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August BA, Kale-Pradhan PB, Giuliano C, Johnson LB. Biomarkers in the intensive care setting: A focus on using procalcitonin and C-reactive protein to optimize antimicrobial duration of therapy. Pharmacotherapy 2023; 43:935-949. [PMID: 37300522 DOI: 10.1002/phar.2834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 06/12/2023]
Abstract
Managing the critically ill patient with infection is complex, requiring clinicians to synthesize considerable information relating to antimicrobial efficacy and treatment duration. The use of biomarkers may play an important role in identifying variation in treatment response and providing information about treatment efficacy. Though a vast number of biomarkers for clinical application have been described, procalcitonin and C-reactive protein (CRP) are the most thoroughly investigated in the critically ill. However, the presence of heterogeneous populations, variable end points, and incongruent methodology in the literature complicates the use of such biomarkers to guide antimicrobial therapy. This review focuses on an appraisal of evidence for use of procalcitonin and CRP to optimize antimicrobial duration of therapy (DOT) in critically ill patients. Procalcitonin-guided antimicrobial therapy in mixed critically ill populations with varying degrees of sepsis appears to be safe and might assist in reducing antimicrobial DOT. Compared to procalcitonin, fewer studies exist examining the impact of CRP on antimicrobial DOT and clinical outcomes in the critically ill. Procalcitonin and CRP have been insufficiently studied in many key intensive care unit populations, including surgical patients with concomitant trauma, renally insufficient populations, the immunocompromised, and patients with septic shock. We believe the available evidence is not strong enough to warrant routine use of procalcitonin or CRP to guide antimicrobial DOT in critically ill patients with infection. So long as its limitations are recognized, procalcitonin could be considered to tailor antimicrobial DOT on a case-by-case basis in the critically ill patient.
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Affiliation(s)
- Benjamin A August
- Critical Care, Henry Ford Hospital, Detroit, Michigan, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Science, Wayne State University, Detroit, Michigan, USA
| | - Pramodini B Kale-Pradhan
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Science, Wayne State University, Detroit, Michigan, USA
- Ascension St. John Hospital, Detroit, Michigan, USA
| | - Christopher Giuliano
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Science, Wayne State University, Detroit, Michigan, USA
- Ascension St. John Hospital, Detroit, Michigan, USA
| | - Leonard B Johnson
- Division of Infectious Diseases, Department of Internal Medicine, Infection Prevention and Antimicrobial Stewardship, Ascension St. John Hospital, Detroit, Michigan, USA
- Wayne State University School of Medicine, Detroit, Michigan, USA
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Sterk E, Wassermann T, Lamonge R, Semenchuck N, Rech MA. Overcultured? Blood cultures on discharged ED patients were ordered more frequently after the SEP-1 bundle initiation. Am J Emerg Med 2023; 67:84-89. [PMID: 36821960 PMCID: PMC10121910 DOI: 10.1016/j.ajem.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION In 2015, the Severe Sepsis and Early Septic Shock Management Bundle (SEP-1) tied hospital reimbursement to performance on a series of time sensitive indicators, including ordering blood cultures on patients with severe sepsis or septic shock. This metric could have broadly shaped ordering practices in the Emergency Department (ED), including for patients who did not have severe sepsis or septic shock. In this study, we sought to evaluate whether the frequency of blood culture orders on adult patients discharged from the ED changed after the SEP-1 metric, whether the rates of positivity for pathogens or contaminants changed after the SEP-1 metric, and whether similar changes were seen in orders for other laboratory tests. METHODS This was a retrospective evaluation of blood culture orders from discharged adult ED patients from a suburban academic hospital between January 1, 2012 and June 30, 2019. We compared the number of blood cultures per discharged adult patient before and after the SEP-1 metric. We categorized each culture that grew an organism as a pathogen or a contaminant, and we compared rates of pathogen and contaminant growth before and after SEP-1. We compared rates of orders of