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Kumar NR, Balraj TA, Kempegowda SN, Prashant A. Multidrug-Resistant Sepsis: A Critical Healthcare Challenge. Antibiotics (Basel) 2024; 13:46. [PMID: 38247605 PMCID: PMC10812490 DOI: 10.3390/antibiotics13010046] [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: 12/02/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Sepsis globally accounts for an alarming annual toll of 48.9 million cases, resulting in 11 million deaths, and inflicts an economic burden of approximately USD 38 billion on the United States healthcare system. The rise of multidrug-resistant organisms (MDROs) has elevated the urgency surrounding the management of multidrug-resistant (MDR) sepsis, evolving into a critical global health concern. This review aims to provide a comprehensive overview of the current epidemiology of (MDR) sepsis and its associated healthcare challenges, particularly in critically ill hospitalized patients. Highlighted findings demonstrated the complex nature of (MDR) sepsis pathophysiology and the resulting immune responses, which significantly hinder sepsis treatment. Studies also revealed that aging, antibiotic overuse or abuse, inadequate empiric antibiotic therapy, and underlying comorbidities contribute significantly to recurrent sepsis, thereby leading to septic shock, multi-organ failure, and ultimately immune paralysis, which all contribute to high mortality rates among sepsis patients. Moreover, studies confirmed a correlation between elevated readmission rates and an increased risk of cognitive and organ dysfunction among sepsis patients, amplifying hospital-associated costs. To mitigate the impact of sepsis burden, researchers have directed their efforts towards innovative diagnostic methods like point-of-care testing (POCT) devices for rapid, accurate, and particularly bedside detection of sepsis; however, these methods are currently limited to detecting only a few resistance biomarkers, thus warranting further exploration. Numerous interventions have also been introduced to treat MDR sepsis, including combination therapy with antibiotics from two different classes and precision therapy, which involves personalized treatment strategies tailored to individual needs. Finally, addressing MDR-associated healthcare challenges at regional levels based on local pathogen resistance patterns emerges as a critical strategy for effective sepsis treatment and minimizing adverse effects.
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Affiliation(s)
- Nishitha R. Kumar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
| | - Tejashree A. Balraj
- Department of Microbiology, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India;
| | - Swetha N. Kempegowda
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
| | - Akila Prashant
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
- Department of Medical Genetics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India
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2
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Amritphale A, Fonarow GC, Amritphale N, Omar B, Crook ED. All-cause unplanned readmissions in the United States: insights from the Nationwide Readmission Database. Intern Med J 2023; 53:262-270. [PMID: 34633136 DOI: 10.1111/imj.15581] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are few studies looking into adult, all-cause and age-group-specific unplanned readmissions. The predictors of such unplanned readmissions for all inpatient encounters remain obscure. AIMS To describe the incidence and factors associated with unplanned readmissions in all inpatient encounters in the United States. METHODS The US Nationwide Readmission Database (NRD) is a representative sample of hospitalisations in the United States (from approximately 28 states) accounting for approximately 60% of the US population. All inpatient encounters during January-November 2017 in the NRD were evaluated for the rates, predictors and costs of unplanned 30 days readmissions for age groups 18-44 years, 45-64 years, 65-75 years and ≥75 years. Elective readmissions and those patients who died on their index hospitalisations were excluded. Weighted analysis was performed to obtain nationally representative data. RESULTS We identified 28 942 224 inpatient encounters with a total of 3 051 189 (10.5%) unplanned readmissions within 30 days. The age groups 18-44 years, 45-64 years, 65-74 years and ≥75 years had 7.0%, 12.0%, 11.7% and 12.3% readmissions respectively. Female gender, private insurance and elective admissions were negative predictors for readmissions. For the group aged 18-44 years, schizophrenia and diabetes mellitus complications were the most frequent primary diagnosis for readmissions, while in all older age groups septicaemia and heart failure were the most frequent primary diagnosis for readmissions. CONCLUSIONS Thirty-day unplanned readmissions are common in patients over age 45 years, leading to significant morbidity. Effective strategies for reducing unplanned readmission may help to improve quality of care, outcomes and higher value care.
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Affiliation(s)
- Amod Amritphale
- Department of Internal Medicine, University Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA
| | - Nupur Amritphale
- Children and Women's Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Bassam Omar
- Department of Internal Medicine, University Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Errol D Crook
- Department of Internal Medicine, University Hospital, University of South Alabama, Mobile, Alabama, USA
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3
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Pandolfi F, Brun-Buisson C, Guillemot D, Watier L. One-year hospital readmission for recurrent sepsis: associated risk factors and impact on 1-year mortality-a French nationwide study. Crit Care 2022; 26:371. [PMID: 36447252 PMCID: PMC9710072 DOI: 10.1186/s13054-022-04212-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/15/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Sepsis is a complex health condition, leading to long-term morbidity and mortality. Understanding the risk factors for recurrent sepsis, as well as its impact on mid- and long-term mortality among other risk factors, is essential to improve patient survival. METHODS A risk factor analysis, based on French nationwide medico-administrative data, was conducted on a cohort of patients above 15 years old, hospitalized with an incident sepsis in metropolitan France between 1st January 2018 and 31st December 2018 and who survived their index hospitalization. Two main analyses, focusing on outcomes occurring 1-year post-discharge, were conducted: a first one to assess risk factors for recurrent sepsis and a second to assess risk factors for mortality. RESULTS Of the 178017 patients surviving an incident sepsis episode in 2018 and included in this study, 22.3% died during the 1-year period from discharge and 73.8% had at least one hospital readmission in acute care, among which 18.1% were associated with recurrent sepsis. Patients aged between 56 and 75, patients with cancer and renal disease, with a long index hospital stay or with mediastinal or cardiac infection had the highest odds of recurrent sepsis. One-year mortality was higher for patients with hospital readmission for recurrent sepsis (aOR 2.93; 99% CI 2.78-3.09). Among all comorbidities, patients with cancer (aOR 4.35; 99% CI 4.19-4.52) and dementia (aOR 2.02; 99% CI 1.90-2.15) had the highest odds of 1-year mortality. CONCLUSION Hospital readmission for recurrent sepsis is one of the most important risk factors for 1-year mortality of septic patients, along with age and comorbidities. Our study suggests that recurrent sepsis, as well as modifiable or non-modifiable other risk factors identified, should be considered in order to improve patient care pathway and survival.
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Affiliation(s)
- Fanny Pandolfi
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France
| | - Christian Brun-Buisson
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France
| | - Didier Guillemot
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France ,grid.50550.350000 0001 2175 4109AP-HP, Paris Saclay, Public Health, Medical Information, Clinical Research, Le Kremlin-Bicêtre, France
| | - Laurence Watier
- grid.508487.60000 0004 7885 7602Epidemiology and Modeling of Bacterial Evasion to Antibacterials Unit (EMEA), Institut Pasteur, Université Paris Cité, Paris, France ,grid.12832.3a0000 0001 2323 0229Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Versailles Saint Quentin-en-Yvelines/Université Paris Saclay, Paris, France
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4
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Lin Z, Ni J, Xu J, Wu Q, Cao Y, Qin Y, Wu C, Wei X, Wu H, Han H, He J. Worse Outcomes After Readmission to a Different Hospital After Sepsis: A Nationwide Cohort Study. J Emerg Med 2022; 63:569-581. [DOI: 10.1016/j.jemermed.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 06/22/2022] [Accepted: 07/09/2022] [Indexed: 12/05/2022]
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5
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Crabtree PA, Bach H, Del Fierro E, Hunter K, Quevada K, Schorr C. Evaluation of Adult Patients Readmitted for Severe Sepsis/Septic Shock Under the BPCI Advanced Program. Am J Med Qual 2022; 37:449-455. [PMID: 35776567 DOI: 10.1097/jmq.0000000000000072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bundled Payments for Care Improvement-Advanced Program (BPCI-A) is designed to pay a single payment covering services provided during an episode of care. Sepsis is associated with increased readmissions, mortality, and health care costs. The purpose of the study was to evaluate the BPCI program patients with sepsis who were readmitted within 90 days versus not readmitted. This was a retrospective cohort study including 271 (110 readmitted) patients enrolled in the BPCI program with Diagnostic-Related Grouping codes of septicemia or severe sepsis. Skin/soft tissue infection was the most common infection. There was a significant difference between the groups for resource needs at discharge including wound care (25.45% versus 11.18%; P = 0.002) and physical therapy (74.55% versus 57.14%; P = 0.004). Mortality was higher among readmissions, 43.64% versus 26.71% no readmission ( P = 0.004). Identifying risk factors for readmission, providing appropriate resources, and follow-up may contribute to improved patient outcomes for patients with sepsis enrolled in the BPCI program.
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Affiliation(s)
| | - Harry Bach
- Cooper Medical School of Rowan University, Camden, NJ
| | | | - Krystal Hunter
- Cooper University Healthcare, Camden, NJ
- Cooper Medical School of Rowan University, Camden, NJ
| | | | - Christa Schorr
- Cooper University Healthcare, Camden, NJ
- Cooper Medical School of Rowan University, Camden, NJ
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6
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Hilton RS, Hauschildt K, Shah M, Kowalkowski M, Taylor S. The Assessment of Social Determinants of Health in Postsepsis Mortality and Readmission: A Scoping Review. Crit Care Explor 2022; 4:e0722. [PMID: 35928537 PMCID: PMC9345631 DOI: 10.1097/cce.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To summarize knowledge and identify gaps in evidence about the relationship between social determinants of health (SDH) and postsepsis outcomes. DATA SOURCES We conducted a comprehensive search of PubMed/Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, and the Cochrane Library. STUDY SELECTION We identified articles that evaluated SDH as risk factors for mortality or readmission after sepsis hospitalization. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION We dual-extracted study characteristics with specific focus on measurement, reporting, and interpretation of SDH variables. DATA SYNTHESIS Of 2,077 articles screened, 103 articles assessed risk factors for postsepsis mortality or readmission. Of these, 28 (27%) included at least one SDH variable. Inclusion of SDH in studies assessing postsepsis adverse outcomes increased over time. The most common SDH evaluated was race/ethnicity (n = 21, 75%), followed by payer type (n = 10, 36%), and income/wealth (n = 9, 32%). Of the studies including race/ethnicity, nine (32%) evaluated no other SDH. Only one study including race/ethnicity discussed the use of this variable as a surrogate for social disadvantage, and none specifically discussed structural racism. None of the studies specifically addressed methods to validate the accuracy of SDH or handling of missing data. Eight (29%) studies included a general statement that missing data were infrequent. Several studies reported independent associations between SDH and outcomes after sepsis discharge; however, these findings were mixed across studies. CONCLUSIONS Our review suggests that SDH data are underutilized and of uncertain quality in studies evaluating postsepsis adverse events. Transparent and explicit ontogenesis and data models for SDH data are urgently needed to support research and clinical applications with specific attention to advancing our understanding of the role racism and racial health inequities in postsepsis outcomes.
