Sepsis-related deaths in Brazil: an analysis of the national mortality registry from 2002 to 2010

Sepsis-related mortality: long-term trends in Northeastern Italy, including pandemic years

BACKGROUND

Global estimates of sepsis mortality are based on multiple causes of death (MCOD, any mention of the condition on death certificates); however, MCOD data are sparse and mainly referring to the pre-pandemic period.

OBJECTIVES

To investigate recent trends in sepsis-related mortality, associated sites of infection, and comorbidities in Veneto (Northeastern Italy).

METHODS

Mortality records from 2008 to 2022 were extracted, and sepsis-related mortality was assessed based both on the underlying cause of death (UCOD) and on MCOD. The average annual percent change in age-standardised rates was estimated by join point regression through the whole study period. MCOD records were investigated to retrieve infection sites and comorbidities.

RESULTS

Sepsis was mentioned in 63,479 death certificates, growing from 4.9% out of all deaths in 2008 to 12.9% in 2022. Age-standardised mortality rates increased yearly by 8.2% (95%CI 2.1-14.7%) based on the UCOD and by 5.9% (95%CI 5.3-6.5%) based on MCOD. Sharp peaks in monthly mortality were observed in correspondence with flu epidemics, COVID-19 pandemic waves, and periods of extreme heat. The percentage of sepsis-related deaths associated to urinary tract infections, and with mention of neurodegenerative disorders and chronic kidney disease increased over time.

CONCLUSION

Raised awareness of physicians, ageing of the population, spread of antimicrobial resistance further fuelled by the COVID-19 pandemic are among reasons of increasing sepsis-related mortality in Italy. Continuous monitoring of sepsis by means of MCOD data and other surveillance tools is warranted.

Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities

OBJECTIVE

In this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score.

DESIGN

This retrospective cohort study was conducted between 2016 and 2021.

SETTING

Two university hospitals in Brazil.

PARTICIPANTS

Patients with sepsis.

INTERVENTIONS

Several clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities.

MAIN VARIABLE OF INTEREST

In-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis.

RESULTS

A total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction.

CONCLUSIONS

Several risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.

Temporal trends of sepsis-related mortality in China, 2006-2020: a population-based study

BACKGROUND

The scarcity of sepsis epidemiologic data from most low- and middle-income countries (LMICs) hampered estimation of regional and global burden of the disease, and provided limited guidance for policy makers. We aimed to characterize and analyze the temporal trends of sepsis-related mortality in China, by population groups, underlying causes of death, geographic regions, and sociodemographic index (SDI) levels.

METHODS

Sepsis-related deaths were identified from the National Mortality Surveillance System (NMSS) of China from 2006 to 2020. Trends of sepsis-related mortality and years of life lost (YLLs), stratified by age, sex, underlying diseases, and regions were analyzed using the Jointpoint regression analysis. We investigated the association of SDI with trends of sepsis-related mortality.

RESULTS

In 2020, sepsis was estimated to be responsible for 986,929 deaths and 17.1 million YLLs in China. Age-standardized sepsis-related mortality significantly declined from 130.2 (95%CI, 129.4-131) per 100,000 population in 2006 to 76.6 (76.3-76.9) in 2020. Age-standardized YLLs decreased from 2172.7 (2169.4-2176) per 100,000 population in 2006 to 1271 (1269.8-1272.2) in 2020. Substantial variations of sepsis-related mortality and YLLs were observed between population groups and regions, with higher burden in males, the elderly, and western China. An inverse relation was noted between SDI and sepsis-related mortality or YLLs.

CONCLUSIONS

Despite declining trends of age-standardized mortality and YLLs of sepsis in China, significant disparities between population groups and regions highlight a need for targeted policies and measures to close the gaps and improve the outcome of sepsis.

Disparities between randomized clinical trial participants and sepsis patients in real-world

BACKGROUND

The external validity or "generalizability" of randomized controlled trials (RCTs) often needs be considered when making treatment decisions. We evaluate whether participants in large multicenter RCTs investigating sepsis were similar in age, disease severity, comorbidities, and mortality to the general population of sepsis patients.

METHODS

Using MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials, RCTs that enrolled 100 or more adult sepsis patients from two or more sites published from 01 January 2000 to 04 August 2019 were identified. The weighted mean age of trial participants was calculated as the main variable, and it was compared with the mean ages of the overall populations derived from the MIMIC database and the EICU database. Two researchers independently screened all abstracts and performed data extraction, then aggregated the data using a random effects model. Multiple linear regression was used to determine whether any factors were significantly associated with age disparities.

