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Tuon FF, Zequinao T, da Silva MS, Silva KO. eHealth and mHealth in Antimicrobial Stewardship to Reduce Mortality in Empirical Antimicrobial Therapy and a Systematic Review with a Meta-Analysis of Adequate Therapy. Infect Dis Rep 2024; 16:707-723. [PMID: 39195005 DOI: 10.3390/idr16040054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 08/29/2024] Open
Abstract
The urgent requirement for swift diagnostic methods in pathogen identification and antimicrobial susceptibility testing is emphasized by rising bacterial resistance and limited treatment options, which are particularly critical in sepsis management. The shift from traditional phenotype-based methods to rapid molecular and mass spectrometry techniques has significantly reduced result turnaround times, enhancing patient outcomes. In this systematic review with meta-analysis, the aspects of correct empirical antimicrobial therapy are evaluated to determine their impact on mortality. We performed a systematic review and meta-analysis on EMBASE, the Cochrane Library, Web of Science, and MEDLINE. Studies evaluating mortality associated with empirical adequate and inadequate therapy in different sites of infection were included. Outcomes included clinical cures in microbiologically evaluable patients. Among the sites of infection, the most studied were bloodstream infections (n = 9), followed by respiratory tract infections (n = 5), intra-abdominal infections (n = 5), and urinary tract infections (evaluated by 3 studies). Inadequate therapy was associated with an increase in mortality between 11 and 68%. Technologies to speed up pathogen identification are extremely necessary to reduce mortality.
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Affiliation(s)
- Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Tiago Zequinao
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Marcelo Silva da Silva
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Kleber Oliveira Silva
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
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Todorovic Markovic M, Todorovic Mitic M, Ignjatovic A, Gottfredsson M, Gaini S. Mortality in Community-Acquired Sepsis and Infections in the Faroe Islands-A Prospective Observational Study. Infect Dis Rep 2024; 16:448-457. [PMID: 38804443 PMCID: PMC11130956 DOI: 10.3390/idr16030033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024] Open
Abstract
The aim of this study was to collect data and analyze mortality among patients hospitalized with community-acquired infections in the Faroe Islands. A prospective observational study was conducted in the Medical Department of the National Hospital of the Faroe Islands from October 2013 to April 2015. Cumulative all-cause, in-hospital, short-term, intermediate-term and long-term mortality rates were calculated. Kaplan-Meier survival curves comparing infection-free patients with infected patients of all severities and different age groups are presented. A log-rank test was used to compare groups. Mortality hazard ratios were calculated for subgroups using Cox regression multivariable models. There were 1309 patients without infection and 755 patients with infection. There were 51% female and 49% male patients. Mean age was 62.73 ± 19.71. Cumulative all-cause mortality and in-hospital mortality were highest in more severe forms of infection. This pattern remained the same for short-term mortality in the model adjusted for sex and age, while there were no significant differences among the various infection groups in regard to intermediate- or long-term survival after adjustment. Overall and short-term mortality rates were highest among those with severe manifestations of infection and those with infection compared to infection-free patients.
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Affiliation(s)
- Marija Todorovic Markovic
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Infectious Diseases, Odense University Hospital, 5000 Odense, Denmark
- Department of Medicine, Infectious Diseases Division, National Hospital of the Faroe Islands, JC. Svabosgøta 41-49, 100 Torshavn, Faroe Islands
| | | | - Aleksandra Ignjatovic
- Department of Medical Statistics and Informatics, School of Medicine, University of Nis, 18108 Nis, Serbia
| | - Magnús Gottfredsson
- Department of Infectious Diseases, Landspitali University Hospital, 105 Reykjavik, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, 101 Reykjavik, Iceland
| | - Shahin Gaini
- Department of Infectious Diseases, Odense University Hospital, 5000 Odense, Denmark
- Department of Medicine, Infectious Diseases Division, National Hospital of the Faroe Islands, JC. Svabosgøta 41-49, 100 Torshavn, Faroe Islands
- Faculty of Health Sciences, University of the Faroe Islands, 100 Torshavn, Faroe Islands
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Tang F, Yuan H, Li X, Qiao L. Effect of delayed antibiotic use on mortality outcomes in patients with sepsis or septic shock: A systematic review and meta-analysis. Int Immunopharmacol 2024; 129:111616. [PMID: 38310764 DOI: 10.1016/j.intimp.2024.111616] [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: 12/31/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND The use of antibiotics is essential in the treatment of sepsis and septic shock, and delaying their administration may impact patient mortality outcomes. However, there is currently a controversial debate surrounding this issue. In this meta-analysis, we aimed to explore the association between delayed antibiotic use and mortality in patients with sepsis and septic shock. METHODS A systematic search was conducted on PubMed, EMBASE, Web of Science, and Cochrane Library to identify relevant studies published from 2013 to 2023. These studies focused on patients with sepsis or septic shock and provided information on various antibiotic administration times and mortality rates. Two independent reviewers screened and extracted the data. The quality of each study was assessed using the Newcastle-Ottawa Scale, and the collected data were analyzed using STATA 15.1 software. RESULTS A total of 29 studies were included, consisting of 17 prospective cohort studies and 12 retrospective cohort studies. The meta-analysis showed that compared to administration of antibiotics within 1 h, each hour of delay in antibiotic administration increased the in-hospital mortality (IHM) (OR = 1.041, 95 % CI: 1.021-1.062), and ministration of antibiotics after 1 h increased the IHM (OR = 1.205, 95 % CI: 1.123-1.293). There was no significant change in the 28-day mortality (OR = 1.297, 95 % CI: 0.882-1.906), 90-day mortality (OR = 1.172, 95 % CI: 0.846-1.622), and 1-year mortality (OR = 0.986, 95 % CI: 0.422-2.303). Administration of antibiotics within 3 h may reduce the IHM (OR = 1.297, 95 % CI: 1.011-1.664, p = 0.041), while administration of antibiotics within 6 h showed no significant association with the IHM. CONCLUSION The administration of antibiotics beyond 1 h after emergency triage or disease identification is strongly associated with an increased IHM in patients with sepsis or septic shock, and each hour of delay in antibiotic administration may be associated with an increase in the IHM. Furthermore, the use of antibiotics identification beyond 3 h after emergency triage / sepsis or septic shock may also increase the IHM.
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Affiliation(s)
- Fajuan Tang
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Hongxiu Yuan
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Xihong Li
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China
| | - Lina Qiao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China; Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China.
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Skei NV, Nilsen TIL, Mohus RM, Prescott HC, Lydersen S, Solligård E, Damås JK, Gustad LT. Trends in mortality after a sepsis hospitalization: a nationwide prospective registry study from 2008 to 2021. Infection 2023; 51:1773-1786. [PMID: 37572240 PMCID: PMC10665235 DOI: 10.1007/s15010-023-02082-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Few studies have reported on mortality beyond one year after sepsis. We aim to describe trends in short- and long-term mortality among patients admitted with sepsis, and to describe the association between clinical characteristics and mortality for improved monitoring, treatment and prognosis. METHODS Patients ≥ 18 years admitted to all Norwegian hospitals (2008-2021) with a first sepsis episode were identified using Norwegian Patient Registry and International Classification of Diseases 10th Revision codes. Sepsis was classified as implicit (known infection site plus organ dysfunction), explicit (unknown infection site), or COVID-19-related sepsis. The outcome was all-cause mortality. We describe age-standardized 30-day, 90-day, 1-, 5- and 10-year mortality for each admission year and estimated the annual percentage change with 95% confidence interval (CI). The association between clinical characteristics and all-cause mortality is reported as hazard ratios (HRs) adjusted for age, sex and calendar year in Cox regression. RESULTS The study included 222,832 patients, of whom 127,059 (57.1%) had implicit, 92,928 (41.7%) had explicit, and 2,845 (1.3%) had COVID-19-related sepsis (data from 2020 and 2021). Trends in overall age-standardized 30-day, 90-day, 1- and 5-year mortality decreased by 0.29 (95% CI - 0.39 to - 0.19), 0.43 (95% CI - 0.56 to - 0.29), 0.61 (95% CI - 0.73 to - 0.49) and 0.66 (95% CI - 0.84 to - 0.48) percent per year, respectively. The decrease was observed for all infections sites but was largest among patients with respiratory tract infections. Implicit, explicit and COVID-19-related sepsis had largely similar overall mortality, with explicit sepsis having an adjusted HR of 0.980 (95% CI 0.969 to 0.991) and COVID-19-related sepsis an adjusted HR of 0.916 (95% CI 0.836 to 1.003) compared to implicit sepsis. Patients with respiratory tract infections have somewhat higher mortality than those with other infection sites. Number of comorbidities was positively associated with mortality, but mortality varied considerably between different comorbidities. Similarly, number of acute organ dysfunctions was strongly associated with mortality, whereas the risk varied for each type of organ dysfunction. CONCLUSION Overall mortality has declined over the past 14 years among patients with a first sepsis admission. Comorbidity, site of infection, and acute organ dysfunction are patient characteristics that are associated with mortality. This could inform health care workers and raise the awareness toward subgroups of patients that needs particular attention to improve long-term mortality.
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Affiliation(s)
- Nina Vibeche Skei
- Department of Anesthesia and Intensive Care, Nord-Trondelag Hospital Trust, Levanger, Norway.
