Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007. Crit Care Med. 2012;40:754-761. [PMID: 21963582 DOI: 10.1097/ccm.0b013e318232db65]

Early prolonged neutrophil activation in critically ill patients with sepsis

We hypothesised that plasma concentrations of biomarkers of neutrophil activation and pro-inflammatory cytokines differ according to the phase of rapidly evolving sepsis. In an observational study, we measured heparin-binding protein (HBP), myeloperoxidase (MPO), IL-6 and IL-8 in 167 sepsis patients on intensive care unit admission. We prospectively used the emergence of the first sepsis-associated organ dysfunction (OD) as a surrogate for the sepsis phase. Fifty-five patients (of 167, 33%) developed the first OD > 1 h before, 74 (44%) within ± 1 h, and 38 (23%) > 1 h after intensive care unit admission. HBP and MPO were elevated at a median of 12 h before the first OD, remained high up to 24 h, and were not associated with sepsis phase. IL-6 and IL-8 rose and declined rapidly close to OD emergence. Elevation of neutrophil activation markers HBP and MPO was an early event in the evolution of sepsis, lasting beyond the subsidence of the pro-inflammatory cytokine reaction. Thus, as sepsis biomarkers, HBP and MPO were not as prone as IL-6 and IL-8 to the effect of sample timing.

Early Detection of Septic Shock Onset Using Interpretable Machine Learners

BACKGROUND

Developing a decision support system based on advances in machine learning is one area for strategic innovation in healthcare. Predicting a patient's progression to septic shock is an active field of translational research. The goal of this study was to develop a working model of a clinical decision support system for predicting septic shock in an acute care setting for up to 6 h from the time of admission in an integrated healthcare setting.

METHOD

Clinical data from Electronic Health Record (EHR), at encounter level, were used to build a predictive model for progression from sepsis to septic shock up to 6 h from the time of admission; that is, T = 1, 3, and 6 h from admission. Eight different machine learning algorithms (Random Forest, XGBoost, C5.0, Decision Trees, Boosted Logistic Regression, Support Vector Machine, Logistic Regression, Regularized Logistic, and Bayes Generalized Linear Model) were used for model development. Two adaptive sampling strategies were used to address the class imbalance. Data from two sources (clinical and billing codes) were used to define the case definition (septic shock) using the Centers for Medicare & Medicaid Services (CMS) Sepsis criteria. The model assessment was performed using Area under Receiving Operator Characteristics (AUROC), sensitivity, and specificity. Model predictions for each feature window (1, 3 and 6 h from admission) were consolidated.

RESULTS

Retrospective data from April 2005 to September 2018 were extracted from the EHR, Insurance Claims, Billing, and Laboratory Systems to create a dataset for septic shock detection. The clinical criteria and billing information were used to label patients into two classes-septic shock patients and sepsis patients at three different time points from admission, creating two different case-control cohorts. Data from 45,425 unique in-patient visits were used to build 96 prediction models comparing clinical-based definition versus billing-based information as the gold standard. Of the 24 consolidated models (based on eight machine learning algorithms and three feature windows), four models reached an AUROC greater than 0.9. Overall, all the consolidated models reached an AUROC of at least 0.8820 or higher. Based on the AUROC of 0.9483, the best model was based on Random Forest, with a sensitivity of 83.9% and specificity of 88.1%. The sepsis detection window at 6 h outperformed the 1 and 3-h windows. The sepsis definition based on clinical variables had improved performance when compared to the sepsis definition based on only billing information.

CONCLUSION

This study corroborated that machine learning models can be developed to predict septic shock using clinical and administrative data. However, the use of clinical information to define septic shock outperformed models developed based on only administrative data. Intelligent decision support tools can be developed and integrated into the EHR and improve clinical outcomes and facilitate the optimization of resources in real-time.

The Outcome of Sepsis Patients Admitted to the Intensive Care Unit: Experience of 100 Cases

Introduction:

The term sepsis has a deep root all over medical history. It defined by a many physician and myth such as Homer’s Iliad. Sepsis defined as a clinical syndrome as an outcome from both systemic inflammatory response syndrome and infection. It can complicate by disturb the function of the organ (severe sepsis) and shock (septic shock).

