Impact of appropriate antimicrobial therapy for patients with severe sepsis and septic shock--a quality improvement study

Bacterial Epidemiology and Antimicrobial Resistance Profiles of Bloodstream Infections Caused by Negative Bacteria in Children's: A Multicenter Study in China (2016-2022)

Objective

Aim to investigate the pathogens distribution and drug resistance of gram-negative bacteria causing bloodstream infection (BSIs) in Infectious Disease Surveillance of Pediatric from 2016 to 2022. The prevalence of four important drug resistance phenotypes was studied: difficult-to-treat resistance, fluoroquinolone resistance, carbapenem resistance, and extended-spectrum cephalosporin resistance, and to provide reference basis for preventing and treating BSIs diseases in children.

Methods

Strain identification and antimicrobial susceptibility tests were independently performed at each hospital. Data were analyzed using Whonet 5.6 and GraphPad Prism 8 software. The Mann-Whitney U-test was used to examine and compare temporal changes.

Results

A total of 39977 BSIs strains were isolated, with 27.1% of the negative bacteria causing BSIs (10824 strains). The highest bacteria detected were E. coli and S. maltophilia in the neonatal and pediatric groups. The detection rate of carbapenem-resistant-K. pneumoniae (CRKPN) in neonate group was 31.4%, significantly increased compared with pediatric group, whose detection rate was 24.7%. The rates of resistance to levofloxacin and trimethoprim/sulfamethoxazole were significantly lower in neonatal groups than pediatric groups in BSIs caused by K. pneumoniae. To imipenem and meropenem were 3.6% and 3.9% among neonatal isolates, which was lower than 4.7% and 5.8 among pediatric BSIs caused by E. coli. Isolated from neonatal BSIs caused by A. baumannii showed lower resistance ratios to all the agents tested than those from pediatric. However, only the prevalence of piperacillin/tazobactam resistance was statistically lower than that in pediatric BSIs caused by P. aeruginosa. The average detection rates of carbapenem resistance, extended-spectrum cephalosporin resistance, and fluoroquinolone resistance for K. pneumoniae and E. coli were 28.1%,41.4%,11.6% and 4.0%,24.3%,31.1%, respectively.

Conclusion

The detection rate of gram-negative pathogens showed an increasing trend among the bloodstream infection. The detection rate of CRKPN assumed a downward trend in 2018. There are differences types of pathogens between the neonatal group and the pediatric group, The detection rate of CRKPN in the neonate group was significantly higher than pediatric group. The first average detection rates for carbapenem resistance, extended-spectrum cephalosporin resistance, and fluoroquinolone resistance were obtained for A. baumannii, K. pneumoniae, and Escherichia coli, respectively. Those data showed a high level of antimicrobial resistance, which has posed an urgent threat to Children's health, suggested that effective monitoring of antimicrobial resistance and antimicrobial stewardship among children in China are required.

Early identification and diagnosis, pathophysiology, and treatment of sepsis-related acute lung injury: a narrative review

Background and Objective

Sepsis is a life-threatening organ dysfunction, and the most common and vulnerable organ is the lungs, with sepsis-related acute respiratory distress syndrome (ARDS) increasing mortality. In recent years, an increasing number of studies have improved our understanding of sepsis-related ARDS in terms of epidemiology, risk factors, pathophysiology, prognosis, and other aspects, as well as our ability to prevent, detect, and treat sepsis-related ARDS. However, sepsis-related lung injury remains an important issue and clinical burden. Therefore, a literature review was conducted on sepsis-related lung injury in order to further guide clinical practice in reducing the acute and chronic consequences of this condition.

Methods

This study conducted a search of the MEDLINE and PubMed databases, among others for literature published from 1991 to 2023 using the following keywords: definition of sepsis, acute lung injury, sepsis-related acute lung injury, epidemiology, risk factors, early diagnosis of sepsis-related acute lung injury, sepsis, ARDS, pathology and physiology, inflammatory imbalance caused by sepsis, congenital immune response, and treatment.

Key Content and Findings

This review explored the risk factors of sepsis, sepsis-related ARDS, early screening and diagnosis, pathophysiology, and treatment and found that in view of the high mortality rate of ARDS associated with sepsis. In response to the high mortality rate of sepsis-related ARDS, some progress has been made, such as rapid identification of sepsis and effective antibiotic treatment, early fluid resuscitation, lung-protective ventilation, etc.

Conclusions

Sepsis remains a common and challenging critical illness to cure. In response to the high mortality rate of sepsis-related ARDS, progress has been made in rapid sepsis identification, effective antibiotic treatment, early fluid resuscitation, and lung-protective ventilation. However, further research is needed regarding long-term effects such as lung recruitment, prone ventilation, and the application of neuromuscular blocking agents and extracorporeal membrane oxygenation.

eHealth and mHealth in Antimicrobial Stewardship to Reduce Mortality in Empirical Antimicrobial Therapy and a Systematic Review with a Meta-Analysis of Adequate Therapy

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.

Door-to-antibiotic time and mortality in patients with sepsis: Systematic review and meta-analysis

OBJECTIVES

To evaluate whether the timing of initial antibiotic administration in patients with sepsis in hospital affects mortality.

METHODS

This systematic review and meta-analysis included studies from inception up to 19 May 2022. Interventional and observational studies including adult human patients with suspected or confirmed sepsis and reported time of antibiotic administration with mortality were included. Data were extracted by two independent reviewers. Summary estimates were calculated by using random-effects model. The primary outcome was mortality.

RESULTS

We included 42 studies comprising 190,896 patients with sepsis. Pooled data showed that the OR for patient mortality who received antibiotics ≤1 hr was 0.83 (95 %CI: 0.67 to 1.04) when compared with patients who received antibiotics >1hr. Significant reductions in the risk of death in patients with earlier antibiotic administration were observed in patients ≤3 hrs versus >3 hrs (OR: 0.80, 95 %CI: 0.68 to 0.94) and ≤6 hrs vs 6 hrs (OR: 0.57, 95 %CI: 0.39 to 0.82).

CONCLUSIONS

Our findings show an improvement in mortality in sepsis patients with early administration of antibiotics at <3 and <6 hrs. Thus, these results suggest that antibiotics should be administered within 3 hrs of sepsis recognition or ED arrival regardless of the presence or absence of shock.