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Tom Ivar Lund Nilsen
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Randi Marie Mohus
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Anesthesia and Intensive Care, St. Olav's University Hospital, Trondheim, Norway
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, (NTNU), Trondheim, Norway
| | - Erik Solligård
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jan Kristian Damås
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Centre of Molecular Inflammation Research, Institute for Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Infectious Diseases, St. Olav's University Hospital, Trondheim, Norway
| | - Lise Tuset Gustad
- Department of Circulation and Medical Imaging, Mid Norway Sepsis Research Center, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
- Department of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
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Dala Ali AHH, Harun SN, Othman N, Ibrahim B, Abdulbagi OE, Abdullah I, Ariffin IA. Determinants of Inadequate Empiric Antimicrobial Therapy in ICU Sepsis Patients in Al-Madinah Al-Munawwarah, Saudi Arabia: A Comparison of Artificial Neural Network and Regression Analysis. Antibiotics (Basel) 2023; 12:1305. [PMID: 37627725 PMCID: PMC10451895 DOI: 10.3390/antibiotics12081305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 08/27/2023] Open
Abstract
In the management of sepsis, providing adequate empiric antimicrobial therapy is one of the most important pillars of sepsis management. Therefore, it is important to evaluate the adequacy of empiric antimicrobial therapy (EAMT) in sepsis patients admitted to intensive care units (ICU) and to identify the determinants of inadequate EAMT. The aim of this study was to evaluate the adequacy of empiric antimicrobial therapy in patients admitted to the ICU with sepsis or septic shock, and the determinants of inadequate EAMT. The data of patients admitted to the ICU units due to sepsis or septic shock in two tertiary healthcare facilities in Al-Madinah Al-Munawwarah were retrospectively reviewed. The current study used logistic regression analysis and artificial neural network (ANN) analysis to identify determinants of inadequate empiric antimicrobial therapy, and evaluated the performance of these two approaches in predicting the inadequacy of EAMT. The findings of this study showed that fifty-three per cent of patients received inadequate EAMT. Determinants for inadequate EAMT were APACHE II score, multidrug-resistance organism (MDRO) infections, surgical history (lower limb amputation), and comorbidity (coronary artery disease). ANN performed as well as or better than logistic regression in predicating inadequate EAMT, as the receiver operating characteristic area under the curve (ROC-AUC) of the ANN model was higher when compared with the logistic regression model (LRM): 0.895 vs. 0.854. In addition, the ANN model performed better than LRM in predicting inadequate EAMT in terms of classification accuracy. In addition, ANN analysis revealed that the most important determinants of EAMT adequacy were the APACHE II score and MDRO. In conclusion, more than half of the patients received inadequate EAMT. Determinants of inadequate EAMT were APACHE II score, MDRO infections, comorbidity, and surgical history. This provides valuable inputs to improve the prescription of empiric antimicrobials in Saudi Arabia going forward. In addition, our study demonstrated the potential utility of applying artificial neural network analysis in the prediction of outcomes in healthcare research.
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Affiliation(s)
- Ahmad Habeeb Hattab Dala Ali
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM), Penang 11800, Malaysia
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Dariyah, Riyadh 13713, Saudi Arabia
| | - Sabariah Noor Harun
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM), Penang 11800, Malaysia
| | - Noordin Othman
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Al-Madinah Al-Munawwarah 42353, Saudi Arabia
- School of Pharmacy, Management and Science University, University Drive, Off Persiaran Olahraga, Shah Alam 40100, Malaysia
| | - Baharudin Ibrahim
- Faculty of Pharmacy, University of Malaya, Wilayah Persekutuan Kuala Lumpur 50603, Malaysia
| | | | - Ibrahim Abdullah
- School of Pharmacy, Management and Science University, University Drive, Off Persiaran Olahraga, Shah Alam 40100, Malaysia
| | - Indang Ariati Ariffin
- Research Management Centre, Management and Science University, University Drive, Off Persiaran Olahraga, Section 13, Shah Alam 40100, Malaysia
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Aliu-Bejta A, Kurshumliu M, Namani S, Dreshaj S, Baršić B. Ability of presepsin concentrations to predict mortality in adult patients with sepsis. J Clin Transl Sci 2023; 7:e121. [PMID: 37313382 PMCID: PMC10260338 DOI: 10.1017/cts.2023.538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 06/15/2023] Open
Abstract
Background Early diagnosis of sepsis is essential for a favorable disease outcome. The aim of this study was to evaluate the association of initial and subsequent presepsin concentrations with sepsis outcomes. Methods One hundred sepsis patients were enrolled in the study from two different university centers. Four times during study, concentrations of presepsin, procalcitonin (PCT), and C-reactive protein (CRP) were measured, and Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE II) score were calculated. Patients were grouped into survivors and nonsurvivors. A sandwich ELISA kit was used to measure presepsin concentrations. To test the changes in biomarkers concentrations and SOFA score and APACHE II score during the disease course and to estimate the differences between outcome groups, generalized linear mixed effects model was used. Receiver operating characteristic curve analysis was performed to determine the prognostic value of presepsin concentrations. Results Initial values of presepsin, SOFA score, and APACHE II score were significantly higher in nonsurvivors compared to survivors. Concentrations of PCT and CRP did not differ significantly between outcome groups. ROC curve analyses show a greater predictive ability of initial presepsin concentrations for predicting mortality compared to subsequent measurements of presepsin concentrations. Conclusions Presepsin has a good ability to predict mortality. Initial presepsin concentrations better reflects poor disease outcome compared to presepsin concentrations 24 and 72 hours after admission.
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Affiliation(s)
- Ajete Aliu-Bejta
- University Clinic of Infectious Diseases, Alexander Fleming, Pristina, 10000, Kosovo
- University of Pristina “Hasan Prishtina”, Faculty of Medicine, Lagja e spitalit, p.n, Pristina, 10000, Kosovo
| | - Mentor Kurshumliu
- “PROLAB” Biochemical Laboratory, Mark Dizdari, Pristina, 10000, Kosovo
| | - Sadie Namani
- University Clinic of Infectious Diseases, Alexander Fleming, Pristina, 10000, Kosovo
- University of Pristina “Hasan Prishtina”, Faculty of Medicine, Lagja e spitalit, p.n, Pristina, 10000, Kosovo
| | - Shemsedin Dreshaj
- University Clinic of Infectious Diseases, Alexander Fleming, Pristina, 10000, Kosovo
- University of Pristina “Hasan Prishtina”, Faculty of Medicine, Lagja e spitalit, p.n, Pristina, 10000, Kosovo
| | - Bruno Baršić
- University of Zagreb, School of Medicine, Šalata 4, Zagreb, 10000, Croatia
- University Hospital for Infectious Diseases “Dr. Fran Mihaljević,”Zagreb, 10000, Croatia
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Seminari E, Colaneri M, Corbella M, De Silvestri A, Muzzi A, Perlini S, Martino IF, Marvulli LN, Arcuri A, Maffezzoni M, Minucci R, Bono E, Cambieri P, Marone P, Bruno R. Reduction of BSI associated mortality after a sepsis project implementation in the ER of a tertiary referral hospital. Sci Rep 2023; 13:5142. [PMID: 36991040 PMCID: PMC10060234 DOI: 10.1038/s41598-023-31219-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 03/08/2023] [Indexed: 03/31/2023] Open
Abstract
The emergency room (ER) is the first gateway for patients with sepsis to inpatient units, and identifying best practices and benchmarks to be applied in this setting might crucially result in better patient's outcomes. In this study, we want to evaluate the results in terms of decreased the in-hospital mortality of patients with sepsis of a Sepsis Project developed in the ER. All patients admitted to the ER of our Hospital from the 1st January, 2016 to the 31stJuly 2019 with suspect of sepsis (MEWS score ≥ of 3) and positive blood culture upon ER admission were included in this retrospective observational study. The study comprises of two periods: Period A: From the 1st Jan 2016 to the 31st Dec 2017, before the implementation of the Sepsis project. Period B: From the 1st Jan 2018 to the 31stJul 2019, after the implementation of the Sepsis project. To analyze the difference in mortality between the two periods, a univariate and multivariate logistic regression was used. The risk of in-hospital mortality was expressed as an odds ratio (OR) and a 95% confidence interval (95% CI). Overall, 722 patients admitted in ER had positive BC on admissions, 408 in period A and 314 in period B. In-hospital mortality was 18.9% in period A and 12.7% in period B (p = 0.03). At multivariable analysis, mortality was still reduced in period B compared to period A (OR 0.64, 95% CI 0.41-0.98; p = 0.045). Having an infection due to GP bacteria or polymicrobial was associated with an increased risk of death, as it was having a neoplasm or diabetes. A marked reduction in in-hospital mortality of patients with documented BSI associated with signs or symptoms of sepsis after the implementation of a sepsis project based on the application of sepsis bundles in the ER.
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Affiliation(s)
- Elena Seminari
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Marta Colaneri
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Marta Corbella
- UOC Microbiologie e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Annalisa De Silvestri
- Servizio di Epidemiologia Clinica e Biometria Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alba Muzzi
- Direzione Medica di Presidio, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Perlini
- Emergency Medicine Unit and Emergency Medicine Postgraduate Training Program, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ilaria Francesca Martino
- Emergency Medicine Unit and Emergency Medicine Postgraduate Training Program, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lea Nadia Marvulli
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Alessia Arcuri
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Marcello Maffezzoni
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Rita Minucci
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Enrica Bono
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Patrizia Cambieri
- UOC Microbiologie e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Piero Marone
- UOC Microbiologie e Virologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raffaele Bruno
- Clinica di Malattie Infettive, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy.
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
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Muacevic A, Adler JR, Hussaini H, Jones Amaowei EE, Rasuli SF, Hussain N, Kaddo S, Memon A. Systematic Review on the Effects of Prompt Antibiotic Treatment on Survival in Septic Shock and Sepsis Patients in Different Hospital Settings. Cureus 2022; 14:e32405. [PMID: 36636534 PMCID: PMC9831358 DOI: 10.7759/cureus.32405] [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: 12/11/2022] [Indexed: 12/14/2022] Open
Abstract
This study aims to determine the impact of prompt administration of antibiotics in evaluating the prognosis of patients with septic shock or sepsis. On January 1, 2022, we searched the Cochrane Library, EMBASE, and MEDLINE databases for English-language articles regarding when antibiotics should be administered to patients with septic shock or sepsis. These articles were required to be published between 2010 and 2021. The primary objective was sudden or expected death from any cause at a specified time. In the study, 154,330 patients from 35 sepsis trials were included. In 19 trials, the effectiveness of antibiotics administered to 20,062 patients was evaluated. Of those, 16,652 received the correct medications. In 24 studies, the length of time it took to administer antibiotics was associated with an increased mortality rate. In fourteen studies, the time limits associated with patient outcomes ranged from 1 to 125 minutes to three to six hours. In eight studies, there were hourly delays, and in two, the time it took to receive an antibiotic played a role. Separately analyzed, the outcomes for septic shock (12,756 patients in 11 trials) and sepsis (24,282 patients in six studies) were identical. Two-thirds of sepsis studies discovered a correlation between early antibiotic treatment and the patient's prognosis. However, antimicrobial timing metrics varied significantly between studies, and there were no clear time limits.