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Affiliation(s)
- Ryan S Hilton
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Katrina Hauschildt
- Center for Clinical Management and Research, VA Ann Arbor Health Care System, Ann Arbor, MI
| | - Milan Shah
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
| | - Stephanie Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine Atrium Health Enterprise, Charlotte, NC
- Critical Illness, Injury, and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, NC
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7
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McPeake J, Bateson M, Christie F, Robinson C, Cannon P, Mikkelsen M, Iwashyna TJ, Leyland AH, Shaw M, Quasim T. Hospital re-admission after critical care survival: a systematic review and meta-analysis. Anaesthesia 2022; 77:475-485. [PMID: 34967011 DOI: 10.1111/anae.15644] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 12/22/2022]
Abstract
Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.
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Affiliation(s)
- J McPeake
- Intensive Care Unit, Glasgow Royal Infirmary and School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | - M Bateson
- University of the West of Scotland, Glasgow, UK
| | - F Christie
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - C Robinson
- Belfast Health and Social Care Trust, Belfast, UK
| | - P Cannon
- University of Glasgow Library, Glasgow, UK
| | - M Mikkelsen
- Center for Clinical Epidemiology and Biostatistics, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - T J Iwashyna
- Centre for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - A H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - M Shaw
- Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - T Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.,Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
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8
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 869] [Impact Index Per Article: 289.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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9
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Minejima E, Wong-Beringer A. Impact of Socioeconomic Status and Race on Sepsis Epidemiology and Outcomes. J Appl Lab Med 2021; 6:194-209. [PMID: 33241269 DOI: 10.1093/jalm/jfaa151] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Socioeconomic status (SES) is a complex variable that is derived primarily from an individual's education, income, and occupation and has been found to be inversely related to outcomes of health conditions. Sepsis is the sixth most common admitting diagnosis and one of the most costly conditions for in-hospital spending in the United States. The objective of this review is to report on the relationship between SES and sepsis incidence and associated outcomes. CONTENT Sepsis epidemiology varies when explored by race, education, geographic location, income, and insurance status. Sepsis incidence was significantly increased in individuals of Black race compared with non-Hispanic white race; in persons who have less formal education, who lack insurance, and who have low income; and in certain US regions. People with low SES are likely to have onset of sepsis significantly earlier in life and to have poorly controlled comorbidities compared with those with higher SES. Sepsis mortality and hospital readmission is increased in individuals who lack insurance, who reside in low-income or medically underserved areas, who live far from healthcare, and who lack higher level education; however, a person's race was not consistently found to increase mortality. SUMMARY Interventions to minimize healthcare disparity for individuals with low SES should target sepsis prevention with increasing measures for preventive care for chronic conditions. Significant barriers described for access to care by people with low SES include cost, transportation, poor health literacy, and lack of a social network. Future studies should include polysocial risk scores that are consistently defined to allow for meaningful comparison across studies.
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Affiliation(s)
- Emi Minejima
- Department of Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA.,Department of Pharmacy, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA
| | - Annie Wong-Beringer
- Department of Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA.,Department of Pharmacy, Huntington Hospital, Pasadena, CA, USA
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10
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1412] [Impact Index Per Article: 470.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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11
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Pharmacokinetics, Pharmacodynamics, and Safety of Nivolumab in Patients With Sepsis-Induced Immunosuppression: A Multicenter, Open-Label Phase 1/2 Study. Shock 2021; 53:686-694. [PMID: 31513050 PMCID: PMC7448837 DOI: 10.1097/shk.0000000000001443] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Sepsis often induces an immunosuppressive state, which is associated with high mortality rates. Immunostimulation may be beneficial for sepsis. We investigated the pharmacokinetics, pharmacodynamics, and safety of nivolumab, a human programmed death-1 immune checkpoint inhibitor approved for the treatment of several cancers. Methods: In this multicenter, open-label phase 1/2 study, a single 480 or 960 mg nivolumab dose was intravenously infused into Japanese patients with immunosuppressive sepsis. Doses were selected to mimic the exposure achieved with the approved dosage for cancer patients (3 mg/kg every 2 weeks [Q2W]). Results: Single 480 and 960 mg nivolumab doses were intravenously infused into five and eight patients, respectively. The maximum concentration after 480 mg (132 μg/mL) was similar to the predicted concentration at the end of infusion with 3 mg/kg Q2W (117 μg/mL). The concentration on Day 28 after 960 mg (33.1 μg/mL) was within the predicted trough concentration range for 3 mg/kg Q2W (90% prediction interval 19.0–163 μg/mL). Absolute lymphocyte counts and monocyte human leukocyte antigen-DR subtype expression levels appeared to increase over time. The incidences of adverse events (AEs) were 80% and 50% in the 480 mg and 960 mg groups, respectively. Drug-related AEs were observed in only one patient in the 480 mg group. No deaths related to nivolumab occurred. Conclusions: A single dose of 960 mg nivolumab appeared to be well tolerated and sufficient to maintain nivolumab blood concentrations. Both 480 mg and 960 mg nivolumab seemed to improve immune system indices over time. Trial registration: JAPIC, JapicCTI-173600.
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12
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Affiliation(s)
- Edward J Septimus
- Department of Population Medicine, Harvard Medical School, Boston Massachusetts, USA, and Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
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13
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14
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Rivera DR, Enewold L, Barrett MJ, Banegas MP, Filipski KK, Freedman AN, Lam CK, Mariotto A. Population-based utilization and costs associated with tyrosine kinase inhibitors for first-line treatment of chronic myelogenous leukemia among elderly patients. J Manag Care Spec Pharm 2020; 26:1494-1504. [PMID: 33251998 PMCID: PMC10391029 DOI: 10.18553/jmcp.2020.26.12.1494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Following approval of imatinib, a breakthrough tyrosine kinase inhibitor (TKI), survival significantly improved by more than 20% since 2001 among treated chronic myelogenous leukemia (CML) patients. Subsequently, more expensive second-generation TKIs with varying selectivity profiles have been approved. Population-based studies are needed to evaluate the real-world utilization of TKI therapies, particularly given their escalating costs and recommendations for maintenance therapy. OBJECTIVE: To assess the utilization patterns of first-line TKIs, overall and by specific agent, among elderly CML patients in the United States, and the cost implications. METHODS: CML patients aged 65 years and older at diagnosis between 2007 and 2015 were identified from population-based cancer registries in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The percentage of CML patients receiving imatinib, dasatinib, or nilotinib within the first year of diagnosis was calculated along with time to first-line treatment initiation. Bivariate comparisons and Cox proportional hazards models were used to identify factors associated with TKI initiation. Average monthly patient responsibility, including patient out-of-pocket (OOP) costs, stratified by Part D low-income subsidy (LIS) status were also calculated. RESULTS: Among the 1,589 CML patients included, receipt of any TKI within 1 year of diagnosis increased from 66.2% to 78.9%. In 2015, the distribution of first-line TKI therapies was 41.3% imatinib, 28.3% dasatinib, and 9.3% nilotinib. Almost 60% of patients initiated TKI treatment within 3 months of diagnosis. Multivariable analysis indicated that TKI use in the first year was lower among the very elderly (aged > 75 years vs. 65-69 years: HR = 0.72; 95% CI = 0.63-0.83), patients with more comorbidities (Hierarchical Condition Category risk score > 2 vs. HR = 0.74, 95% CI = 0.62-0.88), and patients ineligible for LIS (HR = 0.75; 95% CI = 0.65-0.87). Average monthly patient OOP cost was significantly lower for LIS-eligible versus LIS-ineligible patients: imatinib (2016: $12 vs. $487), dasatinib (2016: $34 vs. $557), and nilotinib (2016: $1 vs. $526). CONCLUSIONS: TKI use has increased significantly since 2007. While imatinib remained the most frequently prescribed first-line agent, by 2015 newer TKIs represented one third of the market share. Utilization patterns indicated persistent age, comorbidity, and financial barriers. TKI use is indicated for long-term therapy, and increased adoption of newer, more expensive agents raises concerns about the sustained affordability of CML treatment, particularly among unsubsidized patients. DISCLOSURES: No outside funding supported this study. There are no reported conflicts of interest.
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Affiliation(s)
- Donna R Rivera
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Rockville, MD
| | - Lindsey Enewold
- National Cancer Institute, Division of Cancer Control and Population Sciences, Health Care Delivery Research Program, Rockville, MD
| | | | | | - Kelly K Filipski
- National Cancer Institute, Division of Cancer Control and Population Sciences, Epidemiology and Genomics Research Program, Rockville, MD
| | - Andrew N Freedman
- National Cancer Institute, Division of Cancer Control and Population Sciences, Epidemiology and Genomics Research Program, Rockville, MD
| | - Clara K Lam
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Rockville, MD
| | - Angela Mariotto
- National Cancer Institute, Division of Cancer Control and Population Sciences, Surveillance Research Program, Rockville, MD
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15
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Pertsch NJ, Tang OY, Seicean A, Toms SA, Weil RJ. Sepsis after elective neurosurgery: Incidence, outcomes, and predictive factors. J Clin Neurosci 2020; 78:53-59. [PMID: 32624367 DOI: 10.1016/j.jocn.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/18/2020] [Indexed: 11/25/2022]
Abstract
Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality.
