1
|
Kwak H, Kwon WY, Jo YH, Kim S, Suh GJ, Kim KS, Jung YS, Lee HJ, Kim JY. Afebrile status at the time of emergency department visit is associated with delayed antibiotic therapy in patients with sepsis (revised). Am J Emerg Med 2024; 83:69-75. [PMID: 38976929 DOI: 10.1016/j.ajem.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 06/11/2024] [Accepted: 06/16/2024] [Indexed: 07/10/2024] Open
Abstract
OBJECTIVES To determine whether there is a difference in antibiotic administration time and prognosis in afebrile sepsis patients compared to febrile sepsis patients. METHODS This was retrospective multicenter observational study. Data collected from three referral hospitals. Data were collected from May 2014 through February 2016 under the SEPSIS-2 criteria and from March 2016 to April 2020 under the newly released SEPSIS-3 criteria. Patients were divided into two groups based on body temperature: afebrile (<37.3 °C) and febrile (≥37.3 °C). The relationship between initial body temperature and 28-day mortality were analyzed using multivariable logistic regression. The subgroup analysis was conducted on patients with complete Hour-1 bundle performance records. RESULTS We included 4293 patients in this study. Initial body temperatures in 28-day survivors were significantly higher than in 28-day non-survivors (37.5 °C ± 1.2 °C versus 37.1 °C ± 1.2 °C, p < 0.01). Multivariable logistic regression analysis was performed in afebrile and febrile sepsis patients. Adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.76 (95% Confidence interval 1.46-2.12). As a result of performing the Hour-1 bundle, the number of patients who received antibiotics within 1 h was smaller in the afebrile sepsis patients (323/2076, 15.6%) than in the febrile sepsis patients (395/2156, 18.3%) (p = 0.02). In the subgroup analysis of patients with complete Hour-1 bundle performance records adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.68 (95% Confidence interval 1.34-2.11). The febrile sepsis patients received antibiotics faster than the afebrile sepsis patients (175.5 ± 207.9 versus 209.3 ± 277.9, p < 0.01). CONCLUSIONS Afebrile sepsis patients were associated with higher 28-day mortality compared to their febrile counterparts and were delayed in receiving antibiotics. This underscores the need for improved early detection and treatment strategies for the afebrile sepsis patients.
Collapse
Affiliation(s)
- Hyeongkyu Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Public Health and Medical Service, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
| | - Sola Kim
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea; Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hui Jai Lee
- SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| |
Collapse
|
2
|
Ginestra JC, Coz Yataco AO, Dugar SP, Dettmer MR. Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity. Chest 2024; 165:1421-1430. [PMID: 38246522 PMCID: PMC11177099 DOI: 10.1016/j.chest.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Sepsis causes more than a quarter million deaths among hospitalized adults in the United States each year. Although most cases of sepsis are present on admission, up to one-quarter of patients with sepsis develop this highly morbid and mortal condition while hospitalized. Compared with patients with community-onset sepsis (COS), patients with hospital-onset sepsis (HOS) are twice as likely to require mechanical ventilation and ICU admission, have more than two times longer ICU and hospital length of stay, accrue five times higher hospital costs, and are twice as likely to die. Patients with HOS differ from those with COS with respect to underlying comorbidities, admitting diagnosis, clinical manifestations of infection, and severity of illness. Despite the differences between these patient populations, patients with HOS sepsis are understudied and warrant expanded investigation. Here, we outline important knowledge gaps in the recognition and management of HOS in adults and propose associated research priorities for investigators. Of particular importance are questions regarding standardization of research and clinical case identification, understanding of clinical heterogeneity among patients with HOS, development of tailored management recommendations, identification of impactful prevention strategies, optimization of care delivery and quality metrics, identification and correction of disparities in care and outcomes, and how to ensure goal-concordant care for patients with HOS.
Collapse
Affiliation(s)
- Jennifer C Ginestra
- Palliative and Advanced Illness Research (PAIR) Center, Division of Pulmonary and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA
| | - Angel O Coz Yataco
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Siddharth P Dugar
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew R Dettmer
- Division of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Center for Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH.
| |
Collapse
|
3
|
Swilling AC, O'Dell JC, Beyene RT, Watson CM, Sawyer RG, Chollet-Hinton L, Simpson SQ, Atchison L, Derickson M, Cooper LC, Pennington GP, VandenBerg S, Halimeh BN, Hughes D, Guidry CA. Provider Perceptions of Antibiotic Initiation Strategies for Hospital-Acquired Pneumonia. Surg Infect (Larchmt) 2024; 25:109-115. [PMID: 38252553 DOI: 10.1089/sur.2023.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
Background: The practice of rapidly initiating antibiotic therapy for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice. Hypothesis: We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups. Methods: We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence. Both a paired and unpaired analysis was performed. Results: We collected 51 survey responses from 31 unique participants. Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p = 0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotic agents immediately (Very Comfortable: 83.3% vs. 40.7%; p = 0.004). For the smaller paired analysis, there was no longer a difference in comfort level. Conclusions: There may be differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.
Collapse
Affiliation(s)
- Aubrey C Swilling
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jacob C O'Dell
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robel T Beyene
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Robert G Sawyer
- Department of Surgery, Western Michigan Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Lynn Chollet-Hinton
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Steven Q Simpson
- Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Leanne Atchison
- Department of Pharmaceutical Services, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael Derickson
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lindsey C Cooper
- Department of Pharmaceutical Services, Prisma Health Midlands, Columbia, South Carolina, USA
| | - G Patton Pennington
- Department of Surgery, Florida State University School of Medicine, Tallahassee Memorial Healthcare, Tallahassee, Florida, USA
| | - Sheri VandenBerg
- Department of Surgery, Division of Trauma Surgery, Bronson Methodist Hospital, Kalamazoo, Michigan, USA
| | - Bachar N Halimeh
- Department of Surgery, Boston University Medical Center, Boston, Massachusetts, USA
| | - Dorothy Hughes
- Department of Population Health, University of Kansas School of Medicine, Salina, Kansas, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
4
|
Martin M, Forveille S, Lascarrou JB, Seguin A, Canet E, Lemarié J, Agbakou M, Desmedt L, Blonz G, Zambon O, Corvec S, Le Thuaut A, Reignier J. Immediate vs. culture-initiated antibiotic therapy in suspected non-severe ventilator-associated pneumonia: a before-after study (DELAVAP). Ann Intensive Care 2024; 14:33. [PMID: 38411756 PMCID: PMC10897643 DOI: 10.1186/s13613-024-01243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is the leading nosocomial infection in critical care and is associated with adverse outcomes. When VAP is suspected, starting antibiotic therapy (AT) immediately after pulmonary sampling may expose uninfected patients to unnecessary treatment, whereas waiting for bacteriological confirmation may delay AT in infected patients. As no robust data exist to choose between these strategies, the decision must balance the pre-test diagnostic probability, clinical severity, and risk of antimicrobial resistance. The objective of this study in patients with suspected non-severe VAP was to compare immediate AT started after sampling to conservative AT upon receipt of positive microbiological results. The outcomes were antibiotic sparing, AT suitability, and patient outcomes. METHODS This single-center, before-after study included consecutive patients who underwent distal respiratory sampling for a first suspected non-severe VAP episode (no shock requiring vasopressor therapy or severe acute respiratory distress syndrome). AT was started immediately after sampling in 2019 and upon culture positivity in 2022 (conservative strategy). The primary outcome was the number of days alive without AT by day 28. The secondary outcomes were mechanical ventilation duration, day-28 mortality, and AT suitability (active necessary AT or spared AT). RESULTS The immediate and conservative strategies were applied in 44 and 43 patients, respectively. Conservative and immediate AT were associated with similar days alive without AT (median [interquartile range], 18.0 [0-21.0] vs. 16.0 [0-20.0], p = 0.50) and without broad-spectrum AT (p = 0.53) by day 28. AT was more often suitable in the conservative group (88.4% vs. 63.6%, p = 0.01), in which 27.9% of patients received no AT at all. No significant differences were found for mechanical ventilation duration (median [95%CI], 9.0 [6-19] vs. 9.0 [6-24] days, p = 0.65) or day-28 mortality (hazard ratio [95%CI], 0.85 [0.4-2.0], p = 0.71). CONCLUSION In patients with suspected non-severe VAP, waiting for microbiological confirmation was not associated with antibiotic sparing, compared to immediate AT. This result may be ascribable to low statistical power. AT suitability was better with the conservative strategy. None of the safety outcomes differed between groups. These findings would seem to allow a large, randomized trial comparing immediate and conservative AT strategies.
Collapse
Affiliation(s)
- Maëlle Martin
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France.
| | - Solène Forveille
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | | | - Amélie Seguin
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Emmanuel Canet
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Jérémie Lemarié
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Maïté Agbakou
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Luc Desmedt
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Gauthier Blonz
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Olivier Zambon
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Stéphane Corvec
- Nantes Université, CHU Nantes, Institut de Biologie des Hôpitaux de Nantes, Service de Bactériologie Et Des Contrôles Microbiologiques, Nantes, France
| | - Aurélie Le Thuaut
- Nantes Université, CHU Nantes, Plateforme de méthodologie et biostatistique, Direction de la recherche et de l'innovation, Nantes, France
| | - Jean Reignier
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
- Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Movement - Interactions - Performance, MIP, UR 4334, Nantes, France
| |
Collapse
|
5
|
Ramasco F, Nieves-Alonso J, García-Villabona E, Vallejo C, Kattan E, Méndez R. Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies. J Pers Med 2024; 14:176. [PMID: 38392609 PMCID: PMC10890552 DOI: 10.3390/jpm14020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.
Collapse
Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Jesús Nieves-Alonso
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Esther García-Villabona
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Vallejo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Eduardo Kattan
- Departamento de Medicina Intensiva del Adulto, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| |
Collapse
|
6
|
Howard A, Reza N, Aston S, Woods B, Gerada A, Buchan I, Hope W, Märtson AG. Antimicrobial treatment imprecision: an outcome-based model to close the data-to-action loop. THE LANCET. INFECTIOUS DISEASES 2024; 24:e47-e58. [PMID: 37660712 DOI: 10.1016/s1473-3099(23)00367-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 09/05/2023]
Abstract
Health-care systems, food supply chains, and society in general are threatened by the inexorable rise of antimicrobial resistance. This threat is driven by many factors, one of which is inappropriate antimicrobial treatment. The ability of policy makers and leaders in health care, public health, regulatory agencies, and research and development to deliver frameworks for appropriate, sustainable antimicrobial treatment is hampered by a scarcity of tangible outcome-based measures of the damage it causes. In this Personal View, a mathematically grounded, outcome-based measure of antimicrobial treatment appropriateness, called imprecision, is proposed. We outline a framework for policy makers and health-care leaders to use this metric to deliver more effective antimicrobial stewardship interventions to future patient pathways. This will be achieved using learning antimicrobial systems built on public and practitioner engagement; solid implementation science; advances in artificial intelligence; and changes to regulation, research, and development. The outcomes of this framework would be more ecologically and organisationally sustainable patterns of antimicrobial development, regulation, and prescribing. We discuss practical, ethical, and regulatory considerations involved in the delivery of novel antimicrobial drug development, and policy and patient pathways built on artificial intelligence-augmented measures of antimicrobial treatment imprecision.
