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Úbeda-Iglesias A, Fernández-Burgos I, Alonso-Romero L. Letter to the editor: Admission characteristics predictive of in-hospital death from hospital-acquired sepsis: A comparison to community-acquired sepsis. J Crit Care 2020; 56:318. [DOI: 10.1016/j.jcrc.2019.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/21/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
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Association between prior metformin therapy and sepsis in diabetes patients: a nationwide sample cohort study. J Anesth 2020; 34:358-366. [PMID: 32146543 DOI: 10.1007/s00540-020-02753-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/22/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE There have been no large-scale studies on whether metformin therapy might have a potential benefit for lowering mortality. Thus, this study aimed to investigate the association between prior metformin therapy and the development of sepsis as well as the association between prior metformin therapy and 30-day mortality in sepsis patients. METHODS We evaluated adult diabetes patients registered in the 2010 sample cohort database of the National Health Insurance Service in South Korea. Diabetes was identified according to the International Classification of Disease-10 diagnostic system (E10-E14). The cohorts were divided into the metformin user group (i.e., those who had been prescribed continuous oral metformin over a period of ≥ 90 days) and the control group (i.e., all other individuals). The primary endpoint was the development of sepsis between 2011 and 2015, and the secondary endpoint was 30-day mortality among diabetes patients diagnosed with sepsis. RESULTS In total, 77,337 patients (34,041 in the metformin user group and 43,296 in the control group) were included in the analysis, among whom 2512 patients (3.2%) were diagnosed with sepsis between 2011 and 2015. After propensity score adjustment, metformin use was not significantly associated with both the risk of sepsis (OR: 0.92, 95%CI 0.82-1.03; P = 0.143) and the risk of 30-day mortality after diagnosis of sepsis (OR: 0.94, 95%CI 0.75-1.17; P = 0.571). CONCLUSIONS Prior metformin therapy was not significantly associated with the risk of sepsis and 30-day mortality after diagnosis of sepsis among diabetes patients.
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Kato T, Yaku H, Morimoto T, Inuzuka Y, Tamaki Y, Yamamoto E, Yoshikawa Y, Kitai T, Taniguchi R, Iguchi M, Kato M, Takahashi M, Jinnai T, Ikeda T, Nagao K, Kawai T, Komasa A, Nishikawa R, Kawase Y, Morinaga T, Su K, Kawato M, Seko Y, Inoko M, Toyofuku M, Furukawa Y, Nakagawa Y, Ando K, Kadota K, Shizuta S, Ono K, Sato Y, Kuwahara K, Ozasa N, Kimura T. Association with Controlling Nutritional Status (CONUT) Score and In-hospital Mortality and Infection in Acute Heart Failure. Sci Rep 2020; 10:3320. [PMID: 32094392 PMCID: PMC7039945 DOI: 10.1038/s41598-020-60404-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 02/12/2020] [Indexed: 12/13/2022] Open
Abstract
The high controlling nutritional status (CONUT) score that represents poor nutritional status has been acknowledged to have prognostic implications in chronic heart failure. We aimed to investigate its role in acute decompensated heart failure (ADHF). Using the data from an multicenter registry that enrolled 4056 consecutive patients hospitalized for ADHF in Japan between 2014 and 2016, we analyzed 2466 patients in whom data on the components of the CONUT score at hospital presentation were available. The decrease of lymphocyte count and total cholesterol was assigned with 0, 1, 2, and 3 points and the decrease of albumin was assigned with 0, 2, 4, and 6 points according to the severity. We defined low CONUT score as 0-4 (N = 1568) and high CONUT score as 5-9 (N = 898). The patients in the high CONUT score group were older and more likely to have a smaller body mass index than those in the low CONUT score group. The high CONUT score group was associated with higher rate of death and infection during the index hospitalization compared to the low CONUT score group (9.0% versus 4.4%, and 21.9% versus 12.7%, respectively). After adjusting for confounders, the excess risk of high relative to low CONUT score for mortality and infection was significant (OR: 1.61, 95%CI: 1.05-2.44, and OR: 1.66, 95%CI: 1.30-2.12, respectively). The effect was incremental according to the score. High CONUT score was associated with higher risk for in-hospital mortality and infection in an incremental manner in patients hospitalized for ADHF.
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Affiliation(s)
- Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Hidenori Yaku
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Hyogo, Japan
| | - Yasutaka Inuzuka
- Department of Cardiovascular Medicine, Shiga Medical Center for Adult, Shiga, Japan
| | - Yodo Tamaki
- Division of Cardiology, Tenri Hospital, Nara, Japan
| | - Erika Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Moritake Iguchi
- National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | | | | | | | | | | | - Akihiro Komasa
- Kansai Electric Power Hospital, Osaka, Japan
- Shizuoka General Hospital, Shizuoka, Japan
| | | | | | | | - Kanae Su
- Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | | | | | | | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Hyogo, Japan
| | | | - Kenji Ando
- Kokura Memorial Hospital, Fukuoka, Japan
| | | | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University Graduate School of Medicine, Matsumoto, Japan
| | - Neiko Ozasa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Valik JK, Ward L, Tanushi H, Müllersdorf K, Ternhag A, Aufwerber E, Färnert A, Johansson AF, Mogensen ML, Pickering B, Dalianis H, Henriksson A, Herasevich V, Nauclér P. Validation of automated sepsis surveillance based on the Sepsis-3 clinical criteria against physician record review in a general hospital population: observational study using electronic health records data. BMJ Qual Saf 2020; 29:735-745. [PMID: 32029574 PMCID: PMC7467502 DOI: 10.1136/bmjqs-2019-010123] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Surveillance of sepsis incidence is important for directing resources and evaluating quality-of-care interventions. The aim was to develop and validate a fully-automated Sepsis-3 based surveillance system in non-intensive care wards using electronic health record (EHR) data, and demonstrate utility by determining the burden of hospital-onset sepsis and variations between wards. METHODS A rule-based algorithm was developed using EHR data from a cohort of all adult patients admitted at an academic centre between July 2012 and December 2013. Time in intensive care units was censored. To validate algorithm performance, a stratified random sample of 1000 hospital admissions (674 with and 326 without suspected infection) was classified according to the Sepsis-3 clinical criteria (suspected infection defined as having any culture taken and at least two doses of antimicrobials administered, and an increase in Sequential Organ Failure Assessment (SOFA) score by >2 points) and the likelihood of infection by physician medical record review. RESULTS In total 82 653 hospital admissions were included. The Sepsis-3 clinical criteria determined by physician review were met in 343 of 1000 episodes. Among them, 313 (91%) had possible, probable or definite infection. Based on this reference, the algorithm achieved sensitivity 0.887 (95% CI: 0.799 to 0.964), specificity 0.985 (95% CI: 0.978 to 0.991), positive predictive value 0.881 (95% CI: 0.833 to 0.926) and negative predictive value 0.986 (95% CI: 0.973 to 0.996). When applied to the total cohort taking into account the sampling proportions of those with and without suspected infection, the algorithm identified 8599 (10.4%) sepsis episodes. The burden of hospital-onset sepsis (>48 hour after admission) and related in-hospital mortality varied between wards. CONCLUSIONS A fully-automated Sepsis-3 based surveillance algorithm using EHR data performed well compared with physician medical record review in non-intensive care wards, and exposed variations in hospital-onset sepsis incidence between wards.
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Affiliation(s)
- John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden .,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Logan Ward
- Treat Systems ApS, Aalborg, Denmark.,Center for Model-based Medical Decision Support, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Hideyuki Tanushi
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Kajsa Müllersdorf
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ternhag
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa Aufwerber
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Färnert
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Anders F Johansson
- Department of Clinical microbiology and the Laboratory for Molecular Infection Medicine (MIMS), Umeå University, Umeå, Sweden
| | | | - Brian Pickering
- Department of Anesthesiology and Perioperative medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hercules Dalianis
- Department of Computer and Systems Sciences, Stockholm University, Kista, Sweden
| | - Aron Henriksson
- Department of Computer and Systems Sciences, Stockholm University, Kista, Sweden
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Pontus Nauclér
- Division of Infectious Diseases, Department of Medicine, Solna (MedS), Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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Schulte-Hubbert B, Meiswinkel N, Kutschan U, Kolditz M. Prognostic value of blood pressure drops during the first 24 h after hospital admission for risk stratification of community-acquired pneumonia: a retrospective cohort study. Infection 2020; 48:267-274. [PMID: 32008182 DOI: 10.1007/s15010-020-01391-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/17/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Current risk stratification in community-acquired pneumonia (CAP) does not incorporate the dynamic nature of CAP evolution. Study aim was to evaluate the predictive value of early blood pressure (BP) drop and its consideration within the CRB-65 score. METHODS We performed a retrospective cohort study including consecutive adult hospitalized CAP patients 2013-2014 without documented treatment limitations or direct ICU admission. The CRB-65 score was calculated initially and re-calculated including any BP below the threshold (BP drop) within the first 24 h (CRB-65[BP24]). The primary endpoint was need for mechanical ventilation or vasopressors (MVVS) occurring after 24 h. Prognostic values were evaluated by uni- and multivariate and ROC curve analyses. RESULTS 28/294 patients (9.5%) met the primary endpoint. Only 3 (11%) of them showed an initial BP of < 90 mmHg systolic or ≤ 60 mmHg diastolic, but 21 (75%) developed a BP drop within the first 24 h. 24/178 (13%) with and only 4/116 (3%) without any low BP during the first 24 h needed MVVS (p = 0.004). After multivariate analysis, the predictive value of BP drop was independent of other score parameters and biomarkers (all p < 0.01). In ROC analysis, the new CRB-65(BP24) showed a better prediction than the CRB-65 score (AUC 0.69 vs. 0.62, p = 0.04). 7/13 patients (54%) with MVVS despite an admission CRB-65 of 0 or 1 showed a BP drop. CONCLUSIONS In the evaluated cohort, BP drop within the first 24 h was significantly associated with more need for MVVS in CAP, and its consideration improved the prognostic value of the CRB-65 score.
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Affiliation(s)
- Bernhard Schulte-Hubbert
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Nils Meiswinkel
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Ulrike Kutschan
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Martin Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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Husabø G, Nilsen RM, Flaatten H, Solligård E, Frich JC, Bondevik GT, Braut GS, Walshe K, Harthug S, Hovlid E. Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study. PLoS One 2020; 15:e0227652. [PMID: 31968009 PMCID: PMC6975530 DOI: 10.1371/journal.pone.0227652] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/22/2019] [Indexed: 12/29/2022] Open
Abstract
Background Early recognition of sepsis is critical for timely initiation of treatment. The first objective of this study was to assess the timeliness of diagnostic procedures for recognizing sepsis in emergency departments. We define diagnostic procedures as tests used to help diagnose the condition of patients. The second objective was to estimate associations between diagnostic procedures and time to antibiotic treatment, and to estimate associations between time to antibiotic treatment and mortality. Methods This observational study from 24 emergency departments in Norway included 1559 patients with infection and at least two systemic inflammatory response syndrome criteria. We estimated associations using linear and logistic regression analyses. Results Of the study patients, 72.9% (CI 70.7–75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (42.4–47.4) were examined by a physician in accordance with the triage priority, 44.4% (41.4–46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (23.2–27.7) received antibiotics within 1 hour. Delay or non-completion of these key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (10.1–17.1), in the timespan 2 to 3 hours after admission 5.9% (2.8–9.1), and 4 hours or later after admission 10.5% (5.7–15.3). Conclusions Key procedures for recognizing sepsis were delayed or not completed in a substantial proportion of patients admitted to the emergency department with sepsis. Delay or non-completion of key diagnostic procedures was associated with prolonged time to treatment with antibiotics. This suggests a need for systematic improvement in the initial management of patients admitted to emergency departments with sepsis.