RESULTS

The mean age of the 60,577 participants in the 94 trials included in the analysis was significantly lower than those of the patients in the MIMIC and EICU databases (weighted mean age 62.28 years vs. 64.47 years for MIMIC and 65.20 years for EICU; both p < 0.001). Trial participants were less likely to have known comorbidities such as diabetes (13.96% vs. 30.64% for MIMIC and 35.75% for EICU; both p < 0.001). The weighted mortality rate in trial participants was higher than that in patients in the MIMIC and EICU databases (29.33% vs. 20.72% for MIMIC and 17.53% for EICU; both p < 0.001). Differences in age, severity score, and comorbidities remained statistically significant in sensitivity analyses. Multivariable regression suggested that commercially supported trials were more likely to include patients with higher severity scores (p = 0.002), but after adjustment for study region and sepsis diagnosis inclusion in such trials was not significantly associated with age.

CONCLUSIONS

On average, trial participants were younger than the general sepsis patient population. Commercial support influenced patient selection. Efforts to understand and address the above-described patient disparities are necessary to improve the generalizability of RCT results.

TRIAL REGISTRATION

PROSPERO CRD42019145692.

Body-mass index and long-term risk of sepsis-related mortality: a population-based cohort study of 0.5 million Chinese adults

BACKGROUND

Sepsis represents a major worldwide healthcare burden. However, how body-mass index (BMI) is related to the long-term risk of sepsis-related mortality in low- and middle-income countries remains uncertain.

METHODS

We examined the associations of sepsis-related mortality with both baseline BMI and waist circumference (WC) using data from China Kadoorie Biobank, a prospective cohort recruited during 2004-2008 and followed up to December 2016. After excluding participants with chronic obstructive pulmonary disease, tuberculosis, cancer, heart disease, and stroke, and omitting the first 3 years of follow-up, 440,763 participants remained for analysis.

RESULTS

During a median follow-up of 10.0 years, 1957 sepsis-related deaths (3,134,870 person-years) were included for analysis. Compared with reference BMI of 22.5 to < 25.0 kg/m², the multivariable-adjusted hazard ratios (HRs) for sepsis-related mortality were 2.42 (95% CIs 2.07-2.84) for BMI of < 18.5, 1.59 (1.36-1.85) for 18.5 to < 20.0, 1.21 (1.06-1.38) for 20.0 to < 22.5, 0.97 (0.83-1.13) for 25.0 to < 27.5, 0.98 (0.80-1.21) for 27.5 to < 30.0, and 1.22 (0.93-1.60) for ≥ 30.0 kg/m². Further adjustment for WC led to slightly augmentation of the effect size for the lower BMI groups and null association in the obese group. In the association analysis between WC and sepsis-related mortality, compared with the middle quintile group, only the highest quintile group showed an increased risk of sepsis-related mortality after adjusted for BMI (HR = 1.54; 95% CI 1.28-1.84).

CONCLUSIONS

Underweight, lower normal weight, and abdominal obesity are associated with increased future risk of sepsis-related mortality over 10 years in the Chinese population. The double burden of underweight and obesity indicates a heavy sepsis burden faced by low- and middle-income countries.

Implementation of an Artificial Intelligence Algorithm for sepsis detection

OBJECTIVES

to present the nurses' experience with technological tools to support the early identification of sepsis.

METHODS

experience report before and after the implementation of artificial intelligence algorithms in the clinical practice of a philanthropic hospital, in the first half of 2018.

RESULTS

describe the motivation for the creation and use of the algorithm; the role of the nurse in the development and implementation of this technology and its effects on the nursing work process.

FINAL CONSIDERATIONS

technological innovations need to contribute to the improvement of professional practices in health. Thus, nurses must recognize their role in all stages of this process, in order to guarantee safe, effective and patient-centered care. In the case presented, the participation of the nurses in the technology incorporation process enables a rapid decision-making in the early identification of sepsis.