Collapse
Affiliation(s)
- Alex Howard
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK.
| | - Nada Reza
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Stephen Aston
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Beth Woods
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Alessandro Gerada
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK
| | - Iain Buchan
- Department of Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - William Hope
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK
| | - Anne-Grete Märtson
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| |
Collapse
|
7
|
Donnelly JP, Seelye SM, Kipnis P, McGrath BM, Iwashyna TJ, Pogue J, Jones M, Liu VX, Prescott HC. Impact of Reducing Time-to-Antibiotics on Sepsis Mortality, Antibiotic Use, and Adverse Events. Ann Am Thorac Soc 2024; 21:94-101. [PMID: 37934602 PMCID: PMC10867916 DOI: 10.1513/annalsats.202306-505oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/31/2023] [Indexed: 11/09/2023] Open
Abstract
Rationale: Shorter time-to-antibiotics is lifesaving in sepsis, but programs to hasten antibiotic delivery may increase unnecessary antibiotic use and adverse events. Objectives: We sought to estimate both the benefits and harms of shortening time-to-antibiotics for sepsis. Methods: We conducted a simulation study using a cohort of 1,559,523 hospitalized patients admitted through the emergency department with meeting two or more systemic inflammatory response syndrome criteria (2013-2018). Reasons for hospitalization were classified as septic shock, sepsis, infection, antibiotics stopped early, and never treated (no antibiotics within 48 h). We simulated the impact of a 50% reduction in time-to-antibiotics for sepsis across 12 hospital scenarios defined by sepsis prevalence (low, medium, or high) and magnitude of "spillover" antibiotic prescribing to patients without infection (low, medium, high, or very high). Outcomes included mortality and adverse events potentially attributable to antibiotics (e.g., allergy, organ dysfunction, Clostridiodes difficile infection, and culture with multidrug-resistant organism). Results: A total of 933,458 (59.9%) hospitalized patients received antimicrobial therapy within 48 hours of presentation, including 38,572 (2.5%) with septic shock, 276,082 (17.7%) with sepsis, 370,705 (23.8%) with infection, and 248,099 (15.9%) with antibiotics stopped early. A total of 199,937 (12.8%) hospitalized patients experienced an adverse event; most commonly, acute liver injury (5.6%), new MDRO (3.5%), and Clostridiodes difficile infection (1.7%). Across the scenarios, a 50% reduction in time-to-antibiotics for sepsis was associated with a median of 1 to 180 additional antibiotic-treated patients and zero to seven additional adverse events per death averted from sepsis. Conclusions: The impacts of faster time-to-antibiotics for sepsis vary markedly across simulated hospital types. However, even in the worst-case scenario, new antibiotic-associated adverse events were rare.
Collapse
Affiliation(s)
- John P. Donnelly
- Department of Learning Health Sciences
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- VA Center for Implementation and Evaluation Resources, Ann Arbor, Michigan
| | - Sarah M. Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brenda M. McGrath
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- OCHIN Inc., Portland, Oregon
| | - Theodore J. Iwashyna
- Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jason Pogue
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Makoto Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah; and
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Hallie C. Prescott
- Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| |
Collapse
|
8
|
Prescott HC, Ostermann M. What is new and different in the 2021 Surviving Sepsis Campaign guidelines. Med Klin Intensivmed Notfmed 2023; 118:75-79. [PMID: 37286842 PMCID: PMC10246868 DOI: 10.1007/s00063-023-01028-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/23/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
The Surviving Sepsis Campaign (SSC) International Guidelines for the Management of Sepsis and Septic Shock provide recommendations on the care of hospitalized adult patients with (or at risk for) sepsis. This review discusses what is new or different in the 2021 SSC adult sepsis guidelines compared to 2016. The guidelines include new weak recommendations for use of balanced fluid over saline 0.9%, use of intravenous corticosteroids for septic shock when there is ongoing vasopressor requirement, and peripheral initiation of intravenous vasopressors over delaying initiation in order to obtain central venous access. As before, there is a strong recommendation to initiate antimicrobials within 1 h of sepsis and septic shock, but there are now additional recommendations when the diagnosis is uncertain. The recommendation for initial fluid resuscitation in septic shock of 30 mL/kg crystalloid has been downgraded from strong to weak. Finally, there are 12 new recommendations addressing long-term outcomes from sepsis, including strong recommendations to screen for economic and social support and to make referrals for follow-up where available; use shared decision-making in post-intensive care unit (ICU) and hospital discharge planning; reconcile medications at both ICU and hospital discharge; provide information about sepsis and its sequelae in written and verbal hospital discharge summary; and to provide assessment and follow-up for physical, cognitive, and emotional problems after hospital discharge.
Collapse
Affiliation(s)
- Hallie C Prescott
- Department of Medicine, North Campus Research Center, University of Michigan, 48109-2800, Ann Arbor, MI, USA.
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.
| | | |
Collapse
|
9
|
Pak TR, Young J, McKenna CS, Agan A, DelloStritto L, Filbin MR, Dutta S, Kadri SS, Septimus EJ, Rhee C, Klompas M. Risk of Misleading Conclusions in Observational Studies of Time-to-Antibiotics and Mortality in Suspected Sepsis. Clin Infect Dis 2023; 77:1534-1543. [PMID: 37531612 PMCID: PMC10686960 DOI: 10.1093/cid/ciad450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/20/2023] [Accepted: 07/31/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Influential studies conclude that each hour until antibiotics increases mortality in sepsis. However, these analyses often (1) adjusted for limited covariates, (2) included patients with long delays until antibiotics, (3) combined sepsis and septic shock, and (4) used linear models presuming each hour delay has equal impact. We evaluated the effect of these analytic choices on associations between time-to-antibiotics and mortality. METHODS We retrospectively identified 104 248 adults admitted to 5 hospitals from 2015-2022 with suspected infection (blood culture collection and intravenous antibiotics ≤24 h of arrival), including 25 990 with suspected septic shock and 23 619 with sepsis without shock. We used multivariable regression to calculate associations between time-to-antibiotics and in-hospital mortality under successively broader confounding-adjustment, shorter maximum time-to-antibiotic intervals, stratification by illness severity, and removing assumptions of linear hourly associations. RESULTS Changing covariates, maximum time-to-antibiotics, and severity stratification altered the magnitude, direction, and significance of observed associations between time-to-antibiotics and mortality. In a fully adjusted model of patients treated ≤6 hours, each hour was associated with higher mortality for septic shock (adjusted odds ratio [aOR]: 1.07; 95% CI: 1.04-1.11) but not sepsis without shock (aOR: 1.03; .98-1.09) or suspected infection alone (aOR: .99; .94-1.05). Modeling each hour separately confirmed that every hour of delay was associated with increased mortality for septic shock, but only delays >6 hours were associated with higher mortality for sepsis without shock. CONCLUSIONS Associations between time-to-antibiotics and mortality in sepsis are highly sensitive to analytic choices. Failure to adequately address these issues can generate misleading conclusions.
Collapse
Affiliation(s)
- Theodore R Pak
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica Young
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Caroline S McKenna
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Anna Agan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Laura DelloStritto
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sameer S Kadri
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
10
|
O'Dell JC, Halimeh BN, Johnston J, McCoy CC, Winfield RD, Guidry CA. Antibiotic Initiation Timing and Mortality in Trauma Patients With Ventilator-Associated Pneumonia. Am Surg 2023; 89:4740-4746. [PMID: 36196032 DOI: 10.1177/00031348221129518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early antibiotic initiation is considered a cornerstone in the management of ventilator-associated pneumonia (VAP). However, recent data suggests that early antibiotic initiation may not be necessary in all cases. Additionally, the benefits of early antibiotic administration for infection have not been studied in a dedicated trauma population. This study's aim was to evaluate the impact of antibiotic administration timing on in-hospital mortality in trauma patients with VAP. METHODS This retrospective case-control study identified all trauma patients at a single level 1 academic trauma center from 2016 to 2020. Patients with a TQIP-defined VAP were included and stratified into 2 subgroups by in-hospital mortality. Time interval between airway culture and antibiotic initiation was gathered. Baseline measures of injury and illness severity were collected. Univariate analysis of the data was performed. RESULTS Forty-five patients met inclusion criteria. Overall, 80% of patients survived admission (n = 36) and 20% of patients did not survive admission (n = 9). There were no significant differences in baseline characteristics or cultured organism between survivors and non-survivors. The median time interval between airway culture and antibiotic initiation was 2 hours (IQR 0-4.5) for survivors, and 0 hours (IQR 0-0) for non-survivors (P = .07). Antibiotics were administered within 1 hour of airway culture for 33.3% of survivors, and 77.8% of non-survivors (P = .02). CONCLUSIONS In a population of trauma patients with VAP, survivors had antibiotics initiated in more delayed fashion than non-survivors. These findings question the primacy of early antibiotic administration for suspected infection.