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Affiliation(s)
- Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States.
| | - Oliver Y Tang
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Andreea Seicean
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
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16
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Shankar-Hari M, Saha R, Wilson J, Prescott HC, Harrison D, Rowan K, Rubenfeld GD, Adhikari NKJ. Rate and risk factors for rehospitalisation in sepsis survivors: systematic review and meta-analysis. Intensive Care Med 2020; 46:619-636. [PMID: 31974919 PMCID: PMC7222906 DOI: 10.1007/s00134-019-05908-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/19/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Sepsis survivors have a higher risk of rehospitalisation and of long-term mortality. We assessed the rate, diagnosis, and independent predictors for rehospitalisation in adult sepsis survivors. METHODS We searched for non-randomized studies and randomized clinical trials in MEDLINE, Cochrane Library, Web of Science, and EMBASE (OVID interface, 1992-October 2019). The search strategy used controlled vocabulary terms and text words for sepsis and hospital readmission, limited to humans, and English language. Two authors independently selected studies and extracted data using predefined criteria and data extraction forms. RESULTS The literature search identified 12,544 records. Among 56 studies (36 full and 20 conference abstracts) that met our inclusion criteria, all were non-randomised studies. Studies most often report 30-day rehospitalisation rate (mean 21.4%, 95% confidence interval [CI] 17.6-25.4%; N = 36 studies reporting 6,729,617 patients). The mean (95%CI) rehospitalisation rates increased from 9.3% (8.3-10.3%) by 7 days to 39.0% (22.0-59.4%) by 365 days. Infection was the most common rehospitalisation diagnosis. Risk factors that increased the rehospitalisation risk in sepsis survivors were generic characteristics such as older age, male, comorbidities, non-elective admissions, hospitalisation prior to index sepsis admission, and sepsis characteristics such as infection and illness severity, with hospital characteristics showing inconsistent associations. The overall certainty of evidence was moderate for rehospitalisation rates and low for risk factors. CONCLUSIONS Rehospitalisation events are common in sepsis survivors, with one in five rehospitalisation events occurring within 30 days of hospital discharge following an index sepsis admission. The generic and sepsis-specific characteristics at index sepsis admission are commonly reported risk factors for rehospitalisation. REGISTRATION PROSPERO CRD 42016039257, registered on 14-06-2016.
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Affiliation(s)
- Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, 1st Floor, East Wing, St Thomas' Hospital, SE1 7EH, UK.
- School of Immunology and Microbial Sciences, Kings College London, London, SE1 9RT, UK.
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK.
| | - Rohit Saha
- School of Immunology and Microbial Sciences, Kings College London, London, SE1 9RT, UK
| | - Julie Wilson
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, 1st Floor, East Wing, St Thomas' Hospital, SE1 7EH, UK
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Ann Arbor, MI, 48109-2800, USA
- VA Center for Clinical Management Research, University of Michigan Health System, Ann Arbor, MI, USA
| | - David Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, M4N 3M5, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, D1.08, Toronto, ON, M4N 3M5, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, M4N 3M5, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, D1.08, Toronto, ON, M4N 3M5, Canada
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17
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Frequency and Cause of Readmissions in Sepsis Patients Presenting to a Tertiary Care Hospital in a Low Middle Income Country. Crit Care Explor 2020; 2:e0080. [PMID: 32211612 PMCID: PMC7069593 DOI: 10.1097/cce.0000000000000080] [Citation(s) in RCA: 4] [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
Hospital readmissions are known to be common after sepsis but unfortunately, in a developing country like Pakistan, very little is known of the frequency or cause of these readmissions in sepsis patients and even less about how they can be prevented. To our knowledge, this is the first-ever long-term follow-up study in a developing country in which frequency and cause of readmissions are being evaluated in sepsis patients.
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Courtright KR, Jordan L, Murtaugh CM, Barrón Y, Deb P, Moore S, Bowles KH, Mikkelsen ME. Risk Factors for Long-term Mortality and Patterns of End-of-Life Care Among Medicare Sepsis Survivors Discharged to Home Health Care. JAMA Netw Open 2020; 3:e200038. [PMID: 32101307 PMCID: PMC7137683 DOI: 10.1001/jamanetworkopen.2020.0038] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. OBJECTIVE To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. EXPOSURES Sepsis hospital discharge and 1 or more home health assessments within 1 week. MAIN OUTCOMES AND MEASURES Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. RESULTS Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.
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Affiliation(s)
- Katherine R. Courtright
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lizeyka Jordan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | | | - Yolanda Barrón
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | - Partha Deb
- Department of Economics, Hunter College, The City University of New York (CUNY), New York
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Stanley Moore
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | - Kathryn H. Bowles
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia
| | - Mark E. Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Abstract
OBJECTIVES Severe sepsis is a significant cause of healthcare use and morbidity among pediatric patients, but little is known about readmission diagnoses. We sought to determine the most common readmission diagnoses after pediatric severe sepsis, the extent to which post-sepsis readmissions may be potentially preventable, and whether patterns of readmission diagnoses differ compared with readmissions after other common acute medical hospitalizations. DESIGN Observational cohort study. SETTING National Readmission Database (2013-2014), including all-payer hospitalizations from 22 states. PATIENTS Four-thousand five-hundred twenty-eight pediatric severe sepsis hospitalizations, matched by age, gender, comorbidities, and length of stay to 4,528 pediatric hospitalizations for other common acute medical conditions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared rates of 30-day all cause, diagnosis-specific, and potentially preventable hospital readmissions using McNemar's chi-square tests for paired data. Among 5,841 eligible pediatric severe sepsis hospitalizations with live discharge, 4,528 (77.5%) were matched 1:1 to 4,528 pediatric hospitalizations for other acute medical conditions. Of 4,528 matched sepsis hospitalizations, 851 (18.8% [95% CI, 16.0-18.2]) were rehospitalized within 30 days, compared with 775 (17.1% [95% CI, 17.1-20.0]) of matched hospitalizations for other causes (p = 0.02). The most common readmission diagnoses were chemotherapy, device complications, and sepsis, all of which were several-fold higher after sepsis versus after matched nonsepsis hospitalization. Only 11.5% of readmissions were for ambulatory care sensitive conditions compared with 23% of rehospitalizations after common acute medical conditions. CONCLUSIONS More than one in six children surviving severe sepsis were rehospitalized within 30 days, most commonly for maintenance chemotherapy, medical device complications, or recurrent sepsis. Only a small proportion of readmissions were for ambulatory care sensitive conditions.
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20
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Gadre SK, Shah M, Mireles-Cabodevila E, Patel B, Duggal A. Epidemiology and Predictors of 30-Day Readmission in Patients With Sepsis. Chest 2019; 155:483-490. [PMID: 30846065 DOI: 10.1016/j.chest.2018.12.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with sepsis are particularly vulnerable to readmissions. We describe the associated etiology and risk factors for readmission in patients with sepsis using a large administrative database inclusive of patients of all ages and insurance status. METHODS Our study cohort was derived from the Healthcare Cost and Utilization Project's National Readmission Data from 2013 to 2014 by identifying patients admitted with sepsis. The primary outcome was 30-day readmission with etiology identified by using International Classification of Diseases, Ninth Revision, Clinical Modification, codes. RESULTS From a total 1,030,335 index admissions; mean age, 66.8 ± 17.4 years (60% age ≥65 years), 898,257 patients (87.2%) survived to discharge. A total of 157,235 (17.5%) patients had a 30-day readmission; median time to readmission was 11 days (interquartile range, 5-19). Infectious etiology (42.16%; including sepsis, 22.86%) was the most commonly associated cause for 30-day readmission followed by gastrointestinal (9.6%), cardiovascular (8.73%), pulmonary (7.82%), and renal causes (4.99%). Significant predictors associated with increased 30-day readmission included diabetes (OR, 1.07; 95% CI, 1.06-1.08; P < .001), chronic kidney disease (1.12;1.10-1.14, P < .001), congestive heart failure (OR, 1.16; 95% CI, 1.14-1.18; P < .001), discharge to short-/long-term facility (OR, 1.13; 95% CI, 1.11-1.14; P < .001), Charlson comorbidity index ≥ 2, and length of stay ≥ 3 days during the index admission. The mean cost per readmission was $16,852; annual cost was > $3.5 billion within the United States. CONCLUSION We describe that readmission after a sepsis hospitalization is common and costly. The majority of readmissions were associated with infectious etiologies. The striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this outcome.
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Affiliation(s)
- Shruti K Gadre
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
| | - Mahek Shah
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - Eduardo Mireles-Cabodevila
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Brijesh Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - Abhijit Duggal
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial. Trials 2019; 20:660. [PMID: 31783900 PMCID: PMC6884908 DOI: 10.1186/s13063-019-3792-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/05/2019] [Indexed: 12/29/2022] Open
Abstract
Background Hospital mortality for patients with sepsis has recently declined, but sepsis survivors still suffer from significant long-term mortality and morbidity. There are limited data that support effective strategies to address post-discharge management of patients hospitalized with sepsis. Methods The Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS) study is a pragmatic, randomized controlled trial at three hospitals within a single healthcare delivery system comparing clinical outcomes between sepsis survivors who receive usual care versus care delivered through the Sepsis Transition and Recovery (STAR) program. The STAR program includes a centrally located nurse navigator using telephone counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies for patients during hospitalization and the 30 days after hospital discharge, including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted through the Emergency Department with suspected infection (i.e., antibiotics initiated, bacterial cultures drawn) and deemed, by previously developed risk-stratification models, high risk for readmission or death are included. Eligible patients are randomly allocated 1:1 to either Arm 1, usual care or Arm 2, STAR. Planned enrollment is 708 patients during a 6-month period. The primary outcome is the composite of all-cause hospital readmissions and mortality assessed 30 days post discharge. Secondary outcomes include 30- and 90-day hospital readmissions, mortality, emergency department visits, acute care-free days alive, and acute care and total costs. Discussion This pragmatic evaluation provides the most comprehensive assessment to date of a strategy to improve delivery of recommended post-sepsis care. Trial registration ClinicalTrials.gov, NCT03865602. Registered retrospectively on 6 March 2019.
