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Williams CYK, Edinburgh T, Elbers PWG, Thoral PJ, Ercole A. Application of the Sepsis-3 criteria to describe sepsis epidemiology in the Amsterdam UMCdb intensive care dataset. PLoS One 2024; 19:e0304133. [PMID: 38905261 PMCID: PMC11192388 DOI: 10.1371/journal.pone.0304133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 05/07/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION Sepsis is a major cause of morbidity and mortality worldwide. In the updated, 2016 Sepsis-3 criteria, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, where organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more. We sought to apply the Sepsis-3 criteria to characterise the septic cohort in the Amsterdam University Medical Centres database (Amsterdam UMCdb). METHODS We examined adult intensive care unit (ICU) admissions in the Amsterdam UMCdb, which contains de-identified data for patients admitted to a mixed surgical-medical ICU at a tertiary academic medical centre in the Netherlands. We operationalised the Sepsis-3 criteria, defining organ dysfunction as an increase in the SOFA score of 2 points or more, while infection was defined as a new course of antibiotics or an escalation in antibiotic therapy, with at least one antibiotic given intravenously. Patients with sepsis were determined to be in septic shock if they additionally required the use of vasopressors and had a lactate level >2 mmol/L. RESULTS We identified 18,221 ICU admissions from 16,408 patients in our cohort. There were 6,312 unique sepsis episodes, of which 30.2% met the criteria for septic shock. A total of 4,911/6,312 sepsis (77.8%) episodes occurred on ICU admission. Forty-seven percent of emergency medical admissions and 36.7% of emergency surgical admissions were for sepsis. Overall, there was a 12.5% ICU mortality rate; patients with septic shock had a higher ICU mortality rate (38.4%) than those without shock (11.4%). CONCLUSIONS We successfully operationalised the Sepsis-3 criteria to the Amsterdam UMCdb, allowing the characterization and comparison of sepsis epidemiology across different centres.
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Affiliation(s)
- Christopher Y. K. Williams
- Department of Medicine, Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Bakar Computational Health Sciences Institute, University of California, San Francisco, California, United States of America
| | - Tom Edinburgh
- Department of Medicine, Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, United Kingdom
| | - Paul W. G. Elbers
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick J. Thoral
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ari Ercole
- Department of Medicine, Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, United Kingdom
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Rhee C, Strich JR, Chiotos K, Classen DC, Cosgrove SE, Greeno R, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Terry A, Winslow DL, Yealy DM, Klompas M. Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper. Clin Infect Dis 2024; 78:505-513. [PMID: 37831591 DOI: 10.1093/cid/ciad447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 10/15/2023] Open
Abstract
The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David C Classen
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ron Greeno
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Aisha Terry
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Zafar A, Naeem F, Khalid MZ, Awan S, Riaz MM, Mahmood SBZ. Comparison of five different disseminated intravascular coagulation criteria in predicting mortality in patients with sepsis. PLoS One 2024; 19:e0295050. [PMID: 38452037 PMCID: PMC10919643 DOI: 10.1371/journal.pone.0295050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/14/2023] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE Even though patients with sepsis and DIC have a higher mortality rate compared to those without DIC, screening for DIC is not currently part of sepsis management protocols. This may be due to a lack of literature on the frequency of DIC occurrence in sepsis patients, as well as the absence of evidence on the optimal DIC criteria to use for identifying DIC and predicting mortality among the five criteria available. To address this gap, this study investigates the predictive value of five different criteria for diagnosing DIC and its relationship to patient outcomes in our population of sepsis patients. METHODS In the Medicine department of Aga Khan University Hospital, a retrospective observational study was conducted, enrolling all adult patients with International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding of sepsis and clinical suspicion of DIC between January 2018 and December 2020. To diagnose DIC, five different criteria were utilized, namely the International Society of Thrombosis and Hemostasis (ISTH), the Korean Society on Thrombosis and Hemostasis (KSTH), the Japanese Association for Acute Medicine (JAAM), the revised-JAAM (RJAAM), and the Japanese Ministry of Health and Welfare (JMHW). The study analyzed the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of these five criteria, as well as the overall prediction of mortality. RESULTS Of 222 septic patients included in this study with clinical suspicion of DIC, 94.6% of patient had DIC according to KSTH criteria, followed by JAAM (69.4%), ISTH (64.0%), JMHW (53.2%) and lastly R-JAAM (48.6%). KSTH had sensitivity of 95.4% in diagnosing DIC and predicting mortality with a positive predictive value of 70% but specificity of 7.3% only. JAAM had sensitivity of 75.9%, positive predictive value of 75.9% with a specificity of 45.5%. ISTH had sensitivity of 69.4%, positive predictive value 75.3% and specificity of 48.5%. CONCLUSION DIC can impose a significant burden on septic patients and its presence can lead to higher mortality rates. Early detection through screening for DIC in septic patients can potentially reduce mortality. However, it is necessary to identify the most appropriate diagnostic criteria for each population, as various criteria have demonstrated different performance in different populations. Establishing a gold standard for each population can aid in accurate diagnosis of DIC.
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Affiliation(s)
- Amara Zafar
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Filza Naeem
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Safia Awan
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
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Skei NV, Nilsen TIL, Mohus RM, Prescott HC, Lydersen S, Solligård E, Damås JK, Gustad LT. Trends in mortality after a sepsis hospitalization: a nationwide prospective registry study from 2008 to 2021. Infection 2023; 51:1773-1786. [PMID: 37572240 PMCID: PMC10665235 DOI: 10.1007/s15010-023-02082-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Few studies have reported on mortality beyond one year after sepsis. We aim to describe trends in short- and long-term mortality among patients admitted with sepsis, and to describe the association between clinical characteristics and mortality for improved monitoring, treatment and prognosis. METHODS Patients ≥ 18 years admitted to all Norwegian hospitals (2008-2021) with a first sepsis episode were identified using Norwegian Patient Registry and International Classification of Diseases 10th Revision codes. Sepsis was classified as implicit (known infection site plus organ dysfunction), explicit (unknown infection site), or COVID-19-related sepsis. The outcome was all-cause mortality. We describe age-standardized 30-day, 90-day, 1-, 5- and 10-year mortality for each admission year and estimated the annual percentage change with 95% confidence interval (CI). The association between clinical characteristics and all-cause mortality is reported as hazard ratios (HRs) adjusted for age, sex and calendar year in Cox regression. RESULTS The study included 222,832 patients, of whom 127,059 (57.1%) had implicit, 92,928 (41.7%) had explicit, and 2,845 (1.3%) had COVID-19-related sepsis (data from 2020 and 2021). Trends in overall age-standardized 30-day, 90-day, 1- and 5-year mortality decreased by 0.29 (95% CI - 0.39 to - 0.19), 0.43 (95% CI - 0.56 to - 0.29), 0.61 (95% CI - 0.73 to - 0.49) and 0.66 (95% CI - 0.84 to - 0.48) percent per year, respectively. The decrease was observed for all infections sites but was largest among patients with respiratory tract infections. Implicit, explicit and COVID-19-related sepsis had largely similar overall mortality, with explicit sepsis having an adjusted HR of 0.980 (95% CI 0.969 to 0.991) and COVID-19-related sepsis an adjusted HR of 0.916 (95% CI 0.836 to 1.003) compared to implicit sepsis. Patients with respiratory tract infections have somewhat higher mortality than those with other infection sites. Number of comorbidities was positively associated with mortality, but mortality varied considerably between different comorbidities. Similarly, number of acute organ dysfunctions was strongly associated with mortality, whereas the risk varied for each type of organ dysfunction. CONCLUSION Overall mortality has declined over the past 14 years among patients with a first sepsis admission. Comorbidity, site of infection, and acute organ dysfunction are patient characteristics that are associated with mortality. This could inform health care workers and raise the awareness toward subgroups of patients that needs particular attention to improve long-term mortality.
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Affiliation(s)
- Nina Vibeche Skei
- Department of Anesthesia and Intensive Care, Nord-Trondelag Hospital Trust, Levanger, Norway.
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Tom Ivar Lund Nilsen
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Randi Marie Mohus
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Anesthesia and Intensive Care, St. Olav's University Hospital, Trondheim, Norway
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, (NTNU), Trondheim, Norway
| | - Erik Solligård
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jan Kristian Damås
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Centre of Molecular Inflammation Research, Institute for Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Infectious Diseases, St. Olav's University Hospital, Trondheim, Norway
| | - Lise Tuset Gustad
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
- Department of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
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Stenberg H, Li X, Pello-Esso W, Larsson Lönn S, Thønnings S, Khoshnood A, Knudsen JD, Sundquist K, Jansåker F. The effects of sociodemographic factors and comorbidities on sepsis: A nationwide Swedish cohort study. Prev Med Rep 2023; 35:102326. [PMID: 37519448 PMCID: PMC10374593 DOI: 10.1016/j.pmedr.2023.102326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023] Open
Abstract
Sepsis is a severe condition, representing a significant public health concern, especially in the elderly. There is, however, little insight into the potential effects of sociodemographic factors and comorbidities on sepsis incidence and how these factors interact. This was a nationwide open cohort study including individuals (N = 6 746 010) in Sweden ≥ 18 years of age spanning from 1997 to 2018, with 116 175 995 person years of follow-up. The outcome was time to first occurrence of sepsis. The following variables were included in the analysis: sociodemographic factors (age, sex, income, education, marital status, region of residency, and country of origin), severe mental disorders (schizophrenia and bipolar disorders), and Charlson Comorbidity Index. Interaction tests were conducted. A total of 161 558 individuals were diagnosed with sepsis during the study period, corresponding to an incidence rate of 13.9 per 10 000 person years (95% CI: 13.8 - 14.0). The main findings were that male sex, high age, low education, and comorbid conditions were positively associated with sepsis, after adjustments for the other covariates. Being aged 80 years and above yielded a HR of 18.19 (95% CI: 17.84 - 18.55) and the effect of high age was more than twice as high in men than in women. In conclusion, this large nationwide cohort found that several sociodemographic factors and comorbid conditions were independently associated with sepsis and men were more affected by higher age than women. These findings can help improve sepsis awareness and preventive work in risk groups.
