons (P = .027). Of 61 patients, 47 (77%) had chronic lung disease, diabetes, and/or hazardous alcohol consumption; 22 (36%) were immunocompromised; and 8 (13%) had no identified comorbidities. Disease presentations included pulmonary (69%; 42 of 61), cutaneous (13%; 8 of 61), and disseminated nocardiosis (15%; 9 of 61). The most commonly identified species were Nocardia asteroides and Nocardia cyriacigeorgica (each 11%). Linezolid was the only antimicrobial to which isolates were universally susceptible; 89% (48 of 54), 60% (32 of 53), and 48% (26 of 54) of isolates were susceptible to trimethoprim-sulfamethoxazole, ceftriaxone, and imipenem, respectively. Eighteen patients (30%) required intensive care unit (ICU) admission, and 1-year mortality was 31%. CONCLUSIONS The incidence of nocardiosis in tropical Australia is amongst the highest reported globally. Nocardiosis occurs in both immunocompromised and immunocompetent hosts, and it is associated with high rates of ICU admission, 1-year mortality, and resistance to commonly recommended antimicrobials. Diagnosis should be considered in patients with consistent clinical features, particularly if they are Indigenous or have chronic lung disease.
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Affiliation(s)
| | | | - Rob Baird
- Department of Infectious Diseases and; Territory Pathology, Royal Darwin Hospital, Darwin, Australia
| | - Bart J Currie
- Department of Infectious Diseases and; Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Anna P Ralph
- Department of Infectious Diseases and; Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Nicholas M Anstey
- Department of Infectious Diseases and; Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Ric N Price
- Department of Infectious Diseases and; Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia;; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Joshua S Davis
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia;; Department of Infectious Diseases, John Hunter Hospital, Newcastle, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases and; Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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Tsai D, Stewart P, Goud R, Gourley S, Hewagama S, Krishnaswamy S, Wallis SC, Lipman J, Roberts JA. Optimising meropenem dosing in critically ill Australian Indigenous patients with severe sepsis. Int J Antimicrob Agents 2016; 48:542-546. [PMID: 27771187 DOI: 10.1016/j.ijantimicag.2016.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/03/2016] [Accepted: 08/09/2016] [Indexed: 12/12/2022]
Abstract
Currently there are no pharmacokinetic (PK) data to guide antibiotic dosing in critically ill Australian Indigenous patients with severe sepsis. This study aimed to determine whether the population pharmacokinetics of meropenem were different between critically ill Australian Indigenous and critically ill Caucasian patients. Serial plasma and urine samples as well as clinical and demographic data were collected over two dosing intervals from critically ill Australian Indigenous patients. Plasma meropenem concentrations were assayed by validated chromatography. Concentration-time data were analysed with data from a previous PK study in critically ill Caucasian patients using Pmetrics. The population PK model was subsequently used for Monte Carlo dosing simulations to describe optimal doses for these patients. Six Indigenous and five Caucasian subjects were included. A two-compartment model described the data adequately, with meropenem clearance and volume of distribution of the central compartment described by creatinine clearance (CLCr) and patient weight, respectively. Patient ethnicity was not supported as a covariate in the final model. Significant differences were observed for meropenem clearance between the Indigenous and Caucasian groups [median 11.0 (range 3.0-14.1) L/h vs. 17.4 (4.3-30.3) L/h, respectively; P <0.01]. Standard dosing regimens (1 g intravenous every 8 h as a 30-min infusion) consistently achieved target exposures at the minimum inhibitory concentration breakpoint in the absence of augmented renal clearance. No significant interethnic differences in meropenem pharmacokinetics between the Indigenous and Caucasian groups were detected and CLCr was found to be the strongest determinant of appropriate dosing regimens.