The increase of sepsis-related mortality in Italy: a nationwide study, 2003-2015

The true burden of sepsis is largely unknown. Conventional underlying cause of death (UCoD) statistics largely underestimates sepsis-related mortality. This study aims to analyze all the conditions mentioned in the death certificates (multiple causes of death-MCoD) to estimate the nationwide burden of sepsis-related mortality in Italy, to investigate time trends and main comorbidities in sepsis-related deaths. All death certificates mentioning sepsis from 2003 to 2015 were analyzed. Age-standardized mortality rates were calculated for sepsis as both UCoD and MCoD, by gender and broad age groups. The ratio of the age-standardized proportions of any mention of sepsis in the presence/absence of associated chronic diseases (ASPR) was computed. The number of certificates reporting sepsis increased from 18,939 in 2003 to 49,010 in 2015 (from 3 to 8% of all deaths). The increase in sepsis mortality rates was larger for UCoD (males, + 200%; females, + 175%) than for MCoD-based figures (+ 100%; + 90%); MCoD rates remained noticeably higher than UCoD rates (2015, 87.3 per 100,000 vs. 16.3 for males; 54.9 vs. 11.8 for females). The largest increase was observed among the very elderly. The association between sepsis and chronic diseases was stronger for subjects aged less than 75 years. The increased awareness within the medical community in addition to the growing susceptible elderly population and the spread of antimicrobial resistance could have contributed to the sepsis-related mortality increase. MCoD statistics could help in recognizing sepsis not only as a clinical challenge, but also as a major public health issue.

Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions

OBJECTIVE

To characterize resource availability from a nationally representative random sample of intensive care units in Brazil.

METHODS

A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit.

RESULTS

A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%).

CONCLUSION

Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.

Assessment of clinical and epidemiological characteristics of patients with and without sepsis in intensive care units of a tertiary hospital

OBJECTIVE

To describe the clinical and epidemiological features of patients with and without sepsis at critical care units of a public hospital.

METHODS

A cross-sectional study was carried out from May 2012 to April 2013. Clinical and laboratory data of patients with and without sepsis in the intensive care units were reviewed of medical records.

RESULTS

We evaluated 466 patients, 58% were men, median age was 40 years, and 146 (31%) of them were diagnosed with sepsis. The overall mortality was 20% being significantly higher for patients with sepsis (39%). The factors associated with intensive care unit mortality were the presence of sepsis (OR: 6.1, 95%CI: 3.7-10.5), age (OR: 3.6, 95%CI: 1.4-7.2), and length of hospital stay (OR: 0.96, 95%CI: 0.94-0.98). Pulmonary (49%) and intra-abdominal (20%) infections were most commonly identified sites, and coagulase-negative staphylococci and enteric Gram negative bacilli the most frequent (66%) pathogens isolated.

CONCLUSION

Although the impact of sepsis on mortality is related to patients' clinical and epidemiological characteristics, a critical evaluation of these data is important since they will allow the direct implementation of local policies for managing this serious public health problem.

Noninvasive measurements of hemodynamic, autonomic and endothelial function as predictors of mortality in sepsis: A prospective cohort study

Background and aim

Sepsis is associated with marked alterations in hemodynamic responses, autonomic dysfunction and impaired vascular function. However, to our knowledge, analysis of noninvasive markers to identify greater risk of death has not yet been investigated. Thus, our aim was to explore the prognostic utility of cardiac output (CO), stroke volume (SV), indices of vagal modulation (RMSSD and SD1), total heart rate variability (HRV) indices and FMD of brachial artery (%FMD), all measured noninvasively, in the first 24 hours of the diagnosis of sepsis.

Methods

60 patients were recruited at ICU between 2015 and 2017 and followed by 28 days. CO, SV, RR intervals were measurement. Doppler ultrasound was used to assess brachial artery FMD and the hyperemic response were obtained (%FMD). Patients were divided by survivors (SG) and nonsurvivors groups (NSG).

Results

A total of 60 patients were analysed (SG = 21 and NSG = 39). Survivors were younger (41±15 years vs. 55±11 years) and used less vasoactive drugs. As expected, APACHE and SOFA scores were lower in NSG compared to SG. In addition, higher SD1, triangular index, % FMD, velocity baseline and hyperemia flow velocity as well as lower HR values were observed in the SG, compared to NSG (P<0.05). Interestingly, RMSSD and SD1 indices were independent predictors of %FMD, ΔFMD and FMD_peak. RMSSD threshold of 10.8ms and %FMD threshold of -1 were optimal at discriminatomg survivors and nonsurvivors.