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Affiliation(s)
- Henning Stenberg
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Xinjun Li
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Wazah Pello-Esso
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Sara Larsson Lönn
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Sara Thønnings
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
| | - Ardavan Khoshnood
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
- Department of Emergency Medicine, Skåne University Hospital Lund, Lund, Sweden
| | - Jenny Dahl Knudsen
- Department of Clinical Microbiology, Center of Diagnostic Investigations, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Kristina Sundquist
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
- Center for Community-based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Japan
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Filip Jansåker
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
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Applebaum JR. An Interview with Jason S. Adelman, MD, MS. Jt Comm J Qual Patient Saf 2023; 49:435-440. [PMID: 37516603 DOI: 10.1016/j.jcjq.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
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Islam KR, Prithula J, Kumar J, Tan TL, Reaz MBI, Sumon MSI, Chowdhury MEH. Machine Learning-Based Early Prediction of Sepsis Using Electronic Health Records: A Systematic Review. J Clin Med 2023; 12:5658. [PMID: 37685724 PMCID: PMC10488449 DOI: 10.3390/jcm12175658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/13/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Sepsis, a life-threatening infection-induced inflammatory condition, has significant global health impacts. Timely detection is crucial for improving patient outcomes as sepsis can rapidly progress to severe forms. The application of machine learning (ML) and deep learning (DL) to predict sepsis using electronic health records (EHRs) has gained considerable attention for timely intervention. METHODS PubMed, IEEE Xplore, Google Scholar, and Scopus were searched for relevant studies. All studies that used ML/DL to detect or early-predict the onset of sepsis in the adult population using EHRs were considered. Data were extracted and analyzed from all studies that met the criteria and were also evaluated for their quality. RESULTS This systematic review examined 1942 articles, selecting 42 studies while adhering to strict criteria. The chosen studies were predominantly retrospective (n = 38) and spanned diverse geographic settings, with a focus on the United States. Different datasets, sepsis definitions, and prevalence rates were employed, necessitating data augmentation. Heterogeneous parameter utilization, diverse model distribution, and varying quality assessments were observed. Longitudinal data enabled early sepsis prediction, and quality criteria fulfillment varied, with inconsistent funding-article quality correlation. CONCLUSIONS This systematic review underscores the significance of ML/DL methods for sepsis detection and early prediction through EHR data.
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Affiliation(s)
- Khandaker Reajul Islam
- Department of Physiology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Johayra Prithula
- Department of Electrical and Electronics Engineering, University of Dhaka, Dhaka 1000, Bangladesh
| | - Jaya Kumar
- Department of Physiology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mamun Bin Ibne Reaz
- Department of Electrical and Electronic Engineering, Independent University, Bangladesh Bashundhara, Dhaka 1229, Bangladesh
| | - Md. Shaheenur Islam Sumon
- Department of Biomedical Engineering, Military Institute of Science and Technology (MIST), Dhaka 1216, Bangladesh
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Huang Q, Ding Y, Fang C, Wang H, Kong L. The Emerging Role of Ferroptosis in Sepsis, Opportunity or Challenge? Infect Drug Resist 2023; 16:5551-5562. [PMID: 37641800 PMCID: PMC10460599 DOI: 10.2147/idr.s419993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/01/2023] [Indexed: 08/31/2023] Open
Abstract
Sepsis is a syndrome in multi-organ dysfunction triggered by a deleterious immunological reaction of the body to a condition caused by infection, surgery, or trauma. Currently, sepsis is thought to be primarily associated with abnormal immune responses resulting in organ microcirculatory disturbances, cellular mitochondrial dysfunction, and induced cell death, although the exact pathogenesis of sepsis is still inconclusive. In recent years, the role of abnormal metabolism of trace nutrients in the pathogenesis of sepsis has been investigated. Ferroptosis is a type of cell death that relies on iron and is characterized by unique morphological, biochemical, and genetic features. Unlike other forms of cell death, such as autophagy, apoptosis, necrosis, and pyroptosis, ferroptosis is primarily driven by lipid peroxidation. Ferroptosis cells may be immunogenic, amplify inflammatory responses, cause more cell death, and ultimately induce multi-organ failure. An increasing number of studies have indicated the significance of ferroptosis in sepsis and its role in reducing inflammation. The effectiveness of sepsis treatment has been demonstrated by the use of drugs that specifically target molecules associated with the ferroptosis pathway, including ferroptosis inhibitors. Nevertheless, there is a scarcity of studies investigating the multi-organ dysfunction caused by ferroptosis in sepsis. This article presents a summary and evaluation of recent progress in the role of ferroptosis through molecularly regulated mechanisms and its potential mechanisms of action in the multi-organ dysfunction associated with sepsis. It also discusses the current challenges and prospects in understanding the connection between sepsis and ferroptosis, and proposes innovative ideas and strategies for the treatment of sepsis.
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Affiliation(s)
- Qigang Huang
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Yingwei Ding
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Chao Fang
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Hao Wang
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
| | - Laifa Kong
- Department of Emergency Medicine, Zhejiang University Medical College Affiliated Jinhua Hospital, Jinhua, Zhejiang, People’s Republic of China
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Skei NV, Nilsen TIL, Knoop ST, Prescott H, Lydersen S, Mohus RM, Brkic A, Liyanarachi KV, Solligård E, Damås JK, Gustad LT. Long-term temporal trends in incidence rate and case fatality of sepsis and COVID-19-related sepsis in Norwegian hospitals, 2008-2021: a nationwide registry study. BMJ Open 2023; 13:e071846. [PMID: 37532480 PMCID: PMC10401253 DOI: 10.1136/bmjopen-2023-071846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES To estimate temporal trends in incidence rate (IR) and case fatality during a 14-year period from 2008 to 2021, and to assess possible shifts in these trends during the COVID-19 pandemic. SETTING All Norwegian hospitals 2008-2021. PARTICIPANTS 317 705 patients ≥18 year with a sepsis International Classification of Diseases 10th revision code retrieved from The Norwegian Patient Registry. PRIMARY AND SECONDARY MEASURES Annual age-standardised IRs with 95% CIs. Poisson regression was used to estimate changes in IRs across time, and logistic regression was used to estimate ORs for in-hospital death. RESULTS Among 12 619 803 adult hospitalisations, a total of 317 705 (2.5%) hospitalisations in 222 832 (70.0%) unique patients met the sepsis criteria. The overall age-standardised IR of a first sepsis admission was 246/100 000 (95% CI 245 to 247), whereas the age-standardised IR of all sepsis admissions was 352/100 000 (95% CI 351 to 354). In the period 2009-2019, the annual IR for a first sepsis episode was stable (IR ratio (IRR) per year, 0.999; 95% CI 0.994 to 1.004), whereas for recurrent sepsis the IR increased (annual IRR, 1.048; 95% CI 1.037 to 1.059). During the COVID-19 pandemic, the IRR for a first sepsis was 0.877 (95% CI 0.829 to 0.927) in 2020 and 0.929 (95% CI 0.870 to 0.992) in 2021, and for all sepsis it was 0.870 (95% CI 0.810 to 0.935) in 2020 and 0.908 (95% CI 0.840 to 0.980) in 2021, compared with the previous 11-year period. Case fatality among first sepsis admissions declined in the period 2009-2019 (annual OR 0.954 (95% CI 0.950 to 0.958)), whereas case fatality increased during the COVID-19 pandemic in 2020 (OR 1.061 (95% CI 1.001 to 1.124) and in 2021 (OR 1.164 (95% CI 1.098 to 1.233)). CONCLUSION The overall IR of sepsis increased from 2009 to 2019, due to an increasing IR of recurrent sepsis, and indicates that sepsis awareness with updated guidelines and education must continue.
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Affiliation(s)
- Nina Vibeche Skei
- Department of Anesthesia and Intensive Care, Nord-Trøndelag Hospital Trust, Levanger, Norway
- Institute of Circulation and Medical Imaging, Mid-Norway Centre of Sepsis Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Tom Ivar Lund Nilsen
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Siri Tandberg Knoop
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hallie Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, Michigan, USA
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Randi Marie Mohus
- Institute of Circulation and Medical Imaging, Mid-Norway Centre of Sepsis Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Anaesthesia and Intensive Care, St Olavs Hospital Trondheim University Hospital, Trondheim, Norway
| | - Alen Brkic
- Research Department, Sørlandet Sykehus HF, Kristiansand, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Kristin Vardheim Liyanarachi
- Institute of Circulation and Medical Imaging, Mid-Norway Centre of Sepsis Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Infectious Diseases, St. Olav's University Hospital, Trondheim, Norway
| | - Erik Solligård
- Institute of Circulation and Medical Imaging, Mid-Norway Centre of Sepsis Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jan Kristian Damås
- Institute of Circulation and Medical Imaging, Mid-Norway Centre of Sepsis Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Infectious Diseases, St. Olav's University Hospital, Trondheim, Norway
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lise Tuset Gustad
- Institute of Circulation and Medical Imaging, Mid-Norway Centre of Sepsis Research, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Medicine and Rehabilitation, Nord-Trondelag Hospital Trust, Levanger, Norway
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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10
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Mellhammar L, Wollter E, Dahlberg J, Donovan B, Olséen CJ, Wiking PO, Rose N, Schwarzkopf D, Friedrich M, Fleischmann-Struzek C, Reinhart K, Linder A. Estimating Sepsis Incidence Using Administrative Data and Clinical Medical Record Review. JAMA Netw Open 2023; 6:e2331168. [PMID: 37642964 PMCID: PMC10466163 DOI: 10.1001/jamanetworkopen.2023.31168] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023] Open
Abstract
Importance Despite the large health burden, reliable data on sepsis epidemiology are lacking; studies using International Statistical Classification of Diseases and Related Health Problems (ICD)-coded hospital discharge diagnosis for sepsis identification suffer from limited sensitivity. Also, ICD data do not allow investigation of underlying pathogens and antimicrobial resistance. Objectives To generate reliable epidemiological estimates by linking data from a population-based database to a reference standard of clinical medical record review. Design, Setting, and Participants This was a retrospective, observational cohort study using a population-based administrative database including all acute care hospitals of the Scania region in Sweden in 2019 and 2020 to identify hospital-treated sepsis cases by ICD codes. From this database, clinical medical records were also selected for review within 6 strata defined by ICD discharge diagnosis (both with and without sepsis diagnosis). Data were analyzed from April to October 2022. Main outcomes and measures Hospital and population incidences of sepsis, case fatality, antimicrobial resistance, and temporal dynamics due to COVID-19 were assessed, as well as validity of ICD-10 case identification methods compared with the reference standard of clinical medical record review. Results Out of 295 531 hospitalizations in 2019 in the Scania region of Sweden, 997 patient medical records were reviewed, among which 457 had sepsis according to clinical criteria. Of the patients with clinical sepsis, 232 (51%) were female, and 357 (78%) had at least 1 comorbidity. The median (IQR) age of the cohort was 76 (67-85) years. The incidence of sepsis in hospitalized patients according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria in 2019 was 4.1% (95% CI, 3.6-4.5) by medical record review. This corresponds to an annual incidence rate of 747 (95% CI, 663-832) patients with sepsis per 100 000 population. No significant increase in sepsis during the COVID-19 pandemic nor a decrease in sepsis incidence when excluding COVID-19 sepsis was observed. Few sepsis cases caused by pathogens with antimicrobial resistance were found. The validity of ICD-10-based case identification in administrative data was low. Conclusions and Relevance In this cohort study of sepsis epidemiology, sepsis was a considerable burden to public health in Sweden. Supplying administrative data with information from clinical medical records can help to generate reliable data on sepsis epidemiology.
