The Association Between Antibiotic Delay Intervals and Hospital Mortality Among Patients Treated in the Emergency Department for Suspected Sepsis

Characteristics, clinical care, and outcomes of sepsis among patients boarding in the emergency department

BACKGROUND

Patients who first meet clinical criteria for sepsis while boarding in the emergency department (ED) may not receive optimal sepsis care.

OBJECTIVE

Assess the association between ED boarding status and sepsis quality of care and outcomes.

METHODS

We conducted a retrospective cohort study of adult patients admitted to a large academic hospital from July 2021 to October 2023 who had clinical features consistent with sepsis present while physically in the ED. We compared outcomes for patients who experienced time zero (T-0; the time clinical features of sepsis were first present) while boarding in the ED (physically in the ED but admitted to a different service) to those experiencing T-0 while still under the care of the ED provider team. We used logistic regression to estimate the association between ED boarding status at T-0 and compliance with the US Centers for Medicare & Medicaid Services (CMS) Severe Sepsis and Septic Shock: Management Bundle (SEP-1) core measure, individual bundle element compliance, and hospital mortality adjusting for prespecified covariates. In a subgroup analysis among patients who had not already received antibiotics before T-0, we conducted a Cox proportional hazards model to estimate the association between boarding status on time-to-antibiotics.

RESULTS

Among 4795 patients meeting a clinical definition of sepsis in the ED, 422 (8.8%) experienced T-0 as ED boarders. These patients were similar in age, sex, and comorbidities compared with patients experiencing T-0 while still under ED care. Fewer patients with T-0 as an ED boarder received SEP-1 compliant care (25% vs. 38%, p < .001), including a lower proportion of fluid resuscitation (15% vs. 26%, p = .004) and lactate assessment (62% vs. 94%, p < .001). Overall, more patients in the ED boarder group received antibiotics within 3 hours, but one-third of patients had already received antibiotics prior to T-0. Among patients who had not already received antibiotics prior to T-0, experiencing T-0 as an ED boarder was associated with a decreased likelihood of receiving antibiotics (hazard ratio [HR]: 0.67 [95% confidence interval [CI], 0.54-0.84]) and longer time to antibiotics from T-0 (142 min vs. 100 min, p = .007).

CONCLUSIONS

Sepsis patients experiencing T-0 as a boarder in the ED have a lower likelihood of receiving SEP-1 compliant care compared to patients who experience T-0 while still under ED care.

Mortality of patients with sepsis in intensive care units at tertiary hospitals in Jordan: Prospective cohort study

The aim of this study was to describe the 30-day mortality rate of adult patients with sepsis and septic shock in 6 intensive care units of 2 tertiary hospitals in Jordan. A prospective cohort design was used. Patients with sepsis and septic shock admitted to the medical and surgical intensive care units at 2 tertiary hospitals were followed up during the period between February 2022 and June 2022 (N = 148). Data were analyzed using SPSS, version 23. Moreover, descriptive statistics, chi-square, and binary logistic regression were used. Notably, 52.7% of patients with sepsis and septic shock died within 30 days of diagnosis of sepsis and septic shock. Sequential Organ Failure Assessment score and the history of having solid tumors significantly predicted the 30-day mortality rate. Moreover, 43 (29.0%) patients with sepsis and septic shock had positive blood cultures, and 46 (31.0%) had positive urine cultures. Patients with sepsis and septic shock have a notable mortality rate that can be predicted from total Sequential Organ Failure Assessment scores and from the history of having solid tumors. Early assessment and initiation of treatment for sepsis essentially would reduce the likelihood of progression of sepsis to septic shock and would reduce associated patients' mortality.

Calprotectin, a Promising Serological Biomarker for the Early Diagnosis of Superinfections with Multidrug-Resistant Bacteria in Patients with COVID-19

Bacterial and fungal superinfections are common in COVID-19, and early diagnosis can enable timely intervention. Serum calprotectin levels increase with bacterial, fungal, and viral infections. This study evaluated serum calprotectin as a diagnostic and prognostic tool for microbial superinfections in COVID-19. Serum samples from adult patients with moderate and severe COVID-19 were collected during hospitalization from 2020 to 2024. Calprotectin levels were measured using an enzyme-linked immunosorbent assay in 63 patients with moderate COVID-19, 60 patients with severe COVID-19, and 34 healthy individuals. Calprotectin serum levels were elevated in patients with moderate COVID-19 compared with controls, and these levels were further increased in the severe cases. Patients with severe COVID-19 and vancomycin-resistant enterococci (VRE) bacteremia had elevated calprotectin levels, but their C-reactive protein and procalcitonin levels were not increased. Fungal superinfections and herpes simplex virus reactivation did not change the calprotectin levels. A calprotectin concentration of 31.29 µg/mL can be used to diagnose VRE bloodstream infection with 60% sensitivity and 96% specificity. These data suggest that serum calprotectin may be a promising biomarker for the early detection of VRE bloodstream infections in patients with COVID-19.