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Affiliation(s)
- Gunnar Husabø
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- * E-mail:
| | - Roy M. Nilsen
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erik Solligård
- Clinic of Anaesthesia and Intensive Care, St. Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging and Mid-Norway Sepsis Research Group, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan C. Frich
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gunnar T. Bondevik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Geir S. Braut
- Stavanger University Hospital, Stavanger, Norway
- Norwegian Board of Health Supervision, Oslo, Norway
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, Manchester, England, United Kingdom
| | - Stig Harthug
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Einar Hovlid
- Department of Social Science, Western Norway University of Applied Sciences, Sogndal, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Norwegian Board of Health Supervision, Oslo, Norway
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Srisawat N, Kulvichit W, Tungsanga S, Peerapornratana S, Vorasitchai S, Tangkanakul C, Lumlertgul N, Komaenthammasophon C, Praditpornsilpa K, Tungsanga K, Eiam-Ong S. The role of neutrophil chemotaxis activity as an immunologic biomarker to predict mortality in critically-ill patients with severe sepsis. J Crit Care 2020; 56:215-221. [PMID: 31982695 DOI: 10.1016/j.jcrc.2020.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/09/2019] [Accepted: 01/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Innate immunity is an important host response to infection. However, the role of innate immunity as a prognostic biomarker in severe sepsis is still unknown. This study is to evaluate the discriminatory characteristics of these biomarkers on clinical outcome. MATERIALS AND METHODS Retrospective study was conducted in critically ill patients with severe sepsis. Neutrophil function was assessed by neutrophil chemotaxis activity and CD-11b expression. Monocyte function was assessed by measurement of mHLA-DR expression and presepsin level. The primary end point was 28 day-mortality. RESULTS A total of 136 participants were enrolled. Patients were classified into 2 groups as survivors (n = 63, 46.3%) and non-survivors (n = 73, 53.7%). Neutrophil chemotaxis activity was significantly higher in survivors (46.7% vs. 41.2%, p = .023). There was no difference in the remaining biomarker levels between survivors and non-survivors. Only decreased neutrophil chemotaxis activity was associated with 28-day mortality. Combining neutrophil chemotaxis activity with mHLA-DR, CD-11b expression, presepsin, and SOFA score provided the highest AUC of 0.90 (0.84-0.96) in predicting 28-day mortality. CONCLUSION Neutrophil chemotaxis activity appears to be a promising novel immunologic biomarker in predicting clinical outcome in patients with severe sepsis.
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Affiliation(s)
- Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Academic of Science, Royal Society of Thailand, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
| | - Win Kulvichit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somkanya Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sadudee Peerapornratana
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suttinan Vorasitchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chakorn Tangkanakul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chalermchai Komaenthammasophon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Yinger K, Bernas-Maley M, Bhatia V. Utilization of a Visit-Based Sepsis Assessment to Prevent Hospital Readmissions. Home Healthc Now 2020; 38:131-137. [PMID: 32358440 DOI: 10.1097/nhh.0000000000000864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Sepsis results in 270,000 deaths annually in the United States. Despite the current healthcare focus on sepsis, there exist few postacute best-practice standards to rapidly identify health changes in home healthcare patients to prevent and reduce hospital readmissions due to sepsis. We systematically examined whether an evidence-based process and intervention triggering home healthcare clinicians to activate a Positive Sepsis Assessment would reduce the likelihood that the patient would be readmitted to the acute care hospital. Over 24 months, we tracked the rate of sepsis readmissions to acute care hospitals through the initial phase of early recognition education; assessment, review, and revision of best-practice algorithms; standardized documentation; and proactive care management, in conjunction with the patient's primary care provider. During our review of the last 12 months of data on home care patients triggering the Positive Sepsis Assessment 130 patients were identified to have potential signs of sepsis. Ninety-seven of these patients received early medical intervention in place and were not readmitted to the hospital. Our findings suggest that a multidisciplinary home healthcare team utilizing standard sepsis education and sepsis algorithm on every patient during every visit can reduce and prevent readmissions.
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Affiliation(s)
- Kimberly Yinger
- Kimberly Yinger, BSN, RN, is Nursing Operations Director, WellSpan VNA Home Care, York, Pennsylvania. Melissa Bernas-Maley, MS, OTR/L, is Rehab Clinical Supervisor, WellSpan VNA Home Care, York, Pennsylvania. Vipul Bhatia, MD, MBA, is Medical Director of Continuing Care Services, WellSpan Health, York, Pennsylvania
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A novel id-iri score: development and internal validation of the multivariable community acquired sepsis clinical risk prediction model. Eur J Clin Microbiol Infect Dis 2019; 39:689-701. [PMID: 31823148 DOI: 10.1007/s10096-019-03781-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/27/2019] [Indexed: 02/08/2023]
Abstract
We aimed to develop a scoring system for predicting in-hospital mortality of community-acquired (CA) sepsis patients. This was a prospective, observational multicenter study performed to analyze CA sepsis among adult patients through ID-IRI (Infectious Diseases International Research Initiative) at 32 centers in 10 countries between December 1, 2015, and May 15, 2016. After baseline evaluation, we used univariate analysis at the second and logistic regression analysis at the third phase. In this prospective observational study, data of 373 cases with CA sepsis or septic shock were submitted from 32 referral centers in 10 countries. The median age was 68 (51-77) years, and 174 (46,6%) of the patients were females. The median hospitalization time of the patients was 15 (10-21) days. Overall mortality rate due to CA sepsis was 17.7% (n = 66). The possible predictors which have strong correlation and the variables that cause collinearity are acute oliguria, altered consciousness, persistent hypotension, fever, serum creatinine, age, and serum total protein. CAS (%) is a new scoring system and works in accordance with the parameters in third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The system has yielded successful results in terms of predicting mortality in CA sepsis patients.
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Yo CH, Lai CC, Hsu TC, Wang CY, Galvis AE, Yen D, Hsu WT, Wang J, Lee CC. National Trends of Organ Dysfunctions in Sepsis:An 11-Year Longitudinal Population-Based Cohort Study. J Acute Med 2019; 9:178-188. [PMID: 32995248 PMCID: PMC7440389 DOI: 10.6705/j.jacme.201912_9(4).0004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 12/23/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little is known about the trend of incidence and mortality of specific organ dysfunction among sepsis patients at the population level. This study aimed to examine the trend and mortality of organ dysfunction in patients with sepsis using a nationwide database in Taiwan. METHODS We conducted a study using 2002-2012 data from the nationwide health insurance database of Taiwan. Sepsis hospitalizations were identified by Angus algorithm to include all cases with ICD-9-CM codes for specific sepsis diagnosis and both an infectious process and a diagnosis of acute organ dysfunction. The primary outcome was the trend of incidence and in-hospital mortality of specific type of organ dysfunction in sepsis patients. RESULTS We identified 1,259,578 adult patients with sepsis. Acute respiratory dysfunction, cardiovascular dysfunction/shock, and renal system dysfunction were the leading three types of acute organ dysfunction, accounting for 65.6, 30.5, and 18.3% of all sepsis patients, respectively. All types of organ dysfunction increased over time, except for hepatic and metabolic systems. Renal system (annual increase: 13.5%) and cardiovascular system dysfunction (annual increase: 4.3%) had the fastest increase. Mortality from all sources of infection has decreased significantly in the study period (trend p < 0.001). CONCLUSIONS This is the first true nationwide population-based data showing the trend and outcome of acute organ dysfunction in sepsis patients. Renal and cardiovascular systems dysfunction are increasing at an alarming rate.
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Affiliation(s)
- Chia-Hung Yo
- Far Eastern Memorial Hospital Department of Emergency Medicine New Taipei City Taiwan
| | - Chih-Cheng Lai
- Kaohsiung Veterans General Hospital, Tainan Branch, Department of Internal Medicine Tainan Taiwan
| | - Tzu-Chun Hsu
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Cheng-Yi Wang
- Cardinal Tien Hospital and School of Medicine Department of Internal Medicine New Taipei City Taiwan
- Fu Jen Catholic University College of Medicine New Taipei City Taiwan
| | - Alvaro E Galvis
- Children's Hospital of Orange County, University of California Department of Infectious Diseases Orange CA USA
| | - Debra Yen
- Washington University School of Medicine Department of Medicine Saint Louis MO USA
| | - Wan-Ting Hsu
- Harvard T.H. Chan School of Public Health Department of Epidemiology Boston MA USA
| | - Jason Wang
- Kaohsiung Veterans General Hospital, Tainan Branch, Department of Internal Medicine Tainan Taiwan
| | - Chien-Chang Lee
- University of Nevada Las Vegas School of Medicine Department of Pediatrics Nevada USA
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Severity and Timing of Onset Drive Economic Costs and Clinical Outcomes With Sepsis. Crit Care Med 2019; 46:2043-2044. [PMID: 30444807 DOI: 10.1097/ccm.0000000000003376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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63
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Rhee C, Wang R, Zhang Z, Fram D, Kadri SS, Klompas M. Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data. Crit Care Med 2019; 47:1169-1176. [PMID: 31135503 PMCID: PMC6697188 DOI: 10.1097/ccm.0000000000003817] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis. DESIGN Retrospective cohort study. SETTING 136 U.S. hospitals in the Cerner HealthFacts dataset. PATIENTS Adults hospitalized in 2009-2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) (p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0-2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9-3.2). CONCLUSIONS Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Sameer S. Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Westphal GA, Pereira AB, Fachin SM, Barreto ACC, Bornschein ACGJ, Caldeira Filho M, Koenig Á. Characteristics and outcomes of patients with community-acquired and hospital-acquired sepsis. Rev Bras Ter Intensiva 2019; 31:71-78. [PMID: 30970093 PMCID: PMC6443308 DOI: 10.5935/0103-507x.20190013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Objective To compare the clinical characteristics and outcomes of patients with
community-acquired and hospital-acquired sepsis. Methods This is a retrospective cohort study that included all patients with a
diagnosis of sepsis detected between January 2010 and December 2015 at a
private hospital in southern Brazil. Outcomes (mortality, intensive care
unit and hospital lengths of stay) were measured by analyzing electronic
records. Results There were 543 hospitalized patients with a diagnosis of sepsis, with a
frequency of 90.5 (85 to 105) cases/year. Of these, 319 (58%) cases were
classified as hospital-acquired sepsis. This group exhibited more severe
disease and had a larger number of organ dysfunctions, with higher hospital
[8 (8 - 10) versus 23 (20 - 27) days; p <
0.001] and intensive care unit [5 (4 - 7)
versus 8.5 (7 - 10); p < 0.001] lengths of
stay and higher in-hospital mortality (30.7% versus 15.6%;
p < 0.001) than those with community-acquired sepsis. After adjusting for
age, APACHE II scores, and hemodynamic and respiratory dysfunction,
hospital-acquired sepsis remained associated with increased mortality (OR
1.96; 95%CI 1.15 - 3.32, p = 0.013). Conclusion The present results contribute to the definition of the epidemiological
profile of sepsis in the sample studied, in which hospital-acquired sepsis
was more severe and was associated with higher mortality.