Aim:

Our study aims to recognize sepsis cases in Al-Sader Medical city during 2019 and evaluate the management’s management and the weak point in this management.

Methods:

It is a cross-sectional study done in Al-Sader Medical city; data collected from the archived files in the hospital during 2019, 100 cases reported in this period diagnosed and admitted as sepsis or admitted with other diagnosis evolved sepsis.

Results:

We found that one-third of the patients diagnosed as sepsis admitted to the intensive care unit, the mean duration of management 15.8 days. Many investigations did for these patients, the treatment which given to the patients was iv. fluids and antibiotics for entire patients, we also noted that death occurs in more than half of the patients in our study and death were prevalent among patient with a negative result in blood culture also the male patient was more predominant than the female patient and Najaf residency is more than three-quarters of them. Finally, we found that admission to the intensive care unit from units other than emergency or intensive care unit itself found is nearly one-third of the patient diagnosed as sepsis and the respiratory system was commonly involved and presented as pneumonia.

Conclusion:

More than half of the diagnosed cases died. The maximum common source of admission was from other hospital units, the severe sepsis and no growth of blood culture closely associated with death.

Creation of BLT Humanized Mice for Sepsis Studies

Mice are a suitable animal model for sepsis studies because they recapitulate many aspects of the pathophysiology observed in septic human patients. It is ethically preferable to use mice for research over higher sentient species, when scientifically appropriate. Mice are also advantageous for research due to their small size, modest housing needs, the availability of genetically modified strains, and the broad range of reagents available for scientific assays on this species. Nevertheless, there are some intrinsic differences between mice and humans that should be recognized when considering the translational potential of sepsis therapies. It is often wise to complement traditional mouse studies with animal models that exhibit even greater similarity to humans, and in particular, models that better recapitulate the human immune response. Humanized mice are a promising tool to bridge this interspecies research gap. Herein, we provide a protocol to generate BLT humanized mice and describe their sepsis phenotype after cecal ligation and puncture (CLP).

The Association of Increasing Hospice Use With Decreasing Hospital Mortality: An Analysis of the National Inpatient Sample

EXECUTIVE SUMMARY

Usage of hospice services for patients facing life-limiting illness has steadily increased. In these services, hospitals discharge patients to various hospice settings, including the inpatient model, where a patient may remain in the discharging hospital to receive hospice services. In this discharge practice, the patient is considered a hospital survivor and subsequent hospice death. The purpose of the study was to determine if the decline of in-hospital mortality for six common high-volume admission diagnoses could be attributed in part to an increase in discharges to a hospice setting for end-of-life care. In this retrospective study using the National Inpatient Sample database from 2007 to 2011, we identified patients ≥18 years for six acute and chronic diagnoses: heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, acute myocardial infarction with cardiogenic shock, septic shock, and lung neoplasm (cancer). We categorized patients according to their hospital discharge disposition as hospice or in-hospital mortality. A total of 10,458,728 patients met our criteria, of which 2.72% were discharged to hospice and 6.38% died. Compared to patients who died in the hospital, hospice patients were older, had a shorter length of stay, and experienced more comorbidities. Hospice use was more common in Medicare patients, in nonteaching hospitals, and in the South. White individuals were more likely to be discharged to hospice compared to nonwhites. Among the six selected diagnoses over the 5-year period, hospice use rose as observed mortality decreased. Our findings suggest that variability among hospitals in hospice use will affect benchmarked hospital mortality comparisons and could inappropriately reward or penalize hospitals in their public reporting.

A comprehensive assessment of multi-system responses to a renal inoculation of uropathogenic E. coli in swine

BACKGROUND

The systemic responses to infection and its progression to sepsis remains poorly understood. Progress in the field has been stifled by the shortcomings of experimental models which include poor replication of the human condition. To address these challenges, we developed and piloted a novel large animal model of severe infection that is capable of generating multi-system clinically relevant data.

