Improvements in Sepsis-associated Mortality in Hospitalized Patients with Cancer versus Those without Cancer. A 12-Year Analysis Using Clinical Data

Comparing the clinical characteristics and outcomes of septic shock children with and without malignancies: a retrospective cohort study

OBJECTIVE

There is an amelioration in mortality rates of septic shock patients with malignancies over time, but it remains uncertain in children. Therefore, the authors endeavored to compare the clinical characteristics, treatment needs, and outcomes of septic shock children with or without malignancies.

METHODS

The authors retrospectively analyzed the data of children admitted to the PICU due to septic shock from January 2015 to December 2022 in a tertiary pediatric hospital. The main outcome was in-hospital mortality.

RESULTS

A total of 508 patients were enrolled. The proportion of Gram-negative bacteria and fungal infections in children with malignancies was significantly higher than those without malignancies. Septic shock children with malignancies had a longer length of stay (LOS) in the hospital (21 vs. 11 days, p<0.001). However, there were no statistically significant differences in the LOS of PICU (5 vs. 5 days, p = 0.591), in-hospital mortality (43.0 % vs. 49.4 %, p = 0.276), and 28-day mortality (49.2 % vs. 44.7 %, p = 0.452). The 28-day survival analysis (p = 0.314) also showed no significant differences.

CONCLUSION

Although there are significant differences in the bacterial spectrum of infections, the septic shock children with or without malignancies showed a similar mortality rate. The septic shock children with malignancies had longer LOS of the hospital.

Pseudomonas aeruginosa Bloodstream Infections Presenting with Septic Shock in Neutropenic Cancer Patients: Impact of Empirical Antibiotic Therapy

This large, multicenter, retrospective cohort study including onco-hematological neutropenic patients with Pseudomonas aeruginosa bloodstream infection (PABSI) found that among 1213 episodes, 411 (33%) presented with septic shock. The presence of solid tumors (33.3% vs. 20.2%, p < 0.001), a high-risk Multinational Association for Supportive Care in Cancer (MASCC) index score (92.6% vs. 57.4%; p < 0.001), pneumonia (38% vs. 19.2% p < 0.001), and infection due to multidrug-resistant P. aeruginosa (MDRPA) (33.8% vs. 21.1%, p < 0.001) were statistically significantly higher in patients with septic shock compared to those without. Patients with septic shock were more likely to receive inadequate empirical antibiotic therapy (IEAT) (21.7% vs. 16.2%, p = 0.020) and to present poorer outcomes, including a need for ICU admission (74% vs. 10.5%; p < 0.001), mechanical ventilation (49.1% vs. 5.6%; p < 0.001), and higher 7-day and 30-day case fatality rates (58.2% vs. 12%, p < 0.001, and 74% vs. 23.1%, p < 0.001, respectively). Risk factors for 30-day case fatality rate in patients with septic shock were orotracheal intubation, IEAT, infection due to MDRPA, and persistent PABSI. Therapy with granulocyte colony-stimulating factor and BSI from the urinary tract were associated with improved survival. Carbapenems were the most frequent IEAT in patients with septic shock, and the use of empirical combination therapy showed a tendency towards improved survival. Our findings emphasize the need for tailored management strategies in this high-risk population.

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

PURPOSE OF REVIEW

Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures.

RECENT FINDINGS

The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation - including ICU, hospital, and 28-day mortality - across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement.

SUMMARY

Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.

Clinical spectrum and prognostic impact of cancer in critically ill patients with HIV: a multicentre cohort study

BACKGROUND

Both AIDS-defining and non-AIDS-defining cancers (ADC/NADC) predispose people living with HIV (PLHIV) to critical illnesses. The objective of this multicentre study was to investigate the prognostic impact of ADC and NADC in PLHIV admitted to the intensive care unit (ICU).

METHODS

All PLHIV admitted over the 2015-2020 period in 12 university-affiliated ICUs in France were included in the study cohort. The effect of ADC and NADC on in-hospital mortality (primary study endpoint) was measured through logistic regression with augmented backward elimination of potential independent variables. The association between ADC/NADC and treatment limitation decision (TLD) during the ICU stay (secondary study endpoint) was analysed. One-year mortality in patients discharged alive from the index hospital admission (exploratory study endpoint) was compared between those with ADC, NADC or no cancer.