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Liyanarachi KV, Solligård E, Mohus RM, Åsvold BO, Rogne T, Damås JK. Incidence, recurring admissions and mortality of severe bacterial infections and sepsis over a 22-year period in the population-based HUNT study. PLoS One 2022; 17:e0271263. [PMID: 35819970 PMCID: PMC9275692 DOI: 10.1371/journal.pone.0271263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/28/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose Severe bacterial infections are important causes of hospitalization and loss of health worldwide. In this study we aim to characterize the total burden, recurrence and severity of bacterial infections in the general population during a 22-year period. Methods We investigated hospitalizations due to bacterial infection from eight different foci in the prospective population-based Trøndelag Health Study (the HUNT Study), where all inhabitants aged ≥ 20 in a Norwegian county were invited to participate. Enrollment was between 1995 and 1997, and between 2006 and 2008, and follow-up ended in February 2017. All hospitalizations, positive blood cultures, emigrations and deaths in the follow-up period were captured through registry linkage. Results A total of 79,393 (69.5% and 54.1% of the invited population) people were included, of which 42,237 (53%) were women and mean age was 48.5 years. There were 37,298 hospitalizations due to infection, affecting 15,496 (22% of all included) individuals. The median time of follow-up was 20 years (25th percentile 9.5–75th percentile 20.8). Pneumonia and urinary tract infections were the two dominating foci with incidence rates of 639 and 550 per 100,000 per year, respectively, and with increasing incidence with age. The proportion of recurring admissions ranged from 10.0% (central nervous system) to 30.0% (pneumonia), whilst the proportion with a positive blood culture ranged from 4.7% (skin- and soft tissue infection) to 40.9% (central nervous system). The 30-day mortality varied between 3.2% (skin- and soft tissue infection) and 20.8% (endocarditis). Conclusions In this population-based cohort, we observed a great variation in the incidence, positive blood culture rate, recurrence and mortality between common infectious diseases. These results may help guide policy to reduce the infectious disease burden in the population.
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Affiliation(s)
- Kristin Vardheim Liyanarachi
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- * E-mail:
| | - Erik Solligård
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Anaesthesia and Intensive Care, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Randi Marie Mohus
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Anaesthesia and Intensive Care, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bjørn O. Åsvold
- Department of Endocrinology, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Center, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway
| | - Tormod Rogne
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Clinic of Anaesthesia and Intensive Care, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Chronic Disease Epidemiology and Center for Perinatal, Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, Connecticut, United Ststes of America
| | - Jan Kristian Damås
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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10
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Waagsbø B, Stuve N, Afset JE, Klepstad P, Mo S, Heggelund L, Damås JK. High levels of discordant antimicrobial therapy in hospital-acquired bloodstream infections is associated with increased mortality in an intensive care, low antimicrobial resistance setting. Infect Dis (Lond) 2022; 54:738-747. [PMID: 35708021 DOI: 10.1080/23744235.2022.2083672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Bloodstream infections (BSI) occur frequently and are associated with severe outcomes. In this study we aimed to investigate proportions of patients that received discordant empirical antimicrobial therapy and its association to mortality. METHODS A retrospective cohort study model was undertaken to outline BSI in an intensive care, single centre, and low antimicrobial resistance prevalence setting. We used descriptive statistics to delineate proportions of patients that received discordant empirical antimicrobial therapy, and a correlation model and a logistic regression model to calculate the association with mortality and predictors of receiving discordant therapy, respectively. RESULTS From 2014 to 2018 we included 270 BSI episodes, of which one third were hospital-acquired. Gram negative, Gram positive, and anaerobic pathogens were detected in 49.0%, 45.3% and 5.7% respectively. The proportion of isolates that conferred extended-spectrum beta-lactamase (ESBL) properties were 5.9% among enterobactereales, and no methicillin-resistant Staphylococcus aureus isolates were detected. Empirical antimicrobial therapy for community-acquired (CA) and hospital-acquired (HA) BSI were discordant at day 0 in 6.5% and 24.4%, respectively (p<.001). Discordant therapy was significantly associated with mortality at day 28 (p=.041). HA-onset BSI, enterococcal BSI and BSI of intraabdominal origin were statistically significant predictors of receiving discordant therapy. CONCLUSION A significant proportion of HA-BSI did not receive effective antimicrobial therapy and this was significantly associated with mortality. The results underscore the need for more accurate diagnostic tools, improved communication between the microbiological laboratory and the clinicians, and antimicrobial stewardship measures.
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Affiliation(s)
- Bjørn Waagsbø
- Regional Centre for Disease Control in Central Norway Regional Health Authority, Trondheim University Hospital, Trondheim, Norway
| | - Nora Stuve
- Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Egil Afset
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Medical Microbiology, St. Olavs Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.,Department of Anaesthesiology and Intensive Care Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Skule Mo
- Department of Anaesthesiology and Intensive Care Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Lars Heggelund
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Jan Kristian Damås
- Department of Infectious Diseases, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Centre of Molecular Inflammation Research, department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
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11
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Brevik HS, Hufthammer KO, Hernes ME, Bjørneklett R, Brattebø G. Implementing a new emergency medical triage tool in one health region in Norway: some lessons learned. BMJ Open Qual 2022; 11:bmjoq-2021-001730. [PMID: 35534042 PMCID: PMC9086633 DOI: 10.1136/bmjoq-2021-001730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/22/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Acutely sick or injured patients depend on ambulance and emergency department personnel performing an accurate initial assessment and prioritisation (triage) to effectively identify patients in need of immediate treatment. Triage also ensures that each patient receives fair initial assessment. To improve the patient safety, quality of care, and communication about a patient's medical condition, we implemented a new triage tool (the South African Triage Scale Norway (SATS-N) in all the ambulance services and emergency departments in one health region in Norway. This article describes the lessons we learnt during this implementation process. METHODS The main framework in this quality improvement (QI) work was the plan-do-study-act cycle. Additional process sources were 'The Institute for Healthcare Improvement Model for improvement' and the Norwegian Patient Safety Programme. RESULTS Based on the QI process as a whole, we defined subjects influencing this work to be successful, such as identifying areas for improvement, establishing multidisciplinary teams, coaching, implementing measurements and securing sustainability. After these subjects were connected to the relevant challenges and desired effects, we described the lessons we learnt during this comprehensive QI process. CONCLUSION We learnt the importance of following a structured framework for QI process during the implementation of the SATS-N triage tool. Furthermore, securing anchoring at all levels, from the managements to the medical professionals in direct patient-orientated work, was relevant important. Moreover, establishing multidisciplinary teams with ambulance personnel, emergency department nurses and doctors with various medical specialties provided ownership to the participants. Meanwhile, coaching provided necessary security for the staff directly involved in caring for patients. Keeping the spirit and perseverance high were important factors in completing the implementation. Establishment of the regional network group was found to be important for sustainability and further improvements.
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Affiliation(s)
| | | | | | - Rune Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Guttorm Brattebø
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anaesthesia and Intensive Care, Norwegian National Advisory Unit on Emergency Medical Communication (KoKom), Haukeland University Hospital, Bergen, Norway
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12
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Vesteinsdottir E, Sigurdsson MI, Gottfredsson M, Blondal A, Karason S. Temporal trends in the epidemiology, management, and outcome of sepsis-A nationwide observational study. Acta Anaesthesiol Scand 2022; 66:497-506. [PMID: 35014035 DOI: 10.1111/aas.14026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Registry-based studies have shown increasing incidence of sepsis and declining mortality rates in recent years, but are inherently at risk of bias. The objectives of this study were to describe 11-year trends in the incidence, treatment and outcome of sepsis using clinical criteria with chart review. METHODS This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014, and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria (sepsis-2). Incidence, patient characteristics, treatment and outcome were compared across the study years. RESULTS During the six study years, 9166 patients were admitted to Icelandic ICUs, 971 (10.6%) because of severe sepsis or septic shock. The crude incidence of sepsis requiring admission to ICU remained stable between 0.55 and 0.75 per 1000 inhabitants. No statistically significant trends were observed over time in median patient age (67 years), APACHE II score (21), SOFA score (8) or Charlson Comorbidity Index (4). The time to antibiotic administration (median 1.8 h) in the emergency departments was stable over the study period but the time to lactate measurements decreased from 4.1 h in 2006 to 1.2 h in 2016, p < .001. The 28-day mortality was 25% and 1-year mortality 41%, both with no observed change with time. CONCLUSIONS In a nationwide cohort, diagnosed with clinical criteria, the incidence of sepsis requiring intensive care did not change over an 11-year period. Mortality remained stable and only minimal changes were observed in initial resuscitation in the emergency departments.
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Affiliation(s)
- Edda Vesteinsdottir
- Department of Anaesthesia and Intensive Care Landspitali—The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Martin Ingi Sigurdsson
- Department of Anaesthesia and Intensive Care Landspitali—The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Magnus Gottfredsson
- Faculty of Medicine University of Iceland Reykjavik Iceland
- Department of Infectious Diseases Landspitali—The National University Hospital of Iceland Reykjavik Iceland
| | - Asbjorn Blondal
- Department of Anaesthesia and Intensive Care Akureyri Hospital Akureyri Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care Landspitali—The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
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13
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Vesteinsdottir E, Gottfredsson M, Blondal A, Sigurdsson MI, Karason S. Sepsis after elective surgery - Incidence, aetiology and outcome. Acta Anaesthesiol Scand 2021; 65:457-465. [PMID: 33205403 DOI: 10.1111/aas.13747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sepsis requiring admission to intensive care (ICU) is a rare complication of elective surgery, but is associated with high morbidity and mortality. The aim of this study was to describe the incidence and outcome of sepsis following elective surgery. METHODS This was a retrospective, observational study where all admissions to Icelandic ICUs during calendar years 2006, 2008, 2010, 2012, 2014 and 2016 were screened, identifing patients with sepsis following elective surgery (ACCP/SCCM criteria). The number of elective operations performed at the largest center (Landspitali) during the study years were collected. Descriptive statistics were used to assess the incidence and outcome of patients with sepsis after elective surgery. RESULTS During the study years, 88 patients were admitted to Icelandic ICUs with sepsis following elective surgery. Of those, 80 were operated at Landspitali, where the incidence of sepsis was 0.19% per elective procedure, highest following pancreaticoduodenectomies (14%, CI 6-25) and esophagectomies (13%, CI 4-27), but the greatest number of patients (30% (26/88)) developed sepsis after a colorectal procedure. The most common infection sources were the abdomen (65% (57/88)) and lungs/mediastinum (22% (19/88)), frequently polymicrobial (58% (36/62) of patients with cultures). The incidence of insufficient empirical antibiotics was high (50% (30/60)). The median ICU and hospital length-of-stay were 5.5 and 26 days and the 28-day and 1-year mortality rates were 16% (14/88) and 41% (36/87), respectively. CONCLUSIONS Incidence of sepsis following elective surgery is low in Iceland but mortality is high. Initial antimicrobial therapy needs careful consideration in these hospital-acquired, often polymicrobial infections.
