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Julián-Jiménez A, Lorenzo Álvarez R, Gutiérrez Bueno V, Sánchez Trujillo M, Eduardo García D. [Early source control of infection in patients seen in the emergency department: a systematic review]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2024; 37:323-333. [PMID: 38742536 PMCID: PMC11231492 DOI: 10.37201/req/027.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/05/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE The term source (or focus) control encompasses all those physical measures that can be used to reduce the inoculum and modify those factors in the infectious medium that promote microbial growth or foreign antimicrobial defenses of the host. The main objective of this systematic review (SR) is to know and compare whether early detection and control of the focus (in less than 6 hours) in adult patients treated in the ED for severe infection or sepsis, compared to not controlling the focus or delayed focus control (more than 12 hours) is more effective and safer (improves clinical evolution, mortality, complications, hospital stay or need for ICU admission). METHODS A systematic review is carried out following the PRISMA regulations in the databases of PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase and ClinicalTrials.gov from January 2000 to December 31, 2023 without language restrictions and using a combination of MESH terms: "Source Control", "Early" "Infection OR Bacterial Infection OR Sepsis", "Emergencies OR Emergency OR Emergency Department" and "Adults". Observational cohort studies were included. No meta-analysis techniques were performed, but results were compared narratively. RESULTS A total of 1,658 articles were identified, of which 2 that met the inclusion criteria and were classified as high quality were finally analyzed. The included studies represent a total of 2,404 patients with 678 cases in which an intervention was performed to control the focus (28.20%). In the first study, 28-day mortality was lower in patients who underwent an intervention to control the focus (12.3% vs. 22.5%; P <0.001), with an adjusted HR of 0.538 (95% CI: 0.389-0.744; P<0.001). In the second, it was demonstrated that the time elapsed from when the patient was evaluated for the first time and was hemodynamically stabilized, until the start of surgery was associated with his survival at 60 days with an OR of 0.31 (95% CI: 0.19-0.45; P <0.0001). In fact, for each hour of delay an adjusted OR of 0.29 (95% CI: 0.16-0.47; P<0.0001) is established. So if the intervention is performed before 2 hours at 60 days, 98% of the patients are still alive, if it is performed between 2-4 hours it is reduced to 78%, if it is between 4-6 hours it drops to 55%, but if it is done for more than 6 hours there will be no survivors at 60 days. CONCLUSIONS This review shows that source control carried out after the evaluation of patients attending the ED reduces short-term mortality (30-60 days) and that it would be advisable to implement any required source control intervention as soon as possible, ideally early (within 6 hours).
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Affiliation(s)
- A Julián-Jiménez
- Dr. Agustín Julián-Jiménez, MD, PhD. Servicio de Urgencias-Coordinador de Docencia, Formación, Investigación y Calidad. Complejo Hospitalario Universitario de Toledo, Avda. Río Guadiana s/n. C.P: 45.071. Toledo. Spain.
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Wang L, Zhou B, Wang L. Effect of care bundles based on importance degree analysis on postoperative comorbid state, coping style and disease management ability of patients with coronary heart disease. Medicine (Baltimore) 2024; 103:e38320. [PMID: 38875408 PMCID: PMC11175941 DOI: 10.1097/md.0000000000038320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 01/01/2024] [Accepted: 05/01/2024] [Indexed: 06/16/2024] Open
Abstract
Coronary heart disease (CHD) is a significant global health concern, particularly among the elderly. While care bundles present a comprehensive strategy for clinical disorders, their application in CHD rehabilitation remains understudied. This research addresses this gap by investigating the effectiveness of care bundles in CHD patients. By analyzing important performance degrees, we aim to contribute valuable insights to bridge existing knowledge deficiencies. Our study strives to establish a theoretical foundation for the broader implementation of care bundles, potentially improving the quality of care and patient outcomes in CHD rehabilitation. This is a retrospective study. 360 patients with CHD who were admitted to our hospital from January 2019 to October 2022 were enrolled in this retrospective study and divided into the observation group (n = 180) and control group (n = 180) according to the different care that they received. All cases were given routine nursing after CHD operation, and the observation group was given care bundles on the basis of the analysis of important performance degrees. The perioperative indexes, self-management ability score, depression, anxiety, stress scale (DASS), coping styles, medical compliance and the incidence of complications were compared between the 2 groups. Aftercare, the time of hospitalization and getting out-of-bed in the observation group was notably shorter (P < .05). Aftercare, the scores of self-management ability and related dimensions in the observation group were notably higher (P < .05). After care, the score of depression (P < .001), anxiety (P = .003) and stress (P = .017) of the observation group were notably lower. Aftercare, the observation group face score was significantly higher than the control group (P = .005), while the observation group avoidance score (P = .028) and yield score (P < .001) were significantly lower than the control group scores. Aftercare, the compliance behavior of patients in the observation group was notably better (P = .013). Aftercare, the incidence of complications in the observation group was notably lower (P = .039). Care bundles based on the degree of importance analysis can play a positive role in postoperative comorbid state, coping styles and self-management ability of patients with CHD, which can improve the rehabilitation effects on patients.
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Affiliation(s)
- Lihua Wang
- Department of Adult Ward, Wuhan Asia General Hospital, Wuhan, Hubei, China
| | - Bo Zhou
- Department of Urinary Surgery, Wuhan Asia General Hospital, Wuhan, Hubei, China
| | - Lijuan Wang
- Department of Cardiology, Wuhan Central Hospital, Wuhan, Hubei, China
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Kortz TB, Mediratta RP, Smith AM, Nielsen KR, Agulnik A, Gordon Rivera S, Reeves H, O’Brien NF, Lee JH, Abbas Q, Attebery JE, Bacha T, Bhutta EG, Biewen CJ, Camacho-Cruz J, Coronado Muñoz A, deAlmeida ML, Domeryo Owusu L, Fonseca Y, Hooli S, Wynkoop H, Leimanis-Laurens M, Nicholaus Mally D, McCarthy AM, Mutekanga A, Pineda C, Remy KE, Sanders SC, Tabor E, Teixeira Rodrigues A, Yuee Wang JQ, Kissoon N, Takwoingi Y, Wiens MO, Bhutta A. Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis. Front Pediatr 2024; 12:1397232. [PMID: 38910960 PMCID: PMC11190367 DOI: 10.3389/fped.2024.1397232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/20/2024] [Indexed: 06/25/2024] Open
Abstract
In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.
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Affiliation(s)
- Teresa B. Kortz
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Rishi P. Mediratta
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Audrey M. Smith
- Department of Medicine, Miller School of Medicine, Miami, FL, United States
| | - Katie R. Nielsen
- Department of Pediatrics and Department of Global Health, University of Washington, Seattle, WA, United States
| | - Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Stephanie Gordon Rivera
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Hailey Reeves
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicole F. O’Brien
- Department of Pediatrics, Ohio State University/Nationwide Children’s Hospital, Columbus, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Qalab Abbas
- Department of Pediatrics and Child Health, Section of Pediatric Critical Care Medicine, Aga Khan University, Karachi, Pakistan
| | - Jonah E. Attebery
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
- Barrow Global Health, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Tigist Bacha
- Department of Pediatric and Child Health, Saint Paul Hospital Medical College, Addis Ababa, Ethiopia
| | - Emaan G. Bhutta
- Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Carter J. Biewen
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Jhon Camacho-Cruz
- Department of Pediatrics, Universidad Nacional de Colombia, Fundación Universitaria de Ciencias de la Salud (FUCS), Sociedad de Cirugía de Bogota-Hospital San José, Fundación Universitaria Sanitas, Clínica Reina Sofia Pediátrica y Mujer Colsanitas, Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Bogotá D.C.,Colombia
| | - Alvaro Coronado Muñoz
- Pediatric Critical Care Division, Department of Pediatrics, Children’s Hospital at Montefiore, New York, NY, United States
| | - Mary L. deAlmeida
- Department of Pediatrics, Emory University, Atlanta, GA, United States
| | - Larko Domeryo Owusu
- Pediatric Emergency Unit, Child Health Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Yudy Fonseca
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Shubhada Hooli
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Hunter Wynkoop
- Department of Pediatrics, Ohio State University/Nationwide Children’s Hospital, Columbus, OH, United States
| | - Mara Leimanis-Laurens
- Department of Pediatrics and Human Development, Michigan State University, East Lansing and Helen DeVos Children’s Hospital, Grand Rapids, MI, United States
| | - Deogratius Nicholaus Mally
- Pediatric Intensive Care Unit, Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Amanda M. McCarthy
- Department of Pediatrics, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Andrew Mutekanga
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Carol Pineda
- Department of Pediatrics, Baystate Medical Center, University of Massachusetts Chan Medical School, Springfield, MA, United States
| | - Kenneth E. Remy
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, and Department of Internal Medicine, University Hospitals of Cleveland, Cleveland, OH, United States
| | - Sara C. Sanders
- Department of Pediatrics, Connecticut Children’s and University of Connecticut, Hartford, CT, United States
| | - Erica Tabor
- Department of Biology, Pennsylvania State University, University Park, PA, United States
| | | | - Justin Qi Yuee Wang
- Paediatric Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Edgbaston and NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Walimu, Kampala, Uganda
| | - Adnan Bhutta
- Department of Pediatrics, Indiana University School of Medicine and Riley Children’s Health, Indianapolis, IN, United States
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Gao X, Zhang R, Wang Z, Chen Q, Lei Z, Yang Y, Tian J. Preliminary study on the protective effect of remazolam against sepsis-induced acute respiratory distress syndrome (ARDS). PeerJ 2024; 12:e17205. [PMID: 38646480 PMCID: PMC11032653 DOI: 10.7717/peerj.17205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Background Sepsis can disrupt immune regulation and lead to acute respiratory distress syndrome (ARDS) frequently. Remazolam, a fast-acting hypnotic drug with superior qualities compared to other drugs, was investigated for its potential protective effects against sepsis-induced ARDS. Methods Forty Sprague-Dawley rats were randomly divided into four groups, including the sepsis + saline group, sham operation + saline group, sham operation + remazolam group and the sepsis + remazolam group. Lung tissues of rats were extracted for HE staining to assess lung damage, and the wet weight to dry weight (W/D) ratio was calculated. The levels of proinflammatory factors, anti-inflammatory factors, CD4+ and CD8+ T cells in peripheral blood, MDA, MPO, and ATP in the lung tissue were measured by using ELISA. Western blotting was performed to determine the protein expression of HMGB1 in lung tissues. Results In comparison to the sham operation + saline and sham operation + remazolam groups, the sepsis + saline group exhibited significantly higher values for W/D ratio, lung damage score, IL-1β, IL-6, TNF-α, PCT, CRP, MDP and MPO, while exhibiting lower levels of CD4+ and CD8+ T lymphocytes, PaO2, PCO2, and ATP. The rats in the sepsis + saline group displayed ruptured alveolar walls and evident interstitial lung edema. However, the rats in the sepsis + remazolam group showed improved alveolar structure. Furthermore, the HMGB1 protein expression in the sepsis + remazolam group was lower than the sepsis + saline group. Conclusion Remazolam can alleviate the inflammatory response in infected rats, thereby alleviating lung injury and improving immune function, which may be attributed to the reduction in HMGB1 protein expression.