Conclusion

Noninvasive measurements of autonomic and endotelial function may be important markers of sepsis mortality, which can be easily obtained in the early stages of sepsis at the bedside.

Increased risk of death and readmission after hospital discharge of critically ill patients in a developing country: a retrospective multicenter cohort study

PURPOSE

To describe long-term mortality and hospital readmissions of patients admitted to Brazilian intensive care units (ICU).

METHODS

Retrospective cohort study of adult patients admitted to Brazilian hospitals affiliated to the Public Healthcare System from 10 state capitals. ICU patients were paired to non-ICU patients by frequency matching (ratio 1:2), according to postal code and admission semester. Hospitalization records were linked through deterministic linkage to national mortality data. Primary outcome was mortality up to 1 year. Other outcomes were mortality and readmissions at 30 and 90 days and 3 years. Multiple Cox regressions were used adjusting for age, sex, cancer diagnosis, type of hospital, and surgical status.

RESULTS

We included 324,594 patients (108,302 ICU and 216,292 non-ICU). ICU patients had increased hospital length of stay [9 (5-17) vs. 3 (1-6) days, p < 0.001] and mortality (18.5 vs. 3.6%, p < 0.001) versus non-ICU patients. One year after discharge, ICU patients were more frequently readmitted to hospital (25.4 vs. 17.4%, p < 0.001) and to ICU (31.4 vs. 7.3%, p < 0.001) than controls. Mortality up to 1 year was also higher for ICU patients (14.3 vs. 3.9%, p < 0.001). A significant interaction between surgical status and mortality was found, with adjusted hazard ratios (HRs) up to 1 year of 2.7 [95% confidence interval (CI) 2.5-2.9] for surgical patients, and 3.4 (95%CI 3.3-3.5) for medical patients. The risk for death and readmission diminished over time up to 3 years.

CONCLUSIONS

In a public healthcare system of a developing country, ICU patients have excessive long-term mortality and frequent readmissions. The ICU burden tended to reduce over time after hospital discharge.

Sepsis-related mortality in China: a descriptive analysis

PURPOSE

A population-level description and analysis of sepsis-related mortality in China is key to the planning and assessment of interventional strategies.

METHODS

Retrospective analysis of multiple cause of death (MCOD) recorded in the population-based national mortality surveillance system (NMSS) of China. All sepsis-related deaths occurring in 605 disease surveillance points (DSPs) covering 323.8 million population across China were included in our study. Age-standardized mortality and national estimate of sepsis-related deaths were estimated using the census population in 2010 and 2015, respectively.

RESULTS

In 2015, a total of 1,937,299 deaths occurring in any of the 605 DSPs and standardized sepsis-related mortality rate was 66.7 (95% confidence interval [CI] 66.4-67.0) deaths per 100,000 population. This produced a national estimate of 1,025,997 sepsis-related deaths. Sepsis-related mortality rates exhibited significant geographic variation. In multilevel analysis, male sex (rate ratio [RR] 1.582, 95% CI 1.570-1.595), increasing age (RR 1.914 for 5-year group, 95% CI 1.910-1.917), and presence of comorbidity (RR 2.316, 95% CI 2.298-2.335) were independently associated with increased sepsis-related mortality. Higher disposable income (RR 0.717 for the fourth interquartile range vs. the first interquartile range, 95% CI 0.515-0.978) and mean years of education (RR 0.808 for the fourth interquartile range vs. the first interquartile range, 95% CI 0.684-0.955) were negatively associated with sepsis-related mortality. However, population-based hospital doctors were not significantly associated with sepsis-related mortality.

CONCLUSIONS

The standardized sepsis-related mortality rate in China was high and varied according to socioeconomic indices, even though some uncertainty remained.

Epidemiology of sepsis in Brazil: Incidence, lethality, costs, and other indicators for Brazilian Unified Health System hospitalizations from 2006 to 2015

Background

Sepsis is considered a major worldwide health burden, with high mortality and associated costs. Health indicators are essential to define strategies to improve the treatment of diseases, and the epidemiology information of sepsis in developing countries is scarce. Thus, the aim of this work is to assess trends in the incidence, lethality, costs, and other indicators of sepsis for Brazilian Unified Health System (SUS—Sistema Único de Saúde) hospitalizations for the period from January 2006 to December 2015.

Materials and methods

We conducted this study using data from the SUS hospital information system. We selected registries of SUS hospitalizations of patients diagnosed with sepsis (total of 724,458 cases from 4,271 public and private Brazilian hospitals).