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Affiliation(s)
- Lisa Mellhammar
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Erik Wollter
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Jacob Dahlberg
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Benjamin Donovan
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Carl-Johan Olséen
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Per Ola Wiking
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Norman Rose
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Daniel Schwarzkopf
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Marcus Friedrich
- Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Stiftung Charité, Berlin, Germany
| | | | - Konrad Reinhart
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adam Linder
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
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11
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Kim JS, Kim YJ, Kim YJ, Kim WY. Impact of Developing Dialysis-Requiring Acute Kidney Injury on Long-Term Mortality in Cancer Patients with Septic Shock. Cancers (Basel) 2023; 15:3619. [PMID: 37509280 PMCID: PMC10377237 DOI: 10.3390/cancers15143619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Considering recent advances in both cancer and sepsis management, we chose to evaluate the associated factors for occurrence of septic acute kidney injury in cancer patients using a nationwide population-based cohort data. (2) Methods: Using data from the National Health Insurance Service of Korea, adult cancer patients who presented to emergency departments with septic shock from 2009 to 2017 were analyzed. A Cox-proportional hazard model was conducted to evaluate the clinical effect of sepsis-related acute kidney injury requiring dialysis. (3) Results: Among 42,477 adult cancer patients with septic shock, dialysis-requiring acute kidney injury occurred in 5449 (12.8%). Recovery from dialysis within 30 days was 77.9% and, overall, 30-day and 2-year mortality rates were 52.1% and 85.1%, respectively. Oncologic patients with dialysis-requiring acute kidney injury frequently occurred in males and patients with hematologic cancer. A multivariate Cox-proportional hazard model showed that dialysis-requiring acute kidney injury had the highest adjusted hazard ratio of 1.353 (95% confidence interval 1.313-1.395) for 2-year mortality. (4) Conclusions: Dialysis-requiring septic acute kidney injury did not occur commonly. However, it had a significant association with increased long-term mortality, which suggests emphasis should be placed on the prevention of acute kidney injury, particularly in male hematologic cancer patients.
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Affiliation(s)
- June-Sung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
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12
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Kataria S, Singh O, Juneja D, Goel A, Bhide M, Yadav D. Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients: A comparative observational study. World J Clin Cases 2023; 11:3765-3779. [PMID: 37383132 PMCID: PMC10294150 DOI: 10.12998/wjcc.v11.i16.3765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/17/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization. Nevertheless, raised lactate levels should be interpreted in the clinical context, as there may be other causes of elevated lactate levels. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis.
AIM To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context.
METHODS This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context (Group 1, n = 95) and patients with hyperlactatemia in a non-hypoperfusion context (Group 2, n = 40). Hypoperfusion context was defined by a central venous saturation less than 70%, central venous-arterial PCO2 gradient [P(cv-a)CO2] ≥ 6 mmHg, and capillary refilling time (CRT) ≥ 4 s. The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals. Nominal categorical data were compared using the χ2 or Fisher’s exact test. Non-normally distributed continuous variables were compared using the Mann-Whitney U test. Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate, CRT, and metabolic perfusion parameters to predict the 28-d all-cause mortality. A P value of < 0.05 was considered significant.
RESULTS Patient demographics, comorbidities, baseline laboratory, vital parameters, source of infection, baseline lactate levels, and lactate clearance at 3 h and 6 h, Sequential Organ Failure scores, need for invasive mechanical ventilation, days on mechanical ventilation, and renal replacement therapy-free days within 28 d, duration of intensive care unit stay, and hospital stay were comparable between the two groups. The stratification of patients into hypoperfusion and non-hypoperfusion context did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO2 and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P > 0.05 at all measured intervals. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, P(cv-a)CO2 at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the curve lactate at 6 h: 0.845).
CONCLUSION Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters. Persistently high P(cv-a)CO2 (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.
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Affiliation(s)
- Sahil Kataria
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Amit Goel
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Madhura Bhide
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Devraj Yadav
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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13
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Ogilvie J, Mittal R, Sangster W, Parker J, Lim K, Kyriakakis R, Luchtefeld M. Preoperative Immuno-Nutrition and Complications After Colorectal Surgery: Results of a 2-Year Prospective Study. J Surg Res 2023; 289:182-189. [PMID: 37121044 DOI: 10.1016/j.jss.2023.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Preoperative immuno-nutrition has been associated with reductions in infectious complications and length of stay, but remains unstudied in the setting of an enhanced recovery protocol. The objective was to evaluate outcomes after elective colorectal surgery with the addition of a preoperative immuno-nutrition supplement. METHODS In October 2017, all major colorectal surgeries were given an arginine-based supplement prior to surgery. The control group consisted of cases within the same enhanced recovery protocol from three years prior. The primary outcome was a composite of overall morbidity. Secondary outcomes were infectious complications and length of stay with subgroup analysis based on degrees of malnutrition. RESULTS Of 826 patients, 514 were given immuno-nutrition prospectively and no differences in complication rates (21.5% versus 23.9%, P = 0.416) or surgical site infections (SSIs) (6.4% versus 6.9%, P = 0.801) were observed. Hospitalization was slightly shorter in the immuno-nutrition cohort (5.0 [3.0, 7.0], versus 5.5 days [3.6, 7.9], P = 0.002). There was a clinically insignificant difference in prognostic nutrition index scores between cohorts (35.2 ± 5.6 versus 36.1 ± 5.0, P = 0.021); however, subgroup analysis (< 33, 34-38 and > 38) failed to demonstrate an association with complications (P = 0.275) or SSIs (P = 0.640) and immuno-nutrition use. CONCLUSIONS Complication rates and SSIs were unchanged with the addition of immuno-nutrition before elective colorectal surgery. The association with length of stay is small and without clinical significance; therefore, the routine use of immuno-nutrition in this setting is of questionable benefit.
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Affiliation(s)
- James Ogilvie
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan.
| | - Rohin Mittal
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan
| | - William Sangster
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan
| | - Jessica Parker
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan
| | - Kelvin Lim
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan
| | - Roxanne Kyriakakis
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan
| | - Martin Luchtefeld
- Michigan State University-affiliated hospitals, Spectrum Health, Grand Rapids, Michigan
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14
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Lakbar I, Leone M, Pauly V, Orleans V, Srougbo KJ, Diao S, Llorca PM, Solmi M, Correll CU, Fernandes S, Vincent JL, Boyer L, Fond G. Association of severe mental illness and septic shock case fatality rate in patients admitted to the intensive care unit: A national population-based cohort study. PLoS Med 2023; 20:e1004202. [PMID: 36913434 PMCID: PMC10042353 DOI: 10.1371/journal.pmed.1004202] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/27/2023] [Accepted: 02/16/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Patients with severe mental illness (SMI) (i.e., schizophrenia, bipolar disorder, or major depressive disorder) have been reported to have excess mortality rates from infection compared to patients without SMI, but whether SMI is associated with higher or lower case fatality rates (CFRs) among infected patients remains unclear. The primary objective was to compare the 90-day CFR in septic shock patients with and without SMI admitted to the intensive care unit (ICU), after adjusting for social disadvantage and physical health comorbidity. METHODS AND FINDINGS We conducted a nationwide, population-based cohort study of all adult patients with septic shock admitted to the ICU in France between January 1, 2014, and December 31, 2018, using the French national hospital database. We matched (within hospitals) in a ratio of 1:up to 4 patients with and without SMI (matched-controls) for age (5 years range), sex, degree of social deprivation, and year of hospitalization. Cox regression models were conducted with adjustment for smoking, alcohol and other substance addiction, overweight or obesity, Charlson comorbidity index, presence of trauma, surgical intervention, Simplified Acute Physiology Score II score, organ failures, source of hospital admission (home, transfer from other hospital ward), and the length of time between hospital admission and ICU admission. The primary outcome was 90-day CFR. Secondary outcomes were 30- and 365-day CFRs, and clinical profiles of patients. A total of 187,587 adult patients with septic shock admitted to the ICU were identified, including 3,812 with schizophrenia, 2,258 with bipolar disorder, and 5,246 with major depressive disorder. Compared to matched controls, the 90-day CFR was significantly lower in patients with schizophrenia (1,052/3,269 = 32.2% versus 5,000/10,894 = 45.5%; adjusted hazard ratio (aHR) = 0.70, 95% confidence interval (CI) 0.65,0.75, p < 0.001), bipolar disorder (632/1,923 = 32.9% versus 2,854/6,303 = 45.3%; aHR = 0.70, 95% CI = 0.63,0.76, p < 0.001), and major depressive disorder (1,834/4,432 = 41.4% versus 6,798/14,452 = 47.1%; aHR = 0.85, 95% CI = 0.81,0.90, p < 0.001). Study limitations include inability to capture deaths occurring outside hospital, lack of data on processes of care, and problems associated with missing data and miscoding in medico-administrative databases. CONCLUSIONS Our findings suggest that, after adjusting for social disadvantage and physical health comorbidity, there are improved septic shock outcome in patients with SMI compared to patients without. This finding may be the result of different immunological profiles and exposures to psychotropic medications, which should be further explored.
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Affiliation(s)
- Ines Lakbar
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
- Aix-Marseille University, AP-HM, North Hospital, Department of Anaesthesia and Intensive Care Unit, Marseille, France
| | - Marc Leone
- Aix-Marseille University, AP-HM, North Hospital, Department of Anaesthesia and Intensive Care Unit, Marseille, France
| | - Vanessa Pauly
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
| | - Veronica Orleans
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
| | - Kossi Josue Srougbo
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
| | - Sambou Diao
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
| | - Pierre-Michel Llorca
- FondaMental Fondation, Créteil, France
- University Clermont Auvergne, CMP-B CHU, CNRS, Clermont Auvergne INP, Institut Pascal, Clermont-Ferrand, France
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ontario, Canada
- Department of Mental Health, Ottawa Hospital, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Child and Adolescent Psychiatry, Berlin, Germany
| | - Christoph U. Correll
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Child and Adolescent Psychiatry, Berlin, Germany
- The Zucker Hillside Hospital, Department of Psychiatry, Glen Oaks, New York, United States of America
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Psychiatry and Molecular Medicine, Hempstead, New York, United States of America
| | - Sara Fernandes
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Laurent Boyer
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
- FondaMental Fondation, Créteil, France
| | - Guillaume Fond
- AP-HM, Aix-Marseille Univ, CEReSS, Health Service Research and Quality of Life Centre, School of Medicine—La Timone Medical, Marseille, France
- FondaMental Fondation, Créteil, France
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15
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Development of a Reinforcement Learning Algorithm to Optimize Corticosteroid Therapy in Critically Ill Patients with Sepsis. J Clin Med 2023; 12:jcm12041513. [PMID: 36836046 PMCID: PMC9961939 DOI: 10.3390/jcm12041513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The optimal indication, dose, and timing of corticosteroids in sepsis is controversial. Here, we used reinforcement learning to derive the optimal steroid policy in septic patients based on data on 3051 ICU admissions from the AmsterdamUMCdb intensive care database. METHODS We identified septic patients according to the 2016 consensus definition. An actor-critic RL algorithm using ICU mortality as a reward signal was developed to determine the optimal treatment policy from time-series data on 277 clinical parameters. We performed off-policy evaluation and testing in independent subsets to assess the algorithm's performance. RESULTS Agreement between the RL agent's policy and the actual documented treatment reached 59%. Our RL agent's treatment policy was more restrictive compared to the actual clinician behavior: our algorithm suggested withholding corticosteroids in 62% of the patient states, versus 52% according to the physicians' policy. The 95% lower bound of the expected reward was higher for the RL agent than clinicians' historical decisions. ICU mortality after concordant action in the testing dataset was lower both when corticosteroids had been withheld and when corticosteroids had been prescribed by the virtual agent. The most relevant variables were vital parameters and laboratory values, such as blood pressure, heart rate, leucocyte count, and glycemia. CONCLUSIONS Individualized use of corticosteroids in sepsis may result in a mortality benefit, but optimal treatment policy may be more restrictive than the routine clinical practice. Whilst external validation is needed, our study motivates a 'precision-medicine' approach to future prospective controlled trials and practice.