RESULTS

Amongst the 939 included PLHIV (median age, 52 [43-59] years; combination antiretroviral therapy, 74.4%), 97 (10.3%) and 106 (11.3%) presented with an active NADC (mostly lung and intestinal neoplasms) and an active ADC (predominantly AIDS-defining non-Hodgkin lymphoma), respectively. Inaugural admissions were common. Bacterial sepsis and non-infectious neoplasm-related complications accounted for most of admissions in these subgroups. Hospital mortality was 12.4% in patients without cancer, 30.2% in ADC patients and 45.4% in NADC patients (P < 0.0001). NADC (adjusted odds ratio [aOR], 7.00; 95% confidence interval [CI], 4.07-12.05) and ADC (aOR, 3.11; 95% CI 1.76-5.51) were independently associated with in-hospital death after adjustment on severity and frailty markers. The prevalence of TLD was 8.0% in patients without cancer, 17.9% in ADC patients and 33.0% in NADC patients (P < 0.0001)-organ failures and non-neoplastic comorbidities were less often considered in patients with cancer. One-year mortality in survivors of the index hospital admission was 7.8% in patients without cancer, 17.0% in ADC patients and 33.3% in NADC patients (P < 0.0001).

CONCLUSIONS

NADC and ADC are equally prevalent, stand as a leading argument for TLD, and strongly predict in-hospital death in the current population of PLHIV requiring ICU admission.

Update on Sepsis Epidemiology in the Era of COVID-19

Timely and accurate data on the epidemiology of sepsis is essential to inform public policy, clinical practice, and research priorities. Recent studies have illuminated several ongoing questions about sepsis epidemiology, including the incidence and outcomes of sepsis in non-Western countries and in specialized populations such as surgical patients, patients with cancer, and the elderly. There have also been new insights into the limitations of current surveillance methods using administrative data and increasing experience tracking sepsis incidence and outcomes using "big data" approaches that take advantage of detailed electronic health record data. The COVID-19 pandemic, however, has fundamentally changed the landscape of sepsis epidemiology. It has increased sepsis rates, helped highlight ongoing controversies about how to define sepsis, and intensified debate about the possible unintended consequences of overly rigid sepsis care bundles. Despite these controversies, there is a growing consensus that severe COVID-19 causing organ dysfunction is appropriate to label as sepsis, even though it is treated very differently from bacterial sepsis, and that surveillance strategies need to be modified to reliably identify these cases to fully capture and delineate the current burden of sepsis. This review will summarize recent insights into the epidemiology of sepsis and highlight several urgent questions and priorities catalyzed by COVID-19.

Impact of cancer on mortality rates in patients with sepsis: A meta-analysis and meta-regression of current studies

BACKGROUND

Research suggests that approximately 6% of adult patients admitted to hospitals in the United States present with sepsis and there has been a minimal change in the incidence of this condition in the last decade. Furthermore, patients with cancer generally have a higher incidence of sepsis due to immunosuppression caused by cancer or its treatment.

AIM

To assess if cancer increases the mortality rates in sepsis patients by pooling evidence from contemporary studies.

METHODS

PubMed, Embase, and Google Scholar databases were searched from January 1, 2001 to December 15, 2021 for studies comparing outcomes of sepsis patients based on the presence of active cancer. Mortality data were pooled using a random-effects model, with the odds ratio (OR) and 95% confidence interval (CI) calculated. Meta-regression was conducted to assess the influence of confounders on mortality rates.

RESULTS

Nine studies were included. The meta-analysis demonstrated a non-significant tendency towards increased risk of early mortality (OR = 2.77, 95%CI: 0.88-8.66, I² = 99%) and a statistically significantly increased risk of late mortality amongst sepsis patients with cancer as compared to non-cancer sepsis patients (OR = 2.46, 95%CI: 1.42-4.25, I² = 99%). Overall, cancer was found to significantly increase the risk of mortality in sepsis patients (OR = 2.7, 95%CI: 1.07-6.84, I² = 99%). Meta-analysis indicated a statistically significantly increased risk of mortality in patients with solid tumors as well as hematological malignancies. Meta-regression indicated that an increase in the prevalence of comorbid pulmonary and renal diseases increased the risk of mortality in cancer patients with sepsis. Mortality rates increased with an increase in the percentage of patients with urinary tract infections while an inverse relationship was seen for infections of cutaneous origin.