Results

From 2006 to 2015, the annual sepsis incidence increased 50.5% from 31.5/100,000 to 47.4/100,000 persons. The mean hospital length of stay (LOS) was 9.0 days. A total of 29.1% of the hospitalizations had admission to the intensive care unit (ICU) with a mean ICU LOS of 8.0 days. The mean cost per hospitalization was US$624.0 and for hospitalizations requiring intensive care was U$1,708.1. The overall sepsis lethality rate was 46.3%, and for hospitalizations with admission to the ICU, it was 64.5%. During the study period, the lethality rate for children/teenagers decreased 40.1%, but for all other age groups it increased 11.4%. The sepsis lethality rate in public hospitals (55.5%) was higher than private hospitals (37.0%) (p < 0.001). The mean hospitalization LOS for public hospitals (10.3 days) was higher than private hospitals (7.6 days) (p < 0.001).

Conclusions

The incidence and lethality rate of sepsis increased in SUS hospitalizations during the study period. The SUS’s low reimbursement to hospitals for treating sepsis may be one of the reasons for the high lethality rate.

Exosomes from patients with septic shock convey miRNAs related to inflammation and cell cycle regulation: new signaling pathways in sepsis?

Background

Exosomes isolated from plasma of patients with sepsis may induce vascular apoptosis and myocardial dysfunction by mechanisms related to inflammation and oxidative stress. Despite previous studies demonstrating that these vesicles contain genetic material related to cellular communication, their molecular cargo during sepsis is relatively unknown. In this study, we evaluated the presence of microRNAs (miRNAs) and messenger RNAs (mRNAs) related to inflammatory response and redox metabolism in exosomes of patients with septic shock.

Methods

Blood samples were collected from 24 patients with septic shock at ICU admission and after 7 days of treatment. Twelve healthy volunteers were used as control subjects. Exosomes were isolated by ultracentrifugation, and their miRNA and mRNA content was evaluated by qRT-PCR array.

Results

As compared with healthy volunteers, exosomes from patients with sepsis had significant changes in 65 exosomal miRNAs. Twenty-eight miRNAs were differentially expressed, both at enrollment and after 7 days, with similar kinetics (18 miRNAs upregulated and 10 downregulated). At enrollment, 35 differentially expressed miRNAs clustered patients with sepsis according to survival. The pathways enriched by the miRNAs of patients with sepsis compared with control subjects were related mostly to inflammatory response. The comparison of miRNAs from patients with sepsis according to hospital survival demonstrated pathways related mostly to cell cycle regulation. At enrollment, sepsis was associated with significant increases in the expression of mRNAs related to redox metabolism (myeloperoxidase, 64-fold; PRDX3, 2.6-fold; SOD2, 2.2-fold) and redox-responsive genes (FOXM1, 21-fold; SELS, 16-fold; GLRX2, 3.4-fold). The expression of myeloperoxidase mRNA remained elevated after 7 days (65-fold).

Conclusions

Exosomes from patients with septic shock convey miRNAs and mRNAs related to pathogenic pathways, including inflammatory response, oxidative stress, and cell cycle regulation. Exosomes may represent a novel mechanism for intercellular communication during sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2003-3) contains supplementary material, which is available to authorized users.

How Can We Estimate Sepsis Incidence and Mortality?

Sepsis is one of the oldest and complex syndromes in medicine that has been in debate for over two millennia. Valid and comparable data on the population burden of sepsis constitute an essential resource for guiding health policy and resource allocation. Despite current epidemiological data suggesting that the global burden of sepsis is huge, the knowledge of its incidence, prevalence, mortality, and case-fatality rates is subject to several flaws. The objective of this narrative review is to assess how sepsis incidence and mortality can be estimated, providing examples on how it has been done so far in medical literature and discussing its possible biases. Results of recent studies suggest that sepsis incidence rates are increasing consistently during the last decades. Although estimates might be biased, this probably reflects a real increase in incidence over time. Nevertheless, case fatality rates have decreased, which is a probable reflex of advances in critical care provision to this very sick population at high risk of death. This conclusion can only be drawn with a reasonable degree of certainty for high-income countries. Conversely, adequately designed studies from middle- and low-income countries are urgently needed. In these countries, sepsis incidence and case-fatality rates could be disproportionally higher due to health care provision constraints and ineffective preventive measures.