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Affiliation(s)
- Xiaoxin Gao
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Rujun Zhang
- Department of Cardiology, Hainan Province Clinical Medical Center, Hainan General Hospital; Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhenzhou Wang
- Department of Emergency Medicine, Hainan Cancer Hospital, Haikou, China
| | - Qingan Chen
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Zhenlin Lei
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Yanan Yang
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Jia Tian
- Intensive Medical Unit, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
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Bin Ghaffar W, Nazir S, Siddiqui S, Abdul Ghaffar MB, Khan MF, Latif A, Cheema Z, Hanif S, Sohaib M. Association Between the Site of Infection and Mortality Analysis in Critically Ill Surgical Patients. Cureus 2023; 15:e50033. [PMID: 38186542 PMCID: PMC10768333 DOI: 10.7759/cureus.50033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Background Sepsis remains a critical global health concern, leading to a high mortality rate. Existing literature suggests a potential correlation between infection site and mortality. Mortality data from Pakistan, especially in the context of the infection site, is notably scarce. Purpose The study aimed to explore the relationship between the site of infection and clinical features in deceased septic patients in the surgical intensive care unit. Methods In this retrospective study conducted at the Aga Khan University Hospital, data from patients admitted to the surgical intensive care unit and meeting Sepsis 3 criteria over a five-year period (2016-2020) were analyzed. We analyzed the relation between the infection site and clinical characteristics using analysis of variance (ANOVA), chi-square, or Fisher's exact tests. Multivariable logistic regression models were applied using stepwise forward selection. A p-value of ≤ 0.05 was considered statistically significant. Results A total of 2472 ICU admissions were screened, out of which 170 patients were included in this study. Demographic analysis showed a predominantly male population with a mean age of 47 years. The most prevalent site of infection was the abdomen. Logistic regression analysis identified on-admission septic shock and high Acute Physiology and Chronic Health Evaluation (APACHE) II scores as significant risk factors for 48-hour mortality while colistimethate sodium usage and admission through the operating room were protective. Conclusion Our study provides a comprehensive analysis, outlining infection sites and identifying early mortality-influencing factors within our region. The distinct demographic profile, characterized by younger age, and the prevalence of abdominal infections in the Pakistani cohort contradict established medical literature. Early initiation of broad-spectrum antibiotics, coupled with prompt source control, confers a protective effect upon individuals afflicted with sepsis.
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Affiliation(s)
| | - Sidra Nazir
- Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
| | | | | | | | - Asad Latif
- Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
| | - Zahra Cheema
- Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
| | - Sadaf Hanif
- Medicine, Aga Khan University Hospital, Karachi, PAK
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Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [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: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
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Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
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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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Simpson CEM, Esterman AJ, Ganu SS, Maki K, Keeley SR, Ward EJ, Tsiros MD. Early mobilisation in critically ill children: Does routine patient screening reduce time to commencing mobilisation? Aust Crit Care 2023; 36:208-214. [PMID: 35135715 DOI: 10.1016/j.aucc.2021.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to investigate the impact of daily screening for medical readiness to participate in early mobilisation in the paediatric intensive care unit (PICU), on reducing time to mobilisation and to explore the safety-, feasibility-, and patient-level barriers to the practice. METHODS An interventional study with a historical control group was conducted in a PICU in a tertiary teaching hospital in Australia. The Early Mobilisation Screening Checklist was applied at 24-48 h of PICU stay with the aim to reduce time to commencing mobilisation. All patients aged term to 18 years admitted to the PICU for >48 h were included in this study. Data on time to mobilisation and patient characteristics were collected by an unblinded case note audit of children admitted to the PICU over 5 months in 2018 for the baseline group and over a corresponding period in 2019 for the intervention group. MEASUREMENTS AND MAIN RESULTS A total of 71 children were enrolled. Survival analysis was used to compare time to mobilisation between groups, and a cox regression model found that children in the intervention group were 1.26 times more likely to participate in mobility, but this was not statistically significant (P = 0.391, log rank test for equality of survival functions). Early mobilisation was safe, with no adverse events reported in 177 participant mobilisation days. Feasibility was demonstrated by 62% of participants mobilising within 72 h of admission. Mechanical ventilation during stay (P = 0.043) and days receiving sedation infusion (% of days) (P = 0.042) were associated with a decreased likelihood of participating in mobility. CONCLUSIONS Implementation of routine screening alone does not significantly reduce time to commencing mobility in the PICU. Early mobilisation in the PICU is safe and feasible and resulted in no adverse events during mobilisation. Patient characteristics influencing participation in mobility warrant further exploration.
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Affiliation(s)
- Catherine E M Simpson
- Allied Health Department, Women's and Children's Health Network, Australia; University of South Australia, Alliance for Research in Exercise, Nutrition and Activity, Allied Health and Human Performance, Australia.