blood cultures and lactates as labs related to SEP-1 with rates of orders of D-dimers, lipases, human chorionic gonadotropins (HCGs), and brain natriuretic peptides (BNPs) as labs unrelated to SEP-1 before and after the implementation of the SEP-1 metric. RESULTS There were 144,343 adult patients discharged from the ED during the study period. A total of 6754 blood cultures were drawn from 3827 of those patient visits. The rate increased from 43.1 cultures per 1000 discharged patients before the SEP-1 metric to 75.9 blood cultures per 1000 discharged patients, an increase of 76.2% (p < 0.001). The cultures had a decreased rate of positivity (from 3.93% before SEP-1 to 3.03% after SEP-1, p = 0.044) and an unchanged rate of blood cultures resulting in a contaminant (2.49% to 1.85%, p = 0.071). Overall, orders of the labs unrelated to SEP-1 increased by an average of 16.8% after the SEP-1 metric and orders of the labs related to SEP-1 increased by an average of 81.0%. CONCLUSION After the SEP-1 bundle, blood cultures were ordered more frequently on discharged ED patients. These cultures had a lower rate of positivity for pathogens and an unchanged rate of growth of contaminants. This increase was not matched by a similar increase in other labs. Taken together, these findings suggest that the SEP-1 metric had the unintended consequence of increasing orders of blood cultures on patients healthy enough to be discharged from the ED.
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Affiliation(s)
- Ethan Sterk
- Loyola University Medical Center, Department of Emergency Medicine, Maywood, IL, United States of America.
| | - Travis Wassermann
- Loyola University Medical Center, Department of Emergency Medicine, Maywood, IL, United States of America.
| | - Ralph Lamonge
- Michigan Medicine, Department of Anesthesiology, Ann Arbor, MI, United States of America
| | - Nicolas Semenchuck
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, IL, United States of America
| | - Megan A Rech
- Loyola University Medical Center, Department of Pharmacy, Maywood, IL, United States of America; Loyola University Chicago, Stritch School of Medicine, Department of Emergency Medicine, Maywood, IL, United States of America
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Patient Outcomes and Cost-Effectiveness of a Sepsis Care Quality Improvement Program in a Health System. Crit Care Med 2020; 47:1371-1379. [PMID: 31306176 DOI: 10.1097/ccm.0000000000003919] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Assess patient outcomes in patients with suspected infection and the cost-effectiveness of implementing a quality improvement program. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational single-center study of 13,877 adults with suspected infection between March 1, 2014, and July 31, 2017. The 18-month period before and after the effective date for mandated reporting of the sepsis bundle was examined. The Sequential Organ Failure Assessment score and culture and antibiotic orders were used to identify patients meeting Sepsis-3 criteria from the electronic health record. INTERVENTIONS The following interventions were performed as follows: 1) multidisciplinary sepsis committee with sepsis coordinator and data abstractor; 2) education campaign; 3) electronic health record tools; and 4) a Modified Early Warning System. MAIN OUTCOMES AND MEASURES Primary health outcomes were in-hospital death and length of stay. The incremental cost-effectiveness ratio was calculated and the empirical 95% CI for the incremental cost-effectiveness ratio was estimated from 5,000 bootstrap samples. RESULTS In multivariable analysis, the odds ratio for in-hospital death in the post- versus pre-implementation periods was 0.70 (95% CI, 0.57-0.86) in those with suspected infection, and the hazard ratio for time to discharge was 1.25 (95% CI, 1.20-1.29). Similarly, a decrease in the odds for in-hospital death and an increase in the speed to discharge was observed for the subset that met Sepsis-3 criteria. The program was cost saving in patients with suspected infection (-$272,645.7; 95% CI, -$757,970.3 to -$79,667.7). Cost savings were also observed in the Sepsis-3 group. CONCLUSIONS AND RELEVANCE Our health system's program designed to adhere to the sepsis bundle metrics led to decreased mortality and length of stay in a cost-effective manner in a much larger catchment than just the cohort meeting the Centers for Medicare and Medicaid Services measures. Our single-center model of interventions may serve as a practice-based benchmark for hospitalized patients with suspected infection.