Collapse
Affiliation(s)
- Jacob C O'Dell
- Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Bachar N Halimeh
- Department of Surgery, Boston University Medical Center, Boston, MA, USA
| | - James Johnston
- Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - C Cameron McCoy
- Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert D Winfield
- Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher A Guidry
- Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| |
Collapse
|
11
|
Anesi GL, Admon AJ. Unpacking Regionalization of Sepsis Care Using Hospital Capability Assessments. Crit Care Med 2023; 51:1594-1596. [PMID: 37902344 PMCID: PMC10617649 DOI: 10.1097/ccm.0000000000005987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
12
|
de la Fuente-Nunez C, Cesaro A, Hancock REW. Antibiotic failure: Beyond antimicrobial resistance. Drug Resist Updat 2023; 71:101012. [PMID: 37924726 DOI: 10.1016/j.drup.2023.101012] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
Despite significant progress in antibiotic discovery, millions of lives are lost annually to infections. Surprisingly, the failure of antimicrobial treatments to effectively eliminate pathogens frequently cannot be attributed to genetically-encoded antibiotic resistance. This review aims to shed light on the fundamental mechanisms contributing to clinical scenarios where antimicrobial therapies are ineffective (i.e., antibiotic failure), emphasizing critical factors impacting this under-recognized issue. Explored aspects include biofilm formation and sepsis, as well as the underlying microbiome. Therapeutic strategies beyond antibiotics, are examined to address the dimensions and resolution of antibiotic failure, actively contributing to this persistent but escalating crisis. We discuss the clinical relevance of antibiotic failure beyond resistance, limited availability of therapies, potential of new antibiotics to be ineffective, and the urgent need for novel anti-infectives or host-directed therapies directly addressing antibiotic failure. Particularly noteworthy is multidrug adaptive resistance in biofilms that represent 65 % of infections, due to the lack of approved therapies. Sepsis, responsible for 19.7 % of all deaths (as well as severe COVID-19 deaths), is a further manifestation of this issue, since antibiotics are the primary frontline therapy, and yet 23 % of patients succumb to this condition.
Collapse
Affiliation(s)
- Cesar de la Fuente-Nunez
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA; Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, PA, USA.
| | - Angela Cesaro
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA; Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E W Hancock
- Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, Canada.
| |
Collapse
|
13
|
Herd SH, Allen PL, Reed LJ, O'Hern JA, Fraser J, Flanagan KL. Time to embrace sepsis pathways and antibiotic prescribing decision support in the emergency department: Observations from a retrospective single site clinical audit. Emerg Med Australas 2023; 35:746-753. [PMID: 37038917 DOI: 10.1111/1742-6723.14206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/05/2023] [Accepted: 03/20/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE To compare clinician documentation of sepsis for infective presentations in the ED against a formal sepsis pathway in the ED and to assess appropriateness of the initial parenteral antibiotic prescription for adult patients in ED. METHODS A retrospective, clinical audit of adult patients who received at least one parenteral antibiotic in ED over a 10-week period in 2018. Documented initial clinical impression was compared with an approved sepsis pathway. Antibiotic appropriateness was assessed using National Antimicrobial Prescribing Survey definitions. Assessment was carried out by an infectious diseases pharmacist, with input from an infectious diseases physician. RESULTS Two hundred and nineteen infective presentations were included in the analysis. There was a discordance between the initial documented clinical impression compared with the classification when a sepsis pathway was applied. An initial documented clinical impression of sepsis and septic shock was present in 38 (60.3%) of the presentations compared to 63 presentations when a formal sepsis pathway was applied as a screening tool. There was a significant difference in the proportion of patients in each diagnostic group (infection, sepsis and septic shock) according to documented clinical impression versus sepsis pathway classification (P = 0.0002). There were 386 prescriptions for antibiotics as part of the initial management. Antibiotic appropriateness for the initial prescription was assessed as 63.7% appropriate, 27.2% inappropriate and 9.1% not assessable. CONCLUSION Our observations demonstrate that use of a formal sepsis pathway may improve the screening and early diagnosis of sepsis and septic shock and that there is a need for antibiotic prescribing guidance in the ED.
Collapse
Affiliation(s)
- Sarah H Herd
- Pharmacy Department, Launceston General Hospital, Launceston, Tasmania, Australia
- Launceston Clinical School, Tasmanian School of Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Penny L Allen
- Rural Clinical School, Tasmanian School of Medicine, University of Tasmania, Burnie, Tasmania, Australia
| | - Lucy J Reed
- Emergency Department, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Jennifer A O'Hern
- Department of Infectious Diseases, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Jessica Fraser
- Department of Medicine, Launceston General Hospital, Launceston, Tasmania, Australia
| | - Katie L Flanagan
- Department of Infectious Diseases, Launceston General Hospital, Launceston, Tasmania, Australia
- Tasmanian School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
- School of Health and Biomedical Science, RMIT University, Melbourne, Victoria, Australia
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, Tasmania, Australia
| |
Collapse
|
14
|
Kochanek M, David S. [The current sepsis guidelines-What do you need to know?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:939-945. [PMID: 37702781 DOI: 10.1007/s00108-023-01585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/14/2023]
Abstract
The current international sepsis guidelines from 2021 are based on the work of a panel of 60 international experts from various fields. They include a total of 93 recommendations, some of which include new aspects compared to the 2016 version of the guidelines. This article provides a subjective compilation by two internal medicine intensivists who highlight some aspects, especially of changes within the guidelines compared to the previous version. The focus is on the fields of screening, sepsis bundles, fluid and vasopressor treatment and adjuvant treatment. In addition, for the first time these guidelines address the important issue of long-term sequelae for sepsis survivors and their environment.
Collapse
Affiliation(s)
- Matthias Kochanek
- Medizinische Fakultät und Universitätsklinikum Köln, Klinik I für Innere Medizin, Centrum für Integrierte Onkologie Aachen Bonn Köln Düsseldorf (CIO), Universität zu Köln, Köln, Deutschland.
| | - Sascha David
- Universitätsspital Zürich, Institut für Intensivmedizin, Zürich, Schweiz
- Medizinische Hochschule Hannover, Nieren- und Hochdruckerkrankungen, Hannover, Deutschland
| |
Collapse
|
15
|
Lyons PG, Hough CL. Antimicrobials in Sepsis: Time to Pay Attention to When Delays Happen. Ann Am Thorac Soc 2023; 20:1239-1241. [PMID: 37655955 PMCID: PMC10502879 DOI: 10.1513/annalsats.202306-519ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Affiliation(s)
- Patrick G Lyons
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
- Department of Medical Informatics and Clinical Epidemiology, and
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Catherine L Hough
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| |
Collapse
|
16
|
Hooper GA, Klippel CJ, McLean SR, Stenehjem EA, Webb BJ, Murnin ER, Hough CL, Bledsoe JR, Brown SM, Peltan ID. Concordance Between Initial Presumptive and Final Adjudicated Diagnoses of Infection Among Patients Meeting Sepsis-3 Criteria in the Emergency Department. Clin Infect Dis 2023; 76:2047-2055. [PMID: 36806551 PMCID: PMC10273369 DOI: 10.1093/cid/ciad101] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Guidelines emphasize rapid antibiotic treatment for sepsis, but infection presence is often uncertain at initial presentation. We investigated the incidence and drivers of false-positive presumptive infection diagnosis among emergency department (ED) patients meeting Sepsis-3 criteria. METHODS For a retrospective cohort of patients hospitalized after meeting Sepsis-3 criteria (acute organ failure and suspected infection including blood cultures drawn and intravenous antimicrobials administered) in 1 of 4 EDs from 2013 to 2017, trained reviewers first identified the ED-diagnosed source of infection and adjudicated the presence and source of infection on final assessment. Reviewers subsequently adjudicated final infection probability for a randomly selected 10% subset of subjects. Risk factors for false-positive infection diagnosis and its association with 30-day mortality were evaluated using multivariable regression. RESULTS Of 8267 patients meeting Sepsis-3 criteria in the ED, 699 (8.5%) did not have an infection on final adjudication and 1488 (18.0%) patients with confirmed infections had a different source of infection diagnosed in the ED versus final adjudication (ie, initial/final source diagnosis discordance). Among the subset of patients whose final infection probability was adjudicated (n = 812), 79 (9.7%) had only "possible" infection and 77 (9.5%) were not infected. Factors associated with false-positive infection diagnosis included hypothermia, altered mental status, comorbidity burden, and an "unknown infection source" diagnosis in the ED (odds ratio: 6.39; 95% confidence interval: 5.14-7.94). False-positive infection diagnosis was not associated with 30-day mortality. CONCLUSIONS In this large multihospital study, <20% of ED patients meeting Sepsis-3 criteria had no infection or only possible infection on retrospective adjudication.
Collapse
Affiliation(s)
- Gabriel A Hooper
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Carolyn J Klippel
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Sierra R McLean
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, University of North Carolina Health, Chapel Hill, North Carolina, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Epidemiology, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Brandon J Webb
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Emily R Murnin
- University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Joseph R Bledsoe
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah, USA
- Department of Emergency Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
17
|
Yang A, Kennedy JN, Reitz KM, Phillips G, Terry KM, Levy MM, Angus DC, Seymour CW. Time to treatment and mortality for clinical sepsis subtypes. Crit Care 2023; 27:236. [PMID: 37322546 PMCID: PMC10268363 DOI: 10.1186/s13054-023-04507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Sepsis is common, deadly, and heterogenous. Prior analyses of patients with sepsis and septic shock in New York State showed a risk-adjusted association between more rapid antibiotic administration and bundled care completion, but not an intravenous fluid bolus, with reduced in-hospital mortality. However, it is unknown if clinically identifiable sepsis subtypes modify these associations. METHODS Secondary analysis of patients with sepsis and septic shock enrolled in the New York State Department of Health cohort from January 1, 2015 to December 31, 2016. Patients were classified as clinical sepsis subtypes (α, β, γ, δ-types) using the Sepsis ENdotyping in Emergency CAre (SENECA) approach. Exposure variables included time to 3-h sepsis bundle completion, antibiotic administration, and intravenous fluid bolus completion. Then logistic regression models evaluated the interaction between exposures, clinical sepsis subtypes, and in-hospital mortality. RESULTS 55,169 hospitalizations from 155 hospitals were included (34% α, 30% β, 19% γ, 17% δ). The α-subtype had the lowest (N = 1,905, 10%) and δ-subtype had the highest (N = 3,776, 41%) in-hospital mortality. Each hour to completion of the 3-h bundle (aOR, 1.04 [95%CI, 1.02-1.05]) and antibiotic initiation (aOR, 1.03 [95%CI, 1.02-1.04]) was associated with increased risk-adjusted in-hospital mortality. The association differed across subtypes (p-interactions < 0.05). For example, the outcome association for the time to completion of the 3-h bundle was greater in the δ-subtype (aOR, 1.07 [95%CI, 1.05-1.10]) compared to α-subtype (aOR, 1.02 [95%CI, 0.99-1.04]). Time to intravenous fluid bolus completion was not associated with risk-adjusted in-hospital mortality (aOR, 0.99 [95%CI, 0.97-1.01]) and did not differ among subtypes (p-interaction = 0.41). CONCLUSION Timely completion of a 3-h sepsis bundle and antibiotic initiation was associated with reduced risk-adjusted in-hospital mortality, an association modified by clinically identifiable sepsis subtype.
Collapse
Affiliation(s)
- Anne Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh Medical Center, PA, Pittsburgh, USA.