| | - Adrian J Esterman
- University of South Australia, Clinical and Health Sciences, Australia
| | - Subodh S Ganu
- Department of Paediatric Critical Care Medicine, Women's and Children's Health Network, Australia; University of Adelaide, Adelaide, Australia
| | - Kazuhiro Maki
- Department of Paediatric Critical Care Medicine, Women's and Children's Health Network, Australia
| | - Steve R Keeley
- Department of Paediatric Critical Care Medicine, Women's and Children's Health Network, Australia
| | - Emily J Ward
- University of South Australia, Allied Health and Human Performance, Australia
| | - Margarita D Tsiros
- University of South Australia, Alliance for Research in Exercise, Nutrition and Activity, Allied Health and Human Performance, Australia; University of South Australia, UniSA Allied Health and Human Performance, Innovation, Implementation and Clinical Translation in Health (IIMPACT), Australia
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Zhang Y, Li B, Ning B. Evaluating IL-6 and IL-10 as rapid diagnostic tools for Gram-negative bacteria and as disease severity predictors in pediatric sepsis patients in the intensive care unit. Front Immunol 2022; 13:1043968. [PMID: 36544765 PMCID: PMC9760793 DOI: 10.3389/fimmu.2022.1043968] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/14/2022] [Indexed: 12/11/2022] Open
Abstract
Background To explore the diagnostic performance of interleukin (IL)-6 and IL-10 in discriminating Gram bacteria types and predicting disease severity in intensive care unit (ICU)-hospitalized pediatric sepsis patients. Method We retrospectively collected Th1/Th2 cytokine profiles of 146 microbiologically documented sepsis patients. Patients were categorized into Gram-positive (G+) or Gram-negative (G-) sepsis groups, and cytokine levels were compared. Subgroup analysis was designed to eliminate the influence of other inflammatory responses on cytokine levels. Results After propensity score matching, 78 patients were matched and categorized according to Gram bacteria types. Compared with G+ sepsis, IL-6 and IL-10 were significantly elevated in G- sepsis (p < 0.05). Spearman test proved the linear correlation between IL-6 and IL-10 (r = 0.654, p < 0.001), and their combination indicators (ratio and differences) were effective in identifying G- sepsis. In the subgroup analysis, such cytokine elevation was significant regardless of primary infection site. However, for patients with progressively deteriorating organ function [new or progressive multiple organ dysfunction syndrome (NPMODS)], differences in IL-6 and IL-10 levels were less significant between G+ and G- sepsis. In the receiver operating characteristic (ROC) curves of the G- sepsis group, the area under the curve (AUC) value for IL-6 and IL-10 was 0.679 (95% CI 0.561-0.798) and 0.637 (95% CI 0.512-0.762), respectively. The optimal cutoff value for diagnosing G- sepsis was 76.77 pg/ml and 18.90 pg/ml, respectively. While for the NPMODS group, the AUC for IL-6 and IL-10 was 0.834 (95% CI 0.766-0.902) and 0.781 (95% CI 0.701-0.860), respectively. Conclusion IL-6 and IL-10 are comparably effective in discriminating G+/G- sepsis in pediatric intensive care unit (PICU) patients. The deteriorated organ function observed in ICU patients reveals that complex inflammatory responses might have contributed to the cytokine pattern observed in severe sepsis patients, therefore confounding the discriminating efficacy of Th1/Th2 cytokines in predicting Gram bacteria types.
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10
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Rahn S, Becker-Pauly C. Meprin and ADAM proteases as triggers of systemic inflammation in sepsis. FEBS Lett 2022; 596:534-556. [PMID: 34762736 DOI: 10.1002/1873-3468.14225] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022]
Abstract
Systemic inflammatory disorders (SIDs) comprise a broad range of diseases characterized by dysregulated excessive innate immune responses. Severe forms of SIDs can lead to organ failure and death, and their increasing incidence represents a major issue for the healthcare system. Protease-mediated ectodomain shedding of cytokines and their receptors represents a central mechanism in the regulation of inflammatory responses. The metalloprotease A disintegrin and metalloproteinase (ADAM) 17 is the best-characterized ectodomain sheddase capable of releasing TNF-α and soluble IL-6 receptor, which are decisive factors of systemic inflammation. Recently, meprin metalloproteases were also identified as IL-6 receptor sheddases and activators of the pro-inflammatory cytokines IL-1β and IL-18. In different mouse models of SID, particularly those mimicking a sepsis-like phenotype, ADAM17 and meprins have been found to promote disease progression. In this review, we summarize the role of ADAM10, ADAM17, and meprins in the onset and progression of sepsis and discuss their potential as therapeutic targets.
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Affiliation(s)
- Sascha Rahn
- Biochemical Institute, Christian-Albrechts-University Kiel, Germany
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11
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Kennedy E. Bundling Your Way to Quality Care. J Dr Nurs Pract 2022; 15:11-17. [DOI: 10.1891/jdnp-2021-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BackgroundA bundle is defined by IHI as a small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually. It is important to understand that a bundle is not simply a checklist to complete, it is a set of researched interventions that have been shown to work better when completed together. These interventions are usually already well known and utilized in practice by nurses or providers. A bundle places the priority on the entire set of interventions being completed for the at-risk patient.ObjectiveThe focus of this paper is to explain the principles of a bundle, the evidence supporting their utilization in practice, challenges associated with care bundles, how to overcome these challenges, and recommendations for future success.ConclusionsA literature search on the implementation of bundles demonstrates several challenges to their use. Sustaining a comprehensive quality improvement approach within an institution can be challenging but with the guidelines outlined by IHI for requirements of a bundle and the implementation recommendations, great success can be obtained.
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12
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Kohl PL, Gyimah EA, Diaz J, Kuhlmann FM, Dulience SJL, Embaye F, Brown DS, Guo S, Luby JL, Nicholas JL, Turner J, Chapnick M, Pierre JM, Boncy J, St Fleur R, Black MM, Iannotti LL. Grandi Byen-supporting child growth and development through integrated, responsive parenting, nutrition and hygiene: study protocol for a randomized controlled trial. BMC Pediatr 2022; 22:54. [PMID: 35062907 PMCID: PMC8780724 DOI: 10.1186/s12887-021-03089-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/22/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Poor child growth and development outcomes stem from complex relationships encompassing biological, behavioral, social, and environmental conditions. However, there is a dearth of research on integrated approaches targeting these interwoven factors. The Grandi Byen study seeks to fill this research gap through a three-arm longitudinal randomized controlled trial which will evaluate the impact of an integrated nutrition, responsive parenting, and WASH (water, sanitation and hygiene) intervention on holistic child growth and development. METHODS We will recruit 600 mother-infant dyads living in Cap-Haitien, Haiti and randomize them equally into one of the following groups: 1) standard well-baby care; 2) nutritional intervention (one egg per day for 6 months); and 3) multicomponent Grandi Byen intervention (responsive parenting, nutrition, WASH + one egg per day for 6 months). Primary outcomes include child growth as well as cognitive, language, motor, and social-emotional development. The study also assesses other indicators of child health (bone maturation, brain growth, diarrheal morbidity and allergies, dietary intake, nutrient biomarkers) along with responsive parenting as mediating factors influencing the primary outcomes. An economic evaluation will assess the feasibility of large-scale implementation of the interventions. DISCUSSION This study builds on research highlighting the importance of responsive parenting interventions on overall child health, as well as evidence demonstrating that providing an egg daily to infants during the complementary feeding period can prevent stunted growth. The multicomponent Grandi Byen intervention may provide evidence of synergistic or mediating effects of an egg intervention with instruction on psychoeducational parenting and WASH on child growth and development. Grandi Byen presents key innovations with implications for the well-being of children living in poverty globally. TRIAL REGISTRATION NCT04785352 . Registered March 5, 2021 at https://clinicaltrials.gov/.
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Affiliation(s)
- Patricia L Kohl
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
| | - Emmanuel A Gyimah
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA.
| | - Jenna Diaz
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - F Matthew Kuhlmann
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Sherlie Jean-Louis Dulience
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
| | - Fithi Embaye
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
| | - Derek S Brown
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
| | - Shenyang Guo
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
| | - Joan L Luby
- Department of Psychiatry, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Jennifer L Nicholas
- Department of Radiology, School of Medicine, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH, 44106, USA
| | - Jay Turner
- McKelvey School of Engineering, Washington University in St. Louis, 1 Brookings Dr., St. Louis, MO, 63130, USA
| | - Melissa Chapnick
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
| | - Joseline Marhone Pierre
- Unité de Coordination du Programme National d'Alimentation et de Nutrition, Ministère de la Santé Publique et de la Population, 1, Angle Avenue Maïs Gaté et, Rue Jacques Roumain, Port-au-Prince, Haiti
| | - Jacques Boncy
- Laboratoire National de Santé Publique, Ministère de la Santé Publique et de la Population, 1, Angle Avenue Maïs Gaté et, Rue Jacques Roumain, Port-au-Prince, Haiti
| | | | - Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201, USA
| | - Lora L Iannotti
- Brown School, Washington University in St. Louis, 1 Brookings Dr., Campus Box 1196, St. Louis, MO, 63130, USA
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13
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Qin X, Zhang W, Zhu X, Hu X, Zhou W. Early Fresh Frozen Plasma Transfusion: Is It Associated With Improved Outcomes of Patients With Sepsis? Front Med (Lausanne) 2021; 8:754859. [PMID: 34869452 PMCID: PMC8634960 DOI: 10.3389/fmed.2021.754859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background: So far, no study has investigated the effects of plasma transfusion in the patients with sepsis, especially in the terms of prognosis. Therefore, we aimed to explore the association of early fresh frozen plasma (FFP) transfusion with the outcomes of patients with sepsis. Methods: We performed a cohort study using data extracted from the Medical Information Mart for Intensive Care III database (v1.4). External validation was obtained from the First Affiliated Hospital of Wenzhou Medical University, China. We adopted the Sepsis-3 criteria to extract the patients with sepsis and septic shock. The occurrence of transfusion during the first 3-days of intensive care unit (ICU) stay was regarded as early FFP transfusion. The primary outcome was 28-day mortality. We assessed the association of early FFP transfusion with the patient outcomes using a Cox regression analysis. Furthermore, we performed the sensitivity analysis, subset analysis, and external validation to verify the true strength of the results. Results: After adjusting for the covariates in the three models, respectively, the significantly higher risk of death in the FFP transfusion group at 28-days [e.g., Model 2: hazard ratio (HR) = 1.361, P = 0.018, 95% CI = 1.054–1.756] and 90-days (e.g., Model 2: HR = 1.368, P = 0.005, 95% CI = 1.099–1.704) remained distinct. Contrarily, the mortality increased significantly with the increase of FFP transfusion volume. The outcomes of the patients with sepsis with hypocoagulable state after early FFP transfusion were not significantly improved. Similar results can also be found in the subset analysis of the septic shock cohort. The results of external validation exhibited good consistency. Conclusions: Our study provides a new understanding of the rationale and effectiveness of FFP transfusion for the patients with sepsis. After recognizing the evidence of risk-benefit and cost-benefit, it is important to reduce the inappropriate use of FFP and avoid unnecessary adverse transfusion reactions.