CONCLUSION

Contemporary evidence indicates that the presence of any cancer in sepsis patients significantly increases the risk of mortality. Scarce data suggest that mortality is equally increased for both solid and hematological cancers. Current evidence is limited by high heterogeneity and there is a need for further studies taking into account several confounding variables to present better evidence.

Prognostic Impact of Neutropenia in Cancer Patients with Septic Shock: A 2009–2017 Nationwide Cohort Study

Simple Summary

The prognostic impact of neutropenia on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were analyzed. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. Neutropenia did not increase mortality in cancer patients with septic shock, suggesting that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.

Abstract

(1) Background: Neutropenia’s prognostic impact on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This population-based, case–control study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. (2) Methods: This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were included. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. Cox proportional hazard regression was performed after adjusting for age, sex, Charlson comorbidity index, and neutropenia. (3) Results: In 43,466 adult cancer patients with septic shock, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. In total, 6391 patients had neutropenic septic shock, and the prevalent cancer type was lung cancer, followed by leukemia, non-Hodgkin’s lymphoma, stomach cancer, and colon cancer. Furthermore, 30-day and 1-year mortality was lower in patients with neutropenia than in those without neutropenia. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. (4) Conclusions: In cancer patients presenting to the emergency department with septic shock, the presence of neutropenia did not increase mortality. This suggests that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.

Prevalence and Outcomes of Previously Healthy Adults Among Patients Hospitalized With Community-Onset Sepsis

BACKGROUND

Devastating cases of sepsis in previously healthy patients have received widespread attention and have helped to catalyze state and national mandates to improve sepsis detection and care. However, it is unclear what proportion of patients hospitalized with sepsis previously were healthy and how their outcomes compare with those of patients with comorbidities.

RESEARCH QUESTION

Among adults hospitalized with community-onset sepsis, how many previously were healthy and how do their outcomes compare with those of patients with comorbidities?

STUDY DESIGN AND METHODS

We retrospectively identified all adults with community-onset sepsis hospitalized in 373 US hospitals from 2009 through 2015 using clinical indicators of presumed infection and organ dysfunction (Centers for Disease Control and Prevention's Adult Sepsis Event criteria). Comorbidities were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We applied generalized linear mixed models to measure the associations between the presence or absence of comorbidities and short-term mortality (in-hospital death or discharge to hospice), adjusting for severity of illness on admission.

RESULTS

Of 6,715,286 hospitalized patients, 337,983 (5.0%) were hospitalized with community-onset sepsis. Most patients with sepsis (329,052 [97.4%]) had received a diagnosis of at least one comorbidity; only 2.6% previously were healthy. Patients with sepsis who previously were healthy were younger than those with comorbidities (mean age, 58.0 ± 19.8 years vs 67.0 ± 16.5 years), were less likely to require ICU care on admission (37.9% vs 50.5%), and were more likely to be discharged home (57.9% vs 45.6%), rather than to subacute facilities (16.3% vs 30.8%), but showed higher short-term mortality rates (22.8% vs 20.8%; P < .001 for all). The association between previously healthy status and higher short-term mortality persisted after risk adjustment (adjusted OR, 1.99; 95% CI, 1.87-2.13).

INTERPRETATION

The vast majority of patients hospitalized with community-onset sepsis harbor pre-existing comorbidities. However, previously healthy patients may be more likely to die when they seek treatment at the hospital with sepsis compared with patients with comorbidities. These findings underscore the importance of early sepsis recognition and treatment for all patients.

A nationwide study on characteristics and outcome of cancer patients with sepsis requiring intensive care

BACKGROUND

Sepsis is the leading cause of admission to the intensive care unit (ICU) for cancer patients and survival rates have historically been low. The aims of this nationwide cohort study were to describe the characteristics and outcomes of cancer patients admitted to the ICU with sepsis compared with other sepsis patients requiring ICU admission.

MATERIAL AND METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014 and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria. Clinical characteristics and outcomes of sepsis patients with cancer were compared to those without cancer.