Development and validation of a community acquired sepsis-worsening score in the adult emergency department: a prospective cohort: the CASC score

BACKGROUND

Sepsis is a leading cause of death and serious illness that requires early recognition and therapeutic management to improve survival. The quick-SOFA score helps in its recognition, but its diagnostic performance is insufficient. To develop a score that can rapidly identify a community acquired septic situation at risk of clinical complications in patients consulting the emergency department (ED).

METHODS

We conducted a monocentric, prospective cohort study in the emergency department of a university hospital between March 2016 and August 2018 (NCT03280992). All patients admitted to the emergency department for a suspicion of a community-acquired infection were included. Predictor variables of progression to septic shock or death within the first 90 days were selected using backward stepwise multivariable logistic regression to develop a clinical score. Receiver operating characteristic (ROC) curves were constructed to determine the discriminating power of the area under the curve (AUC). We also determined the threshold of our score that optimized the performance required for a sepsis-worsening score. We have compared our score with the NEWS-2 and qSOFA scores.

RESULTS

Among the 21,826 patients admitted to the ED, 796 patients were suspected of having community-acquired infection and 461 met the sepsis criteria; therefore, these patients were included in the analysis. The median [interquartile range] age was 72 [54-84] years, 248 (54%) were males, and 244 (53%) had respiratory symptoms. The clinical score ranged from 0 to 90 and included 8 variables with an area under the ROC curve of 0.85 (confidence interval [CI] 95% 0.81-0.89). A cut-off of 26 yields a sensitivity of 88% (CI 95% 0.79-0.93), a specificity of 62% (CI 95% 57-67), and a negative predictive value of 95% (CI 95% 91-97). The area under the ROC curve for our score was 0.85 (95% CI, 0.81-0.89) versus 0.73 (95% CI, 0.68-0.78) for qSOFA and 0.66 (95% CI, 0.60-0.72) for NEWS-2.

CONCLUSIONS

Our study provides an accurate clinical score for identifying septic patients consulting the ED early at risk of worsening disease. This score could be implemented at admission.

High mortality associated with inappropriate initial antibiotic therapy in hematological malignancies with Klebsiella pneumoniae bloodstream infections

Bloodstream infections caused by multidrug-resistant organisms such as Klebsiella pneumoniae are a significant challenge in managing hematological malignancies. This study aims to characterize the epidemiology of Klebsiella pneumoniae bloodstream infections specifically in patients with hematological malignancies, delineate the patterns of initial antibiotic therapy, assess the prevalence of resistant strains, identify risk factors for these resistant strains, and evaluate factors influencing patient outcomes. A retrospective analysis was conducted at a single center from January 2017 to December 2020, focusing on 182 patients with hematological malignancies who developed Klebsiella pneumoniae bloodstream infections. We compared the 30-day mortality rates between patients receiving appropriate and inappropriate antibiotic treatments, including the effectiveness of both single-drug and combination therapies. Kaplan-Meier survival analysis and multivariate logistic and Cox regression were used to identify factors influencing mortality risk. The 30-day all-cause mortality rate was 30.2% for all patients. The 30-day all-cause mortality rates were 77.2% and 8.8% in patients who received inappropriate initial treatment and appropriate initial treatment (p < 0.001). Inappropriate initial treatment significantly influenced mortality and was a key predictor of 30-day mortality, along with septic shock and previous intensive care unit (ICU) stays. Patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infections exhibited more severe clinical symptoms compared to the CSKP group. The study demonstrates a significant association between empirical carbapenem administration and the escalating prevalence of CRKP and multidrug-resistant K. pneumoniae (MDR-KP) infections. Furthermore, the study identified inappropriate initial antibiotic therapy, septic shock, and ICU admission as independent risk factors for 30-day mortality.

Blood calprotectin as a biomarker for infection and sepsis - the prospective CASCADE trial

BACKGROUND

Early in the host-response to infection, neutrophils release calprotectin, triggering several immune signalling cascades. In acute infection management, identifying infected patients and stratifying these by risk of deterioration into sepsis, are crucial tasks. Recruiting a heterogenous population of patients with suspected infections from the emergency department, early in the care-path, the CASCADE trial aimed to evaluate the accuracy of blood calprotectin for detecting bacterial infections, estimating disease severity, and predicting clinical deterioration.

METHODS

In a prospective, observational trial from February 2021 to August 2022, 395 patients (n = 194 clinically suspected infection; n = 201 controls) were enrolled. Blood samples were collected at enrolment. The accuracy of calprotectin to identify bacterial infections, and to predict and identify sepsis and mortality was analysed. These endpoints were determined by a panel of experts.

