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Klompas M, Rhee C. Victories and Opportunities in the Surviving Sepsis Campaign's Antibiotic Timing Guidance. Crit Care Med 2024; 52:1138-1141. [PMID: 38869386 DOI: 10.1097/ccm.0000000000006274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
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2
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Paudel R, Lessard S, Jaekel C, Albrecht P, Forati AM, Heiderscheit C. Enhancing Sepsis Outcomes: A 7-Year Multidisciplinary Endeavor. Am J Med Qual 2024; 39:145-153. [PMID: 39038274 DOI: 10.1097/jmq.0000000000000194] [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: 07/24/2024]
Abstract
Regulatory bodies in the United States have implemented quality metrics aimed at improving outcomes for patients with severe sepsis and septic shock. The current study was a quality improvement (QI) project in a community-based academic center aimed at improving adherence to sepsis quality metrics, time to antibiotic administration, and patient outcomes. Electronic health record systems were utilized to capture sepsis-related data. Regular audits and feedback sessions were conducted to identify areas for improvement, with a focus on the timely administration of antibiotics. Interventions included improving access to antibiotics, transitioning from intravenous piggyback to intravenous push formulations, and providing continuous staff education and training. This multidisciplinary QI initiative led to significant improvements in the mortality index, length of stay index, and direct cost index for patients with sepsis. Targeted multidisciplinary QI interventions resulted in improved quality metrics and patient outcomes.
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Affiliation(s)
- Robin Paudel
- Department of Pulmonary & Critical Care, University of Wisconsin, Madison, WI
| | - Sarah Lessard
- Department of Pharmacy, Mayo Clinic Health System, La Crosse, WI
| | - Camilla Jaekel
- Department of Nursing, Mayo Clinic Health System, La Crosse, WI
| | - Pamela Albrecht
- Quality: Data & Analytics - Hospital Regulatory, Mayo Clinic Health System, La Crosse, WI
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3
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Peng Q, Liu X, Ai M, Huang L, Li L, Liu W, Zhao C, Hu C, Zhang L. Cerebral autoregulation-directed optimal blood pressure management reduced the risk of delirium in patients with septic shock. JOURNAL OF INTENSIVE MEDICINE 2024; 4:376-383. [PMID: 39035614 PMCID: PMC11258506 DOI: 10.1016/j.jointm.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 07/23/2024]
Abstract
Background When resuscitating patients with septic shock, cerebrovascular reactivity parameters are calculated by monitoring regional cerebral oxygen saturation (rSO2) using near-infrared spectroscopy to determine the optimal blood pressure. Here, we aimed to analyze the impact of cerebral autoregulation-directed optimal blood pressure management on the incidence of delirium and the prognosis of patients with septic shock. Methods This prospective randomized controlled clinical study was conducted in the Xiangya Hospital of Central South University, China. Fifty-one patients with septic shock (December 2020-May 2022) were enrolled and randomly allocated to the experimental (n=26) or control group (n=25). Using the ICM+ software, we monitored the dynamic changes in rSO2 and mean arterial pressure (MAP) and calculated the cerebrovascular reactivity parameter tissue oxygen reactivity index to determine the optimal blood pressure to maintain normal cerebral autoregulation function during resuscitation in the experimental group. The control group was treated according to the Surviving Sepsis Campaign Guidelines. Differences in the incidence of delirium and 28-day mortality between the two groups were compared, and the risk factors were analyzed. Results The 51 patients, including 39 male and 12 female, had a mean age of (57.0±14.9) years. The incidence of delirium was 40.1% (23/51), and the 28-day mortality rate was 29.4% (15/51). The mean MAP during the first 24 h of intensive care unit (ICU) admission was higher ([84.5±12.2] mmHg vs. [77.4±11.8] mmHg, P=0.040), and the incidence of delirium was lower (30.8% vs. 60.0%, P=0.036) in the experimental group than in the control group. The use of cerebral autoregulation-directed optimal blood pressure (odds ratio [OR]=0.090, 95% confidence interval [CI]: 0.009 to 0.923, P=0.043) and length of ICU stay (OR=1.473, 95% CI: 1.093 to 1.985, P=0.011) were risk factors for delirium during septic shock. Vasoactive drug dose (OR=8.445, 95% CI: 1.26 to 56.576, P=0.028) and partial pressure of oxygen (PaO2) (OR=0.958, 95% CI: 0.921 to 0.996, P=0.032) were the risk factors for 28-day mortality. Conclusions The use of cerebral autoregulation-directed optimal blood pressure management during shock resuscitation reduces the incidence of delirium in patients with septic shock. Trial Registration ClinicalTrials.gov ldentifer: NCT03879317.
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Affiliation(s)
- Qianyi Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xia Liu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Meilin Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Huang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Li
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wei Liu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chunguang Zhao
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chenghuan Hu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Provincial Clinical Research Center for Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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4
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Xu M, Chen C, You Z, Xu S, Wu T, Lin H, Zhuang W, Chen Y, Chen Y. Nursing of a case of sepsis caused by catheter balloon ectopic in ureter. Panminerva Med 2024; 66:220-222. [PMID: 37877891 DOI: 10.23736/s0031-0808.23.04995-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Affiliation(s)
- Mianmian Xu
- Department of Urinary Surgery, Jinjiang Municipal Hospital, Quanzhou, China
| | - Chuanzhen Chen
- Department of Nursing, Jinjiang Municipal Hospital, Quanzhou, China
| | - Zhijiao You
- Department of Urinary Surgery, Jinjiang Municipal Hospital, Quanzhou, China -
| | - Sanmei Xu
- Department of Obstetrics and Gynecology, Chendai Central Hospital, Quanzhou, Fujian, China
| | - Tianen Wu
- Department of Urinary Surgery, Jinjiang Municipal Hospital, Quanzhou, China
| | - Heqin Lin
- Department of Urinary Surgery, Jinjiang Municipal Hospital, Quanzhou, China
| | - Wanling Zhuang
- Department of Urinary Surgery, Jinjiang Municipal Hospital, Quanzhou, China
| | - Yuyan Chen
- Department of Urinary Surgery, Jinjiang Municipal Hospital, Quanzhou, China
| | - Yafang Chen
- Department of Neurology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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Chatoor R, Sekhar P, Mahony E, Nehme E, Cox S, Cudini D, Shao J, Smith K, Anderson D, Nehme Z, Udy A. The burden and prognostic significance of suspected sepsis in the prehospital setting: A state-wide population-based cohort study. Emerg Med Australas 2024; 36:348-355. [PMID: 38081764 DOI: 10.1111/1742-6723.14357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/13/2023] [Accepted: 11/18/2023] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Despite high in-hospital mortality, the epidemiology of prehospital suspected sepsis presentations is not well described. This retrospective cohort study aimed to quantify the burden of such presentations, and to determine whether such a diagnosis was independently associated with longer-term mortality. METHODS Retrospective, observational population-based cohort study examining all adult prehospital presentations in Victoria, between January 2015 and June 2019, who required subsequent in-hospital assessment. Linked data were extracted from clinical and administrative datasets. Demographics, illness severity, prehospital treatment and mortality were compared between prehospital suspected sepsis and non-sepsis patients. Multivariable logistic regression was used to determine the adjusted association between prehospital assessment (suspected sepsis vs non-sepsis) and 6-month mortality. RESULTS A total of 1 218 047 patients were included. The age-adjusted incidence rate of prehospital suspected sepsis was 65 cases per 100 000 person-years. Those with prehospital suspected sepsis were older (74 vs 62 years), more frequently male (55% vs 47%), with greater physiological derangement. Intravenous cannulas were more often inserted prehospital (60% vs 29%). Crude in-hospital mortality was 6.5-fold higher in the prehospital suspected sepsis group (11.8% vs 1.8%), and by 6 months, 22.6% had died. After adjustment for demographics, illness severity, comorbidity, treatment and hospital location, a diagnosis of prehospital suspected sepsis was associated with a 35% higher likelihood of 6-month mortality (OR 1.35, 95% CI 1.29-1.41). CONCLUSIONS The burden of prehospital suspected sepsis in the Australian setting is significant, with paramedics identifying patients at high-risk of poor longer-term outcomes. This implies the need to consider improved care pathways for this highly vulnerable group.
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Affiliation(s)
- Richard Chatoor
- Intensive Care Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Praba Sekhar
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emily Mahony
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Emily Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Shelley Cox
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Daniel Cudini
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Shao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Research and Innovation, Silverchain, Melbourne, Victoria, Australia
| | - David Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
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Hixon AM, Micek S, Fraser VJ, Kollef M, Guillamet MCV. Impact of Gram-Negative Bacilli Resistance Rates on Risk of Death in Septic Shock and Pneumonia. Open Forum Infect Dis 2024; 11:ofae219. [PMID: 38770211 PMCID: PMC11103621 DOI: 10.1093/ofid/ofae219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 05/22/2024] Open
Abstract
Background Sepsis is a major cause of morbidity and mortality worldwide. When selecting empiric antibiotics for sepsis, clinicians are encouraged to use local resistance rates, but their impact on individual outcomes is unknown. Improved methods to predict outcomes are needed to optimize treatment selection and improve antibiotic stewardship. Methods We expanded on a previously developed theoretical model to estimate the excess risk of death in gram-negative bacilli (GNB) sepsis due to discordant antibiotics using 3 factors: the prevalence of GNB in sepsis, the rate of antibiotic resistance in GNB, and the mortality difference between discordant and concordant antibiotic treatments. We focused on ceftriaxone, cefepime, and meropenem as the anti-GNB treatment backbone in sepsis, pneumonia, and urinary tract infections. We analyzed both publicly available data and data from a large urban hospital. Results Publicly available data were weighted toward culture-positive cases. Excess risk of death with discordant antibiotics was highest in septic shock and pneumonia. In septic shock, excess risk of death was 4.53% (95% confidence interval [CI], 4.04%-5.01%), 0.6% (95% CI, .55%-.66%), and 0.19% (95% CI, .16%-.21%) when considering resistance to ceftriaxone, cefepime, and meropenem, respectively. Results were similar in pneumonia. Local data, which included culture-negative cases, showed an excess risk of death in septic shock of 0.75% (95% CI, .57%-.93%) for treatment with discordant antibiotics in ceftriaxone-resistant infections and 0.18% (95% CI, .16%-.21%) for cefepime-resistant infections. Conclusions Estimating the excess risk of death for specific sepsis phenotypes in the context of local resistance rates, rather than relying on population resistance data, may be more informative in deciding empiric antibiotics in GNB infections.