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Bassetti M, Vena A, Meroi M, Cardozo C, Cuervo G, Giacobbe DR, Salavert M, Merino P, Gioia F, Fernández-Ruiz M, López-Cortés LE, Almirante B, Escolà-Vergé L, Montejo M, Aguilar-Guisado M, Puerta-Alcalde P, Tasias M, Ruiz-Gaitán A, González F, Puig-Asensio M, Marco F, Pemán J, Fortún J, Aguado JM, Soriano A, Carratalá J, Garcia-Vidal C, Valerio M, Sartor A, Bouza E, Muñoz P. Factors associated with the development of septic shock in patients with candidemia: a post hoc analysis from two prospective cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:117. [PMID: 32216822 PMCID: PMC7099832 DOI: 10.1186/s13054-020-2793-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Almost one third of the patients with candidemia develop septic shock. The understanding why some patients do and others do not develop septic shock is very limited. The objective of this study was to identify variables associated with septic shock development in a large population of patients with candidemia. METHODS A post hoc analysis was performed on two prospective, multicenter cohort of patients with candidemia from 12 hospitals in Spain and Italy. All episodes occurring from September 2016 to February 2018 were analyzed to assess variables associated with septic shock development defined according to The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3). RESULTS Of 317 candidemic patients, 99 (31.2%) presented septic shock attributable to candidemia. Multivariate logistic regression analysis identifies the following factors associated with septic shock development: age > 50 years (OR 2.57, 95% CI 1.03-6.41, p = 0.04), abdominal source of the infection (OR 2.18, 95% CI 1.04-4.55, p = 0.04), and admission to a general ward at the time of candidemia onset (OR 0.21, 95% CI, 0.12-0.44, p = 0.001). Septic shock development was independently associated with a greater risk of 30-day mortality (OR 2.14, 95% CI 1.08-4.24, p = 0.02). CONCLUSIONS Age and abdominal source of the infection are the most important factors significantly associated with the development of septic shock in patients with candidemia. Our findings suggest that host factors and source of the infection may be more important for development of septic shock than intrinsic virulence factors of organisms.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy. .,Department of Health Sciences, University of Genoa, Genoa, Italy. .,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy.
| | - Antonio Vena
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Marco Meroi
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata, Piazzale Santa Maria della Misericordia 15, 33010, Udine, Italy
| | - Celia Cardozo
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Guillermo Cuervo
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Daniele Roberto Giacobbe
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | | | - Paloma Merino
- Hospital Universitario Clínico "San Carlos", Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Hospital Universitario Virgen Macarena/Instituto de Biomedicina de Sevilla (IBiS)/Universidad de Sevilla/Centro Superior de Investigaciones Científicas, Seville, Spain
| | - Benito Almirante
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Escolà-Vergé
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Pedro Puerta-Alcalde
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Mariona Tasias
- Hospital Universitari I Politecnic "La Fe", Valencia, Spain
| | | | | | - Mireia Puig-Asensio
- Hospital Universitari Vall d'Hebron, VHIR (Vall d'Hebron Institut de Recerca), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Marco
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Javier Pemán
- Hospital Universitari I Politecnic "La Fe", Valencia, Spain
| | - Jesus Fortún
- Hospital Universitario "Ramón y Cajal", Madrid, Spain
| | - Jose Maria Aguado
- Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), Universidad Complutense de Madrid, Madrid, Spain
| | - Alejandro Soriano
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Jordi Carratalá
- Hospital Universitari de Bellvitge, IDIBELL (Institut D'Investigació Biomèdica de Bellvitge), Universitat de Barcelona, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Hospital Clínic, IDIBAPS (Institut d'Investigacions biomèdiques Agust Pi i Sunyer), Universitat de Barcelona, Barcelona, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Integrata Santa Maria della Misericordia, Udine, Italy
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Udine, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Udine, Spain
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