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Affiliation(s)
- Xiaoyi Qin
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaodan Zhu
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiang Hu
- Department of Endocrine and Metabolic Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei Zhou
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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14
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Implementation and Routinization of the ABCDE Bundle: A Mixed Methods Evaluation. Dimens Crit Care Nurs 2021; 40:333-344. [PMID: 34606224 DOI: 10.1097/dcc.0000000000000495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The ABCDE (Awakening and Breathing Coordination, Delirium monitoring and management, and Early exercise/mobility) bundle has been associated with reductions in delirium incidence and improved patient outcomes but has not been widely adopted. OBJECTIVE The objective of this study was to determine how to facilitate ABCDE bundle adoption by examining the impact of different implementation strategies on bundle adherence rates and assessing clinicians' perceptions of the bundle and implementation efforts. METHODS This study examined the effect of 2 bundle implementation strategies on patient care in 8 adult intensive care units. The basic strategy included electronic health record (EHR) modification, whereas the enhanced strategy included EHR modification plus additional bundle training, clinical champions, and staff engagement. A total of 84 nurses, physicians, and therapists participated in interviews and a survey to assess bundle implementation. RESULTS Respondents indicated bundle use resulted in "best care" through care standardization and coordination and improved patient outcomes. Intensive care units in both intervention groups had significant improvements in bundle adherence after implementation efforts, but intensive care units in the basic intervention group outperformed other sites after initiating their own implementation strategies. Successful implementation tactics included incorporating the bundle into multidisciplinary rounds and providing ongoing support, training, and routine auditing and feedback. DISCUSSION The ABCDE bundle can improve quality of care and outcomes, and implementation can be accelerated through EHR tools, trainings, and performance feedback.
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15
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Dellinger RP, Levy MM, Schorr CA, Townsend SR. 50 Years of Sepsis Investigation/Enlightenment Among Adults-The Long and Winding Road. Crit Care Med 2021; 49:1606-1625. [PMID: 34342304 DOI: 10.1097/ccm.0000000000005203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Phillip Dellinger
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | | | - Christa A Schorr
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | - Sean R Townsend
- University of California Pacific Medical Center, (Sutter Health), San Francisco, CA
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16
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Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. Evidence for the Application of Sepsis Bundles in 2021. Semin Respir Crit Care Med 2021; 42:706-716. [PMID: 34544188 DOI: 10.1055/s-0041-1733899] [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
Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
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17
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Abstract
BACKGROUND Nurses are in a prime position to identify sepsis early by screening patients for sepsis, a skill that should be embedded into their daily practice. However, compliance with the sepsis bundle remains low. AIMS To explore the effects of sepsis training on knowledge, skills and attitude among ward-based nurses. METHODS Registered nurses from 16 acute surgical and medical wards were invited to anonymously complete a questionnaire. FINDINGS Response rate was 39% (98/250). Nurses with sepsis training had better knowledge of the National Early Warning Score 2 for sepsis screening, and the systemic inflammatory response syndrome (SIRS) criteria, demonstrated a more positive attitude towards sepsis screening and management, were more confident in screening patients for sepsis and more likely to have screened a patient for sepsis. CONCLUSIONS Sepsis training improves nurses' attitudes, knowledge and confidence with regards to sepsis screening and management, resulting in adherence to evidence-based care, and should become mandatory for all clinical staff.
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Affiliation(s)
- Eirian Edwards
- Advanced Nurse Practitioner, Betsi Cadwaladr University Health Board, Bangor, Gwynedd
| | - Lorelei Jones
- Lecturer in Healthcare Sciences (Healthcare improvement), School of Health Sciences, Bangor University, Bangor, Gwynedd
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18
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Nunnally ME, Ferrer R, Martin GS, Martin-Loeches I, Machado FR, De Backer D, Coopersmith CM, Deutschman CS. The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis. Intensive Care Med Exp 2021; 9:34. [PMID: 34212256 PMCID: PMC8249046 DOI: 10.1186/s40635-021-00400-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/07/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To identify priorities for administrative, epidemiologic and diagnostic research in sepsis. Design As a follow-up to a previous consensus statement about sepsis research, members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis. Methods Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified through a consensus process. Results The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?; (2) What is the epidemiology of sepsis susceptibility and response to treatment?; (3) What information identifies organ dysfunction?; (4) How can we screen for sepsis in various settings?; (5) How do we identify septic shock?; and (6) What in-hospital clinical information is associated with important outcomes in patients with sepsis? Conclusions There is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritize initiatives to improve an understanding of individual patient and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care.
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Affiliation(s)
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation (SODIR) Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Grady Memorial Hospital and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | | | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,The Feinstein Institute for Medical Research/ Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
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19
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Weinberger J, Rhee C, Klompas M. A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis. J Infect Dis 2021; 222:S110-S118. [PMID: 32691835 DOI: 10.1093/infdis/jiaa146] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The Surviving Sepsis Campaign recommends immediate antibiotics for all patients with suspected sepsis and septic shock, ideally within 1 hour of recognition. Immediate antibiotic treatment is lifesaving for some patients, but a substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions. Aggressive time-to-antibiotic targets risk promoting antibiotic overuse and antibiotic-associated harms for this subset of the population. An accurate understanding of the precise relationship between time-to-antibiotics and mortality for patients with possible sepsis is therefore critical to finding the best balance between assuring immediate antibiotics for those patients who truly need them versus allowing clinicians some time for rapid investigation to minimize the risk of overtreatment and antibiotic-associated harms for patients who are not infected. More than 30 papers have been published assessing the relationship between time-to-antibiotics and outcomes, almost all of which are observational cohort studies. Most report significant associations but all have important limitations. Key limitations include focusing just on the sickest subset of patients (only patients requiring intensive care and/or patients with septic shock), blending together mortality estimates from patients with very long intervals until antibiotics with patients with shorter intervals and reporting a single blended (and thus inflated) estimate for the average increase in mortality associated with each hour until antibiotics, and failure to control for large potential confounders including patients' presenting signs and symptoms and granular measures of comorbidities and severity of illness. In this study, we elaborate on these potential sources of bias and try to distill a better understanding of what the true relationship between time-to-antibiotics and mortality may be for patients with suspected sepsis or septic shock.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Cheshire J, Jones L, Munthali L, Kamphinga C, Liyaya H, Phiri T, Parry-Smith W, Dunlop C, Makwenda C, Devall AJ, Tobias A, Nambiar B, Merriel A, Williams HM, Gallos I, Wilson A, Coomarasamy A, Lissauer D. The FAST-M complex intervention for the detection and management of maternal sepsis in low-resource settings: a multi-site evaluation. BJOG 2021; 128:1324-1333. [PMID: 33539610 DOI: 10.1111/1471-0528.16658] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate whether the implementation of the FAST-M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low-resource setting. DESIGN A before-and-after design. SETTING Fifteen government healthcare facilities in Malawi. POPULATION Women suspected of having maternal sepsis. METHODS The FAST-M complex intervention consisted of the following components: the FAST-M maternal sepsis treatment bundle and the FAST-M implementation programme. Performance of selected process outcomes was compared between a 2-month baseline phase and 6-month intervention phase with compliance used as a proxy measure of feasibility. MAIN OUTCOME RESULT Compliance with vital sign recording and use of the FAST-M maternal sepsis bundle. RESULTS Following implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P < 0.001). Recognition of suspected maternal sepsis improved with more cases identified following the intervention (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001). Sepsis management improved, with women more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition (0/12 [0%] versus 21/107 [19.6%], P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis. CONCLUSION Implementation of the FAST-M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low-resource setting such as Malawi. TWEETABLE ABSTRACT Implementation of a sepsis care bundle for low-resources improved recognition & management of maternal sepsis.