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16
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Barker N, Scott IA, Seaton R, Mehta N, Kalke VR, Redpath L. Recognition and Management of Hospital-Acquired Sepsis Among Older General Medical Inpatients: A Multi-Site Retrospective Study. Int J Gen Med 2023; 16:1039-1046. [PMID: 36987405 PMCID: PMC10039973 DOI: 10.2147/ijgm.s400839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023] Open
Abstract
Purpose To assess accuracy of early diagnosis, appropriateness and timeliness of response, and clinical outcomes of older general medical inpatients with hospital-acquired sepsis. Methods Hospital abstracts of inpatient encounters from seven digital Queensland public hospitals between July 2018 and September 2020 were screened retrospectively for diagnoses of hospital-acquired sepsis. Electronic medical records were retrieved and cases meeting selection criteria and classified as confirmed or probable sepsis using pre-specified criteria were included. Investigations and treatments following the first digitally generated alert of clinical deterioration were compared with a best practice sepsis care bundle. Outcome measures comprised 30-day all-cause mortality after deterioration, and unplanned readmissions at 14 days after discharge. Results Of the 169 screened care episodes, 59 comprised probable or confirmed cases of sepsis treated by general medicine teams at the time of initial deterioration. Of these, 43 (72.9%) had no mention of sepsis in the differential diagnosis on first medical review, and only 38 (64%) were managed as having sepsis. Each care bundle component of blood cultures, serum lactate, and intravenous fluid resuscitation and antibiotics was only delivered in approximately 30% of cases, and antibiotic administration was delayed more than an hour in 28 of 38 (73.7%) cases. Conclusion Early recognition of sepsis and timely implementation of care bundles are challenging in older general medical patients. Education programs in sepsis care standards targeting nurses and junior medical staff, closer patient monitoring, and post-discharge follow-up may improve patient outcomes.
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Affiliation(s)
- Nicholas Barker
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Correspondence: Ian A Scott, Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, 4102, Australia, Tel +61-7-31767355, Fax +61-7-31765214, Email
| | - Robert Seaton
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
| | - Naitik Mehta
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
| | - Vikrant R Kalke
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
| | - Lyndell Redpath
- Patient Quality and Safety Improvement Service, Queensland Health, Brisbane, Australia
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17
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Wang X, Zhang X, Sun L, Gao G, Li Y. Protective effect of Secukinumab on severe sepsis model rats by neutralizing IL-17A to inhibit IKBα/NFκB inflammatory signal pathway. Eur J Med Res 2022; 27:206. [PMID: 36253831 PMCID: PMC9578221 DOI: 10.1186/s40001-022-00845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/09/2022] [Indexed: 11/10/2022] Open
Abstract
Secukinumab is a specific neutralizing antibody for IL-17A. At present, numerous studies have confirmed the important role of IL-17A in sepsis, but the role of secukinumab in sepsis has not been studied. The present study explored the protective effect and underlying mechanism of secukinumab in severe sepsis model rats. We established a severe sepsis rat model using cecal ligation and puncture (CLP). The optimal dose of secukinumab was determined by observing the 7-day survival rate of severe sepsis model rats. The expression levels of TNF-α, IL-6, and IL-17A in plasma and lung tissue were determined by enzyme-linked immunosorbent assay. The degree of pathological damage to lung tissue was evaluated by hematoxylin–eosin (H–E) staining and pathological damage scale. The expressions of IKBα/NFκB pathway proteins and downstream-related inflammatory factors were detected by western blotting and real-time quantitative polymerase chain reaction (RT-qPCR). Our results show that high-dose secukinumab can inhibit the activation of the IKBα/NFκB inflammatory pathway by neutralizing IL-17A and reducing the gene expression of pathway-related inflammatory cytokines, thereby reducing the levels of inflammatory cytokines in lung tissue and plasma, thereby reducing the damage of lung tissue in severe sepsis model rats and improving the systemic inflammatory response.
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Affiliation(s)
- Xingsheng Wang
- Intensive Care Unit, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Intensive Care Unit, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xinxin Zhang
- Department of Emergency Medicine, Fuyang People's Hospital, Fuyang, Anhui, China
| | - Li Sun
- Intensive Care Unit, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Intensive Care Unit, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Guangsheng Gao
- Intensive Care Unit, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China. .,Intensive Care Unit, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China. .,Central Hospital Affiliated to Shandong First Medical University, NO. 105 Jiefang Road, Jinan, 250000, Shandong, China.
| | - Yun Li
- Intensive Care Unit, Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China. .,Intensive Care Unit, Jinan Central Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China. .,Central Hospital Affiliated to Shandong First Medical University, NO. 105 Jiefang Road, Jinan, 250000, Shandong, China.
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18
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Abstract
Sepsis is defined as life-threatening organ dysfunction triggered by an underlying infection. A recent study noted that the overall sepsis-related mortality rate in the United States is stable. In this study, we evaluated the sepsis-related mortality rates and trends associated with the three most common sites of infection.
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19
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Chan HK, Khose S, Chavez S, Patel B, Wang HE. Updated estimates of sepsis hospitalizations at United States academic medical centers. J Am Coll Emerg Physicians Open 2022; 3:e12782. [PMID: 35859855 PMCID: PMC9288236 DOI: 10.1002/emp2.12782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Sepsis is a major public health problem. Understanding the epidemiology of sepsis subtypes is important to quantify the magnitude of the problem and identify targets for system wide treatment strategies. We sought to describe the current national epidemiology of community‐acquired (CAS), hospital‐acquired (HAS) and healthcare‐associated sepsis (HCAS) hospitalizations among academic medical centers in the United States using current discharge diagnosis taxonomies. Methods Retrospective analysis of patient discharge data from the Vizient Clinical Data Base/Resource Manager. We identified sepsis hospitalizations using four ICD‐10 coding strategies: (1) “Martin” sepsis codes (21 ICD‐10 codes), (2) “Angus” sepsis codes (ICD‐10 infection + ICD‐10 organ dysfunction), (3) Medicare “SEP‐1” codes (28 ICD‐10 codes), and (4) “explicit sepsis” codes (ICD‐10 R65.20 and R65.21). Using present‐on‐admission flags for each diagnosis, we also distinguished: (1) community‐acquired sepsis (CAS), (2) hospital‐acquired sepsis (HAS), and (3) healthcare associated sepsis (HCAS). Results Among 22,655,240 hospitalizations, the number and incidence of sepsis hospitalizations were: (1) Martin (n = 1,718,257, 75.8 per 1000 hospitalizations), (2) Angus (n = 2,749,163, 121.3 per 1000), (3) SEP‐1 (n = 1,624,909, 71.7 per 1000), and (4) explicit sepsis (n = 655,853, 28.9 per 1000). CAS was the most common sepsis subtype. HAS exhibited higher adjusted mortality than CAS. ICU admission was highest for HAS (Martin, 1.5%; Angus, 1.5%; SEP‐1, 1.6%; Explicit, 1.9%). Conclusions These results illustrate the prevalence of sepsis at US academic medical centers using the most current sepsis classification taxonomies and discharge diagnosis codes. These results highlight important considerations when using hospital discharge data to characterize the epidemiology of sepsis.
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Affiliation(s)
- Hei Kit Chan
- Department of Emergency Medicine, Department of Biostatistics The University of Texas Health Science Center at Houston Houston Texas USA
| | - Swapnil Khose
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health The University of Texas Health Science Center at Houston Houston Texas USA
- Department of Emergency Medicine, McGovern Medical School The University of Texas Health Science Center at Houston Houston Texas USA
| | - Summer Chavez
- Department of Emergency Medicine, Department of Biostatistics The University of Texas Health Science Center at Houston Houston Texas USA
| | - Bela Patel
- Department of Medicine, Division of Critical Care Medicine The University of Texas Health Science Center at Houston Houston Texas USA
| | - Henry E. Wang
- Department of Emergency Medicine The Ohio State University Columbus Ohio USA
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Prognostic Impact of Neutropenia in Cancer Patients with Septic Shock: A 2009–2017 Nationwide Cohort Study. Cancers (Basel) 2022; 14:cancers14153601. [PMID: 35892860 PMCID: PMC9332608 DOI: 10.3390/cancers14153601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The prognostic impact of neutropenia on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were analyzed. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. Neutropenia did not increase mortality in cancer patients with septic shock, suggesting that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock. Abstract (1) Background: Neutropenia’s prognostic impact on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This population-based, case–control study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. (2) Methods: This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were included. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. Cox proportional hazard regression was performed after adjusting for age, sex, Charlson comorbidity index, and neutropenia. (3) Results: In 43,466 adult cancer patients with septic shock, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. In total, 6391 patients had neutropenic septic shock, and the prevalent cancer type was lung cancer, followed by leukemia, non-Hodgkin’s lymphoma, stomach cancer, and colon cancer. Furthermore, 30-day and 1-year mortality was lower in patients with neutropenia than in those without neutropenia. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. (4) Conclusions: In cancer patients presenting to the emergency department with septic shock, the presence of neutropenia did not increase mortality. This suggests that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.
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Inflammation: A New Look at an Old Problem. Int J Mol Sci 2022; 23:ijms23094596. [PMID: 35562986 PMCID: PMC9100490 DOI: 10.3390/ijms23094596] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 02/07/2023] Open
Abstract
Pro-inflammatory stress is inherent in any cells that are subject to damage or threat of damage. It is defined by a number of universal components, including oxidative stress, cellular response to DNA damage, unfolded protein response to mitochondrial and endoplasmic reticulum stress, changes in autophagy, inflammasome formation, non-coding RNA response, formation of an inducible network of signaling pathways, and epigenetic changes. The presence of an inducible receptor and secretory phenotype in many cells is the cause of tissue pro-inflammatory stress. The key phenomenon determining the occurrence of a classical inflammatory focus is the microvascular inflammatory response (exudation, leukocyte migration to the alteration zone). This same reaction at the systemic level leads to the development of life-critical systemic inflammation. From this standpoint, we can characterize the common mechanisms of pathologies that differ in their clinical appearance. The division of inflammation into alternative variants has deep evolutionary roots. Evolutionary aspects of inflammation are also described in the review. The aim of the review is to provide theoretical arguments for the need for an up-to-date theory of the relationship between key human pathological processes based on the integrative role of the molecular mechanisms of cellular and tissue pro-inflammatory stress.