METHODS

Male swine (n = 5) were anesthetized, mechanically ventilated, and surgically instrumented for continuous hemodynamic monitoring and serial blood sampling. Animals were inoculated with uropathogenic E. coli by direct injection into the renal parenchyma and were maintained until a priori endpoints were met. The natural history of the infection was studied. Animals were not resuscitated. Multi-system data were collected hourly to 6 hours; all animals were euthanized at predetermined physiologic endpoints.

RESULTS

Core body temperature progressively increased from mean (SD) 37.9(0.8)°C at baseline to 43.0(1.2)°C at experiment termination (p = 0.006). Mean arterial pressure did not begin to decline until 6h post inoculation, dropping from 86(9) mmHg at baseline to 28(5) mmHg (p = 0.005) at termination. Blood glucose progressively declined but lactate levels did not elevate until the last hours of the experiment. There were also temporal changes in whole blood concentrations of a number of metabolites including increases in the catecholamine precursors, tyrosine (p = 0.005) and phenylalanine (p = 0.005). Lung, liver, and kidney function parameters worsened as infection progressed and at study termination there was histopathological evidence of injury in these end-organs.

CONCLUSION

We demonstrate a versatile, multi-system, longitudinal, swine model of infection that could be used to further our understanding of the mechanisms that underlie infection-induced multi-organ dysfunction and failure, optimize resuscitation protocols and test therapeutic interventions. Such a model could improve translation of findings from the bench to the bedside, circumventing a significant obstacle in sepsis research.

A Multi-mRNA Host-Response Molecular Blood Test for the Diagnosis and Prognosis of Acute Infections and Sepsis: Proceedings from a Clinical Advisory Panel

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 InSep^TM test (Inflammatix, Burlingame, CA, formerly known as HostDx^TM 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.

Myeloperoxidase-Derived 2-Chlorohexadecanal Is Generated in Mouse Heart during Endotoxemia and Induces Modification of Distinct Cardiomyocyte Protein Subsets In Vitro

Sepsis is a major cause of mortality in critically ill patients and associated with cardiac dysfunction, a complication linked to immunological and metabolic aberrations. Cardiac neutrophil infiltration and subsequent release of myeloperoxidase (MPO) leads to the formation of the oxidant hypochlorous acid (HOCl) that is able to chemically modify plasmalogens (ether-phospholipids) abundantly present in the heart. This reaction gives rise to the formation of reactive lipid species including aldehydes and chlorinated fatty acids. During the present study, we tested whether endotoxemia increases MPO-dependent lipid oxidation/modification in the mouse heart. In hearts of lipopolysaccharide-injected mice, we observed significantly higher infiltration of MPO-positive cells, increased fatty acid content, and formation of 2-chlorohexadecanal (2-ClHDA), an MPO-derived plasmalogen modification product. Using murine HL-1 cardiomyocytes as in vitro model, we show that exogenously added HOCl attacks the cellular plasmalogen pool and gives rise to the formation of 2-ClHDA. Addition of 2-ClHDA to HL-1 cardiomyocytes resulted in conversion to 2-chlorohexadecanoic acid and 2-chlorohexadecanol, indicating fatty aldehyde dehydrogenase-mediated redox metabolism. However, a recovery of only 40% indicated the formation of non-extractable (protein) adducts. To identify protein targets, we used a clickable alkynyl analog, 2-chlorohexadec-15-yn-1-al (2-ClHDyA). After Huisgen 1,3-dipolar cycloaddition of 5-tetramethylrhodamine azide (N₃-TAMRA) and two dimensional-gel electrophoresis (2D-GE), we were able to identify 51 proteins that form adducts with 2-ClHDyA. Gene ontology enrichment analyses revealed an overrepresentation of heat shock and chaperone, energy metabolism, and cytoskeletal proteins as major targets. Our observations in a murine endotoxemia model demonstrate formation of HOCl-modified lipids in the heart, while pathway analysis in vitro revealed that the chlorinated aldehyde targets specific protein subsets, which are central to cardiac function.