The noncanonical inflammasome-induced pyroptosis and septic shock

Sepsis remains one of the most common and lethal conditions globally. Currently, no proposed target specific to sepsis improves survival in clinical trials. Thus, an in-depth understanding of the pathogenesis of sepsis is needed to propel the discovery of effective treatment. Recently attention to sepsis has intensified because of a growing recognition of a non-canonical inflammasome-triggered lytic mode of cell death termed pyroptosis upon sensing cytosolic lipopolysaccharide (LPS). Although the consequences of activation of the canonical and non-canonical inflammasome are similar, the non-canonical inflammasome formation requires caspase-4/5/11, which enzymatically cleave the pore-forming protein gasdermin D (GSDMD) and thereby cause pyroptosis. The non-canonical inflammasome assembly triggers such inflammatory cell death by itself; or leverages a secondary activation of the canonical NLRP3 inflammasome pathway. Excessive cell death induced by oligomerization of GSDMD and NINJ1 leads to cytokine release and massive tissue damage, facilitating devastating consequences and death. This review summarized the updated mechanisms that initiate and regulate non-canonical inflammasome activation and pyroptosis and highlighted various endogenous or synthetic molecules as potential therapeutic targets for treating sepsis.

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

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.

Shortening identification times: comparative observational study of three early blood culture testing protocols

Background

While early appropriate antibiotic therapy is a proven means of limiting the progression of infections, especially bacteremia, empirical antibiotic therapy in sepsis is ineffective up to 30%. The aim of this study was to compare early blood culture testing protocols in terms of their ability to shorten the delay between blood sampling and appropriate antibiotic therapy.

Methods

In this french observational study, we compared three blood culture testing protocols. Positive blood cultures were tested using either GenMark ePlex panels (multiplex PCR period), a combination of MRSA/SA PCR, β-Lacta and oxidase tests (multitest period), or conventional identification and susceptibility tests only (reference period). Conventional identification and susceptibility tests were performed in parallel for all samples, as the gold standard.

Results

Among the 270 patients with positive blood cultures included, early and conventional results were in good agreement, especially for the multitest period. The delay between a blood culture positivity and initial results was 3.8 (2.9-6.9) h in the multiplex PCR period, 2.6 (1.3-4.5) h in the multitest period and 3.7 (1.8-8.2) h in the reference period (p<0.01). Antibiotic therapy was initiated or adjusted in 68 patients based on early analysis results. The proportion of patients receiving appropriate antibiotic therapy within 48 h of blood sampling was higher in the multiplex PCR and multitest periods, (respectively 90% and 88%) than in the reference period (71%).

Conclusion

These results suggest rapid bacterial identification and antibiotic resistance tests are feasible, efficient and can expedite appropriate antibiotic therapy.

Next-Generation Sequencing in Critically Ill COVID-19 Patients with Suspected Bloodstream Infections: A Retrospective Cohort Study

BACKGROUND

Rapid pathogen identification and appropriate antimicrobial therapy are crucial in critically ill COVID-19 patients with bloodstream infections (BSIs). This study aimed to evaluate the diagnostic performance and potential therapeutic benefit of additional next-generation sequencing (NGS) of microbial DNA from plasma in these patients.

METHODS

This monocentric descriptive retrospective study reviewed clinical data and pathogen diagnostics in COVID-19 ICU patients. NGS (DISQVER^®) and blood culture (BC) samples were obtained on suspicion of BSIs. Data were reviewed regarding the adjustment of antimicrobial therapy and diagnostic procedures seven days after sampling and analyzed using the Chi²-test.

RESULTS

Twenty-five cases with simultaneous NGS and BC sampling were assessed. The NGS positivity rate was 52% (13/25) with the detection of 23 pathogens (14 bacteria, 1 fungus, 8 viruses), and the BC positivity rate was 28% (7/25, 8 bacteria; p = 0.083). The NGS-positive patients were older (75 vs. 59.5 years; p = 0.03) with a higher prevalence of cardiovascular disease (77% vs. 33%; p = 0.03). These NGS results led to diagnostic procedures in four cases and to the commencement of four antimicrobial therapies in three cases. Empirical treatment was considered appropriate and continued in three cases.

CONCLUSIONS

In COVID-19 patients with suspected BSIs, NGS may provide a higher positivity rate than BC and enable new therapeutic approaches.

The clinical and paraclinical effectiveness of four-hour infusion vs. half-hour infusion of high-dose ampicillin-sulbactam in treatment of critically ill patients with sepsis or septic shock: An assessor-blinded randomized clinical trial

PURPOSE

This study was conducted to determine whether critically ill patients admitted to the intensive care unit (ICU) with sepsis and septic shock may benefit from extended infusion of ampicillin/sulbactam compared with those receiving intermittent infusion.

MATERIAL AND METHODS

This randomized assessor-blinded clinical trial was conducted in the ICUs of Nemazee and Shahid Rajaee hospital, Shiraz, Iran, from August 2019 to August 2021. The participants randomly received 9 g Ampicillin/Sulbactam every 8 h by either extended (infused over 4 h) or intermittent (infused over 30 min) intravenous infusion if their estimated glomerular filtration rate based on Cockrorft-Gault formula was higher than 60 ml/min.

RESULTS

Totally, 136 patients were enrolled and allocated to the intervention and control groups, each with 68 patients. Clinical cure was significantly higher in the extended group (P = 0.039), but ICU and hospital length of stay did not differ between the groups (P = 0.87 and 0.83, respectively). The ICU (P = 0.031) and hospital (P = 0.037) mortality rates in the extended infusion group were significantly lower than those in the intermittent infusion group.

CONCLUSION

These data should be replicated in larger clinical trials before providing any recommendation in favor of this method of administration in clinical practice.

Systematic Review on the Effects of Prompt Antibiotic Treatment on Survival in Septic Shock and Sepsis Patients in Different Hospital Settings

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.

Clinical outcome of rapid diagnosis and antibiotic stewardship in patients with bloodstream infection in Lampang Hospital

Bloodstream infection is a significant cause of morbidity and mortality. Early diagnosis and appropriate antibiotic treatment contribute to a favorable prognosis. We demonstrate a reduction of time to proper antibiotics and reduced mortality utilizing prompt diagnosis and antibiotic stewardship by infectious diseases physicians at a general hospital in Thailand.

Using a Knowledge-Based Clinical Decision Support System to Reduce the Time to Appropriate Antimicrobial Therapy in Hospitalized Patients With Bloodstream Infections: A Single-Center Observational Study

BACKGROUND

Inappropriate antimicrobial use is a crucial determinant of mortality in hospitalized patients with bloodstream infections. Current literature reporting on the impact of clinical decision support systems on optimizing antimicrobial prescription and reducing the time to appropriate antimicrobial therapy is limited.