RESULTS

In the study period, 235 of 971 (24%) patients admitted to Icelandic ICUs because of sepsis had cancer, most often a solid tumour (100), followed by metastatic tumours (69) and haematological malignancies (66). Infections were more often hospital-acquired in cancer patients (52%) than other sepsis patients (18%, p < 0.001) and sites of infections differed, with abdominal infections being most common in patients with solid and metastatic tumours but lungs and bloodstream infections in haematological malignancies. The length of stay in the ICU was shorter for sepsis patients with metastatic disease than other sepsis patients (2 vs. 4 days, p < 0.001) and they were more likely to have treatment limitations (52 vs. 19%, p < 0.05). Median survival of patients with metastatic disease was 19 days from ICU admission. The 28-day mortality (25%) of solid tumour patients was comparable to that of sepsis patients without cancer (20%, p < 0.001).

CONCLUSIONS

Cancer is a common comorbidity in patients admitted to the ICU with sepsis. The clinical presentation and outcome differs between cancer types. Individuals with metastatic cancer were unlikely to receive prolonged invasive ICU care treatment. Comparable short-term outcome was found for patients with solid tumours and no cancer.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors

BACKGROUND

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy.

METHODS

The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected.

RESULTS

Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037).

CONCLUSIONS

These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Outcomes and Predictors of 28-Day Mortality in Patients With Hematologic Malignancies and Septic Shock Defined by Sepsis-3 Criteria

BACKGROUND

To describe short-term outcomes and independent predictors of 28-dayx mortality in adult patients with hematologic malignancies and septic shock defined by the new Third International Consensus Definitions (Sepsis-3) criteria.

METHODS

We performed a retrospective cohort study of patients admitted to the medical ICU with septic shock from April 2016 to March 2019. Demographic and clinical features and short-term outcomes were collected. We used descriptive statistics to summarize patient characteristics, logistic regression to identify predictors of 28-day mortality, and Kaplan-Meier plots to assess survival.

RESULTS

Among the 459 hematologic patients with septic shock admitted to the ICU, 109 (23.7%) had received hematopoietic stem cell transplant. The median age was 63 years (range, 18-89 years), and 179 (39%) were women. Nonsurvivors had a higher Charlson comorbidity index (P=.007), longer length of stay before ICU admission (P=.01), and greater illness severity at diagnosis and throughout the hospital course (P<.001). The mortality rate at 28 days was 67.8% and increased with increasing sequential organ failure assessment score on admission (odds ratio [OR], 1.11; 95% CI, 1.03-1.20), respiratory failure (OR, 3.12; 95% CI, 1.49-6.51), and maximum lactate level (OR, 1.16; 95% CI, 1.10-1.22). Aminoglycosides administration (OR, 0.42; 95% CI, 0.26-0.69), serum albumin (OR, 0.51; 95% CI, 0.31-0.86), and granulocyte colony-stimulating factor (G-CSF) (OR, 0.40; 95% CI, 0.24-0.65) were associated with lower 28-day mortality. Life support limitations were present in 81.6% of patients at death. At 90 days, 19.4% of the patients were alive.

CONCLUSIONS

Despite efforts to enhance survival, septic shock in patients with hematologic malignancies is still associated with high mortality rates and poor 90-day survival. These results demonstrate the need for an urgent call to action with higher awareness, including the further evaluation of interventions such as earlier ICU admission, aminoglycosides administration, and G-CSF treatment.

Epidemiology, Outcomes, and Trends of Patients With Sepsis and Opioid-Related Hospitalizations in U.S. Hospitals

OBJECTIVES

Widespread use and misuse of prescription and illicit opioids have exposed millions to health risks including serious infectious complications. Little is known, however, about the association between opioid use and sepsis.

DESIGN

Retrospective cohort study.

SETTING

About 373 U.S. hospitals.