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Affiliation(s)
- Edda Vesteinsdottir
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Magnus Gottfredsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Infectious Diseases, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Asbjorn Blondal
- Department of Anaesthesia and Intensive Care, Akureyri Hospital, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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14
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Asner SA, Desgranges F, Schrijver IT, Calandra T. Impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis and septic shock. J Infect 2021; 82:125-134. [PMID: 33722641 DOI: 10.1016/j.jinf.2021.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To review the impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis or septic shock. METHODS We searched MEDLINE, EMBASE, the Cochrane Library, Web of Science, Open-SIGLE databases, ClinicalTrials.gov and the metaRegister of Controlled Trials on July 27, 2020 for relevant studies on the timing of antibiotic therapy in adult patients with sepsis or septic shock. The primary outcome measure was all-cause crude or adjusted mortality at reported time points. RESULTS We included 35 sepsis studies involving 154,330 patients. Nineteen studies (54%) provided information on the appropriateness of antibiotic therapy in 20,062 patients of whom 16,652 patients (83%) received appropriate antibiotics. Twenty-four studies (68.6%) reported an association between time-to-antibiotics and mortality. Time thresholds associated with patient's outcome varied considerably between studies consisting of a wide range of time cutoffs (1 h, 125 min, 3 h or 6 h) in 14 studies, hourly delays (derived from the analyses of time intervals ranging from to 1 to 24 h) in 8 studies or time-to-antibiotic in 2 studies. Analyses of subsets of studies that focused on patients with septic shock (11 studies, 12,756 patients) or with sepsis (6 studies, 24,281 patients) yielded similar results. CONCLUSIONS While two-thirds of sepsis studies reported an association between early administration of antibiotic therapy and patient outcome, the time-to-antibitiocs metrics varied significantly across studies and no robust time thresholds emerged.
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Affiliation(s)
- Sandra A Asner
- Pediatric Infectious Diseases and Vaccinology Unit, Department Mother-Woman-Child, Lausanne University Hospital, University of Lausanne, Switzerland; Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Florian Desgranges
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Irene T Schrijver
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 46, Lausanne CH-1011, Switzerland.
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15
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Impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections in the emergency department: implications for antimicrobial stewardship. Clin Microbiol Infect 2020; 27:175-181. [PMID: 32120032 DOI: 10.1016/j.cmi.2020.02.032] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/15/2020] [Accepted: 02/23/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock and bacterial meningitis, but may not be as important for other infectious syndromes. A better understanding of which patients can tolerate a delay in start of therapy is important for antibiotic stewardship purposes. OBJECTIVES To explore the existing evidence on the impact of time to antibiotics on clinical outcomes in patients presenting to the emergency department (ED) with bacterial infections of different severity of illness and source of infection. SOURCES A literature search was performed in the PubMed/MEDLINE database using combined search terms for various infectious syndromes (sepsis/septic shock, bacterial meningitis, lower respiratory tract infections, urinary tract infections, intra-abdominal infections and skin and soft tissue infections), time to antibiotic treatment, and clinical outcome. CONTENT The literature search generated 8828 hits. After screening titles and abstracts and assessing potentially relevant full-text papers, 60 original articles (four randomized controlled trials, 43 observational studies) were included. Most articles addressed sepsis/septic shock, while few studies evaluated early initiation of therapy in mild to moderate disease. The lack of randomized trials and the risk of confounding factors and biases in observational studies warrant caution in the interpretation of results. We conclude that the literature supports prompt administration of effective antibiotics for septic shock and bacterial meningitis, but there is no clear evidence showing that a delayed start of therapy is associated with worse outcome for less severe infectious syndromes. IMPLICATIONS For patients presenting with suspected bacterial infections, withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established (e.g. by 4-8 h) seems acceptable in most cases unless septic shock or bacterial meningitis are suspected. This approach promotes the use of ecologically favourable antibiotics in the ED, reducing the risks of side effects and selection of resistance.
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16
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Szabo BG, Kiss R, Lenart KS, Marosi B, Vad E, Lakatos B, Ostorhazi E. Clinical and microbiological characteristics and outcomes of community-acquired sepsis among adults: a single center, 1-year retrospective observational cohort study from Hungary. BMC Infect Dis 2019; 19:584. [PMID: 31349818 PMCID: PMC6659200 DOI: 10.1186/s12879-019-4219-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/26/2019] [Indexed: 12/12/2022] Open
Abstract
Background Community-acquired sepsis is a life-threatening systemic reaction, which starts within ≤72 h of hospital admittance in an infected patient without recent exposure to healthcare risks. Our aim was to evaluate the characteristics and the outcomes concerning community-acquired sepsis among patients admitted to a Hungarian high-influx national medical center. Methods A retrospective, observational cohort study of consecutive adult patients hospitalized with community-acquired sepsis during a 1-year period was executed. Clinical and microbiological data were collected, patients with pre-defined healthcare associations were excluded. Sepsis definitions and severity were given according to ACCP/SCCM criteria. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were intensive care unit (ICU) admittance, length-of-stay (LOS), source control and bacteraemia rates. Statistical differences were explored with classical comparison tests, predictors of in-hospital all-cause mortality were modelled by multivariate logistic regression. Results 214 patients (median age 60.0 ± 33.1 years, 57% female, median Charlson score 4.0 ± 5.0) were included, 32.7% of them (70/214) had severe sepsis, and 28.5% (61/214) had septic shock. Prevalent sources of infections were genitourinary (53/214, 24.8%) and abdominal (52/214, 24.3%). The causative organisms were dominantly E. coli (60/214, 28.0%), S. pneumoniae (18/214, 8.4%) and S. aureus (14/214, 6.5%), and bacteraemia was documented in 50.9% of the cases (109/214). In-hospital mortality was high (30/214, 14.0%), and independently associated with shock, absence of fever, male gender and the need for ICU admittance, but source control and de-escalation of empirical antimicrobial therapy were protective. ICU admittance was 27.1% (58/214), source control was achieved in 18.2% (39/214). Median LOS was 10.0 ± 8.0, ICU LOS was 8.0 ± 10.8 days. Conclusions Community-acquired sepsis poses a significant burden of disease with characteristic causative agents and sources. Patients at a higher risk for poor outcomes might be identified earlier by the contributing factors shown above.
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Affiliation(s)
- Balint Gergely Szabo
- Semmelweis University, School of PhD Studies, H-1085 Ulloi ut 26., Budapest, Hungary. .,Department of Infectious Diseases, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, H-1097 Albert Florian ut 5-7., Budapest, Hungary. .,Infectious Disease Specialist Training, Semmelweis University, Faculty of Medicine, H-1085 Ulloi ut 26., Budapest, Hungary.
| | - Rebeka Kiss
- Department of Infectious Diseases, Markhot Ferenc Teaching Hospital, H-3300 Szechenyi utca 27-29., Eger, Hungary
| | - Katalin Szidonia Lenart
- Department of Infectious Diseases, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, H-1097 Albert Florian ut 5-7., Budapest, Hungary.,Infectious Disease Specialist Training, Semmelweis University, Faculty of Medicine, H-1085 Ulloi ut 26., Budapest, Hungary
| | - Bence Marosi
- Faculty of Medicine, Students' Scientific Association, Semmelweis University, H-1085 Ulloi ut 26., Budapest, Hungary
| | - Eszter Vad
- Semmelweis University, School of PhD Studies, H-1085 Ulloi ut 26., Budapest, Hungary.,South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, Core Microbiology Laboratory, H-1097 Albert Florian ut 5-7., Budapest, Hungary
| | - Botond Lakatos
- Department of Infectious Diseases, South Pest Central Hospital, National Institute of Hematology and Infectious Diseases, Saint Ladislaus Campus, H-1097 Albert Florian ut 5-7., Budapest, Hungary
| | - Eszter Ostorhazi
- Semmelweis University, Institute of Medical Microbiology, H-1098 Nagyvarad ter 4., Budapest, Hungary
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17
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Delay of appropriate antibiotic treatment is associated with high mortality in patients with community-onset sepsis in a Swedish setting. Eur J Clin Microbiol Infect Dis 2019; 38:1223-1234. [PMID: 30911928 PMCID: PMC6570779 DOI: 10.1007/s10096-019-03529-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023]
Abstract
Early appropriate antimicrobial therapy is crucial in patients with sepsis and septic shock. Studies often focus on time to first dose of appropriate antibiotics, but subsequent dosing is equally important. Our aim was to investigate the impact of fulfillment of early treatment, with focus on appropriate administration of first and second doses of antibiotics, on 28-day mortality in patients with community-onset severe sepsis and septic shock. A retrospective study on adult patients admitted to the emergency department with community-onset sepsis and septic shock was conducted 2012–2013. The criterion “early appropriate antibiotic treatment” was defined as administration of the first dose of adequate antibiotics within 1 h, and the second dose given with less than 25% delay after the recommended dose interval. A high-risk patient was defined as a septic patient with either shock within 24 h after arrival or red triage level on admittance according to the Medical Emergency Triage and Treatment System Adult. Primary endpoint was 28-day mortality. Of 90 patients, less than one in four (20/87) received early appropriate antibiotic treatment, and only one in three (15/44) of the high-risk patients. The univariate analysis showed a more than threefold higher mortality among high-risk patients not receiving early appropriate antibiotic treatment. Multivariable analysis identified early non-appropriate antibiotic treatment as an independent predictor of mortality with an odds ratio for mortality of 10.4. Despite that the importance of early antibiotic treatment has been established for decades, adherence to this principle was very poor.