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Affiliation(s)
- Alison M Hixon
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy Practice, St Louis College of Pharmacy, St Louis, Missouri, USA
| | - Victoria J Fraser
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - M Cristina Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri, USA
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Su L, Liu S, Yang Y, Jiang H, Ye X, Weng L, Zhu W, Tian X, Long Y. Positive fluid balance and poor outcomes after initial intensive care unit admission in sepsis resuscitation: a retrospective study. Arch Med Sci 2024; 20:464-475. [PMID: 38757044 PMCID: PMC11094850 DOI: 10.5114/aoms/172160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 05/18/2024] Open
Abstract
Introduction Fluid resuscitation of patients with sepsis is crucial. This study explored the role of fluid balance in the early resuscitation of sepsis patients in the intensive care unit (ICU). Material and methods A retrospective study of patients with sepsis using the Peking Union Medical College Hospital Intensive Care Medical Information System and Database from January 2014 to June 2020 was performed. Based on the survival status on day 28, the training cohort was divided into an alive group (n = 1,803) and a deceased group (n = 429). Univariate and multivariate analyses were used to identify risk factors, and the integrated learning XGBoost algorithm was used to construct a model for predicting outcomes. ROC and Kaplan-Meier survival curves were used to evaluate the effectiveness of the model. A verification cohort (n = 433) was used to verify the model. Results Univariate analysis showed that fluid balance is an important covariate. Based on the scatterplot distribution, a significant difference in mortality was determined between groups stratified with a balance of 1000 ml. There were associations in the multivariate analysis between poor outcomes and sex, PO2/FiO2, serum creatinine, FiO2, platelets, respiratory rate, SPO2, temperature, and total fluid volume (1000 ml). Among these variables, total fluid balance (1000 ml) had an OR of 1.98 (CI: 1.41-2.77, p < 0.001). Therefore, the model was built with these nine factors using XGBoost. Cross validation was used to verify generalizability. This model performed better than the SOFA and APACHE II models. The result was well verified in the verification cohort. A causal forest model suggested that patients with hypoxemia may suffer from positive fluid balance. Conclusions Sepsis fluid resuscitation in the ICU should be a targeted and goal-oriented treatment. A new prognostic prediction model was constructed and indicated that a 6-hour positive fluid balance after ICU initial admission is a risk factor for poor outcomes in sepsis patients. A 6-hour fluid balance above 1000 ml should be performed with caution.
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Affiliation(s)
- Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yingying Yang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huizhen Jiang
- Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiangyang Ye
- Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Li Weng
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Weiguo Zhu
- Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinlun Tian
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Grønmo MM, Møller-Stray J, Akselsen PE, Lindemann PC, Fostervold A, Knudsen CV, Knudsen PK, Lindbæk M, Tonby K, Sundsfjord A. Gentamicin should remain part of the empirical sepsis regimen for adults. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2024; 144:23-0659. [PMID: 38415563 DOI: 10.4045/tidsskr.23.0659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
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9
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Leisman DE, Deng H, Lee AH, Flynn MH, Rutkey H, Copenhaver MS, Gay EA, Dutta S, McEvoy DS, Dunham LN, Mort EA, Lucier DJ, Sonis JD, Aaronson EL, Hibbert KA, Safavi KC. Effect of Automated Real-Time Feedback on Early-Sepsis Care: A Pragmatic Clinical Trial. Crit Care Med 2024; 52:210-222. [PMID: 38088767 DOI: 10.1097/ccm.0000000000006057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To determine if a real-time monitoring system with automated clinician alerts improves 3-hour sepsis bundle adherence. DESIGN Prospective, pragmatic clinical trial. Allocation alternated every 7 days. SETTING Quaternary hospital from December 1, 2020 to November 30, 2021. PATIENTS Adult emergency department or inpatients meeting objective sepsis criteria triggered an electronic medical record (EMR)-embedded best practice advisory. Enrollment occurred when clinicians acknowledged the advisory indicating they felt sepsis was likely. INTERVENTION Real-time automated EMR monitoring identified suspected sepsis patients with incomplete bundle measures within 1-hour of completion deadlines and generated reminder pages. Clinicians responsible for intervention group patients received reminder pages; no pages were sent for controls. The primary analysis cohort was the subset of enrolled patients at risk of bundle nonadherent care that had reminder pages generated. MEASUREMENTS AND MAIN RESULTS The primary outcome was orders for all 3-hour bundle elements within guideline time limits. Secondary outcomes included guideline-adherent delivery of all 3-hour bundle elements, 28-day mortality, antibiotic discontinuation within 48-hours, and pathogen recovery from any culture within 7 days of time-zero. Among 3,269 enrolled patients, 1,377 had reminder pages generated and were included in the primary analysis. There were 670 (48.7%) at-risk patients randomized to paging alerts and 707 (51.3%) to control. Bundle-adherent orders were placed for 198 intervention patients (29.6%) versus 149 (21.1%) controls (difference: 8.5%; 95% CI, 3.9-13.1%; p = 0.0003). Bundle-adherent care was delivered for 152 (22.7%) intervention versus 121 (17.1%) control patients (difference: 5.6%; 95% CI, 1.4-9.8%; p = 0.0095). Mortality was similar between groups (8.4% vs 8.3%), as were early antibiotic discontinuation (35.1% vs 33.4%) and pan-culture negativity (69.0% vs 68.2%). CONCLUSIONS Real-time monitoring and paging alerts significantly increased orders for and delivery of guideline-adherent care for suspected sepsis patients at risk of 3-hour bundle nonadherence. The trial was underpowered to determine whether adherence affected mortality. Despite enrolling patients with clinically suspected sepsis, early antibiotic discontinuation and pan-culture negativity were common, highlighting challenges in identifying appropriate patients for sepsis bundle application.
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Affiliation(s)
- Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Hao Deng
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Andy H Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Micah H Flynn
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Hayley Rutkey
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Martin S Copenhaver
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, MA
| | - Elizabeth A Gay
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
- Mass General Brigham Digital, Mass General Brigham Health System, Sommerville, MA
| | - Dustin S McEvoy
- Mass General Brigham Digital, Mass General Brigham Health System, Sommerville, MA
| | - Lisette N Dunham
- Mass General Brigham Digital, Mass General Brigham Health System, Sommerville, MA
| | - Elizabeth A Mort
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - David J Lucier
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Kyan C Safavi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, MA
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10
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Harden Waibel B, Kamien AJ. Resuscitation and Preparation of the Emergency General Surgery Patient. Surg Clin North Am 2023; 103:1061-1084. [PMID: 37838456 DOI: 10.1016/j.suc.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.
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Affiliation(s)
- Brett Harden Waibel
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
| | - Andrew James Kamien
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
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Hayashi Y, Shimazui T, Tomita K, Shimada T, Miura RE, Nakada TA. Associations between fluid overload and outcomes in critically ill patients with acute kidney injury: a retrospective observational study. Sci Rep 2023; 13:17410. [PMID: 37833430 PMCID: PMC10575912 DOI: 10.1038/s41598-023-44778-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/12/2023] [Indexed: 10/15/2023] Open
Abstract
Increased fluid overload (FO) is associated with poor outcomes in critically ill patients, especially in acute kidney injury (AKI). However, the exact timing from when FO influences outcomes remains unclear. We retrospectively screened intensive care unit (ICU) admitted patients with AKI between January 2011 and December 2015. Logistic or linear regression analyses were performed to determine when hourly %FO was significant on 90-day in-hospital mortality (primary outcome) or ventilator-free days (VFDs). In total, 1120 patients were enrolled in this study. Univariate analysis showed that a higher %FO was significantly associated with higher mortality from the first hour of ICU admission (odds ratio 1.34, 95% confidence interval 1.15-1.56, P < 0.001), whereas multivariate analysis adjusted with age, sex, APACHE II score, and sepsis etiology showed the association was significant from the 27th hour. Both univariate and multivariate analyses showed that a higher %FO was significantly associated with shorter VFDs from the 1st hour. The significant associations were retained during all following observation periods after they showed significance. In patients with AKI, a higher %FO was associated with higher mortality and shorter VFDs from the early phase after ICU admission. FO should be administered with a physiological target or goal in place from the initial phase of critical illness.
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Affiliation(s)
- Yosuke Hayashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Takashi Shimazui
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Keisuke Tomita
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Tadanaga Shimada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
| | - Rie E Miura
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan
- Smart119 Inc., 2-5-1 Chuo, Chiba, 260-0013, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba, 260-8677, Japan.
- Smart119 Inc., 2-5-1 Chuo, Chiba, 260-0013, Japan.