RESULTS

The Area Under the Receiver Operating Characteristic (AUROC) of calprotectin for detecting bacterial infections was 0.90. For sepsis within 72 h, calprotectin's AUROC was 0.83. For 30-day mortality it was 0.78. In patients with diabetes, calprotectin had an AUROC of 0.94 for identifying bacterial infection.

CONCLUSIONS

Calprotectin showed notable accuracy for all endpoints. Using calprotectin in the emergency department could improve diagnosis and management of severe infections, in combination with current biomarkers.

CLINICAL TRIAL REGISTRATION NUMBER

DRKS00020521.

Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper

The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.

Effect of Automated Real-Time Feedback on Early-Sepsis Care: A Pragmatic Clinical Trial

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.

Risk of Misleading Conclusions in Observational Studies of Time-to-Antibiotics and Mortality in Suspected Sepsis

BACKGROUND

Influential studies conclude that each hour until antibiotics increases mortality in sepsis. However, these analyses often (1) adjusted for limited covariates, (2) included patients with long delays until antibiotics, (3) combined sepsis and septic shock, and (4) used linear models presuming each hour delay has equal impact. We evaluated the effect of these analytic choices on associations between time-to-antibiotics and mortality.

METHODS

We retrospectively identified 104 248 adults admitted to 5 hospitals from 2015-2022 with suspected infection (blood culture collection and intravenous antibiotics ≤24 h of arrival), including 25 990 with suspected septic shock and 23 619 with sepsis without shock. We used multivariable regression to calculate associations between time-to-antibiotics and in-hospital mortality under successively broader confounding-adjustment, shorter maximum time-to-antibiotic intervals, stratification by illness severity, and removing assumptions of linear hourly associations.

RESULTS

Changing covariates, maximum time-to-antibiotics, and severity stratification altered the magnitude, direction, and significance of observed associations between time-to-antibiotics and mortality. In a fully adjusted model of patients treated ≤6 hours, each hour was associated with higher mortality for septic shock (adjusted odds ratio [aOR]: 1.07; 95% CI: 1.04-1.11) but not sepsis without shock (aOR: 1.03; .98-1.09) or suspected infection alone (aOR: .99; .94-1.05). Modeling each hour separately confirmed that every hour of delay was associated with increased mortality for septic shock, but only delays >6 hours were associated with higher mortality for sepsis without shock.

CONCLUSIONS

Associations between time-to-antibiotics and mortality in sepsis are highly sensitive to analytic choices. Failure to adequately address these issues can generate misleading conclusions.

Association of Time of Day with Delays in Antimicrobial Initiation among Ward Patients with Hospital-Onset Sepsis

Rationale: Although the mainstay of sepsis treatment is timely initiation of broad-spectrum antimicrobials, treatment delays are common, especially among patients who develop hospital-onset sepsis. The time of day has been associated with suboptimal clinical care in several contexts, but its association with treatment initiation among patients with hospital-onset sepsis is unknown. Objectives: Assess the association of time of day with antimicrobial initiation among ward patients with hospital-onset sepsis. Methods: This retrospective cohort study included ward patients who developed hospital-onset sepsis while admitted to five acute care hospitals in a single health system from July 2017 through December 2019. Hospital-onset sepsis was defined by the Centers for Disease Control and Prevention Adult Sepsis Event criteria. We estimated the association between the hour of day and antimicrobial initiation among patients with hospital-onset sepsis using a discrete-time time-to-event model, accounting for time elapsed from sepsis onset. In a secondary analysis, we fit a quantile regression model to estimate the association between the hour of day of sepsis onset and time to antimicrobial initiation. Results: Among 1,672 patients with hospital-onset sepsis, the probability of antimicrobial initiation at any given hour varied nearly fivefold throughout the day, ranging from 3.0% (95% confidence interval [CI], 1.8-4.1%) at 7 a.m. to 13.9% (95% CI, 11.3-16.5%) at 6 p.m., with nadirs at 7 a.m. and 7 p.m. and progressive decline throughout the night shift (13.4% [95% CI, 10.7-16.0%] at 9 p.m. to 3.2% [95% CI, 2.0-4.0] at 6 a.m.). The standardized predicted median time to antimicrobial initiation was 3.2 hours (interquartile range [IQR], 2.5-3.8 h) for sepsis onset during the day shift (7 a.m.-7 p.m.) and 12.9 hours (IQR, 10.9-14.9 h) during the night shift (7 p.m.-7 a.m.). Conclusions: The probability of antimicrobial initiation among patients with new hospital-onset sepsis declined at shift changes and overnight. Time to antimicrobial initiation for patients with sepsis onset overnight was four times longer than for patients with onset during the day. These findings indicate that time of day is associated with important care processes for ward patients with hospital-onset sepsis. Future work should validate these findings in other settings and elucidate underlying mechanisms to inform quality-enhancing interventions.