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18
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Xue M, Xie J, Liu L, Huang Y, Guo F, Xu J, Yang Y, Qiu H. Early and dynamic alterations of Th2/Th1 in previously immunocompetent patients with community-acquired severe sepsis: a prospective observational study. J Transl Med 2019; 17:57. [PMID: 30813927 PMCID: PMC6391803 DOI: 10.1186/s12967-019-1811-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/21/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND T helper (Th) cells regulate sepsis processes, including primary pathogen clear and secondary pathogen defence. The objectives of this study were to determine the early and dynamic alterations of Th1 and Th2 populations to community-acquired severe sepsis upon onset among previously immunocompetent patients and whether it was related to clinical outcomes. METHODS This prospective observational cohort study was conducted at a general intensive care unit (ICU) of a tertiary teaching hospital in China. Immunocompetent patients with community-acquired severe sepsis within 24 h upon onset were included as septic group. Healthy volunteers and critically ill patients without severe sepsis were recruited as controls. Whole blood was collected on D0, 3rd day (D3) and 7th day (D7) for septic group and once upon enrollment for controls. Th1 and Th2 populations were measured by flow cytometry and assessed for associations with 28-day mortality using cox proportional hazard models. Associations of dynamic alterations of Th cell subpopulations with clinical outcomes were investigated. RESULTS This study demonstrated that community-acquired severe sepsis patients (n = 71) had increased Th2/Th1 and Th2 populations, compared to healthy controls (n = 7) and critically ill patients without severe sepsis (n = 7) at admission. Among the septic cohort, values of Th2/Th1 were significantly higher in non-survivors than survivors on D0 (p = 0.04), D3 (p < 0.001) and D7 (p < 0.001). Patients with persistently increasing Th2/Th1 demonstrated the highest mortality (47.1%) and incidence of ICU-acquired infections (64.7%). CONCLUSIONS Th2/Th1 was markedly up-regulated with Th2 dominance upon community-acquired severe sepsis onset among previously immunocompetent patients and its persistently dynamic increase was associated with ICU-acquired infections and 28-day death. Trial registration Institutional Ethics Committee of Zhongda Hospital, 2014ZDSYLL086, registered in June 2014-prospectively registered; ClinicalTrials.gov, NCT02883218, registered on 25 Aug 2016-retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT02883218?cond=NCT02883218&rank=1.
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Affiliation(s)
- Ming Xue
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Yingzi Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Fengmei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jingyuan Xu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
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19
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Todorovic Markovic M, Pedersen C, Gottfredsson M, Todorovic Mitic M, Gaini S. Focus of infection and microbiological etiology in community-acquired infections in hospitalized adult patients in the Faroe Islands. BMC Infect Dis 2019; 19:16. [PMID: 30612543 PMCID: PMC6322335 DOI: 10.1186/s12879-018-3650-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/21/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The aim of the present study was to gain national data on the clinical and microbiological characteristics of community-acquired infections in the Faroe Islands and to compare these data with data from other geographical areas. METHODS A prospective, observational study involving all patients > = 16 years admitted at the Department of Medicine at the National Hospital, Torshavn, Faroe Islands from October 2013 until April 2015. RESULTS Of 5279 admissions, 1054 cases were with community-acquired infection and were included in the study. Out of these 1054 cases, 471 did not meet the criteria for SIRS (Systemic Inflammatory Response Syndrome), while the remaining 583 cases had sepsis. Mean age was 68 years. At least one comorbidity was found in 80% of all cases. Documented infections were present in 75%, and a plausible pathogen was identified in 29% of all cases. The most common gram-positive pathogen was Staphylococcus aureus, and the most frequent gram-negative pathogen was Escherichia coli. The most common focus of infection was lower respiratory tract, followed by urinary tract, and skin-soft tissue/bone-joint. Bacteremia was found in 10% of the cases. CONCLUSION In community-acquired infections in hospitalized patients in the Faroe Islands the lower respiratory tract and the urinary tract were the most frequent foci of infection. Gram-negative pathogens and Escherichia coli were the most frequent pathogens in infection without Systemic Inflammatory Response Syndrome, in sepsis and in bacteremia. Our data on clinical characteristics and microbiological etiology provide new information which may be used to develop local guidelines for the managing of patients admitted with community-acquired infections.
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Affiliation(s)
- Marija Todorovic Markovic
- Medical Department, Infectious Diseases Division, National Hospital of the Faroe Islands, JC. Svabosgøta 41-49, Tórshavn, Faroe Islands
- Department of Infectious Diseases, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Court Pedersen
- Department of Infectious Diseases, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Magnús Gottfredsson
- Department of Infectious Diseases, Landspitali University Hospital, Reykjavík, Iceland
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | | | - Shahin Gaini
- Medical Department, Infectious Diseases Division, National Hospital of the Faroe Islands, JC. Svabosgøta 41-49, Tórshavn, Faroe Islands
- Department of Infectious Diseases, Odense University Hospital and University of Southern Denmark, Odense, Denmark
- Centre of Health Research and Department of Science and Technology, University of the Faroe Islands, Torshavn, Faroe Islands
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20
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Todorovic Markovic M, Pedersen C, Gottfredsson M, Todorovic Mitic M, Gaini S. Epidemiology of community-acquired sepsis in the Faroe Islands - a prospective observational study. Infect Dis (Lond) 2018; 51:38-49. [PMID: 30460859 DOI: 10.1080/23744235.2018.1511056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION The aim of the study was to gather nation-wide epidemiological and clinical data in order to characterize community-acquired sepsis in the Faroe Islands, and to compare these data with epidemiological studies performed in other geographical areas. METHODS A prospective, observational study conducted from October 2013 until April 2015 to characterize sepsis, and to calculate incidence rates for community-acquired sepsis of any severity, community-acquired severe sepsis, community-acquired septic shock and community-acquired sepsis without community-acquired severe sepsis or community-acquired septic shock. RESULTS Of 5279 admissions, 583 cases fulfilled the criteria for community-acquired sepsis of any severity. The mean age of all cases was 67.6 ± 18.3 years. Men accounted for 298 (51.5%) admissions. Charlson comorbidity index was greater than 2 in 247 (42.4%) cases. The incidence of community-acquired sepsis of any severity was 1414/100,000 person-years at risk (95% CI, 1374-1440). The incidence rate for community-acquired sepsis without community-acquired severe sepsis and community-acquired septic shock was 719/100,000 person-years at risk (95% CI, 695-742), for community-acquired severe sepsis 644/100,000 person-years at risk (95% CI, 623-668), for community-acquired septic shock 51/100,000 person-years at risk (95% CI, 45-58). The highest incidence was seen in elderly patients. CONCLUSION The incidence rates were slightly higher in men and increased with age, especially in those older than 85 years. Incidence rates of sepsis of any severity were higher than previously published from other countries.
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Affiliation(s)
- Marija Todorovic Markovic
- a Medical Department, Infectious Diseases Division , National Hospital of the Faroe Islands , Tórshavn , Faroe Islands.,b Department of Infectious Diseases , Odense University Hospital and University of Southern Denmark , Odense , Denmark
| | - Court Pedersen
- b Department of Infectious Diseases , Odense University Hospital and University of Southern Denmark , Odense , Denmark
| | - Magnús Gottfredsson
- c Department of Infectious Diseases , Landspitali University Hospital , Reykjavík , Iceland.,d Faculty of Medicine, School of Health Sciences , University of Iceland , Reykjavík , Iceland
| | | | - Shahin Gaini
- a Medical Department, Infectious Diseases Division , National Hospital of the Faroe Islands , Tórshavn , Faroe Islands.,b Department of Infectious Diseases , Odense University Hospital and University of Southern Denmark , Odense , Denmark.,f Centre of Health Research and Department of Science and Technology , University of the Faroe Islands , Tórshavn , Faroe Islands
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21
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Kano KI, Shime N, Nishiyama K. Implementation of an empirical antimicrobial protocol in a critical care setting: A single-center retrospective observational cohort study in bacteremic patients. J Infect Chemother 2018; 24:965-968. [PMID: 30253915 DOI: 10.1016/j.jiac.2018.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/11/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022]
Abstract
In the treatment of severe infections in critical care settings, the selection of initial empirical antimicrobials affects patient outcomes and antimicrobial overuse. The application of a comprehensive treatment guidance might facilitate appropriate antimicrobial selection. Therefore, we developed such an antimicrobial guidance for use in emergency and critical care center and verified its efficacy. We retrospectively analyzed the data of 195 patients (96 patients before guidance introduction [control group] and 99 after guidance introduction [intervention group]) who were ultimately diagnosed with bacteremia to assess the effects of the guidance (the intervention). The appropriateness of the empirical therapy was greater in the intervention than in the control group (96% vs. 90%, respectively; P = 0.10). Moreover, the rate of carbapenem use was significantly lower in the intervention than in the control group (6% vs. 20%, respectively; P < 0.01). The control and intervention groups had similar 28-day survival rates of 81% and 85%, respectively; P = 0.50). These findings imply that introducing an empirical antimicrobial guidance in emergency outpatient and emergency intensive care settings could improve antimicrobial stewardship without affecting patient mortality. The data of this study can be used as a reference for establishing the study design of a large-scale prospective trial, aimed at verifying guidance efficacy.
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Affiliation(s)
- Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kei Nishiyama
- Department of Emergency Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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22
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Viale P, Tedeschi S, Scudeller L, Attard L, Badia L, Bartoletti M, Cascavilla A, Cristini F, Dentale N, Fasulo G, Legnani G, Trapani F, Tumietto F, Verucchi G, Virgili G, Berlingeri A, Ambretti S, De Molo C, Brizi M, Cavazza M, Giannella M. Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department. Clin Infect Dis 2018; 65:1253-1259. [PMID: 28605525 DOI: 10.1093/cid/cix548] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 06/11/2017] [Indexed: 12/27/2022] Open
Abstract
Background The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. Methods A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Results Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026). Conclusion Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.