PATIENTS

Adults hospitalized between January 2009 and September 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sepsis was identified by clinical indicators of concurrent infection and organ dysfunction. Opioid-related hospitalizations were identified by the International Classification of Diseases, 9th Revision, Clinical Modification codes and/or inpatient orders for buprenorphine. Clinical characteristics and outcomes were compared by sepsis and opioid-related hospitalization status. The association between opioid-related hospitalization and all-cause, in-hospital mortality in patients with sepsis was assessed using mixed-effects logistic models to adjust for baseline characteristics and severity of illness.The cohort included 6,715,286 hospitalizations; 375,479 (5.6%) had sepsis, 130,399 (1.9%) had opioid-related hospitalizations, and 8,764 (0.1%) had both. Compared with sepsis patients without opioid-related hospitalizations (n = 366,715), sepsis patients with opioid-related hospitalizations (n = 8,764) were younger (mean 52.3 vs 66.9 yr) and healthier (mean Elixhauser score 5.4 vs 10.5), had more bloodstream infections from Gram-positive and fungal pathogens (68.9% vs 47.0% and 10.6% vs 6.4%, respectively), and had lower in-hospital mortality rates (10.6% vs 16.2%; adjusted odds ratio, 0.73; 95% CI, 0.60-0.79; p < 0.001 for all comparisons). Of 1,803 patients with opioid-related hospitalizations who died in-hospital, 928 (51.5%) had sepsis. Opioid-related hospitalizations accounted for 1.5% of all sepsis-associated deaths, including 5.7% of sepsis deaths among patients less than 50 years old. From 2009 to 2015, the proportion of sepsis hospitalizations that were opioid-related increased by 77% (95% CI, 40.7-123.5%).

CONCLUSIONS

Sepsis is an important cause of morbidity and mortality in patients with opioid-related hospitalizations, and opioid-related hospitalizations contribute disproportionately to sepsis-associated deaths among younger patients. In addition to ongoing efforts to combat the opioid crisis, public health agencies should focus on raising awareness about sepsis among patients who use opioids and their providers.

Sepsis Hospitalizations With Versus Without Cancer: Epidemiology, Outcomes, and Trends in Nationwide Analysis From 2008 to 2017

BACKGROUND

Sepsis and cancer continue to be one of the leading causes of death in the United States. Concomitantly, hospitalizations for sepsis with underlying cancer over the years have shown a decrease in mortality. However, large-scale contemporary data on mortality trends in sepsis hospitalizations with underlying malignancy are lacking.

RESEARCH QUESTION

Are there any identifiable trends in patients hospitalized for sepsis with underlying malignancy versus without malignancy?

STUDY DESIGN AND METHODS

We performed a retrospective cohort study using the National Inpatient Sample database from 2008 to 2017 to identify sepsis hospitalizations with versus without cancer. Baseline variables and mortality trends were compared between the 2 groups.

RESULTS

Of the 19,160,734 sepsis hospitalizations identified between 2008 and 2017, 3,913,813 (20.4%) were associated with cancer and 15,246,921 (79.6%) did not have underlying malignancy. Compared with 2008 to 2009, the multivariable-adjusted odds ratio (aOR) of death was lower in 2016 to 2017 for both cancer (aOR: 0.55, 95% confidence interval [CI]: 0.53-0.57) and noncancer-associated (aOR: 0.55, 95% CI: 0.53-0.57) sepsis hospitalizations. The nonsignificant interaction term (P=0.2239) revealed that the rate of decline in mortality did not differ between the 2 groups. Stratification of the mortality in sepsis hospitalizations by various age groups revealed that the odds of death associated with cancer were highest in the younger population (18 to 44 y) with an aOR: 3.40, 95% CI: 3.24-3.57. The aOR: showed a declining trend with increasing age until cancer-associated admissions had slightly lower odds of mortality than the noncancer group at age 85 years old and older (aOR: 0.93, 95% CI: 0.91-0.95).

CONCLUSION

In the 10-year study period, mortality in cancer and noncancer-associated sepsis hospitalizations has shown a declining trend. Furthermore, differences in mortality between the 2 groups decreased with increasing age.

Excess cost of care associated with sepsis in cancer patients: Results from a population-based case-control matched cohort

BACKGROUND

Cancer patients are at significant risk of developing sepsis due to underlying malignancy and necessary treatments. Little is known about the economic burden of sepsis in this high-risk population. We estimate the short- and long-term healthcare costs of care of cancer patients with and without sepsis using individual-level linked-administrative data.

METHODS

We conducted a population-based matched cohort study of cancer patients aged ≥18, diagnosed between 2010 and 2017. Cases were identified if diagnosed with sepsis during the study period, and were matched 1:1 by age, sex, cancer type and other variables to controls without sepsis. Mean costs (2018 Canadian dollars) for patients with and without sepsis up to 5 years were estimated adjusted using survival probabilities at partitioned intervals. We estimated excess cost associated with sepsis presented as a cost difference between the two cohorts. Haematological and solid cancers were analysed separately.