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22
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Davis FM, Schaller MA, denDekker A, Joshi AD, Kimball AS, Evanoff H, Wilke C, Obi AT, Melvin WJ, Cavassani K, Scola M, Carson B, Moser S, Blanc V, Engoren M, Moore BB, Kunkel SL, Gallagher KA. Sepsis Induces Prolonged Epigenetic Modifications in Bone Marrow and Peripheral Macrophages Impairing Inflammation and Wound Healing. Arterioscler Thromb Vasc Biol 2019; 39:2353-2366. [PMID: 31644352 PMCID: PMC6818743 DOI: 10.1161/atvbaha.119.312754] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Sepsis represents an acute life-threatening disorder resulting from a dysregulated host response. For patients who survive sepsis, there remains long-term consequences, including impaired inflammation, as a result of profound immunosuppression. The mechanisms involved in this long-lasting deficient immune response are poorly defined. Approach and Results: Sepsis was induced using the murine model of cecal ligation and puncture. Following a full recovery period from sepsis physiology, mice were subjected to our wound healing model and wound macrophages (CD11b+, CD3-, CD19-, Ly6G-) were sorted. Post-sepsis mice demonstrated impaired wound healing and decreased reepithelization in comparison to controls. Further, post-sepsis bone marrow-derived macrophages and wound macrophages exhibited decreased expression of inflammatory cytokines vital for wound repair (IL [interleukin]-1β, IL-12, and IL-23). To evaluate if decreased inflammatory gene expression was secondary to epigenetic modification, we conducted chromatin immunoprecipitation on post-sepsis bone marrow-derived macrophages and wound macrophages. This demonstrated decreased expression of Mll1, an epigenetic enzyme, and impaired histone 3 lysine 4 trimethylation (activation mark) at NFκB (nuclear factor kappa-light-chain-enhancer of activated B cells)-binding sites on inflammatory gene promoters in bone marrow-derived macrophages and wound macrophages from postcecal ligation and puncture mice. Bone marrow transplantation studies demonstrated epigenetic modifications initiate in bone marrow progenitor/stem cells following sepsis resulting in lasting impairment in peripheral macrophage function. Importantly, human peripheral blood leukocytes from post-septic patients demonstrate a significant reduction in MLL1 compared with nonseptic controls. CONCLUSIONS These data demonstrate that severe sepsis induces stable mixed-lineage leukemia 1-mediated epigenetic modifications in the bone marrow, which are passed to peripheral macrophages resulting in impaired macrophage function and deficient wound healing persisting long after sepsis recovery.
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Affiliation(s)
- Frank M. Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Matthew A. Schaller
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, FL
| | - Aaron denDekker
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Amrita D. Joshi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andrew S. Kimball
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Holly Evanoff
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Carol Wilke
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Andrea T. Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - William J Melvin
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Karen Cavassani
- Urological Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Melissa Scola
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Beau Carson
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Stephanie Moser
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Victoria Blanc
- Biorepository Office of Research, University of Michigan, Ann Arbor, MI
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Bethany B. Moore
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department Microbiology and Immunology, University of Michigan, Ann Arbor, MI
| | | | - Katherine A. Gallagher
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
- Department Microbiology and Immunology, University of Michigan, Ann Arbor, MI
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23
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Temporal Trends in Incidence, Sepsis-Related Mortality, and Hospital-Based Acute Care After Sepsis. Crit Care Med 2019; 46:354-360. [PMID: 29474320 DOI: 10.1097/ccm.0000000000002872] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES A growing number of patients survive sepsis hospitalizations each year and are at high risk for readmission. However, little is known about temporal trends in hospital-based acute care (emergency department treat-and-release visits and hospital readmission) after sepsis. Our primary objective was to measure temporal trends in sepsis survivorship and hospital-based acute care use in sepsis survivors. In addition, because readmissions after pneumonia are subject to penalty under the national readmission reduction program, we examined whether readmission rates declined after sepsis hospitalizations related to pneumonia. DESIGN AND SETTING Retrospective, observational cohort study conducted within an academic healthcare system from 2010 to 2015. PATIENTS We used three validated, claims-based approaches to identify 17,256 sepsis or severe sepsis hospitalizations to examine trends in hospital-based acute care after sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From 2010 to 2015, sepsis as a proportion of medical and surgical admissions increased from 3.9% to 9.4%, whereas in-hospital mortality rate for sepsis hospitalizations declined from 24.1% to 14.8%. As a result, the proportion of medical and surgical discharges at-risk for hospital readmission after sepsis increased from 2.7% to 7.8%. Over 6 years, 30-day hospital readmission rates declined modestly, from 26.4% in 2010 to 23.1% in 2015, driven largely by a decline in readmission rates among survivors of nonsevere sepsis, and nonpneumonia sepsis specifically, as the readmission rate of severe sepsis survivors was stable. The modest decline in 30-day readmission rates was offset by an increase in emergency department treat-and-release visits, from 2.8% in 2010 to a peak of 5.4% in 2014. CONCLUSIONS Owing to increasing incidence and declining mortality, the number of sepsis survivors at risk for hospital readmission rose significantly between 2010 and 2015. The 30-day hospital readmission rates for sepsis declined modestly but were offset by a rise in emergency department treat-and-release visits.
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Deb P, Murtaugh CM, Bowles KH, Mikkelsen ME, Khajavi HN, Moore S, Barrón Y, Feldman PH. Does Early Follow-Up Improve the Outcomes of Sepsis Survivors Discharged to Home Health Care? Med Care 2019; 57:633-640. [PMID: 31295191 DOI: 10.1097/mlr.0000000000001152] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is little evidence to guide the care of over a million sepsis survivors following hospital discharge despite high rates of hospital readmission. OBJECTIVE We examined whether early home health nursing (first visit within 2 days of hospital discharge and at least 1 additional visit in the first posthospital week) and early physician follow-up (an outpatient visit in the first posthospital week) reduce 30-day readmissions among Medicare sepsis survivors. DESIGN A pragmatic, comparative effectiveness analysis of Medicare data from 2013 to 2014 using nonlinear instrumental variable analysis. SUBJECTS Medicare beneficiaries in the 50 states and District of Columbia discharged alive after a sepsis hospitalization and received home health care. MEASURES The outcomes, protocol parameters, and control variables were from Medicare administrative and claim files and the home health Outcome and Assessment Information Set (OASIS). The primary outcome was 30-day all-cause hospital readmission. RESULTS Our sample consisted of 170,571 mostly non-Hispanic white (82.3%), female (57.5%), older adults (mean age, 76 y) with severe sepsis (86.9%) and a multitude of comorbid conditions and functional limitations. Among them, 44.7% received only the nursing protocol, 11.0% only the medical doctor protocol, 28.1% both protocols, and 16.2% neither. Although neither protocol by itself had a statistically significant effect on readmission, both together reduced the probability of 30-day all-cause readmission by 7 percentage points (P=0.006; 95% confidence interval=2, 12). CONCLUSIONS Our findings suggest that, together, early postdischarge care by home health and medical providers can reduce hospital readmissions for sepsis survivors.
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Affiliation(s)
- Partha Deb
- Hunter College, City University of New York (CUNY) and National Bureau of Economic Research (NBER)
| | - Christopher M Murtaugh
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | - Kathryn H Bowles
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
- University of Pennsylvania School of Nursing
| | - Mark E Mikkelsen
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Hoda Nouri Khajavi
- Hunter College and the Graduate Center, City University of New York (CUNY), New York, NY
| | | | - Yolanda Barrón
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
| | - Penny H Feldman
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY
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Singh A, Bhagat M, George SV, Gorthi R, Chaturvedula C. Factors Associated with 30-day Unplanned Readmissions of Sepsis Patients: A Retrospective Analysis of Patients Admitted with Sepsis at a Community Hospital. Cureus 2019; 11:e5118. [PMID: 31523549 PMCID: PMC6741358 DOI: 10.7759/cureus.5118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Introduction Mortality from sepsis is decreasing in recent years owing to improved quality of care, targeted programs, and the implementation of sepsis bundles. This has led to an increased pool of sepsis survivors at risk of readmissions. Studies have shown that these sepsis readmissions are common and expensive. The factors associated with these readmissions remain elusive and have incited a lot of research in recent years. The 30-day sepsis readmission rate is increasingly being used as a quality metric for hospitals. A conducted a retrospective chart review analysis of patients admitted with sepsis to find factors affecting the 30-day readmissions of sepsis survivors. Methods Patients admitted to our hospital either on the medical-surgical floor or in the intensive care unit (ICU) with an administrative coding for sepsis between January 2014 to November 2015 were identified. A literature search, as well as expert opinion, was considered for the list of factors to be studied, including age, sex, residence on admission, length of stay, getting hemodialysis, hospitalization in the prior year, presence of acute kidney injury (AKI), source of sepsis, discharge disposition, receipt of red blood cell (RBC) products, and route of antibiotics on discharge. A univariate binary logistic regression analysis was performed to test the association between the above-mentioned variables and sepsis readmission. Variables with statistical significance in the univariate analysis were used to compute the multivariate regression analysis along, with adjusted OR and their 95% CI. Results A total of 1297 patients were identified with sepsis. Of these, 1068 patients met inclusion criteria. The readmission rate in our study population was 19.19%, and 52% of the readmissions were secondary to an infectious cause. After controlling for the effect of all the potential confounders, the factors that showed a positive association with readmissions were hospitalizations in the year prior to the index hospitalization and discharge to either nursing home or short-term rehab. The requirement of the intensive care unit was not associated with increased readmission. High hemoglobin on discharge was associated with a reduced chance of readmission. Conclusions Readmissions after sepsis hospitalization are common and mostly caused by infections. Several factors associated with index sepsis hospitalization can be associated with readmissions. Some of these factors are modifiable and more research is needed to see if these readmissions can be prevented.