Negative Fluid Balance in Sepsis: When and How?

Fluid resuscitation plays a fundamental role in the treatment of septic shock. Administration of inappropriately large quantities of fluid may lead to volume overload, which is increasingly recognized as an independent risk factor for morbidity and mortality in critical illness. In the early treatment of sepsis, timely fluid challenges should be given to optimize organ perfusion, but continuous positive fluid balance is discouraged. In fact, achievement of a negative fluid balance during treatment of sepsis is associated with better outcomes. This review will discuss the relationship between fluid overload and unfavorable outcomes in sepsis, and how fluid overload can be prevented and managed.

Epidemiology and impact on all-cause mortality of sepsis in Norwegian hospitals: A national retrospective study

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 10^th 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.

Emergency medical service personnel need to improve knowledge and attitude regarding prehospital sepsis care

Objective

We aimed to evaluate the knowledge and attitudes of emergency medical service (EMS) personnel pertaining to sepsis. We also compared EMS personnel’s knowledge of sepsis and their intention to engage in prehospital sepsis management.

Methods

The survey was conducted during education conferences for EMS personnel in December 2013 and January 2015 in Seoul, Korea. The questionnaire composed of 10 questions relevant to sepsis, was distributed on-scene, and was retrieved by investigators after the conference. We classified subjects into active and passive groups based on intent to participate in prehospital sepsis care.

Results

A total of 271 questionnaires were distributed; 255 EMS personnel (94%) completed the survey, 126 (49%) of whom were first-degree emergency medical technicians (EMTs). Less than 75% of subjects provided clinically relevant responses to questions about the definitions of sepsis, tachycardia, tachypnea, hypotension, hypothermia, fluid resuscitation, and vasopressor. Only 15% of participants had suspected that a patient had sepsis, and 9% reported that they could identify patients with sepsis during transportation. Overall, first-degree EMTs showed higher levels of knowledge and a positive attitude to sepsis compared with non-first-degree EMTs. Sixty percent of the participants reported that they were actively involved in prehospital sepsis care. The active group showed significantly higher levels of knowledge and more positive responses to the clinical impact of prehospital sepsis care.

Conclusion

Our study showed that is a substantial portion of EMS personnel lacks appropriate level of knowledge on sepsis care. We also found that the intention to engage in sepsis management was associated with appropriate knowledge of sepsis.

Comorbidities Might Condition the Recovery of Quality of Life in Survivors of Sepsis

PURPOSE:

To assess how preexisting disabling comorbidities (DC) affect the recovery rate of quality of life (QOL) over time in sepsis survivors.

METHODS:

A prospective study was conducted on sepsis survivors who answered the 36-Item Short Form Health Survey (SF-36) 7 days after discharge from the intensive care unit. Subsequent interviews were held at 3, 6, and 12 months. The results of the physical component score (PCS) and mental component score (MCS) of the SF-36 were evaluated. Patients were divided into 2 groups to compare patients with DC (DC group) and without DC (no-DC group). Quantile regression was used to model changes in PCS and MCS between different time points.

RESULTS:

Seventy-nine sepsis survivors were enrolled. After controlling for baseline age and QOL, the QOL scores were lower among patients with DC than in no-DC patients. The QOL of DC group got worse when compared to no-DC group. Recovery rate of PCS and MCS was higher in the DC group than in the no-DC group (PCS: 20.51 vs 16.96, P < .01; MCS: 19.24 vs 9.66, P < .01). Their baseline QOL was recovered only by 6 months after the sepsis episode.

CONCLUSION:

Quality-of-life impairment and its recovery rhythm in patients with sepsis appear to be conditioned by coexisting DC.

Admission factors associated with intensive care unit readmission in critically ill oncohematological patients: a retrospective cohort study

Objective

The purpose of our study was to determine the admission factors associated with intensive care unit readmission among oncohematological patients.

Methods

Retrospective cohort study using an intensive care unit database from a tertiary oncological center. The participants included 1,872 critically ill oncohematological patients who were admitted to the intensive care unit from January 2012 to December 2014 and who were subsequently discharged alive. We used univariate and multivariate analysis to identify the admission risk factors associated with later intensive care unit readmission.