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Concomitant Sepsis Diagnoses in Acute Myocardial Infarction-Cardiogenic Shock: 15-Year National Temporal Trends, Management, and Outcomes. Crit Care Explor 2022; 4:e0637. [PMID: 35141527 PMCID: PMC8820909 DOI: 10.1097/cce.0000000000000637] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES: DESIGN: SETTING: PARTICIPANTS: INTERVENTIONS: MEASUREMENTS AND MAIN RESULTS: CONCLUSIONS:
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Yan MY, Gustad LT, Nytrø Ø. Sepsis prediction, early detection, and identification using clinical text for machine learning: a systematic review. J Am Med Inform Assoc 2022; 29:559-575. [PMID: 34897469 PMCID: PMC8800516 DOI: 10.1093/jamia/ocab236] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/11/2021] [Accepted: 10/11/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To determine the effects of using unstructured clinical text in machine learning (ML) for prediction, early detection, and identification of sepsis. MATERIALS AND METHODS PubMed, Scopus, ACM DL, dblp, and IEEE Xplore databases were searched. Articles utilizing clinical text for ML or natural language processing (NLP) to detect, identify, recognize, diagnose, or predict the onset, development, progress, or prognosis of systemic inflammatory response syndrome, sepsis, severe sepsis, or septic shock were included. Sepsis definition, dataset, types of data, ML models, NLP techniques, and evaluation metrics were extracted. RESULTS The clinical text used in models include narrative notes written by nurses, physicians, and specialists in varying situations. This is often combined with common structured data such as demographics, vital signs, laboratory data, and medications. Area under the receiver operating characteristic curve (AUC) comparison of ML methods showed that utilizing both text and structured data predicts sepsis earlier and more accurately than structured data alone. No meta-analysis was performed because of incomparable measurements among the 9 included studies. DISCUSSION Studies focused on sepsis identification or early detection before onset; no studies used patient histories beyond the current episode of care to predict sepsis. Sepsis definition affects reporting methods, outcomes, and results. Many methods rely on continuous vital sign measurements in intensive care, making them not easily transferable to general ward units. CONCLUSIONS Approaches were heterogeneous, but studies showed that utilizing both unstructured text and structured data in ML can improve identification and early detection of sepsis.
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Affiliation(s)
- Melissa Y Yan
- Department of Computer Science, Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lise Tuset Gustad
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medicine, Levanger Hospital, Clinic of Medicine and Rehabilitation, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Øystein Nytrø
- Department of Computer Science, Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology, Trondheim, Norway
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Riester MR, Bosco E, Silva JBB, Bardenheier BH, Goyal P, O’Neil ET, van Aalst R, Chit A, Gravenstein S, Zullo AR. Causes and timing of 30-day rehospitalization from skilled nursing facilities after a hospital admission for pneumonia or sepsis. PLoS One 2022; 17:e0260664. [PMID: 35051181 PMCID: PMC8775208 DOI: 10.1371/journal.pone.0260664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis. METHODS AND FINDINGS This national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up. CONCLUSION Among older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions.
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Affiliation(s)
- Melissa R. Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
| | - Joe B. B. Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
| | - Barbara H. Bardenheier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States of America
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Emily T. O’Neil
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
| | - Robertus van Aalst
- Sanofi Pasteur, Swiftwater, PA, United States of America
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ayman Chit
- Sanofi Pasteur, Swiftwater, PA, United States of America
- Leslie Dan School of Pharmacy, University of Toronto, Ontario, Canada
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, United States of America
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, United States of America
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States of America
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States of America
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States of America
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, United States of America
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Obi ON, Alqalyoobi S. Response. Chest 2022; 161:e67-e69. [DOI: 10.1016/j.chest.2021.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 08/25/2021] [Indexed: 10/19/2022] Open
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Rhee C, Yu T, Wang R, Kadri SS, Fram D, Chen HC, Klompas M. Association Between Implementation of the Severe Sepsis and Septic Shock Early Management Bundle Performance Measure and Outcomes in Patients With Suspected Sepsis in US Hospitals. JAMA Netw Open 2021; 4:e2138596. [PMID: 34928358 PMCID: PMC8689388 DOI: 10.1001/jamanetworkopen.2021.38596] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In October 2015, the Centers for Medicare & Medicaid Services began requiring US hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the association of SEP-1 implementation with sepsis treatment patterns and outcomes in diverse hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study with interrupted time-series analysis and logistic regression models was conducted among adults admitted to 114 hospitals from October 2013 to December 2017 with suspected sepsis (blood culture orders, ≥2 systemic inflammatory response syndrome criteria, and acute organ dysfunction) within 24 hours of hospital arrival. Data analysis was conducted from September 2020 to September 2021. EXPOSURES SEP-1 implementation in the fourth quarter (Q4) of 2015. MAIN OUTCOMES AND MEASURES The primary outcome was quarterly rates of risk-adjusted short-term mortality (in-hospital death or discharge to hospice). Secondary outcomes included lactate testing and administration of anti-methicillin-resistant Staphylococcus aureus (MRSA) or antipseudomonal β-lactam antibiotics within 24 hours of hospital arrival. Generalized estimating equations with robust sandwich variances were used to fit logistic regression models to assess for changes in level or trends in these outcomes, adjusting for baseline characteristics and severity of illness. RESULTS The cohort included 117 510 patients (median [IQR] age, 67 years [55-78] years; 60 530 [51.5%] men and 56 980 [48.5%] women) with suspected sepsis. Lactate testing rates increased from 55.1% (95% CI, 53.9%-56.2%) in Q4 of 2013 to 76.7% (95% CI, 75.4%-78.0%) in Q4 of 2017, with a significant level change following SEP-1 implementation (odds ratio [OR], 1.34; 95% CI, 1.04-1.74). There were increases in use of anti-MRSA antibiotics (19.8% [95% CI, 18.9%-20.7%] in Q4 of 2013 to 26.3% [95% CI, 24.9%-27.7%] in Q4 of 2017) and antipseudomonal antibiotics (27.7% [95% CI, 26.7%-28.8%] in Q4 of 2013 to 40.5% [95% CI, 38.9%-42.0%] in Q4 of 2017), but these trends preceded SEP-1 and did not change with SEP-1 implementation. Unadjusted short-term mortality rates were similar in the pre-SEP-1 period (Q4 of 2013 through Q3 of 2015) vs the post-SEP-1 period (Q1 of 2016 through Q4 of 2017) (20.3% [95% CI, 20.0%-20.6%] vs 20.4% [95% CI, 20.1%-20.7%]), and SEP-1 implementation was not associated with changes in level (OR, 0.94; 95% CI, 0.68-1.29) or trend (OR, 1.00; 95% CI, 0.97-1.04) for risk-adjusted short-term mortality rates. CONCLUSIONS AND RELEVANCE In this cohort study, SEP-1 implementation was associated with an immediate increase in lactate testing rates, no change in already-increasing rates of broad-spectrum antibiotic use, and no change in short-term mortality rates for patients with suspected sepsis. Other approaches to decrease sepsis mortality may be warranted.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tingting Yu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | | | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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27
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Tsou PY, Yo CH, Hsein YC, Yungtum G, Hsu WT, Chung JY, Su KY, Chang A, Chang IJ, Lee CC. Temporal Trends in the Microbiological Characteristics of Sepsis in the United States: A Population Based Study. J Intensive Care Med 2021; 37:936-945. [PMID: 34787474 DOI: 10.1177/08850666211053778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiologic studies are needed for monitoring population-level trends in sepsis. This study examines sepsis-causing microorganisms from 2006 to 2014 in the United States using data from the Nationwide Inpatient Sample database. METHODS 7 860 686 adults hospitalized with sepsis were identified using a validated ICD-9 coding approach. Associated microorganisms were identified by ICD-9 code and classified by major groups (Gram-positive, Gram-negative, fungi, anaerobes) and specific species for analysis of their incidence and mortality. RESULTS The rate of sepsis incidence has increased for all four major categories of pathogens, while the mortality rate decreased. In 2014, Gram-negative pathogens had a higher incidence than Gram-positives. Anaerobes increased the fastest with an average annual increase of 20.17% (p < 0.001). Fungi had the highest mortality (19.28%) and the slowest annual decrease of mortality (-2.31%, p = 0.006) in 2013, while anaerobic sepsis had the highest hazard of mortality (adjusted HR 1.60, 95% CI 1.53-1.66). CONCLUSIONS Gram-negative pathogens have replaced Gram-positives as the leading cause of sepsis in the United States in 2014 during the study period (2006-2014). The incidence of anaerobic sepsis has an annual increase of 20%, while the mortality of fungal sepsis has not decreased at the same rate as other microorganisms. These findings should inform the diagnosis and management of septic patients, as well as the implementation of public health programs.
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Affiliation(s)
| | - Chia-Hung Yo
- 46608FarEastern Memorial Hospital, New Taipei City, Taiwan
| | - Yenh-Chen Hsein
- 37999National Taiwan University Yunlin Branch, Douliou, Taiwan
| | - Gregory Yungtum
- 12321Warren Alpert Medical School of Brown University, RI, USA
| | - Wan-Ting Hsu
- 1857Harvard Chan School of Public Health, Boston, MA, USA
| | | | - Ke-Ying Su
- 38006National Taiwan University Hospital, Taipei, Taiwan
| | | | - I-Jing Chang
- 63474Taipei Medical University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- 38006National Taiwan University Hospital, Taipei, Taiwan.,Stanford University, Palo Alto, CA, USA.,38006National Taiwan University Hospital, Taiwan
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Conducting Sepsis Surveillance by Applying Sepsis-3 Criteria to Electronic Health Record Data: Promises and Potential Pitfalls. Crit Care Med 2021; 49:1983-1986. [PMID: 34643579 DOI: 10.1097/ccm.0000000000005223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sehgal M, Ladd HJ, Totapally B. Trends in Epidemiology and Microbiology of Severe Sepsis and Septic Shock in Children. Hosp Pediatr 2021; 10:1021-1030. [PMID: 33208389 DOI: 10.1542/hpeds.2020-0174] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES To explore the microbiologic etiology and trends in incidence and survival of nonneonatal pediatric sepsis in the United States by using the 2006, 2009, and 2012 Kids' Inpatient Database. METHODS Children with sepsis were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for severe sepsis and septic shock (ICD-9-CM cohort) and by the modified Angus method, which incorporates ICD-9-CM codes for infection and organ dysfunction (Angus cohort). Temporal trends in incidence and microbiologic etiology were evaluated. RESULTS Among 8 830 057 discharges, 26 470 patients in the ICD-9-CM cohort were diagnosed with severe sepsis and septic shock (29.97 per 10 000 discharges) and 89 505 patients in the Angus cohort (101.34 per 10 000 discharges). The incidence of sepsis increased in both cohorts from 2006 to 2012 (P < .01). In the Angus cohort, the case-fatality rate was the highest for methicillin-resistant Staphylococcus aureus (14.42%, P < .01) among Gram-positive organisms and for Pseudomonas (21.49%; odds ratio: 2.58 [95% confidence interval: 1.88-3.54]; P < .01) among Gram-negative organisms. CONCLUSIONS The incidence of sepsis has increased, and the sepsis case-fatality rate has decreased, without a decrease in the overall sepsis-associated mortality rate among hospitalized children. Also, bacterial and fungal organisms associated with the pediatric sepsis have changed over these years. These findings are important for focusing the allocation of health care resources and guiding the direction of future studies.