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Affiliation(s)
- Danny Tsai
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia; Pharmacy Department, Alice Springs Hospital, Alice Springs, Northern Territory, Australia.
| | - Penelope Stewart
- Department of Intensive Care Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Rajendra Goud
- Department of Intensive Care Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Stephen Gourley
- Emergency Department, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Saliya Hewagama
- Department of Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia; Department of Infectious Diseases, The Northern Hospital, Epping, Melbourne, Victoria, Australia
| | - Sushena Krishnaswamy
- Department of Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia; Monash Infectious Diseases, Monash Health, Clayton, Melbourne, Victoria, Australia
| | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Joynes EL, Martin J, Ross M. Management of Septic Shock in the Remote Prehospital Setting. Air Med J 2016; 35:235-238. [PMID: 27393760 DOI: 10.1016/j.amj.2016.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/20/2016] [Accepted: 04/02/2016] [Indexed: 06/06/2023]
Abstract
This study aims to assess the management of septic shock by air medical retrieval teams in the remote setting. A retrospective observational study was performed over 36 months. Sixty-seven adult patients who met the criteria for septic shock were included. Respiratory sepsis was the working diagnosis for 53% of patients; this was confirmed on intensive care unit (ICU) discharge in 39% of patients. Intravenous antibiotics and oxygen were delivered in over 90% of patients. Central and arterial line insertions were performed in 48% and 40% of patients, respectively, and 79% of patients were catheterized. Thirty-three percent of patients required intubation, and 80% of patients received an initial crystalloid fluid bolus of 20 mL/kg. Vasopressors were started in 89% of patients. Upon reaching definitive care, 91% of patients were admitted to a high-dependency or ICU setting, with a median length of ICU stay of 4 days and a 30-day mortality of 13%. Of those admitted to the ICU, intubation was required in 48%, new renal support in 20%, and blood pressure support in 84% of patients, respectively. Septic shock was recognized early and managed aggressively by remote retrieval teams, which may have contributed to the low mortality rate observed.
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Affiliation(s)
- Emma Lucy Joynes
- Careflight Darwin, Darwin Airport, Northern Territory, Australia.
| | - Jodie Martin
- Careflight Darwin, Darwin Airport, Northern Territory, Australia
| | - Mark Ross
- Careflight Darwin, Darwin Airport, Northern Territory, Australia
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Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, Angus DC, Reinhart K. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med 2016; 193:259-72. [PMID: 26414292 DOI: 10.1164/rccm.201504-0781oc] [Citation(s) in RCA: 2093] [Impact Index Per Article: 261.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Reducing the global burden of sepsis, a recognized global health challenge, requires comprehensive data on the incidence and mortality on a global scale. OBJECTIVES To estimate the worldwide incidence and mortality of sepsis and identify knowledge gaps based on available evidence from observational studies. METHODS We systematically searched 15 international citation databases for population-level estimates of sepsis incidence rates and fatality in adult populations using consensus criteria and published in the last 36 years. MEASUREMENTS AND MAIN RESULTS The search yielded 1,553 reports from 1979 to 2015, of which 45 met our criteria. A total of 27 studies from seven high-income countries provided data for metaanalysis. For these countries, the population incidence rate was 288 (95% confidence interval [CI], 215-386; τ = 0.55) for hospital-treated sepsis cases and 148 (95% CI, 98-226; τ = 0.99) for hospital-treated severe sepsis cases per 100,000 person-years. Restricted to the last decade, the incidence rate was 437 (95% CI, 334-571; τ = 0.38) for sepsis and 270 (95% CI, 176-412; τ = 0.60) for severe sepsis cases per 100,000 person-years. Hospital mortality was 17% for sepsis and 26% for severe sepsis during this period. There were no population-level sepsis incidence estimates from lower-income countries, which limits the prediction of global cases and deaths. However, a tentative extrapolation from high-income country data suggests global estimates of 31.5 million sepsis and 19.4 million severe sepsis cases, with potentially 5.3 million deaths annually. CONCLUSIONS Population-level epidemiologic data for sepsis are scarce and nonexistent for low- and middle-income countries. Our analyses underline the urgent need to implement global strategies to measure sepsis morbidity and mortality, particularly in low- and middle-income countries.