METHODS

Kaohsiung Veterans General Hospital implemented a hospital-wide, knowledge-based, active-delivery clinical decision support system, named RAPID (Real-time Alert for antimicrobial Prescription from virtual Infectious Diseases experts), to detect whether there was an antimicrobial agent-pathogen mismatch when a blood culture result was positive. Once RAPID determines the current antimicrobials as inappropriate, an alert text message is immediately sent to the clinicians in charge. This study evaluated how RAPID impacted the time to appropriate antimicrobial therapy among patients with bloodstream infections.

RESULTS

During the study period, 633 of 11 297 recorded observations (5.6%) were determined as inappropriate antimicrobial prescriptions. The time to appropriate antimicrobial therapy was significantly shortened after the implementation of RAPID (1.65 vs 2.45 hours, P < .001), especially outside working hours (1.24 vs 6.43 hours, P < .001), in the medical wards (1.40 vs 2.14 hours, P < .001), in participants with candidemia (0.74 vs 5.36 hours, P < .001), and for bacteremia due to non-multidrug-resistant organisms (1.66 vs 2.49 hours, P < .001).

CONCLUSIONS

Using a knowledge-based clinical decision support system to reduce the time to appropriate antimicrobial therapy in a real-world scenario is feasible and effective. Our results support the continued use of RAPID.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Time to administration of antibiotics and mortality in sepsis

OBJECTIVE

To examine the association between delay of antibiotic treatment and 28-day mortality in a study of septic patients identified by the Sepsis-3 criteria.

METHODS

A prospective observational cohort study of patients (≥ 18 years) with sepsis admitted to a Danish emergency department between October 2017 and March 2018. The interval between arrival to the ED and first delivery of antibiotics was used as time to antibiotic treatment (TTA). Logistic regression was used in the analysis of the association between TTA and mortality adjusted for potential confounding.

RESULTS

A total of 590 patients, median age 74.2 years, were included. Overall 28-day mortality was 14.6% (95% confidence interval [CI], 11.8-17.7). Median TTA was 4.7 hours (interquartile range 2.7-8.1). The mortality in patients with TTA ≤1 hour was 26.5% (95% CI, 12.8-44.4), and 15.3% (95% CI, 9.8-22.5), 10.5% (95% CI, 6.6-15.8), and 12.8 (95% CI, 7.3-20.1) in the timespans 1-3, 3-6, and 6-9 hours, respectively, and 18.8% (95% CI, 12.0-27.2) in patients with TTA >9 hours. With patients with lowest mortality (TTA timespan 3-6 hours) as reference, the adjusted odds ratio of mortality was 4.53 (95% CI, 1.67-3.37) in patients with TTA ≤1 hour, 1.67 (95% CI, 0.83-3.37) in TTA timespan 1-3 hours, 1.17 (95% CI, 0.56-2.49) in timespan 6-9 hours, and 1.91 (95% CI, 0.96-3.85) in patient with TTA >9 hours.

CONCLUSIONS

The adjusted odds of 28-day mortality were lowest in emergency department (ED) patients with sepsis who received antibiotics between 1 and 9 hours and highest in patients treated within 1 and >9 hours after admission to the ED.

Impact of the timeliness of antibiotic therapy on the outcome of patients with sepsis and septic shock

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.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Prediction of culture-positive sepsis and selection of empiric antibiotics in critically ill patients with complicated intra-abdominal infections: a retrospective study

Purpose

To compare the mortality rates between culture-positive and culture-negative sepsis in complicated intra-abdominal infections (cIAI) and investigate the predictors of culture-positivity and their causative microorganisms.

Materials and methods

The medical records of 1581 adult patients who underwent emergency gastrointestinal surgery between January 2013 and December 2018 were reviewed retrospectively. A total of 239 patients with sepsis or septic shock who were admitted to an emergency department, underwent emergency surgery for cIAI, and needed postoperative intensive care unit care were included and divided into two groups according to their initial blood and peritoneal culture results.

Results

Among the 239 patients, 200 were culture-negative and 39 were culture-positive. The culture-positive group had higher in-hospital (35.9% vs 14.5%; P = .001) and 30-day mortality (30.8% vs 12.0%; P = .003) than the culture-negative group. Colon involvement (OR 4.211; 95% CI 1.909–9.287; P < .001) and higher Sequential Organ Failure Assessment (SOFA) score (OR 1.169; 95% CI 1.065–1.282; P = .001) were shown to be the predictors of culture-positive sepsis for cIAI. Regarding antibiotic sensitivity, 31.6% of the gram-positive bacteria were methicillin-resistant and 42.1% of the gram-negative bacteria were extended spectrum β-lactamase-producing Enterobacteriaceae.

Conclusions

Patients with cIAI had higher mortality rates in culture-positive sepsis than in culture-negative sepsis. High SOFA score and colon involvement were the risk factors associated with culture-positivity. The most common single species grown in the blood or peritoneal cultures was Escherichia coli, and the most common group was Gram-positive cocci.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01535-6) contains supplementary material, which is available to authorized users.

Assessment of fluid resuscitation on time to hemodynamic stability in obese patients with septic shock

PURPOSE

Assess time to hemodynamic stability (HDS) in obese patients with septic shock who received <30 vs. ≥30 ml/kg of initial fluid resuscitation based on actual body weight (ABW).

MATERIALS AND METHODS

Multicenter, retrospective, cohort analysis of 322 patients.

RESULTS

Overall 216 (67%) patients received <30 ml/kg of initial fluid resuscitation. Initial fluid received was lower in the <30 ml/kg vs. ≥30 ml/kg group (16 vs. 37 ml/kg). The ≥30 ml/kg group had shorter time to HDS (multivariable p = 0.038) and lower riskof in-hospital death (multivariable p = 0.038). An exploratory subgroup analysis (n = 227) was performed, classifying patients by dosing strategy [ABW, adjusted body weight (AdjBW), ideal body weight (IBW)] based on fluid received at 3 h divided by 30 ml/kg. ABW dosed patients had a shorter time to HDS (multivariable p = 0.013) and lower risk of in-hospital death (multivariable p = 0.008) vs. IBW. Similar outcomes were observed between ABW vs. AdjBW.