Results

One hundred seventy-two patients (9.2% of 1,872 oncohematological patients discharged alive from the intensive care unit) were readmitted after intensive care unit discharge. The readmitted patients were sicker compared with the non-readmitted group and had higher hospital mortality (32.6% versus 3.7%, respectively; p < 0.001). In the multivariate analysis, the independent risk factors for intensive care unit readmission were male sex (OR: 1.5, 95% CI: 1.07 - 2.12; p = 0.019), emergency surgery as the admission reason (OR: 2.91, 95%CI: 1.53 - 5.54; p = 0.001), longer hospital length of stay before intensive care unit transfer (OR: 1.02, 95%CI: 1.007 - 1.035; p = 0.003), and mechanical ventilation (OR: 2.31, 95%CI: 1.57 - 3.40; p < 0.001).

Conclusions

In this cohort of oncohematological patients, we identified some risk factors associated with intensive care unit readmission, most of which are not amenable to interventions. The identification of risk factors at intensive care unit discharge might be a promising approach.

Global end-diastolic volume index vs CVP goal-directed fluid resuscitation for COPD patients with septic shock: a randomized controlled trial

PURPOSE

This study aimed to investigate the clinical effects of early goal-directed therapy according to the global end-diastolic volume index (GEDI) on chronic obstructive pulmonary disease (COPD) patients with septic shock.

METHODS

A total of 71 COPD patients with septic shock were randomly assigned to 2 groups. In the control group (n = 37), fluid resuscitation was performed based on the central venous pressure. In the study group (n = 34), fluid resuscitation was performed until GEDI reached 800 mL/m². The following indices were observed for the 2 groups: 6- and 24-hour fluid volumes, norepinephrine dosage, 24-hour blood lactate clearance rate, duration of mechanical ventilation, intensive care unit (ICU) length of stay, ICU mortality, and 90-day survival rate.

RESULTS

At both 6- and 24-hour measurements, the fluid volume was lower and norepinephrine dosage was higher in the control group than in the study group (P < .05). The blood lactate clearance rate was lower, the duration of mechanical ventilation was longer, and the length of stay in the ICU was longer in the control group than in the study group (P < .05). No significant difference in mortality or 90-day survival rate was found between the 2 groups.

CONCLUSIONS

The GEDI goal-directed fluid resuscitation shows better clinical effects than that shown by central venous pressure for COPD patients with septic shock; however, it cannot reduce the mortality rate.

Growing burden of sepsis-related mortality in northeastern Italy: a multiple causes of death analysis

BACKGROUND

Few population-based data are available on mortality due to sepsis. The aim of the study was to estimate sepsis-related mortality rates and to assess the associated comorbidities.

METHODS

From multiple causes of death data (MCOD) of the Veneto Region (northeastern Italy), all deaths with sepsis mentioned anywhere in the death certificate were retrieved for the period 2008-2013. Among these deaths the prevalence of common chronic comorbidities was investigated, as well as the distribution of the underlying cause of death (UCOD), the single disease selected from all condition mentioned in the certificate and usually tabulated in mortality statistics. Age-standardized mortality rates were computed for sepsis selected as the UCOD, and for sepsis mentioned anywhere in the certificate.

RESULTS

Overall 16,906 sepsis-related deaths were tracked. Sepsis was mentioned in 6.3 % of all regional deaths, increasing from 4.9 in 2008 to 7.7 % in 2013. Sepsis was the UCOD in 0.6 % of total deaths in 2008, and in 1.6 % in 2013. Age-standardized mortality rates increased by 45 % for all sepsis-related deaths, and by 140 % for sepsis as the UCOD. Sepsis was often reported in the presence of chronic comorbidities, especially neoplasms, diabetes, circulatory diseases, and dementia. Respiratory tract and intra-abdominal infections were the most frequently associated sites of infection.

CONCLUSIONS

MCOD analyses provide an estimate of the burden of sepsis-related mortality. MCOD data suggest an increasing importance attributed to sepsis by certifying physicians, but also a real increase in mortality rates, thus confirming trends reported in some other countries by analyses of hospital discharge records.