Monocyte chemoattractant protein-1 as a potential marker for patients with sepsis: a systematic review and meta-analysis

Objective

To investigate the diagnostic value of monocyte chemoattractant protein-1 (MCP-1) as a biomarker for adult patients with sepsis.

Methods

Related studies on the diagnostic value of MCP-1 in adult patients with sepsis were searched in PubMed, Cochrane Library, Embase, CNKI, CBM, Web of Science, Scopus, and Wanfang Data databases (published to February 20, 2023) was performed if studies assessed the diagnostic accuracy of MCP-1 in adult patients with sepsis and provided appropriate information sufficient to construct a 2 × 2 linked table, studies were included.

Results

Data from 8 studies with a total of 805 patients were included. The combined sensitivity was 0.84 (95% CI 0.70-0.92), the specificity was 0.82 (95% CI 0.67-0.91), the combined positive likelihood ratio was 3.711 (2.119-6.500), the negative likelihood ratio was 0.287 (0.198-0.415), and the area under the working characteristic curve for combined subjects was 0.88. The diagnostic odds ratio (DOR) was 16.508 (7.632-35.706). Meta-regression analysis showed that the results were not significant. Deeks' funnel plot showed that there was no publication bias.

Conclusion

According to our meta-analysis, MCP-1 is a valuable biomarker and may provide evidence for the diagnosis of sepsis in adults.

Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years: A Critical Care Perspective

For 20 years, induced hypothermia and targeted temperature management have been recommended to mitigate brain injury and increase survival after cardiac arrest. On the basis of animal research and small clinical trials, the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34 °C for 12-24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia. The intervention was implemented worldwide. In the past decade, hypothermia and targeted temperature management have been investigated in larger clinical randomized trials focusing on target temperature depth, target temperature duration, prehospital versus in-hospital initiation, nonshockable rhythms, and in-hospital cardiac arrest. Systematic reviews suggest little or no effect of delivering the intervention on the basis of the summary of evidence, and the International Liaison Committee on Resuscitation today recommends only to treat fever and keep body temperature below 37.5 °C (weak recommendation, low-certainty evidence). Here we describe the evolution of temperature management for patients with cardiac arrest during the past 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, bringing up both whether fever management is at all beneficial for patients with cardiac arrest and which knowledge gaps future clinical trials in temperature management should address.

Identifying high-risk phenotypes and associated harms of delayed time-to-antibiotics in patients with ICU onset sepsis: A retrospective cohort study

PURPOSE

To identify phenotypes of Intensive Care Unit (ICU) onset sepsis and its associated harms of delayed time-to-antibiotics.

MATERIALS AND METHODS

The Medical Information Mart for Intensive Care IV (MIMIC-IV) database was employed to identify patients with ICU onset sepsis. The primary exposure was time-to-antibiotics, as measured from sepsis recognition to first antibiotic administered. Latent profile analysis (LPA) was used to identify phenotypes of sepsis based on individual organ failure score derived from Sequential Organ Failure Assessment (SOFA). Interactions between phenotypes and time-to-antibiotics on 28-day mortality were explored.

RESULTS

6246 patients were enrolled in final analysis. The overall 28-day mortality was 12.7%. Delayed time-to-antibiotics was associated with increased 28-day mortality in patients with ICU onset sepsis (HR 1.12, 95% CI 1.08-1.18). Four phenotypes of sepsis were identified: phenotype 1 was characterized by respiratory dysfunction, phenotype 2 was characterized by cardiovascular dysfunction, phenotype 3 was characterized by multiple organ dysfunction, and phenotype 4 was characterized by neurological dysfunction. The adjusted HR of 28-day mortality was 1.16 (95% CI 1.08-1.25) in phenotype 1, and 1.06 (95% CI 1.00-1.13) in phenotype 2, while no significant interaction was observed.

CONCLUSIONS

Septic patients with respiratory or cardiovascular dysfunction were associated with harms of delayed time-to-antibiotics.

Association between timing and adequacy of antibiotics and adverse outcomes in patients with sepsis and septic shock: A multicentre retrospective cohort study

OBJECTIVES

To investigate the association between the timing and adequacy of antibiotics administered to patients presenting with culture-positive sepsis and septic shock to the ED and in-hospital mortality and/or intensive care unit (ICU) admission.

METHODS

Multicentre retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia between January 2017 and November 2019. Encounters for patients aged ≥16 years meeting specified criteria for sepsis or septic shock with antibiotic administration within the first 6 h of presentation were included.