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
| | - Jason N Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gary Phillips
- The Ohio State University, Center for Biostatistics, Columbus, OH, USA
| | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
18
|
Baghdadi JD, Goodman KE, Magder LS, Heil EL, Claeys K, Bork J, Harris AD. Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients. JAC Antimicrob Resist 2023; 5:dlad054. [PMID: 37193004 PMCID: PMC10182731 DOI: 10.1093/jacamr/dlad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023] Open
Abstract
Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
Collapse
Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jacqueline Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
19
|
Guarino M, Perna B, Cesaro AE, Maritati M, Spampinato MD, Contini C, De Giorgio R. 2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department. J Clin Med 2023; 12:jcm12093188. [PMID: 37176628 PMCID: PMC10179263 DOI: 10.3390/jcm12093188] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Sepsis/septic shock is a life-threatening and time-dependent condition that requires timely management to reduce mortality. This review aims to update physicians with regard to the main pillars of treatment for this insidious condition. METHODS PubMed, Scopus, and EMBASE were searched from inception with special attention paid to November 2021-January 2023. RESULTS The management of sepsis/septic shock is challenging and involves different pathophysiological aspects, encompassing empirical antimicrobial treatment (which is promptly administered after microbial tests), fluid (crystalloids) replacement (to be established according to fluid tolerance and fluid responsiveness), and vasoactive agents (e.g., norepinephrine (NE)), which are employed to maintain mean arterial pressure above 65 mmHg and reduce the risk of fluid overload. In cases of refractory shock, vasopressin (rather than epinephrine) should be combined with NE to reach an acceptable level of pressure control. If mechanical ventilation is indicated, the tidal volume should be reduced from 10 to 6 mL/kg. Heparin is administered to prevent venous thromboembolism, and glycemic control is recommended. The efficacy of other treatments (e.g., proton-pump inhibitors, sodium bicarbonate, etc.) is largely debated, and such treatments might be used on a case-to-case basis. CONCLUSIONS The management of sepsis/septic shock has significantly progressed in the last few years. Improving knowledge of the main therapeutic cornerstones of this challenging condition is crucial to achieve better patient outcomes.
Collapse
Affiliation(s)
- Matteo Guarino
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Benedetta Perna
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Alice Eleonora Cesaro
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Martina Maritati
- Infectious and Dermatology Diseases, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Michele Domenico Spampinato
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Carlo Contini
- Infectious and Dermatology Diseases, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| |
Collapse
|
20
|
Trial of antibiotic restraint in presumed pneumonia: A Surgical Infection Society multicenter pilot. J Trauma Acute Care Surg 2023; 94:232-240. [PMID: 36534474 DOI: 10.1097/ta.0000000000003839] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pneumonia is the most common intensive care unit-acquired infection in the trauma and emergency general surgery population. Despite guidelines urging rapid antibiotic use, data supporting immediate antibiotic initiation in cases of suspected infection are limited. Our hypothesis was that a protocol of specimen-initiated antibiotic initiation would have similar compliance and outcomes to an immediate initiation protocol. METHODS We devised a pragmatic cluster-randomized crossover pilot trial. Four surgical and trauma intensive care units were randomized to either an immediate initiation or specimen-initiated antibiotic protocol for intubated patients with suspected pneumonia and bronchoscopically obtained cultures who did not require vasopressors. In the immediate initiation arm, antibiotics were started immediately after the culture regardless of patient status. In the specimen-initiated arm, antibiotics were delayed until objective Gram stain or culture results suggested infection. Each site participated in both arms after a washout period and crossover. Outcomes were protocol compliance, all-cause 30-day mortality, and ventilator-free alive days at 30 days. Standard statistical techniques were applied. RESULTS A total of 186 patients had 244 total cultures, of which only the first was analyzed. Ninety-three patients (50%) were enrolled in each arm, and 94.6% were trauma patients (84.4% blunt trauma). The median age was 50.5 years, and 21% of the cohort was female. There were no differences in demographics, comorbidities, sequential organ failure assessment, Acute Physiology and Chronic Health Evaluation II, or Injury Severity Scores. Antibiotics were started significantly later in the specimen-initiated arm (0 vs. 9.3 hours; p < 0.0001) with 19.4% avoiding antibiotics completely for that episode. There were no differences in the rate of protocol adherence, 30-day mortality, or ventilator-free alive days at 30 days. CONCLUSION In this cluster-randomized crossover trial, we found similar compliance rates between immediate and specimen-initiated antibiotic strategies. Specimen-initiated antibiotic protocol in patients with a suspected hospital-acquired pneumonia did not result in worse clinical outcomes compared with immediate initiation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
Collapse
|
21
|
Taylor SP, Weissman GE, Kowalkowski M, Admon AJ, Skewes S, Xia Y, Chou SH. A Quantitative Study of Decision Thresholds for Initiation of Antibiotics in Suspected Sepsis. Med Decis Making 2023; 43:175-182. [PMID: 36062810 DOI: 10.1177/0272989x221121279] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Clinicians' decision thresholds for initiating antibiotics in patients with suspected sepsis have not been quantified. We aimed to define an average threshold of infection likelihood at which clinicians initiate antibiotics when treating a patient with suspected infection and to evaluate the influence of severity of illness and clinician-related factors on the threshold. DESIGN This was a prospective survey of 153 clinicians responding to 8 clinical vignettes constructed from real-world data from 3 health care systems in the United States. We treated each hour in the vignette as a decision to treat or not treat with antibiotics and assigned an infection probability to each hour using a previously developed infection prediction model. We then estimated decision thresholds using regression models based on the timing of antibiotic initiation. We compared thresholds across categories of severity of illness and clinician-related factors. RESULTS Overall, the treatment threshold occurred at a 69% probability of infection, but the threshold varied significantly across severity of illness categories-when patients had high severity of illness, the treatment threshold occurred at a 55% probability of infection; when patients had intermediate severity, the threshold for antibiotic initiation occurred at an infection probability of 69%, and the threshold was 84% when patients had low severity of illness (P < 0.001 for group differences). Thresholds differed significantly across specialty, highest among infectious disease and lowest among emergency medicine clinicians and across years of experience, decreasing with increasing years of experience. CONCLUSIONS The threshold infection probability above which physicians choose to initiate antibiotics in suspected sepsis depends on illness severity as well as clinician factors. IMPLICATIONS Incorporating these context-dependent thresholds into discriminating and well-calibrated models will inform the development of future sepsis clinical decision support systems. Clinician-related differences in treatment thresholds suggests potential unwarranted variation and opportunities for performance improvement. HIGHLIGHTS Decision making about antibiotic initiation in suspected sepsis occurs under uncertainty, and little is known about clinicians' thresholds for treatment.In this prospective study, 153 clinicians from 3 health care systems reviewed 8 real-world clinical vignettes representing patients with sepsis and indicated the time that they would initiate antibiotics.Using a model-based approach, we estimated decision thresholds and found that thresholds differed significantly across illness severity categories and by clinician specialty and years of experience.
Collapse
Affiliation(s)
- Stephanie Parks Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine, Atrium Health, Charlotte NC, USA.,Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Charlotte NC, USA.,Center for Outcomes Research and Evaluation, Atrium Health, Charlotte NC, USA
| | - Gary E Weissman
- Palliative and Advanced Illness Research (PAIR) Center University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Pulmonary, Allergy, and Critical Care Division University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, And Institute for Biomedical Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte NC, USA
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Pulmonary Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sable Skewes
- Department of Internal Medicine, Wake Forest University School of Medicine, Atrium Health, Charlotte NC, USA
| | - Yunfei Xia
- Department of Mathematics and Statistics, University of North Carolina, Charlotte, NC, USA
| | - Shih-Hsuing Chou
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte NC, USA
| |
Collapse
|
22
|
Christensen EE, Binde C, Leegaard M, Tonby K, Dyrhol-Riise AM, Kvale D, Amundsen EK, Holten AR. DIAGNOSTIC ACCURACY AND ADDED VALUE OF INFECTION BIOMARKERS IN PATIENTS WITH POSSIBLE SEPSIS IN THE EMERGENCY DEPARTMENT. Shock 2022; 58:251-259. [PMID: 36130401 PMCID: PMC9584040 DOI: 10.1097/shk.0000000000001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Background: Biomarkers for early recognition of infection are warranted. The hypothesis of this study was that calprotectin, C-reactive protein (CRP), IL-6 and procalcitonin (PCT), alone or in combination, provide clinically useful information to the clinicians for early identification of infection in patients with possible sepsis in the emergency department (ED). Biomarker dynamics in the first week of hospitalization were explored. Methods: Adult patients in rapid response teams in the ED were included in a prospective observational study (n = 391). Patients who received antibiotics after biomarker availability were excluded. The ED clinician (EDC) decision whether to start antibiotics was registered. Calprotectin, CRP, IL-6, and PCT were analyzed in blood samples drawn within 15 min after ED arrival and in a subgroup for 1 week. Infection likelihood was evaluated post hoc . Results: In identifying patients with infection, CRP (area under the receiver operating characteristic curve [AUC], 0.913) and IL-6 (AUC, 0.895) were superior to calprotectin (AUC, 0.777) and PCT (AUC, 0.838). The best regression model predicting infections included EDC, CRP, and IL-6. Using optimal cutoff values, CRP and IL-6 in combination reached 95% positive and 90% negative predictive values for infection. The EDC undertreated or overtreated 65 of 391 patients (17%), and CRP and IL-6 optimal cutoff values could correct this in 32 of 65 patients (49%). Longitudinal samples revealed that IL-6 peaked in the ED, whereas CRP and PCT peaked later. Conclusion: C-reactive protein and IL-6 were superior to calprotectin and PCT for recognizing infection in patients with possible sepsis in the ED. Combining these two biomarkers with different dynamics improved recognition of infection and could aid clinical management in rapid response teams in the ED.