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Affiliation(s)
| | | | | | | | | | | | - Álvaro Koenig
- Centro Hospitalar Unimed Joinville - Joinville (SC), Brasil
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65
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Jansen MPB, Huisman A, Claessen N, Florquin S, Roelofs JJTH. Experimental thrombocytopenia does not affect acute kidney injury 24 hours after renal ischemia reperfusion in mice. Platelets 2019; 31:383-391. [PMID: 31364433 DOI: 10.1080/09537104.2019.1646899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The pathophysiology of renal ischemia/reperfusion (I/R) injury is characterized by excessive activation of inflammation and coagulation processes followed by abnormal renal tissue repair, resulting in renal injury and function loss. Platelets are important actors in these processes, however to what extent platelets contribute to the pathophysiology of renal I/R injury still needs to be elucidated. In the current study, we treated wild-type mice with a platelet depleting antibody, which caused thrombocytopenia. We then investigated the role of platelets during the pathophysiology of renal I/R by subjecting control wild-type mice with normal platelet counts and thrombocytopenic wild-type mice to renal I/R injury. Our results showed that in the early phase of renal I/R injury, thrombocytopenia 24 hours after ischemia reperfusion does not influence renal injury, neutrophil infiltration and accumulation of inflammatory chemokines (e.g. keratinocyte chemoattractant, monocyte chemoattractant protein 1, tumor necrosis factor alpha). In the recovery and regeneration phase of I/R injury, respectively 5 and 10 days post-ischemia, thrombocytopenia did also not affect the accumulation of intra-renal neutrophils and macrophages, renal injury, and renal fibrosis. Together, these results imply that lowering platelet counts do not impact the pathogenesis of I/R injury in mice.
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Affiliation(s)
- Marcel P B Jansen
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Andras Huisman
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nike Claessen
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sandrine Florquin
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam Infection & Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Huang CT, Ruan SY, Tsai YJ, Ku SC, Yu CJ. Clinical Trajectories and Causes of Death in Septic Patients with a Low APACHE II Score. J Clin Med 2019; 8:jcm8071064. [PMID: 31330785 PMCID: PMC6678558 DOI: 10.3390/jcm8071064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023] Open
Abstract
Clinical course and mortality in septic patients with low disease severity remain poorly understood and is worth further investigation. We enrolled septic patients admitted to intensive care units (ICUs) between 2010 and 2014 with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of ≤15. We sought to determine their clinical trajectories and causes of death, and to analyze risk factors associated with in-hospital mortality. A total of 352 patients were included, of whom 89 (25%) did not survive to hospital discharge, at a rate higher than predicted (<21%) by the APACHE II score. Approximately one third (31/89) of non-survivors succumbed to index sepsis; however, more patients (34/89) died of subsequent sepsis. New-onset ICU sepsis developed in 99 (28%) patients and was an independent risk factor for mortality. In addition, septic patients with comorbid malignancy or index infection acquired in the hospital settings were more likely to have in-hospital mortality than those without. In conclusion, septic patients with low APACHE II scores were at a higher mortality risk than expected, and subsequent sepsis rather than index sepsis was the primary cause of death. This study provides insight into unexpected clinical trajectories and outcomes of septic patients with low disease severity at ICU admission and highlights the need for more research and clinical attention in this patient population.
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Affiliation(s)
- Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Sheng-Yuan Ruan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Yi-Ju Tsai
- Graduate Institute of Biomedical and Pharmaceutical Science, College of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
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Leisman DE, Angel C, Schneider SM, D’Amore JA, D’Angelo JK, Doerfler ME. Sepsis Presenting in Hospitals versus Emergency Departments: Demographic, Resuscitation, and Outcome Patterns in a Multicenter Retrospective Cohort. J Hosp Med 2019; 14:340-348. [PMID: 30986182 PMCID: PMC6625440 DOI: 10.12788/jhm.3188] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Differences between hospital-presenting sepsis (HPS) and emergency department-presenting sepsis (EDPS) are not well described. OBJECTIVES We aimed to (1) quantify the prevalence of HPS versus EDPS cases and outcomes; (2) compare HPS versus EDPS characteristics at presentation; (3) compare HPS versus EDPS in process and patient outcomes; and (4) estimate risk differences in patient outcomes attributable to initial resuscitation disparities. DESIGN Retrospective consecutive-sample cohort. SETTING Nine hospitals from October 1, 2014, to March 31, 2016. PATIENTS All hospitalized patients with sepsis or septic shock, as defined by simultaneous (1) infection, (2) ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and (3) ≥1 acute organ dysfunction criterion. EDPS met inclusion criteria while physically in the emergency department (ED). HPS met the criteria after leaving the ED. MEASUREMENTS We assessed overall HPS versus EDPS contributions to case prevalence and outcomes, and then compared group differences. Process outcomes included 3-hour bundle compliance and discrete bundle elements (eg, time to antibiotics). The primary patient outcome was hospital mortality. RESULTS Of 11,182 sepsis hospitalizations, 2,509 (22.4%) were hospital-presenting. HPS contributed 785 (35%) sepsis mortalities. HPS had more frequent heart failure (OR: 1.31, CI: 1.18-1.47), renal failure (OR: 1.62, CI: 1.38-1.91), gastrointestinal source of infection (OR: 1.84, CI: 1.48-2.29), euthermia (OR: 1.45, CI: 1.10-1.92), hypotension (OR: 1.85, CI: 1.65-2.08), or impaired gas exchange (OR: 2.46, CI: 1.43-4.24). HPS were admitted less often from skilled nursing facilities (OR: 0.44, CI: 0.32-0.60), had chronic obstructive pulmonary disease (OR: 0.53, CI: 0.36-0.78), tachypnea (OR: 0.76, CI: 0.58-0.98), or acute kidney injury (OR: 0.82, CI: 0.68-0.97). In a propensity-matched cohort (n = 3,844), HPS patients had less than half the odds of 3-hour bundle compliant care (17.0% vs 30.3%, OR: 0.47, CI: 0.40-0.57) or antibiotics within three hours (66.2% vs 83.8%, OR: 0.38, CI: 0.32-0.44) vs EDPS. HPS was associated with higher mortality (31.2% vs 19.3%, OR: 1.90, CI: 1.64-2.20); 23.3% of this association was attributable to differences in initial resuscitation (resuscitation-adjusted OR: 1.69, CI: 1.43-2.00). CONCLUSIONS HPS differed from EDPS by admission source, comorbidities, and clinical presentation. These patients received markedly less timely initial resuscitation; this disparity explained a moderate proportion of mortality differences.
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Affiliation(s)
- Daniel E Leisman
- Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- Global Sepsis Alliance, Jena,
Germany
- Corresponding Author: Daniel E Leisman, BS; E-mail: ; Telephone: 516-941-8468
| | - Catalina Angel
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sandra M Schneider
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- American College of Emergency Physicians, Irving, Texas
| | - Jason A D’Amore
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - John K D’Angelo
- Department of Emergency Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
| | - Martin E Doerfler
- Department of Medicine, Hofstra-Northwell School of Medicine, Hempstead, New York
- Department of Science Education, Hofstra-Northwell School of Medicine, Hempstead, New York
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Guirgis FW, Padro T, Smotherman C, Gautam S, Gerdik C, Gray-Eurom K. Response to Editor letter "Admission characteristics predictive of in-hospital death from hospital-acquired sepsis: A comparison to community-acquired sepsis". J Crit Care 2019; 56:319-320. [PMID: 31056223 DOI: 10.1016/j.jcrc.2019.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Faheem W Guirgis
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States.
| | - Teresa Padro
- University of Florida College of Medicine, Jacksonville, Department of Neurosurgery, Jacksonville, FL, United States
| | - Carmen Smotherman
- University of Florida College of Medicine, Jacksonville, Center for Health Equity and Quality Research, Jacksonville, FL, United States
| | - Shiva Gautam
- University of Florida College of Medicine, Jacksonville, Center for Health Equity and Quality Research, Jacksonville, FL, United States
| | - Cynthia Gerdik
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States
| | - Kelly Gray-Eurom
- University of Florida College of Medicine, Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States
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Abstract
To investigate the epidemiology trend and characteristics of sepsis-related hospitalizations in Taiwan, and to compare the differences among different severity levels of sepsis.This study is a retrospective national claim database analysis. Hospitalized adult patients with sepsis between 2010 and 2014 were identified from the Two-Million-Sample Longitudinal Health and Welfare Database (LHWD) by the International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM). The patients were divided into 3 severity groups based on their medical records during hospitalization.The study results showed that in Taiwan, there were 643 new cases of sepsis in 100,000 Taiwanese. The mortality of all septic patients in Taiwan was 287 per 100,000 people, and the case fatality was 29.2%. It was found that the mortality and incidence of sepsis in Taiwan have increased year by year, but there has been no significant change over time. In addition, demographic variation exists in the epidemiology of sepsis. In all the rates investigated, the men's were higher than the women's and the elderly's were higher than the youths'. The analysis results also showed that the respiratory system was the most common site of organ failure in septic patients.The incidence and mortality of any severity level of sepsis were 643, and 287 per 100,000 people in Taiwan, respectively, and the average case fatality was 29.2% during the study period (2010-2014). The respiratory system was the major infected site and site of organ dysfunction, especially in the more severe levels.