RESULTS

Of 7611 encounters included in the study, 2328 (31%) were culture positive, and 2228 (29%) met the criteria for septic shock. In culture-positive sepsis encounters, partial or inadequate antibiotic coverage was associated with higher risk of death or ICU admission (adjusted odds ratio [AOR] 1.50, 95% confidence interval [CI] 1.04-2.06 and 1.95, 95% CI 1.28-2.99, respectively). This effect was not significant in septic shock encounters (AOR 1.10, 95% CI 0.64-1.88) with partial coverage and (AOR 1.63, 95% CI 0.81-3.3) inadequate coverage. Time to antibiotics was not significantly associated with the risk of mortality/ICU admission. This inference remained the same when analysis was restricted to cases with adequate antibiotic coverage.

CONCLUSIONS

In a large multicentre sample of patients with culture-positive sepsis, inadequacy of antibiotics was associated with higher risk of in-hospital mortality or ICU admission.

Current sepsis therapeutics

Management of the patient with sepsis comprises three key branches: control of the underlying infection, haemodynamic stabilization, and modulation of the host response. Each aspect should be considered in all patients and, when relevant, managed at the same time. Infection control is applicable to all patients with sepsis and will include antibiotic therapy and often surgical intervention to remove an infectious source. Haemodynamic support involves fluid administration in all patients and vasoactive agents in patients with associated circulatory shock. Noradrenaline is the first choice vasopressor agent; inotropic agents, usually dobutamine, may be added in case of myocardial depression. No interventions directed at individual components of the host response to sepsis have yet been shown to improve outcomes, but glucocorticoids and vasopressin have a global impact on the response and can thus be considered in this category. A move toward more personalized treatment is needed across all three arms of sepsis management.

Calprotectin as a diagnostic marker for sepsis: A meta-analysis

Introduction

Sepsis is a life-threatening condition, and biomarkers are needed to diagnose sepsis fast and accurately. We aimed to perform this meta-analysis to investigate the diagnostic value of calprotectin on sepsis in critically ill patients.

Methods

The investigators searched MEDLINE, Embase, Web of Science and Cochrane Library. Studies were included if they assessed the diagnostic accuracy of serum calprotectin for sepsis in intensive care unit (ICU). We estimated its diagnostic value and explored the source of heterogeneity. The bivariate model and the hierarchical summary receiver operating characteristic (HSROC) curve were used in the meta-analysis.

Results

Six records assessing 821 patients were included in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio (PLR), and diagnostic odds ratio (DOR) were separately as 0.77, 0.85, 5.20, 0.27, respectively. The Fagan's nomogram showed post-test probabilities of 91% and 35% for positive and negative outcomes, respectively. Subgroup analysis indicated that sepsis definition could be a possible source of heterogeneity, but there's no sufficient data to investigate sepsis-3 definition. Sensitivity analysis suggested that two studies could affect the stability of pooled results.

Conclusion

On the basis of our meta-analysis, calprotectin is a helpful marker for early diagnosis of sepsis on ICU admission.

Characteristics of bloodstream infection and initial antibiotic use in critically ill burn patients and their impact on patient prognosis

To investigate the bacterial epidemiology of blood cultures taken during the treatment of critically ill burn patients, the use of antibiotics at admission and before the observation of positive blood cultures, and their effect on prognosis. A retrospective study method was used. From January 1, 2010, to December 31, 2019, burn patients who met the inclusion criteria and were treated at the Burn Department, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, were enrolled in the study. Data were collected from the patients' electronic medical records. General patient information, including length of hospital stay, length of intensive care unit (ICU) stay, in-hospital mortality, the bacteria epidemiological characteristics of blood cultures, and the use of antibiotics within 24 h after admission and before a positive blood culture was observed, was collected. Independent sample t tests and χ² tests were used to compare the effects of a positive blood culture and the use of appropriate antibiotics within 24 h after admission and before the observation of a positive blood culture on prognosis. (1) The three most frequently detected bacteria in the blood cultures were Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii, and the amount of K. pneumoniae detected increased gradually. (2) Compared with the group of patients who were negative for bloodstream infection , the positive bloodstream infection group had a larger total body burn surface area (TBSA) (t = - 5.097, P = 0.000) and third-degree burn area (t = - 5.133, P = 0.000), a significantly longer length of hospital stay (t = 3.003, P = 0.003) and the length of ICU stay (t = 4.258, P = 0.000), and a significantly higher rate of in-hospital mortality (χ² = 8.485, P = 0.004). When K. pneumoniae was detected, the length of hospital stay (t = 2.148, P = 0.035) and the length of ICU stay (t = 2.880, P = 0.005) were significantly prolonged. (3) The two antibiotics that were most frequently used in patients with acute burns within 24 h after admission were lincomycin (90 cases, 29.32%) and carbapenems (79 cases, 25.73%). Comparing the clinical characteristics of the lincomycin group and the carbapenem group, the TBSA (t = - 3.34, P = 0.001) and the third-degree burn area (t = - 6.08, P = 0.000) of the patients in the carbapenem group were larger, and the length of hospital stay (t = - 2.136, P = 0.035) and length of ICU stay (t = - 5.18, P = 0.000) were longer, but the difference in in-hospital mortality was not statistically significant (χ² = 1.983, P = 0.159). (4) Comparing the group with appropriate initial antibiotic use within 24 h of admission to the inappropriate use group, the TBSA (t = - 0.605, P = 0.547), the third-degree burn area (t = 0.348, P = 0.729), the length of hospital stay (t = - 0.767, P = 0.445), the length of ICU stay (t = - 0.220, P = 0.827) and in-hospital mortality (χ² = 1.271, P = 0.260) were not significantly different. (5) Comparing the group with appropriate antibiotic use before a positive blood culture was observed to the group with inappropriate antibiotic use, the TBSA (t = - 0.418, P = 0.677), the third-degree burn area (t = 0.266, P = 0.791), the length of hospital stay, the length of ICU stay (t = 0.995, P = 0.322) and in-hospital mortality (χ² = 1.274, P = 0.259) were not significantly different. We found that patients with a positive blood culture had a larger burn area and a worse prognosis; that the greater the amount of K. pneumoniae in the bloodstream of burn patients was, the longer the hospital and ICU stays were; that whether appropriate antibiotics were administered to acute critical burn patients 24 h after admission had no effect on the prognosis; and that whether appropriate antibiotics were administered before a positive blood culture was observed had no effect on prognosis.