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Affiliation(s)
- Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Luigia Scudeller
- Clinical Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Policlinic San Matteo Foundation, Pavia
| | - Luciano Attard
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Lorenzo Badia
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Alessandra Cascavilla
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Francesco Cristini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Nicola Dentale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Giovanni Fasulo
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Giorgio Legnani
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Filippo Trapani
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Fabio Tumietto
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Gabriella Verucchi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Giulio Virgili
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Andrea Berlingeri
- Microbiology, Department of Diagnosis and Prevention, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Simone Ambretti
- Microbiology, Department of Diagnosis and Prevention, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Chiara De Molo
- Microbiology, Department of Diagnosis and Prevention, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mara Brizi
- Emergency Department, Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Mario Cavazza
- Emergency Department, Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
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Mosevoll KA, Skrede S, Markussen DL, Fanebust HR, Flaatten HK, Aßmus J, Reikvam H, Bruserud Ø. Inflammatory Mediator Profiles Differ in Sepsis Patients With and Without Bacteremia. Front Immunol 2018; 9:691. [PMID: 29681903 PMCID: PMC5897503 DOI: 10.3389/fimmu.2018.00691] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/20/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic levels of cytokines are altered during infection and sepsis. This prospective observational study aimed to investigate whether plasma levels of multiple inflammatory mediators differed between sepsis patients with and those without bacteremia during the initial phase of hospitalization. A total of 80 sepsis patients with proven bacterial infection and no immunosuppression were included in the study. Plasma samples were collected within 24 h of hospitalization, and Luminex® analysis was performed on 35 mediators: 16 cytokines, six growth factors, four adhesion molecules, and nine matrix metalloproteases (MMPs)/tissue inhibitors of metalloproteinases (TIMPs). Forty-two patients (52.5%) and 38 (47.5%) patients showed positive and negative blood cultures, respectively. There were significant differences in plasma levels of six soluble mediators between the two “bacteremia” and “non-bacteremia” groups, using Mann–Whitney U test (p < 0.0014): tumor necrosis factor alpha (TNFα), CCL4, E-selectin, vascular cell adhesion molecule-1 (VCAM-1), intracellular adhesion molecule-1 (ICAM-1), and TIMP-1. Ten soluble mediators also significantly differed in plasma levels between the two groups, with p-values ranging between 0.05 and 0.0014: interleukin (IL)-1ra, IL-10, CCL2, CCL5, CXCL8, CXCL11, hepatocyte growth factor, MMP-8, TIMP-2, and TIMP-4. VCAM-1 showed the most robust results using univariate and multivariate logistic regression. Using unsupervised hierarchical clustering, we found that TNFα, CCL4, E-selectin, VCAM-1, ICAM-1, and TIMP-1 could be used to discriminate between patients with and those without bacteremia. Patients with bacteremia were mainly clustered in two separate groups (two upper clusters, 41/42, 98%), with higher levels of the mediators. One (2%) patient with bacteremia was clustered in the lower cluster, which compromised most of the patients without bacteremia (23/38, 61%) (χ2 test, p < 0.0001). Our study showed that analysis of the plasma inflammatory mediator profile could represent a potential strategy for early identification of patients with bacteremia.
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Affiliation(s)
- Knut Anders Mosevoll
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Jörg Aßmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Le C, Chu F, Dunlay R, Villar J, Fedullo P, Wardi G. Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock. Am J Emerg Med 2017; 36:1380-1385. [PMID: 29321120 DOI: 10.1016/j.ajem.2017.12.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/24/2017] [Accepted: 12/24/2017] [Indexed: 12/21/2022] Open
Abstract
STUDY OBJECTIVE To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen. METHODS Retrospective cohort study conducted between 2012 and 2015 in which 342 patients with culture-positive severe sepsis or septic shock who received initial vancomycin and piperacillin-tazobactam were reviewed to determine appropriateness of antimicrobial therapy, risk factors for inappropriate use, and outcome data. Univariate and multivariate regression analyses were determined to identify associations between inappropriate antibiotic use and outcomes and to identify risk factors that may predict which patients would benefit from an alternative initial regimen. RESULTS Vancomycin and piperacillin-tazobactam were inappropriate for 24% of patients with severe sepsis or septic shock, largely due to non-susceptible infections, particularly ESBL organisms and Clostridium difficile. Risk factors included multiple sources of infection (OR 4.383), admission from a skilled nursing facility (OR 3.763), a history of chronic obstructive pulmonary disease (COPD) (OR 3.175), intra-abdominal infection (OR 2.890), and immunosuppression (OR 1.930). We did not find a mortality impact. CONCLUSION Vancomycin and piperacillin-tazobactam were an inappropriate antibiotic combination for approximately 24% of patients with either severe sepsis or septic shock in the ED. Patients with known COPD, residence at a skilled nursing facility, a history concerning for Clostridium difficile, and immunosuppression would benefit from an alternative regimen. Future prospective studies are needed to validate these findings.
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Affiliation(s)
- Christina Le
- Department of Pharmacy, University of California, San Diego Health, San Diego, CA, United States.
| | - Frank Chu
- Department of Pharmacy, University of California, San Diego Health, San Diego, CA, United States
| | - Ronald Dunlay
- Department of Pharmacy, University of California, San Diego Health, San Diego, CA, United States
| | - Julian Villar
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Peter Fedullo
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, CA, United States
| | - Gabriel Wardi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, San Diego, CA, United States
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25
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Knoop ST, Skrede S, Langeland N, Flaatten HK. Epidemiology and impact on all-cause mortality of sepsis in Norwegian hospitals: A national retrospective study. PLoS One 2017; 12:e0187990. [PMID: 29149187 PMCID: PMC5693291 DOI: 10.1371/journal.pone.0187990] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/30/2017] [Indexed: 12/29/2022] Open
Abstract
Background Although sepsis is the leading cause of death from infection, there are few population-level epidemiological sepsis reports. The impact of sepsis-related deaths on all-cause hospital mortality is insufficiently described, in particular in Europe where data are non-existent. The objective of this study was to provide nationwide epidemiological results on sepsis hospitalizations in Norway and to estimate sepsis’ contribution to overall hospital mortality in a European setting. Methods We performed a retrospective study using data from the Norwegian Patient Registry and Statistics Norway. The occurrence, patient characteristics and outcomes of sepsis hospitalizations during the years 2011 and 2012 were estimated and compared with Norwegian population data. Sepsis was defined as organ dysfunction caused by a dysregulated host response to infection and identified with International Classification of Diseases 10th revision codes. Results We identified 18 460 sepsis admissions occurring in 13 582 individuals. The annual population incidence of hospitalized sepsis was 140 patients per 100 000 inhabitants; ranging from 10 to 2270 per 100 000 in different age groups and with statistically significant male predominance in all adult cohorts. Hospital mortality for sepsis admissions was 19.4% and overall, 26.4% of the included patients died while hospitalized for sepsis. Sepsis related deaths constituted 12.9% of all hospital fatalities, while hospitalizations with sepsis accounted for 1.0% of the total number of admissions and 3.5% of the total admission days during 2011 and 2012. Conclusions This study confirms that hospitalized sepsis is frequent in Norway and a major contributor to hospital fatalities in a European setting. The incidence is higher among men than women. Sepsis is in particular a disease of the elderly, and its impact on health-care will assumingly continue to increase in parallel with an aging population. Improvements in treatment and survival of sepsis could influence population mortality, and sepsis should receive greater attention in official death statistics in the future.
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Affiliation(s)
- Siri Tandberg Knoop
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nina Langeland
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hans Kristian Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Sherwin R, Winters ME, Vilke GM, Wardi G. Does Early and Appropriate Antibiotic Administration Improve Mortality in Emergency Department Patients with Severe Sepsis or Septic Shock? J Emerg Med 2017; 53:588-595. [PMID: 28916120 DOI: 10.1016/j.jemermed.2016.12.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/16/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Severe sepsis and septic shock remain significant public health concerns. Appropriate emergency department management includes early recognition, hemodynamic resuscitation, source control, and prompt antibiotic administration. Current international guidelines strongly recommend administration of early and appropriate antibiotics for patients with severe sepsis and septic shock. Interestingly, a recent Cochrane Review found insufficient evidence to provide a similar recommendation on antibiotic administration. The goal of this literature search was to systematically review the available literature on early and appropriate antimicrobial therapy and provide emergency physicians an evidence-based approach to antibiotic therapy for septic patients. METHODS Four PubMed searches were completed to identify abstracts of relevant interest. We limited studies to those completed in adult humans that were composed in English between 2005 and 2015. Included studies were randomized controlled trials, meta-analyses, prospective trials, and retrospective cohort studies. These studies were identified by a rigorous search methodology. No review articles, case series, or case reports were included. Predefined criteria were used to evaluate the quality and appropriateness of selected articles as part of a structured review. RESULTS A total of 1552 abstracts were evaluated for inclusion. After the review of these studies, 14 were included for formal review. The authors then systematically evaluated each study, which formed the basis for this clinical statement. CONCLUSIONS Patients with severe sepsis and septic shock should receive early and appropriate antibiotics in the emergency department. Patients with septic shock who received appropriate antimicrobial therapy within 1 h of recognition had the greatest benefit in mortality.
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Affiliation(s)
- Robert Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan
| | - Michael E Winters
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California, San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, University of California-San Diego, San Diego, California
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Coulter S, Roberts JA, Hajkowicz K, Halton K. The Use of Bloodstream Infection Mortality to Measure the Impact of Antimicrobial Stewardship Interventions: Assessing the Evidence. Infect Dis Rep 2017; 9:6849. [PMID: 28458799 PMCID: PMC5391541 DOI: 10.4081/idr.2017.6849] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/14/2016] [Accepted: 12/28/2016] [Indexed: 12/19/2022] Open
Abstract
This review sets out to evaluate the current evidence on the impact of inappropriate therapy on bloodstream infections (BSI) and associated mortality. Based on the premise that better prescribing practices should result in better patient outcomes, BSI mortality may be a useful metric to evaluate antimicrobial stewardship (AMS) interventions. A systematic search was performed in key medical databases to identify papers published in English between 2005 and 2015 that examined the association between inappropriate prescribing and BSI mortality in adult patients. Only studies that included BSIs caused by ESKAPE (Enterococcus faecium/faecalis, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) organisms were included. Study quality was assessed using the GRADE criteria and results combined using a narrative synthesis. We included 46 studies. Inappropriate prescribing was associated with an overall increase in mortality in BSI. In BSI caused by resistant gram positive organisms, such as methicillin resistant S. aureus, inappropriate therapy resulted in up to a 3-fold increase in mortality. In BSI caused by gram negative (GN) resistant organisms a much greater impact ranging from 3 to 25 fold increase in the risk of mortality was observed. While the overall quality of the studies is limited by design and the variation in the definition of appropriate prescribing, there appears to be some evidence to suggest that inappropriate prescribing leads to increased mortality in patients due to GN BSI. The highest impact of inappropriate prescribing was seen in patients with GN BSI, which may be a useful metric to monitor the impact of AMS interventions.