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12
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Ewoldt TMJ, Abdulla A, Rietdijk WJR, Hunfeld N, Muller AE, Endeman H, Koch BCP. Which patients benefit from model-informed precision dosing of beta-lactam antibiotics and ciprofloxacin at the ICU? Int J Antimicrob Agents 2023; 62:106931. [PMID: 37482257 DOI: 10.1016/j.ijantimicag.2023.106931] [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: 04/12/2023] [Revised: 06/26/2023] [Accepted: 07/15/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES Antibiotic dosing is not optimal in the ICU. Our recent trial investigated the effect of model-informed precision dosing (MIPD) of beta-lactam antibiotics and ciprofloxacin and showed no significant differences in clinical outcomes in all patients. This study aimed to identify subgroups of patients in which the MIPD of these antibiotics could be beneficial for clinical outcomes. METHODS We analysed data from the DOLPHIN randomized controlled trial, which compared MIPD to standard dosing of beta-lactam antibiotics and ciprofloxacin in 388 ICU patients. We divided patients into subgroups based on baseline characteristics and assessed the effect of MIPD on 28-day mortality, 6-month mortality, change in sequential organ failure assessment (delta-SOFA), and ICU length of stay (LOS). RESULTS We found a lower 28-day mortality in patients with a SOFA below 8 randomized to MIPD (OR 0.40; 95% CI 0.17-0.88). However, patients with a higher SOFA show an increased 28-day mortality (OR 1.94; 95% CI 1.07-3.59) in the MIPD group. ICU LOS was increased in patients receiving MIPD with a SOFA below 8 (IRR 1.36; 95% CI 1.01-1.83) and those receiving MIPD for ceftriaxone (IRR 1.76; 95% CI 1.24-2.51). Patients receiving a dose recommendation within 24 hours show a trend towards decreased ICU LOS (IRR 0.77; 95% CI 0.52-1.16) and higher delta-SOFA (estimate -1.19; 95% CI -2.98-0.60). CONCLUSIONS ICU patients with a SOFA below 8 using MIPD had an increased ICU LOS but a lower 28-day mortality. Fast dose recommendations using MIPD of beta-lactam antibiotics and ciprofloxacin needs to be investigated in ICU patients.
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Affiliation(s)
- Tim M J Ewoldt
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands.
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Wim J R Rietdijk
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole Hunfeld
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
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13
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Xu S, Song Z, Han F, Zhang C. Effect of appropriate empirical antimicrobial therapy on mortality of patients with Gram-negative bloodstream infections: a retrospective cohort study. BMC Infect Dis 2023; 23:344. [PMID: 37221465 DOI: 10.1186/s12879-023-08329-2] [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: 04/11/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Little evidence exists regarding the prevalence of pathogens in bloodstream infections (BSIs), the mortality risk, and the benefit of combination therapy over monotherapy. This study aims to describe patterns of empiric antimicrobial therapy, and the epidemiology of Gram-negative pathogens, and to investigate the effect of appropriate therapy and appropriate combination therapy on the mortality of patients with BSIs. METHODS This was a retrospective cohort study including all patients with BSIs of Gram-negative pathogens from January 2017 to December 2022 in a Chinese general hospital. The in-hospital mortality was compared between appropriate and inappropriate therapy, and between monotherapy and combination therapy for patients receiving appropriate therapy. We used Cox regression analysis to identify factors independently associated with in-hospital mortality. RESULTS We included 205 patients in the study, of whom 147 (71.71%) patients received appropriate therapy compared with 58 (28.29%) who received inappropriate therapy. The most common Gram-negative pathogen was Escherichia coli (37.56%). 131 (63.90%) patients received monotherapy and 74 (36.10%) patients received combination therapy. The in-hospital mortality was significantly lower in patients administered appropriate therapy than inappropriate therapy (16.33% vs. 48.28%, p = 0.004); adjusted hazard ratio [HR] 0.55 [95% CI 0.35-0.84], p = 0.006). In-hospital mortality was also not different in combination therapy and monotherapy in the multivariate Cox regression analyses (adjusted HR 0.42 [95% CI 0.15-1.17], p = 0.096). However, combination therapy was associated with lower mortality than monotherapy in patients with sepsis or septic shock (adjusted HR 0.94 [95% CI 0.86-1.02], p = 0.047). CONCLUSIONS Appropriate therapy was associated with a protective effect on mortality among patients with BSIs due to Gram-negative pathogens. Combination therapy was associated with improved survival in patients with sepsis or septic shock. Clinicians need to choose optical empirical antimicrobials to improve survival outcomes in patients with BSIs.
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Affiliation(s)
- Shanshan Xu
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Zhihui Song
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Furong Han
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Chao Zhang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
- , No.1 Dongjiaomin Lane, Beijing, Dongcheng District, China.
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14
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Zheng R, Jin X, Liao W, Lin L. Association between the volume of fluid resuscitation and mortality modified by disease severity in patients with sepsis in ICU: a retrospective cohort study. BMJ Open 2023; 13:e066056. [PMID: 37041062 PMCID: PMC10106076 DOI: 10.1136/bmjopen-2022-066056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVE The important effect modifiers of high disease severity on the relationship between the different volumes of early fluid resuscitation and prognosis in septic patients are unknown. Thus, this study was designed to assess whether the efficacy of different volumes in the early fluid resuscitation treatment of sepsis is affected by disease severity. DESIGN Retrospective cohort study. SETTING Adult intensive care unit (ICU) patients with sepsis from 2001 to 2012 in the MIMIC-III database. INTERVENTIONS The intravenous fluid volume within 6 hours after the sepsis diagnosis serves as the primary exposure. The patients were divided into the standard (≥ 30 mL/kg) and restrict (<30 mL/kg) groups. Disease severity was defined by the sequential organ failure assessment (SOFA) score at ICU admission. Propensity score matching analysis was performed to ensure the robustness of our results. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint of this study was 28-day mortality. Days without needing mechanical ventilation or vasopressor administration within 28-day of ICU admission serving as the secondary endpoint. RESULTS In total, 5154 consecutive individuals were identified in data analysis, 776 patients had a primary end-point event, 386 (49.68%) in the restrict group and 387 (49.81%) in the standard group. Compared with the restrict group, the standard group had higher 28-day mortality (adjusted HR, 1.32; 95% CI 1.03 to 1.70; p=0.03) in the subgroup with a sequential organ failure assessment (SOFA) score ≥10. By contrast, the risk of mortality reduction was modest in the subgroup with an SOFA score <10 (adjusted HR, 0.85; 95% CI 0.70 to 1.03; p=0.10). The effect of the interaction between the SOFA score and fluid resuscitation strategies on the 28-day mortality was significant (p=0.0035). CONCLUSIONS High disease severity modifies the relationship between the volume of fluid resuscitation and mortality in patients with sepsis in the ICU; future studies investigating this interaction are warranted.
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Affiliation(s)
- Rui Zheng
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Xinhao Jin
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Weichao Liao
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Ling Lin
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China
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15
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Liu R, Hunold KM, Caterino JM, Zhang P. Estimating treatment effects for time-to-treatment antibiotic stewardship in sepsis. NAT MACH INTELL 2023; 5:421-431. [PMID: 37125081 PMCID: PMC10135432 DOI: 10.1038/s42256-023-00638-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/02/2023] [Indexed: 05/02/2023]
Abstract
Sepsis is a life-threatening condition with a high in-hospital mortality rate. The timing of antibiotic administration poses a critical problem for sepsis management. Existing work studying antibiotic timing either ignores the temporality of the observational data or the heterogeneity of the treatment effects. Here we propose a novel method (called T4) to estimate treatment effects for time-to-treatment antibiotic stewardship in sepsis. T4 estimates individual treatment effects by recurrently encoding temporal and static variables as potential confounders, and then decoding the outcomes under different treatment sequences. We propose mini-batch balancing matching that mimics the randomized controlled trial process to adjust the confounding. The model achieves interpretability through a global-level attention mechanism and a variable-level importance examination. Meanwhile, we equip T4 with an uncertainty quantification to help prevent overconfident recommendations. We demonstrate that T4 can identify effective treatment timing with estimated individual treatment effects for antibiotic stewardship on two real-world datasets. Moreover, comprehensive experiments on a synthetic dataset exhibit the outstanding performance of T4 compared with the state-of-the-art models on estimation of individual treatment effect.
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Affiliation(s)
- Ruoqi Liu
- Department of Computer Science and Engineering, The Ohio State University, Columbus, OH, USA
| | - Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine, The Ohio State University, Columbus, OH, USA
| | - Ping Zhang
- Department of Computer Science and Engineering, The Ohio State University, Columbus, OH, USA
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
- Translational Data Analytics institute, The Ohio State University, Columbus, OH, USA
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16
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Coen D. Fluids and vasopressors in septic shock: basic knowledge for a first approach in the emergency department. EMERGENCY CARE JOURNAL 2023. [DOI: 10.4081/ecj.2023.10810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Much research, both pathophysiological and clinical, has been produced about septic shock during the last 20 years. Nevertheless, many aspects of treatment are still controversial, among these the approach to the administration of fluids and vasopressors. After the first clinical trial on Early goal-directed therapy (EGDT) was published, a liberal approach to the use of fluids and conservative use of vasopressors prevailed, but in recent years a more restrictive use of fluids and an earlier introduction of vasopressors seem to be preferred. Although both treatments are based on sound pathophysiological knowledge, clinical evidence is still inadequate and somehow controversial. In this non-systematic review, recent research on the hemodynamics of septic shock and its treatment with fluids and inotropes is discussed. As a conclusion, general indications are proposed for a practical approach to patients in septic shock.