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Affiliation(s)
| | - Fu-Lun Chen
- Division of Infectious Diseases, Wan Fang Hospital
| | - Jin-Hua Chen
- Research Center of Biostatistics and Graduate Institute of Data Science, College of Management
| | - Man-Tzu Marcie Wu
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University
| | | | | | - Yu Ko
- Department of Pharmacy, College of Pharmacy
- Research Center for Pharmacoeconomics, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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Song H, Moon HG, Kim SH. Efficacy of quick Sequential Organ Failure Assessment with lactate concentration for predicting mortality in patients with community-acquired pneumonia in the emergency department. Clin Exp Emerg Med 2019; 6:1-8. [PMID: 30781940 PMCID: PMC6453698 DOI: 10.15441/ceem.17.262] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/26/2017] [Indexed: 12/29/2022] Open
Abstract
Objective Community-acquired pneumonia (CAP) is a major cause of sepsis, and sepsis-related acute organ dysfunction affects patient mortality. Although the quick Sequential Organ Failure Assessment (qSOFA) is a new screening tool for patients with suspected infection, its predictive value for the mortality of patients with CAP has not been validated. Lactate concentration is a valuable biomarker for critically ill patients. Thus, we investigated the predictive value of qSOFA with lactate concentration for in-hospital mortality in patients with CAP in the emergency department (ED). Methods From January 2015 to June 2015, 443 patients, who were diagnosed with CAP in the ED, were retrospectively analyzed. We defined high qSOFA or lactate concentrations as a qSOFA score ≥2 or a lactate concentration >2 mmol/L upon admission at the ED. The primary outcome was all-cause in-hospital mortality. Results Among the 443 patients, 44 (9.9%) died. Based on the receiver operating characteristic (ROC) analysis, the areas under the curves for the prediction of mortality were 0.720, 0.652, and 0.686 for qSOFA, CURB-65 (confusion, urea, respiratory rate, blood pressure, and age), and Pneumonia Severity Index, respectively. The area under the ROC curve of qSOFA was lower than that of SOFA (0.720 vs. 0.845, P=0.004). However, the area under the ROC curve of qSOFA with lactate concentration was not significantly different from that of SOFA (0.828 vs. 0.845, P=0.509). The sensitivity and specificity of qSOFA with lactate concentration were 71.4% and 83.2%, respectively. Conclusion qSOFA with lactate concentration is a useful and practical tool for the early prediction of in-hospital mortality among patients with CAP in the ED.
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Affiliation(s)
- Hwan Song
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyung Gi Moon
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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71
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Padro T, Smotherman C, Gautam S, Gerdik C, Gray-Eurom K, Guirgis FW. Admission characteristics predictive of in-hospital death from hospital-acquired sepsis: A comparison to community-acquired sepsis. J Crit Care 2019; 51:145-148. [PMID: 30825788 DOI: 10.1016/j.jcrc.2019.02.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/21/2019] [Accepted: 02/19/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Healthcare associated (HA) sepsis is associated with increased resource utilization and mortality compared with community acquired (CA) sepsis. The purpose of this study was to identify independent predictors of in-hospital mortality from HA-sepsis. MATERIALS AND METHODS Retrospective study of adult patients admitted with HA or CA-sepsis. Predictors were identified using logistic regression. RESULTS There were 3917 sepsis encounters, of which 3186 were CA and 731 were HA. History of stroke (83/731, 11%) and myocardial infarction (70/731, 10%) were higher in HA than CA-sepsis (stroke: 258/3186, 8%, p = .005; myocardial infarction: 213/3186, 7%, p = .007). HA-sepsis patients required more mechanical ventilation (153/731, 21%) than CA-patients (218/3186, 7%, p < .001) and had a higher rate of vasopressor use (334/731, 46%) than CA patients (832/3186, 26%, p < .001). The HA group had longer ICU lengths of stay (LOS) than CA patients did at 9 days and 2.8 days, respectively (p < .0001). Moderate to severe liver disease (OR = 27, 95%CI 1.4, 513, p = .031) and congestive heart failure (CHF, 5.81, 95% CI 1.3, 26, p = .025) were predictive of in-hospital mortality from HA-sepsis. CONCLUSIONS Liver disease and CHF were independent predictors of in-hospital mortality in HA-sepsis. HA-sepsis patients had increased prevalence of previous stroke, myocardial infarction, and liver disease.
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Affiliation(s)
- Teresa Padro
- University of Florida College of Medicine-Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States of America
| | - Carmen Smotherman
- University of Florida College of Medicine-Jacksonville, Center for Health Equity and Quality Research, Jacksonville, FL, United States of America
| | - Shiva Gautam
- University of Florida College of Medicine-Jacksonville, Center for Health Equity and Quality Research, Jacksonville, FL, United States of America
| | - Cynthia Gerdik
- University of Florida College of Medicine-Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States of America
| | - Kelly Gray-Eurom
- University of Florida College of Medicine-Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States of America
| | - Faheem W Guirgis
- University of Florida College of Medicine-Jacksonville, Department of Emergency Medicine, Jacksonville, FL, United States of America.
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Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the "one-size-fits-all" approach. J Crit Care 2019; 51:94-98. [PMID: 30784983 DOI: 10.1016/j.jcrc.2019.02.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/16/2019] [Accepted: 02/02/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality. DESIGN Retrospective, observational study. SETTING 1136-bed academic and 235-bed community hospital (January 2015-June 2016). PATIENTS Patients with septic shock. INTERVENTIONS Crystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS. MEASUREMENTS Associations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported. MAIN RESULTS Overall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76-1.41. CONCLUSIONS These findings question a "one-size-fits-all" approach to fluid administration and performance measures for patients with sepsis.
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73
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Dolin HH, Papadimos TJ, Chen X, Pan ZK. Characterization of Pathogenic Sepsis Etiologies and Patient Profiles: A Novel Approach to Triage and Treatment. Microbiol Insights 2019; 12:1178636118825081. [PMID: 30728724 PMCID: PMC6350122 DOI: 10.1177/1178636118825081] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022] Open
Abstract
Pathogenic sepsis is not a monolithic condition. Three major types of sepsis exist within this category: bacterial, viral, and fungal, each with its own mechanism of action. While similar in symptoms, the etiologies and immune mechanisms of these types differ enough that a discrete patient base can be recognized for each one. Non-specific treatment, such as broad-spectrum antibiotics, without determination of sepsis origins may worsen sepsis symptoms and leads to increased morbidity and mortality in patients. However, recognition of current and historical patterns in likely patients for each sepsis type may aid in differentiation between pathogens prior to definitive blood testing. Clinicians may ultimately be able to diagnose and treat bacterial, viral, and fungal sepsis using analysis of previous patient patterns and circumstances in addition to standard care. This method is likely to decrease incidence of multidrug-resistant organisms, organ failure due to ineffective treatment, and turnaround time to the correct treatment for each sepsis patient. Ultimately, we aim to provide classification information on these patient populations and to suggest epidemiology-based screening methods that can be integrated into critical care medicine, specifically triage and treatment of sepsis.
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Affiliation(s)
- Hallie H Dolin
- Departments of Medicine and Medical Microbiology and Immunology, University of Toledo Medical Center, Toledo, OH, USA
| | - Thomas J Papadimos
- Departments of Medicine and Medical Microbiology and Immunology, University of Toledo Medical Center, Toledo, OH, USA
| | - Xiaohuan Chen
- Departments of Medicine and Medical Microbiology and Immunology, University of Toledo Medical Center, Toledo, OH, USA
| | - Zhixing K Pan
- Departments of Medicine and Medical Microbiology and Immunology, University of Toledo Medical Center, Toledo, OH, USA
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Le S, Hoffman J, Barton C, Fitzgerald JC, Allen A, Pellegrini E, Calvert J, Das R. Pediatric Severe Sepsis Prediction Using Machine Learning. Front Pediatr 2019; 7:413. [PMID: 31681711 PMCID: PMC6798083 DOI: 10.3389/fped.2019.00413] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/25/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Early detection of pediatric severe sepsis is necessary in order to optimize effective treatment, and new methods are needed to facilitate this early detection. Objective: Can a machine-learning based prediction algorithm using electronic healthcare record (EHR) data predict severe sepsis onset in pediatric populations? Methods: EHR data were collected from a retrospective set of de-identified pediatric inpatient and emergency encounters for patients between 2-17 years of age, drawn from the University of California San Francisco (UCSF) Medical Center, with encounter dates between June 2011 and March 2016. Results: Pediatric patients (n = 9,486) were identified and 101 (1.06%) were labeled with severe sepsis following the pediatric severe sepsis definition of Goldstein et al. (1). In 4-fold cross-validation evaluations, the machine learning algorithm achieved an AUROC of 0.916 for discrimination between severe sepsis and control pediatric patients at the time of onset and AUROC of 0.718 at 4 h before onset. The prediction algorithm significantly outperformed the Pediatric Logistic Organ Dysfunction score (PELOD-2) (p < 0.05) and pediatric Systemic Inflammatory Response Syndrome (SIRS) (p < 0.05) in the prediction of severe sepsis 4 h before onset using cross-validation and pairwise t-tests. Conclusion: This machine learning algorithm has the potential to deliver high-performance severe sepsis detection and prediction through automated monitoring of EHR data for pediatric inpatients, which may enable earlier sepsis recognition and treatment initiation.
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Affiliation(s)
- Sidney Le
- Dascena Inc., Oakland, CA, United States
| | | | - Christopher Barton
- Dascena Inc., Oakland, CA, United States.,Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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75
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Validation of the REGARDS Severe Sepsis Risk Score. J Clin Med 2018; 7:jcm7120536. [PMID: 30544923 PMCID: PMC6306847 DOI: 10.3390/jcm7120536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 12/29/2022] Open
Abstract
There are no validated systems for characterizing long-term risk of severe sepsis in community-dwelling adults. We tested the ability of the REasons for Geographic and Racial Differences in Stroke-Severe Sepsis Risk Score (REGARDS-SSRS) to predict 10-year severe sepsis risk in separate cohorts of community-dwelling adults. We internally tested the REGARDS-SSRS on the REGARDS-Medicare subcohort. We then externally validated the REGARDS-SSRS using (1) the Cardiovascular Health Study (CHS) and (2) the Atherosclerosis Risk in Communities (ARIC) cohorts. Participants included community-dwelling adults: REGARDS-Medicare, age ≥65 years, n = 9522; CHS, age ≥65 years, n = 5888; ARIC, age 45–64 years, n = 11,584. The primary exposure was 10-year severe sepsis risk, predicted by the REGARDS-SSRS from participant sociodemographics, health behaviors, chronic medical conditions and select biomarkers. The primary outcome was first severe sepsis hospitalizations, defined as the concurrent presence of ICD-9 discharge diagnoses for a serious infection and organ dysfunction. Median SSRS in the cohorts were: REGARDS-Medicare 11 points (IQR 7–16), CHS 10 (IQR 6–15), ARIC 7 (IQR 5–10). Severe sepsis incidence rates were: REGARDS-Medicare 30.7 per 1000 person-years (95% CI: 29.2–32.2); CHS 11.9 (10.9–12.9); ARIC 6.8 (6.3–7.3). SSRS discrimination for first severe sepsis events were: REGARDS-Medicare C-statistic 0.704 (95% CI: 0.691–0.718), CHS 0.696 (0.675–0.716), ARIC 0.697 (0.677–0.716). The REGARDS-SRSS may potentially play a role in identifying community-dwelling adults at high severe sepsis risk.