CONCLUSIONS

Obese patients given ≥30 ml/kg based on ABW had a shorter time to HDS and a lower risk of in-hospital death. Exploratory results suggest improved outcomes resuscitating by ABW vs. IBW; ABW showed no strong benefit over AdjBW. Further prospective studies are needed to confirm the optimal fluid dosing in obese patients.

Perfil microbiologico y de resistencia antimicrobiana en infecciones adquiridas en la comunidad. Hospital Universitario San José de Popayán

Objetivo. Describir el perfil microbiológico y de resistencia bacteriana de los aislamientos en adultos con infecciones adquiridas en comunidad en el Hospital Universitario San José de junio 2016 a diciembre 2019. Metodología. Se realizó un estudio descriptivo de corte transversal, análisis retrospectivo de los aislamientos microbiológicos en adultos desde junio 2016 a diciembre 2019, basado en la data institucional. Se analizó la información con STATA15,0. Se obtuvo la aprobación del comité de ética del hospital. Resultados. Se incluyeron 5121 aislamientos microbiológicos, el 61% en el servicio de urgencias. El urocultivo fue la muestra más frecuente. E. coli fue el germen más común tanto a nivel general como en urocultivos, hemocultivos y cultivos de líquido peritoneal. La resistencia a ampicilina y amp/sul fue elevada, hasta del 68% para E. coli. El 20% de los S. aureus fueron resistentes a meticilina. Se observó una resistencia inusual a carbapenémicos por parte de P. aeruginosa. Discusión. El perfil microbiológico concuerda con la literatura mundial y nacional, sin embargo, el HUSJ tiene un comportamiento microbiológico que debe ser estudiado a profundidad. Conclusión. Los porcentajes de resistencia a antibióticos de uso frecuente son elevados. Se requiere ajustes de las guías de manejo institucionales y nacionales.

Antibiotic treatment with one single dose of gentamicin at admittance in addition to a β-lactam antibiotic in the treatment of community-acquired bloodstream infection with sepsis

Background

Combination therapy in the treatment of sepsis, especially the value of combining a β-Lactam antibiotic with an aminoglycoside, has been discussed. This retrospective cohort study including patients with sepsis or septic shock aimed to investigate whether one single dose of gentamicin at admittance (SGA) added to β-Lactam antibiotic could result in a lower risk of mortality than β-Lactam monotherapy, without exposing the patient to the risk of nephrotoxicity.

Methods and findings

All patients with positive blood cultures were evaluated for participation (n = 1318). After retrospective medical chart review, a group of patients with community-acquired sepsis with positive blood cultures who received β-Lactam antibiotic with or without the addition of SGA (n = 399) were included for the analysis. Mean age was 74.6 yrs. (range 19–98) with 216 (54%) males. Sequential Organ Failure Assessment score (SOFA score) median was 3 (interquartile range [IQR] 2–5) and the median Charlson Comorbidity Index for the whole group was 2 (IQR 1–3). Sixty-seven (67) patients (17%) had septic shock. The 28-day mortality in the combination therapy group was 10% (20 of 197) and in the monotherapy group 22% (45 of 202), adjusted HR 3.5 (95% CI (1.9–6.2), p = < 0.001. No significant difference in incidence of acute kidney injury (AKI) was detected.

Conclusion

This retrospective observational study including patients with community-acquired sepsis or septic shock and positive blood cultures, who meet Sepsis-3 criteria, shows that the addition of one single dose of gentamicin to β-lactam treatment at admittance was associated with a decreased risk of mortality and was not associated with AKI. This antibiotic regime may be an alternative to broad-spectrum antibiotic treatment of community-acquired sepsis. Further prospective studies are warranted to confirm these results.

Multicenter evaluation of a syndromic rapid multiplex PCR test for early adaptation of antimicrobial therapy in adult patients with pneumonia

Background

Improving timeliness of pathogen identification is crucial to allow early adaptation of antibiotic therapy and improve prognosis in patients with pneumonia. We evaluated the relevance of a new syndromic rapid multiplex PCR test (rm-PCR) on respiratory samples to guide empirical antimicrobial therapy in adult patients with community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-acquired pneumonia (VAP).

Methods

This retrospective multicenter study was conducted in four French university hospitals. Respiratory samples were obtained from patients with clinical and radiological signs of pneumonia and simultaneously tested using conventional microbiological methods and the rm-PCR. A committee composed of an intensivist, a microbiologist, and an infectious diseases specialist retrospectively assessed all medical files and agreed on the most appropriate antimicrobial therapy for each pneumonia episode, according to the results of rm-PCR and blinded to the culture results. The rm-PCR-guided antimicrobial regimen was compared to the empirical treatment routinely administered to the patient in standard care.

Results

We included 159 pneumonia episodes. Most patients were hospitalized in intensive care units (n = 129, 81%), and episodes were HAP (n = 68, 43%), CAP (n = 54, 34%), and VAP (n = 37, 23%). Conventional culture isolated ≥ 1 microorganism(s) at significant level in 95 (60%) patients. The syndromic rm-PCR detected at least one bacteria in 132 (83%) episodes. Based on the results of the rm-PCR, the multidisciplinary committee proposed a modification of the empirical therapy in 123 (77%) pneumonia episodes. The modification was a de-escalation in 63 (40%), an escalation in 35 (22%), and undetermined in 25 (16%) patients. In microbiologically documented episodes (n = 95), the rm-PCR increased appropriateness of the empirical therapy to 83 (87%), as compared to 73 (77%) in routine care.

Conclusions

Use of a syndromic rm-PCR test has the potential to reduce unnecessary antimicrobial exposure and increase the appropriateness of empirical antibiotic therapy in adult patients with pneumonia.

Appropriateness of antibiotic prescribing in the Emergency Department

Background

Antibiotics are some of the most commonly prescribed drugs in the Emergency Department (ED) and yet data describing the overall appropriateness of antibiotic prescribing in the ED is scarce.

Objectives

To describe the appropriateness of antibiotic prescribing in the ED.

Methods

A retrospective, observational study of current practice. All patients who presented to the ED during the study period and were prescribed at least one antibiotic were included. Specialists from Infectious Disease, Microbiology and Emergency Medicine and a Senior Pharmacist assessed antibiotic appropriateness against evidence-based guidelines.

