Compliance with SEP-1 guidelines is associated with improved outcomes for septic shock but not for severe sepsis

Clinical phenotyping of septic shock with latent profile analysis: A retrospective multicenter study

BACKGROUND

Septic shock (SS) is a highly fatal and heterogeneous syndrome. Identifying distinct clinical phenotypes provides valuable insights into the underlying pathophysiological mechanisms and may help to propose precise clinical management strategies.

METHODS

Latent profile analysis (LPA), a model-based unsupervised method, was used for phenotyping in the MIMIC cohort, and the model was externally independently validated in the eICU and AUMC cohorts.

RESULTS

Three phenotypes, labeled phenotype I, II, and III, were derived. These phenotypes varied in demographics, clinical features, comorbidities, patterns of organ dysfunction, organ support, and prognosis. Phenotype I, characterized by the most severe organ dysfunction (especially liver), the youngest age, and the highest BMI, had the highest mortality (p < 0.001). Phenotype II, with moderate mortality, was characterized by severe renal injury. In contrast, phenotype III, associated with the oldest age and the fewest comorbidities, exhibited significantly lower mortality. Phenotype I patients had the steepest survival curves and demonstrated an ultra-high risk of death, particularly within the first few days after SS onset.

CONCLUSIONS

The individualized identification of phenotypes is well suited to clinical practice. The three SS phenotypes differed significantly in pathophysiological and clinical outcomes, which are crucial for informing management decisions and prognosis.

Bundle compliance patterns in septic shock and their association with patient outcomes: an unsupervised cluster analysis

Adhering to bundle-based care recommendations within stringent time constraints presents a profound challenge. Elements within these bundles hold varying degrees of significance. We aimed to evaluate the Surviving Sepsis Campaign (SSC) hour-one bundle compliance patterns and their association with patient outcomes. Utilizing the Medical Information Mart for Intensive Care-IV 1.0 dataset, this retrospective cohort study evaluated patients with sepsis who developed shock and were admitted to the intensive care unit between 2008 and 2019. The execution of five hour-one bundle interventions were assessed. Patients with similar treatment profiles were categorized into clusters using unsupervised machine learning. Primary outcomes included in-hospital and 1-year mortality. Four clusters were identified: C#0 (n = 4716) had the poorest bundle compliance. C#1 (n = 1117) had perfect antibiotic adherence with modest fluid and serum lactate measurement adherence. C#2 (n = 850) exhibited full adherence to lactate measurement and low adherence to fluid administration, blood culture, and vasopressors, while C#3 (n = 381) achieved complete adherence to fluid administration and the highest adherence to vasopressor requirements in the entire cohort. Adjusting for covariates, C#1 and C#3 were associated with reduced odds of in-hospital mortality compared to C#0 (adjusted odds ratio [aOR] = 0·83; 95% confidence interval [CI] 0·7-0·97 and aOR = 0·7; 95% CI 0·53-0·91, respectively). C#1 exhibited significantly better 1-year survival (adjusted hazard ratio [aHR] = 0·9; 95%CI 0·81-0·99). We were able to identify distinct clusters of SSC hour-one bundle adherence patterns using unsupervised machine learning techniques, which were associated with patient outcomes.

Outcomes of Hospitalized Patients With Sepsis Before and After Implementation of a Sepsis Care Improvement Initiative at a Community Hospital

Purpose: Prompt treatment of sepsis and septic shock is critical as delays increase mortality risk. Various tools, such as electronic alerts, standardized order sets, and rapid response teams, are used to expedite sepsis bundled care, yet their individual effects on outcomes and antimicrobial timing are unclear. This study evaluated the impact of an Inpatient Code Sepsis protocol, featuring an overhead page and order set, on mortality in hospitalized patients with sepsis and septic shock. Methods: A retrospective cohort study was conducted at a 371-bed hospital from July 1, 2020, to July 31, 2023. Hospitalized adults (≥18 years) diagnosed with sepsis and septic shock before and after the Inpatient Code Sepsis protocol implementation were included. The primary outcome was 30-day all-cause mortality; secondary outcomes were hospital length of stay, 30-day readmission, and time to antibiotic administration. Patients were excluded if they were identified for sepsis without infection, had sepsis due to non-bacterial causes, lost to follow-up within 30 days of admission, received empiric antibiotics in an emergency department or outside hospital, or were missing antibiotic administration time. Results: A total of 138 patients were included in the analysis. Mortality within 30 days did not significantly differ preprotocol and postprotocol (p = 0.381). However, a significant reduction in time to antibiotic administration was noted postimplementation (p < 0.05). Hospital length of stay and 30-day readmission showed no significant changes. Conclusion: The Inpatient Code Sepsis protocol did not impact 30-day mortality but did improve the time to antibiotic administration.