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76
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Fang M, Hume E, Ibrahim S. Race, Bundled Payment Policy, and Discharge Destination After TKA: The Experience of an Urban Academic Hospital. Geriatr Orthop Surg Rehabil 2018; 9:2151459318803222. [PMID: 30370172 PMCID: PMC6201172 DOI: 10.1177/2151459318803222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/22/2018] [Accepted: 09/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Total knee arthroplasty (TKA) provides good clinical outcomes for the treatment of end-stage osteoarthritis; however, discharge destination after TKA has major implications on postoperative adverse outcomes and readmissions. With the initiation of Bundled Payments for Care Improvement (BPCI), it is unclear how racial disparities in discharge destination after TKA will be affected by the new bundled payment for TKA. Methods Bundled Payments for Care Improvement was implemented in July 01, 2014, at the University of Pennsylvania. We compared differences during early implementation (July 1, 2014, to, March 30, 2016) and during late policy implementation (April 1, 2016, to February 28, 2017) in patient characteristics (including race: African American [AA], white, and other race), discharge destination (skilled nursing facility [SNF], inpatient rehabilitation facility, home, home with home health, or other), and outcomes. Results We identified 2276 patients who underwent TKA (43.8% AA, 48.2% white, and 8.0% other race). African American patients were more likely to be discharged to SNF as opposed to home than white patients both during the early BPCI (AA: 53.0%, n = 320; white: 32.4%, n = 210, P < .05) and late BPCI implementation (AA: 44.4%, n = 169, white: 26.9%, n = 120, P < .05), though all races showed trends to decreasing SNF use during the late BPCI implementation. Discussion There were no significant differences in readmissions, length of stay, mortality, or intensive care unit days during early and late implementation of BPCI or when AA patients were compared to white patients. Conclusion We found no significant changes in racial variations in discharge destination and outcomes after elective TKA. Bundled Payments for Care Improvement has encouraged better preoperative preparation of patients and discharge planning; however, payment reforms alone might not be sufficient to address variation in post-op management following elective surgery.
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Affiliation(s)
- Michele Fang
- Division of Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric Hume
- Division of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Said Ibrahim
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
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77
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Fitzgerald JC, Ross ME, Thomas NJ, Weiss SL, Balamuth F, Anderson AH. Risk factors and inpatient outcomes associated with acute kidney injury at pediatric severe sepsis presentation. Pediatr Nephrol 2018; 33:1781-1790. [PMID: 29948309 DOI: 10.1007/s00467-018-3981-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/23/2018] [Accepted: 05/02/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little data exist on acute kidney injury (AKI) risk factors in pediatric sepsis. We identified risk factors and inpatient outcomes associated with AKI at sepsis recognition in children with severe sepsis. METHODS Retrospective, cross-sectional study with inpatient outcome description of 315 patients > 1 month to < 20 years old with severe sepsis in a pediatric intensive care unit over 3 years. Exposures included demographics, vitals, and laboratory data. The primary outcome was kidney disease: Improving Global Outcomes creatinine-defined AKI within 24 h of sepsis recognition. Factors associated with AKI and AKI severity were identified using multivariable Poisson and multinomial logistic regression, respectively. RESULTS AKI was present in 42% (133/315) of severe sepsis patients, and 26% (83/315) had severe (stage 2/3) AKI. In multivariable-adjusted analysis, hematologic/immunologic comorbidities, malignancies, chronic kidney disease (CKD), abdominal infection, admission illness severity, and minimum systolic blood pressure (SBP) ≤ 5th percentile for age and sex within 24 h of sepsis recognition were associated with AKI. Factors associated with mild AKI were CKD and abdominal infection, while factors associated with severe AKI were younger age, hematologic/immunologic comorbidities, malignancy, abdominal infection, and minimum SBP ≤ 5th percentile. Patients with AKI had increased hospital mortality (17 vs. 8%, P = 0.02) and length of stay [median 20 (IQR 10-47) vs. 16 days (IQR 7-37), P = 0.03]. CONCLUSIONS In pediatric severe sepsis, AKI is associated with age, comorbidities, infection characteristics, and hypotension. Future evaluation of risk factors for AKI progression during sepsis is warranted to minimize AKI progression in this high-risk population.
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Affiliation(s)
- Julie C Fitzgerald
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 8th Floor Main Hospital, Room 8571, Philadelphia, PA, 19104, USA. .,Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, USA.
| | - Michelle E Ross
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA, USA
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 8th Floor Main Hospital, Room 8571, Philadelphia, PA, 19104, USA
| | - Fran Balamuth
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda Hyre Anderson
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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78
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Wei S, Kao LS, Wang HE, Chang R, Podbielski J, Holcomb JB, Wade CE. Protocol for a pilot randomized controlled trial comparing plasma with balanced crystalloid resuscitation in surgical and trauma patients with septic shock. Trauma Surg Acute Care Open 2018; 3:e000220. [PMID: 30271882 PMCID: PMC6157534 DOI: 10.1136/tsaco-2018-000220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/07/2018] [Indexed: 12/29/2022] Open
Abstract
Background Septic shock is a public health problem with high mortality. There remains a knowledge gap regarding the optimal resuscitation fluid to improve clinical outcomes, and the underlying mechanism by which fluids exert their effect. Shock-induced endotheliopathy (SHINE) is thought to be a shared pathophysiologic mechanism associated with worsened outcomes in critically ill trauma and sepsis patients. SHINE is characterized by breakdown of the glycocalyx—a network of membrane-bound proteoglycans and glycoproteins that covers the endothelium. This has been associated with capillary leakage and microvascular thrombosis, organ dysfunction, and mortality. Biomarkers of SHINE have been shown to correlate with clinical outcomes in patients with septic shock. Interventions to mitigate SHINE may improve outcomes in patients with septic shock. In surgical/trauma patients with septic shock, initial plasma resuscitation as compared with balanced crystalloid (BC) resuscitation will mitigate biomarkers of SHINE and improve clinical outcomes. Methods A pilot, single-center randomized controlled trial (RCT) will compare initial plasma to BC resuscitation in surgical and trauma patients with septic shock. Patients will be enrolled based on a Sepsis Screening Score of ≥4 with a suspected source of infection. Patient randomization only occurs if they meet the criteria: (1) hypotension with mean arterial pressure <65 mm Hg, and (2) evidence of hypoperfusion including lactic acid >4 mmol/L, altered mental status or decreased urine output of <0.5 mL/kg in the past hour. Results The primary outcome is a reduction in serum biomarkers at 6 hours. Secondary outcomes will include clinical outcomes such as intensive care unit-free days, organ dysfunction, and in-hospital mortality. Discussion This trial will provide insights into the effects of initial plasma resuscitation on SHINE. Furthermore, it will provide unbiased estimates regarding the feasibility, safety, and clinical efficacy of plasma resuscitation in septic shock on which to base subsequent adequately powered multicenter RCTs. Trail registration number ClinicalTrials.gov (NCT03366220).
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Affiliation(s)
- Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Center for Surgical Trials and Evidence-based Practice, Departments of Surgery and Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Center for Surgical Trials and Evidence-based Practice, Departments of Surgery and Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Henry E Wang
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Ronald Chang
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Jeanette Podbielski
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - John B Holcomb
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA.,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
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79
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Greenberg JA, Hohmann SF, James BD, Shah RC, Hall JB, Kress JP, David MZ. Hospital Volume of Immunosuppressed Patients with Sepsis and Sepsis Mortality. Ann Am Thorac Soc 2018; 15:962-969. [PMID: 29856657 PMCID: PMC6322036 DOI: 10.1513/annalsats.201710-819oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/01/2018] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Immunosuppressive medical conditions are risk factors for mortality from severe infections. It is unknown whether hospital characteristics affect this risk. OBJECTIVES To determine whether the odds of death for an immunosuppressed patient with sepsis relative to a nonimmunosuppressed patient with sepsis varies according to the hospital's yearly case volume of immunosuppressed patients with sepsis. METHODS Patients with sepsis at hospitals in the Vizient database were characterized as immunosuppressed or not immunosuppressed on the basis of diagnosis codes and medication use. Hospitals were grouped into quartiles based on their average volumes of immunosuppressed patients with sepsis per year. Multilevel logistic regression with clustering of patients by hospital was used to determine whether the odds of in-hospital death from sepsis owing to a suppressed immune state varied by hospital quartile. RESULTS There were 350,183 patients with sepsis at 60 hospitals in the Vizient database from 2010 to 2012. Immunosuppressed patients with sepsis at the 15 hospitals in the lowest quartile (64 to 224 immunosuppressed patients with sepsis per year) had an increased odds of in-hospital death relative to nonimmunosuppressed patients with sepsis at these hospitals (adjusted odds ratio, 1.38; 95% confidence interval, 1.27-1.50; P < 0.001). The odds of in-hospital death for immunosuppressed patients with sepsis relative to nonimmunosuppressed patients with sepsis was similar for patients at hospitals in the second, third, and fourth quartiles (225 to 1,056 immunosuppressed patients with sepsis per year). The adjusted odds of death from sepsis owing to a suppressed immune state of 1.21 (95% confidence interval, 1.18-1.25; P < 0.001) for patients at these 45 hospitals was significantly less than for patients at the 15 hospitals in the lowest quartile (P = 0.004 for difference). CONCLUSIONS The risk of death from sepsis owing to a suppressed immune state was greatest at hospitals with the lowest volume of immunosuppressed patients with sepsis. Further study is needed to determine whether this finding is related to differences in patient characteristics or in care delivery at hospitals with different amounts of exposure to immunosuppressed patients.
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Affiliation(s)
- Jared A. Greenberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Samuel F. Hohmann
- Department of Health Systems Management
- Center for Advanced Analytics, Vizient, Chicago, Illinois
| | - Bryan D. James
- Department of Internal Medicine
- Rush Alzheimer’s Disease Center, and
| | - Raj C. Shah
- Rush Alzheimer’s Disease Center, and
- Department of Family Medicine, Rush University Medical Center, Chicago, Illinois
| | - Jesse B. Hall
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - John P. Kress
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Michael Z. David
- Division of Infectious Disease, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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80
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Hajj J, Blaine N, Salavaci J, Jacoby D. The "Centrality of Sepsis": A Review on Incidence, Mortality, and Cost of Care. Healthcare (Basel) 2018; 6:E90. [PMID: 30061497 PMCID: PMC6164723 DOI: 10.3390/healthcare6030090] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 12/27/2022] Open
Abstract
Sepsis is a serious and fatal medical condition that has overburdened the US healthcare system. The purpose of this paper is to provide a review of published literature on severe sepsis with a distinct focus on incidence, mortality, cost of hospital care, and postdischarge care. A review of the nature of postsepsis syndrome and its impact on septic patients is also included. The literature review was conducted utilizing the PubMed database, identifying 34 studies for inclusion. From the evaluation of these studies, it was determined that the incidence of sepsis continues to be on the rise according to three decades of epidemiological data. Readmissions, mortality, and length of stay were all higher among septic patients when compared to patients treated for other conditions. The cost of treating sepsis is remarkably high and exceeds the cost of treating patients with congestive heart failure and acute myocardial infarction. The overall cost of sepsis is reflective of not only the cost of initial hospitalization but also the postdischarge care costs, including postsepsis syndrome and cognitive and functional disabilities that require a significant amount of healthcare resources long term. Sepsis and its impact on patients and the US healthcare system is a current quality-of-life and cost-burden issue that needs to be addressed with a greater focus on preventative strategies.