Results

A total of 1019 (13.6%) of patient presentations involved the prescription of at least one antibiotic. Of these, 640 (62.8%) antibiotic prescriptions were assessed as appropriate, 333 (32.7%) were assessed as inappropriate and 46 (4.5%) were deemed to be not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% versus 22.9%; difference 14.1%, 95% CI 7.2%–21.0%). Patients who met quick Sepsis-related Organ Failure Assessment (qSOFA) criteria were more likely to be prescribed inappropriate antibiotics (56.7% versus 36.1%; difference 20.5%, 95% CI, 2.4%–38.7%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition (admitted/discharged), reason for antibiotic administration (treatment/prophylaxis) or time of shift (day/night).

Conclusions

Inappropriate administration of antibiotics can lead to unnecessary adverse events, treatment failure and antimicrobial resistance. With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms.

Delay in Antibiotic Administration Is Associated With Mortality Among Septic Shock Patients With Staphylococcus aureus Bacteremia

OBJECTIVES

The relationship between the timing of antibiotics and mortality among septic shock patients has not been examined among patients specifically with Staphylococcus aureus bacteremia.

DESIGN

Retrospective analysis of a Veterans Affairs S. aureus bacteremia database.

SETTING

One-hundred twenty-two hospitals in the Veterans Affairs Health System.

PATIENTS

Patients with septic shock and S. aureus bacteremia admitted directly from the emergency department to the ICU from January 1, 2003, to October 1, 2015, were evaluated.

INTERVENTIONS

Time to appropriate antibiotic administration and 30-day mortality.

MEASUREMENTS AND MAIN RESULTS

A total of 506 patients with S. aureus bacteremia and septic shock were included in the analysis. Thirty-day mortality was 78.1% for the entire cohort and was similar for those participants with methicillin-resistant S. aureus and methicillin-sensitive S. aureus bacteremia. Our multivariate analysis revealed that, as compared with those who received appropriate antibiotics within 1 hour after emergency department presentation, each additional hour that passed before appropriate antibiotics were administered produced an odds ratio of 1.11 (95% CI, 1.02-1.21) of mortality within 30 days. This odds increase equates to an average adjusted mortality increase of 1.3% (95% CI, 0.4-2.2%) for every hour that passes before antibiotics are administered.

CONCLUSIONS

The results of this study further support the importance of prompt appropriate antibiotic administration for patients with septic shock. Physicians should consider acting quickly to administer antibiotics with S. aureus coverage to any patient suspected of having septic shock.

Ignorance of pre-ED healthcare setting is a factor leading to inappropriate initial antibiotic treatment of sepsis in ED and poor outcomes in ICU

OBJECTIVES

Appropriate initial antibiotic therapy is critical for successfully treating sepsis. In the emergency department (ED), clinicians often rely on septic symptoms to guide empirical therapy. The aim of this study was to investigate whether history of contacting pre-ED healthcare setting is easy to be neglected and whether the patients received more inappropriate initial antibiotic therapy and developed poorer outcomes.

METHODS

Septic patients (n = 453) admitted from ED to the intensive care unit (ICU) between 2014 and 2017 were retrospectively selected. Appropriate antibiotic treatment or not was determined by checking whether the selected antibiotics can effectively eradicate the bacteria identified. Various indexes were compared between patients with appropriate and inappropriate initial antibiotic treatments, including septic symptoms (qSOFA scores) in ED, septic-severity change in ICU (SOFA-score ratios), and septic outcomes (APACHE II scores, stay length, 30-day survival probability). These indexes were also compared between pre-ED healthcare and pre-ED community patients.

RESULTS

In comparison with pre-ED community patients, pre-ED healthcare patients received more inappropriate initial antibiotic treatment in ED, showing poorer outcomes in ICU, including septic severity, stay-lengths in ICU and 30-day survival probabilities. Pre-ED settings is more significant than qSOFA scores to predict the inappropriate initial antibiotic treatment.

CONCLUSIONS

Pre-ED healthcare settings, which are indexes for infection with antibiotic resistant pathogens, are easy to be neglected in the first hour in ED. We suggested that standard operating procedure for getting enough information of pre-ED settings should be incorporated to the 1 h bundle of sepsis guideline.

Clinical Prediction Score for Community-Onset Bloodstream Infections Caused by Extended-Spectrum Beta-Lactamase-Producing Escherichia coli and Klebsiella Species

BACKGROUND

This study aimed to identify the predictors and build a prediction score for community-onset bloodstream infections (CO-BSIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species.

METHODS

All CO-BSIs caused by E. coli and Klebsiella species from 2012 to 2015 were grouped into derivation (BSIs from 2012 to 2014) and validation (BSIs in 2015) cohorts. A prediction score was built using the coefficients of the multivariate logistic regression model from the derivation cohort.

RESULTS

The study included 886 CO-BSIs (594 and 292 in the derivation and validation cohorts, respectively). The independent predictors of CO-BSIs caused by ESBL-producing E. coli and Klebsiella species included: 1) identification of ESBL-producing microorganisms from any clinical culture within one year of admission, 2) beta-lactam or fluoroquinolone treatment within 30 days (with 2 or more courses within 90 days; with 1 course within 90 days), 3) hospitalization within one year, 4) the presence of an indwelling urinary catheter at the time of admission. The area under the curve (AUC) of the clinical prediction score was 0.72 (95% confidence interval [CI], 0.68-0.77). In the validation cohort, the AUC was 0.70 (95% CI, 0.63-0.77).

CONCLUSIONS

The results of this study suggest a simple and easy-to-use scoring system to predict CO-BSIs caused by ESBL-producing E. coli and Klebsiella species.

Influencing outcomes with automated time zero for sepsis through statistical validation and process improvement

BACKGROUND

Sepsis is a life threating complication of infection acquired by more than 1.5 million people in the United State annually. Each year, sepsis claims the lives of at least 250,000 people. Real-time, automated surveillance for sepsis among hospitalized patients is of critical importance, given that one in three people who die in hospitals have sepsis. The early identification and treatment of sepsis is associated with reduced mortality and costly intensive care bed days. The objective of this analysis was to improve the performance of an electronic medical record based sepsis algorithm (early identification) and improve evidence based bundle compliance (early intervention) with the addition of a real-time, automated time zero calculation.

METHODS

Data from our enterprise-wide health information systems were landed in a data lake platform and was used to statistically validate existing sepsis algorithms. An additional algorithm calculating time zero was introduced and a post-hoc comparison of measures of test performance, alert timing, bundle compliance, ICU length of stay, and all-hospital mortality were performed.