RESULTS

77,483 cancer patients with sepsis were identified and matched. 64.3% of the cohort were aged ≥65, 46.3% female and 17.8% with haematological malignancies. Among solid tumour patients, the excess cost of care among patients who developed sepsis was $29,081 (95%CI, $28,404-$29,757) in the first year, rising to $60,714 (95%CI, $59,729-$61,698) over 5 years. This was higher for haematology patients; $46,154 (95%CI, $45,505-$46,804) in year 1, increasing to $75,931 (95%CI, $74,895-$76,968).

CONCLUSIONS

Sepsis imposes substantial economic burden and can result in a doubling of cancer care costs, particularly during the first year of cancer diagnosis. These estimates are helpful in improving our understanding of burden of sepsis along the cancer pathway and to deploy targeted strategies to alleviate this burden.

Temporal Trends in Sepsis Incidence and Mortality in Patients With Cancer in the US Population

BACKGROUND

Few population-based studies assess the impact of cancer on sepsis incidence and mortality.

OBJECTIVES

To evaluate epidemiological trends of sepsis in patients with cancer.

METHODS

This retrospective cohort study included adults (≥20 years old) identified using sepsis-indicator International Classification of Diseases codes from the Nationwide Inpatient Sample database (2006-2014). A generalized linear model was used to trend incidence and mortality. Outcomes in patients with cancer and patients without cancer were compared using propensity score matching. Cox regression modeling was used to calculate hazard ratios for mortality rates.

RESULTS

The study included 13 996 374 patients, 13.6% of whom had cancer. Gram-positive infections were most common, but the incidence of gram-negative infections increased at a greater rate. Compared with patients without cancer, those with cancer had significantly higher rates of lower respiratory tract (35.0% vs 31.6%), intra-abdominal (5.5% vs 4.6%), fungal (4.8% vs 2.9%), and anaerobic (1.2% vs 0.9%) infections. Sepsis incidence increased at a higher rate in patients with cancer than in those without cancer, but hospital mortality rates improved equally in both groups. After propensity score matching, hospital mortality was higher in patients with cancer than in those without cancer (hazard ratio, 1.25; 95% CI, 1.24-1.26). Of patients with sepsis and cancer, those with lung cancer had the lowest survival (hazard ratio, 1.65) compared with those with breast cancer, who had the highest survival.

CONCLUSIONS

Cancer patients are at high risk for sepsis and associated mortality. Research is needed to guide sepsis monitoring and prevention in patients with cancer.

Tumor-Specific T Cells Exacerbate Mortality and Immune Dysregulation during Sepsis

Sepsis induces significant immune dysregulation characterized by lymphocyte apoptosis and alterations in the cytokine milieu. Because cancer patients exhibit a 10-fold greater risk of developing sepsis compared with the general population, we aimed to understand how pre-existing malignancy alters sepsis-induced immune dysregulation. To address this question, we assessed the impact of tumor-specific CD8⁺ T cells on the immune response in a mouse model of cecal ligation and puncture (CLP)-induced sepsis. Tumor-bearing animals containing Thy1.1⁺ tumor-specific CD8⁺ T cells were subjected to CLP, and groups of animals received anti-Thy1.1 mAb to deplete tumor-specific CD8⁺ T cells or isotype control. Results indicated that depleting tumor-specific T cells significantly improved mortality from sepsis. The presence of tumor-specific CD8⁺ T cells resulted in increased expression of the 2B4 coinhibitory receptor and increased apoptosis of endogenous CD8⁺ T cells. Moreover, tumor-specific T cells were not reduced in number in the tumors during sepsis but did exhibit impaired IFN-γ production in the tumor, tumor draining lymph node, and spleen 24 h after CLP. Our research provides novel insight into the mechanisms by which pre-existing malignancy contributes to increased mortality during sepsis.

Surveillance for Healthcare-Associated Infections: Hospital-Onset Adult Sepsis Events versus Current Reportable Conditions

BACKGROUND

U.S. hospitals are required by CMS to publicly report CLABSI, CAUTI, C.diffficile, MRSA bacteremia, and selected SSIs for benchmarking and pay-for-performance programs. It is unclear, however, to what extent these conditions capture the full breadth of serious healthcare-associated infections (HAIs). CDC's hospital-onset Adult Sepsis Event (HO-ASE) definition could facilitate more comprehensive and efficient surveillance for serious HAIs, but the overlap between HO-ASE and currently reportable HAIs is unknown.