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Affiliation(s)
- Jihane Hajj
- Department of Nursing, Widener University, One University Pl, Chester, PA 19013, USA.
| | - Natalie Blaine
- Department of Pharmacy, Penn Presbyterian Medical Center, 51 N 39th St, Philadelphia, PA 19104, USA.
| | - Jola Salavaci
- Department of Pharmacy, Penn Presbyterian Medical Center, 51 N 39th St, Philadelphia, PA 19104, USA.
| | - Douglas Jacoby
- Department of Cardiology, Penn Presbyterian Medical Center, 51 N 39th St, Philadelphia, PA 19104, USA.
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81
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Chaudhary NS, Donnelly JP, Wang HE. Racial Differences in Sepsis Mortality at U.S. Academic Medical Center-Affiliated Hospitals. Crit Care Med 2018; 46:878-883. [PMID: 29438109 PMCID: PMC5953774 DOI: 10.1097/ccm.0000000000003020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the racial disparities in severe sepsis hospitalizations and outcomes in U.S. academic medical center-affiliated hospitals. DESIGN Retrospective analysis of sepsis hospitalizations. SETTINGS U.S. academic medical center-affiliated hospitals participating in Vizient Consortium from 2012 to 2014. PATIENTS Sepsis hospitalizations using International Classification of Diseases, Ninth revision, discharge diagnoses codes defined by the Angus method. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared rates of sepsis hospitalization, ICU admission, organ dysfunction, and hospital mortality between blacks and whites. We repeated the analyses stratified by community-acquired, healthcare-associated, and hospital-acquired sepsis subtypes. Of 10,244,780 hospitalizations in our cohort, 1,114,386 (10.9%) had sepsis. Sepsis subtypes included community-acquired sepsis (61.8%), healthcare-associated sepsis (23.8%), and hospital-acquired sepsis (14.4%). Although the proportion of discharges with sepsis was lower for blacks than whites (106.72 vs 109.43 per 1,000 hospitalizations; p < 0.001), the proportion of black sepsis hospitalizations was higher for individuals greater than 30 years old. Blacks exhibited lower adjusted sepsis hospital mortality than whites (odds ratio, 0.85; 95% CI, 0.84-0.86). The adjusted odds of hospital mortality following community-acquired, healthcare-associated, and hospital-acquired sepsis were lower for blacks than whites. CONCLUSIONS In this current series of hospital discharges at U.S. academic medical center-affiliated hospitals, blacks exhibited lower adjusted rates of sepsis hospitalizations and mortality than whites.
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Affiliation(s)
- Ninad S. Chaudhary
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John P. Donnelly
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, TX
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82
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Martischang R, Pires D, Masson-Roy S, Saito H, Pittet D. Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:92. [PMID: 29653553 PMCID: PMC5899328 DOI: 10.1186/s13054-018-2011-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/07/2018] [Indexed: 12/29/2022]
Abstract
Sepsis is estimated to affect more than 30 million patients with potentially five million deaths every year worldwide. Prevention of sepsis, as well as early recognition, diagnosis and treatment, can’t be overlooked to mitigate this global public health threat. World Health Organization (WHO) promotes hand hygiene in health care through its annual global campaign, SAVE LIVES: Clean Your Hands campaign on 5 May every year. The 2018 campaign targets sepsis with the overall theme “It’s in your hands; prevent sepsis in health care”.
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Affiliation(s)
- Romain Martischang
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Daniela Pires
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.,Department of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Sarah Masson-Roy
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.,Département de Microbiologie et d'Infectiologie, Centre Hospitalier Affilié Universitaire Hôtel-Dieu de Lévis, Lévis, Québec, Canada
| | - Hiroki Saito
- Infection Prevention and Control Global Unit, Department of Service Delivery and Safety, World Health Organization, Geneva, Switzerland
| | - Didier Pittet
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.
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83
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Abstract
Importance Survival from sepsis has improved in recent years, resulting in an increasing number of patients who have survived sepsis treatment. Current sepsis guidelines do not provide guidance on posthospital care or recovery. Observations Each year, more than 19 million individuals develop sepsis, defined as a life-threatening acute organ dysfunction secondary to infection. Approximately 14 million survive to hospital discharge and their prognosis varies. Half of patients recover, one-third die during the following year, and one-sixth have severe persistent impairments. Impairments include development of an average of 1 to 2 new functional limitations (eg, inability to bathe or dress independently), a 3-fold increase in prevalence of moderate to severe cognitive impairment (from 6.1% before hospitalization to 16.7% after hospitalization), and a high prevalence of mental health problems, including anxiety (32% of patients who survive), depression (29%), or posttraumatic stress disorder (44%). About 40% of patients are rehospitalized within 90 days of discharge, often for conditions that are potentially treatable in the outpatient setting, such as infection (11.9%) and exacerbation of heart failure (5.5%). Compared with patients hospitalized for other diagnoses, those who survive sepsis (11.9%) are at increased risk of recurrent infection than matched patients (8.0%) matched patients (P < .001), acute renal failure (3.3% vs 1.2%, P < .001), and new cardiovascular events (adjusted hazard ratio [HR] range, 1.1-1.4). Reasons for deterioration of health after sepsis are multifactorial and include accelerated progression of preexisting chronic conditions, residual organ damage, and impaired immune function. Characteristics associated with complications after hospital discharge for sepsis treatment are not fully understood but include both poorer presepsis health status, characteristics of the acute septic episode (eg, severity of infection, host response to infection), and quality of hospital treatment (eg, timeliness of initial sepsis care, avoidance of treatment-related harms). Although there is a paucity of clinical trial evidence to support specific postdischarge rehabilitation treatment, experts recommend referral to physical therapy to improve exercise capacity, strength, and independent completion of activities of daily living. This recommendation is supported by an observational study involving 30 000 sepsis survivors that found that referral to rehabilitation within 90 days was associated with lower risk of 10-year mortality compared with propensity-matched controls (adjusted HR, 0.94; 95% CI, 0.92-0.97, P < .001). Conclusions and Relevance In the months after hospital discharge for sepsis, management should focus on (1) identifying new physical, mental, and cognitive problems and referring for appropriate treatment, (2) reviewing and adjusting long-term medications, and (3) evaluating for treatable conditions that commonly result in hospitalization, such as infection, heart failure, renal failure, and aspiration. For patients with poor or declining health prior to sepsis who experience further deterioration after sepsis, it may be appropriate to focus on palliation of symptoms.
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Affiliation(s)
- Hallie C Prescott
- Department of Internal Medicine and Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
| | - Derek C Angus
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Associate Editor
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84
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Mechanistic insights into the protective impact of zinc on sepsis. Cytokine Growth Factor Rev 2017; 39:92-101. [PMID: 29279185 DOI: 10.1016/j.cytogfr.2017.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/19/2017] [Indexed: 12/11/2022]
Abstract
Sepsis, a systemic inflammation as a response to a bacterial infection, is a huge unmet medical need. Data accumulated over the last decade suggest that the nutritional status of patients as well as composition of their gut microbiome, are strongly linked with the risk to develop sepsis, the severity of the disease and prognosis. In particular, the essential micronutrient zinc is essential in the resistance against sepsis and has shown to be protective in animal models as well as in human patients. The potential mechanisms by which zinc protects in sepsis are discussed in this review paper: we will focus on the inflammatory response, chemotaxis, phagocytosis, immune response, oxidative stress and modulation of the microbiome. A full understanding of the mechanism of action of zinc may open new preventive and therapeutic interventions in sepsis.
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85
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López-Mestanza C, Andaluz-Ojeda D, Gómez-López JR, Bermejo-Martín JF. Clinical factors influencing mortality risk in hospital-acquired sepsis. J Hosp Infect 2017; 98:194-201. [PMID: 28882641 DOI: 10.1016/j.jhin.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. AIM To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. METHODS Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality. FINDINGS HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality. CONCLUSION This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.
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Affiliation(s)
- C López-Mestanza
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain.
| | - D Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J R Gómez-López
- General Surgery Service, Hospital de Medina del Campo, SACYL, Medina del Campo-Valladolid, Spain
| | - J F Bermejo-Martín
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain
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86
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What Is the National Burden of Sepsis in U.S. Emergency Departments? It Depends on the Definition. Crit Care Med 2017; 45:1569-1571. [PMID: 28816842 DOI: 10.1097/ccm.0000000000002561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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87
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Prasad PA, Shea ER, Shiboski S, Sullivan MC, Gonzales R, Shimabukuro D. Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data. Anesth Analg 2017; 125:507-513. [PMID: 28514322 DOI: 10.1213/ane.0000000000002085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data. METHODS We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT). RESULTS Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32-0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03-1.24). CONCLUSIONS The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.
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Affiliation(s)
- Priya A Prasad
- From the *Division of General Internal Medicine, School of Medicine, University of California, San Francisco, California; †Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California; ‡Department of Quality, Sepsis Program, University of California, San Francisco, California; and §Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California
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88
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Frenzen FS, Kutschan U, Meiswinkel N, Schulte-Hubbert B, Ewig S, Kolditz M. Admission lactate predicts poor prognosis independently of the CRB/CURB-65 scores in community-acquired pneumonia. Clin Microbiol Infect 2017; 24:306.e1-306.e6. [PMID: 28710027 DOI: 10.1016/j.cmi.2017.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/06/2017] [Accepted: 07/04/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Community-acquired pneumonia (CAP) is associated with a high risk of respiratory failure or septic organ dysfunction. Lactate is an established early marker of prognosis and sepsis severity, but few data exist in patients with CAP. METHODS We performed a retrospective cohort study of consecutive adult CAP patients without treatment restrictions or direct intensive care unit admission. Lactate was measured as a point-of-care test within the capillary admission blood gas analysis, and its prognostic value was compared to the CRB/CURB-65 criteria by multivariate and receiver operating characteristic (ROC) curve analysis. The primary endpoint was the combination of need for mechanical ventilation, vasopressors, intensive care unit admission or hospital mortality. RESULTS Of 303 included patients, 75 (25%) met the primary endpoint. After ROC analysis, lactate predicted the primary endpoint (area under the curve 0.67) with an optimal cutoff of >1.8 mmol/L. Of the 76 patients with lactate above this threshold, 35 (46%) met the primary endpoint. After multivariate analysis, the predictive value of lactate was independent of the CRB/CURB-65 scores. The addition of lactate >1.8 mmol/L to the CRB/CURB-65 scores resulted in significantly improved area under the curves (0.69 to 0.74, p 0.005 and 0.71 to 0.75, p 0.008 respectively). Fourteen (42%) of 33 and 11 (39%) of 28 patients meeting the endpoint despite presenting with 0 or 1 CRB/CURB-65 criteria had lactate >1.8 mmol/L. CONCLUSIONS Admission lactate levels significantly improved the prognostic value of the CRB/CURB-65 scores in CAP patients. Lactate may therefore be considered a rapid, cheap and broadly available additional criterion for the assessment of risk in patients with CAP.