RESULTS

A total of 55,918 alerts for sepsis were generated over the one-year study period across 30 inpatient facilities. The addition of an automated time zero algorithm improved several key indicators including superior positive predictive value (37% to 52%), enhanced timing of the alert (79% occurred within six hours, 77% within the critical 180-minute SEP-1 window, 47% within an hour of time zero), a 14% increase in bundle compliance, a 10% reduction in ICU length of stay, and a decrease in mortality from sepsis.

CONCLUSIONS

The addition of a real-time, automated sepsis time zero calculation improved the performance and timeliness of a predictive sepsis alert provided through a system developed mobile application for clinicians and administrators.

KEYWORDS

Sepsis; validation studies; decision making; computer assisted.

Blood Culture Turnaround Time in U.S. Acute Care Hospitals and Implications for Laboratory Process Optimization

The rapid identification of blood culture isolates and antimicrobial susceptibility test (AST) results play critical roles for the optimal treatment of patients with bloodstream infections. Whereas others have looked at the time to detection in automated culture systems, we examined the overall time from specimen collection to actionable test results. We examined four points of time, namely, blood specimen collection, Gram stain, organism identification (ID), and AST reports, from electronic data from 13 U.S. hospitals for the 11 most common, clinically significant organisms in septic patients. We compared the differences in turnaround times and the times from when specimens were collected and the results were reported in the 24-h spectrum. From January 2015 to June 2016, 165,593 blood specimens were collected, of which, 9.5% gave positive cultures. No matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry was used during the study period. Across the 10 common bacterial isolates (n = 6,412), the overall median (interquartile range) turnaround times were 0.80 (0.64 to 1.08), 1.81 (1.34 to 2.46), and 2.71 (2.46 to 2.99) days for Gram stain, organism ID, and AST, respectively. For all positive cultures, approximately 25% of the specimens were collected between 6:00 a.m. and 11:59 a.m. In contrast, more of the laboratory reporting times were concentrated between 6:00 a.m. and 11:59 a.m. for Gram stain (43%), organism ID (78%), and AST (82%), respectively (P < 0.001). The overall average turnaround times from specimen collection for Gram stain, organism ID, and AST were approximately 1, 2, and 3 days, respectively. The laboratory results were reported predominantly in the morning hours. Laboratory automation and work flow optimization may play important roles in reducing the microbiology result turnaround time.

New paradigm for rapid achievement of appropriate therapy in special populations: coupling antibiotic dose optimization rapid microbiological methods

INTRODUCTION

Some special patient populations (e.g. critically ill, burns, hematological malignancy, post-major surgery, post-major trauma) have characteristics that lead to higher rates of failure and mortality associated with infection. Choice of effective antibiotics and optimized doses are challenging in these patients that are commonly infected by multidrug-resistant pathogens. Areas covered: A review of the importance of diagnosis and the place of newer microbiological methods (e.g. whole-genome sequencing) to ensure rapid transition from empiric to directed antibiotic therapy is provided. The effects of pathophysiological changes on antibiotic pharmacokinetics are also provided. Expert opinion: Product information dosing regimens do not address the pharmacokinetic alterations that can occur in special patient populations and increase the likelihood of therapeutic failure and the emergence of bacterial resistance. Altered dosing approaches, supplemented with the use of dosing software and therapeutic drug monitoring, may be needed to ensure optimal antibiotic exposure and better therapeutic outcomes in these patients with severe infection. Dose optimization needs to be coupled with advanced microbiological techniques that enable rapid microbiological identification and characterization of resistance mechanism to ensure that maximally effective directed therapy can be chosen.

Early administration of appropriate antimicrobial agents to improve the outcome of carbapenem-resistant Acinetobacter baumannii complex bacteraemic pneumonia

Carbapenem-resistant Acinetobacter baumannii complex (CRABC) is an emerging pathogen that causes bloodstream infections and nosocomial pneumonia. This study aimed to describe severe infection associated with CRABC bacteraemic pneumonia and to investigate risk factors for 28-day mortality. All patients aged ≥18 years with CRABC bacteraemic pneumonia were enrolled retrospectively at five teaching hospitals in South Korea. Empirical antimicrobial therapy was defined as appropriate if administration of at least one antimicrobial agent, to which the causative pathogen was susceptible, for >48 h, within 5 days of the onset of bacteraemia. During the study period, 146 patients with CRABC bacteraemic pneumonia were enrolled. Among them, 128 (87.7%) patients were treated in the intensive care unit; of these, 110 (75.3%) had ventilator-associated pneumonia. A total of 42 patients (28.8%) received appropriate empirical therapy. There was no difference in baseline characteristics between the appropriate and inappropriate empirical treatment groups. However, 28-day mortality was higher in the inappropriate therapy group (54.8% vs. 76.9%; P = 0.008). Multivariate Cox regression analysis revealed that Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥20 [hazard ratio (HR)  = 1.28, 95% confidence interval (CI) 1.04-1.58; P = 0.02], septic shock (HR = 3.49, 95% CI 2.15-5.67; P <0.001) and inappropriate empirical therapy (HR = 3.24, 95% CI 1.94-5.42; P <0.001) were independently associated with an adverse outcome. In conclusion, the mortality rate of CRABC bacteraemic pneumonia was extremely high. Appropriate empirical therapy might improve the outcome of patients with CRABC bacteraemic pneumonia.

The Timing of Early Antibiotics and Hospital Mortality in Sepsis

RATIONALE

Prior sepsis studies evaluating antibiotic timing have shown mixed results.

OBJECTIVES

To evaluate the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within 6 hours of emergency department registration.

METHODS

Retrospective study of 35,000 randomly selected inpatients with sepsis treated at 21 emergency departments between 2010 and 2013 in Northern California. The primary exposure was antibiotics given within 6 hours of emergency department registration. The primary outcome was adjusted in-hospital mortality. We used detailed physiologic data to quantify severity of illness within 1 hour of registration and logistic regression to estimate the odds of hospital mortality based on antibiotic timing and patient factors.

MEASUREMENTS AND MAIN RESULTS

The median time to antibiotic administration was 2.1 hours (interquartile range, 1.4-3.1 h). The adjusted odds ratio for hospital mortality based on each hour of delay in antibiotics after registration was 1.09 (95% confidence interval [CI], 1.05-1.13) for each elapsed hour between registration and antibiotic administration. The increase in absolute mortality associated with an hour's delay in antibiotic administration was 0.3% (95% CI, 0.01-0.6%; P = 0.04) for sepsis, 0.4% (95% CI, 0.1-0.8%; P = 0.02) for severe sepsis, and 1.8% (95% CI, 0.8-3.0%; P = 0.001) for shock.