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17
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Ohnuma T, Chihara S, Costin B, Treggiari MM, Bartz RR, Raghunathan K, Krishnamoorthy V. Association of Appropriate Empirical Antimicrobial Therapy With In-Hospital Mortality in Patients With Bloodstream Infections in the US. JAMA Netw Open 2023; 6:e2249353. [PMID: 36598788 PMCID: PMC9857618 DOI: 10.1001/jamanetworkopen.2022.49353] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Bloodstream infections (BSIs) are a major public health problem associated with high morbidity. Little evidence exists regarding the epidemiology of BSIs and the use of appropriate empirical antimicrobial therapy. OBJECTIVE To estimate the association between receipt of appropriate initial empirical antimicrobial therapy and in-hospital mortality. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study used data from the Premier Healthcare database from 2016 to 2020. The analysis included 32 100 adult patients (aged ≥18 years) with BSIs from 183 US hospitals who received at least 1 new systemic antimicrobial agent within 2 days after blood samples were collected during the hospitalization. Patients with polymicrobial infections were excluded from the analysis. EXPOSURES Appropriate empirical therapy was defined as initiation of at least 1 new empirical antimicrobial agent to which the pathogen isolated from blood culture was susceptible either on the day of or the day after the blood sample was collected. MAIN OUTCOMES AND MEASURES Multilevel logistic regression models were used to estimate the association between receipt of appropriate initial empirical antimicrobial therapy and in-hospital mortality for patients infected with gram-negative rods (GNRs), gram-positive cocci (GPC), and Candida species. RESULTS Among 32 100 patients who had BSIs and received new empirical antimicrobial agents, the mean (SD) age was 64 (16) years; 54.8% were male, 69.9% were non-Hispanic White, and in-hospital mortality was 14.3%. The most common pathogens were Escherichia coli (58.4%) and Staphylococcus aureus (31.8%). Among patients infected with S aureus, methicillin-resistant S aureus was isolated in 43.6%. The crude proportions of appropriate empirical therapy use were 94.4% for GNR, 97.0% for GPC, and 65.1% for Candida species. The proportions of appropriate therapy use for resistant organisms were 55.3% for carbapenem-resistant Enterobacterales species and 60.4% for vancomycin-resistant Enterococcus species. Compared with inappropriate empirical therapy, receipt of appropriate empirical antimicrobial therapy was associated with lower in-hospital risk of death for 3 pathogen groups (GNR: adjusted odds ratio [aOR], 0.52 [95% CI, 0.42-0.64]; GPC: aOR, 0.60 [95% CI, 0.47-0.78]; Candida species: aOR, 0.43 [95% CI, 0.21-0.87]). CONCLUSIONS AND RELEVANCE In this cross-sectional study of patients hospitalized with BSIs, receipt of appropriate initial empirical antimicrobial therapy was associated with lower in-hospital mortality. It is important for clinicians to carefully choose empirical antimicrobial agents to improve outcomes in patients with BSIs.
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Affiliation(s)
- Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Shingo Chihara
- Section of Infectious Diseases, Department of Internal Medicine, Virginia Mason Medical Center, Seattle, Washington
| | - Blair Costin
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | - Raquel R. Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
- Anesthesia Service, Durham VA Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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18
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Machine-learning-derived sepsis bundle of care. Intensive Care Med 2023; 49:26-36. [PMID: 36446854 DOI: 10.1007/s00134-022-06928-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Compliance to the Surviving Sepsis Campaign (SSC) guidelines is limited. This is known to be associated with increased mortality. The aim of this retrospective cohort study was to identify among the SCC guidelines the optimal bundle of recommendations that minimize 28-day mortality. METHODS We used a training cohort to identify, using a least absolute shrinkage and selection operator penalized machine learning model, this bundle. Patients with sepsis/septic shock admitted to the intensive care unit (ICU) were extracted from two US databases, the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database (training and internal validation cohorts) and the eICU Collaborative Research Database (eICU-CRD) (external validation cohort). In the validation cohorts, we defined a bundle group that includes patients who were treated with at least all the recommendations selected in our bundle and a no-bundle group that includes patients in whom at least one recommendation from our bundle was omitted. RESULTS All-cause 28-day mortality was the primary outcome measure. A total of 42,735 patients were included. Six recommendations (antimicrobials, balanced crystalloid, insulin therapy, corticosteroids, vasopressin, and bicarbonate therapy) were identified from the training cohort to be included in our bundle. In the propensity score-(PS)-matched internal validation cohort, the bundle group was associated with a lower mortality (OR 0.41 [0.33-0.53]; p < 0.001) compared to the no-bundle group. This was confirmed in the PS-matched external validation cohort (OR 0.75 [0.60-0.94]; p 0.02). CONCLUSION Our bundle of six recommendations is associated with a dramatic reduction in mortality in sepsis and septic shock. This bundle needs to be evaluated prospectively.
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19
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Li Y, Ma M, Xu X, Li Q, Ji C. Value of digital PCR in the early diagnosis of sepsis: A systematic review and meta-analysis. J Crit Care 2022; 72:154138. [PMID: 36084378 DOI: 10.1016/j.jcrc.2022.154138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND We systematically assessed whether a digital polymerase chain reaction (PCR) could detect pathogenic microorganisms in patients with sepsis early and accurately. METHODS We searched the Cochrane Library, MEDLINE, Embase, CNKI, CBM, and Wanfang Data databases for eligible studies to compare the detection of pathogenic microorganisms in blood samples by digital PCR with the gold standard. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate bias risk, and a random-effects meta-analysis approach was used for sensitivity and specificity calculations. RESULTS Among the eight articles, there were eight identified studies with a total of 1278 subjects. The pooled sensitivity of digital PCR was 94% (95% confidence interval [CI], 85%-98%), the specificity was 87% (95% CI, 76%-94%), the positive likelihood ratio was 7.3 (95% CI, 3.8-14.2), the negative likelihood ratio was 0.07 (95% CI, 0.03-0.17), the positive predictive value was 84.7%, the negative predictive value was 89.2%, the diagnostic odds ratio was 105 (95% CI, 37-303), and the area under the receiver operating characteristic curve was 0.97 (95% CI, 0.95-1.00). Digital PCR can shorten the detection time of pathogenic microorganisms in patients with sepsis. CONCLUSIONS Digital PCR can detect pathogenic microorganisms in patients with sepsis earlier than blood culture. Therefore, digital PCR can be used as a potential strategy for the detection of pathogenic microorganisms in patients with sepsis.
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Affiliation(s)
- Yu Li
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Minjun Ma
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiujuan Xu
- Critical Care Department, Tongde Hospital of Zhejiang Province, Hangzhou, China.
| | - Qiushuang Li
- Clinical Evaluation Center, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Conghua Ji
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China; Clinical Evaluation Center, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China.
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20
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Klompas M, Rhee C. Antibiotics: it is all about timing, isn't it? Curr Opin Crit Care 2022; 28:513-521. [PMID: 35942689 DOI: 10.1097/mcc.0000000000000969] [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: 11/03/2022]
Abstract
PURPOSE OF REVIEW Sepsis guidelines and quality measures set aggressive deadlines for administering antibiotics to patients with possible sepsis or septic shock. However, the diagnosis of sepsis is often uncertain, particularly upon initial presentation, and pressure to treat more rapidly may harm some patients by exposing them to unnecessary or inappropriate broad-spectrum antibiotics. RECENT FINDINGS Observational studies that report that each hour until antibiotics increases mortality often fail to adequately adjust for comorbidities and severity of illness, fail to account for antibiotics given to uninfected patients, and inappropriately blend the effects of long delays with short delays. Accounting for these factors weakens or eliminates the association between time-to-antibiotics and mortality, especially for patients without shock. These findings are underscored by analyses of the Centers for Medicaid and Medicare Services SEP-1 measure: it has increased sepsis diagnoses and broad-spectrum antibiotic use but has not improved outcomes. SUMMARY Clinicians are advised to tailor the urgency of antibiotics to their certainty of infection and patients' severity of illness. Immediate antibiotics are warranted for patients with possible septic shock or high likelihood of infection. Antibiotics can safely be withheld to allow for more investigation, however, in most patients with less severe illnesses if the diagnosis of infection is uncertain.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Ward MA, Kuttab HI, Tuck N, Taleb A, Okut H, Badgett RG. The Effect of Fluid Initiation Timing on Sepsis Mortality: A Meta-Analysis. J Intensive Care Med 2022; 37:1504-1511. [PMID: 35946105 DOI: 10.1177/08850666221118513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Current guidelines suggest the immediate initiation of crystalloid for sepsis-induced hypoperfusion but note that supporting evidence is low quality. The aim of this study is to examine the effect of timing of fluid initiation on mortality for adults with sepsis. DATA SOURCES Two authors independently reviewed relevant articles and extracted study details from PubMed, Scopus, Cochrane, Google Scholar, and previous relevant systematic reviews from 1-1-2000 to 1-6-2022. Registered with PROSPERO (CRD42021245431) and bias assessed using CLARITY. STUDY SELECTION A minimum of severe sepsis (Sepsis-2) or sepsis (Sepsis-3) for patients ≥18 years old. Fluid initiation timing ranging from prehospital to 120 min within sepsis onset defined as "early" initiation. DATA EXTRACTION Included studies providing mortality-based odds ratios (or comparable) adjusting for confounders or prospective trials. DATA SYNTHESIS From 1643 citations, five retrospective cohort studies were included (n = 20,209) with in-hospital mortality of 21.8%. A pooled analysis (odds ratio = OR [95% CI]) did not observe an impact on mortality for the early initiation of fluids among all patients, OR = 0.79 [0.62-1.02]; heterogeneity: I2 = 86% [70-94%], but when studies analyzed cases of hypotension where available, a survival benefit was observed, OR = 0.74 [0.61-0.90]. Initiation of fluids in two prehospital studies did not impact mortality, OR = 0.82 [0.27-2.43]. However, both prehospital cohorts observed benefit among hypotensive patients individually, although heterogenous results precluded significance when pooled, OR = 0.50 [0.21-1.18]. Three hospital-based studies with initiation stratified at 30, 100, and 120 min, observed survival benefit both individually and when pooled, OR = 0.78 [0.63-0.97]. No differences were observed between prehospital versus hospital subgroups. CONCLUSION This meta-analysis supports the guideline recommendations for early fluid initiation once sepsis is recognized, especially in cases of hypotension. Findings are limited by the small number, heterogeneity, and retrospective nature of available studies. Further retrospective investigations may be worthwhile as randomized studies on fluid initiation are unlikely.