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Affiliation(s)
- Aditi Singh
- Internal Medicine, St. Vincent Hospital, Worcester, USA
| | - Milind Bhagat
- Internal Medicine, Rhode Island Hospital, Providence, USA
| | | | - Ramya Gorthi
- Internal Medicine, St. Vincent Hospital, Worcester, USA
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Victims or Culprits, B Cells May Serve as Markers for Mortality Risk and Targeted Therapy in Sepsis. Crit Care Med 2019; 45:1951-1952. [PMID: 29028700 DOI: 10.1097/ccm.0000000000002670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Triangulating Weakness, Morbidity, and Mortality Among Acute Respiratory Distress Syndrome Survivors: A Story Emerges. Crit Care Med 2019; 45:370-371. [PMID: 28098638 DOI: 10.1097/ccm.0000000000002118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Takata T, Katoka Y. Preventability of Early Versus Late Hospital Readmissions. Ann Intern Med 2019; 170:218-219. [PMID: 30716746 DOI: 10.7326/l18-0606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Tetsuo Takata
- Hyogo Prefectural Amagasaki General Medical Center, Kobe City, Japan (T.T.)
| | - Yuki Katoka
- Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan (Y.K.)
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Kim JS, Kim YJ, Ryoo SM, Sohn CH, Ahn S, Seo DW, Lim KS, Kim WY. Risk Factors for Same Pathogen Sepsis Readmission Following Hospitalization for Septic Shock. J Clin Med 2019; 8:jcm8020181. [PMID: 30717469 PMCID: PMC6406311 DOI: 10.3390/jcm8020181] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 01/30/2019] [Accepted: 02/01/2019] [Indexed: 12/12/2022] Open
Abstract
(1) Background: Septic shock survivors frequently readmit because of subsequent infection. This study aimed to determine the rate and risk factors for same pathogen sepsis readmissions following hospitalization for septic shock. (2) Methods: We performed this retrospective study using data from a prospective septic shock registry at a single urban tertiary center. All the patients were treated with a protocol-driven resuscitation bundle therapy between 2011 and 2016. We collected data from adult (older than 18 years) patients readmitted with sepsis within 90 days of discharge following hospitalization for septic shock. (3) Results: Among 2062 septic shock patients, 690 were readmitted within 90 days of discharge. After excluding scheduled and non-sepsis admissions, we analyzed the data from 274 (13.3%) patients readmitted for sepsis. Most of the readmissions following septic shock were new infections rather than relapses of the initial infection. The culture-negative rate was 51.4% (141/274), while the same pathogen was isolated in 25% of cases (69/274). Multivariate analysis revealed that previous gram-negative bacteremia (OR, 9.902; 95% CI, 2.843⁻34.489), urinary tract infection (OR, 4.331; 95% CI, 1.723⁻10.882) and same site infection (OR, 6.894; 95% CI, 2.390⁻19.886) were significantly associated with readmission for sepsis caused by the same pathogen. (4) Conclusions: The sepsis readmission rate following the previous hospitalization for septic shock was 13.3% and one-quarter of those patients had the same pathogen isolated. Previous gram-negative bacteremia, and/or same site infection are predisposing factors for recurrent same-pathogen sepsis.
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Affiliation(s)
- June-Sung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Dong Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
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Lane-Fall MB, Kuza CM, Fakhry S, Kaplan LJ. The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder. Anesthesiol Clin 2018; 37:135-150. [PMID: 30711227 DOI: 10.1016/j.anclin.2018.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.
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Affiliation(s)
- Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA.
| | - Catherine M Kuza
- Department of Anesthesiology and Critical Care, Keck School of Medicine of the University of Southern California, Los Angeles County Health System, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, USA
| | - Samir Fakhry
- Department of Surgery, Synergy Surgicalists, Inc, Reston Hospital Center, 1850 Town Center Parkway Suite 309, Reston, VA 20190, USA
| | - Lewis J Kaplan
- Surgical Services, Department of Surgery, Division of Trauma, Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, Veteran's Administration Medical Center, Corporal Michael J Crescenz VA Medical Center, Perelman School of Medicine, University of Pennsylvania, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
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Genga KR, Lo C, Cirstea MS, Leitao Filho FS, Walley KR, Russell JA, Linder A, Francis GA, Boyd JH. Impact of PCSK9 loss-of-function genotype on 1-year mortality and recurrent infection in sepsis survivors. EBioMedicine 2018; 38:257-264. [PMID: 30473376 PMCID: PMC6306489 DOI: 10.1016/j.ebiom.2018.11.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 12/22/2022] Open
Abstract
Background Reduced activity of proprotein convertase subtilisin/kexin type 9 (PCSK9) has been associated with decreased short-term death in patients with septic shock. Whether PCSK9 genotype influences long-term outcomes in sepsis survivors is unknown. Methods We evaluated the impact of PCSK9 loss-of-function (LOF) genotype on both 1-year mortality and infection-related readmission (IRR) after an index sepsis admission. The Derivation cohort included 342 patients who survived 28 days after a sepsis admission in a tertiary hospital (Vancouver/Canada, 2004–2014), while an independent Validation cohort included 1079 septic shock patients admitted at the same hospital (2000–2006). All patients were genotyped for three common missense PCSK9 LOF variants rs11591147, rs11583680, rs562556 and were classified in 3 groups: Wildtype, single PCSK9 LOF, and multiple PCSK9 LOF, according to the number of LOF alleles per patient. We also performed a meta-analysis using both cohorts to investigate the effects of PCSK9 genotype on 90-day survival. Findings In the Derivation cohort, patients carrying multiple PCSK9 LOF alleles showed lower risk for the composite outcome 1-year death or IRR (HR: 0.40, P = 0.006), accelerated reduction on neutrophil counts (P = 0.010), and decreased levels of PCSK9 (P = 0.037) compared with WT/single LOF groups. Our meta-analysis revealed that the presence of multiple LOF alleles was associated with lower 90-day mortality risk (OR = 0.69, P = 0.020). Interpretation The presence of multiple PCSK9 LOF alleles decreased the risk of 1-year death or IRR in sepsis survivors. Biological measures suggest this may be related to an enhanced resolution of the initial infection. Funding Canadian Institutes of Health Research (PJT-156056).
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Affiliation(s)
- Kelly Roveran Genga
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Cody Lo
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Mihai S Cirstea
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Fernando Sergio Leitao Filho
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Keith R Walley
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - James A Russell
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Adam Linder
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Gordon A Francis
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - John H Boyd
- Corresponding author at: Centre for Heart Lung Innovation, St. Paul's Hospital, Room 166 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
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Sazhin VP, Karsanov AM, Kulchiev AA, Remizov OV, Maskin SS, A YV. [Reality and prospects of sepsis epidemiology research]. Khirurgiia (Mosk) 2018:85-89. [PMID: 30113601 DOI: 10.17116/hirurgia2018885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Current foreign and Russian literature for sepsis epidemiology is reviewed. There is advanced incidence of sepsis in developing countries among young people as a rule. Absent high-quality epidemiological studies lead to overdiagnosis of sepsis and increased morbidity. National and territorial screening and diagnostic programs for sepsis became possible with introduction of new recommendations 'Sepsis-3'. Thus, there is a possibility to systematize regular epidemiological studies devoted to sepsis.
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Affiliation(s)
| | - A M Karsanov
- North Ossetian State Medical Academy, Vladikavkaz
| | - A A Kulchiev
- North Ossetian State Medical Academy, Vladikavkaz
| | - O V Remizov
- North Ossetian State Medical Academy, Vladikavkaz
| | | | - Y V A
- Pavlov Ryazan State Medical University
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Kuriyama A, Katsura M, Urushidani S, Takada T. Impact of polymyxin B hemoperfusion in the treatment of patients with sepsis and septic shock: a meta-analysis of randomized controlled trials. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:206. [PMID: 30023369 DOI: 10.21037/atm.2018.05.41] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Polymyxin B hemoperfusion is a strategy to remove circulating endotoxin in patients with sepsis. Previous systematic reviews derived from randomized and non-randomized studies suggested that use of polymyxin B hemoperfusion reduced mortality, based on the pooled data from various time points in the clinical course of sepsis. We conducted a meta-analysis of randomized controlled trials to assess the impact of polymyxin B hemoperfusion specifically on 28-day mortality in patients with sepsis and septic shock. Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for eligible trials from inception through July 30, 2017. All randomized controlled trials were eligible if they examined the impact of polymyxin B hemoperfusion on 28-day mortality in patients with sepsis and septic shock. Risk of bias was evaluated with the Cochrane risk of bias assessment tool. Data were pooled using the DerSimonian and Laird random-effects model. Results Seven trials involving 586 participants were identified for the analysis. Use of polymyxin B hemoperfusion was not associated with a reduced risk of 28-day mortality [risk ratio (RR), 0.76; 95% CI, 0.54-1.07] compared with usual care. One unpublished trial also showed no significant 28-day survival benefit. Conclusions There is no evidence to support the use of polymyxin B hemoperfusion for patients with sepsis and septic shock with respect to 28-day mortality.