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Affiliation(s)
- J Cheshire
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - L Jones
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - L Munthali
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - C Kamphinga
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - H Liyaya
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - T Phiri
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - W Parry-Smith
- World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK.,Department of Obstetrics and Gynaecology, Shrewsbury and Telford NHS Trust, The Princess Royal Hospital, Telford, UK
| | - C Dunlop
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - C Makwenda
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - A J Devall
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - A Tobias
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - B Nambiar
- Institute for Global Child Health, University College London, London, UK
| | - A Merriel
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - H M Williams
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - I Gallos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - A Wilson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - D Lissauer
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,College of Medicine, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
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22
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Guidry CA, Sawyer RG, Winfield RD. Challenging the Dogma of Aggressive Initiation of Antibiotics in Sepsis. Surg Infect (Larchmt) 2020; 22:473-476. [PMID: 33232638 DOI: 10.1089/sur.2020.244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher A Guidry
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Critical Care, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
| | - Robert D Winfield
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Critical Care, The University of Kansas Medical Center, Kansas City, Kansas, USA
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23
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Johnson AS, Fatemi R, Winlow W. SARS-CoV-2 Bound Human Serum Albumin and Systemic Septic Shock. Front Cardiovasc Med 2020; 7:153. [PMID: 33088822 PMCID: PMC7498713 DOI: 10.3389/fcvm.2020.00153] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/22/2020] [Indexed: 12/26/2022] Open
Abstract
The emergence of the COVID-19 virus and the subsequent pandemic have driven a great deal of research activity. The effects of COVID-19 are caused by the severe respiratory syndrome coronavirus 2 (SARS-CoV-2) and it is the underlying actions of SARs-CoV-2 virions on the endothelial glycocalyx that we consider here. One of the key factors in COVID-19 infection is its almost unique age-related profile, with a doubling in mortality every 10 years after the age of 50. The endothelial glycocalyx layer is essential in maintaining normal fluid homeostasis, but is fragile and prone to pathophysiological damage. It is physiologically significant in capillary microcirculation and in fluid distribution to the tissues. Human serum albumin (HSA), the most abundant protein in plasma, is created in the liver which also maintains its concentration, but this reduces by 10-15% after 50 years of age. HSA transports hormones, free fatty acids and maintains oncotic pressure, but SARS-CoV-2 virions bind competitively to HSA diminishing its normal transport function. Furthermore, hypoalbuminemia is frequently observed in patients with such conditions as diabetes, hypertension, and chronic heart failure, i.e., those most vulnerable to SARS-CoV-2 infection. Hypoalbuminemia, coagulopathy, and vascular disease have been linked in COVID-19 and have been shown to predict outcome independent of age and morbidity. Hypoalbuminemia is also known factor in sepsis and Acute respiratory distress syndrome (ARDS) occurs when fluids build-up in the alveoli and it is associated with sepsis, whose mechanism is systemic, being associated with the fluid and logistic mechanisms of the circulation. Glycocalyx damage is associated with changes plasma protein concentration, particularly HSA and blockage of albumin transport can produce the systemic symptoms seen in SARS-CoV-2 infection and sepsis. We therefore conclude that albumin binding to SARS-CoV-2 virions may inhibit the formation of the endothelial glycocalyx by inhibition of albumin transport binding sites. We postulate that albumin therapy to replace bound albumin might alleviate some of the symptoms leading to sepsis and that clinical trials to test this postulation should be initiated as a matter of urgency.
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Affiliation(s)
- Andrew S. Johnson
- Dipartimento di Biologia, Università Degli Studi di Naples, Federico II, Naples, Italy
| | - Rouholah Fatemi
- Physiology Research Center (PRC), School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - William Winlow
- Dipartimento di Biologia, Università Degli Studi di Naples, Federico II, Naples, Italy
- Institute of Ageing and Chronic Diseases, The Apex Building, University of Liverpool, Liverpool, United Kingdom
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24
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Plata-Menchaca EP, Ferrer R, Ruiz Rodríguez JC, Morais R, Póvoa P. Antibiotic treatment in patients with sepsis: a narrative review. Hosp Pract (1995) 2020; 50:203-213. [PMID: 32627615 DOI: 10.1080/21548331.2020.1791541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Juan Carlos Ruiz Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal
| | - Pedro Póvoa
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
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25
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Cuenca-Estrella M, Kett DH, Wauters J. Defining standards of CARE for invasive fungal diseases in the ICU. J Antimicrob Chemother 2020; 74:ii9-ii15. [PMID: 31222308 DOI: 10.1093/jac/dkz038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The aim of this article is to review the current recommendations for the diagnosis and treatment of invasive fungal infection in the ICU setting and to explore whether there are standards of care for this patient population. The text focuses mainly on the two most common invasive fungal diseases that afflict non-neutropenic patients: candidaemia and invasive candidosis (IC), and invasive pulmonary aspergillosis (IPA).
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Affiliation(s)
- Manuel Cuenca-Estrella
- Instituto de Salud Carlos III, Ctra. Majadahonda-Pozuelo Km 2, Majadahonda, Madrid, Spain
| | - Daniel H Kett
- Division of Pulmonary, Critical Care and Sleep Medicine at the University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joost Wauters
- Clinical Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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26
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Zhang E, Zhao X, MA H, Luo D, Hu Y, Hou L, Luo Z. A subanesthetic dose of sevoflurane combined with oxygen exerts bactericidal effects and prevents lung injury through the nitric oxide pathway during sepsis. Pharmacotherapy 2020; 127:110169. [DOI: 10.1016/j.biopha.2020.110169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 10/24/2022]
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27
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Llópez-Espinós P, Palazón-Bru A, Beneyto-Ripoll C, Martínez-Díaz AM, Gil-Guillén VF, Carbonell-Torregrosa MDLÁ. Quality assessment of meta-analyses evaluating randomized clinical trials to improve the prognosis of septic shock: an overview of systematic reviews. Curr Med Res Opin 2020; 36:929-939. [PMID: 32267785 DOI: 10.1080/03007995.2020.1754188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Clinical guidelines for the treatment of septic shock are based on the studies with the best scientific evidence, which are meta-analyses of clinical trials. However, these meta-analyses may have methodological limitations that prevent their conclusions from being extrapolated to routine clinical practice. Therefore, the objective of this study is to determine the quality of these meta-analyses through a systematic review.Methods: In this systematic review, we searched MEDLINE, Scopus and EMBASE from inception to May 2019. We selected meta-analyses from clinical trials that determined the effectiveness of an intervention in reducing the incidence of mortality in patients with septic shock. All items were extracted from the Overview Quality Assessment Questionnaire (OQAQ), which collects information from both systematic reviews and meta-analyses.Results: A total of 34 studies were included. Most elements of the OQAQ were conducted satisfactorily, although 35.3% of meta-analyses did not use a quality assessment of the studies included in other analyses. In 52.9% of meta-analyses, the quality of the studies was high or very high.Conclusions: The methods used to obtain the results should be taken into account when recommending an intervention to treat septic shock if the evidence comes from a meta-analysis of the analyzed characteristics.
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Affiliation(s)
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
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28
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Effects of End-Tidal Carbon Dioxide-Guided Fluid Resuscitation on Outcomes in a Cecal Ligation and Puncture Induced Rat Model of Sepsis. Shock 2020; 51:519-525. [PMID: 30875342 DOI: 10.1097/shk.0000000000001179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cecal ligation and puncture (CLP) was used to cause severe sepsis in male Sprague-Dawley rats. There are four groups in this study: sham (n = 5), CLP (n = 10), end-tidal carbon dioxide (ETCO2) (n = 10), and mean arterial pressure (MAP) (n = 10). In ETCO2 group, fluid resuscitation (FR) began when ETCO2 at most 25 mmHg. In MAP group, FR began when MAP at most 100 mmHg. Electrocardiogram, aortic pressure, core temperature, and ETCO2 values were recorded at baseline, 2, 4, 6, 8, 10, and 12 h post-CLP. Lactate level, cardiac output (CO), perfused small vessel density (PSVD), and microvascular flow index (MFI) were assessed at the same time points as above. The results showed that MAP, CO, and ETCO2 gradually decreased after CLP. After FR, MAP, ETCO2, and CO in the ETCO2 group increased compared with the MAP group 12 h after CLP (all P < 0.05). Lactate level remains high in MAP group while decreasing in the ETCO2 group 8 h post-CLP. Both PSVD and MFI deteriorated after CLP in CLP group, though significantly improved in the ETCO2 group 8 h post-CLP. The average survival time in the ETCO2 group was significantly greater than MAP group (14.95 ± 3.90 h vs. 11.15 ± 1.76 h; t = 2.804, P = 0.012). Moreover, ETCO2 showed a negative correlation with lactic acid levels and a positive correlation with CO, PSVD, and MFI. In conclusion, ETCO2 can guide FR implement and improve outcomes of severe sepsis in CLP-inducted rat model. ETCO2 might be a potential index to guiding early FR in severe sepsis.
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29
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Abstract
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of β‑lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).