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Affiliation(s)
- Michael A Ward
- Department of Emergency, 5232University of Wisconsin-Madison, Madison, WI, USA
| | - Hani I Kuttab
- Department of Emergency, 5232University of Wisconsin-Madison, Madison, WI, USA
| | - Nicholas Tuck
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Ali Taleb
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Hayrettin Okut
- Office of Research, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Robert G Badgett
- Department of Internal Medicine, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
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22
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Waagsbø B, Stuve N, Afset JE, Klepstad P, Mo S, Heggelund L, Damås JK. High levels of discordant antimicrobial therapy in hospital-acquired bloodstream infections is associated with increased mortality in an intensive care, low antimicrobial resistance setting. Infect Dis (Lond) 2022; 54:738-747. [PMID: 35708021 DOI: 10.1080/23744235.2022.2083672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Bloodstream infections (BSI) occur frequently and are associated with severe outcomes. In this study we aimed to investigate proportions of patients that received discordant empirical antimicrobial therapy and its association to mortality. METHODS A retrospective cohort study model was undertaken to outline BSI in an intensive care, single centre, and low antimicrobial resistance prevalence setting. We used descriptive statistics to delineate proportions of patients that received discordant empirical antimicrobial therapy, and a correlation model and a logistic regression model to calculate the association with mortality and predictors of receiving discordant therapy, respectively. RESULTS From 2014 to 2018 we included 270 BSI episodes, of which one third were hospital-acquired. Gram negative, Gram positive, and anaerobic pathogens were detected in 49.0%, 45.3% and 5.7% respectively. The proportion of isolates that conferred extended-spectrum beta-lactamase (ESBL) properties were 5.9% among enterobactereales, and no methicillin-resistant Staphylococcus aureus isolates were detected. Empirical antimicrobial therapy for community-acquired (CA) and hospital-acquired (HA) BSI were discordant at day 0 in 6.5% and 24.4%, respectively (p<.001). Discordant therapy was significantly associated with mortality at day 28 (p=.041). HA-onset BSI, enterococcal BSI and BSI of intraabdominal origin were statistically significant predictors of receiving discordant therapy. CONCLUSION A significant proportion of HA-BSI did not receive effective antimicrobial therapy and this was significantly associated with mortality. The results underscore the need for more accurate diagnostic tools, improved communication between the microbiological laboratory and the clinicians, and antimicrobial stewardship measures.
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Affiliation(s)
- Bjørn Waagsbø
- Regional Centre for Disease Control in Central Norway Regional Health Authority, Trondheim University Hospital, Trondheim, Norway
| | - Nora Stuve
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Egil Afset
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Medical Microbiology, St. Olavs Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.,Department of Anaesthesiology and Intensive Care Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Skule Mo
- Department of Anaesthesiology and Intensive Care Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Lars Heggelund
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Jan Kristian Damås
- Department of Infectious Diseases, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Centre of Molecular Inflammation Research, department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
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23
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Murata J, Buckley M, Lehn J, Agarwal SK, Stevenson B, Martinez B, MacLaren R. Incidence of Hypotension Associated With Two Different Vasopressin Discontinuation Strategies in the Recovery Phase of Septic Shock. J Pharm Pract 2022:8971900221078270. [PMID: 35331049 DOI: 10.1177/08971900221078270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Safe and effective vasopressor withdrawal strategies during the recovery phase of septic shock lack consensus and are not addressed in clinical practice guidelines. The purpose of this study was to compare the incidence of clinically relevant hypotension associated with different vasopressin (AVP) discontinuation strategies. METHODS This was a single-center, retrospective, cohort study, conducted at a university medical center over a three-year period. Adult patients ≥18 years with septic shock were included in the study. Patients were stratified into two groups; patients incrementally weaned from AVP and patients in which AVP was abruptly discontinued. The primary endpoint was to compare the incidence of clinically relevant hypotension between study groups up to 24 hours following discontinuation. Secondary analyses included the incidence of any hypotensive event up to 24 hours after AVP cessation, intensive care unit and hospital length of stay, and in-hospital mortality. RESULTS A total of 74 patients (n = 46 AVP wean and n = 28 AVP no-wean) met inclusion criteria and were included in the study. The primary outcome was not statistically different between groups. Clinically relevant hypotension occurred in 24 patients (52.3%) and 16 patients (57.1%) in the AVP wean and AVP no-wean groups, respectively (P = .68). There were no significant differences in any secondary clinical outcome between the two study groups. CONCLUSION No differences were found in the incidence of clinically relevant hypotension, length of stay, or mortality between AVP weaning and no-weaning discontinuation strategies. These findings suggest incremental weaning and abrupt withdrawal of AVP are both acceptable discontinuation strategies.
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Affiliation(s)
- Joseph Murata
- Department of Pharmacy, 22386Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Mitchell Buckley
- Department of Pharmacy, 22386Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Julie Lehn
- Department of Pharmacy, 22386Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Sumit K Agarwal
- Department of Care Transformation, 22386Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Byron Stevenson
- Pharmacy Practice Resident, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Brandon Martinez
- Department of Pharmacy, 22386Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Murphy CV, Reed EE, Herman DD, Magrum B, Beatty JJ, Stevenson KB. Antimicrobial Stewardship in the ICU. Semin Respir Crit Care Med 2022; 43:131-140. [PMID: 35172363 DOI: 10.1055/s-0041-1740977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Increasing rates of infection and multidrug-resistant pathogens, along with a high use of antimicrobial therapy, make the intensive care unit (ICU) an ideal setting for implementing and supporting antimicrobial stewardship efforts. Overuse of antimicrobial agents is common in the ICU, as practitioners are challenged daily with achieving early, appropriate empiric antimicrobial therapy to improve patient outcomes. While early antimicrobial stewardship programs focused on the financial implications of antimicrobial overuse, current goals of stewardship programs align closely with those of critical care providers-to optimize patient outcomes, reduce development of resistance, and minimize adverse outcomes associated with antibiotic overuse and misuse such as acute kidney injury and Clostridioides difficile-associated disease. Significant opportunities exist in the ICU for critical care clinicians to support stewardship practices at the bedside, including thoughtful and restrained initiation of antimicrobial therapy, use of biomarkers in addition to rapid diagnostics, Staphylococcus aureus screening, and traditional microbiologic culture and susceptibilities to guide antibiotic de-escalation, and use of the shortest duration of therapy that is clinically appropriate. Integration of critical care practitioners into the initiatives of antimicrobial stewardship programs is key to their success. This review summarizes key components of antimicrobial stewardship programs and mechanisms for critical care practitioners to share the responsibility for antimicrobial stewardship.
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Affiliation(s)
- Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Erica E Reed
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Derrick D Herman
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - BrookeAnne Magrum
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julia J Beatty
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kurt B Stevenson
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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25
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Luis-Silva F, Menegueti MG, Sepeda CDR, Petroski-Moraes BC, Sato L, Peres LM, Becari C, Basile-Filho A, Evora PR, Martins-Filho OA, Auxiliadora-Martins M. Effect of methylene blue on hemodynamic and metabolic response in septic shock patients. Medicine (Baltimore) 2022; 101:e28599. [PMID: 35060528 PMCID: PMC8772761 DOI: 10.1097/md.0000000000028599] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Septic shock is a lethal disease responsible for a large proportion of deaths in the Intensive Care Unit (ICU), even with therapy centered on fluid resuscitation, use of vasopressors and empirical antibiotic therapy applied within the first hour of diagnosis. Considering the multifactorial pathophysiology of septic shock and the mechanism of action of vasopressors, some patients may not respond adequately, which can lead to the maintenance of vasodilatation, hypotension and increased morbidity, and mortality. This protocol aims to verify whether the use of methylene blue in septic patients with an early diagnosis can contribute to an earlier resolution of a shock compared to standard treatment. METHODS AND ANALYSIS This is a study protocol for a single-center randomized clinical trial design in an ICU of a tertiary university hospital. In this study, we intend to include 64 patients aged between 18 and 80 years with a diagnosis of septic shock, of any etiology, with up to 72 hours of evolution after volume restoration, using norepinephrine at a dose ≥0.2 μg/kg/min and vasopressin at a dose of 0.04 IU/min. After the initial approach, we will randomize patients into two groups, standard care, and standard care plus methylene blue. The sample size was calculated in order to show 30% differences in septic shock resolution between groups. The Research Ethics Committee approved the study, and all patients included will sign an informed consent form (Clinical registration: RBR-96584w4).