METHODS

We retrospectively assessed the overlap between HO-ASEs and reportable HAIs among adults hospitalized between June 2015-June 2018 in 3 hospitals. Medical record reviews were conducted for 110 randomly selected HO-ASE cases to determine clinical correlates.

RESULTS

Amongst 282,441 hospitalized patients, 2,301 (0.8%) met HO-ASE criteria and 1,260 (0.4%) had reportable HAIs. In-hospital mortality rates were higher with HO-ASEs than reportable HAIs (28.6% vs 12.9%). Mortality rates for HO-ASE missed by reportable HAIs were substantially higher than mortality rates for reportable HAIs missed by HO-ASE (28.1% vs 6.3%). Reportable HAIs were only present in 334/2,301 (14.5%) HO-ASEs, most commonly CLABSIs (6.0% of HO-ASEs), C.difficile (5.0%), and CAUTI (3.0%). On medical record review, most HO-ASEs were caused by pneumonia (39.1%, of which only 34.9% were ventilator-associated), bloodstream infections (17.4%, of which only 10.5% were central line-associated), non-C.difficile intra-abdominal infections (14.5%), urinary infections (7.3%, of which 87.5% were catheter-associated), and skin/soft tissue infections (6.4%).

CONCLUSIONS

CDC's HO-ASE definition detects many serious nosocomial infections missed by currently reportable HAIs. HO-ASE surveillance could increase the efficiency and clinical significance of surveillance while identifying new targets for prevention.

Albumin replacement therapy in immunocompromised patients with sepsis - Secondary analysis of the ALBIOS trial

BACKGROUND

The best fluid replacement strategy and the role of albumin in immunocompromised patients with sepsis is unclear.

METHODS

We performed a secondary analysis of immunocompromised patients enrolled in the ALBIOS trial which randomized patients with severe sepsis or septic shock to receive either 20% albumin (target 30 g per liter or more) and crystalloid or crystalloid alone during ICU stay.

RESULTS

Of 1818 patients originally enrolled, 304 (16.4%) were immunocompromised. One-hundred-thirty-nine (45.7%) patients were randomized in the albumin while 165 (54.2%) in the crystalloid group. At 90 days, 69 (49.6%) in the albumin group and 89 (53.9%) in the crystalloids group died (hazard ratio - HR - 0.94; 95% CI 0.69-1.29). No differences were observed with regards to 28-day mortality, SOFA score (and sub-scores), length of stay in the ICU and in the hospital, proportion of patients who had developed acute kidney injury or received renal replacement therapy, duration of mechanical ventilation. Albumin was not independently associated with a higher or lower 90-day mortality (HR 0.979, 95% CI 0.709-1.352) as compared to crystalloid.

CONCLUSION

Albumin replacement during the ICU stay, as compared with crystalloids alone, did not affect clinical outcomes in a cohort of immunocompromised patients with sepsis.

Short and Long-Term Mortality Trends for Cancer Patients with Septic Shock Stratified by Cancer Type from 2009 to 2017: A Population-Based Cohort Study

Simple Summary

This study aimed to assess short and long-term mortality trends in cancer patients with septic shock from 2009 to 2017. Among 43,466 adult cancer patients with septic shock (90% solid and 10% hematologic cancer cases) who presented at an emergency department (ED) in Korea between 2009 and 2017, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. The overall 30-day mortality decreased by 4.8% annually from 2013 to 2017, whereas the 1-year mortality only showed a 1.9% annual decrease over this same period. Pancreatic cancer cases showed the most significant improvement in the 30-day mortality since 2014, and lung and stomach cancer showed a sustained decrease in this metric during the whole study period. The outcomes of cancer patients with septic shock have improved in recent years across most cancer types. Physicians should have expectations of improved prognoses in cancer patients admitted to the ED with septic shock.