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Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Morihiro Katsura
- Department of Surgery, Okinawa Prefectural Miyako Hospital, Okinawa, Japan
| | - Seigo Urushidani
- Emergency and Critical Care Center, Kurashiki Central Hospital, Okayama, Japan
| | - Tadaaki Takada
- Department of Emergency Medicine, Tokushima Red Cross Hospital, Tokushima, Japan
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Readmissions With Multidrug-Resistant Infection in Patients With Prior Multidrug Resistant Infection. Infect Control Hosp Epidemiol 2017; 39:12-19. [PMID: 29248023 DOI: 10.1017/ice.2017.254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine incidence of and risk factors for readmissions with multidrug-resistant organism (MDRO) infections among patients with previous MDRO infection. DESIGN Retrospective cohort of patients admitted between January 1, 2006, and October 1, 2015. SETTING Barnes-Jewish Hospital, a 1,250-bed academic tertiary referral center in St Louis, Missouri. METHODS We identified patients with MDROs obtained from the bloodstream, bronchoalveolar lavage (BAL)/bronchial wash, or other sterile sites. Centers for Disease Control and prevention (CDC) and European CDC definitions of MDROs were utilized. All readmissions ≤1 year from discharge from the index MDRO hospitalization were evaluated for bloodstream, BAL/bronchial wash, or other sterile site cultures positive for the same or different MDROs. RESULTS In total, 4,429 unique patients had a positive culture for an MDRO; 3,453 of these (78.0%) survived the index hospitalization. Moreover, 2,127 patients (61.6%) were readmitted ≥1 time within a year, for a total of 5,849 readmissions. Furthermore, 512 patients (24.1%) had the same or a different MDRO isolated from blood, BAL/bronchial wash, or another sterile site during a readmission. Bone marrow transplant, end-stage renal disease, lymphoma, methicillin-resistant Staphylococcus aureus, or carbapenem-resistant Pseudomonas aeruginosa during index hospitalization were factors associated with increased risk of having an MDRO isolated during a readmission. MDROs isolated during readmissions were in the same class of MDRO as the index hospitalization 9%-78% of the time, with variation by index pathogen. CONCLUSIONS Readmissions among patients with MDRO infections are frequent. Various patient and organism factors predispose to readmission. When readmitted patients had an MDRO, it was often a pathogen in the same class as that isolated during the index admission, with the exception of Acinetobacter (~9%). Infect Control Hosp Epidemiol 2018;39:12-19.
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Venet F, Monneret G. Advances in the understanding and treatment of sepsis-induced immunosuppression. Nat Rev Nephrol 2017; 14:121-137. [PMID: 29225343 DOI: 10.1038/nrneph.2017.165] [Citation(s) in RCA: 464] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sepsis is defined as a life-threatening organ dysfunction that is caused by a dysregulated host response to infection. Sepsis can induce acute kidney injury and multiple organ failures and represents the most common cause of death in the intensive care unit. Sepsis initiates a complex immune response that varies over time, with the concomitant occurrence of both pro-inflammatory and anti-inflammatory mechanisms. As a result, most patients with sepsis rapidly display signs of profound immunosuppression, which is associated with deleterious consequences. Scientific advances have highlighted the role of metabolic failure, epigenetic reprogramming, myeloid-derived suppressor cells, immature suppressive neutrophils and immune alterations in primary lymphoid organs (the thymus and bone marrow) in sepsis. An improved understanding of the mechanisms underlying this immunosuppression as well as of the similarities between sepsis-induced immunosuppression and immune defects in cancer or immunosenescence has led to novel therapeutic strategies aimed at stimulating immune function in patients with sepsis. Trials assessing the therapeutic benefit of IL-7, granulocyte-macrophage colony-stimulating factor (GM-CSF) and antibodies against programmed cell death protein 1 (PD1) and programmed cell death 1 ligand 1 (PDL1) for the treatment of sepsis are in progress. The reappraisal of sepsis pathophysiology has also resulted in a novel approach to the design of clinical trials evaluating sepsis treatments, based on an evaluation of the immune status and biomarker-based stratification of patients.
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Affiliation(s)
- Fabienne Venet
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Immunology Department, Flow Division, 69003 Lyon, France.,Equipe d'Accueil 7426, Pathophysiology of Injury-Induced Immunosuppression, Université Claude Bernard Lyon 1, Hospices Civils de Lyon - bioMérieux, Hôpital Edouard Herriot, 69003 Lyon, France
| | - Guillaume Monneret
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Immunology Department, Flow Division, 69003 Lyon, France.,Equipe d'Accueil 7426, Pathophysiology of Injury-Induced Immunosuppression, Université Claude Bernard Lyon 1, Hospices Civils de Lyon - bioMérieux, Hôpital Edouard Herriot, 69003 Lyon, France
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Abstract
OBJECTIVES Sepsis hospitalizations are frequently followed by hospital readmissions, often for recurrent sepsis. However, it is unclear how often sepsis readmissions are for relapsed/recrudescent versus new infections. The aim of this study was to assess the extent to which 90-day readmissions for recurrent sepsis are due to infection of the same site and same pathogen as the initial episode. DESIGN Retrospective cohort study. SETTING University of Michigan Health System. PATIENTS All hospitalizations (May 15, 2013 to May 14, 2015) with a principal International Classification of Diseases, Ninth revision, Clinical Modification diagnosis of septicemia (038.x), severe sepsis (995.92), or septic shock (785.52), as well as all subsequent hospitalizations and sepsis readmissions within 90 days. We determined organism and site of sepsis through manual chart abstraction. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 472 readmissions within 90 days of sepsis, of which 137 (29.1%) were for sepsis. In sepsis readmissions, the site and organisms were most commonly urinary (29.2%), gastrointestinal (20.4%), Gram negative (29.9%), Gram positive (16.8%), and culture negative (30.7%). Ninety-four readmissions (68.6%) were for infection at the same site as initial sepsis hospitalization. Nineteen percent of readmissions were confirmed to be same site and same organism. However, accounting for the uncertainty from culture-negative sepsis, as many as 53.2% of readmissions could plausibly due to infections with both the same organism and same site. CONCLUSIONS Of the patients readmitted with sepsis within 90 days, two thirds had infection at the same site as their initial admission. Just 19% had infection confirmed to be from the same site and organism as the initial sepsis hospitalization. Half of readmissions were definitively for new infections, whereas an additional 34% were unclear since cultures were negative in one of the hospitalizations.
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Weinreich MA, Styrvoky K, Chang S, Girod CE, Ruggiero R. Sepsis at a Safety Net Hospital: Risk Factors Associated With 30-Day Readmission. J Intensive Care Med 2017; 34:1017-1022. [PMID: 28820039 DOI: 10.1177/0885066617726753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sepsis is a leading cause of hospitalization, and subsequent readmissions are frequent and costly. There is an expanding body of literature describing risk factors for readmissions in patients with sepsis. However, there are little data studying medically underserved patients who typically receive their care at a safety net hospital. METHODS In a retrospective cohort study, we evaluated 1355 sepsis survivors at risk of hospital readmission in fiscal year 2013 at a safety net hospital. We described patient characteristics during their initial and readmission hospitalizations and analyzed risk factors associated with 30-day readmission. RESULTS The 30-day readmission rate among sepsis survivors was 22.6%. Comorbid conditions associated with readmissions included end-stage renal disease (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.17-1.36), malignancy (OR, 1.14; 95% CI, 1.08-1.21), and cirrhosis (OR, 1.11; 95% CI, 1.02-1.20). Bacteremia during the initial hospitalization (OR, 1.07; 95% CI, 1.01-1.15) and being discharged with a vascular catheter (OR, 1.10; 95% CI, 1.01-1.20) were associated with readmission. Less severe sepsis during the initial hospitalization was associated with a reduced risk of 30-day readmission (OR, 0.91; 95% CI, 0.87-0.94). CONCLUSIONS At a safety net hospital, patients who survived their initial sepsis hospitalization had a 30-day readmission rate to our institution of 22.6% that is comparable to rates described in prior studies. Readmission was commonly due to infection. Factors associated with readmission included multiple comorbid medical conditions, bacteremia, and being discharged with a vascular catheter. Further studies in this population are needed to determine potential modifiability of these risk factors in an attempt to reduce sepsis readmissions.
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Affiliation(s)
- Mark A Weinreich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kim Styrvoky
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shelley Chang
- Parkland Center for Clinical Innovation, Dallas, TX, USA
| | - Carlos E Girod
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Rosechelle Ruggiero
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Sepsis-Associated 30-Day Risk-Standardized Readmissions: Analysis of a Nationwide Medicare Sample. Crit Care Med 2017; 45:1130-1137. [PMID: 28471814 DOI: 10.1097/ccm.0000000000002476] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine national readmission rates among sepsis survivors, variations in rates between hospitals, and determine whether measures of quality correlate with performance on sepsis readmissions. DESIGN Cross-sectional study of sepsis readmissions between 2008 and 2011 in the Medicare fee-for-service database. SETTING Acute care, Medicare participating hospitals from 2008 to 2011. PATIENTS Septic patients as identified by International Classification of Diseases, Ninth Revision codes using the Angus method. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We generated hospital-level, risk-standardized, 30-day readmission rates among survivors of sepsis and compared rates across region, ownership, teaching status, sepsis volume, hospital size, and proportion of underserved patients. We examined the relationship between risk-standardized readmission rates and hospital-level composite measures of quality and mortality. From 633,407 hospitalizations among 3,315 hospitals from 2008 to 2011, median risk-standardized readmission rates was 28.7% (interquartile range, 26.1-31.9). There were differences in risk-standardized readmission rates by region (Northeast, 30.4%; South, 29.6%; Midwest, 28.8%; and West, 27.7%; p < 0.001), teaching versus nonteaching status (31.1% vs 29.0%; p < 0.001), and hospitals serving the highest proportion of underserved patients (30.6% vs 28.7%; p < 0.001). The best performing hospitals on a composite quality measure had highest risk-standardized readmission rates compared with the lowest (32.0% vs 27.5%; p < 0.001). Risk-standardized readmission rates was lower in the highest mortality hospitals compared with those in the lowest (28.7% vs 30.7%; p < 0.001). CONCLUSIONS One third of sepsis survivors were readmitted and wide variation exists between hospitals. Several demographic and structural factors are associated with this variation. Measures of higher quality in-hospital care were correlated with higher readmission rates. Several potential explanations are possible including poor risk standardization, more research is needed.