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Affiliation(s)
- Fabio Luis-Silva
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- Professor of Clinical Medicine, Barao de Maua University Center - Ribeirão Preto / São Paulo, Brazil
| | | | - Corina dos Reis Sepeda
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Bruno C. Petroski-Moraes
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lucas Sato
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Leandro Moreira Peres
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Christiane Becari
- Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Paulo R.B. Evora
- Division of Cardiac Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Maria Auxiliadora-Martins
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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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: 880] [Impact Index Per Article: 293.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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27
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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: 1425] [Impact Index Per Article: 475.0] [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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Ravi C, Johnson DW. Optimizing Fluid Resuscitation and Preventing Fluid Overload in Patients with Septic Shock. Semin Respir Crit Care Med 2021; 42:698-705. [PMID: 34544187 DOI: 10.1055/s-0041-1733898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravenous fluid administration remains an important component in the care of patients with septic shock. A common error in the treatment of septic shock is the use of excessive fluid in an effort to overcome both hypovolemia and vasoplegia. While fluids are necessary to help correct the intravascular depletion, vasopressors should be concomitantly administered to address vasoplegia. Excessive fluid administration is associated with worse outcomes in septic shock, so great care should be taken when deciding how much fluid to give these vulnerable patients. Simple or strict "recipes" which mandate an exact amount of fluid to administer, even when weight based, are not associated with better outcomes and therefore should be avoided. Determining the correct amount of fluid requires the clinician to repeatedly assess and consider multiple variables, including the fluid deficit, organ dysfunction, tolerance of additional fluid, and overall trajectory of the shock state. Dynamic indices, often involving the interaction between the cardiovascular and respiratory systems, appear to be superior to traditional static indices such as central venous pressure for assessing fluid responsiveness. Point-of-care ultrasound offers the bedside clinician a multitude of applications which are useful in determining fluid administration in septic shock. In summary, prevention of fluid overload in septic shock patients is extremely important, and requires the careful attention of the entire critical care team.
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Affiliation(s)
- Chandni Ravi
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Daniel W Johnson
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Kalil AC, Stebbing J. Baricitinib: the first immunomodulatory treatment to reduce COVID-19 mortality in a placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2021; 9:1349-1351. [PMID: 34480862 PMCID: PMC8409093 DOI: 10.1016/s2213-2600(21)00358-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Justin Stebbing
- Department of Surgery and Cancer, Imperial College London, London, UK
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Abstract
BACKGROUND Circulating complement C3 fragments released during septic shock might contribute to the development of complications such as profound hypotension and disseminated intravascular coagulation. The role of C3 in the course of septic shock varies in the literature, possibly because circulating C3 exists in different forms indistinguishable via traditional ELISA-based methods. We sought to test the relationship between C3 forms, measured by Western blotting with its associated protein size differentiation feature, and clinical outcomes. METHODS Secondary analysis of two prospective cohorts of patients with septic shock: a discovery cohort of 24 patents and a validation cohort of 181 patients. C3 levels were measured by Western blotting in both cohorts using blood obtained at enrollment. Differences between survivors and non-survivors were compared, and the independent prognostic values of C3 forms were assessed. RESULTS In both cohorts there were significantly lower levels of the C3-alpha chain in non-survivors than in survivors, and persisted after controlling for sequential organ failure assessment score. Area under the receiver operating characteristics to predict survival was 0.65 (95% confidence interval: 0.56-0.75). At a best cutoff value (Youden) of 970.6 μg/mL, the test demonstrated a sensitivity of 68.5% and specificity of 61.5%. At this cutoff point, Kaplan-Meier survival analysis showed that patients with lower levels of C3-alpha chain had significantly lower survival than those with higher levels (P < 0.001). CONCLUSION Circulating C3-alpha chain levels is a significant independent predictor of survival in septic shock patients.
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Do not just sit there, do something … but do no harm: the worrying aspects of COVID-19 experimental interventions. Intensive Care Med 2021; 47:896-898. [PMID: 34223922 PMCID: PMC8255728 DOI: 10.1007/s00134-021-06460-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/09/2021] [Indexed: 12/15/2022]
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Assessment of a Cellular Host Response Test as a Sepsis Diagnostic for Those With Suspected Infection in the Emergency Department. Crit Care Explor 2021; 3:e0460. [PMID: 34151282 PMCID: PMC8208428 DOI: 10.1097/cce.0000000000000460] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Sepsis is a common cause of morbidity and mortality. A reliable, rapid, and early indicator can help improve efficiency of care and outcomes. To assess the IntelliSep test, a novel in vitro diagnostic that quantifies the state of immune activation by measuring the biophysical properties of leukocytes, as a rapid diagnostic for sepsis and a measure of severity of illness, as defined by Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation-II scores and the need for hospitalization. Design, Setting, SUBJECTS: Adult patients presenting to two emergency departments in Baton Rouge, LA, with signs of infection (two of four systemic inflammatory response syndrome criteria, with at least one being aberration of temperature or WBC count) or suspicion of infection (a clinician order for culture of a body fluid), were prospectively enrolled. Sepsis status, per Sepsis-3 criteria, was determined through a 3-tiered retrospective and blinded adjudication process consisting of objective review, site-level clinician review, and final determination by independent physician adjudicators. MEASUREMENTS AND MAIN RESULTS: Of 266 patients in the final analysis, those with sepsis had higher IntelliSep Index (median = 6.9; interquartile range, 6.1–7.6) than those adjudicated as not septic (median = 4.7; interquartile range, 3.7–5.9; p < 0.001), with an area under the receiver operating characteristic curve of 0.89 and 0.83 when compared with unanimous and forced adjudication standards, respectively. Patients with higher IntelliSep Index had higher Sequential Organ Failure Assessment (3 [interquartile range, 1–5] vs 1 [interquartile range, 0–2]; p < 0.001) and Acute Physiology and Chronic Health Evaluation-II (7 [interquartile range, 3.5–11.5] vs 5 [interquartile range, 2–9]; p < 0.05) and were more likely to be admitted to the hospital (83.6% vs 48.3%; p < 0.001) compared with those with lower IntelliSep Index. CONCLUSIONS: In patients presenting to the emergency department with signs or suspicion of infection, the IntelliSep Index is a promising tool for the rapid diagnosis and risk stratification for sepsis.
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Comparative Early Hemodynamic Profiles in Patients Presenting to the Emergency Department with Septic and Nonseptic Acute Circulatory Failure Using Focused Echocardiography. Shock 2021; 53:695-700. [PMID: 31568225 PMCID: PMC7237072 DOI: 10.1097/shk.0000000000001449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Objective: We evaluated the early hemodynamic profile of patients presenting with acute circulatory failure to the Emergency Department (ED) using focused echocardiography performed by emergency physicians after a dedicated training program. Methods: Patients presenting to the ED with an acute circulatory failure of any origin were successively examined by a recently trained emergency physician and by an expert in critical care echocardiography. Operators independently performed and interpreted online echocardiographic examinations to determine the leading mechanism of acute circulatory failure. Results: Focused echocardiography could be performed in 100 of 114 screened patients (55 with sepsis/septic shock and 45 with shock of other origin) after a median fluid loading of 500 mL (interquartile range: 187–1,500 mL). A hypovolemic profile was predominantly observed whether the acute circulatory failure was of septic origin or not (33/55 [60%] vs. 23/45 [51%]: P = 0.37). Although a vasoplegic profile associated with a hyperkinetic left ventricle was most frequently identified in septic patients when compared with their counterparts (17/55 [31%] vs. 5/45 [11%]: P = 0.02), early left or right ventricular failure was observed in 31% of them. Hemodynamic profiles were adequately appraised by recently trained emergency physicians, as reflected by a good-to-excellent agreement with the expert's assessment (Κ: 0.61–0.85). Conclusions: Hypovolemia was predominantly identified in patients presenting to the ED with acute circulatory failure. Although vasoplegia was more frequently associated with sepsis, early ventricular dysfunction was also depicted in septic patients. Focused echocardiography seemed reliable when performed by recently trained emergency physicians without previous experience in ultrasound.
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Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Be Quick But Don't Hurry: Septic Shock, Staphylococcus aureus Bacteremia, and the Timing of Appropriate Antibiotics. Crit Care Med 2021; 48:608-609. [PMID: 32205613 DOI: 10.1097/ccm.0000000000004278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu R, Greenstein JL, Fackler JC, Bembea MM, Winslow RL. Spectral clustering of risk score trajectories stratifies sepsis patients by clinical outcome and interventions received. eLife 2020; 9:58142. [PMID: 32959779 PMCID: PMC7508552 DOI: 10.7554/elife.58142] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022] Open
Abstract
Sepsis is not a monolithic disease, but a loose collection of symptoms with diverse outcomes. Thus, stratification and subtyping of sepsis patients is of great importance. We examine the temporal evolution of patient state using our previously-published method for computing risk of transition from sepsis into septic shock. Risk trajectories diverge into four clusters following early prediction of septic shock, stratifying by outcome: the highest-risk and lowest-risk groups have a 76.5% and 10.4% prevalence of septic shock, and 43% and 18% mortality, respectively. These clusters differ also in treatments received and median time to shock onset. Analyses reveal the existence of a rapid (30–60 min) transition in risk at the time of threshold crossing. We hypothesize that this transition occurs as a result of the failure of compensatory biological systems to cope with infection, resulting in a bifurcation of low to high risk. Such a collapse, we believe, represents the true onset of septic shock. Thus, this rapid elevation in risk represents a potential new data-driven definition of septic shock.