Review: sepsis guidelines and core measure bundles

Sepsis is a major cause of mortality worldwide and is the third-leading cause of death in the United States. Sepsis is resource-intensive and requires prompt recognition and treatment to reduce mortality. The impact of sepsis is not only on in-hospital survival but extends into post-discharge quality of life and risk of re-admission. As the understanding of sepsis physiology evolved, so have the recommended screening tools and treatment protocol which challenge prior standards of care. There have been noteworthy efforts by the Surviving Sepsis Campaign, the Third International Consensus Definitions for Sepsis and the Centers for Medicare and Medicaid Services to establish core measure bundles. This review highlights both the 2021 SSC International Guidelines and the 2015 CMS Severe Sepsis/Septic Shock Core Measure Bundle, or SEP-1. Notably, the SEP-1 bundle was implemented as a value-based purchasing program, linking care of sepsis patients to financial incentives. The objective is to explore the most current evidence-based data to inform clinical practice while utilizing the available guidelines as a roadmap.

State of the art of sepsis care for the emergency medicine clinician

Sepsis impacts 1.7 million Americans annually. It is a life-threatening disruption of organ function because of the body's host response to infection. Sepsis remains a condition frequently encountered in emergency departments (ED) with an estimated 850,000 annual visits affected by sepsis each year in the United States. The pillars of managing sepsis remain timely identification, initiation of antimicrobials while aiming for source control and resuscitation with a goal of restoring tissue perfusion. The focus herein is current evidence and best practice recommendations for state-of-the-art sepsis care that begins in the ED.

Evaluating Sepsis Bundle Compliance as a Predictor for Patient Outcomes at a Community Hospital: A Retrospective Study

BACKGROUND

Clinicians are encouraged to use the Centers for Medicare & Medicaid Services early management bundle for severe sepsis and septic shock (SEP-1); however, it is unclear whether this process measure improves patient outcomes.

PURPOSE

The purpose of this study was to evaluate whether compliance with the SEP-1 bundle is a predictor of hospital mortality, length of stay (LOS), and intensive care unit LOS at a suburban community hospital.

METHODS

A retrospective observational study was conducted.

RESULTS

A total of 577 patients were included in the analysis. Compliance with the SEP-1 bundle was not a significant predictor for patient outcomes.

CONCLUSIONS

SEP-1 compliance may not equate with quality of health care. Efforts to comply with SEP-1 may help organizations develop systems and structures that improve patient outcomes. Health care leaders should evaluate strategies beyond SEP-1 compliance to ensure continuous improvement of outcomes for patients experiencing sepsis.

Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat?

Objective

Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study's purpose was to evaluate the impact of time-to-CDI treatment on disease progression.

Methods

A case-control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable.

Results

272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69-81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6-8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11).

Conclusion

Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.

Sepsis Prediction Model for Determining Sepsis vs SIRS, qSOFA, and SOFA

Importance

The Sepsis Prediction Model (SPM) is a proprietary decision support tool created by Epic Systems; it generates a predicting sepsis score (PSS). The model has not undergone validation against existing sepsis prediction tools, such as Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), or quick Sepsis-Related Organ Failure Asessement (qSOFA).

Objective

To assess the validity and timeliness of the SPM compared with SIRS, qSOFA, and SOFA.

Design, Setting, and Participants

This retrospective cohort study included all adults admitted to 5 acute care hospitals in a single US health system between June 5, 2019, and December 31, 2020. Data analysis was conducted from March 2021 to February 2023.

Main Outcomes and Measures

A sepsis event was defined as receipt of 4 or more days of antimicrobials, blood cultures collected within ±48 hours of initial antimicrobial, and at least 1 organ dysfunction as defined by the organ dysfunction criteria optimized for the electronic health record (eSOFA). Time zero was defined as 15 minutes prior to qualifying antimicrobial or blood culture order.

Results

Of 60 507 total admissions, 1663 (2.7%) met sepsis criteria, with 1324 electronic health record-confirmed sepsis (699 [52.8%] male patients; 298 [22.5%] Black patients; 46 [3.5%] Hispanic/Latinx patients; 945 [71.4%] White patients), 339 COVID-19 sepsis (183 [54.0%] male patients; 98 [28.9%] Black patients; 36 [10.6%] Hispanic/Latinx patients; and 189 [55.8%] White patients), and 58 844 (97.3%; 26 632 [45.2%] male patients; 12 698 [21.6%] Black patients; 3367 [5.7%] Hispanic/Latinx patients; 40 491 White patients) did not meet sepsis criteria. The median (IQR) age was 63 (51 to 73) years for electronic health record-confirmed sepsis, 69 (60 to 77) years for COVID-19 sepsis, and 60 (42 to 72) years for nonsepsis admissions. Within the vendor recommended threshold PSS range of 5 to 8, PSS of 8 or greater had the highest balanced accuracy for classifying a sepsis admission at 0.79 (95% CI, 0.78 to 0.80). Change in SOFA score of 2 or more had the highest sensitivity, at 0.97 (95% CI, 0.97 to 0.98). At a PSS of 8 or greater, median (IQR) time to score positivity from time zero was 68.00 (6.75 to 605.75) minutes. For SIRS, qSOFA, and SOFA, median (IQR) time to score positivity was 7.00 (-105.00 to 08.00) minutes, 74.00 (-22.25 to 599.25) minutes, and 28.00 (-108.50 to 134.00) minutes, respectively.