Neuropilin-1highCD4⁺CD25⁺ Regulatory T Cells Exhibit Primary Negative Immunoregulation in Sepsis

Regulatory T cells (Tregs) appear to be involved in sepsis-induced immune dysfunction; neuropilin-1 (Nrp-1) was identified as a surface marker for CD4⁺CD25⁺Tregs. In the current study, we investigated the negative immunoregulation of Nrp-1^highCD4⁺CD25⁺Tregs and the potential therapeutic value of Nrp-1 in sepsis. Splenic CD4⁺CD25⁺Tregs from cecal ligation and puncture (CLP) mouse models were further segregated into Nrp-1^highTregs and Nrp-1^lowTregs; they were cocultured with CD4⁺CD25⁻  T cells. The expression of forkhead/winged helix transcription factor-3 (Foxp-3), cytotoxic T-lymphocyte associated antigen-4 (CTLA-4), membrane associated transforming growth factor-β (TGF-β^m+), apoptotic rate, and secretive ability [including TGF-β and interleukin-10 (IL-10)] for various types of Tregs, as well as the immunosuppressive ability of Tregs on CD4⁺CD25⁻  T cells, were determined. Meanwhile, the impact of recombinant Nrp-1 polyclonal antibody on the demethylation of Foxp-3-TSDR (Treg-specific demethylated region) was measured in in vitro study. Sepsis per se markedly promoted the expression of Nrp-1 of CD4⁺CD25⁺Tregs. Foxp-3/CTLA-4/TGF-β^m+ of Nrp-1^highTregs were upregulated by septic challenge. Nrp-1^highTregs showed strong resilience to apoptosis and secretive ability and the strongest immunosuppressive ability on CD4⁺CD25⁻  T cells. In the presence of lipopolysaccharide (LPS), the recombinant Nrp-1 polyclonal antibody reduced the demethylation of Foxp-3-TSDR. Nrp-1^highTregs might reveal primary negative immunoregulation in sepsis; Nrp-1 could represent a new potential therapeutic target for the study of immune regulation in sepsis.

Designing phase 3 sepsis trials: application of learned experiences from critical care trials in acute heart failure

Substantial attention and resources have been directed to improving outcomes of patients with critical illnesses, in particular sepsis, but all recent clinical trials testing various interventions or strategies have failed to detect a robust benefit on mortality. Acute heart failure is also a critical illness, and although the underlying etiologies differ, acute heart failure and sepsis are critical care illnesses that have a high mortality in which clinical trials have been difficult to conduct and have not yielded effective treatments. Both conditions represent a syndrome that is often difficult to define with a wide variation in patient characteristics, presentation, and standard management across institutions. Referring to past experiences and lessons learned in acute heart failure may be informative and help frame research in the area of sepsis. Academic heart failure investigators and industry have worked closely with regulators for many years to transition acute heart failure trials away from relying on dyspnea assessments and all-cause mortality as the primary measures of efficacy, and recent trials have been designed to assess novel clinical composite endpoints assessing organ dysfunction and mortality while still assessing all-cause mortality as a separate measure of safety. Applying the lessons learned in acute heart failure trials to severe sepsis and septic shock trials might be useful to advance the field. Novel endpoints beyond all-cause mortality should be considered for future sepsis trials.

Tuftsin-derived T-peptide prevents cellular immunosuppression and improves survival rate in septic mice

The primary mechanisms of sepsis induced cellular immunesuppression involve immune dysfunction of T lymphocytes and negative immunoregulation of regulatory T cells (Tregs). It has been found that tuftsin is an immune modulating peptide derived from IgG in spleen. T-peptide is one of tuftsin analogs. Herein, we examined the effect of T-peptide on cell-mediated immunity in the presence of lipopolysaccharide (LPS) and the survival rate in septic mice. T-peptide regulated the proliferative ability of CD4⁺CD25⁻ T cells in dual responses. Meanwhile, 10 and 100 μg/ml T-peptides were able to enhance the apoptotic rate of CD4⁺CD25⁻ T cells compared with 1 μg/ml T-peptide, but markedly lowered interleukin (IL)-2 levels. When CD4⁺CD25⁺ Tregs were treated with T-peptide for 24 hours, and co-cultured with normal CD4⁺CD25⁻ T cells, the suppressive ability of CD4⁺CD25⁺ Tregs on CD4⁺CD25⁻ T cells was significantly lowered, along with decreased expression in forkhead/winged helix transcription factor p-3 (Foxp-3) as well as cytotoxic T lymphocyte-associated antigen (CTLA)-4, and secretion of transforming growth factor (TGF)-β. Moreover, T-peptide has the ability to improve outcome of septic mice in a dose- and time- dependent manner, and associated with improvement in the microenvironment of cellular immunosuppression in septic mice.