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Affiliation(s)
- Carolin Fleischmann
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - André Scherag
- 3 Clinical Epidemiology, Integrated Research and Treatment Center, Center for Sepsis Control and Care, and
| | - Neill K J Adhikari
- 4 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Christiane S Hartog
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
| | - Thomas Tsaganos
- 5 4th Department of Internal Medicine, University of Athens, Medical School, Athens, Greece; and
| | - Peter Schlattmann
- 6 Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Derek C Angus
- 7 Critical Care Medicine Division, Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Konrad Reinhart
- 1 Department for Anesthesiology and Intensive Care Medicine.,2 Integrated Research and Treatment Center, Center for Sepsis Control and Care
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Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, Angus DC, Rubenfeld GD, Singer M. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:775-87. [PMID: 26903336 PMCID: PMC4910392 DOI: 10.1001/jama.2016.0289] [Citation(s) in RCA: 1399] [Impact Index Per Article: 174.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition. OBJECTIVE To develop a new definition and clinical criteria for identifying septic shock in adults. DESIGN, SETTING, AND PARTICIPANTS The Society of Critical Care Medicine and the European Society of Intensive Care Medicine convened a task force (19 participants) to revise current sepsis/septic shock definitions. Three sets of studies were conducted: (1) a systematic review and meta-analysis of observational studies in adults published between January 1, 1992, and December 25, 2015, to determine clinical criteria currently reported to identify septic shock and inform the Delphi process; (2) a Delphi study among the task force comprising 3 surveys and discussions of results from the systematic review, surveys, and cohort studies to achieve consensus on a new septic shock definition and clinical criteria; and (3) cohort studies to test variables identified by the Delphi process using Surviving Sepsis Campaign (SSC) (2005-2010; n = 28,150), University of Pittsburgh Medical Center (UPMC) (2010-2012; n = 1,309,025), and Kaiser Permanente Northern California (KPNC) (2009-2013; n = 1,847,165) electronic health record (EHR) data sets. MAIN OUTCOMES AND MEASURES Evidence for and agreement on septic shock definitions and criteria. RESULTS The systematic review identified 44 studies reporting septic shock outcomes (total of 166,479 patients) from a total of 92 sepsis epidemiology studies reporting different cutoffs and combinations for blood pressure (BP), fluid resuscitation, vasopressors, serum lactate level, and base deficit to identify septic shock. The septic shock-associated crude mortality was 46.5% (95% CI, 42.7%-50.3%), with significant between-study statistical heterogeneity (I2 = 99.5%; τ2 = 182.5; P < .001). The Delphi process identified hypotension, serum lactate level, and vasopressor therapy as variables to test using cohort studies. Based on these 3 variables alone or in combination, 6 patient groups were generated. Examination of the SSC database demonstrated that the patient group requiring vasopressors to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L (18 mg/dL) after fluid resuscitation had a significantly higher mortality (42.3% [95% CI, 41.2%-43.3%]) in risk-adjusted comparisons with the other 5 groups derived using either serum lactate level greater than 2 mmol/L alone or combinations of hypotension, vasopressors, and serum lactate level 2 mmol/L or lower. These findings were validated in the UPMC and KPNC data sets. CONCLUSIONS AND RELEVANCE Based on a consensus process using results from a systematic review, surveys, and cohort studies, septic shock is defined as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a serum lactate level greater than 2 mmol/L after adequate fluid resuscitation.
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Affiliation(s)
- Manu Shankar-Hari
- Division of Asthma, Allergy, and Lung Biology, King's College London, London, United Kingdom2Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London SE17EH, United Kingdom
| | - Gary S Phillips
- The Ohio State University College of Medicine, Department of Biomedical Informatics, Center for Biostatistics, Columbus
| | - Mitchell L Levy
- Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Clifford S Deutschman
- Department of Pediatrics, Hofstra-North Shore-Long Island Jewish-Hofstra School of Medicine, Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York8Department of Molecular Medicine, Hofstra-North Shore-Long Island Jewish-Hofstra Sch
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania10Associate Editor, JAMA
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada12Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