Conclusions and Relevance

In this cohort study of hospital admissions, balanced accuracy of the SPM outperformed other models at higher threshold PSS; however, application of the SPM in a clinical setting was limited by poor timeliness as a sepsis screening tool as compared to SIRS and SOFA.

Risk for primary cephalosporin resistance in Gram-negative bacteremia

Objective

This study aimed to examine the clinical risk factors for cephalosporin resistance in patients with Gram-negative bacteremia caused by Escherichia coli (EC), Klebsiella pneumoniae (KP), Enterobacter cloacae (ENC), and Pseudomonas aeruginosa (PS).

Methods

This retrospective cohort study included 400 adults with Gram-negative bacteremia. The goal was to review 100 cases involving each species and approximately half resistant and half susceptible to first-line cephalosporins, ceftriaxone (EC or KP), or cefepime (ENC or PS). Logistic regression was used to identify factors predictive of resistance.

Results

A total of 378 cases of Gram-negative bacteremia were included in the analysis. Multivariate analysis identified significant risk factors for resistance, including admission from a chronic care hospital, skilled nursing facility, or having a history of infection within the prior 6 months (OR 3.00, P < .0001), requirement for mechanical ventilation (OR 3.76, P < .0001), presence of hemiplegia (OR 3.54, P = .0304), and presence of a connective tissue disease (OR 3.77, P = .0291).

Conclusions

Patients without the identified risk factors should be strongly considered for receiving ceftriaxone or cefepime rather than carbapenems and newer broad-spectrum agents.

Prehospital Fluid Administration for Suspected Sepsis in a Large EMS System: Opportunities to Improve Goal Fluid Delivery

OBJECTIVES

Despite EMS-implemented screening and treatment protocols for suspected sepsis patients, prehospital fluid therapy is variable. We sought to describe prehospital fluid administration in suspected sepsis patients, including demographic and clinical factors associated with fluid outcomes.

METHODS

A retrospective cohort of adult patients from a large, county-wide EMS system from January 2018-February 2020 was identified. Patient care reports for suspected sepsis were included, as identified by EMS clinician impression of sepsis, or keywords "sepsis" or "septic" in the narrative. Outcomes were the proportions of suspected sepsis patients for whom intravenous (IV) therapy was attempted and those who received ≥500 mL IV fluid if IV access was successful. Associations between patient demographics and clinical factors with fluid outcomes were estimated with multivariable logistic regression adjusting for transport interval.

RESULTS

Of 4,082 suspected sepsis patients identified, the mean patient age was 72.5 (SD 16.2) years, 50.6% were female, and 23.8% were Black. Median (interquartile range [IQR]) transport interval was 16.5 (10.9-23.2) minutes. Of identified patients, 1,920 (47.0%) had IV fluid therapy attempted, and IV access was successful in 1,872 (45.9%). Of those with IV access, 1,061 (56.7%) received ≥500mL of fluid from EMS. In adjusted analyses, female (versus male) sex (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.69-0.90), Black (versus White) race (OR 0.57, 95% CI 0.49-0.68), and end stage renal disease (OR 0.51, 95% CI 0.32-0.82) were negatively associated with attempted IV therapy. Systolic blood pressure (SBP) <90 mmHg (OR 3.89, 95% CI 3.25-4.65) and respiratory rate >20 (OR 1.90, 95% CI 1.61-2.23) were positively associated with attempted IV therapy. Female sex (OR 0.72, 95% CI 0.59-0.88) and congestive heart failure (CHF) (OR 0.55, 95% CI 0.40-0.75) were negatively associated with receiving goal fluid volume while SBP <90 mmHg (OR 2.30, 95% CI 1.83-2.88) and abnormal temperature (>100.4 F or <96 F) (OR 1.41, 95% CI 1.16-1.73) were positively associated.

CONCLUSIONS

Fewer than half of EMS sepsis patients had IV therapy attempted, and of those, approximately half met fluid volume goal, especially when hypotensive and no CHF. Further studies are needed on improving EMS sepsis training and prehospital fluid delivery.