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Affiliation(s)
- Ran Liu
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, United States.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Baltimore, United States
| | - Joseph L Greenstein
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, United States
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, United States.,Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, United States
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, United States.,Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, United States
| | - Raimond L Winslow
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, United States.,Department of Biomedical Engineering, The Johns Hopkins University School of Medicine & Whiting School of Engineering, Baltimore, United States
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Supply Chain Delays in Antimicrobial Administration After the Initial Clinician Order and Mortality in Patients With Sepsis. Crit Care Med 2020; 47:1388-1395. [PMID: 31343474 DOI: 10.1097/ccm.0000000000003921] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES There is mounting evidence that delays in appropriate antimicrobial administration are responsible for preventable deaths in patients with sepsis. Herein, we examine the association between potentially modifiable antimicrobial administration delays, measured by the time from the first order to the first administration (antimicrobial lead time), and death among people who present with new onset of sepsis. DESIGN Observational cohort and case-control study. SETTING The emergency department of an academic, tertiary referral center during a 3.5-year period. PATIENTS Adult patients with new onset of sepsis or septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We enrolled 4,429 consecutive patients who presented to the emergency department with a new diagnosis of sepsis. We defined 0-1 hour as the gold standard antimicrobial lead time for comparison. Fifty percent of patients had an antimicrobial lead time of more than 1.3 hours. For an antimicrobial lead time of 1-2 hours, the adjusted odds ratio of death at 28 days was 1.28 (95% CI, 1.07-1.54; p = 0.007); for an antimicrobial lead time of 2-3 hours was 1.07 (95% CI, 0.85-1.36; p = 0.6); for an antimicrobial lead time of 3-6 hours was 1.57 (95% CI, 1.26-1.95; p < 0.001); for an antimicrobial lead time of 6-12 hours was 1.36 (95% CI, 0.99-1.86; p = 0.06); and for an antimicrobial lead time of more than 12 hours was 1.85 (95% CI, 1.29-2.65; p = 0.001). CONCLUSIONS Delays in the first antimicrobial execution, after the initial clinician assessment and first antimicrobial order, are frequent and detrimental. Biases inherent to the retrospective nature of the study apply. Known biologic mechanisms support these findings, which also demonstrate a dose-response effect. In contrast to the elusive nature of sepsis onset and sepsis onset recognition, antimicrobial lead time is an objective, measurable, and modifiable process.
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Rhee C, Kadri SS, Dekker JP, Danner RL, Chen HC, Fram D, Zhang F, Wang R, Klompas M. Prevalence of Antibiotic-Resistant Pathogens in Culture-Proven Sepsis and Outcomes Associated With Inadequate and Broad-Spectrum Empiric Antibiotic Use. JAMA Netw Open 2020; 3:e202899. [PMID: 32297949 PMCID: PMC7163409 DOI: 10.1001/jamanetworkopen.2020.2899] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Broad-spectrum antibiotics are recommended for all patients with suspected sepsis to minimize the risk of undertreatment. However, little is known regarding the net prevalence of antibiotic-resistant pathogens across all patients with community-onset sepsis or the outcomes associated with unnecessarily broad empiric treatment. OBJECTIVE To elucidate the epidemiology of antibiotic-resistant pathogens and the outcomes associated with both undertreatment and overtreatment in patients with culture-positive community-onset sepsis. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 17 430 adults admitted to 104 US hospitals between January 2009 and December 2015 with sepsis and positive clinical cultures within 2 days of admission. Data analysis took place from January 2018 to December 2019. EXPOSURES Inadequate empiric antibiotic therapy (ie, ≥1 pathogen nonsusceptible to all antibiotics administered on the first or second day of treatment) and unnecessarily broad empiric therapy (ie, active against methicillin-resistant Staphylococcus aureus [MRSA]; vancomycin-resistant Enterococcus [VRE]; ceftriaxone-resistant gram-negative [CTX-RO] organisms, including Pseudomonas aeruginosa; or extended-spectrum β-lactamase [ESBL] gram-negative organisms when none of these were isolated). MAIN OUTCOMES AND MEASURES Prevalence and empiric treatment rates for antibiotic-resistant organisms and associations of inadequate and unnecessarily broad empiric therapy with in-hospital mortality were assessed, adjusting for baseline characteristics and severity of illness. RESULTS Of 17 430 patients with culture-positive community-onset sepsis (median [interquartile range] age, 69 [57-81] years; 9737 [55.9%] women), 2865 (16.4%) died in the hospital. The most common culture-positive sites were urine (9077 [52.1%]), blood (6968 [40.0%]), and the respiratory tract (2912 [16.7%]). The most common pathogens were Escherichia coli (5873 [33.7%]), S aureus (3706 [21.3%]), and Streptococcus species (2361 [13.5%]). Among 15 183 cases in which all antibiotic-pathogen susceptibility combinations could be calculated, most (12 398 [81.6%]) received adequate empiric antibiotics. Empiric therapy targeted resistant organisms in 11 683 of 17 430 cases (67.0%; primarily vancomycin and anti-Pseudomonal β-lactams), but resistant organisms were uncommon (MRSA, 2045 [11.7%]; CTX-RO, 2278 [13.1%]; VRE, 360 [2.1%]; ESBLs, 133 [0.8%]). The net prevalence for at least 1 resistant gram-positive organism (ie, MRSA or VRE) was 13.6% (2376 patients), and for at least 1 resistant gram-negative organism (ie, CTX-RO, ESBL, or CRE), it was 13.2% (2297 patients). Both inadequate and unnecessarily broad empiric antibiotics were associated with higher mortality after detailed risk adjustment (inadequate empiric antibiotics: odds ratio, 1.19; 95% CI, 1.03-1.37; P = .02; unnecessarily broad empiric antibiotics: odds ratio, 1.22; 95% CI, 1.06-1.40; P = .007). CONCLUSIONS AND RELEVANCE In this study, most patients with community-onset sepsis did not have resistant pathogens, yet broad-spectrum antibiotics were frequently administered. Both inadequate and unnecessarily broad empiric antibiotics were associated with higher mortality. These findings underscore the need for better tests to rapidly identify patients with resistant pathogens and for more judicious use of broad-spectrum antibiotics for empiric sepsis treatment.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - John P. Dekker
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert L. Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | | | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
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Chacko B. Kidney Injury in Sepsis: Fuel to the Fire. Indian J Crit Care Med 2020; 24:216-217. [PMID: 32565629 PMCID: PMC7297247 DOI: 10.5005/jp-journals-10071-23414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Chacko B. Kidney Injury in Sepsis: Fuel to the Fire. Indian J Crit Care Med 2020;24(4):216-217.
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Affiliation(s)
- Binila Chacko
- Medical Intensive Care Unit, Division of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India
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Reynolds PM, Wells L, MacLaren R, Scoular SK. Establishing the Therapeutic Index of Fluid Resuscitation in the Septic Patient: A Narrative Review and Meta-Analysis. Pharmacotherapy 2020; 40:256-269. [PMID: 31970818 DOI: 10.1002/phar.2371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/29/2022]
Abstract
This comprehensive review comparatively evaluates the safety and benefits of parenteral fluids used in resuscitation with a focus on sepsis. It also provides a random-effects meta-analysis of studies comparing restrictive resuscitation and usual care in sepsis with the primary outcome of mortality. In the septic patient, fluid therapy remains a complex interplay between fluid compartments in the body, the integrity of the endothelial barrier, and the inflammatory tone of the patient. Recent data have emerged describing the pharmacokinetics of fluid resuscitation that can be affected by the factors just listed, as well as mean arterial pressure, rate of infusion, volume of fluid infusate, nature of the fluid, and drug interactions. Fluid overload in sepsis has been associated with vasodilation, kidney injury, and increased mortality. Restrictive resuscitation after the initial septic insult is an emerging practice. Our search strategy of Medline databases revealed six randomized studies with 706 patients that examined restrictive resuscitation in sepsis. Results of this meta-analysis demonstrated no differences in mortality with restrictive resuscitation compared with usual care (30.6% vs 37.8%; risk ratio 0.83, 95% confidence interval 0.66-1.05, respectively) but was limited by the small number of studies and larger quantities of pre-randomization fluids. Another approach to address fluid overload is active (diuresis) de-resuscitation strategies that may shorten the need for mechanical ventilation and intensive care unit length of stay. Data suggest that colloids may confer mortality benefit over saline in the most severely ill septic patients. Compared with isotonic saline, balanced resuscitation fluids are associated with a lower incidence of acute kidney injury and mortality. The benefits of balanced resuscitation fluids are most evident when higher volumes of fluids are used for sepsis. Clinicians should consider these pharmacotherapeutic factors when selecting a fluid, its quantity, and rate of infusion.
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Affiliation(s)
- Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Lauren Wells
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Sarah K Scoular
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
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Kalil AC. Lack of Benefit of High-Dose Vitamin C, Thiamine, and Hydrocortisone Combination for Patients With Sepsis. JAMA 2020; 323:419-420. [PMID: 31950983 DOI: 10.1001/jama.2019.22438] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
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Gazmuri RJ, de Gomez CA. From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case. J Crit Care 2020; 56:294-304. [PMID: 31926637 DOI: 10.1016/j.jcrc.2019.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/28/2019] [Accepted: 11/13/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation. MATERIAL AND METHODS Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case. RESULTS Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution. CONCLUSIONS We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome.