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Hua M, Gong MN, Miltiades A, Wunsch H. Outcomes after Rehospitalization at the Same Hospital or a Different Hospital Following Critical Illness. Am J Respir Crit Care Med 2017; 195:1486-1493. [PMID: 27805834 DOI: 10.1164/rccm.201605-0912oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Intensive care unit (ICU) patients who receive mechanical ventilation are at high risk for early rehospitalization. Given the medical complexity of these patients, a lack of continuity of care may adversely affect their outcomes during rehospitalization. OBJECTIVES To determine whether outcomes differ for patients who are rehospitalized at a different hospital versus the hospital of their index ICU stay. METHODS We conducted a retrospective cohort study of mechanically ventilated ICU patients rehospitalized within 30 days in New York State hospitals between 2008 and 2013. MEASUREMENTS AND MAIN RESULTS We measured frequency of rehospitalization at a different hospital, mortality, length of stay, and costs during rehospitalization. Of 26,947 mechanically ventilated ICU patients rehospitalized within 30 days of discharge, 8,443 (31.3%) were rehospitalized at a different hospital than that of the index ICU stay. For patients at a different hospital, 13.7% died during rehospitalization versus 11.1% who died at the index hospital (adjusted rate ratio [aRR], 1.11; 95% confidence interval [CI], 1.03-1.20; P = 0.009). Patients who died at a different hospital had shorter length of stay (aRR, 0.80; 95% CI, 0.70-0.92; P = 0.001) and decreased costs (adjusted mean difference, -$9,632.73; 95% CI, -$16,387.60 to -$2,877.88; P = 0.005), whereas survivors of rehospitalization at a different hospital had a modest increase in length of stay (aRR, 1.06; 95% CI, 1.01-1.11; P = 0.009) and increased costs of care (adjusted mean difference, $1,665.34; 95% CI, $602.12-$2,728.56; P = 0.002). CONCLUSIONS Almost one-third of mechanically ventilated critically ill patients were rehospitalized at a different hospital than that of the index ICU stay. This care discontinuity was associated with increased mortality.
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Affiliation(s)
- May Hua
- 1 Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York.,2 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Michelle Ng Gong
- 3 Department of Medicine and.,4 Department of Epidemiology and Population Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Andrea Miltiades
- 1 Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hannah Wunsch
- 1 Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York.,5 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and.,6 Department of Anesthesia and.,7 Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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40
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Genga KR, Russell JA. Update of Sepsis in the Intensive Care Unit. J Innate Immun 2017; 9:441-455. [PMID: 28697503 DOI: 10.1159/000477419] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/08/2017] [Indexed: 01/28/2023] Open
Abstract
Sepsis, the most common cause of admission to an intensive care unit (ICU), has had an increased incidence and prevalence over the last years with a simultaneous decrease in its short-term mortality. Sepsis survivors are more frequently discharged from hospital and often experience long-term outcomes such as late mortality, immune dysfunction, secondary infections, impaired quality of life, and unplanned readmissions. Early recognition and management of sepsis have challenged emergency care and critical care physicians and nurses. New sepsis definitions were produced and the Surviving Sepsis Campaign (SSC) 2016 was updated recently. Although hospital readmissions after sepsis are common, associated risk factors and how to manage patients who survive an episode of sepsis still need clarification. The immune dysfunction caused by sepsis/septic shock is complex, persistent, affects inflammatory and anti-inflammatory systems, and might be associated with long-term outcomes of sepsis. Several randomized controlled trials (RCT) that analyzed new (and old) interventions in sepsis/septic shock are discussed in this review in parallel with the SSC 2016 recommendations and other guidelines when relevant. RCTs addressing incidence, treatment, and prevention of important sepsis-associated organ dysfunction such as the acute respiratory distress syndrome, acute kidney injury, and brain dysfunction are highlighted. Finally, we briefly discuss the need for novel targets, predictive biomarkers, and new designs of RCTs in sepsis.
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Affiliation(s)
- Kelly Roveran Genga
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
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The Relationship Between Index Hospitalizations, Sepsis, and Death or Transition to Hospice Care During 30-Day Hospital Readmissions. Med Care 2017; 55:362-370. [PMID: 27820595 DOI: 10.1097/mlr.0000000000000669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hospital readmissions are common, expensive, and increasingly used as a metric for assessing quality of care. The relationship between index hospitalizations and specific outcomes among those readmitted remains largely unknown. OBJECTIVES Identify risk factors present during the index hospitalization associated with death or transition to hospice care during 30-day readmissions and examine the contribution of infection in readmissions resulting in death. RESEARCH DESIGN Retrospective cohort study. SUBJECTS A total of 17,716 30-day readmissions in an academic health system. MEASURES We used mixed-effects multivariable logistic regression models to identify risk factors associated with the primary outcome, in-hospital death, or transition to hospice during 30-day readmissions. RESULTS Of 17,716 30-day readmissions, 1144 readmissions resulted in death or transition to hospice care (6.5%). Risk factors identified included: age, burden, and type of comorbid conditions, recent hospitalizations, nonelective index admission type, outside hospital transfer, low discharge hemoglobin, low discharge sodium, high discharge red blood cell distribution width, and disposition to a setting other than home. Sepsis (OR=1.33; 95% CI, 1.02-1.72; P=0.03) and shock (OR=1.78; 95% CI, 1.22-2.58; P=0.002) during the index admission were associated with the primary outcome, and in-hospital mortality specifically. In patients who died, infection was the primary cause for readmission in 51.6% of readmissions after sepsis and 28.6% of readmissions after a nonsepsis hospitalization (P=0.009). CONCLUSIONS We identified factors, including sepsis and shock during the index hospitalization, associated with death or transition to hospice care during readmission. Infection was frequently implicated as the cause of a readmission that ended in death.
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Amland RC, Haley JM, Lyons JJ. A Multidisciplinary Sepsis Program Enabled by a Two-Stage Clinical Decision Support System: Factors That Influence Patient Outcomes. Am J Med Qual 2016; 31:501-508. [PMID: 26491116 PMCID: PMC5098699 DOI: 10.1177/1062860615606801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Sepsis is an inflammatory response triggered by infection, with risk of in-hospital mortality fueled by disease progression. Early recognition and intervention by multidisciplinary sepsis programs may reverse the inflammatory response among at-risk patient populations, potentially improving outcomes. This retrospective study of a sepsis program enabled by a 2-stage sepsis Clinical Decision Support (CDS) system sought to evaluate the program's impact, identify early indicators that may influence outcomes, and uncover opportunities for quality improvement. Data encompassed 16 527 adult hospitalizations from 2014 and 2015. Of 2108 non-intensive care unit patients screened-in by sepsis CDS, 97% patients were stratified by 177 providers. Risk of adverse outcome improved 30% from baseline to year end, with gains materializing and stabilizing at month 7 after sepsis program go-live. Early indicators likely to influence outcomes include patient age, recent hospitalization, electrolyte abnormalities, hypovolemic shock, hypoxemia, patient location when sepsis CDS activated, and specific alert patterns.
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Shankar-Hari M, Rubenfeld GD. Understanding Long-Term Outcomes Following Sepsis: Implications and Challenges. Curr Infect Dis Rep 2016; 18:37. [PMID: 27709504 PMCID: PMC5052282 DOI: 10.1007/s11908-016-0544-7] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis is life-threating organ dysfunction due to infection. Incidence of sepsis is increasing and the short-term mortality is improving, generating more sepsis survivors. These sepsis survivors suffer from additional morbidities such as higher risk of readmissions, cardiovascular disease, cognitive impairment and of death, for years following index sepsis episode. In the first year following index sepsis episode, approximately 60 % of sepsis survivors have at least one rehospitalisation episode, which is most often due to infection and one in six sepsis survivors die. Sepsis survivors also have a higher risk of cognitive impairment and cardiovascular disease contributing to the reduced life expectancy seen in this population, when assessed with life table comparisons. For optimal design of interventional trials to reduce these bad outcomes in sepsis survivors, in-depth understanding of major risk factors for these morbid events, their modifiability and a causal relationship to the pathobiology of sepsis is essential. This review highlights the recent advances, clinical and methodological challenges in our understanding of these morbid events in sepsis survivors.
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Affiliation(s)
- Manu Shankar-Hari
- Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE17EH, UK.
- Division of Asthma, Allergy and Lung Biology, Kings College London, London, SE1 9RT, UK.
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, D5 03, Toronto, ON, M4N 3M5, Canada
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Carson WF, Kunkel SL. Regulation of Cellular Immune Responses in Sepsis by Histone Modifications. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2016; 106:191-225. [PMID: 28057212 DOI: 10.1016/bs.apcsb.2016.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Severe sepsis, septic shock, and related inflammatory syndromes are driven by the aberrant expression of proinflammatory mediators by immune cells. During the acute phase of sepsis, overexpression of chemokines and cytokines drives physiological stress leading to organ failure and mortality. Following recovery from sepsis, the immune system exhibits profound immunosuppression, evidenced by an inability to produce the same proinflammatory mediators that are required for normal responses to infectious microorganisms. Gene expression in inflammatory responses is influenced by the transcriptional accessibility of the chromatin, with histone posttranslational modifications determining whether inflammatory gene loci are set to transcriptionally active, repressed, or poised states. Experimental evidence indicates that histone modifications play a central role in governing the cytokine storm of severe sepsis, and that aberrant chromatin modifications induced during the acute phase of sepsis may mediate chronic immunosuppression in sepsis survivors. This review will focus on the role of histone modifications in governing immune responses in severe sepsis, with an emphasis on specific leukocyte subsets and the histone modifications observed in these cells during chronic stages of sepsis. Additionally, the expression and function of chromatin-modifying enzymes (CMEs) will be discussed in the context of severe sepsis, as potential mediators of epigenetic regulation of gene expression in sepsis responses. In summary, this review will argue for the use of chromatin modifications and CME expression in leukocytes as potential biomarkers of immunosuppression in patients with severe sepsis.