Oroxylin A alleviates immunoparalysis of CLP mice by degrading CHOP through interacting with FBXO15

Clinical reports have found that with the improvement of treatment, most septic patients are able to survive the severe systemic inflammatory response and to enter the immunoparalysis stage. Considering that immunoparalysis leads to numerous deaths of clinical sepsis patients, alleviation of the occurrence and development of immunoparalysis has become a top priority in the treatment of sepsis. In our study, we investigate the effects of oroxylin A on sepsis in cecal ligation and puncture (CLP) mice. We find that the 60 h + 84 h (30 mg/kg) injection scheme of oroxylin A induce the production of pro-inflammatory factors, and further significantly improves the survival of CLP mice during the middle or late stages of sepsis. Mechanistically, C/EBP-homologous protein (CHOP) is upregulated and plays anti-inflammatory roles to facilitate the development of immunoparalysis in CLP mice. Oroxylin A induces the transcription of E3 ligase F-box only protein 15 gene (fbxo15), and activated FBXO15 protein binds to CHOP and further mediates the degradation of CHOP through the proteasome pathway, which eventually relieves the immunoparalysis of CLP mice. Taken together, these findings suggest oroxylin A relieves the immunoparalysis of CLP mice by degrading CHOP through interacting with FBXO15.

Arginine vasopressin receptor 2 activation promotes microvascular permeability in sepsis

Methicillin-resistant Staphylococcus aureus (MRSA) sepsis is a severe condition associated with vascular leakage and poor prognosis. The hemodynamic management of sepsis targets hypotension, but there is no specific treatment available for vascular leakage. Arginine vasopressin (AVP) has been used in sepsis to promote vasoconstriction by activating AVP receptor 1 (V₁R). However, recent evidence suggests that increased fluid retention may be associated with the AVP receptor 2 (V₂R) activation worsening the outcome of sepsis. Hence, we hypothesized that the inhibition of V₂R activation ameliorates the severity of microvascular hyperpermeability during sepsis. The hypothesis was tested using a well-characterized and clinically relevant ovine model of MRSA pneumonia/sepsis and in vitro assays of human lung microvascular endothelial cells (HMVECs). in vivo experiments demonstrated that the treatment of septic sheep with tolvaptan (TLVP), an FDA-approved V₂R antagonist, significantly attenuated the sepsis-induced fluid retention and markedly reduced the lung water content. These pathological changes were not affected by the treatment with V₂R agonist, desmopressin (DDAVP). Additionally, the incubation of cultured HMVECs with DDAVP, and DDAVP along with MRSA significantly increased the paracellular permeability. Finally, both the DDAVP and MRSA-induced hyperpermeability was significantly attenuated by TLVP. Subsequent protein and gene expression assays determined that the V₂R-induced increase in permeability is mediated by phospholipase C beta (PLCβ) and the potent permeability factor angiopoietin-2. In conclusion, our results indicate that the activation of the AVP-V₂R axis is critical in the pathophysiology of severe microvascular hyperpermeability during Gram-positive sepsis. The use of the antagonist TLVP should be considered as adjuvant treatment for septic patients. The results from this clinically relevant animal study are highly translational to clinical practice.

Inpatient hospital performance is associated with post-discharge sepsis mortality

Background

Post-discharge deaths are common in patients hospitalized for sepsis, but the drivers of post-discharge deaths are unclear. The objective of this study was to test the hypothesis that hospitals with high risk-adjusted inpatient sepsis mortality also have high post-discharge mortality, readmissions, and discharge to nursing homes.

Methods

Retrospective cohort study of age-qualifying Medicare beneficiaries with sepsis hospitalization between January 2013 and December 2014. Hospital survivors were followed for 180-days post-discharge, and mortality, readmissions, and new admission to skilled nursing facility were measured. Inpatient hospital-specific sepsis risk-adjusted mortality ratio (observed: expected) was the primary exposure.