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30
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Martínez ML, Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. An approach to antibiotic treatment in patients with sepsis. J Thorac Dis 2020; 12:1007-1021. [PMID: 32274170 PMCID: PMC7139065 DOI: 10.21037/jtd.2020.01.47] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, which is time-dependent and associated with unacceptably high mortality. Thus, when treating suspicious or confirmed cases of sepsis, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Optimizing antibiotic use is essential to ensure successful outcomes and to reduce adverse antibiotic effects, as well as preventing drug resistance. All likely pathogens involved should be considered to provide an appropriate antibiotic coverage. Clinicians must investigate on the previous risk of multidrug-resistant (MDR) pathogens, and the principle of individualized dosing should replace the principle of standard dosing. The loading dose is an initial higher dose of an antibiotic for all patients, yet an individualized treatment approach for further doses should be implemented according to pharmacokinetics (PK)/pharmacodynamics (PD) and the presence of renal/liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring (TDM) can help to achieve therapeutic levels of antimicrobials. Reevaluation of duration and appropriateness of treatment at regular intervals are also necessary. De-escalation and shortened courses of antimicrobials must be considered for most patients, except in some justified circumstances. Leadership, teamwork, antimicrobial stewardship (AS) frameworks, guideline’s recommendations on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients’ quality of care.
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Affiliation(s)
- María Luisa Martínez
- Department of Intensive Care, Hospital Universitario General de Catalunya, Barcelona, Spain
| | - Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias, Barcelona, Spain
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31
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France
- Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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32
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 495] [Impact Index Per Article: 123.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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Lissauer D, Cheshire J, Dunlop C, Taki F, Wilson A, Smith JM, Daniels R, Kissoon N, Malata A, Chirwa T, Lwesha VM, Mhango C, Mhango E, Makwenda C, Banda L, Munthali L, Nambiar B, Hussein J, Williams HM, Devall AJ, Gallos I, Merriel A, Bonet M, Souza JP, Coomarasamy A. Development of the FAST-M maternal sepsis bundle for use in low-resource settings: a modified Delphi process. BJOG 2019; 127:416-423. [PMID: 31677228 PMCID: PMC7384197 DOI: 10.1111/1471-0528.16005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2019] [Indexed: 01/14/2023]
Abstract
Objective To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. Design Modified Delphi process. Setting Participants from 34 countries. Population Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. Methods We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. Main outcome measure Consensus on bundle items. Results Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’. Conclusion A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. Tweetable abstract A maternal sepsis bundle for low resource settings has been developed by international consensus. A maternal sepsis bundle for low resource settings has been developed by international consensus.
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Affiliation(s)
- D Lissauer
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi
| | - J Cheshire
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - C Dunlop
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - F Taki
- The Hillingdon Hospitals NHS Foundation Trust, London, UK
| | - A Wilson
- World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - J M Smith
- The Bill & Melinda Gates Foundation's Maternal, Newborn & Child Health Team, Seattle, WA, USA
| | - R Daniels
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Malata
- Malawi University of Science and Technology, Limbe, Malawi
| | - T Chirwa
- Chitipa District Hospital, Chitipa, Malawi
| | - V M Lwesha
- Save the Children Norway, Lilongwe, Malawi
| | - C Mhango
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - E Mhango
- Chitipa District Hospital, Chitipa, Malawi
| | - C Makwenda
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - L Banda
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - L Munthali
- Parent and Child Health Initiative (PACHI) Trust, Lilongwe, Malawi
| | - B Nambiar
- Institute for Global Child Health, University College London, London, UK
| | - J Hussein
- Independent Maternal Health Consultant, Aberdeen, UK
| | - H M Williams
- World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK.,Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - A J Devall
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - I Gallos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - A Merriel
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - M Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - J P Souza
- Department of Social Medicine, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,World Health Organization Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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Abe T, Kushimoto S, Tokuda Y, Phillips GS, Rhodes A, Sugiyama T, Komori A, Iriyama H, Ogura H, Fujishima S, Shiraishi A, Saitoh D, Mayumi T, Naito T, Takuma K, Nakada TA, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Hagiwara A, Yamakawa K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. Implementation of earlier antibiotic administration in patients with severe sepsis and septic shock in Japan: a descriptive analysis of a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:360. [PMID: 31744549 PMCID: PMC6862854 DOI: 10.1186/s13054-019-2644-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/09/2019] [Indexed: 12/13/2022]
Abstract
Background Time to antibiotic administration is a key element in sepsis care; however, it is difficult to implement sepsis care bundles. Additionally, sepsis is different from other emergent conditions including acute coronary syndrome, stroke, or trauma. We aimed to describe the association between time to antibiotic administration and outcomes in patients with severe sepsis and septic shock in Japan. Methods This prospective observational study enrolled 1184 adult patients diagnosed with severe sepsis based on the Sepsis-2 criteria and admitted to 59 intensive care units (ICUs) in Japan between January 1, 2016, and March 31, 2017, as the sepsis cohort of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) study. We compared the characteristics and in-hospital mortality of patients administered with antibiotics at varying durations after sepsis recognition, i.e., 0–60, 61–120, 121–180, 181–240, 241–360, and 361–1440 min, and estimated the impact of antibiotic timing on risk-adjusted in-hospital mortality using the generalized estimating equation model (GEE) with an exchangeable, within-group correlation matrix, with “hospital” as the grouping variable. Results Data from 1124 patients in 54 hospitals were used for analyses. Of these, 30.5% and 73.9% received antibiotics within 1 h and 3 h, respectively. Overall, the median time to antibiotic administration was 102 min [interquartile range (IQR), 55–189]. Compared with patients diagnosed in the emergency department [90 min (IQR, 48–164 min)], time to antibiotic administration was shortest in patients diagnosed in ICUs [60 min (39–180 min)] and longest in patients transferred from wards [120 min (62–226)]. Overall crude mortality was 23.4%, where patients in the 0–60 min group had the highest mortality (28.0%) and a risk-adjusted mortality rate [28.7% (95% CI 23.3–34.1%)], whereas those in the 61–120 min group had the lowest mortality (20.2%) and risk-adjusted mortality rates [21.6% (95% CI 16.5–26.6%)]. Differences in mortality were noted only between the 0–60 min and 61–120 min groups. Conclusions We could not find any association between earlier antibiotic administration and reduction in in-hospital mortality in patients with severe sepsis.
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Affiliation(s)
- Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan. .,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Tokuda
- Department of Medicine, Muribushi Project for Okinawa Residency Programs, Urasoe, Japan
| | - Gary S Phillips
- Department of Biomedical Informatics, Ohio State University, Columbus, OH, USA
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's University Hospitals Foundation Trust, London, UK
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.,Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshio Naito
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Akiyoshi Hagiwara
- Department of Emergency Medicine, Niizashiki Chuo General Hospital, Niiza, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.,Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Berrevoets MAH, Ten Oever J, Hoogerwerf J, Kullberg BJ, Atsma F, Hulscher ME, Schouten JA. Appropriate empirical antibiotic use in the emergency department: full compliance matters! JAC Antimicrob Resist 2019; 1:dlz061. [PMID: 34222935 PMCID: PMC8210121 DOI: 10.1093/jacamr/dlz061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/18/2019] [Accepted: 10/03/2019] [Indexed: 12/29/2022] Open
Abstract
Background Little is known about determinants of appropriate antibiotic use in the emergency department (ED). We measured appropriateness of antibiotic use for seven quality indicators (QIs) and studied patient-related factors that determine their variation. Patients and methods A retrospective analysis of 948 patients presumptively diagnosed as having an infection needing empirical antibiotic treatment in the ED was performed. Outcomes of seven previously validated QIs were calculated using computerized algorithms. We used logistic regression analysis to identify patient-related factors of QI performance and evaluated whether more appropriate antibiotic use in the ED results in better patient outcomes (length-of-stay, in-hospital mortality, 30 day readmission). Results QI performance ranged from 57.3% for guideline-adherent empirical therapy to 97.3% for appropriate route of administration in patients with sepsis. QI performance was positively associated with patients’ disease severity on admission (presence of fever, tachycardia and hypotension). Overall, the clinical diagnosis and thus the guidelines followed influenced QI performance. The difference in complexity between the guidelines was a possible explanation for the variation in QI performance. A QI performance sum score of 100% was associated with reduced in-hospital mortality. QI performance was not associated with readmission rates. Conclusions We gained insights into factors that determine quality of antibiotic prescription in the ED. Adherence to the full bundle of QIs was associated with reduced in-hospital mortality. These findings suggest that future stewardship interventions in the ED should focus on the entire process of antibiotic prescribing in the ED and not on a single metric only.