CONCLUSIONS

In a large, contemporary, and multicenter sample of patients with sepsis in the emergency department, hourly delays in antibiotic administration were associated with increased odds of hospital mortality even among patients who received antibiotics within 6 hours. The odds increased within each sepsis severity strata, and the increased odds of mortality were greatest in septic shock.

Clinical factors influencing mortality risk in hospital-acquired sepsis

BACKGROUND

Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition.

AIM

To evaluate the clinical characteristics and factors associated with mortality in patients with HAS.

METHODS

Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality.

FINDINGS

HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality.

CONCLUSION

This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.

A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study

OBJECTIVE To evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management. DESIGN Interventional, nonrandomized, controlled study. SETTING Tertiary-care referral hospital, Sydney, Australia. PATIENTS Consecutive, adult, non-intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015. INTERVENTION All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger. RESULTS In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04-1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant. CONCLUSION Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes. Infect Control Hosp Epidemiol 2017;38:1032-1038.

Results of an early intervention programme for patients with bacteraemia: analysis of prognostic factors and mortality

Background

Bacteraemia is a common cause of morbidity and mortality in patients admitted to hospital. The aim of this study is to analyse the results of a two-year programme for the early optimisation of antibiotic treatment in patients admitted to the Costa del Sol Hospital (Marbella. Spain).

Methods

A prospective two-year cohort study was conducted, evaluating all episodes of bacteraemia at the Costa del Sol Hospital. Epidemiological and microbiological characteristics, any modification of the initial antibiotic treatment, prognostic risk stratification, early mortality related to the episode of bacteraemia, and mortality after the seventh day, were included in the analysis.

Results

Seven hundred seventy-three episodes of bacteraemia were treated, 61.6% males and 38.4% females. The mean age was 65.2 years. The condition was most commonly acquired in the community (41.4%). The bacteraemia was most frequently urological in nature (30.5%), and E coli was the microorganism most frequently isolated (31.6%). In 51.1% of the episodes, a modification was made to optimise the treatment. In the first week, 8.2% died from bacteraemia, and 4.5% had died when they were located. The highest rates of death were associated with older patients, nosocomial acquisition, no source, McCabe score rapidly fatal, Charlson index ≥3, Pitt index ≥3 and treatment remained unmodified.

Conclusion

The existence of bacteraemia control programmes and teams composed of clinicians who are experienced in the treatment of infectious diseases, can improve the disease outcome by enabling more severe episodes of bacteraemia to be recognised and their empirical treatment optimised.

Outcomes and Predictive Factors Associated with Adequacy of Antimicrobial Therapy in Patients with Central Line-Associated Bloodstream Infection

BACKGROUND

Central venous catheters are significant risk factors for bloodstream infection (BSI), which are directly associated with increased morbidity and mortality.

METHODS

This study was a retrospective cohort study for the time period of July 2011-June 2014 in patients with central line-associated bloodstream infection (CLABSI) to determine the microbiological profile and antimicrobial adequacy of patients with CLABSI in a tertiary hospital.

RESULTS

One hundred and twenty-one CLABSI cases were identified. Ninety-two percent (n = 111) of patients had monomicrobial BSI. Gram-negative bacteria were the most prevalent (49%, n = 63), with Klebsiella spp. predominating (30%, n = 19). Among the Gram-positive bacteria (n = 43, 33%), coagulase-negative staphylococci was the major pathogen (58%, n = 25), and all isolates were methicillin resistant. Antimicrobial therapy was assessed as adequate in 81% (n = 98) of cases. In-hospital mortality was 36% (n = 43 cases).

CONCLUSION

Our CLABSI patients had a high mortality, although antimicrobial therapy was appropriate. Gram-negative bacteria were responsible for almost half of the cases and there was a high rate of bacteria resistance to extended-spectrum antibiotics.

Individualized antibiotic strategies

PURPOSE OF REVIEW

Infections are common complications in critically ill patients and are frequently treated with antibiotics. Unfortunately, delivery of optimal therapy is complicated because efficacy of antimicrobials is influenced by the timing of treatment initiation, the use of combination therapy, and the optimization of drug dosing.

RECENT FINDINGS

Early diagnosis of infection is mandatory to provide a rapid and appropriate antibiotic therapy. The presence of less susceptible strains, in particular for hospital-acquired infections, or patients with severe disease, such as the presence of septic shock, may need combination antibiotic therapy. Antibiotic pharmacokinetics, notably volume of distribution and total body clearance, are significantly altered in these critically ill patients and can influence the attainment of adequate circulating levels when standard dosage regimens are administered. Higher dosing should be considered in such patients, although in case of renal impairment and reduced clearance, drug accumulation could also result in some side-effects. Nebulized antibiotics may provide a better clinical response than systemic antibiotics in ventilator-associated pneumonia because of multidrug-resistant pathogens.

SUMMARY

The optimal use of antibiotics in the management of severe infections is an important challenge for ICU physicians. Antimicrobial therapy needs to be individualized according to specific patient characteristics, infecting organisms, and susceptibility patterns.

Risk factors and outcomes of afebrile bacteremia patients in an emergency department

OBJECTIVE

There is limited research on afebrile bacteremia. We aimed to compare the risk factors and outcomes of patients with afebrile and febrile infections.

METHODS

This was a retrospective cohort study of bloodstream isolates from 994 adults admitted to the emergency department of a university hospital. Afebrile infections, defined as the absence of fever history or measured fever through the emergency department course, was compared with febrile infection. Frequencies and proportions of sources of infection, comorbidities, along with organ failure and mortality were presented. The major outcome measure was 30-day survival. chi-Square or Student's t test was used for univariate analysis, and Cox proportional hazard model was used for multivariate analysis.

RESULTS

We found that the risk factors and outcomes of febrile and afebrile bacteremia patients were very different. The afebrile patients were older, have higher Charlson comorbidity index, and had poorer outcomes than the febrile patients. We also found that oldest old age, nonhematologic malignancy, necrotizing fasciitis, spontaneous bacterial peritonitis, and pneumonia were each positive independent predictors of afebrile bacteremia, whereas Escherichia coli infection and liver abscess were independent negative predictors of afebrile bacteremia. Finally, the 30-day all-cause mortality was higher in the afebrile group than in the febrile group (45% versus 12%, log-rank P<0.001).