Results

A total of 830,721 patients in the cohort were hospitalized for sepsis, with inpatient mortality of 20% and 90-day mortality of 48%. Higher hospital-specific sepsis risk-adjusted mortality was associated with increased 90-day post-discharge mortality (aOR 1.03 per each 0.1 increase in hospital inpatient O:E ratio, 95% CI 1.03–1.04). Higher inpatient risk adjusted mortality was also associated with increased probability of being discharged to a nursing facility (aOR 1.03, 95% CI 1.02–1.03) and 90-day readmissions (aOR 1.03, 95% CI 1.02–1.03).

Conclusions

Hospitals with the highest risk-adjusted sepsis inpatient mortality also have higher post-discharge mortality and increased readmissions, suggesting that post-discharge complications are a modifiable risk that may be affected during inpatient care. Future work will seek to elucidate inpatient and healthcare practices that can reduce sepsis post-discharge complications.

Sepsis and septic shock in France: incidences, outcomes and costs of care

Background

Sepsis is one of the leading causes of death worldwide. The associated incidence, mortality and trends do not differ greatly between documented reports. The purpose of this study was to provide an in-depth description of patients with sepsis and septic shock hospitalized in France from 2010 to 2015 and to explore the temporal trends of their clinical characteristics, costs and outcomes.

Methods

Retrospective cohort study of the French hospital administrative database in which organ failure therapies and severity scores are systematically registered. All patients admitted between 2010 and 2015 for sepsis and septic shock as defined by an ICD-10 code for infection, and for organ failure or the use of organ failure supplementation were included. Incidence, outcomes and trends were analyzed. Subgroup analyses based on several coding strategies and adjusted for severity scores were performed.

Results

A total of 737,147 patients with sepsis and 492,902 patients with septic shock were included. From 2010 to 2015, the incidence of sepsis and septic shock increased, respectively, from 206 to 243 and from 135 to 171 cases per 100,000 population. Case fatality remained at 34% for sepsis, but decreased from 46 to 44% for septic shock.

Median hospital stay costs amounted to €11,400 (IQR: 5036; 24,364) for patients with sepsis and €16,439 (IQR: 7339; 29,360) for patients with septic shock.

After adjustment for case-mix and illness severity, the risk of death was stable for sepsis (0.08% [− 0.04; 0.20] per year), but decreased for sepsis patients admitted to the intensive care unit and for cases of septic shock (− 0.33%[ − 0.40; − 0.27] per year).

Conclusions

Sepsis is common, frequently fatal and expensive to treat. Its incidence has increased. Case fatality has decreased in most severely affected patients, owing partly to general improvements in care.

Indwelling medical device use and sepsis risk at a health professional shortage area hospital: Possible interaction with length of hospitalization

BACKGROUND

We aimed to identify risk factors for sepsis diagnosis and possible interaction with length of hospital stay (LOS) among inpatients at a rural Health Professional Shortage Area hospital.

METHODS

This case-control study examined 600 adult patients (300 cases and 300 controls) admitted to a rural health system in North Carolina between 2012 and 2018. Case selection was based on assignment of ICD-9-CM diagnostic codes for sepsis. Controls were patients with a medical diagnosis other than sepsis during the observational period. Logistic regression was used to model sepsis diagnosis as a function of indwelling medical device use and stratified by LOS.

RESULTS

Indwelling medical device use preadmission and postadmission were significantly associated with increased risk of sepsis diagnosis among patients with extended hospital stays (LOS ≥ 5 days) (odds ratio [OR] = 5.51; 95% confidence interval [CI] = 1.95-15.62; P = .001 and OR = 3.28; 95% CI = 1.24-8.68; P = .017, respectively). Among patients with LOS <5 days, association with sepsis diagnosis was only significant for indwelling medical device use preadmission (OR = 9.61; 95% CI = 3.68-25.08; P < .0001).

CONCLUSIONS

Indwelling medical device use was significantly associated with increased risk of sepsis diagnosis and the risk was higher with longer hospitalization.

Association of acute pyelonephritis with double-J ureteral stenting: a nationwide population-based case control study

OBJECTIVE

Urinary Tract Infections (UTIs) due to ureteral catheters has been frequently seen. The risk factors of this include both timing and those of the female gender. However, the association of Acute Pyelonephritis (APN) with use of ureteral DJ stents has rarely been investigated.