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Affiliation(s)
- Marvin A H Berrevoets
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Jan Kullberg
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Femke Atsma
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies E Hulscher
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Marik PE, Farkas JD, Spiegel R, Weingart S. POINT: Should the Surviving Sepsis Campaign Guidelines Be Retired? Yes. Chest 2019; 155:12-14. [PMID: 30616719 DOI: 10.1016/j.chest.2018.10.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/02/2018] [Indexed: 01/29/2023] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington VT
| | - Rory Spiegel
- Department Emergency Medicine, Critical Care Fellow Division of Pulmonary Critical Care University of Maryland Medical Center, Baltimore, MD
| | - Scott Weingart
- Department Emergency Medicine, Stony Brook School of Medicine, Stony Brook, NY
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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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Impact of premix antimicrobial preparation and time to administration in septic patients. CAN J EMERG MED 2019; 20:565-571. [PMID: 30033892 DOI: 10.1017/cem.2017.33] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Strategies that reduce the time to antimicrobial administration, such as the availability of premix antimicrobials (PMAs) in the emergency department (ED), may better align with the goals of the Surviving Sepsis Campaign and improve outcomes in septic patients. The objective of this study was to evaluate the impact of antimicrobial preparation on time to administration in septic patients located in the emergency department (ED). METHODS This was a retrospective, single-center, cohort study and adult patients with a diagnosis of sepsis who received at least one initial intravenous (IV) antimicrobial in the ED were included. Time to complete an empiric antimicrobial therapy was defined as the time between prescriber order entry and the infusion initiation time of the final antimicrobial agent of a patient's antimicrobial regimen. Appropriate, empiric antimicrobial therapy was based on treatment recommendations by nationally accepted guidelines for the specific indication. RESULTS The first antimicrobial was initiated earlier when available as a PMA preparation (median (IQR): premix 25 minutes (16.5-42.3) vs. non-premix 46 minutes (20-102), p=0.027). When comparing complete, empiric antimicrobial regimen administration, there was no difference in time to administration between regimens containing one or more non-premix antimicrobials and regimens containing all PMAs (median (IQR): premix 69 minutes (21-115) vs. non-premix 65 minutes (38.5-133.8); p=0.455). CONCLUSIONS PMA preparations significantly reduced time to administration of the first antimicrobial agent for septic patients treated in the ED, but time to administration of subsequent antimicrobials were not improved.
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Abstract
Objective: Sepsis is a deadly infection that causes injury to tissues and organs. Infection and anti-infective treatment are the eternal themes of sepsis. The successful control of infection is a key factor of resuscitation for sepsis and septic shock. This review examines evidence for the treatment of sepsis. This evidence is combined with clinical experiments to reveal the rules and a standard flowchart of anti-infection therapy for sepsis. Data Sources: We retrieved information from the PubMed database up to October 2018 using various search terms and their combinations, including sepsis, septic shock, infection, antibiotics, and anti-infection. Study Selection: We included data from peer-reviewed journals printed in English on the relationships between infections and antibiotics. Results: By combining the literature review and clinical experience, we propose a 6Rs rule for sepsis and septic shock management: right patients, right time, right target, right antibiotics, right dose, and right source control. This rule encompasses rational decisions regarding the timing of treatment, the identification of the correct pathogen, the selection of appropriate antibiotics, the formulation of a scientifically based antibiotic dosage regimen, and the adequate control of infectious foci. Conclusions: This review highlights how to recognize and treat sepsis and septic shock and provides rules and a standard flowchart for anti-infection therapy for sepsis and septic shock for use in the clinical setting.
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Rhee C, Jones TM, Hamad Y, Pande A, Varon J, O’Brien C, Anderson DJ, Warren DK, Dantes RB, Epstein L, Klompas M. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Netw Open 2019; 2:e187571. [PMID: 30768188 PMCID: PMC6484603 DOI: 10.1001/jamanetworkopen.2018.7571] [Citation(s) in RCA: 304] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. OBJECTIVE To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. DESIGN, SETTING, AND PARTICIPANTS Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018. MAIN OUTCOMES AND MEASURES Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale. RESULTS The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable. CONCLUSIONS AND RELEVANCE In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.
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Affiliation(s)
- Chanu Rhee
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Travis M. Jones
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Yasir Hamad
- Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri
| | - Anupam Pande
- Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri
| | - Jack Varon
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Cara O’Brien
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - David K. Warren
- Department of Medicine, Washington University School of Medicine at St Louis, St Louis, Missouri
| | - Raymund B. Dantes
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, Georgia
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael Klompas
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Hasan GM, Al-Eyadhy AA, Temsah MHA, Al-Haboob AA, Alkhateeb MA, Al-Sohime F. Feasibility and efficacy of sepsis management guidelines in a pediatric intensive care unit in Saudi Arabia: a quality improvement initiative. Int J Qual Health Care 2019; 30:587-593. [PMID: 29697828 DOI: 10.1093/intqhc/mzy077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/04/2018] [Indexed: 12/25/2022] Open
Abstract
Objectives Evaluation of feasibility and effectiveness of Surviving Sepsis Campaign (SSC) Guidelines implementation at a Pediatric Intensive Care Unit (PICU) in Saudi Arabia to reduce severe sepsis associated mortality. Design Retrospective data analysis for a prospective quality improvement (QI) initiative. Settings PICU at King Saud University Medical City, Saudi Arabia. Participants Children ≤14 years of age admitted to the PICU from July 2010 to March 2011 with suspected or proven sepsis. Comparisons were made to a previously admitted group of patients with sepsis from October 2009 to June 2010. Interventions Adaptation and implementation of the Surviving Sepsis Campaign-Clinical Practice Guidelines (SSC-CPGs) through AGREE instrument and ADAPTE process. Main Outcome Measures We reported pre- and post-implementation outcome of interest for this QI initiative, annual sepsis-related mortality rate. Furthermore, we reported follow-up of annual mortality rate until December 2016. Results Sixty-five patients was included in the study (42 in post-guidelines implementation group and 23 in pre-guidelines implementation group). Mortality was insignificantly lower in the post-implementation group (26.2% vs. 47.8%; P = 0.079). However, when adjusted for severity, identified by number of failing organs in the multivariate regression analysis, the mortality difference was favorable for the post-implementation group (P = 0.006). The lower sepsis-related mortality rate was also sustained, with an average mortality rate of 15.11% for the subsequent years (2012-16). Conclusions Adaptation and implementation of SSC Guidelines in our setting support its feasibility and potential benefits. However, a larger study is recommended to explore detailed compliance rates.
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Affiliation(s)
- Gamal M Hasan
- Intensive Care Unit, Department of Pediatrics, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Intensive Care Unit, Department of Pediatrics, Faculty of Medicine, Assiut University Children Hospital, Assiut University, Assiut, Egypt
| | - Ayman A Al-Eyadhy
- Intensive Care Unit, Department of Pediatrics, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed-Hani A Temsah
- Intensive Care Unit, Department of Pediatrics, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ali A Al-Haboob
- Intensive Care Unit, Department of Pediatrics, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad A Alkhateeb
- Intensive Care Unit, Department of Pediatrics, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Al-Sohime
- Intensive Care Unit, Department of Pediatrics, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Audit-and-Feedback and Workflow Changes Improve Emergency Department Care of Critically Ill Children. Pediatr Qual Saf 2019; 4:e128. [PMID: 30937410 PMCID: PMC6426493 DOI: 10.1097/pq9.0000000000000128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/20/2018] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Children with severe infection have improved outcomes when they received antibiotics promptly. Positive cultures help guide physicians in antibiotic selection. In 2011, 30% of children intubated in the emergency department received antibiotics and had respiratory culture collected within 60 minutes of intubation. Knowing the risk of delaying appropriate antibiotics, we charted a quality improvement team to improve compliance with 80% of intubated patients receiving both. Methods: The team evaluated all children intubated with concern for infection in the emergency department. Using a multidisciplinary team and employing quality improvement methods, we implemented multiple plan-do-study-act cycles to improve time to antibiotics and respiratory cultures. The team continued to implement successful interventions and restarted interventions directly affecting improvement. Results: While multiple interventions had small effects on the baseline of 30% compliance, 2 interventions appeared more influential than others. Workflow changes and audit-and-feedback created the largest, persistent positive changes. The importance of audit-and-feedback became very obvious when the project entered sustain mode. An abrupt decrease in compliance occurred when audit-and-feedback stopped. Complete recovery in compliance to greater than 80% occurred with the resumption of the audit-and-feedback intervention. Conclusions: Workflow changes and audit-and-feedback interventions resulted in large improvements. Loss of compliance with cessation of the audit-and-feedback and resumption demonstrated the importance of this intervention. Recovery to >80% compliance with the renewal of the audit-and-feedback program indicates its strength as a positive intervention.
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Nurse Influence in Meeting Compliance With the Centers for Medicare and Medicaid Services Quality Measure. Dimens Crit Care Nurs 2019; 38:70-82. [DOI: 10.1097/dcc.0000000000000340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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[Consensus document for sepsis code implementation and development in the Community of Madrid]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32:400-409. [PMID: 31345006 PMCID: PMC6719654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.