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Affiliation(s)
- Raúl J Gazmuri
- Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine and ICU, Captain James A. Lovell Federal Health Care Center, USA.
| | - Cristina Añez de Gomez
- Internal Medicine Physician, Northwestern Medical Group, Northwestern Medicine Lake Forrest Hospital, USA
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Scully TG, Huang Y, Huang S, McLean AS, Orde SR. The effects of static and dynamic measurements using transpulmonary thermodilution devices on fluid therapy in septic shock: A systematic review. Anaesth Intensive Care 2020; 48:11-24. [DOI: 10.1177/0310057x19893703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transpulmonary thermodilution devices have been widely shown to be accurate in septic shock patients in assessing fluid responsiveness. We conducted a systematic review to assess the relationship between fluid therapy protocols guided by transpulmonary thermodilution devices on fluid balance and the amount of intravenous fluid used in septic shock. We searched MEDLINE, Embase and The Cochrane Library. Studies were eligible for inclusion if they were prospective, parallel trials that were conducted in an intensive care setting in patients with septic shock. The comparator group was either central venous pressure, early goal-directed therapy or pulmonary artery occlusion pressure. Studies assessing only the accuracy of fluid responsiveness prediction by transpulmonary thermodilution devices were excluded. Two reviewers independently performed the search, extracted data and assessed the bias of each study. In total 27 full-text articles were identified for eligibility; of these, nine studies were identified for inclusion in the systematic review. Three of these trials used dynamic parameters derived from transpulmonary thermodilution devices and six used primarily static parameters to guide fluid therapy. There was evidence for a significant reduction in positive fluid balance in four out of the nine studies. From the available studies, the results suggest the benefit of transpulmonary thermodilution monitoring in the septic shock population with regard to reducing positive fluid balance is seen when the devices are utilised for at least 72 hours. Both dynamic and static parameters derived from transpulmonary thermodilution devices appear to lead to a reduction in positive fluid balance in septic shock patients compared to measurements of central venous pressure and early goal-directed therapy.
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Affiliation(s)
| | - Yifan Huang
- Intensive Care Unit, Nepean Hospital, Kingswood, Australia
| | - Stephen Huang
- Intensive Care Unit, Nepean Hospital, Kingswood, Australia
- Discipline of Intensive Care Medicine, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Anthony S McLean
- Intensive Care Unit, Nepean Hospital, Kingswood, Australia
- Discipline of Intensive Care Medicine, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Sam R Orde
- Intensive Care Unit, Nepean Hospital, Kingswood, Australia
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Gibson SB, Green SI, Liu CG, Salazar KC, Clark JR, Terwilliger AL, Kaplan HB, Maresso AW, Trautner BW, Ramig RF. Constructing and Characterizing Bacteriophage Libraries for Phage Therapy of Human Infections. Front Microbiol 2019; 10:2537. [PMID: 31781060 PMCID: PMC6861333 DOI: 10.3389/fmicb.2019.02537] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 10/21/2019] [Indexed: 12/21/2022] Open
Abstract
Phage therapy requires libraries of well-characterized phages. Here we describe the generation of phage libraries for three target species: Escherichia coli, Pseudomonas aeruginosa, and Enterobacter cloacae. The basic phage characteristics on the isolation host, sequence analysis, growth properties, and host range and virulence on a number of contemporary clinical isolates are presented. This information is required before phages can be added to a phage library for potential human use or sharing between laboratories for use in compassionate use protocols in humans under eIND (emergency investigational new drug). Clinical scenarios in which these phages can potentially be used are discussed. The phages presented here are currently being characterized in animal models and are available for eINDs.
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Affiliation(s)
- Shelley B. Gibson
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Sabrina I. Green
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Carmen Gu Liu
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Keiko C. Salazar
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Justin R. Clark
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Austen L. Terwilliger
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Heidi B. Kaplan
- Department of Microbiology and Molecular Genetics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Anthony W. Maresso
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Barbara W. Trautner
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Robert F. Ramig
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
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Infectious Diseases Society of America (IDSA) POSITION STATEMENT: Why IDSA Did Not Endorse the Surviving Sepsis Campaign Guidelines. Clin Infect Dis 2019; 66:1631-1635. [PMID: 29182749 DOI: 10.1093/cid/cix997] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022] Open
Abstract
IDSA did not endorse the 2016 Surviving Sepsis Campaign Guidelines despite being represented in the working group that drafted the guidelines document. Leadership from the IDSA, the Surviving Sepsis Campaign Guidelines, and the Society of Critical Care Medicine had numerous amicable discussions primarily regarding the bolded, rated guidelines recommendations. Our societies had different perspectives, however, regarding the interpretation of the major studies that informed the guidelines' recommendations, thus leading us to different conclusions and different perspectives on the recommendations. IDSA consequently elected not to endorse the guidelines. IDSA nonetheless hopes to be able to continue collaborating with the Surviving Sepsis Campaign and the Society of Critical Care Medicine to resolve our differences and to develop further strategies together to prevent sepsis and septic shock as well as reduce death and disability from these conditions both nationally and globally.
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Pepper DJ, Sun J, Cui X, Welsh J, Natanson C, Eichacker PQ. Antibiotic- and Fluid-Focused Bundles Potentially Improve Sepsis Management, but High-Quality Evidence Is Lacking for the Specificity Required in the Centers for Medicare and Medicaid Service's Sepsis Bundle (SEP-1). Crit Care Med 2019; 47:1290-1300. [PMID: 31369426 PMCID: PMC10802116 DOI: 10.1097/ccm.0000000000003892] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To address three controversial components in the Centers for Medicare and Medicaid Service's sepsis bundle for performance measure (SEP-1): antibiotics within 3 hours, a 30 mL/kg fluid infusion for all hypotensive patients, and repeat lactate measurements within 6 hours if initially elevated. We hypothesized that antibiotic- and fluid-focused bundles like SEP-1 would probably show benefit, but evidence supporting specific antibiotic timing, fluid dosing, or serial lactate requirements would not be concordant. Therefore, we performed a meta-analysis of studies of sepsis bundles like SEP-1. DATA SOURCES PubMed, Embase, ClinicalTrials.gov through March 15, 2018. STUDY SELECTION Studies comparing survival in septic adults receiving versus not receiving antibiotic- and fluid-focused bundles. DATA EXTRACTION Two investigators (D.J.P., P.Q.E.). DATA SYNTHESIS Seventeen observational studies (11,303 controls and 4,977 bundle subjects) met inclusion criteria. Bundles were associated with increased odds ratios of survival (odds ratio [95% CI]) in 15 studies with substantial heterogeneity (I = 61%; p < 0.01). Survival benefits were consistent in the five largest (1,697-12,486 patients per study) (1.20 [1.11-1.30]; I = 0%) and six medium-sized studies (167-1,029) (2.03 [1.52-2.71]; I = 8%) but not the six smallest (64-137) (1.25 [0.42-3.66]; I = 57%). Bundles were associated with similarly increased survival benefits whether requiring antibiotics within 1 hour (n = 7 studies) versus 3 hours (n = 8) versus no specified time (n = 2); or 30 mL/kg fluid (n = 7) versus another volume (≥ 2 L, n = 1; ≥ 20 mL/kg, n = 2; 1.5-2 L or 500 mL, n = 1 each; none specified, n = 4) (p = 0.19 for each comparison). In the only study employing serial lactate measurements, survival was not increased versus others. No study had a low risk of bias or assessed potential adverse bundle effects. CONCLUSIONS Available studies support the notion that antibiotic- and fluid-focused sepsis bundles like SEP-1 improve survival but do not demonstrate the superiority of any specific antibiotic time or fluid volume or of serial lactate measurements. Until strong reproducible evidence demonstrates the safety and benefit of any fixed requirement for these interventions, the present findings support the revision of SEP-1 to allow flexibility in treatment according to physician judgment.
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Affiliation(s)
- Dominique J Pepper
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Judith Welsh
- NIH Library, National Institutes of Health, Bethesda, MD
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD
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Abstract
OBJECTIVE To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock. DESIGN A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion. The entire committee iteratively developed the entire document and recommendations. METHODS Each committee member independently gave their top five priorities for sepsis research. A total of 88 suggestions (Supplemental Table 1, Supplemental Digital Content 2, http://links.lww.com/CCM/D636) were grouped into categories by the committee co-chairs, leading to the formation of seven subgroups: infection, fluids and vasoactive agents, adjunctive therapy, administration/epidemiology, scoring/identification, post-intensive care unit, and basic/translational science. Each subgroup had teleconferences to go over each priority followed by formal voting within each subgroup. The entire committee also voted on top priorities across all subgroups except for basic/translational science. RESULTS The Surviving Sepsis Research Committee provides 26 priorities for sepsis and septic shock. Of these, the top six clinical priorities were identified and include the following questions: 1) can targeted/personalized/precision medicine approaches determine which therapies will work for which patients at which times?; 2) what are ideal endpoints for volume resuscitation and how should volume resuscitation be titrated?; 3) should rapid diagnostic tests be implemented in clinical practice?; 4) should empiric antibiotic combination therapy be used in sepsis or septic shock?; 5) what are the predictors of sepsis long-term morbidity and mortality?; and 6) what information identifies organ dysfunction? CONCLUSIONS While the Surviving Sepsis Campaign guidelines give multiple recommendations on the treatment of sepsis, significant knowledge gaps remain, both in bedside issues directly applicable to clinicians, as well as understanding the fundamental mechanisms underlying the development and progression of sepsis. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Is Procalcitonin-Guided Therapy Associated With Beneficial Outcomes in Critically Ill Patients With Sepsis? Crit Care Med 2019; 46:811-812. [PMID: 29652705 DOI: 10.1097/ccm.0000000000003024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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49
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Quick Sequential Organ Failure Assessment Is Not Good for Ruling Sepsis In or Out. Chest 2019; 156:197-199. [DOI: 10.1016/j.chest.2019.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 01/10/2023] Open
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50
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Should We Manage All Septic Patients Based on a Single Definition? An Alternative Approach. Crit Care Med 2019; 46:177-180. [PMID: 29068856 DOI: 10.1097/ccm.0000000000002778] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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