Interventions for rapid recognition and treatment of sepsis in the emergency department: a narrative review

BACKGROUND

Sepsis is a major cause of morbidity and mortality worldwide. Early recognition and treatment of sepsis is associated with improved outcome. The emergency department (ED) is the department where patients with sepsis seek care. However, recognition of sepsis in the ED remains difficult. Different alert and triage systems, screening scores and intervention strategies have been developed to assist clinicians in early recognition of sepsis and to optimize management.

OBJECTIVES

This narrative review describes currently applied interventions or interventions we can start using today, such as screening scores, (automated) triage systems, sepsis teams and clinical pathways in sepsis care; and it summarizes evidence for the effect of implementation of these interventions in the ED on patient management and outcomes.

SOURCES

A systematic literature search was conducted in PubMed, resulting in 39 eligible studies.

CONTENT

The main sepsis interventions in the ED are (automated) triage systems, sepsis teams and clinical pathways, the most integrative being a clinical pathway. Implementation of any of these interventions in sepsis care will generally lead to increased protocol adherence. Presumably increased adherence to sepsis guidelines and bundles will lead to better patient outcomes, but the level of evidence to support this improvement is low, whereas implementation of interventions is often complex and costly. No studies comparing different interventions were identified. Two essential factors for success of interventions in the ED are obtaining the support from all professionals and providing ongoing education. The vulnerability of these interventions lies in the lack of accurate tools to identify sepsis; diagnosing sepsis ultimately still relies on clinical assessments. A lack of specificity or sepsis alerts may lead to alert fatigue and/or overtreatment.

IMPLICATIONS

The severity and poor outcome of sepsis as well as the frequency of its presentation in EDs make a structured, protocol-based approach towards these patients essential, preferably as part of a clinical pathway.

Prophylaxis of implant-related infections by local release of vancomycin from a hydrogel in rabbits

Local prophylaxis with antibiotic-loaded bone cement is a successful method to prevent post-operative infections in patients receiving orthopaedic implants. No comparable method is available for uncemented implants. Therefore, a hydrogel consisting of hyaluronic and polylactic acids was evaluated in a rabbit model for delivery of antimicrobial agents to prevent post-operative infections. In a pilot study, the suitability of the in vivo model was assessed by testing the hydrogel as carrier material for antimicrobial agents.In the main study, the antimicrobial-agent-loaded hydrogel was evaluated for infection prophylaxis. Rabbits received a titanium rod intramedullary in the tibia after contamination with Staphylococcus aureus. The rods were coated with unloaded hydrogel (Gel), hydrogel loaded with 2 % (Van2) or 5 % vancomycin (Van5), bioactive glass (BAG) or N-acetyl-L-cysteine (NAC). To analyse the infection severity after 28 d, histopathological, bacteriological, micro-computed tomographic and haematological analyses were performed. In the pilot study, the Van5 group had less infection (0/6 infected) as compared to the Gel group (5/5, p = 0.000) and the in vivo model was deemed suitable. In the main study, in the Van2 and Van5 groups, the number of infected animals was lower [1/6 (p = 0.006) and 2/6 (p = 0.044) infected, respectively]. In contrast, BAG and NAC groups showed no infection reduction (5/6 both groups, p = 0.997). The hydrogel can be used as a local carrier of vancomycin for prophylaxis of implant-related infections.The present study showed promising results for local delivery of antibacterial agents by hydrogel to prevent implant-related infections.

Colonization of Libyan civil war casualties with multidrug-resistant bacteria

In November 2011 51 Libyan war casualties were admitted to the Major Incident Hospital in Utrecht and from there were transferred to 26 other Dutch hospitals. Cultures and clinical data were collected to establish the prevalence of multidrug-resistant (MDR) bacteria in this patient group and to identify the associated risk factors. The prevalence of MDR bacteria was 59% (30/51 patients); extended spectrum β-lactamase-producing enterobacteriaceae were most common (26/51 patients: 51%). The major risk factor for carriage of MDR bacteria was the presence of open wounds at admission to the Major Incident Hospital.

Candidemic complications in patients with intravascular catheters colonized with Candida species: an indication for preemptive antifungal therapy?

BACKGROUND

The impact of Candida-colonized catheter tips in patients without candidemia is unclear.

METHODS

A retrospective study of patients with tip cultures positive for Candida was conducted over an 8-year period, to determine the outcomes in patients with Candida cultured from an intravascular catheter tip in the absence of preceding Candida-positive blood cultures. The primary outcome measure was definite candidemia. Secondary outcomes included possible candidemia and in-hospital mortality. A possible candidemia was defined as clinical signs and symptoms of invasive candidiasis without explanation other than a candidemia, but with negative blood cultures.

RESULTS

Sixty-eight cultures from 64 patients were included in the study. Definite candidemia developed in three cases (4%) and possible candidemia developed in five cases (7%). In-hospital mortality was significantly increased in patients with definite or possible candidemia (63% vs. 22%, p=0.028). Risk factors for the development of definite or possible candidemia were catheter time in situ >8 days (odds ratio (OR) 6.0, 95% confidence interval (CI) 1.1-32.9) and abdominal surgery (OR 6.0, 95% CI 1.1-32.4).