CONCLUSIONS

This series of patients with afebrile bacteremia confirmed the previously reported associations with old age and immunocompromised conditions. Clinicians should explore the possibility of occult severe infection, and initiate early hemodynamic support and empirical antimicrobial therapy for patients with the aforementioned risk factors.

Effect of the inadequacy of antibiotic therapy in the Emergency Department on hospital stays

INTRODUCTION

The main objective of the study was to determine the frequency of patients receiving inappropriate empiric antibiotic therapy and to assess the impact in terms of increase length of hospital stay, 30-day re-admissions, and 30-day mortality.

METHODS

An observational retrospective cohort study was conducted over a one-month period that included all patients hospitalised from an Emergency Department (ED) due to infection. Demographic variables, comorbidity, multi-resistance risk factors, site of infection, microbiological findings, and antibiotic prescribed in ED were collected. Outcomes were length of hospital stay, 30-day re-admissions, and 30-day mortality.

RESULTS

A total of 376 patients were included, with a mean age of 71.1 (SD 21) years. The most frequent causes were respiratory (45.7%) and urine (23.9%) infections. The number of patients with length of stay over the median (≥9 days) was 165 (46.1%), with re-admissions 74 (19.7%), and mortality at 30 days 44 (11.7%). There was inappropriate antibiotic treatment in 42 (11.2%) cases. After adjusting for demographic data, comorbidity, risk factors for multidrug resistant organism, presence of sepsis criteria in ED, and site of infection, inappropriate treatment was associated with an extended length of hospital stay (OR 2.22; 95% CI; 1.07-4.60; P=.032), but did not to an increase in mortality (P=.271) or re-admission (P=.784) at 30 days.

CONCLUSION

The inappropriate empirical antibiotic therapy in patients admitted from the ED leads to an extended hospital stay, but did not increase mortality or readmission.

The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis

OBJECTIVES

We sought to systematically review and meta-analyze the available data on the association between timing of antibiotic administration and mortality in severe sepsis and septic shock.

DATA SOURCES

A comprehensive search criteria was performed using a predefined protocol.

STUDY SELECTION

INCLUSION CRITERIA

adult patients with severe sepsis or septic shock, reported time to antibiotic administration in relation to emergency department triage and/or shock recognition, and mortality.

EXCLUSION CRITERIA

immunosuppressed populations, review article, editorial, or nonhuman studies.

DATA EXTRACTION

Two reviewers screened abstracts with a third reviewer arbitrating. The effect of time to antibiotic administration on mortality was based on current guideline recommendations: 1) administration within 3 hours of emergency department triage and 2) administration within 1 hour of severe sepsis/septic shock recognition. Odds ratios were calculated using a random effect model. The primary outcome was mortality.

DATA SYNTHESIS

A total of 1,123 publications were identified and 11 were included in the analysis. Among the 11 included studies, 16,178 patients were evaluable for antibiotic administration from emergency department triage. Patients who received antibiotics more than 3 hours after emergency department triage (< 3 hr reference) had a pooled odds ratio for mortality of 1.16 (0.92-1.46; p = 0.21). A total of 11,017 patients were evaluable for antibiotic administration from severe sepsis/septic shock recognition. Patients who received antibiotics more than 1 hour after severe sepsis/shock recognition (< 1 hr reference) had a pooled odds ratio for mortality of 1.46 (0.89-2.40; p = 0.13). There was no increased mortality in the pooled odds ratios for each hourly delay from less than 1 to more than 5 hours in antibiotic administration from severe sepsis/shock recognition.

CONCLUSION

Using the available pooled data, we found no significant mortality benefit of administering antibiotics within 3 hours of emergency department triage or within 1 hour of shock recognition in severe sepsis and septic shock. These results suggest that currently recommended timing metrics as measures of quality of care are not supported by the available evidence.

Agreement on the prescription of antimicrobial drugs

BACKGROUND

There is universal awareness of the difficulties faced by doctors when prescribing antimicrobials.

METHODS

Over a six-month period patients hospitalized in the ICU and under treatment with antibiotics and/or antifungals were eligible to participate in the study. The data were assessed by two infectious diseases specialists. Once completed, all case forms were sent independently to both evaluators (TZSC and ARM) by e-mail. Based on the data received, the evaluator completed a form automatically generated on the e-mail and returned it to the original mailbox for further analysis. We assessed the level of agreement between infectious disease specialists and the physicians directly responsible for the decision to begin antimicrobial therapy, as well as to assess the appropriateness of the regimen prescribed.

RESULTS

Among the antimicrobial regimens prescribed to the 177 patients, 36% were considered inappropriate by specialist #1 and 38% were considered inappropriate by specialist #2. We found 78% agreement by at least one of the infectious disease specialists with the prescribed antimicrobial regimen, and in 49% of cases both specialists agreed with the prescribed regimen. Both disagreed with the prescribed regimen in 22% of the cases and they disagreed between themselves in 29% of the cases.

CONCLUSION

This study highlights the difficulties in prescribing effective empirical antimicrobial therapy--they are of such magnitude that even two specialists in infectious diseases, well acquainted with our hospital's resistance patterns and our patients' profiles have considerable disagreement.

Quality improvement in pediatric sepsis

PURPOSE OF REVIEW

Although there is abundant literature detailing the impact of quality improvement in adult sepsis, the pediatric literature is lacking. Despite consensus definitions for sepsis, which patients along the sepsis spectrum should receive aggressive management and the exact onset of sepsis ('time zero') are not clearly established. In the adult emergency department (ED), sepsis onset is defined as the time of entry into the ED; however, this definition cannot be applied to hospitalized patients or patients who evolve during their ED course. Since the time of sepsis onset will dictate the timeliness of subsequent process measures, the variable definitions in the literature make it difficult to generalize findings among prior studies.

RECENT FINDINGS

Despite the variation in defining time zero, aggressive fluid administration, timely antibiotics, and compliance with sepsis bundles have been shown to improve mortality and to reduce hospital and intensive care length of stay. In addition, early identification tools show promise in beginning to define sepsis onset and retrospective search tools may allow improved case finding of those children of concern for sepsis.

SUMMARY

Quality improvement in pediatric sepsis is evolving. As we continue to define quality measures, we must standardize the definition of sepsis onset. This definition should be applicable to any treatment venue to ensure measures can be evaluated across all settings. In addition, we must delineate which patients along the sepsis spectrum should be candidates for timely interventions and standardize other outcome measures beyond mortality.