Antibiotics: it is all about timing, isn't it?

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.

Selective Cerebrospinal Fluid Hypothermia: Bioengineering Development and In Vivo Study of an Intraventricular Cooling Device (V-COOL)

Hypothermia is a promising therapeutic strategy for severe vasospasm and other types of non-thrombotic cerebral ischemia, but its clinical application is limited by significant systemic side effects. We aimed to develop an intraventricular device for the controlled cooling of the cerebrospinal fluid, to produce a targeted hypothermia in the affected cerebral hemisphere with a minimal effect on systemic temperature. An intraventricular cooling device (acronym: V-COOL) was developed by in silico modelling, in vitro testing, and in vivo proof-of-concept application in healthy Wistar rats (n = 42). Cerebral cortical temperature, rectal temperature, and intracranial pressure were monitored at increasing flow rate (0.2 to 0.8 mL/min) and duration of application (10 to 60 min). Survival, neurological outcome, and MRI volumetric analysis of the ventricular system were assessed during the first 24 h. The V-COOL prototyping was designed to minimize extra-cranial heat transfer and intra-cranial pressure load. In vivo application of the V-COOL device produced a flow rate-dependent decrease in cerebral cortical temperature, without affecting systemic temperature. The target degree of cerebral cooling (- 3.0 °C) was obtained in 4.48 min at the flow rate of 0.4 mL/min, without significant changes in intracranial pressure. Survival and neurological outcome at 24 h showed no significant difference compared to sham-treated rats. MRI study showed a transient dilation of the ventricular system (+ 38%) in a subset of animals. The V-COOL technology provides an effective, rapid, selective, and safe cerebral cooling to a clinically relevant degree of - 3.0 °C.

Precision Care in Cardiac Arrest: ICECAP (PRECICECAP) Study Protocol and Informatics Approach

BACKGROUND

Most trials in critical care have been neutral, in part because between-patient heterogeneity means not all patients respond identically to the same treatment. The Precision Care in Cardiac Arrest: Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (PRECICECAP) study will apply machine learning to high-resolution, multimodality data collected from patients resuscitated from out-of-hospital cardiac arrest. We aim to discover novel biomarker signatures to predict the optimal duration of therapeutic hypothermia and 90-day functional outcomes. In parallel, we are developing a freely available software platform for standardized curation of intensive care unit-acquired data for machine learning applications.

METHODS

The Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP) study is a response-adaptive, dose-finding trial testing different durations of therapeutic hypothermia. Twelve ICECAP sites will collect data for PRECICECAP from multiple modalities routinely used after out-of-hospital cardiac arrest, including ICECAP case report forms, detailed medication data, cardiopulmonary and electroencephalographic waveforms, and digital imaging and communications in medicine files (DICOMs). We partnered with Moberg Analytics to develop a freely available software platform to allow high-resolution critical care data to be used efficiently and effectively. We will use an autoencoder neural network to create low-dimensional representations of all raw waveforms and derivative features, censored at rewarming to ensure clinical usability to guide optimal duration of hypothermia. We will also consider simple features that are historically considered to be important. Finally, we will create a supervised deep learning neural network algorithm to directly predict 90-day functional outcome from large sets of novel features.

RESULTS

PRECICECAP is currently enrolling and will be completed in late 2025.

CONCLUSIONS

Cardiac arrest is a heterogeneous disease that causes substantial morbidity and mortality. PRECICECAP will advance the overarching goal of titrating personalized neurocritical care on the basis of robust measures of individual need and treatment responsiveness. The software platform we develop will be broadly applicable to hospital-based research after acute illness or injury.