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Pertzov B, Eliakim-Raz N, Atamna H, Trestioreanu AZ, Yahav D, Leibovici L. Hydroxymethylglutaryl-CoA reductase inhibitors (statins) for the treatment of sepsis in adults - A systematic review and meta-analysis. Clin Microbiol Infect 2018; 25:280-289. [PMID: 30472427 DOI: 10.1016/j.cmi.2018.11.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 10/14/2018] [Accepted: 11/03/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The pleiotropic effect of hydroxymethylglutaryl-CoA reductase inhibitors (statins) might have a beneficial effect in sepsis through several mechanisms. The aim was to assess the efficacy and safety of statins, compared with placebo, for the treatment of sepsis in adults. METHODS We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2017, Issue 12), OVID MEDLINE (from 1966 to January 2018), Embase (Ovid SP, from 1974 to January 2018), and LILACS (from 1986 to January 2018). We also searched the trial registries ISRCTN and ClinicalTrials.gov to January 2018. The eligibility criteria were randomized controlled trials comparing the treatment of statins versus placebo in adult patients who were hospitalized due to sepsis. Participants were adults (16 years and older) hospitalized because of sepsis or who developed sepsis during admission. Interventions were treatment with hydroxymethylglutaryl-CoA reductase inhibitors (statins) versus no treatment or placebo. We performed a systematic review of all randomized controlled trials published until January 2018, assessing the efficacy and safety of statins in sepsis treatment. Two primary outcomes were assessed: 30-day overall mortality and deterioration to severe sepsis during management. Secondary outcomes were hospital mortality, need for mechanical ventilation and drug related adverse events. RESULTS Fourteen trials evaluating 2628 patients were included. Statins did not reduce 30-day all-cause mortality neither in all patients (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.83-1.10), nor in a subgroup of patients with severe sepsis (RR 0.97, 95% CI 0.84-1.12). The certainty of evidence for both outcomes was high. There was no change in the rate of adverse events between study arms (RR 1.24, 95% CI 0.94 to 1.63). The certainty of evidence for this outcome was high. CONCLUSIONS The use of statin therapy in adults for the indication of sepsis is not recommended.
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Affiliation(s)
- B Pertzov
- Department of Medicine E, Beilinson Hospital, Rabin Medical Centre, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - N Eliakim-Raz
- Department of Medicine E, Beilinson Hospital, Rabin Medical Centre, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - H Atamna
- Department of Medicine E, Beilinson Hospital, Rabin Medical Centre, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A Z Trestioreanu
- Department of Family Medicine, Beilinson Hospital, Rabin Medical Centre, Petah Tikva, Israel
| | - D Yahav
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Infectious Diseases Unit, Rabin Medical Centre, Beilinson Hospital, Petah-Tikva, Israel
| | - L Leibovici
- Department of Medicine E, Beilinson Hospital, Rabin Medical Centre, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Lynn NB, Gupta C, Vaaler M, Held J, Leon L. Severe sepsis 3-hour bundle compliance and mortality. Am J Infect Control 2018; 46:1299-1300. [PMID: 29884575 DOI: 10.1016/j.ajic.2018.04.228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 10/14/2022]
Abstract
Severe sepsis is a major cause of mortality among hospitalized patients. We tracked severe sepsis 3-hour bundle compliance and mortality over time. Those patients with severe sepsis who received the entire bundle had improved in-hospital survivability over those patients who did not receive the bundle.
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48
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Jabaley CS, Groff RF, Stentz MJ, Moll V, Lynde GC, Blum JM, O'Reilly-Shah VN. Highly visible sepsis publications from 2012 to 2017: Analysis and comparison of altmetrics and bibliometrics. J Crit Care 2018; 48:357-371. [PMID: 30296750 DOI: 10.1016/j.jcrc.2018.09.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE We sought to delineate highly visible publications related to sepsis. Within these subsets, elements of altmetrics performance, including mentions on Twitter, and the correlation between altmetrics and conventional citation counts were ascertained. MATERIALS AND METHODS Three subsets of sepsis publications from 2012 to 2017 were synthesized by the overall Altmetric.com attention score, number of mentions by unique Twitter users, and conventional citation counts. For these subsets, geolocated Twitter activity was plotted on a choropleth, the lag between publication date and altmetrics mentions was characterized, and correlations were examined between altmetrics performance and normalized conventional citation counts. RESULTS Of 57,152 PubMed query results, Altmetric.com data was available for 28,344 (49.6%). The top 50 publications by Altmetric.com attention score and Twitter attention represented a mix of original research and other types of work, garnering attention from Twitter users in 143 countries that was highly contemporaneous with publication. Altmetrics performance and conventional citation counts were poorly correlated. CONCLUSIONS While unreliable to gauge impact or future citation potential, altmetrics may be valuable for parties who wish to detect and drive public awareness of research findings and may enable researchers to dynamically explore the reach of their work in novel dimensions.
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Affiliation(s)
- Craig S Jabaley
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA; Anesthesiology Service Line, Division of Critical Care Medicine, Atlanta Veterans Affairs Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.
| | - Robert F Groff
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA; Anesthesiology Service Line, Division of Critical Care Medicine, Atlanta Veterans Affairs Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.
| | - Michael J Stentz
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA.
| | - Vanessa Moll
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA.
| | - Grant C Lynde
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA.
| | - James M Blum
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA; Anesthesiology Service Line, Division of Critical Care Medicine, Atlanta Veterans Affairs Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA; Department of Biomedical Informatics, Emory University School of Medicine, 201 Bowman Dr, Atlanta, GA 30322, USA.
| | - Vikas N O'Reilly-Shah
- Department of Anesthesiology, Emory University, 1750 Gambrell Dr, Atlanta, GA 30322, USA; Department of Anesthesiology, Children's Healthcare of Atlanta, 1405 Clifton Rd, Atlanta, GA 30329, USA.
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Spiegel R, Farkas JD, Rola P, Kenny JE, Olusanya S, Marik PE, Weingart SD. The 2018 Surviving Sepsis Campaign's Treatment Bundle: When Guidelines Outpace the Evidence Supporting Their Use. Ann Emerg Med 2018; 73:356-358. [PMID: 30193754 DOI: 10.1016/j.annemergmed.2018.06.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Rory Spiegel
- Department of Emergency Medicine and Division of Pulmonary and Critical Care, University of Maryland Medical Center, Baltimore, MD.
| | - Joshua D Farkas
- Division of Pulmonary and Critical Care Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montreal, Quebec, Canada
| | | | - Segun Olusanya
- Department of Perioperative Medicine, St Bartholomew's Hospital, London, UK
| | - Paul E Marik
- Department of Internal Medicine and Pulmonary and Critical Care Medicine, Eastern Virginia Medical School
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Rubens M, Saxena A, Ramamoorthy V, Das S, Khera R, Hong J, Armaignac D, Veledar E, Nasir K, Gidel L. Increasing Sepsis Rates in the United States: Results From National Inpatient Sample, 2005 to 2014. J Intensive Care Med 2018; 35:858-868. [DOI: 10.1177/0885066618794136] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives:To examine the trends in hospitalization rates, mortality, and costs for sepsis during the years 2005 to 2014.Methods:This was a retrospective serial cross-sectional analysis of patients ≥18 years admitted for sepsis in National Inpatient Sample. Trends in sepsis hospitalizations were estimated, and age- and sex-adjusted rates were calculated for the years 2005 to 2014.Results:There were 541 694 sepsis admissions in 2005 and increased to 1 338 905 in 2014. Sepsis rates increased significantly from 1.2% to 2.7% during the years 2005 to 2014 (relative increase: 123.8%; Ptrend< .001). However, the relative increase changed by 105.8% ( Ptrend< .001) after adjusting for age and sex and maintained significance. Although total cost of hospitalization due to sepsis increased significantly from US$22.2 to US$38.1 billion ( Ptrend< .001), the mean hospitalization cost decreased significantly from US$46,470 to US$29,290 ( Ptrend< .001).Conclusions:Hospitalizations for sepsis increased during the years 2005 to 2014. Our study paradoxically found declining rates of in-hospital mortality, length of stay, and mean hospitalization cost for sepsis. These findings could be due to biases introduced by International Classification of Diseases, Ninth Revision, Clinical Modification coding rules and increased readmission rates or alternatively due to increased awareness and surveillance and changing disposition status. Standardized epidemiologic registries should be developed to overcome these biases.
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Affiliation(s)
- Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Anshul Saxena
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
| | | | - Sankalp Das
- Employee Health and Wellness Advantage, Baptist Health South Florida, Miami, FL, USA
| | - Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jonathan Hong
- Division of Cardiovascular Surgery, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Donna Armaignac
- Teleheath Center of Excellence, Baptist Health South Florida, Miami, FL, USA
| | - Emir Veledar
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
| | - Khurram Nasir
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University, Baltimore, MD, USA
| | - Louis Gidel
- Teleheath Center of Excellence, Baptist Health South Florida, Miami, FL, USA
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