CONCLUSIONS

Intravascular catheter tip colonization in patients without preceding blood cultures with Candida is associated with candidemia in from 4% of patients (definite candidemia) up to 12% of patients (definite and possible candidemia combined). Considering the adverse prognosis associated with delayed treatment of candidemia, preemptive treatment based on catheter tip cultures might outweigh the disadvantages of costs and side effects of antifungal therapy.

[Endocarditis due to meticillin-resistant Staphylococcus aureus originating from pigs]

A 63-year-old woman with a kidney transplant was admitted with endocarditis caused by meticillin-resistant Staphylococcus aureus (MRSA). Once her antibiotic therapy had been adjusted to the sensitivity-pattern of the bacterial strain she recovered, without the need for surgical intervention. The isolated S. aureus was typed by multi-locus sequence typing as sequence type 398, a MRSA-strain that has recently been isolated from a high percentage of Dutch pigs. This is the first report of a life-threatening infection with this pig MRSA. This strain is genetically different from the globally dispersed nosocomial MRSA-strains, and also from the strains that have been epidemic for several years in the USA as the causative agent ofcommunity-acquired skin infections. The Dutch Working Group on Infection Prevention (WIP) has recently adjusted its guidelines to halt further spread of this strain, and advises that the population at risk (pig breeders, slaughterhouse personnel and veterinarians) be held in isolation when hospitalised until MRSA colonisation has been excluded. The patient described here, however, did not belong to this population at risk.

[Colistin as last resort in 2 patients with pulmonary infection with multiresistant nosocomial bacteria]

A 57-year-old man requiring ventilation after gastric-tube reconstruction (due to oesophageal carcinoma) and a 16-year-old boy with thoracic trauma developed pneumonia caused by Pseudomonas aeruginosa and other pathogens. Their infections persisted during treatment with antibiotics. The antibiotic colistin was added and the clinical condition improved in both patients after 3-4 weeks. Eventually, they both were transferred to a rehabilitation clinic. The use of colistin was abandoned in the 1970s due to alleged nephro- and neurotoxicity. In recent observational studies, the drug appeared to cause fewer toxic side-effects than previously thought. Colistin is only registered for inhaled use for lung infections and for resistant pulmonary infections in patients with cystic fibrosis, but it may also be effective in the treatment of other patients with multidrug-resistant, Gram-negative bacteria.

Metal versus plastic spacers: an in vitro and in vivo comparison

This study compared the metal Nebuchamber with the polycarbonate Volumatic spacer in vivo as well as in vitro. Seventeen asthmatic patients were evaluated in a crossover placebo-controlled double-blind study. Bronchodilation, heart rate and serum potassium levels were measured at baseline and 15 min after administration of salbutamol. Cumulative dose-response curves (200, 400, 800 and 1600 microg) were constructed. The Andersen Cascade Impactor was used to compare the aerodynamic particle size distribution. The FEV(1) measurements showed highly significant differences between placebo and the two active preparations (P<0.001), but not between the two active preparations (P=0.433). The serum potassium levels also showed highly significant differences between placebo and the two active preparations (P=0.009), but not between the two active preparations (P=0.532). Only 1600 microg salbutamol dose raised the heart rate significantly, but the difference between the two active preparations was not significant. The in vitro deposition study revealed no significant differences in the delivered dose or in the fine particle dose (P>0.05). In conclusion, there are no significant differences between the Volumatic and Nebuchamber either in vivo or in vitro.

Identification and characterization of an in vivo regulated D15/Oma87 homologue in Shigella flexneri using differential display polymerase chain reaction

Shigella genes expressed during infection likely contribute to adaptation and virulence in the host. Using differential display PCR (DDPCR), a cDNA fragment from Shigella flexneri serotype 5 that showed enhanced expression in a murine model was identified, cloned and sequenced. Enhanced expression was verified by RNA dot blot. The full-length gene was cloned using PCR and sequenced. The complete gene sequence was BLAST searched against GenBank, and exhibited strong homology to genes encoding Haemophilus influenzae D15 and Pasteurella multocida Oma87 protective outer membrane antigens. The S. flexneri gene putatively encodes a approximately 90-kDa protein and was termed oma90. The deduced amino acid sequence from oma90 was analyzed and compared to the D15/Oma87 antigens. Additionally, oma90 mapped to a cluster of orthologous groups, and probably contains an ancient conserved domain. The chromosomal organization of oma90 was similar to that for H. influenzae and P. multocida as well as for other known homologues. Northern blot revealed that the oma90 transcript encoded only oma90. This report represents the first description of a S. flexneri gene identified based on enhanced expression in the host. Furthermore, we report the first evidence demonstrating in vivo regulation of a member of the d15/oma87 gene family.