Temporal trends in the epidemiology, management, and outcome of sepsis-A nationwide observational study

BACKGROUND

Registry-based studies have shown increasing incidence of sepsis and declining mortality rates in recent years, but are inherently at risk of bias. The objectives of this study were to describe 11-year trends in the incidence, treatment and outcome of sepsis using clinical criteria with chart review.

METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014, and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria (sepsis-2). Incidence, patient characteristics, treatment and outcome were compared across the study years.

RESULTS

During the six study years, 9166 patients were admitted to Icelandic ICUs, 971 (10.6%) because of severe sepsis or septic shock. The crude incidence of sepsis requiring admission to ICU remained stable between 0.55 and 0.75 per 1000 inhabitants. No statistically significant trends were observed over time in median patient age (67 years), APACHE II score (21), SOFA score (8) or Charlson Comorbidity Index (4). The time to antibiotic administration (median 1.8 h) in the emergency departments was stable over the study period but the time to lactate measurements decreased from 4.1 h in 2006 to 1.2 h in 2016, p < .001. The 28-day mortality was 25% and 1-year mortality 41%, both with no observed change with time.

CONCLUSIONS

In a nationwide cohort, diagnosed with clinical criteria, the incidence of sepsis requiring intensive care did not change over an 11-year period. Mortality remained stable and only minimal changes were observed in initial resuscitation in the emergency departments.

Adverse effects of delayed antimicrobial treatment and surgical source control in adults with sepsis: results of a planned secondary analysis of a cluster-randomized controlled trial

BACKGROUND

Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain.

METHODS

We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing.

RESULTS

Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1-3 h, or 1 h versus 3-6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04).

CONCLUSIONS

Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov ( NCT01187134 ). Registered 23 August 2010, NCT01187134.

Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: a prospective nationwide multicenter cohort study

Background

Timely administration of antibiotics is one of the most important interventions in reducing mortality in sepsis. However, administering antibiotics within a strict time threshold in all patients suspected with sepsis will require huge amount of effort and resources and may increase the risk of unintentional exposure to broad-spectrum antibiotics in patients without infection with its consequences. Thus, controversy still exists on whether clinicians should target different time-to-antibiotics thresholds for patients with sepsis versus septic shock.

Methods

This study analyzed prospectively collected data from an ongoing multicenter cohort of patients with sepsis identified in the emergency department. Adjusted odds ratios (ORs) were compared for in-hospital mortality of patients who had received antibiotics within 1 h to that of those who did not. Spline regression models were used to assess the association of time-to-antibiotics as continuous variables and increasing risk of in-hospital mortality. The differences in the association between time-to-antibiotics and in-hospital mortality were assessed according to the presence of septic shock.

Results

Overall, 3035 patients were included in the analysis. Among them, 601 (19.8%) presented with septic shock, and 774 (25.5%) died. The adjusted OR for in-hospital mortality of patients whose time-to-antibiotics was within 1 h was 0.78 (95% confidence interval [CI] 0.61–0.99; p = 0.046). The adjusted OR for in-hospital mortality was 0.66 (95% CI 0.44–0.99; p = 0.049) and statistically significant in patients with septic shock, whereas it was 0.85 (95% CI 0.64–1.15; p = 0.300) in patients with sepsis but without shock. Among patients who received antibiotics within 3 h, those with septic shock showed 35% (p = 0.042) increased risk of mortality for every 1-h delay in antibiotics, but no such trend was observed in patients without shock.

Conclusion

Timely administration of antibiotics improved outcomes in patients with septic shock; however, the association between early antibiotic administration and outcome was not as clear in patients with sepsis without shock.

Delays in Time-To-Antibiotics for Young Febrile Infants With Serious Bacterial Infections: A Prospective Single-Center Study

INTRODUCTION

Fear of missed serious bacterial infections (SBIs) results in many febrile young infants receiving antibiotics. We aimed to compare the time to antibiotics between infants with SBIs and those without.

MATERIALS AND METHODS

We recruited febrile infants ≤ 90 days old seen in the emergency department (ED) between December 2017 and April 2021. SBI was defined as (1) urinary tract infection, (2) bacteremia or (3) bacterial meningitis. We compared the total time (median with interquartile range, IQR) from ED arrival to infusion of antibiotics, divided into (i) time from triage to decision for antibiotics and (ii) time from decision for antibiotics to administration of antibiotics.