Materials and Methods: This study enrolled a total of 6,459 patients who were being treated with a ureteral catheter over a 10 year period from the nationwide database of Taiwan's National Health Insurance Bureau. From these subjects, episodes of APN were found in a total of 500 patients. Additionally, 2,000 patients without APN were randomly enrolled as a control group in order to analyze the associated factors.

RESULTS

The results indicate that the percentage of those with regards gender, age, duration of implantation, ureteral stent type, hypertension, T2DM, presence of urinary tract infection, benign prostate hyperplasia and pregnancy status were significantly statistically higher in APN patients than non-APN patients. APN did not associate with the use of antibiotics, urolithiasis, chronic kidney disease, malignancy, or uric acid stone in patients with a ureteral catheter.

Conclusion: In conclusion, patients with a ureteral catheter associated with APN should be given close attention with regards to the above risk factors. Early removal of the catheter is the best policy for the prevention of APN.

Application of machine learning to the prediction of postoperative sepsis after appendectomy

BACKGROUND

We applied various machine learning algorithms to a large national dataset to model the risk of postoperative sepsis after appendectomy to evaluate utility of such methods and identify factors associated with postoperative sepsis in these patients.

METHODS

The National Surgery Quality Improvement Program database was used to identify patients undergoing appendectomy between 2005 and 2017. Logistic regression, support vector machines, random forest decision trees, and extreme gradient boosting machines were used to model the occurrence of postoperative sepsis.

RESULTS

In the study, 223,214 appendectomies were identified; 2,143 (0.96%) were indicated as having postoperative sepsis. Logistic regression (area under the curve 0.70; 95% confidence interval, 0.68-0.73), random forest decision trees (area under the curve 0.70; 95% confidence interval, 0.68-0.73), and extreme gradient boosting (area under the curve 0.70; 95% confidence interval, 0.68-0.73) afforded similar performance, while support vector machines (area under the curve 0.51; 95% confidence interval, 0.50-0.52) had worse performance. Variable importance analyses identified preoperative congestive heart failure, transfusion, and acute renal failure as predictors of postoperative sepsis.

CONCLUSION

Machine learning methods can be used to predict the development of sepsis after appendectomy with moderate accuracy. Such predictive modeling has potential to ultimately allow for preoperative recognition of patients at risk for developing postoperative sepsis after appendectomy thus facilitating early intervention and reducing morbidity.

Sepsis and septic shock after craniotomy: Predicting a significant patient safety and quality outcome measure

OBJECTIVES

Sepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations.

METHODS

Multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012-2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS.

RESULTS

There were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location.

CONCLUSIONS

The data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population.

Supervised classification techniques for prediction of mortality in adult patients with sepsis

BACKGROUND

Sepsis mortality is still unacceptably high and an appropriate prognostic tool may increase the accuracy for clinical decisions.

OBJECTIVE

To evaluate several supervised techniques of Artificial Intelligence (AI) for classification and prediction of mortality, in adult patients hospitalized by emergency services with sepsis diagnosis.

METHODS

Secondary data analysis of a prospective cohort in three university hospitals in Medellín, Colombia. We included patients >18 years hospitalized for suspected or confirmed infection and any organ dysfunction according to the Sepsis-related Organ Failure Assessment. The outcome variable was hospital mortality and the prediction variables were grouped into those related to the initial clinical treatment and care or to the direct measurement of physiological disturbances. Four supervised classification techniques were analyzed: the C4.5 Decision Tree, Random Forest, artificial neural networks (ANN) and support vector machine (SVM) models. Their performance was evaluated by the concordance between the observed and predicted outcomes and by the discrimination according to AUC-ROC.

RESULTS

A total of 2510 patients with a median age of 62 years (IQR = 46-74) and an overall hospital mortality rate of 11.5% (n = 289). The best discrimination was provided by the SVM and ANN using physiological variables, with an AUC-ROC of 0.69 (95%CI: 0.62; 0.76) and AUC-ROC of 0.69 (95%CI: 0.61; 0.76) respectively.