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Affiliation(s)
- Mukul Sehgal
- Division of Pediatric Critical Care Medicine, Nicklaus Children's Hospital, Miami, Florida.,Division of Pediatric Critical Care Medicine, University of South Alabama Children and Women's Hospital, Mobile, Alabama; and
| | - Hugh J Ladd
- Division of Pediatric Critical Care Medicine, Nicklaus Children's Hospital, Miami, Florida
| | - Balagangadhar Totapally
- Division of Pediatric Critical Care Medicine, Nicklaus Children's Hospital, Miami, Florida; .,Department of Pediatrics, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
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Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards. Sci Rep 2021; 11:16222. [PMID: 34376757 PMCID: PMC8355110 DOI: 10.1038/s41598-021-95648-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022] Open
Abstract
The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice. Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.
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Quantifying the Burden of Viral Sepsis During the Coronavirus Disease 2019 Pandemic and Beyond. Crit Care Med 2021; 49:2140-2143. [PMID: 34259668 PMCID: PMC8594516 DOI: 10.1097/ccm.0000000000005207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Nunnally ME, Ferrer R, Martin GS, Martin-Loeches I, Machado FR, De Backer D, Coopersmith CM, Deutschman CS. The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis. Intensive Care Med Exp 2021; 9:34. [PMID: 34212256 PMCID: PMC8249046 DOI: 10.1186/s40635-021-00400-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/07/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To identify priorities for administrative, epidemiologic and diagnostic research in sepsis. Design As a follow-up to a previous consensus statement about sepsis research, members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis. Methods Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified through a consensus process. Results The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?; (2) What is the epidemiology of sepsis susceptibility and response to treatment?; (3) What information identifies organ dysfunction?; (4) How can we screen for sepsis in various settings?; (5) How do we identify septic shock?; and (6) What in-hospital clinical information is associated with important outcomes in patients with sepsis? Conclusions There is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritize initiatives to improve an understanding of individual patient and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care.
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Affiliation(s)
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation (SODIR) Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Grady Memorial Hospital and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | | | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,The Feinstein Institute for Medical Research/ Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
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Descriptors of Sepsis Using the Sepsis-3 Criteria: A Cohort Study in Critical Care Units Within the U.K. National Institute for Health Research Critical Care Health Informatics Collaborative. Crit Care Med 2021; 49:1883-1894. [PMID: 34259454 PMCID: PMC8508729 DOI: 10.1097/ccm.0000000000005169] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. To describe the epidemiology of sepsis in critical care by applying the Sepsis-3 criteria to electronic health records.
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SEP-1 Has Brought Much Needed Attention to Improving Sepsis Care…But Now Is the Time to Improve SEP-1. Crit Care Med 2021; 48:779-782. [PMID: 32433077 DOI: 10.1097/ccm.0000000000004305] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Nanduri SA, Onukwube J, Apostol M, Alden N, Petit S, Farley M, Harrison LH, Como-Sabetti K, Smelser C, Burzlaff K, Cieslak P, Schaffner W, Van Beneden CA. Challenges in Surveillance for Streptococcal Toxic Shock Syndrome: Active Bacterial Core Surveillance, United States, 2014-2017. Public Health Rep 2021; 137:687-694. [PMID: 33960856 DOI: 10.1177/00333549211013460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Routine surveillance for streptococcal toxic shock syndrome (STSS), a severe manifestation of invasive group A Streptococcus (GAS) infections, likely underestimates its true incidence. The objective of our study was to evaluate routine identification of STSS in a national surveillance system for invasive GAS infections. METHODS Active Bacterial Core surveillance (ABCs) conducts active population-based surveillance for invasive GAS disease in selected US counties in 10 states. We categorized invasive GAS cases with a diagnosis of STSS made by a physician as STSS-physician and cases that met the Council of State and Territorial Epidemiologists (CSTE) clinical criteria for STSS based on data in the medical record as STSS-CSTE. We evaluated agreement between the 2 methods for identifying STSS and compared the estimated national incidence of STSS when applying proportions of STSS-CSTE and STSS-physician among invasive GAS cases from this study with national invasive GAS estimates for 2017. RESULTS During 2014-2017, of 7572 invasive GAS cases in ABCs, we identified 1094 (14.4%) as STSS-CSTE and 203 (2.7%) as STSS-physician, a 5.3-fold difference. Of 1094 STSS-CSTE cases, we identified only 132 (12.1%) as STSS-physician cases. Agreement between the 2 methods for identifying STSS was low (κ = 0.17; 95% CI, 0.14-0.19). Using ABCs data, we estimated 591 cases of STSS-physician and 3618 cases of STSS-CSTE occurred nationally in 2017. CONCLUSIONS We found a large difference in estimates of incidence of STSS when applying different surveillance methods and definitions. These results should help with better use of currently available surveillance data to estimate the incidence of STSS and to evaluate disease prevention efforts, in addition to guiding future surveillance efforts for STSS.
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Affiliation(s)
- Srinivas Acharya Nanduri
- 1242 Respiratory Diseases Branch, National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer Onukwube
- 1242 Respiratory Diseases Branch, National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mirasol Apostol
- 43885 California Emerging Infections Program, Oakland, CA, USA
| | - Nisha Alden
- 2915 Colorado Department of Public Health and Environment, Denver, CO, USA
| | - Susan Petit
- 3758 Connecticut Department of Public Health, Hartford, CT, USA
| | - Monica Farley
- 1371 Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Atlanta, GA, USA
| | - Lee H Harrison
- 25802 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Chad Smelser
- 1107 New Mexico Department of Health, Santa Fe, NM, USA
| | - Kari Burzlaff
- 1094 New York State Department of Health, Albany, NY, USA
| | - Paul Cieslak
- 159301 Oregon Health Authority Public Health Division, Portland, OR, USA
| | | | - Chris A Van Beneden
- 1242 Respiratory Diseases Branch, National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
OBJECTIVES Sepsis is a life-threatening condition and is one of the leading causes of death in the United States. The burden of sepsis-related mortality in the United States in recent years is not well characterized. We sought to describe sepsis-related mortality rates and mortality trends in the United States from 2005 to 2018. DESIGN Retrospective population-based study. SETTING We used the Multiple Cause of Death Database available through the Centers for Disease Control and Prevention website. PATIENTS Decedents with sepsis-related deaths were identified using previously validated International Classification of Diseases codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From 2005 to 2018, 6.7% of decedents had a diagnosis of sepsis. The overall sepsis-related mortality rates remained stable in both males (57 deaths per 100,000) and females (45.1 deaths per 100,000) during this period. Compared with Whites, the sepsis-related mortality rates were higher in Blacks (rate ratio = 1.78), Native Americans (rate ratio = 1.43), and Hispanics (rate ratio = 1.04) and were lower in Asians (rate ratio = 0.73). Sepsis-related mortality rates declined in Blacks, Hispanics, and Asians but increased in Whites and Native Americans. The majority of sepsis-related deaths occurred in the hospital. The percentage of deaths in the nursing home decreased, whereas deaths occurring at home and hospice increased. CONCLUSIONS From 2005 to 2018, the overall sepsis-related mortality rates were stable, but there were significant racial and gender disparities in mortality trends. Further research is needed to evaluate the genetic and environmental contributors to these differences.
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Wayne MT, Molling D, Wang XQ, Hogan CK, Seelye S, Liu VX, Prescott HC. Measurement of Sepsis in a National Cohort Using Three Different Methods to Define Baseline Organ Function. Ann Am Thorac Soc 2021; 18:648-655. [PMID: 33476245 PMCID: PMC8008999 DOI: 10.1513/annalsats.202009-1130oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/20/2021] [Indexed: 12/21/2022] Open
Abstract
Rationale: In 2017, the U.S. Centers for Disease Control and Prevention (CDC) developed a new surveillance definition of sepsis, the adult sepsis event (ASE), to better track sepsis epidemiology. The ASE requires evidence of acute organ dysfunction and defines baseline organ function pragmatically as the best in-hospital value. This approach may undercount sepsis if new organ dysfunction does not resolve by discharge.Objectives: To understand how sepsis identification and outcomes differ when using the best laboratory values during hospitalization versus methods that use historical lookbacks to define baseline organ function.Methods: We identified all patients hospitalized at 138 Veterans Affairs hospitals (2013-2018) admitted via the emergency department with two or more systemic inflammatory response criteria, were treated with antibiotics within 48 hours (i.e., had potential infection), and completed 4+ days of antibiotics (i.e., had suspected infection). We considered the following three approaches to defining baseline renal, hematologic, and liver function: the best values during hospitalization (as in the Centers for Disease Control and Prevention's ASE), the best values during hospitalization plus the prior 90 days (3-mo baseline), and the best values during hospitalization plus the prior 180 days (6-mo baseline). We determined how many patients met the criteria for sepsis by each approach, and then compared characteristics and outcomes of sepsis hospitalizations between the three approaches.Results: Among 608,128 hospitalizations with potential infection, 72.1%, 68.5%, and 58.4% had creatinine, platelet, and total bilirubin measured, respectively, in the prior 3 months. A total of 86.0%, 82.6%, and 74.8%, respectively, had these labs in the prior 6 months. Using the hospital baseline, 100,568 hospitalizations met criteria for community-acquired sepsis. By contrast, 111,983 and 117,435 met criteria for sepsis using the 3- and 6-month baselines, for a relative increase of 11% and 17%, respectively. Patient characteristics were similar across the three approaches. In-hospital mortality was 7.2%, 7.0%, and 6.8% for sepsis hospitalizations identified using the hospital, 3-month baseline, and 6-month baseline. The 30-day mortality was 12.5%, 12.7%, and 12.5%, respectively.Conclusions: Among veterans hospitalized with potential infection, the majority had laboratory values in the prior 6 months. Using 3- and 6-month lookbacks to define baseline organ function resulted in an 11% and 17% relative increase, respectively, in the number of sepsis hospitalizations identified.