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Affiliation(s)
- F S Frenzen
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - U Kutschan
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - N Meiswinkel
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - B Schulte-Hubbert
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - S Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, EVK Herne and Augusta-Kranken-Anstalt Bochum, Bochum, Germany
| | - M Kolditz
- Division of Pulmonology, Medical Department I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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89
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Ngo Ndjom CG, Kantor LV, Jones HP. CRH Affects the Phenotypic Expression of Sepsis-Associated Virulence Factors by Streptococcus pneumoniae Serotype 1 In vitro. Front Cell Infect Microbiol 2017; 7:263. [PMID: 28690980 PMCID: PMC5479890 DOI: 10.3389/fcimb.2017.00263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/02/2017] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a life-threatening health condition caused by infectious pathogens of the respiratory tract, and accounts for 28–50% of annual deaths in the US alone. Current treatment regimen advocates the use of corticosteroids as adjunct treatment with antibiotics, for their broad inhibitory effect on the activity and production of pro-inflammatory mediators. However, despite their use, corticosteroids have not proven to be able to reverse the death incidence among septic patients. We have previously demonstrated the potential for neuroendocrine factors to directly influence Streptococcus pneumoniae virulence, which may in turn mediate disease outcome leading to sepsis and septic shock. The current study investigated the role of Corticotropin-releasing hormone (CRH) in mediating key markers of pneumococcal virulence as important phenotypic determinants of sepsis and septic shock risks. In vitro cultures of serotype 1 pneumococcal strain with CRH promoted growth rate, increased capsule thickness and penicillin resistance, as well as induced pneumolysin gene expression. These results thus provide significant insights of CRH–pathogen interactions useful in understanding the underlying mechanisms of neuroendocrine factor's role in the onset of community acquired pneumonias (CAP), sepsis and septic shock.
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Affiliation(s)
- Colette G Ngo Ndjom
- Department of Molecular and Medical Genetics, University of North Texas Health Science CenterFort Worth, TX, United States
| | - Lindsay V Kantor
- Graduate School of Biomedical Sciences, University of North Texas Health Science CenterFort Worth, TX, United States
| | - Harlan P Jones
- Department of Molecular and Medical Genetics, University of North Texas Health Science CenterFort Worth, TX, United States
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90
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Derivation of Novel Risk Prediction Scores for Community-Acquired Sepsis and Severe Sepsis. Crit Care Med 2017; 44:1285-94. [PMID: 27031381 DOI: 10.1097/ccm.0000000000001666] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We sought to derive and internally validate a Sepsis Risk Score and a Severe Sepsis Risk Score predicting future sepsis and severe sepsis events among community-dwelling adults. DESIGN National population-based cohort. SETTING United States. SUBJECTS A total of 30,239 community-dwelling adults 45 years old or older in the national REasons for Geographic And Racial Differences in Stroke cohort. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Over a median of 6.6 years (interquartile range, 5.1-8.1 yr) of follow-up, there were 1,532 first sepsis (prevalence 8.3 per 1,000 person-years) and 1,151 first severe sepsis (6.2 per 1,000 person-years) events. Risk factors in the best derived Sepsis Risk Score and Severe Sepsis Risk Score included chronic lung disease, age 75 years or older, peripheral artery disease, diabetes, tobacco use, white race, stroke, atrial fibrillation, coronary artery disease, obesity, hypertension, deep vein thrombosis, male sex, high-sensitivity C-reactive protein greater than 3.0 mg/dL, cystatin C ≥1.11 mg/dL, estimated glomerular filtration rate less than 60 mL/min/1.73 m, and albumin-to-creatinine ratio protein greater than 30 μg/mg. Sepsis Risk Score risk categories were very low (0-3 points; 2.3 events per 1,000 person-years), low (4-6; 4.1), medium (7-9; 6.5), high (10-12; 9.7), and very high (13-38; 21.1). Severe Sepsis Risk Score risk categories were very low (0-5 points; 1.5 events per 1,000 person-years), low (6-9; 3.4), medium (10-13; 6.7), high (14-17; 9.9), and very high (18-45; 22.1). The Sepsis Risk Score and Severe Sepsis Risk Score exhibited good discrimination (bootstrapped C index, 0.703 and 0.742) and calibration (p = 0.65 and 0.06). CONCLUSIONS The Sepsis Risk Score and Severe Sepsis Risk Score predict 10-year sepsis and severe sepsis risk among community-dwelling adults and may aid in sepsis prevention or mitigation efforts.
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91
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Jeganathan N, Yau S, Ahuja N, Otu D, Stein B, Fogg L, Balk R. The characteristics and impact of source of infection on sepsis-related ICU outcomes. J Crit Care 2017; 41:170-176. [PMID: 28564621 DOI: 10.1016/j.jcrc.2017.05.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/02/2017] [Accepted: 05/20/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Source of infection is an independent predictor of sepsis-related mortality. To date, studies have failed to evaluate differences in septic patients based on the source of infection. METHODS Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12month time period. RESULTS Sepsis due to intravascular device and multiple sources had the highest number of positive blood cultures and microbiology whereas lung and abdominal sepsis had the least. The observed hospital mortality was highest for sepsis due to multiple sources and unknown cause, and was lowest when due to abdominal, genitourinary (GU) or skin/soft tissue. Patients with sepsis due to lungs, unknown and multiple sources had the highest rates of multi-organ failure, whereas those with sepsis due to GU and skin/soft tissue had the lowest rates. Those with multisource sepsis had a significantly higher median ICU length of stay and hospital cost. CONCLUSION There are significant differences in patient characteristics, microbiology positivity, organs affected, mortality, length of stay and cost based on the source of sepsis. These differences should be considered in future studies to be able to deliver personalized care.
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Affiliation(s)
- Niranjan Jeganathan
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Stephen Yau
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Neha Ahuja
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Dara Otu
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Brian Stein
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Rush Medical College, Chicago, IL, USA
| | - Louis Fogg
- College of Nursing, Rush Medical College, Chicago, IL, USA
| | - Robert Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Rush Medical College, Chicago, IL, USA
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92
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Nygård ST, Skrede S, Langeland N, Flaatten HK. An observational study of community-acquired severe sepsis comparing intensive care and non-intensive care patients. Acta Anaesthesiol Scand 2017; 61:194-204. [PMID: 28058720 DOI: 10.1111/aas.12848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Most studies of sepsis are from intensive care units (ICUs). We aimed to investigate community-acquired severe sepsis in a broader population, in order to compare patients treated in or outside an ICU . METHODS We performed a 1-year prospective observational study with enrollment of patients from three units; a general ICU, a combined ICU/non-ICU and a medical ward with limited surveillance facilities. Hospital survivors were followed up for 5 years. RESULTS Overall, 220 patients were included, of which 107 received ICU treatment. The majority of abdominal (77%, P = 0.003) and genitourinary (81%, P < 0.001) infections were found in ICU and non-ICU patients, respectively. Time to first antibiotic administration was longer in ICU-patients (median 3.5 vs. 2.0 h in non-ICU patients, P = 0.011). ICU developed more organ dysfunctions than non-ICU patients (P < 0.001), nevertheless supportive therapy with vasoactive drugs and non-invasive ventilation was documented in 22% and 27% of the latter. Median hospital length of stay was 15 vs. 9 days (P = 0.001), and hospital and 5-year mortality rates 35% vs. 16% (P = 0.002) and 57% vs. 58% (P = 0.892) among ICU and non-ICU patients, respectively. Increasing age (HR 1.06 (1.04, 1.07) per year, P < 0.001), not care level during hospitalization (HR 1.19 (0.70, 2.02), P = 0.514), influenced long-term survival. CONCLUSION Half of the subjects with community-acquired severe sepsis never received ICU treatment. Still, use of organ supportive therapy outside the ICU was considerable. Hospital mortality was higher, whereas 5-year survival was similar when comparing ICU with non-ICU patients.
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Affiliation(s)
- S. T. Nygård
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - N. Langeland
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - H. K. Flaatten
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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93
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Arefian H, Heublein S, Scherag A, Brunkhorst FM, Younis MZ, Moerer O, Fischer D, Hartmann M. Hospital-related cost of sepsis: A systematic review. J Infect 2016; 74:107-117. [PMID: 27884733 DOI: 10.1016/j.jinf.2016.11.006] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This article systematically reviews research on the costs of sepsis and, as a secondary aim, evaluates the quality of economic evaluations reported in peer-reviewed journals. METHODS We systematically searched the MEDLINE, National Health Service (Abstracts of Reviews of Effects, Economic Evaluation and Health Technology Assessment), Cost-effectiveness Analysis Registry and Web of Knowledge databases for studies published between January 2005 and June 2015. We selected original articles that provided cost and cost-effectiveness analyses, defined sepsis and described their cost calculation method. Only studies that considered index admissions and re-admissions in the first 30 days were published in peer-reviewed journals and used standard treatments were considered. All costs were adjusted to 2014 US dollars. Medians and interquartile ranges (IQRs) for various costs of sepsis were calculated. The quality of economic studies was assessed using the Drummond 10-item checklist. RESULTS Overall, 37 studies met our eligibility criteria. The median of the mean hospital-wide cost of sepsis per patient was $32,421 (IQR $20,745-$40,835), and the median of the mean ICU cost of sepsis per patient was $27,461 (IQR $16,007-$31,251). Overall, the quality of economic studies was low. CONCLUSIONS Estimates of the hospital-related costs of sepsis varied considerably across the included studies depending on the method used for cost calculation, the type of sepsis and the population that was examined. A standard model for conducting cost improve the quality of studies on the costs of sepsis.