CONCLUSION

Deep learning and AI are increasingly used as support tools in clinical medicine. Their performance in a syndrome as complex and heterogeneous as sepsis may be a new horizon in clinical research. SVM and ANN seem promising for improving sepsis classification and prognosis.

Immunothrombosis and thromboinflammation in host defense and disease

Platelets are increasingly being recognized for playing roles beyond thrombosis and hemostasis. Today we know that they mediate inflammation by direct interactions with innate immune cells or secretion of cytokines/chemokines. Here we review their interactions with neutrophils and monocytes/macrophages in infection and sepsis, stroke, myocardial infarction and venous thromboembolism. We discuss new roles for platelet surface receptors like GPVI or GPIb and also look at platelet contributions to the formation of neutrophil extracellular traps (NETs) as well as to deep vein thrombosis during infection, e.g. in COVID-19 patients.

Efficient Early Diagnosis of Sepsis Using Whole-Blood PCR-Reverse Blot Hybridization Assay Depending on Serum Procalcitonin Levels

Sepsis is one of the medical emergencies, and its early detection, within the first hours of development, and proper management improve outcomes. Molecular diagnostic assays using whole blood collected from patients with suspected sepsis have been developed, but the decision making is difficult because of the possibility of false positives, due to contamination. Here, we evaluated the performance of the reverse blot hybridization assay (REBA) Sepsis-ID test for the detection of sepsis-causing microorganisms using whole-blood samples. In addition, the concentrations of C-reactive protein (CRP) and procalcitonin (PCT) were determined to evaluate whether these biomarkers can provide criteria for performing REBA Sepsis-ID in clinical settings. For this study, EDTA-anticoagulated whole blood was simultaneously collected for REBA Sepsis-ID and blood culture from 440 patients with suspected sepsis, from January to October 2015. In addition, CRP and PCT concentrations were measured in 227 patients. The overall positive rates of REBA Sepsis-ID and blood culture were 16.6% (73/440) and 13.9% (61/440), respectively. The pathogen-positive rates of REBA Sepsis-ID and blood culture were 9.8% (43/440) and 9.5% (42/440), respectively. The areas under the receiver operating characteristic (AUROC) curves of PCT and CRP for predicting pathogen-positive results of REBA Sepsis-ID were 0.72 and 0.69, respectively. The PCT concentrations in the group of patients aged ≥50 years were significantly higher than those in the group aged <50 years. After adjusting for age, the PCT AUROC value was 0.77 for predicting pathogen-positive results of REBA Sepsis-ID. The optimal cutoff values of PCT concentrations for subsequent application of REBA Sepsis-ID were 0.12 ng/mL in all patients and 0.22 ng/mL in patients aged ≥50 years. Our observations showed that REBA Sepsis-ID using whole blood was advantageous for the early detection of sepsis-causing microorganisms, and the PCT concentration could be used to determine the necessity of using REBA Sepsis-ID in clinical settings. The application of REBA Sepsis-ID using whole blood, based on the PCT concentration, may contribute to a highly efficient detection of sepsis-causing microorganisms.

α1AMP-Activated Protein Kinase Protects against Lipopolysaccharide-Induced Endothelial Barrier Disruption via Junctional Reinforcement and Activation of the p38 MAPK/HSP27 Pathway