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Affiliation(s)
- Sonali Coulter
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane.,Royal Brisbane and Women's Hospital, Brisbane
| | | | - Kate Halton
- Faculty of Health, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
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28
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Nygård ST, Skrede S, Langeland N, Flaatten HK. An observational study of community-acquired severe sepsis comparing intensive care and non-intensive care patients. Acta Anaesthesiol Scand 2017; 61:194-204. [PMID: 28058720 DOI: 10.1111/aas.12848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Most studies of sepsis are from intensive care units (ICUs). We aimed to investigate community-acquired severe sepsis in a broader population, in order to compare patients treated in or outside an ICU . METHODS We performed a 1-year prospective observational study with enrollment of patients from three units; a general ICU, a combined ICU/non-ICU and a medical ward with limited surveillance facilities. Hospital survivors were followed up for 5 years. RESULTS Overall, 220 patients were included, of which 107 received ICU treatment. The majority of abdominal (77%, P = 0.003) and genitourinary (81%, P < 0.001) infections were found in ICU and non-ICU patients, respectively. Time to first antibiotic administration was longer in ICU-patients (median 3.5 vs. 2.0 h in non-ICU patients, P = 0.011). ICU developed more organ dysfunctions than non-ICU patients (P < 0.001), nevertheless supportive therapy with vasoactive drugs and non-invasive ventilation was documented in 22% and 27% of the latter. Median hospital length of stay was 15 vs. 9 days (P = 0.001), and hospital and 5-year mortality rates 35% vs. 16% (P = 0.002) and 57% vs. 58% (P = 0.892) among ICU and non-ICU patients, respectively. Increasing age (HR 1.06 (1.04, 1.07) per year, P < 0.001), not care level during hospitalization (HR 1.19 (0.70, 2.02), P = 0.514), influenced long-term survival. CONCLUSION Half of the subjects with community-acquired severe sepsis never received ICU treatment. Still, use of organ supportive therapy outside the ICU was considerable. Hospital mortality was higher, whereas 5-year survival was similar when comparing ICU with non-ICU patients.
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Affiliation(s)
- S. T. Nygård
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - N. Langeland
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - H. K. Flaatten
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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Affiliation(s)
- H. Flaatten
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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Mariansdatter SE, Eiset AH, Søgaard KK, Christiansen CF. Differences in reported sepsis incidence according to study design: a literature review. BMC Med Res Methodol 2016; 16:137. [PMID: 27733132 PMCID: PMC5062833 DOI: 10.1186/s12874-016-0237-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/29/2016] [Indexed: 11/30/2022] Open
Abstract
Background Sepsis and severe sepsis are common conditions in hospital settings, and are associated with high rates of morbidity and mortality, but reported incidences vary considerably. In this literature review, we describe the variation in reported population-based incidences of sepsis and severe sepsis. We also examine methodological and demographic differences between studies that may explain this variation. Methods We carried out a literature review searching three major databases and reference lists of relevant articles, to identify all original studies reporting the incidence of sepsis or severe sepsis in the general population. Two authors independently assessed all articles, and the final decision to exclude an article was reached by consensus. We extracted data according to predetermined variables, including study country, sepsis definition, and data source. We then calculated descriptive statistics for the reported incidences of sepsis and severe sepsis. The studies were classified according to the method used to identify cases of sepsis or severe sepsis: chart-based (i.e. review of patient charts) or code-based (i.e. predetermined International Classification of Diseases [ICD] codes). Results Among 482 articles initially screened, we identified 23 primary publications reporting incidence of sepsis and/or severe sepsis in the general population. The reported incidences ranged from 74 to 1180 per 100,000 person-years and 3 to 1074 per 100,000 person-years for sepsis and severe sepsis, respectively. Most chart-based studies used the Bone criteria (or a modification hereof) and Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study criteria to identify cases of sepsis and severe sepsis. Most code-based studies used ICD-9 codes, but the number of codes used ranged from 1 to more than 1200. We found that the incidence varied according to how sepsis was identified (chart-based vs. code-based), calendar year, data source, and world region. Conclusion The reported incidences of sepsis and severe sepsis in the general population varied greatly between studies. Such differences may be attributable to differences in the methods used to collect the data, the study period, or the world region where the study was undertaken. This finding highlights the importance of standardised definitions and acquisition of data regarding sepsis and severe sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s12874-016-0237-9) contains supplementary material, which is available to authorized users.
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Klastrup V, Hvass AM, Mackenhauer J, Fuursted K, Schønheyder HC, Kirkegaard H. Site of infection and mortality in patients with severe sepsis or septic shock. A cohort study of patients admitted to a Danish general intensive care unit. Infect Dis (Lond) 2016; 48:726-31. [PMID: 27389656 DOI: 10.3109/23744235.2016.1168938] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The search for the site of infection has high priority in patients with severe sepsis and septic shock. However, it is questionable whether mortality is associated with the specific site of infection in patients admitted to an intensive care unit (ICU). Therefore, the 30-day and 90-day mortalities in ICU patients admitted with suspected or confirmed community-acquired infection were studied. METHODS A retrospective cohort study was conducted, including all adult patients admitted to a multi-specialty tertiary ICU with severe sepsis or septic shock from November 2008 to October 2010. The site of infection was classified according to criteria set for healthcare associated infections and infections in the acute care setting by Centers for Disease Control and Prevention (CDC). Kaplan-Meier curves and Poisson regression analysis were used to evaluate the association between site of infection and 30- and 90-day all-cause mortality, adjusting for age, sex and comorbidities. RESULTS Three hundred and eighty-eight patients were included. One or more comorbidities were present in 76% of patients. Across all sites of infection, there were more patients with septic shock than patients with severe sepsis. The most frequent site of infection was pneumonia, followed by gastrointestinal infection. Urinary tract infection was found to be an independent predictor of mortality among septic ICU patients when adjusting for sex, age and comorbidities. CONCLUSIONS The results suggest that identification of correct site of infection is important in the management of severe sepsis and septic shock.
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Affiliation(s)
- Vibeke Klastrup
- a Department of Infectious Diseases , Aarhus University Hospital , Aarhus , Denmark
| | - Anne Mette Hvass
- a Department of Infectious Diseases , Aarhus University Hospital , Aarhus , Denmark
| | - Julie Mackenhauer
- b Research Center for Emergency Medicine , Aarhus University Hospital , Aarhus , Denmark
| | | | - Henrik Carl Schønheyder
- d Department of Clinical Microbiology , Aalborg University Hospital , Aalborg , Denmark ;,e Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - Hans Kirkegaard
- b Research Center for Emergency Medicine , Aarhus University Hospital , Aarhus , Denmark
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Askim Å, Mehl A, Paulsen J, DeWan AT, Vestrheim DF, Åsvold BO, Damås JK, Solligård E. Epidemiology and outcome of sepsis in adult patients with Streptococcus pneumoniae infection in a Norwegian county 1993-2011: an observational study. BMC Infect Dis 2016; 16:223. [PMID: 27216810 PMCID: PMC4877975 DOI: 10.1186/s12879-016-1553-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 05/07/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Invasive pneumococcal disease (IPD) is responsible for significant mortality and morbidity worldwide. There are however few longitudinal studies on the changes in case fatality rate of IPD in recent years. We carried out a prospective observational study of patients with IPD in Nord Trøndelag county in Norway from 1993 to 2011 to study the clinical variables and disease outcome. The main outcome was all-cause mortality after 30 and 90 days. METHODS Patients with positive blood cultures were registered prospectively by the microbiology laboratory and clinical variables were registered retrospectively from patients' hospital records. The severity of sepsis was assigned according to the 2001 International Sepsis Definition Conference criteria. The association between mortality and predictive factors was studied using a logistic regression model. RESULTS The total number of patients was 414 with mean age of 67 years and 53 % were male. Comorbidity was assessed by the Charlson Comorbidity Index (CCI). A CCI-score of 0 was registered in 144 patients (34.8 %), whereas 190 had a score of 1-2 (45.9 %) and 80 (19.3 %) had a score ≥3. 68.8 % of the patients received appropriate antibiotics within the first 6 h. The 30-day mortality risk increased by age and was 3-fold higher for patients aged ≥80 years (24.9, 95 % CI 16.4-33.4 %) compared to patients aged <70 (8.0, 95 % CI 3.5-12.4 %). 110 patients, (26.6 %) had severe sepsis and 37 (8.9 %) had septic shock. The 30 day all-cause mortality risk for those with sepsis without organ failure was 5.4 % (95 % CI 2.7-8.0 %), 20.2 % (95 % CI 13.5-27.4 %) for those with severe sepsis and 35.0 % (95 % CI 21.6-49.0 %) for those with septic shock. The mortality risk did not differ between the first and the second halves of the study period with a 30-day mortality risk of 13.5 % (95 % CI 7.9-19.2 %) for 1993-2002 versus 11.8 % (95 % CI 8.2-15.3 %) for 2003-2011. CONCLUSION IPD carries a high mortality despite early and appropriate antibiotics in most cases. We found no substantial decrease in case fatality rate during the study period of 18 years. Older age and higher severity of disease were important risk factors for death in IPD.
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Affiliation(s)
- Åsa Askim
- Clinic of Anaesthesia and Intensive Care, St Olav University Hospital, Trondheim, Norway.
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
- Middle Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim, Norway.