RESULTS

We analyzed 81 and 266 infants with and without SBIs. Median age of those with and without SBIs were 44 (IQR 19-72) and 29 (IQR 7-56) days, respectively (p = 0.002). All infants with SBIs and 168/266 (63.2%) infants without SBIs received antibiotics. Among 249 infants who received antibiotics, the median total time from ED arrival to infusion of antibiotics was 277.0 (IQR 236.0-385.0) mins for infants with SBIs and 304.5 (IQR 238.5-404.0) mins for those without (p = 0.561). The median time to decision for antibiotics was 156.0 (IQR 115.0-255.0) mins and 144.0 (IQR 105.5-211.0) mins, respectively (p = 0.175). Following decision for antibiotics, infants with SBIs received antibiotics much faster compared to those without [107.0 (IQR 83.0-168.0) vs. 141.0 (94.0-209.5) mins, p = 0.017].

CONCLUSION

There was no difference in total time taken to antibiotics between infants with SBIs and without SBIs. Both recognition and administration delays were observed. While all infants with SBIs were adequately treated, more than half of the infants without SBIs received unnecessary antibiotics. This highlights the challenge in managing young febrile infants at initial presentation, and demonstrates the need to examine various aspects of care to improve the overall timeliness to antibiotics.

Temporal Trends and Hospital Variation in Time-to-Antibiotics Among Veterans Hospitalized With Sepsis

Importance

It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives.

Objective

To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system.

Design, Setting, and Participants

This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021.

Exposures

Time from presentation to antibiotic administration.

Main Outcomes and Measures

The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models.

Results

A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P < .001). In multilevel models adjusted for patient characteristics, median time-to-antibiotics declined by 9.0 (95% CI, 8.8-9.2) minutes per calendar year. Temporal trends in time-to-antibiotics were similar across patient subgroups, but hospitals with faster baseline time-to-antibiotics had less change over time, with hospitals in the slowest tertile decreasing time-to-antibiotics by 16.6 minutes (23.1%) per year, while hospitals in the fastest tertile decreased time-to-antibiotics by 7.2 minutes (13.1%) per year. In the most recent years (2017-2018), median time-to-antibiotics ranged from 3.1 to 6.7 hours across hospitals (after adjustment for patient characteristics), 6.8% of variation in time-to-antibiotics was explained at the hospital level, and odds of receiving antibiotics within 3 hours increased by 65% (95% CI, 56%-77%) for the median patient if moving to a hospital with faster time-to-antibiotics.

Conclusions and Relevance

This cohort study across nationwide VA hospitals found that time-to-antibiotics for sepsis has declined over time. However, there remains significant variability in time-to-antibiotics not explained by patient characteristics, suggesting potential unwarranted practice variation in sepsis treatment. Efforts to further accelerate time-to-antibiotics must be weighed against risks of overtreatment.

Initial antimicrobial management of sepsis

Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.

Diagnosis of Mycobacterium tuberculosis Septic Shock in Patients With Anti-synthetase Syndrome Based on Next-Generation Sequencing: A Case Report and Literature Review

A 51-year-old woman was transferred to the intensive care unit with such symptoms as fever, swollen left knee joint, pain and hypotension. After preliminary evaluation, she was diagnosed as suffering acute suppurative arthritis and septic shock. Then, she was rescued and prescribed to receive treatment with broad-spectrum antibiotics. However, there was no source of infection identified except for the knee joint. The bacterial and fungal cultures of blood samples and articular effusion were shown to be negative, while the results obtained from the next-generation sequencing of blood and articular effusion revealed that Mycobacterium tuberculosis was positive. The patient was then put on five combinations of anti-tuberculosis therapeutic treatment. Nevertheless, despite the active anti-tuberculosis treatment put in place, her general condition still deteriorated progressively. As the level of her bilirubin continued to rise, further treatment was affected, which prompted the change made to the anti-tuberculosis treatment program. Her clinical condition continued to deteriorate, which led to the development of unstable vital signs and the multiple organ dysfunction syndrome. In spite of our best efforts to save her life, the patient still ended up with death.

Update on Coagulase-Negative Staphylococci-What the Clinician Should Know

Coagulase-negative staphylococci (CoNS) are among the most frequently recovered bacteria in routine clinical care. Their incidence has steadily increased over the past decades in parallel to the advancement in medicine, especially in regard to the utilization of foreign body devices. Many new species have been described within the past years, while clinical information to most of those species is still sparse. In addition, interspecies differences that render some species more virulent than others have to be taken into account. The distinct populations in which CoNS infections play a prominent role are preterm neonates, patients with implanted medical devices, immunodeficient patients, and those with other relevant comorbidities. Due to the property of CoNS to colonize the human skin, contamination of blood cultures or other samples occurs frequently. Hence, the main diagnostic hurdle is to correctly identify the cases in which CoNS are causative agents rather than contaminants. However, neither phenotypic nor genetic tools have been able to provide a satisfying solution to this problem. Another dilemma of CoNS in clinical practice pertains to their extensive antimicrobial resistance profile, especially in healthcare settings. Therefore, true infections caused by CoNS most often necessitate the use of second-line antimicrobial drugs.