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Affiliation(s)
- W F Carson
- University of Michigan Medical School, Ann Arbor, MI, United States.
| | - S L Kunkel
- University of Michigan Medical School, Ann Arbor, MI, United States
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Abstract
OBJECTIVES Hospital readmission is common after sepsis, yet the relationship between the index admission and readmission remains poorly understood. We sought to examine the relationship between infection during the index acute care hospitalization and readmission and to identify potentially modifiable factors during the index sepsis hospitalization associated with readmission. DESIGN In a retrospective cohort study, we evaluated 444 sepsis survivors at risk of an unplanned hospital readmission in 2012. The primary outcome was 30-day unplanned hospital readmission. SETTING Three hospitals within an academic healthcare system. SUBJECTS Four hundred forty-four sepsis survivors. MEASUREMENTS AND MAIN RESULTS Of 444 sepsis survivors, 23.4% (95% CI, 19.6-27.6%) experienced an unplanned 30-day readmission compared with 10.1% (95% CI, 9.6-10.7%) among 11,364 nonsepsis survivors over the same time period. The most common cause for readmission after sepsis was infection (69.2%, 72 of 104). Among infection-related readmissions, 51.4% were categorized as recurrent/unresolved. Patients with sepsis present on their index admission who also developed a hospital-acquired infection ("second hit") were nearly twice as likely to have an unplanned 30-day readmission compared with those who presented with sepsis at admission and did not develop a hospital-acquired infection or those who presented without infection and then developed hospital-acquired sepsis (38.6% vs 22.2% vs 20.0%, p = 0.04). Infection-related hospital readmissions, specifically, were more likely in patients with a "second hit" and patients receiving a longer duration of antibiotics. The use of total parenteral nutrition (p = 0.03), longer duration of antibiotics (p = 0.047), prior hospitalizations, and lower discharge hemoglobin (p = 0.04) were independently associated with hospital readmission. CONCLUSIONS We confirmed that the majority of unplanned hospital readmissions after sepsis are due to an infection. We found that patients with sepsis at admission who developed a hospital-acquired infection, and those who received a longer duration of antibiotics, appear to be high-risk groups for unplanned, all-cause 30-day readmissions and infection-related 30-day readmissions.
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46
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Shankar-Hari M, Ambler M, Mahalingasivam V, Jones A, Rowan K, Rubenfeld GD. Evidence for a causal link between sepsis and long-term mortality: a systematic review of epidemiologic studies. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:101. [PMID: 27075205 PMCID: PMC4831092 DOI: 10.1186/s13054-016-1276-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/31/2016] [Indexed: 12/29/2022]
Abstract
Background In addition to acute hospital mortality, sepsis is associated with higher risk of death following hospital discharge. We assessed the strength of epidemiological evidence supporting a causal link between sepsis and mortality after hospital discharge by systematically evaluating the available literature for strength of association, bias, and techniques to address confounding. Methods We searched Medline and Embase using the following ‘mp’ terms, MESH headings and combinations thereof - sepsis, septic shock, septicemia, outcome. Studies published since 1992 where one-year post-acute mortality in adult survivors of acute sepsis could be calculated were included. Two authors independently selected studies and extracted data using predefined criteria and data extraction forms to assess risk of bias, confounding, and causality. The difference in proportion between cumulative one-year mortality and acute mortality was defined as post-acute mortality. Meta-analysis was done by sepsis definition categories with post-acute mortality as the primary outcome. Results The literature search identified 11,156 records, of which 59 studies met our inclusion criteria and 43 studies reported post-acute mortality. In patients who survived an index sepsis admission, the post-acute mortality was 16.1 % (95 % CI 14.1, 18.1 %) with significant heterogeneity (p < 0.001), on random effects meta-analysis. In studies reporting non-sepsis control arm comparisons, sepsis was not consistently associated with a higher hazard ratio for post-acute mortality. The additional hazard associated with sepsis was greatest when compared to the general population. Older age, male sex, and presence of comorbidities were commonly reported independent predictors of post-acute mortality in sepsis survivors, challenging the causality relationship. Sensitivity analyses for post-acute mortality were consistent with primary analysis. Conclusions Epidemiologic criteria for a causal relationship between sepsis and post-acute mortality were not consistently observed. Additional epidemiologic studies with recent patient level data that address the pre-illness trajectory, confounding, and varying control groups are needed to estimate sepsis-attributable additional risk and modifiable risk factors to design interventional trials. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1276-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK. .,Division of Asthma, Allergy and Lung Biology, Kings College London, London, SE1 9RT, UK.
| | - Michael Ambler
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Viyaasan Mahalingasivam
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Andrew Jones
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK.,Division of Asthma, Allergy and Lung Biology, Kings College London, London, SE1 9RT, UK
| | - Kathryn Rowan
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, D5 03, Toronto, Ontario, M4N 3M5, Canada
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Abstract
RATIONALE The epidemiology of post-acute care use and hospital readmission after sepsis remains largely unknown. OBJECTIVES To examine the rate of post-acute care use and hospital readmission after sepsis and to examine risk factors and outcomes for hospital readmissions after sepsis. METHODS In an observational cohort study conducted in an academic health care system (2010-2012), we compared post-acute care use at discharge and hospital readmission after 3,620 sepsis hospitalizations with 108,958 nonsepsis hospitalizations. We used three validated, claims-based approaches to identify sepsis and severe sepsis. MEASUREMENTS AND MAIN RESULTS Post-acute care use at discharge was more likely after sepsis, driven by skilled care facility placement (35.4% after sepsis vs. 15.8%; P < 0.001), with the highest rate observed after severe sepsis. Readmission rates at 7, 30, and 90 days were higher postsepsis (P < 0.001). Compared with nonsepsis hospitalizations (15.6% readmitted within 30 d), the increased readmission risk was present regardless of sepsis severity (27.3% after sepsis and 26.0-26.2% after severe sepsis). After controlling for presepsis characteristics, the readmission risk was found to be 1.51 times greater (95% CI, 1.38-1.66) than nonsepsis hospitalizations. Readmissions after sepsis were more likely to result in death or transition to hospice care (6.1% vs. 13.3% after sepsis; P < 0.001). Independent risk factors associated with 30-day readmissions after sepsis hospitalizations included age, malignancy diagnosis, hospitalizations in the year prior to the index hospitalization, nonelective index admission type, one or more procedures during the index hospitalization, and low hemoglobin and high red cell distribution width at discharge. CONCLUSIONS Post-acute care use and hospital readmissions were common after sepsis. The increased readmission risk after sepsis was observed regardless of sepsis severity and was associated with adverse readmission outcomes.
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48
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Maley JH, Mikkelsen ME. Short-term Gains with Long-term Consequences: The Evolving Story of Sepsis Survivorship. Clin Chest Med 2016; 37:367-80. [PMID: 27229651 DOI: 10.1016/j.ccm.2016.01.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Sepsis is an acute, life-threatening condition that afflicts millions of patients annually. Advances in care and heightened awareness have led to substantial declines in short-term mortality. An expanding body of literature describes the long-term impact of sepsis, revealing long-term cognitive and functional impairments, sustained inflammation and immune dysfunction, increased healthcare resource use, reduced health-related quality of life, and increased mortality. The evidence challenges the notion that sepsis is an acute, transient illness, revealing rather that sepsis is an acute illness with lingering consequences. This article provides a state-of-the-art review of the emerging literature of the long-term consequences of sepsis.
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Affiliation(s)
- Jason H Maley
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark E Mikkelsen
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
OBJECTIVE Although recent studies have shown that 30-day readmissions following sepsis are common, the overall fiscal impact of these rehospitalizations and their variability between hospitals relative to other high-risk conditions, such as congestive heart failure and acute myocardial infarction, are unknown. The objectives of this study were to characterize the frequency, cost, patient-level risk factors, and hospital-level variation in 30-day readmissions following sepsis compared with congestive heart failure and acute myocardial infarction. DESIGN A retrospective cohort analysis of hospitalizations from 2009 to 2011. SETTING All acute care, nonfederal hospitals in California. PATIENTS Hospitalizations for sepsis (n = 240,198), congestive heart failure (n = 193,153), and acute myocardial infarction (n = 105,684) identified by administrative discharge codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcomes were the frequency and cost of all-cause 30-day readmissions following hospitalization for sepsis compared with congestive heart failure and acute myocardial infarction. Variability in predicted readmission rates between hospitals was calculated using mixed-effects logistic regression analysis. The all-cause 30-day readmission rates were 20.4%, 23.6%, and 17.7% for sepsis, congestive heart failure, and acute myocardial infarction, respectively. The estimated annual costs of 30-day readmissions in the state of California during the study period were $500 million/yr for sepsis, $229 million/yr for congestive heart failure, and $142 million/yr for acute myocardial infarction. The risk- and reliability-adjusted readmission rates across hospitals ranged from 11.0% to 39.8% (median, 19.9%; interquartile range, 16.1-26.0%) for sepsis, 11.3% to 38.4% (median, 22.9%; interquartile range, 19.2-26.6%) for congestive heart failure, and 3.6% to 40.8% (median, 17.0%; interquartile range, 12.2-20.0%) for acute myocardial infarction. Patient-level factors associated with higher odds of 30-day readmission following sepsis included younger age, male gender, Black or Native American race, a higher burden of medical comorbidities, urban residence, and lower income. CONCLUSION Sepsis is a leading contributor to excess healthcare costs due to hospital readmissions. Interventions at clinical and policy levels should prioritize identifying effective strategies to reduce sepsis readmissions.
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Bateson M, Patton A. Sepsis: contemporary issues and implications for nursing. ACTA ACUST UNITED AC 2015; 24:864, 866. [PMID: 26419712 DOI: 10.12968/bjon.2015.24.17.864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Andrea Patton
- Principal Information Analyst, Scottish Antimicrobial Prescribing Group
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