Collapse
Affiliation(s)
- Erik E. Christensen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Christina Binde
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Marianne Leegaard
- Division of Emergencies and Critical Care, Emergency Department, Oslo University Hospital, Oslo, Norway
| | - Kristian Tonby
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Anne-Ma Dyrhol-Riise
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Dag Kvale
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway
| | - Erik K. Amundsen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Department of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Aleksander R. Holten
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
23
|
Klompas M, Rhee C. Antibiotics: it is all about timing, isn't it? Curr Opin Crit Care 2022; 28:513-521. [PMID: 35942689 DOI: 10.1097/mcc.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Sepsis guidelines and quality measures set aggressive deadlines for administering antibiotics to patients with possible sepsis or septic shock. However, the diagnosis of sepsis is often uncertain, particularly upon initial presentation, and pressure to treat more rapidly may harm some patients by exposing them to unnecessary or inappropriate broad-spectrum antibiotics. RECENT FINDINGS Observational studies that report that each hour until antibiotics increases mortality often fail to adequately adjust for comorbidities and severity of illness, fail to account for antibiotics given to uninfected patients, and inappropriately blend the effects of long delays with short delays. Accounting for these factors weakens or eliminates the association between time-to-antibiotics and mortality, especially for patients without shock. These findings are underscored by analyses of the Centers for Medicaid and Medicare Services SEP-1 measure: it has increased sepsis diagnoses and broad-spectrum antibiotic use but has not improved outcomes. SUMMARY Clinicians are advised to tailor the urgency of antibiotics to their certainty of infection and patients' severity of illness. Immediate antibiotics are warranted for patients with possible septic shock or high likelihood of infection. Antibiotics can safely be withheld to allow for more investigation, however, in most patients with less severe illnesses if the diagnosis of infection is uncertain.
Collapse
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
24
|
Lanckohr C, Bracht H. Antimicrobial stewardship. Curr Opin Crit Care 2022; 28:551-556. [PMID: 35942707 DOI: 10.1097/mcc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes. Antimicrobial stewardship (AMS) is a bundle of interventions aimed at promoting the responsible use of antiinfectives. The ICU is an important field of activity for AMS because of high rates of antimicrobial use, high prevalence of resistant pathogens and complex pharmacology. This review discusses aims and interventions of AMS with special emphasis on the ICU. RECENT FINDINGS AMS-interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes. The de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure. Owing to the complex nature of critical illness, the pharmacological optimization of antimicrobial therapy is an important goal in the ICU. AMS-objectives and strategies are also applicable to patients with sepsis. This is reflected in the most recent guidelines by the Surviving Sepsis Campaign. AMS-interventions need to be adapted to their respective setting and be mindful of local prescribing cultures and prescribers' attitudes. SUMMARY AMS in the ICU is effective and safe. Intensivists should be actively involved in AMS-programs and propagate responsible use of antimicrobials.
Collapse
Affiliation(s)
- Christian Lanckohr
- Antibiotic Stewardship Team, Institute of Hygiene, University Hospital Münster, Münster
| | - Hendrik Bracht
- Central Emergency Services, University Hospital Ulm, Ulm, Germany
| |
Collapse
|
25
|
Prescott HC, Seelye S, Wang XQ, Hogan CK, Smith JT, Kipnis P, Barreda F, Donnelly JP, Pogue JM, Iwashyna TJ, Jones MM, Liu VX. Temporal Trends in Antimicrobial Prescribing During Hospitalization for Potential Infection and Sepsis. JAMA Intern Med 2022; 182:805-813. [PMID: 35759274 PMCID: PMC9237797 DOI: 10.1001/jamainternmed.2022.2291] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Importance Some experts have cautioned that national and health system emphasis on rapid administration of antimicrobials for sepsis may increase overall antimicrobial use even among patients without sepsis. Objective To assess whether temporal changes in antimicrobial timing for sepsis are associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among all hospitalized patients at risk for sepsis. Design, Setting, and Participants This is an observational cohort study of hospitalized patients at 152 hospitals in 2 health care systems during 2013 to 2018, admitted via the emergency department with 2 or more systemic inflammatory response syndrome (SIRS) criteria. Data analysis was performed from June 10, 2021, to March 22, 2022. Exposures Hospital-level temporal trends in time to first antimicrobial administration. Outcomes Antimicrobial outcomes included antimicrobial use, days of therapy, and broadness of antibacterial coverage. Clinical outcomes included in-hospital mortality, 30-day mortality, length of hospitalization, and new multidrug-resistant (MDR) organism culture positivity. Results Among 1 559 523 patients admitted to the hospital via the emergency department with 2 or more SIRS criteria (1 269 998 male patients [81.4%]; median [IQR] age, 67 [59-77] years), 273 255 (17.5%) met objective criteria for sepsis. In multivariable models adjusted for patient characteristics, the adjusted median (IQR) time to first antimicrobial administration to patients with sepsis decreased by 37 minutes, from 4.7 (4.1-5.3) hours in 2013 to 3.9 (3.6-4.4) hours in 2018, although the slope of decrease varied across hospitals. During the same period, antimicrobial use within 48 hours, days of antimicrobial therapy, and receipt of broad-spectrum coverage decreased among the broader cohort of patients with SIRS. In-hospital mortality, 30-day mortality, length of hospitalization, new MDR culture positivity, and new MDR blood culture positivity decreased over the study period among both patients with sepsis and those with SIRS. When examining hospital-specific trends, decreases in antimicrobial use, days of therapy, and broadness of antibacterial coverage for patients with SIRS did not differ by hospital antimicrobial timing trend for sepsis. Overall, there was no evidence that accelerating antimicrobial timing for sepsis was associated with increasing antimicrobial use or impaired antimicrobial stewardship. Conclusions and Relevance In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among the broader population at-risk for sepsis, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.
Collapse
Affiliation(s)
- Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Xiao Qing Wang
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Joshua T. Smith
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Fernando Barreda
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - John P. Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
| | - Jason M. Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor
| | - Theodore J. Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Makoto M. Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
| |
Collapse
|
26
|
Brant EB, Kennedy JN, King AJ, Gerstley LD, Mishra P, Schlessinger D, Shalaby J, Escobar GJ, Angus DC, Seymour CW, Liu VX. Developing a shared sepsis data infrastructure: a systematic review and concept map to FHIR. NPJ Digit Med 2022; 5:44. [PMID: 35379946 PMCID: PMC8979949 DOI: 10.1038/s41746-022-00580-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/24/2022] [Indexed: 12/26/2022] Open
Abstract
The development of a shared data infrastructure across health systems could improve research, clinical care, and health policy across a spectrum of diseases, including sepsis. Awareness of the potential value of such infrastructure has been heightened by COVID-19, as the lack of a real-time, interoperable data network impaired disease identification, mitigation, and eradication. The Sepsis on FHIR collaboration establishes a dynamic, federated, and interoperable system of sepsis data from 55 hospitals using 2 distinct inpatient electronic health record systems. Here we report on phase 1, a systematic review to identify clinical variables required to define sepsis and its subtypes to produce a concept mapping of elements onto Fast Healthcare Interoperability Resources (FHIR). Relevant papers described consensus sepsis definitions, provided criteria for sepsis, severe sepsis, septic shock, or detailed sepsis subtypes. Studies not written in English, published prior to 1970, or "grey" literature were prospectively excluded. We analyzed 55 manuscripts yielding 151 unique clinical variables. We then mapped variables to their corresponding US Core FHIR resources and specific code values. This work establishes the framework to develop a flexible infrastructure for sharing sepsis data, highlighting how FHIR could enable the extension of this approach to other important conditions relevant to public health.
Collapse
Affiliation(s)
- Emily B Brant
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Assistant Professor of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine,, 200 Lothrop Street, #607, Pittsburgh, PA, 15261, USA.
| | - Jason N Kennedy
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Andrew J King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Pranita Mishra
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | | | | | | | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vincent X Liu
- Kaiser Permanente Division of Research, Oakland, CA, USA
| |
Collapse
|
27
|
Finding the balance between overtreatment versus undertreatment for hospital-acquired pneumonia. Infect Control Hosp Epidemiol 2022; 43:376-378. [PMID: 34847978 DOI: 10.1017/ice.2021.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
28
|
Martín-Fernández M, Heredia-Rodríguez M, González-Jiménez I, Lorenzo-López M, Gómez-Pesquera E, Poves-Álvarez R, Álvarez FJ, Jorge-Monjas P, Beltrán-DeHeredia J, Gutiérrez-Abejón E, Herrera-Gómez F, Guzzo G, Gómez-Sánchez E, Tamayo-Velasco Á, Aller R, Pelosi P, Villar J, Tamayo E. Hyperoxemia in postsurgical sepsis/septic shock patients is associated with reduced mortality. Crit Care 2022; 26:4. [PMID: 35000603 PMCID: PMC8744280 DOI: 10.1186/s13054-021-03875-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/20/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite growing interest in treatment strategies that limit oxygen exposure in ICU patients, no studies have compared conservative oxygen with standard oxygen in postsurgical patients with sepsis/septic shock, although there are indications that it may improve outcomes. It has been proven that high partial pressure of oxygen in arterial blood (PaO2) reduces the rate of surgical-wound infections and mortality in patients under major surgery. The aim of this study is to examine whether PaO2 is associated with risk of death in adult patients with sepsis/septic shock after major surgery. METHODS We performed a secondary analysis of a prospective observational study in 454 patients who underwent major surgery admitted into a single ICU. Patients were stratified in two groups whether they had hyperoxemia, defined as PaO2 > 100 mmHg (n = 216), or PaO2 ≤ 100 mmHg (n = 238) at the day of sepsis/septic shock onset according to SEPSIS-3 criteria maintained during 48 h. Primary end-point was 90-day mortality after diagnosis of sepsis. Secondary endpoints were ICU length of stay and time to extubation. RESULTS In patients with PaO2 ≤ 100 mmHg, we found prolonged mechanical ventilation (2 [8] vs. 1 [4] days, p < 0.001), higher ICU stay (8 [13] vs. 5 [9] days, p < 0.001), higher organ dysfunction as assessed by SOFA score (9 [3] vs. 7 [5], p < 0.001), higher prevalence of septic shock (200/238, 84.0% vs 145/216) 67.1%, p < 0.001), and higher 90-day mortality (37.0% [88] vs. 25.5% [55], p = 0.008). Hyperoxemia was associated with higher probability of 90-day survival in a multivariate analysis (OR 0.61, 95%CI: 0.39-0.95, p = 0.029), independent of age, chronic renal failure, procalcitonin levels, and APACHE II score > 19. These findings were confirmed when patients with severe hypoxemia at the time of study inclusion were excluded. CONCLUSIONS Oxygenation with a PaO2 above 100 mmHg was independently associated with lower 90-day mortality, shorter ICU stay and intubation time in critically ill postsurgical sepsis/septic shock patients. Our findings open a new venue for designing clinical trials to evaluate the boundaries of PaO2 in postsurgical patients with severe infections.