- Faculty of medicine, Department of Circulation and Medical Imaging, Po box 8905, N-7491, Trondheim, Norway.
| | - Arne Mehl
- Centre of Molecular Inflammation Research Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
- Middle Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim, Norway
| | - Julie Paulsen
- Centre of Molecular Inflammation Research Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
- Middle Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim, Norway
| | - Andrew T DeWan
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | | | - Bjørn Olav Åsvold
- Department of Public Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St Olav University Hospital, Trondheim, Norway
- Middle Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Kristian Damås
- Centre of Molecular Inflammation Research Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, St Olav University Hospital, Trondheim, Norway
- Middle Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik Solligård
- Clinic of Anaesthesia and Intensive Care, St Olav University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
- Middle Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim, Norway
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Tsertsvadze A, Royle P, Seedat F, Cooper J, Crosby R, McCarthy N. Community-onset sepsis and its public health burden: a systematic review. Syst Rev 2016; 5:81. [PMID: 27194242 PMCID: PMC4870814 DOI: 10.1186/s13643-016-0243-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/12/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sepsis is a life-threatening condition and major contributor to public health and economic burden in the industrialised world. The difficulties in accurate diagnosis lead to great variability in estimates of sepsis incidence. There has been even greater uncertainty regarding the incidence of and risk factors for community-onset sepsis (COS). We systematically reviewed the recent evidence on the incidence and risk factors of COS in high income countries (North America, Australasia, and North/Western Europe). METHODS Cohort and case-control studies were eligible for inclusion. Medline and Embase databases were searched from 2002 onwards. References of relevant publications were hand-searched. Two reviewers screened titles/abstracts and full-texts independently. One reviewer extracted data and appraised studies which were cross-checked by independent reviewers. Disagreements were resolved via consensus. Odds ratios (ORs) and 95 percent confidence intervals (95 % CIs) were ascertained by type of sepsis (non-severe, severe, and septic shock). RESULTS Ten cohort and 4 case-control studies were included. There was a wide variation in the incidence (# cases per 100,000 per year) of non-severe sepsis (range: 64-514), severe sepsis (range: 40-455), and septic shock (range: 9-31). Heterogeneity precluded statistical pooling. Two cohort and 4 case-control studies reported risk factors for sepsis. In one case-control and one cohort study, older age and diabetes were associated with increased risk of sepsis. The same case-control study showed an excess risk for sepsis in participants with clinical conditions (e.g., immunosuppression, lung disease, and peripheral artery disease). In one cohort study, higher risk of sepsis was associated with being a nursing home resident (OR = 2.60, 95 % CI: 1.20, 5.60) and in the other cohort study with being physically inactive (OR = 1.33, 95 % CI: 1.13, 1.56) and smoking tobacco (OR = 1.85, 95 % CI: 1.54, 2.22). The evidence on sex, ethnicity, statin use, and body mass index as risk factors was inconclusive. CONCLUSIONS The lack of a valid standard approach for defining sepsis makes it difficult to determine the true incidence of COS. Differences in case ascertainment contribute to the variation in incidence of COS. The evidence on COS is limited in terms of the number and quality of studies. This review highlights the urgent need for an accurate and standard method for identifying sepsis. Future studies need to improve the methodological shortcomings of previous research in terms of case definition, identification, and surveillance practice. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023484.
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Affiliation(s)
- Alexander Tsertsvadze
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Pam Royle
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Farah Seedat
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Jennifer Cooper
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Rebecca Crosby
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Noel McCarthy
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,NIHR Health Protections Research Unit in Gastrointestinal Infections, University of Oxford, Oxford, UK
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McClay K, Mehboob S, Yu J, Santarsiero BD, Deng J, Cook JL, Jeong H, Johnson ME, Steffan RJ. Indole trimers with antibacterial activity against Gram-positive organisms produced using combinatorial biocatalysis. AMB Express 2015; 5:125. [PMID: 26112315 PMCID: PMC4480272 DOI: 10.1186/s13568-015-0125-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 06/10/2015] [Indexed: 11/22/2022] Open
Abstract
The I100V isoform of toluene-4-monooxygenase was used to catalyze the oxidative polymerization of anthranil and various indoles under mildly acidic conditions, favoring the production of trimers. Compounds produced in sufficient yield were purified and tested for their ability to inhibit the growth of B. anthracis, E. faecalis, L. monocytogenes, S. aureus, and in some cases, F. tularensis. 15 of the compounds displayed promising antibacterial activity (MIC < 5 µg/ml) against one or more of the strains tested, with the best MIC values being <0.8 µg/ml. All of these compounds had good selectivity, showing minimal cytotoxicity towards HepG2 cells. The structure was solved for six of the compounds that could be crystallized, revealing that minimally two classes of indole based trimers were produced. One compound class produced was a group of substituted derivatives of the natural product 2,2-bis(3-indolyl) indoxyl. The other group of compounds identified was classified as tryptanthrin-like compounds, all having multi-ring pendant groups attached at position 11 of tryptanthrin. One compound of particular interest, SAB-J85, had a structure that suggests that any compound, with a ring structure that can be activated by an oxygenase, might serve as a substrate for combinatorial biocatalysis.
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Tsertsvadze A, Royle P, McCarthy N. Community-onset sepsis and its public health burden: protocol of a systematic review. Syst Rev 2015; 4:119. [PMID: 26394931 PMCID: PMC4579606 DOI: 10.1186/s13643-015-0103-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 08/19/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Sepsis is a life-threatening condition and major contributor of public health and economic burden in the industrialised world. The heterogeneity, absence of more specific definition, and difficulties in accurate diagnosis lead to great variability in the estimates of sepsis incidence. There has been uncertainty regarding the incidence and risk factors attributable to community-onset as opposed to hospital-acquired sepsis. Community-onset sepsis has distinct host characteristics, risk factors, pathogens, and prognosis. A systematic assessment of recent evidence is warranted in light of secular changes in epidemiology, pathogens, and the uncertainties around the incidence and risk factors of community-onset sepsis. This protocol describes a systematic review which aims to synthesise the recent empirical evidence on the incidence and risk factors of community-onset sepsis, severe sepsis, and septic shock in high-income countries. METHODS/DESIGN English-language publications of cohort and case-control studies reporting incidence and risk factors of community-onset sepsis will be eligible for inclusion. MEDLINE and Embase databases will be searched from 2002 and onwards. References of relevant publications will be hand-searched. Two reviewers will independently screen titles/abstracts and full texts as well as extract data and appraise the risk of bias of included studies. The data extractions and risk of bias assessments will be cross-checked. Any disagreements will be resolved via consensus. The data on incidence and risk factors of sepsis will be organised and synthesised in text, tables, and forest plots. The evidence will be pooled given sufficient data and degree of similarity across study populations, exposures, and outcomes. The heterogeneity will be assessed through visual inspection of forest plots, Chi-square-based p value, and I (2) statistic. The sources of heterogeneity will be explored via subgroup analysis. DISCUSSION Timeliness and accuracy of diagnosis of sepsis are both crucial aspects for improving the patient's outcome. The findings of this review will be discussed with a view to better inform future recommendations on improving public-facing campaigns, timely presentation, and diagnosis of sepsis in the community. The review will also discuss gaps in evidence and highlight future research and policy-making avenues for improving public health planning. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023484.
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Affiliation(s)
- Alexander Tsertsvadze
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies; Division of Health Sciences; Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Pam Royle
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies; Division of Health Sciences; Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Noel McCarthy
- Communicable Disease Control Epidemiology and Evidence; Populations, Evidence and Technologies; Division of Health Sciences; Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
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Garnacho-Montero J, Gutiérrez-Pizarraya A, Escoresca-Ortega A, Fernández-Delgado E, López-Sánchez JM. Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality. Crit Care 2015; 19:302. [PMID: 26307060 PMCID: PMC4549859 DOI: 10.1186/s13054-015-1000-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/10/2015] [Indexed: 11/13/2022] Open
Abstract
Introduction In patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission. Methods We conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU. Results A total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402). Conclusions The administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.
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Affiliation(s)
- José Garnacho-Montero
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Red Española de Investigación en Patología infecciosa (REIPI), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - Antonio Gutiérrez-Pizarraya
- Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Red Española de Investigación en Patología infecciosa (REIPI), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - Ana Escoresca-Ortega
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - Esperanza Fernández-Delgado
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - José María López-Sánchez
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
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Yokota PKO, Marra AR, Martino MDV, Victor ES, Durão MS, Edmond MB, dos Santos OFP. Impact of appropriate antimicrobial therapy for patients with severe sepsis and septic shock--a quality improvement study. PLoS One 2014; 9:e104475. [PMID: 25375775 PMCID: PMC4222820 DOI: 10.1371/journal.pone.0104475] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 07/14/2014] [Indexed: 12/29/2022] Open
Abstract
Background There is ample literature available on the association between both time to antibiotics and appropriateness of antibiotics and clinical outcomes from sepsis. In fact, the current state of debate surrounds the balance to be struck between prompt empirical therapy and care in the choice of appropriate antibiotics (both in terms of the susceptibility of infecting organism and minimizing resistance arising from use of broad-spectrum agents). The objective of this study is to determine sepsis bundle compliance and the appropriateness of antimicrobial therapy in patients with severe sepsis and septic shock and its impact on outcomes. Material This study was conducted in the ICU of a tertiary care, private hospital in São Paulo, Brazil. A retrospective cohort study was conducted from July 2005 to December 2012 in patients with severe sepsis and septic shock. Results A total of 1,279 patients were identified with severe sepsis and septic shock, of which 358 (32.1%) had bloodstream infection (BSI). The inpatient mortality rate was 29%. In evaluation of the sepsis bundle, over time there was a progressive increase in serum arterial lactate collection, obtaining blood cultures prior to antibiotic administration, administration of broad-spectrum antibiotics within 1 hour, and administration of appropriate antimicrobials, with statistically significant differences in the later years of the study. We also observed a significant decrease in mortality. In patients with bloodstream infection, after adjustment for other covariates the administration of appropriate antimicrobial therapy was associated with a decrease in mortality in patients with severe sepsis and septic shock (p = 0.023). Conclusions The administration of appropriate antimicrobial therapy was independently associated with a decline in mortality in patients with severe sepsis and septic shock due to bloodstream infection. As protocol adherence increased over time, the crude mortality rate decreased, which reinforces the need to implement institutional guidelines and monitor appropriate antimicrobial therapy compliance.
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Affiliation(s)
- Paula K. O. Yokota
- Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alexandre R. Marra
- Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
- * E-mail:
| | | | - Elivane S. Victor
- Statistics Department, Instituto Israelita de Ensino e Pesquisa (IIEP), Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelino S. Durão
- Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michael B. Edmond
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States of America
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