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Finfer S, Machado FR. The Global Epidemiology of Sepsis. Does It Matter That We Know So Little? Am J Respir Crit Care Med 2016; 193:228-30. [DOI: 10.1164/rccm.201510-1976ed] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ore T. Trends and disparities in sepsis hospitalisations in Victoria, Australia. AUST HEALTH REV 2016; 40:511-518. [DOI: 10.1071/ah15106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/12/2015] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to determine the clinical and epidemiological characteristics of patients with sepsis admitted to hospitals in Victoria, Australia, during the period 2004–14. The data include incidence, severity and mortality. Methods In all, 44 222 sepsis hospitalisations were identified between 2004–05 and 2013–14 from the Victorian Admitted Episodes Dataset. The dataset contains clinical and demographic information on all admissions to acute public and private hospitals. Using the International Classification of Diseases (10th Revision) Australian Modification codes, incidence rates, severity of disease and mortality were calculated. Results Sepsis hospitalisation rates per 10 000 population increased significantly (P < 0.01) over the period, from 6.9 (95% confidence interval (CI) 5.6–7.8) to 10.0 (95% CI 9.1–11.1), an annual growth rate of 3.8%. The age-standardised in-hospital death rates per 100 000 population grew significantly (P < 0.01) from 9.2 (95% CI 7.8–10.4) in 2004–05 to 13.0 (95% CI 11.7–14.6) in 2013–14, an annual growth rate of 3.1%. Among people under 45 years of age, the 0–4 years age group had the highest hospitalisation rate (3.0 per 10 000 population; 95% CI 2.7–3.4). Nearly half (46.2%) of all sepsis hospitalisations were among patients born overseas, with a rate of 14.5 per 10 000 population (95% CI 12.4–16.2) in that group compared with a rate of 5.9 per 10 000 population (95% CI 5.3–6.7) for patients born in Australia. The age-standardised sepsis hospitalisation rate was 2.6-fold greater in the lowest compared with highest socioeconomic areas (12.7 per 10 000 population (95% CI 11.2–13.8) vs 4.8 per 10 000 population (95% CI 4.1–5.7), respectively). Conclusion This paper shows a significant upward trend in both sepsis separation rates and in-hospital death rates over the period; unlike sepsis, in-hospital death rates from all diagnoses fell over the same period. The results can be used to stimulate review of clinical practice. Greater understanding of the epidemiology of sepsis could improve care quality and outcomes. What is known about the topic? Sepsis is associated with high mortality rates and severe sepsis is the most common cause of death in intensive care units (ICU). The last published study of sepsis in Victoria (in 2005) showed a gradual rise in rates; since then, there is little information as to whether there has been any significant improvement in treatment outcomes. What does this paper add? This paper provides new information by analysing trends and variations in sepsis hospitalisations in Victoria by several demographic groups from 2004–05 to 2013–14. What are the implications for practitioners? Patients with severe sepsis consume approximately half the ICU resources. Reliable and recent data on the growth of this disease are important for prevention, allocation of resources and to track the effectiveness of care. A key area for intervention is promoting greater adherence to clinical guidelines.
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Nyein PP, Aung NM, Kyi TT, Htet ZW, Anstey NM, Kyi MM, Hanson J. High Frequency of Clinically Significant Bacteremia in Adults Hospitalized With Falciparum Malaria. Open Forum Infect Dis 2016; 3:ofw028. [PMID: 26989752 PMCID: PMC4794945 DOI: 10.1093/ofid/ofw028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/05/2016] [Indexed: 11/14/2022] Open
Abstract
Background. African children with severe falciparum malaria commonly have concomitant Gram-negative bacteremia, but co-infection has been thought to be relatively rare in adult malaria. Methods. Adults with a diagnosis of falciparum malaria hospitalized at 4 tertiary referral hospitals in Myanmar had blood cultures collected at admission. The frequency of concomitant bacteremia and the clinical characteristics of the patients, with and without bacteremia, were explored. Results. Of 67 adults hospitalized with falciparum malaria, 9 (13% [95% confidence interval, 5.3%-21.6%]) were also bacteremic on admission, 7 (78%) with Gram-negative enteric organisms (Escherichia coli [n = 3], typhoidal Salmonella species [n = 3], nontyphoidal Salmonella [n = 1]). Bacteremic adults had more severe disease (median Respiratory Coma Acidosis Malaria [RCAM] score 3; interquartile range [IQR], 1-4) than those without bacteremia (median RCAM score 1; IQR, 1-2) and had a higher frequency of acute kidney injury (50% vs 16%, P = .03). Although 35 (52%) were at high risk of death (RCAM score ≥2), all 67 patients in the study survived, 51 (76%) of whom received empirical antibiotics on admission. Conclusions. Bacteremia was relatively frequent in adults hospitalized with falciparum malaria in Myanmar. Like children in high transmission settings, bacteremic adults in this low transmission setting were sicker than nonbacteremic adults, and were often difficult to identify at presentation. Empirical antibiotics may also be appropriate in adults hospitalized with falciparum malaria in low transmission settings, until bacterial infection is excluded.
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Affiliation(s)
| | | | | | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
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