Collapse
Affiliation(s)
- Marta Martín-Fernández
- Department of Medicine, Toxicology and Dermatology, University of Valladolid, Valladolid, Spain
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - María Heredia-Rodríguez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | | | - Mario Lorenzo-López
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Estefanía Gómez-Pesquera
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Rodrigo Poves-Álvarez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - F. Javier Álvarez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacology, University of Valladolid, Valladolid, Spain
| | - Pablo Jorge-Monjas
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Eduardo Gutiérrez-Abejón
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacology, University of Valladolid, Valladolid, Spain
| | - Francisco Herrera-Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gabriella Guzzo
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Esther Gómez-Sánchez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Álvaro Tamayo-Velasco
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Hematology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Rocío Aller
- Department of Medicine, Toxicology and Dermatology, University of Valladolid, Valladolid, Spain
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Department of Gastroenterology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019 Las Palmas de Gran Canaria, Spain
- Li Ka Shing Knowledge Institute at St. Michael’s Hospital, Toronto, ON Canada
| | - Eduardo Tamayo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Department of Surgery, University of Valladolid, Valladolid, Spain
| |
Collapse
|
29
|
Ho BS, Wu Lee YH, Lin YB. Impact of hourly serial SOFA score on signaling emerging sepsis. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2022.100999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
30
|
Baghela A, Pena OM, Lee AH, Baquir B, Falsafi R, An A, Farmer SW, Hurlburt A, Mondragon-Cardona A, Rivera JD, Baker A, Trahtemberg U, Shojaei M, Jimenez-Canizales CE, Dos Santos CC, Tang B, Bouma HR, Cohen Freue GV, Hancock REW. Predicting sepsis severity at first clinical presentation: The role of endotypes and mechanistic signatures. EBioMedicine 2022; 75:103776. [PMID: 35027333 PMCID: PMC8808161 DOI: 10.1016/j.ebiom.2021.103776] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/01/2021] [Accepted: 12/10/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Inter-individual variability during sepsis limits appropriate triage of patients. Identifying, at first clinical presentation, gene expression signatures that predict subsequent severity will allow clinicians to identify the most at-risk groups of patients and enable appropriate antibiotic use. METHODS Blood RNA-Seq and clinical data were collected from 348 patients in four emergency rooms (ER) and one intensive-care-unit (ICU), and 44 healthy controls. Gene expression profiles were analyzed using machine learning and data mining to identify clinically relevant gene signatures reflecting disease severity, organ dysfunction, mortality, and specific endotypes/mechanisms. FINDINGS Gene expression signatures were obtained that predicted severity/organ dysfunction and mortality in both ER and ICU patients with accuracy/AUC of 77-80%. Network analysis revealed these signatures formed a coherent biological program, with specific but overlapping mechanisms/pathways. Given the heterogeneity of sepsis, we asked if patients could be assorted into discrete groups with distinct mechanisms (endotypes) and varying severity. Patients with early sepsis could be stratified into five distinct and novel mechanistic endotypes, named Neutrophilic-Suppressive/NPS, Inflammatory/INF, Innate-Host-Defense/IHD, Interferon/IFN, and Adaptive/ADA, each based on ∼200 unique gene expression differences, and distinct pathways/mechanisms (e.g., IL6/STAT3 in NPS). Endotypes had varying overall severity with two severe (NPS/INF) and one relatively benign (ADA) groupings, consistent with reanalysis of previous endotype studies. A 40 gene-classification tool (accuracy=96%) and several gene-pairs (accuracy=89-97%) accurately predicted endotype status in both ER and ICU validation cohorts. INTERPRETATION The severity and endotype signatures indicate that distinct immune signatures precede the onset of severe sepsis and lethality, providing a method to triage early sepsis patients.
Collapse
Affiliation(s)
- Arjun Baghela
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada; Bioinformatics Graduate Program, Genome Sciences Centre, 570 W 7th Ave, Vancouver V5T 4S6, Canada
| | - Olga M Pena
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Amy H Lee
- Department of Molecular Biology and Biochemistry, Simon Fraser University, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada
| | - Beverlie Baquir
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Reza Falsafi
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Andy An
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Susan W Farmer
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada
| | - Andrew Hurlburt
- Vancouver General Hospital, 899 W 12th Ave, Vancouver V5Z 1M9, Canada
| | - Alvaro Mondragon-Cardona
- Hospital Universitario Hernando Moncaleano, Calle 9 No. 15-25, Neiva, Colombia; Department of Internal Medicine, Universidad Surcolombiana, Calle 9 Carrera 14, Neiva, Colombia
| | - Juan Diego Rivera
- Hospital Universitario Hernando Moncaleano, Calle 9 No. 15-25, Neiva, Colombia; Department of Internal Medicine, Universidad Surcolombiana, Calle 9 Carrera 14, Neiva, Colombia
| | - Andrew Baker
- Keenan Research Centre for Biomedical Science, Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5G1W8, Canada
| | - Uriel Trahtemberg
- Keenan Research Centre for Biomedical Science, Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5G1W8, Canada
| | - Maryam Shojaei
- The Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia
| | - Carlos Eduardo Jimenez-Canizales
- Hospital Universitario Hernando Moncaleano, Calle 9 No. 15-25, Neiva, Colombia; Department of Internal Medicine, Universidad Surcolombiana, Calle 9 Carrera 14, Neiva, Colombia
| | - Claudia C Dos Santos
- Keenan Research Centre for Biomedical Science, Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5G1W8, Canada
| | - Benjamin Tang
- The Westmead Institute for Medical Research, 176 Hawkesbury Rd, Westmead, NSW 2145, Australia
| | - Hjalmar R Bouma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 AV, the Netherland; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 AV, the Netherland
| | - Gabriela V Cohen Freue
- Department of Statistics, University of British Columbia, 2207 Main Mall, Vancouver V6T 1Z4, Canada
| | - Robert E W Hancock
- Centre for Microbial Diseases and Immunity Research, University of British Colombia, 232-2259 Lower Mall, Vancouver V6T 1Z4, Canada.
| |
Collapse
|
31
|
Patient Heterogeneity and the J-Curve Relationship Between Time-to-Antibiotics and the Outcomes of Patients Admitted With Bacterial Infection. Crit Care Med 2021; 50:799-809. [PMID: 34974496 DOI: 10.1097/ccm.0000000000005429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Sepsis remains a leading and preventable cause of hospital utilization and mortality in the United States. Despite updated guidelines, the optimal definition of sepsis as well as optimal timing of bundled treatment remain uncertain. Identifying patients with infection who benefit from early treatment is a necessary step for tailored interventions. In this study, we aimed to illustrate clinical predictors of time-to-antibiotics among patients with severe bacterial infection and model the effect of delay on risk-adjusted outcomes across different sepsis definitions. DESIGN A multicenter retrospective observational study. SETTING A seven-hospital network including academic tertiary care center. PATIENTS Eighteen-thousand three-hundred fifteen patients admitted with severe bacterial illness with or without sepsis by either acute organ dysfunction (AOD) or systemic inflammatory response syndrome positivity. MEASUREMENTS AND MAIN RESULTS The primary exposure was time to antibiotics. We identified patient predictors of time-to-antibiotics including demographics, chronic diagnoses, vitals, and laboratory results and determined the impact of delay on a composite of inhospital death or length of stay over 10 days. Distribution of time-to-antibiotics was similar across patients with and without sepsis. For all patients, a J-curve relationship between time-to-antibiotics and outcomes was observed, primarily driven by length of stay among patients without AOD. Patient characteristics provided good to excellent prediction of time-to-antibiotics irrespective of the presence of sepsis. Reduced time-to-antibiotics was associated with improved outcomes for all time points beyond 2.5 hours from presentation across sepsis definitions. CONCLUSIONS Antibiotic timing is a function of patient factors regardless of sepsis criteria. Similarly, we show that early administration of antibiotics is associated with improved outcomes in all patients with severe bacterial illness. Our findings suggest identifying infection is a rate-limiting and actionable step that can improve outcomes in septic and nonseptic patients.
Collapse
|
32
|
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 923] [Impact Index Per Article: 307.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
33
|
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1507] [Impact Index Per Article: 502.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
34
|
Wayne MT, Seelye S, Molling D, Wang XQ, Donnelly JP, Hogan CK, Jones MM, Iwashyna TJ, Liu VX, Prescott HC. Temporal Trends and Hospital Variation in Time-to-Antibiotics Among Veterans Hospitalized With Sepsis. JAMA Netw Open 2021; 4:e2123950. [PMID: 34491351 PMCID: PMC8424480 DOI: 10.1001/jamanetworkopen.2021.23950] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/01/2021] [Indexed: 12/19/2022] Open
Abstract
Importance It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. Objective To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. Design, Setting, and Participants This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021. Exposures Time from presentation to antibiotic administration. Main Outcomes and Measures The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models. Results A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P < .001). In multilevel models adjusted for patient characteristics, median time-to-antibiotics declined by 9.0 (95% CI, 8.8-9.2) minutes per calendar year. Temporal trends in time-to-antibiotics were similar across patient subgroups, but hospitals with faster baseline time-to-antibiotics had less change over time, with hospitals in the slowest tertile decreasing time-to-antibiotics by 16.6 minutes (23.1%) per year, while hospitals in the fastest tertile decreased time-to-antibiotics by 7.2 minutes (13.1%) per year. In the most recent years (2017-2018), median time-to-antibiotics ranged from 3.1 to 6.7 hours across hospitals (after adjustment for patient characteristics), 6.8% of variation in time-to-antibiotics was explained at the hospital level, and odds of receiving antibiotics within 3 hours increased by 65% (95% CI, 56%-77%) for the median patient if moving to a hospital with faster time-to-antibiotics. Conclusions and Relevance This cohort study across nationwide VA hospitals found that time-to-antibiotics for sepsis has declined over time. However, there remains significant variability in time-to-antibiotics not explained by patient characteristics, suggesting potential unwarranted practice variation in sepsis treatment. Efforts to further accelerate time-to-antibiotics must be weighed against risks of overtreatment.