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Affiliation(s)
- Max T. Wayne
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Daniel Molling
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Xiao Qing Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Cainnear K. Hogan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
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Prevalence and Clinical Characteristics of Patients With Sepsis Discharge Diagnosis Codes and Short Lengths of Stay in U.S. Hospitals. Crit Care Explor 2021; 3:e0373. [PMID: 33786449 PMCID: PMC7994044 DOI: 10.1097/cce.0000000000000373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives: Some patients diagnosed with sepsis have very brief hospitalizations. Understanding the prevalence and clinical characteristics of these patients may provide insight into how sepsis diagnoses are being applied as well as the breadth of illnesses encompassed by current sepsis definitions. Design: Retrospective observational study. Setting: One-hundred ten U.S. hospitals in the Cerner HealthFacts dataset (primary cohort) and four hospitals in Eastern Massachusetts (secondary cohort used for detailed medical record reviews). Patients: Adults hospitalized from April 2016 to December 2017. Interventions: None. Measurements and Main Results: We identified hospitalizations with International Classification of Diseases, 10th Edition codes for sepsis (including sepsis, septicemia, severe sepsis, and septic shock) and compared “short stay sepsis” patients (defined as discharge alive within 3 d) versus nonshort stay sepsis patients using detailed electronic health record data. In the Cerner cohort, 67,733 patients had sepsis discharge diagnosis codes, including 6,918 (10.2%) with short stays. Compared with nonshort stay sepsis patients, short stay patients were younger (median age 60 vs 67 yr) and had fewer comorbidities (median Elixhauser score 5 vs 13), lower rates of positive blood cultures (8.2% vs 24.1%), lower rates of ICU admission (6.2% vs 31.6%), and less frequently had severe sepsis/septic shock codes (13.5% vs 36.6%). Almost all short stay and nonshort stay sepsis patients met systemic inflammatory response syndrome criteria at admission (84.5% and 87.5%, respectively); 47.2% of those with short stays had Sequential Organ Failure Assessment scores of 2 or greater at admission versus 73.2% of those with longer stays. Findings were similar in the secondary four-hospital cohort. Medical record reviews demonstrated that physicians commonly diagnosed sepsis based on the presence of systemic inflammatory response syndrome criteria, elevated lactates, or positive blood cultures without concurrent organ dysfunction. Conclusions: In this large U.S. cohort, one in 10 patients coded for sepsis were discharged alive within 3 days. Although most short stay patients met systemic inflammatory response syndrome criteria, they met Sepsis-3 criteria less than half the time. Our findings underscore the incomplete uptake of Sepsis-3 definitions, the breadth of illness severities encompassed by both traditional and new sepsis definitions, and the possibility that some patients with sepsis recover very rapidly.
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Shappell CN, Klompas M, Rhee C. Surveillance Strategies for Tracking Sepsis Incidence and Outcomes. J Infect Dis 2021; 222:S74-S83. [PMID: 32691830 DOI: 10.1093/infdis/jiaa102] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Sepsis is a leading cause of death and the target of intense efforts to improve recognition, management and outcomes. Accurate sepsis surveillance is essential to properly interpreting the impact of quality improvement initiatives, making meaningful comparisons across hospitals and geographic regions, and guiding future research and resource investments. However, it is challenging to reliably track sepsis incidence and outcomes because sepsis is a heterogeneous clinical syndrome without a pathologic reference standard, allowing for subjectivity and broad discretion in assigning diagnoses. Most epidemiologic studies of sepsis to date have used hospital discharge codes and have suggested dramatic increases in sepsis incidence and decreases in mortality rates over time. However, diagnosis and coding practices vary widely between hospitals and are changing over time, complicating the interpretation of absolute rates and trends. Other surveillance approaches include death records, prospective clinical registries, retrospective medical record reviews, and analyses of the usual care arms of randomized controlled trials. Each of these strategies, however, has substantial limitations. Recently, the US Centers for Disease Control and Prevention released an "Adult Sepsis Event" definition that uses objective clinical indicators of infection and organ dysfunction that can be extracted from most hospitals' electronic health record systems. Emerging data suggest that electronic health record-based clinical surveillance, such as surveillance of Adult Sepsis Event, is accurate, can be applied uniformly across diverse hospitals, and generates more credible estimates of sepsis trends than administrative data. In this review, we discuss the advantages and limitations of different sepsis surveillance strategies and consider future directions.
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Affiliation(s)
- Claire N Shappell
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts
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Nassery N, Horberg MA, Rubenstein KB, Certa JM, Watson E, Somasundaram B, Shamim E, Townsend JL, Galiatsatos P, Pitts SI, Hassoon A, Newman-Toker DE. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. ACTA ACUST UNITED AC 2021; 8:469-478. [PMID: 33650389 DOI: 10.1515/dx-2020-0140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this study was to identify delays in early pre-sepsis diagnosis in emergency departments (ED) using the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach. METHODS SPADE methodology was employed using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (KPMAS). Study cohort included KPMAS members ≥18 years with ≥1 sepsis hospitalization 1/1/2013-12/31/2018. A look-back analysis identified treat-and-release ED visits in the month prior to sepsis hospitalizations. Top 20 diagnoses associated with these ED visits were identified; two diagnosis categories were distinguished as being linked to downstream sepsis hospitalizations. Observed-to-expected (O:E) and temporal analyses were performed to validate the symptom selection; results were contrasted to a comparison group. Demographics of patients that did and did not experience sepsis misdiagnosis were compared. RESULTS There were 3,468 sepsis hospitalizations during the study period and 766 treat-and-release ED visits in the month prior to hospitalization. Patients discharged from the ED with fluid and electrolyte disorders (FED) and altered mental status (AMS) were most likely to have downstream sepsis hospitalizations (O:E ratios of 2.66 and 2.82, respectively). Temporal analyses revealed that these symptoms were overrepresented and temporally clustered close to the hospitalization date. Approximately 2% of sepsis hospitalizations were associated with prior FED or AMS ED visits. CONCLUSIONS Treat-and-release ED encounters for FED and AMS may represent harbingers for downstream sepsis hospitalizations. The SPADE approach can be used to develop performance measures that identify pre-sepsis.
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Affiliation(s)
- Najlla Nassery
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
- Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Kevin B Rubenstein
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Julia M Certa
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Eric Watson
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Brinda Somasundaram
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Ejaz Shamim
- Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
- Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Jennifer L Townsend
- Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samantha I Pitts
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmed Hassoon
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David E Newman-Toker
- Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kim YJ, Kim MJ, Kim YJ, Kim WY. Short and Long-Term Mortality Trends for Cancer Patients with Septic Shock Stratified by Cancer Type from 2009 to 2017: A Population-Based Cohort Study. Cancers (Basel) 2021; 13:cancers13040657. [PMID: 33562125 PMCID: PMC7931033 DOI: 10.3390/cancers13040657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 01/22/2023] Open
Abstract
Simple Summary This study aimed to assess short and long-term mortality trends in cancer patients with septic shock from 2009 to 2017. Among 43,466 adult cancer patients with septic shock (90% solid and 10% hematologic cancer cases) who presented at an emergency department (ED) in Korea between 2009 and 2017, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. The overall 30-day mortality decreased by 4.8% annually from 2013 to 2017, whereas the 1-year mortality only showed a 1.9% annual decrease over this same period. Pancreatic cancer cases showed the most significant improvement in the 30-day mortality since 2014, and lung and stomach cancer showed a sustained decrease in this metric during the whole study period. The outcomes of cancer patients with septic shock have improved in recent years across most cancer types. Physicians should have expectations of improved prognoses in cancer patients admitted to the ED with septic shock. Abstract There have been recent advances in both cancer and sepsis management. This study aimed to assess short and long-term mortality trends in cancer patients with septic shock from 2009 to 2017 by cancer type. This nationwide population-based cohort study using data from the National Health Insurance Service of Korea included adult cancer patients who presented to an emergency department (ED) with septic shock from 2009 to 2017. Among 43,466 adult cancer patients with septic shock (90% solid and 10% hematologic cancer cases), the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. The overall 30-day mortality showed a marked decrease of 4.8% annually from 2013 to 2017, but the annual decrease in the 1-year mortality over the same period was only 1.9%. Pancreatic cancer cases showed the most significant improvement in 30-day mortality between 2014 and 2019 (11.0% decrease/year). Lung and stomach cancers showed a sustained decrease in 30-day mortality during the whole study period (1.7% and 2.0% decrease/year, respectively). The outcomes of cancer patients with septic shock have improved in recent years across most cancer types. Physicians should have expectations of an improved prognosis in cancer patients admitted to the ED with septic shock.
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Affiliation(s)
- Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea;
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul 05505, Korea; (M.-J.K.); (Y.-J.K.)
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul 05505, Korea; (M.-J.K.); (Y.-J.K.)
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea;
- Correspondence: ; Tel.: +82-2-3010-3350
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Rezel-Potts E, Gulliford MC. Sepsis recording in primary care electronic health records, linked hospital episodes and mortality records: Population-based cohort study in England. PLoS One 2020; 15:e0244764. [PMID: 33382845 PMCID: PMC7774940 DOI: 10.1371/journal.pone.0244764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background Sepsis is a growing concern for health systems, but the epidemiology of sepsis is poorly characterised. We evaluated sepsis recording across primary care electronic records, hospital episodes and mortality registrations. Methods and findings Cohort study including 378 general practices in England from Clinical Practice Research Datalink (CPRD) GOLD database from 2002–2017 with 36,209,676 patient-years of follow-up with linked Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality registrations. Incident sepsis episodes were identified for each source. Concurrent records from different sources were identified and age-standardised and age-specific incidence rates compared. Logistic regression analysis evaluated associations of gender, age-group, fifth of deprivation and period of diagnosis with concurrent sepsis recording. There were 20,206 first episodes of sepsis from primary care, 20,278 from HES and 13,972 from ONS. There were 4,117 (20%) first HES sepsis events and 2,438 (17%) mortality records concurrent with incident primary care sepsis records within 30 days. Concurrent HES and primary care records of sepsis within 30 days before or after first diagnosis were higher at younger or older ages and for patients with the most recent period of diagnosis. Those diagnosed during 2007:2011 were less likely to have a concurrent HES record given CPRD compared to those diagnosed during 2012–2017 (odd ratio 0.65, 95% confidence interval 0.60–0.70). At age 85 and older, primary care incidence was 5.22 per 1,000 patient years (95% CI 1.75–11.97) in men and 3.55 (0.87–9.58) in women which increased to 10.09 (4.86–18.51) for men and 7.22 (2.96–14.72) for women after inclusion of all three sources. Conclusion Explicit recording of ‘sepsis’ is inconsistent across healthcare sectors with a high proportion of non-concurrent records. Incidence estimates are higher when linked data are analysed.