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Affiliation(s)
- Habibollah Arefian
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Hospital Pharmacy, Jena University Hospital, Jena, Germany.
| | - Steffen Heublein
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Hospital Pharmacy, Jena University Hospital, Jena, Germany
| | - André Scherag
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Research group Clinical Epidemiology, CSCC, Jena University Hospital, Jena, Germany
| | - Frank Martin Brunkhorst
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Center for Clinical Studies, Jena University Hospital, Jena, Germany; Paul-Martini-Clinical Sepsis Research Unit, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Mustafa Z Younis
- Health Policy and Management, Jackson State University, Jackson, MS, USA
| | - Onnen Moerer
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medicine, Georg-August-University, Goettingen, Germany
| | - Dagmar Fischer
- Department of Pharmaceutical Technology, Friedrich-Schiller University Jena, Germany
| | - Michael Hartmann
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Hospital Pharmacy, Jena University Hospital, Jena, Germany
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94
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Kadri SS, Rhee C, Strich JR, Morales MK, Hohmann S, Menchaca J, Suffredini AF, Danner RL, Klompas M. Estimating Ten-Year Trends in Septic Shock Incidence and Mortality in United States Academic Medical Centers Using Clinical Data. Chest 2016; 151:278-285. [PMID: 27452768 DOI: 10.1016/j.chest.2016.07.010] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/08/2016] [Accepted: 07/05/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Reports that septic shock incidence is rising and mortality rates declining may be confounded by improving recognition of sepsis and changing coding practices. We compared trends in septic shock incidence and mortality in academic hospitals using clinical vs claims data. METHODS We identified all patients with concurrent blood cultures, antibiotics, and vasopressors for ≥ two consecutive days, and all patients with International Classification of Diseases, 9th edition (ICD-9) codes for septic shock, at 27 academic hospitals from 2005 to 2014. We compared annual incidence and mortality trends. We reviewed 967 records from three hospitals to estimate the accuracy of each method. RESULTS Of 6.5 million adult hospitalizations, 99,312 (1.5%) were flagged by clinical criteria, 82,350 (1.3%) by ICD-9 codes, and 44,651 (0.7%) by both. Sensitivity for clinical criteria was higher than claims (74.8% vs 48.3%; P < .01), whereas positive predictive value was comparable (83% vs 89%; P = .23). Septic shock incidence, based on clinical criteria, rose from 12.8 to 18.6 cases per 1,000 hospitalizations (average, 4.9% increase/y; 95% CI, 4.0%-5.9%), while mortality declined from 54.9% to 50.7% (average, 0.6% decline/y; 95% CI, 0.4%-0.8%). In contrast, septic shock incidence, based on ICD-9 codes, increased from 6.7 to 19.3 per 1,000 hospitalizations (19.8% increase/y; 95% CI, 16.6%-20.9%), while mortality decreased from 48.3% to 39.3% (1.2% decline/y; 95% CI, 0.9%-1.6%). CONCLUSIONS A clinical surveillance definition based on concurrent vasopressors, blood cultures, and antibiotics accurately identifies septic shock hospitalizations and suggests that the incidence of patients receiving treatment for septic shock has risen and mortality rates have fallen, but less dramatically than estimated on the basis of ICD-9 codes.
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Affiliation(s)
- Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD; Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA.
| | - Jeffrey R Strich
- Department of Internal Medicine, Georgetown University Hospital, Washington, DC; Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Megan K Morales
- Division of Infectious Diseases, Georgetown University Hospital, Washington, DC
| | - Samuel Hohmann
- University HealthSystem Consortium, Chicago, IL; Department of Health Systems Management, Rush University, Chicago, IL
| | - Jonathan Menchaca
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Anthony F Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
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95
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Donnelly JP, Locke JE, MacLennan PA, McGwin G, Mannon RB, Safford MM, Baddley JW, Muntner P, Wang HE. Inpatient Mortality Among Solid Organ Transplant Recipients Hospitalized for Sepsis and Severe Sepsis. Clin Infect Dis 2016; 63:186-94. [PMID: 27217215 DOI: 10.1093/cid/ciw295] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/23/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are at elevated risk of sepsis. The impact of SOT on outcomes following sepsis is unclear. METHODS We performed a retrospective cohort study using data from University HealthSystem Consortium, a consortium of academic medical center affiliates. We examined the association between SOT and mortality among patients hospitalized with severe sepsis or explicitly coded sepsis in 2012-2014. We used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify severe sepsis, explicitly coded sepsis, and SOT (kidney, liver, heart, lung, pancreas, or intestine transplants). We fit random-intercept logistic regression models to account for clustering by hospital. RESULTS There were 903 816 severe sepsis hospitalizations (39 618 [4.4%] with SOT) and 410 623 sepsis hospitalizations (14 526 [3.9%] with SOT) in 250 hospitals. SOT recipients were younger and more likely to be insured by Medicare than those without SOT. Among hospitalizations for severe sepsis and sepsis, in-hospital mortality was lower among those with vs those without SOT (5.5% vs 9.4% for severe sepsis; 8.7% vs 12.7% for sepsis). After adjustment, the odds ratio for mortality comparing SOT patients vs non-SOT was 0.83 (95% confidence interval [CI], .79-.87) for severe sepsis and 0.78 (95% CI, .73-.84) for sepsis. Compared to non-SOT patients, kidney, liver, and co-transplant (kidney-pancreas/kidney-liver) recipients demonstrated lower mortality. No association was present for heart transplant, and lung transplant was associated with higher mortality. CONCLUSIONS Among patients hospitalized for severe sepsis or sepsis, those with SOT had lower inpatient mortality than those without SOT. Identifying the specific strategies employed for populations with improved mortality could inform best practices for sepsis among SOT and non-SOT populations.
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Affiliation(s)
- John P Donnelly
- Department of Emergency Medicine, School of Medicine Department of Medicine, Division of Preventive Medicine Department of Epidemiology, School of Public Health
| | - Jayme E Locke
- Comprehensive Transplant Institute Department of Surgery, Division of Transplantation
| | - Paul A MacLennan
- Comprehensive Transplant Institute Department of Surgery, Division of Transplantation
| | | | - Roslyn B Mannon
- Comprehensive Transplant Institute Department of Surgery, Division of Transplantation Department of Medicine, Division of Nephrology
| | - Monika M Safford
- Department of Medicine Department of Medicine, Weill Cornell Medical College, New York, New York
| | - John W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Paul Muntner
- Department of Epidemiology, School of Public Health
| | - Henry E Wang
- Department of Emergency Medicine, School of Medicine
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96
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Tsertsvadze A, Royle P, Seedat F, Cooper J, Crosby R, McCarthy N. Community-onset sepsis and its public health burden: a systematic review. Syst Rev 2016; 5:81. [PMID: 27194242 PMCID: PMC4870814 DOI: 10.1186/s13643-016-0243-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/12/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sepsis is a life-threatening condition and major contributor to public health and economic burden in the industrialised world. The difficulties in accurate diagnosis lead to great variability in estimates of sepsis incidence. There has been even greater uncertainty regarding the incidence of and risk factors for community-onset sepsis (COS). We systematically reviewed the recent evidence on the incidence and risk factors of COS in high income countries (North America, Australasia, and North/Western Europe). METHODS Cohort and case-control studies were eligible for inclusion. Medline and Embase databases were searched from 2002 onwards. References of relevant publications were hand-searched. Two reviewers screened titles/abstracts and full-texts independently. One reviewer extracted data and appraised studies which were cross-checked by independent reviewers. Disagreements were resolved via consensus. Odds ratios (ORs) and 95 percent confidence intervals (95 % CIs) were ascertained by type of sepsis (non-severe, severe, and septic shock). RESULTS Ten cohort and 4 case-control studies were included. There was a wide variation in the incidence (# cases per 100,000 per year) of non-severe sepsis (range: 64-514), severe sepsis (range: 40-455), and septic shock (range: 9-31). Heterogeneity precluded statistical pooling. Two cohort and 4 case-control studies reported risk factors for sepsis. In one case-control and one cohort study, older age and diabetes were associated with increased risk of sepsis. The same case-control study showed an excess risk for sepsis in participants with clinical conditions (e.g., immunosuppression, lung disease, and peripheral artery disease). In one cohort study, higher risk of sepsis was associated with being a nursing home resident (OR = 2.60, 95 % CI: 1.20, 5.60) and in the other cohort study with being physically inactive (OR = 1.33, 95 % CI: 1.13, 1.56) and smoking tobacco (OR = 1.85, 95 % CI: 1.54, 2.22). The evidence on sex, ethnicity, statin use, and body mass index as risk factors was inconclusive. CONCLUSIONS The lack of a valid standard approach for defining sepsis makes it difficult to determine the true incidence of COS. Differences in case ascertainment contribute to the variation in incidence of COS. The evidence on COS is limited in terms of the number and quality of studies. This review highlights the urgent need for an accurate and standard method for identifying sepsis. Future studies need to improve the methodological shortcomings of previous research in terms of case definition, identification, and surveillance practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023484.
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Affiliation(s)
- Alexander Tsertsvadze
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Pam Royle
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Farah Seedat
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Jennifer Cooper
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Rebecca Crosby
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Noel McCarthy
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,NIHR Health Protections Research Unit in Gastrointestinal Infections, University of Oxford, Oxford, UK
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97
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Jeganathan N, Ahuja N, Yau S, Otu D, Stein B, Balk RA. Impact of End-Stage Renal Disease and Acute Kidney Injury on ICU Outcomes in Patients With Sepsis. J Intensive Care Med 2016; 32:444-450. [PMID: 27146924 DOI: 10.1177/0885066616645308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To report the characteristics and outcomes of patients with sepsis in the intensive care unit (ICU) with end-stage renal disease (ESRD) and acute kidney injury (AKI) compared to patients with nonkidney injury (non-KI). METHODS Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12-month time period. Data were obtained from the University Health Consortium database and a chart review of the electronic medical records. RESULTS We identified 39 cases of ESRD, 106 cases of AKI, and 103 cases of non-KI. Intensive care unit mortality was 15.4% for ESRD, 30.2% for AKI, and 13.6% for non-KI ( P < .01). Hospital mortality was 20.5% for ESRD, 32.1% for AKI, and 13.6% for non-KI ( P < .01). Early AKI and late AKI had an ICU mortality of 24.4% versus 50% ( P <.01), hospital mortality of 26.8% versus 50% ( P = .03), ICU length of stay (LOS) of 3 and 6 days ( P = .04), and hospital LOS of 7 and 12.5 days ( P <.01), respectively. CONCLUSION Patients with sepsis having AKI have a higher mortality rate than those with ESRD and non-KI. Hospital and ICU mortality rates for patients with ESRD were similar to non-KI patients. Late AKI compared to early AKI had a higher mortality and longer LOS.
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Affiliation(s)
- Niranjan Jeganathan
- 1 Division of Pulmonary and Critical Care Medicine, Rush University Medical Center and Rush Medical College, Chicago, IL, USA
| | - Neha Ahuja
- 2 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Stephen Yau
- 2 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Dara Otu
- 2 Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Brian Stein
- 1 Division of Pulmonary and Critical Care Medicine, Rush University Medical Center and Rush Medical College, Chicago, IL, USA
| | - Robert A Balk
- 1 Division of Pulmonary and Critical Care Medicine, Rush University Medical Center and Rush Medical College, Chicago, IL, USA
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98
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Jones SL, Ashton CM, Kiehne LB, Nicolas JC, Rose AL, Shirkey BA, Masud F, Wray NP. Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type. Med Care 2016; 54:303-10. [PMID: 26759980 PMCID: PMC4751740 DOI: 10.1097/mlr.0000000000000481] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative. METHODS A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas. RESULTS Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P<0.001) and were more costly ($68,050±184,541 vs. $19,498±31,506, P<0.001) versus community hospitals. CONCLUSIONS Greater emphasis is needed on public awareness of sepsis and the detection of sepsis in the prehospitalization and early hospitalization period. Hospital characteristics and case mix should be accounted for in cross-hospital comparisons of sepsis outcomes and costs.
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Affiliation(s)
| | | | | | | | | | | | - Faisal Masud
- Anesthesia-Critical Care, Houston, Methodist Research Institute, Houston Methodist Hospital, Houston, TX
| | - Nelda P. Wray
- Departments of Surgery, Center for Outcomes Research
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