Collapse
Affiliation(s)
- Max T. Wayne
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Daniel Molling
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Xiao Qing Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - John P. Donnelly
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | | | - Makoto M. Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| |
Collapse
|
35
|
Recalibrating Our Approach to the Management of Sepsis. How the Four Moments of Antibiotic Decision-Making Can Help. Ann Am Thorac Soc 2021; 18:200-203. [PMID: 33252987 DOI: 10.1513/annalsats.202005-484ip] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
36
|
Siewers K, Abdullah SMOB, Sørensen RH, Nielsen FE. Time to administration of antibiotics and mortality in sepsis. J Am Coll Emerg Physicians Open 2021; 2:e12435. [PMID: 34027515 PMCID: PMC8119622 DOI: 10.1002/emp2.12435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 11/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Karina Siewers
- Respiratory Research Unit, Department of Respiratory MedicineCopenhagen University HospitalBispebjerg and FrederiksbergCopenhagenDenmark
- Department of Emergency MedicineCopenhagen University Hospital‐Bispebjerg and FrederiksbergCopenhagenDenmark
| | | | | | - Finn Erland Nielsen
- Department of Emergency MedicineCopenhagen University Hospital‐Bispebjerg and FrederiksbergCopenhagenDenmark
- Copenhagen Center for Translational ResearchCopenhagen University Hospital, Bispebjerg and FrederiksbergCopenhagenDenmark
| |
Collapse
|
37
|
Chen M, Hernández A. Towards an explainable model for Sepsis detection based on sensitivity analysis. Ing Rech Biomed 2021. [DOI: 10.1016/j.irbm.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
38
|
Vaughn VM, Gandhi TN, Petty LA, Patel PK, Prescott HC, Malani AN, Ratz D, McLaughlin E, Chopra V, Flanders SA. Empiric Antibacterial Therapy and Community-onset Bacterial Coinfection in Patients Hospitalized With Coronavirus Disease 2019 (COVID-19): A Multi-hospital Cohort Study. Clin Infect Dis 2021; 72:e533-e541. [PMID: 32820807 PMCID: PMC7499526 DOI: 10.1093/cid/ciaa1239] [Citation(s) in RCA: 249] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Antibacterials may be initiated out of concern for bacterial coinfection in coronavirus disease 2019 (COVID-19). We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial coinfections in hospitalized patients with COVID-19. METHODS A randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020 and 6/18/2020. Data were collected on early (within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial coinfections (positive microbiologic test ≤3 days). Poisson generalized estimating equation models were used to assess predictors. RESULTS Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27% to 84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00-1.08] per 10 years); had a lower body mass index (ARR: 0.99 [0.99-1.00] per kg/m2), more severe illness (eg, severe sepsis; ARR: 1.16 [1.07-1.27]), a lobar infiltrate (ARR: 1.21 [1.04-1.42]); or were admitted to a for-profit hospital (ARR: 1.30 [1.15-1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs April [85.2%, 628/737], P < .001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs March) decreased. CONCLUSIONS The prevalence of confirmed community-onset bacterial coinfections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.
Collapse
Affiliation(s)
- Valerie M Vaughn
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
39
|
Taylor SP, Anderson WE, Beam K, Taylor B, Ellerman J, Kowalkowski MA. The Association Between Antibiotic Delay Intervals and Hospital Mortality Among Patients Treated in the Emergency Department for Suspected Sepsis. Crit Care Med 2021; 49:741-747. [PMID: 33591002 DOI: 10.1097/ccm.0000000000004863] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Rapid delivery of antibiotics is a cornerstone of sepsis therapy, although time targets for specific components of antibiotic delivery are unknown. We quantified time intervals comprising the task of antibiotic delivery and evaluated the association between interval delays and hospital mortality among patients treated in the emergency department for suspected sepsis. DESIGN Retrospective cohort. SETTING Twelve hospitals in Southeastern United States from 2014 to 2017. PATIENTS Twenty-four thousand ninety-three encounters among 20,026 adults with suspected sepsis in 12 emergency departments. MEASUREMENTS AND MAIN RESULTS We divided antibiotic administration into two intervals: time from emergency department triage to antibiotic order (recognition delay) and time from antibiotic order to infusion (administration delay). We used generalized linear mixed models to evaluate associations between these intervals and hospital mortality. Median time from emergency department triage to antibiotic administration was 3.4 hours (interquartile range, 2.0-6.0 hr), separated into a median recognition delay (time from emergency department triage to antibiotic order) of 2.7 hours(interquartile range, 1.5-4.7 hr) and median administration delay (time from antibiotic order to infusion) of 0.6 hours (0.3-1.2 hr). Adjusting for other risk factors, both recognition delay and administration delay were associated with mortality, but pairwise comparison with a no-delay reference group was not significant for up to 6 hours of recognition delay or up to 1.5 hours of administration delay. CONCLUSIONS Both recognition delays and administration delays were associated with increased hospital mortality, but only for longer delays. These results suggest that both metrics may be important to measure and improve for patients with suspected sepsis but do not support targets less than 1 hour.
Collapse
Affiliation(s)
- Stephanie Parks Taylor
- Department of Internal Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - William E Anderson
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
| | - Kent Beam
- Department of Internal Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Brice Taylor
- Department of Internal Medicine, Atrium Health's Carolinas Medical Center, Charlotte, NC
| | - Justin Ellerman
- Department of Internal Medicine, University of Alabama, Birmingham, AL
| | - Marc A Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
| |
Collapse
|
40
|
Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
Collapse
Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
41
|
Townsend SR, Rivers EP, Duseja R. Centers for Medicare and Medicaid Services Measure Stewards' Assessment of the Infectious Diseases Society of America's Position Paper on SEP-1. Clin Infect Dis 2021; 72:553-555. [PMID: 32374387 DOI: 10.1093/cid/ciaa458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/17/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sean R Townsend
- Division of Pulmonary, Critical Care Medicine, California Pacific Medical Center, San Francisco, California, USA.,University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Emanuel P Rivers
- Department of Emergency Medicine and Surgery, Henry Ford Hospital, Detroit, Michigan, USA.,Wayne State University, Detroit, Michigan, USA
| | - Reena Duseja
- Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
| |
Collapse
|
42
|
Ducharme J, Self WH, Osborn TM, Ledeboer NA, Romanowsky J, Sweeney TE, Liesenfeld O, Rothman RE. A Multi-mRNA Host-Response Molecular Blood Test for the Diagnosis and Prognosis of Acute Infections and Sepsis: Proceedings from a Clinical Advisory Panel. J Pers Med 2020; 10:jpm10040266. [PMID: 33297498 PMCID: PMC7762405 DOI: 10.3390/jpm10040266] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/12/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022] Open
Abstract
Current diagnostics are insufficient for diagnosis and prognosis of acute infections and sepsis. Clinical decisions including prescription and timing of antibiotics, ordering of additional diagnostics and level-of-care decisions rely on understanding etiology and implications of a clinical presentation. Host mRNA signatures can differentiate infectious from noninfectious etiologies, bacterial from viral infections, and predict 30-day mortality. The 29-host-mRNA blood-based InSepTM test (Inflammatix, Burlingame, CA, formerly known as HostDxTM Sepsis) combines machine learning algorithms with a rapid point-of-care platform with less than 30 min turnaround time to enable rapid diagnosis of acute infections and sepsis, as well as prediction of disease severity. A scientific advisory panel including emergency medicine, infectious disease, intensive care and clinical pathology physicians discussed technical and clinical requirements in preparation of successful introduction of InSep into the market. Topics included intended use; patient populations of greatest need; patient journey and sample flow in the emergency department (ED) and beyond; clinical and biomarker-based decision algorithms; performance characteristics for clinical utility; assay and instrument requirements; and result readouts. The panel identified clear demand for a solution like InSep, requirements regarding test performance and interpretability, and a need for focused medical education due to the innovative but complex nature of the result readout. Innovative diagnostic solutions such as the InSep test could improve management of patients with suspected acute infections and sepsis in the ED, thereby lessening the overall burden of these conditions on patients and the healthcare system.
Collapse
Affiliation(s)
- James Ducharme
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37220, USA;
| | - Tiffany M. Osborn
- Department of Medicine, Division of Emergency Medicine and Department of Surgery, Washington University, St. Louis, MO 63110, USA;
| | - Nathan A. Ledeboer
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | | | | | - Oliver Liesenfeld
- Inflammatix Inc., Burlingame, CA 94010, USA; (J.R.); (T.E.S.)
- Correspondence: ; Tel.: +1-925-963-9470
| | - Richard E. Rothman
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, MD 21264, USA;
| |
Collapse
|
43
|
Guidry CA, Sawyer RG, Winfield RD. Challenging the Dogma of Aggressive Initiation of Antibiotics in Sepsis. Surg Infect (Larchmt) 2020; 22:473-476. [PMID: 33232638 DOI: 10.1089/sur.2020.244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher A Guidry
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Critical Care, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
| | - Robert D Winfield
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Critical Care, The University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
44
|
Harrison WN, Workman JK, Bonafide CP, Lockwood JM. Surviving Sepsis Screening: The Unintended Consequences of Continuous Surveillance. Hosp Pediatr 2020; 10:e14-e17. [PMID: 33184126 DOI: 10.1542/hpeds.2020-002121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Wade N Harrison
- Pediatric Residency Program and Divisions of Pediatric Inpatient Medicine and .,Division of Hospital Pediatrics, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer K Workman
- Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Justin M Lockwood
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| |
Collapse
|
45
|
Winter A, Jones WS, Allen AJ, Price DA, Rostron A, Filieri R, Graziadio S. The Clinical Need for New Diagnostics in the Identification and Management of Patients with Suspected Sepsis in UK NHS Hospitals: A Survey of Healthcare Professionals. Antibiotics (Basel) 2020; 9:antibiotics9110737. [PMID: 33114715 PMCID: PMC7693654 DOI: 10.3390/antibiotics9110737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/16/2022] Open
Abstract
Development of a new diagnostic is ideally driven by an understanding of the clinical need that the test addresses and the optimal role the test will have within a care pathway. This survey aimed to understand the clinical need for new sepsis diagnostics and to identify specific clinical scenarios that could be improved by testing. An electronic, cross-sectional survey was circulated to UK National Health Service (NHS) doctors and nurses who care for patients with suspected sepsis in hospitals. Two hundred and sixty-five participants completed the survey, representing 64 NHS Trusts in England. Sixty-seven percent of respondents suggested that the major cause of delay was during the initial identification of sepsis and the subsequent recognition of patients who were deteriorating. Existing blood tests did not enhance the confidence of consultants making their diagnoses. Those surveyed identified a role for a near-patient test to "rule out" suspected sepsis and, thereby, stop or postpone use of antibiotics. Current diagnostic tests are slow, non-specific, and do not reliably identify patients with a high suspicion of sepsis. As a result, they have a limited use in patient management and antibiotic stewardship. Future development of sepsis diagnostics should focus on overcoming these limitations.
Collapse
Affiliation(s)
- Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-Operative, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK; (A.J.A.); (S.G.)
- The Newcastle Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK;
- Correspondence:
| | - William Stephen Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (W.S.J.); (A.R.)
| | - A. Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-Operative, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK; (A.J.A.); (S.G.)