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Affiliation(s)
- Emma Rezel-Potts
- School of Population Health and Environmental Sciences, Guy's Campus, King's College London, London, United Kingdom.,National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' Hospitals London, Great Maze Pond, London, United Kingdom
| | - Martin C Gulliford
- School of Population Health and Environmental Sciences, Guy's Campus, King's College London, London, United Kingdom.,National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' Hospitals London, Great Maze Pond, London, United Kingdom
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Griffith MF, Levy CR, Parikh TJ, Stevens-Lapsley JE, Eber LB, Palat SIT, Gozalo PL, Teno JM. Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia. J Am Med Dir Assoc 2020; 21:1879-1884. [PMID: 33263287 PMCID: PMC7577734 DOI: 10.1016/j.jamda.2020.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 11/18/2022]
Abstract
Objectives Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia. Design Retrospective cohort study. Setting and Participants Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia. Methods Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS. Results In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome. Conclusions and Implications Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.
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Affiliation(s)
- Matthew F Griffith
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA.
| | - Cari R Levy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Toral J Parikh
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jennifer E Stevens-Lapsley
- Geriatric Research Education and Clinical Center (GRECC), VA Eastern Colorado Health Care System, Aurora, CO, USA
| | | | - Sing-I T Palat
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI, USA
| | - Joan M Teno
- Division of General Internal Medicine, Oregon Health and Science University, Portland, OR, USA
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Trends of Pediatric Bloodstream Infections in Stockholm, Sweden: A 20-year Retrospective Study. Pediatr Infect Dis J 2020; 39:1069-1074. [PMID: 32773664 DOI: 10.1097/inf.0000000000002850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The etiology of bloodstream infections (BSIs) changes over time due to updated immunization programs, new antibiotic-use strategies, changes in patient mix and travel. Continuous surveillance can guide empiric therapy and identify targets for prevention. METHOD We conducted a descriptive retrospective analysis among children <18 years of age who were detected with BSI between July 1998 and June 2018 for changes in the incidence, risk factors, and etiology of BSI in a Swedish tertiary hospital (Karolinska University Hospital). RESULTS We evaluated 2079 episodes of BSI. During the study period, the incidence of BSI in children 0-17 years of age decreased (τ = -0.45, P = 0.016), which was most evident among children 3 months to 2 years of age (τ = -0.59, P = 0.0006) and in early neonatal period (0-7 days; τ = -0.44, P = 0.0069). These were explained by the reduced occurrence of Streptococcus pneumoniae in children 3 months to 2 years of age and Streptococcus agalactiae and Candida spp. in neonates. Staphylococcus aureus was the commonest pathogen, accounting for 31.6% of episodes. The proportion of hospital-acquired infection was higher in patients with underlying risk factors (47.6% vs. 2.6%). The etiology of hospital-acquired infection BSI was more diverse than that of community-acquired infections and was related to underlying risk factors. The crude mortality rate was 5.7%. For children admitted to the neonatal ward, the mortality was 17.6%, but declined (τ = -0.469, P = 0.004) over the study period. CONCLUSIONS There was a decreasing trend of pediatric BSI and mortality over last 20 years, which was associated with pneumococcal immunization and antimicrobial prophylaxis for high-risk patients.
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Sepsis and septic shock in France: incidences, outcomes and costs of care. Ann Intensive Care 2020; 10:145. [PMID: 33079281 PMCID: PMC7575668 DOI: 10.1186/s13613-020-00760-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/08/2020] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is one of the leading causes of death worldwide. The associated incidence, mortality and trends do not differ greatly between documented reports. The purpose of this study was to provide an in-depth description of patients with sepsis and septic shock hospitalized in France from 2010 to 2015 and to explore the temporal trends of their clinical characteristics, costs and outcomes. Methods Retrospective cohort study of the French hospital administrative database in which organ failure therapies and severity scores are systematically registered. All patients admitted between 2010 and 2015 for sepsis and septic shock as defined by an ICD-10 code for infection, and for organ failure or the use of organ failure supplementation were included. Incidence, outcomes and trends were analyzed. Subgroup analyses based on several coding strategies and adjusted for severity scores were performed. Results A total of 737,147 patients with sepsis and 492,902 patients with septic shock were included. From 2010 to 2015, the incidence of sepsis and septic shock increased, respectively, from 206 to 243 and from 135 to 171 cases per 100,000 population. Case fatality remained at 34% for sepsis, but decreased from 46 to 44% for septic shock. Median hospital stay costs amounted to €11,400 (IQR: 5036; 24,364) for patients with sepsis and €16,439 (IQR: 7339; 29,360) for patients with septic shock. After adjustment for case-mix and illness severity, the risk of death was stable for sepsis (0.08% [− 0.04; 0.20] per year), but decreased for sepsis patients admitted to the intensive care unit and for cases of septic shock (− 0.33%[ − 0.40; − 0.27] per year). Conclusions Sepsis is common, frequently fatal and expensive to treat. Its incidence has increased. Case fatality has decreased in most severely affected patients, owing partly to general improvements in care.
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Shan B, Li JY, Liu YJ, Tang XB, Zhou Z, Luo LX. LncRNA H19 Inhibits the Progression of Sepsis-Induced Myocardial Injury via Regulation of the miR-93-5p/SORBS2 Axis. Inflammation 2020; 44:344-357. [PMID: 32996061 DOI: 10.1007/s10753-020-01340-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022]
Abstract
Sepsis is an infectious disease that seriously endangers human health. It usually leads to myocardial injury which seriously endangers to the health of human beings. H19 has been confirmed to play key roles in various diseases, including sepsis. However, its function in the progression of sepsis-induced myocardial injury remains largely unknown. H9C2 cells were treated with lipopolysaccharide (LPS) to mimic sepsis-induced myocardial injury in vitro. Cell proliferation and apoptosis were detected by MTT assay and flow cytometry, respectively. In addition, gene and protein expression levels in H9C2 cells were measured by quantitative real-time PCR (qRT-PCR) and Western blotting. The levels of inflammatory cytokines in H9C2 cell supernatants were tested by ELISA. JC-1 staining was performed to observe the mitochondrial membrane potential level in H9C2 cells. H19 and SORBS2 were downregulated in H9C2 cells following LPS treatment, while miR-93-5p was upregulated. Moreover, LPS-induced cell growth inhibition and mitochondrial damage were significantly reversed by overexpression of H19. In addition, H19 upregulation notably suppressed LPS-induced inflammatory responses in H9C2 cells. Moreover, H19 sponged miR-93-5p to promote SORBS2 expression. Overall, H19 suppressed sepsis-induced myocardial injury via regulation of the miR-93-5p/SORBS2 axis. H19 attenuated the development of sepsis-induced myocardial injury in vitro via modulation of the miR-93-5p/SORBS2 axis. Thus, H19 could serve as a potential target for the treatment of sepsis-induced myocardial injury.
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Affiliation(s)
- Bin Shan
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, No. 8, Qinnian Avenue Road, Chenzhou, 423000, Hunan Province, People's Republic of China
| | - Jia-Yan Li
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, No. 8, Qinnian Avenue Road, Chenzhou, 423000, Hunan Province, People's Republic of China
| | - Ya-Jiang Liu
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, No. 8, Qinnian Avenue Road, Chenzhou, 423000, Hunan Province, People's Republic of China
| | - Xiao-Bin Tang
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, No. 8, Qinnian Avenue Road, Chenzhou, 423000, Hunan Province, People's Republic of China
| | - Zheng Zhou
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, No. 8, Qinnian Avenue Road, Chenzhou, 423000, Hunan Province, People's Republic of China
| | - Liang-Xian Luo
- Department of Critical Care Medicine, The First People's Hospital of Chenzhou, No. 8, Qinnian Avenue Road, Chenzhou, 423000, Hunan Province, People's Republic of China.
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Early recognition of surgical patients with sepsis: Contribution of nursing records. Appl Nurs Res 2020; 57:151352. [PMID: 32896443 DOI: 10.1016/j.apnr.2020.151352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/05/2020] [Accepted: 08/23/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to analyze the contribution of nursing records to the early identification and management of sepsis in surgical patients at a university hospital. METHOD This is a study with a quantitative, retrospective, descriptive, and correlational design. Data collection was performed through hospital information systems in the first semester of 2017 with the approval of the research ethics committee. We included 28 patients who met the inclusion criteria of the study. RESULTS The analysis of the content of the records evidenced the development of the first signs of systemic inflammatory response syndrome (SIRS) and organ dysfunction until the fifth day of hospitalization in 19 patients (67.8%). Confirmation or hypothesis of sepsis diagnosis occurred until the 10th day of hospitalization in 15 patients (53.5%). The analysis of the content of the records showed that the first signs of SIRS were predominantly identified in the electronic patient monitoring system in 26 cases (92.9%), whereas the first signs of organ dysfunction were described in the nursing staff records in 24 patients (85.7%). CONCLUSION The results confirm the importance of the quality of nursing records for risk identification, early recognition, and proper management of sepsis in surgical patients, aiming at achieving greater effectiveness in the management of healthcare processes.
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Epidemiology, Clinical and Microbiologic Profile and Risk Factors for Inpatient Mortality in Pediatric Severe Sepsis in the United States From 2003 to 2014: A Large Population Analysis. Pediatr Infect Dis J 2020; 39:781-788. [PMID: 32221163 DOI: 10.1097/inf.0000000000002669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the national trends in pediatric severe sepsis in the United States from 2003 to 2014. STUDY DESIGN For this study, we included nonoverlapping years of Kids Inpatient database and National Inpatient Sample database while including hospitalizations of children between 1 and 20 years of age from more than 4200 hospitals across the United States. We identified patient hospitalizations with severe sepsis using specific ICD codes and modified Angus Criteria. Trend analysis of various factors associated with severe sepsis was calculated using the Cochrane-Armitage test. Associated foci of infection and comorbid conditions were identified using specific ICD codes, and a multivariate regression analysis with death as outcome variable was done to evaluate for in hospital predictors of mortality. RESULTS Totally, 109,026 episodes of severe sepsis were identified during the study period between 2003 and 2014. Incidence of severe sepsis hospitalizations increased by 2.5 times (0.64-1.57 per 10,000 population) over the study period with notable concurrent significant decrease in mortality by more than 50%. Lower age, African American, Hispanic ethnicity, complex neurologic conditions, infective endocarditis, immunodeficient states including primary immunodeficiency disorder, HIV, burns, malignancy and transplant status are associated with mortality. There is a significant increase in use of healthcare resources (P < 0.001) with mean charges of 94,966$ despite a notable decrease in mean length of stay (22 vs. 16 days, P < 0.001) over the study period. CONCLUSION Incidence of pediatric severe sepsis is high leading to a significant use of healthcare resources. This study provides a detailed analysis of associated inpatient factors and comorbidities associated with mortality.
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