Abstract

There have been recent advances in both cancer and sepsis management. This study aimed to assess short and long-term mortality trends in cancer patients with septic shock from 2009 to 2017 by cancer type. This nationwide population-based cohort study using data from the National Health Insurance Service of Korea included adult cancer patients who presented to an emergency department (ED) with septic shock from 2009 to 2017. Among 43,466 adult cancer patients with septic shock (90% solid and 10% hematologic cancer cases), the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. The overall 30-day mortality showed a marked decrease of 4.8% annually from 2013 to 2017, but the annual decrease in the 1-year mortality over the same period was only 1.9%. Pancreatic cancer cases showed the most significant improvement in 30-day mortality between 2014 and 2019 (11.0% decrease/year). Lung and stomach cancers showed a sustained decrease in 30-day mortality during the whole study period (1.7% and 2.0% decrease/year, respectively). The outcomes of cancer patients with septic shock have improved in recent years across most cancer types. Physicians should have expectations of an improved prognosis in cancer patients admitted to the ED with septic shock.

Prevalence of Antibiotic-Resistant Pathogens in Culture-Proven Sepsis and Outcomes Associated With Inadequate and Broad-Spectrum Empiric Antibiotic Use

IMPORTANCE

Broad-spectrum antibiotics are recommended for all patients with suspected sepsis to minimize the risk of undertreatment. However, little is known regarding the net prevalence of antibiotic-resistant pathogens across all patients with community-onset sepsis or the outcomes associated with unnecessarily broad empiric treatment.

OBJECTIVE

To elucidate the epidemiology of antibiotic-resistant pathogens and the outcomes associated with both undertreatment and overtreatment in patients with culture-positive community-onset sepsis.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 17 430 adults admitted to 104 US hospitals between January 2009 and December 2015 with sepsis and positive clinical cultures within 2 days of admission. Data analysis took place from January 2018 to December 2019.

EXPOSURES

Inadequate empiric antibiotic therapy (ie, ≥1 pathogen nonsusceptible to all antibiotics administered on the first or second day of treatment) and unnecessarily broad empiric therapy (ie, active against methicillin-resistant Staphylococcus aureus [MRSA]; vancomycin-resistant Enterococcus [VRE]; ceftriaxone-resistant gram-negative [CTX-RO] organisms, including Pseudomonas aeruginosa; or extended-spectrum β-lactamase [ESBL] gram-negative organisms when none of these were isolated).

MAIN OUTCOMES AND MEASURES

Prevalence and empiric treatment rates for antibiotic-resistant organisms and associations of inadequate and unnecessarily broad empiric therapy with in-hospital mortality were assessed, adjusting for baseline characteristics and severity of illness.

RESULTS

Of 17 430 patients with culture-positive community-onset sepsis (median [interquartile range] age, 69 [57-81] years; 9737 [55.9%] women), 2865 (16.4%) died in the hospital. The most common culture-positive sites were urine (9077 [52.1%]), blood (6968 [40.0%]), and the respiratory tract (2912 [16.7%]). The most common pathogens were Escherichia coli (5873 [33.7%]), S aureus (3706 [21.3%]), and Streptococcus species (2361 [13.5%]). Among 15 183 cases in which all antibiotic-pathogen susceptibility combinations could be calculated, most (12 398 [81.6%]) received adequate empiric antibiotics. Empiric therapy targeted resistant organisms in 11 683 of 17 430 cases (67.0%; primarily vancomycin and anti-Pseudomonal β-lactams), but resistant organisms were uncommon (MRSA, 2045 [11.7%]; CTX-RO, 2278 [13.1%]; VRE, 360 [2.1%]; ESBLs, 133 [0.8%]). The net prevalence for at least 1 resistant gram-positive organism (ie, MRSA or VRE) was 13.6% (2376 patients), and for at least 1 resistant gram-negative organism (ie, CTX-RO, ESBL, or CRE), it was 13.2% (2297 patients). Both inadequate and unnecessarily broad empiric antibiotics were associated with higher mortality after detailed risk adjustment (inadequate empiric antibiotics: odds ratio, 1.19; 95% CI, 1.03-1.37; P = .02; unnecessarily broad empiric antibiotics: odds ratio, 1.22; 95% CI, 1.06-1.40; P = .007).

CONCLUSIONS AND RELEVANCE

In this study, most patients with community-onset sepsis did not have resistant pathogens, yet broad-spectrum antibiotics were frequently administered. Both inadequate and unnecessarily broad empiric antibiotics were associated with higher mortality. These findings underscore the need for better tests to rapidly identify patients with resistant pathogens and for more judicious use of broad-spectrum antibiotics for empiric sepsis treatment.