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (W.S.J.); (A.R.)
| | - D. Ashley Price
- The Newcastle Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK;
| | - Anthony Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (W.S.J.); (A.R.)
- Integrated Critical Care Unit, Sunderland Royal Hospital, South Tyneside and Sunderland NHS Foundation Trust, Kayll Road, Sunderland SR4 7TP, UK
| | - Raffaele Filieri
- Audencia Business School, Marketing Department, 8 Route de la Jonelière, B.P. 31222, 44312 Nantes, CEDEX 3, France;
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-Operative, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4HH, UK; (A.J.A.); (S.G.)
- The Newcastle Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK;
| |
Collapse
|
46
|
Nagendran M, Chen Y, Gordon AC. Real time self-rating of decision certainty by clinicians: a systematic review. Clin Med (Lond) 2020; 19:369-374. [PMID: 31530683 DOI: 10.7861/clinmed.2019-0169] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BackgroundWe sought to establish to what extent decision certainty has been measured in real time and whether high or low levels of certainty correlate with clinical outcomes.MethodsOur pre-specified study protocol is published on PROSPERO, CRD42019128112. We identified prospective studies from Medline, Embase and PsycINFO up to February 2019 that measured real time self-rating of the certainty of a medical decision by a clinician.FindingsNine studies were included and all were generally at high risk of bias. Only one study assessed long-term clinical outcomes: patients rated with high diagnostic uncertainty for heart failure had longer length of stay, increased mortality and higher readmission rates at 1 year than those rated with diagnostic certainty. One other study demonstrated the danger of extreme diagnostic confidence - 7% of cases (24/341) labelled as having either 0% or 100% diagnostic likelihood of heart failure were made in error.ConclusionsThe literature on real time self-rated certainty of clinician decisions is sparse and only relates to diagnostic decisions. Further prospective research with a view to generating hypotheses for testable interventions that can better calibrate clinician certainty with accuracy of decision making could be valuable in reducing diagnostic error and improving outcomes.
Collapse
Affiliation(s)
- Myura Nagendran
- NIHR academic clinical fellow in intensive care medicine, Imperial College London, UK
| | - Yang Chen
- NIHR academic clinical fellow in cardiology, Institute of Cardiovascular Science, University College London, UK
| | - Anthony C Gordon
- Imperial College London, UK and Centre for Perioperative and Critical Care Research, London, UK
| |
Collapse
|
47
|
Lane DJ, Wunsch H, Saskin R, Cheskes S, Lin S, Morrison LJ, Scales DC. Screening strategies to identify sepsis in the prehospital setting: a validation study. CMAJ 2020; 192:E230-E239. [PMID: 32152051 DOI: 10.1503/cmaj.190966] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In the prehospital setting, differentiating patients who have sepsis from those who have infection but no organ dysfunction is important to initiate sepsis treatments appropriately. We aimed to identify which published screening strategies for paramedics to use in identifying patients with sepsis provide the most certainty for prehospital diagnosis. METHODS We identified published strategies for screening by paramedics through a literature search. We then conducted a validation study in Alberta, Canada, from April 2015 to March 2016. For adult patients (≥ 18 yr) who were transferred by ambulance, we linked records to an administrative database and then restricted the search to patients with infection diagnosed in the emergency department. For each patient, the classification from each strategy was determined and compared with the diagnosis recorded in the emergency department. For all strategies that generated numeric scores, we constructed diagnostic prediction models to estimate the probability of sepsis being diagnosed in the emergency department. RESULTS We identified 21 unique prehospital screening strategies, 14 of which had numeric scores. We linked a total of 131 745 eligible patients to hospital databases. No single strategy had both high sensitivity (overall range 0.02-0.85) and high specificity (overall range 0.38-0.99) for classifying sepsis. However, the Critical Illness Prediction (CIP) score, the National Early Warning Score (NEWS) and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score predicted a low to high probability of a sepsis diagnosis at different scores. The qSOFA identified patients with a 7% (lowest score) to 87% (highest score) probability of sepsis diagnosis. INTERPRETATION The CIP, NEWS and qSOFA scores are tools with good predictive ability for sepsis diagnosis in the prehospital setting. The qSOFA score is simple to calculate and may be useful to paramedics in screening patients with possible sepsis.
Collapse
Affiliation(s)
- Daniel J Lane
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont.
| | - Hannah Wunsch
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Refik Saskin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Sheldon Cheskes
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Steve Lin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Laurie J Morrison
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Damon C Scales
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (Lane, Wunsch, Saskin, Lin, Scales), Interdepartmental Division of Critical Care (Wunsch, Scales), Division of Emergency Medicine, Department of Family and Community Medicine (Cheskes), and Division of Emergency Medicine, Department of Medicine (Lin, Morrison), University of Toronto; Rescu, Li Ka Shing Knowledge Institute (Lane, Cheskes, Lin, Morrison), St. Michael's Hospital; Department of Critical Care Medicine (Wunsch) and Sunnybrook Centre for Prehospital Medicine (Cheskes), Sunnybrook Health Sciences Centre, Toronto, Ont
| |
Collapse
|
48
|
Anderson CM, Pitt WG. Effect of dilution on sedimentational separation of bacteria from blood. Biotechnol Prog 2020; 36:e3056. [PMID: 32715664 DOI: 10.1002/btpr.3056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/18/2020] [Accepted: 07/04/2020] [Indexed: 11/07/2022]
Abstract
Bacteria must be separated from septic whole blood in preparation for rapid antibiotic susceptibility tests. This work improves upon past work isolating bacteria from whole blood by exploring an important experimental factor: Whole blood dilution. Herein, we use the continuity equation to model red blood cell sedimentation and show that overall spinning time decreases as the blood is diluted. We found that the bacteria can also be captured more efficiently from diluted blood, up to approximately 68 ± 8% recovery (95% confidence interval). However, diluting blood both requires and creates extra fluid that end users must handle; an optimal dilution, which maximizes bacteria recovery and minimizes waste, was found to scale with the square root of the whole blood hematocrit. This work also explores a hypothesis that plasma backflow, which occurs as red cells move radially outward, causes bacterial enrichment in the supernatant plasma with an impact proportional to the plasma backflow velocity. Bacteria experiments carried out with diluted blood demonstrate such bacterial enrichment, but not in the hypothesized manner as enrichment occurred only in undiluted blood samples at physiological hematocrit.
Collapse
Affiliation(s)
- Clifton M Anderson
- Department of Chemical Engineering, Brigham Young University, Provo, Utah, USA
| | - William G Pitt
- Department of Chemical Engineering, Brigham Young University, Provo, Utah, USA
| |
Collapse
|
49
|
Strich JR, Heil EL, Masur H. Considerations for Empiric Antimicrobial Therapy in Sepsis and Septic Shock in an Era of Antimicrobial Resistance. J Infect Dis 2020; 222:S119-S131. [PMID: 32691833 PMCID: PMC7372215 DOI: 10.1093/infdis/jiaa221] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with sepsis present across a spectrum of infection sites and severity of illnesses requiring complex decision making at the bedside as to when prompt antibiotics are indicated and which regimen is warranted. Many hemodynamically stable patients with sepsis and low acuity of illness may benefit from further work up before initiating therapy, whereas patients with septic shock warrant emergent broad-spectrum antibiotics. The precise empiric regimen is determined by assessing patient and epidemiological risk factors, likely source of infection based on presenting signs and symptoms, and severity of illness. Hospitals should implement quality improvement measures to aid in the rapid and accurate diagnosis of septic patients and to ensure antibiotics are given to patients in an expedited fashion after antibiotic order.
Collapse
Affiliation(s)
- Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Henry Masur
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| |
Collapse
|
50
|
Klompas M, Ochoa A, Ji W, McKenna C, Clark R, Shenoy ES, Hooper D, Rhee C. Prevalence of Clinical Signs Within Reference Ranges Among Hospitalized Patients Prescribed Antibiotics for Pneumonia. JAMA Netw Open 2020; 3:e2010700. [PMID: 32678449 PMCID: PMC7368172 DOI: 10.1001/jamanetworkopen.2020.10700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Antibiotics are frequently prescribed for suspected pneumonia, but overdiagnosis is common and fixed regimens are often used despite randomized trials suggesting it is safe to stop antibiotics once clinical signs are normalizing. OBJECTIVE To quantify potential excess antibiotic prescribing by characterizing antibiotic use relative to patients' initial clinical signs and subsequent trajectories. DESIGN, SETTING, AND PARTICIPANTS An observational cohort study was conducted in 2 tertiary and 2 community hospitals in Eastern Massachusetts. All nonventilated adult patients admitted between May 1, 2017, and July 1, 2018 (194 521 hospitalizations), were included. MAIN OUTCOMES AND MEASURES Identification of all antibiotic starts for possible community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) per clinicians' stated indications. Potential excess antibiotic prescribing was quantified by characterizing the frequency of patients in whom all clinical signs were within reference ranges on the first day of antibiotic therapy and by how long antibiotic therapy was continued after all clinical signs were normal, including postdischarge antibiotics. RESULTS Among 194 521 hospitalizations, 9540 patients were treated for possible CAP (4574 [48.0%] women; mean [SD] age, 67.6 [17.0] years) and 2733 for possible HAP (1211 [44.3%] women; mean [SD] age, 66.7 [16.2] years). Temperature, respiratory rate, oxygen saturation, and white blood cell count were all within reference ranges on the first day of antibiotics in 1779 of 9540 (18.6%) episodes of CAP and 370 of 2733 (13.5%) episodes of HAP. Antibiotics were continued for 3 days or longer after all clinical signs were normal in 3322 of 9540 (34.8%) episodes of CAP and 1050 of 2733 (38.4%) episodes of HAP. Up to 24 978 of 71 706 (34.8%) antibiotic-days prescribed for possible pneumonia may have been unnecessary. CONCLUSIONS AND RELEVANCE In this study, almost one-fifth of hospitalized patients treated for pneumonia did not have any of the cardinal signs of pneumonia on the first day of treatment and antibiotics were continued for 3 days or longer after all signs were normal in more than a third of patients. These observations suggest substantial opportunities to improve antibiotic prescribing.
Collapse
Affiliation(s)
- Michael Klompas
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aileen Ochoa
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Wenjing Ji
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Pharmacy Administration and Clinical Pharmacy, Xi’an Jiaotong University School of Pharmacy, Xi’an, Shaanxi, China
| | - Caroline McKenna
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Roger Clark
- Department of Medicine, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts
| | - Erica S. Shenoy
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - David Hooper
- Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Chanu Rhee
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|