Vascular hyperpermeability is a determinant factor in the pathophysiology of sepsis. While, AMP-activated protein kinase (AMPK) is known to play a role in maintaining endothelial barrier function in this condition. Therefore, we investigated the underlying molecular mechanisms of this protective effect. α1AMPK expression and/or activity was modulated in human dermal microvascular endothelial cells using either α1AMPK-targeting small interfering RNA or the direct pharmacological AMPK activator 991, prior to lipopolysaccharide (LPS) treatment. Western blotting was used to analyze the expression and/or phosphorylation of proteins that compose cellular junctions (zonula occludens-1 (ZO-1), vascular endothelial cadherin (VE-Cad), connexin 43 (Cx43)) or that regulate actin cytoskeleton (p38 MAPK; heat shock protein 27 (HSP27)). Functional endothelial permeability was assessed by in vitro Transwell assays, and quantification of cellular junctions in the plasma membrane was assessed by immunofluorescence. Actin cytoskeleton remodeling was evaluated through actin fluorescent staining. We consequently demonstrate that α1AMPK deficiency is associated with reduced expression of CX43, ZO-1, and VE-Cad, and that the drastic loss of CX43 is likely responsible for the subsequent decreased expression and localization of ZO-1 and VE-Cad in the plasma membrane. Moreover, α1AMPK activation by 991 protects against LPS-induced endothelial barrier disruption by reinforcing cortical actin cytoskeleton. This is due to a mechanism that involves the phosphorylation of p38 MAPK and HSP27, which is nonetheless independent of the small GTPase Rac1. This results in a drastic decrease of LPS-induced hyperpermeability. We conclude that α1AMPK activators that are suitable for clinical use may provide a specific therapeutic intervention that limits sepsis-induced vascular leakage.

Sepsis in the era of data-driven medicine: personalizing risks, diagnoses, treatments and prognoses

Sepsis is a series of clinical syndromes caused by the immunological response to infection. The clinical evidence for sepsis could typically attribute to bacterial infection or bacterial endotoxins, but infections due to viruses, fungi or parasites could also lead to sepsis. Regardless of the etiology, rapid clinical deterioration, prolonged stay in intensive care units and high risk for mortality correlate with the incidence of sepsis. Despite its prevalence and morbidity, improvement in sepsis outcomes has remained limited. In this comprehensive review, we summarize the current landscape of risk estimation, diagnosis, treatment and prognosis strategies in the setting of sepsis and discuss future challenges. We argue that the advent of modern technologies such as in-depth molecular profiling, biomedical big data and machine intelligence methods will augment the treatment and prevention of sepsis. The volume, variety, veracity and velocity of heterogeneous data generated as part of healthcare delivery and recent advances in biotechnology-driven therapeutics and companion diagnostics may provide a new wave of approaches to identify the most at-risk sepsis patients and reduce the symptom burden in patients within shorter turnaround times. Developing novel therapies by leveraging modern drug discovery strategies including computational drug repositioning, cell and gene-therapy, clustered regularly interspaced short palindromic repeats -based genetic editing systems, immunotherapy, microbiome restoration, nanomaterial-based therapy and phage therapy may help to develop treatments to target sepsis. We also provide empirical evidence for potential new sepsis targets including FER and STARD3NL. Implementing data-driven methods that use real-time collection and analysis of clinical variables to trace, track and treat sepsis-related adverse outcomes will be key. Understanding the root and route of sepsis and its comorbid conditions that complicate treatment outcomes and lead to organ dysfunction may help to facilitate identification of most at-risk patients and prevent further deterioration. To conclude, leveraging the advances in precision medicine, biomedical data science and translational bioinformatics approaches may help to develop better strategies to diagnose and treat sepsis in the next decade.

Modified early warning score-based clinical decision support: cost impact and clinical outcomes in sepsis

OBJECTIVE

The objective of this study was to assess the clinical and financial impact of a quality improvement project that utilized a modified Early Warning Score (mEWS)-based clinical decision support intervention targeting early recognition of sepsis decompensation.

MATERIALS AND METHODS

We conducted a retrospective, interrupted time series study on all adult patients who received a diagnosis of sepsis and were exposed to an acute care floor with the intervention. Primary outcomes (total direct cost, length of stay [LOS], and mortality) were aggregated for each study month for the post-intervention period (March 1, 2016-February 28, 2017, n = 2118 visits) and compared to the pre-intervention period (November 1, 2014-October 31, 2015, n = 1546 visits).

RESULTS

The intervention was associated with a decrease in median total direct cost and hospital LOS by 23% (P = .047) and .63 days (P = .059), respectively. There was no significant change in mortality.

DISCUSSION

The implementation of an mEWS-based clinical decision support system in eight acute care floors at an academic medical center was associated with reduced total direct cost and LOS for patients hospitalized with sepsis. This was seen without an associated increase in intensive care unit utilization or broad-spectrum antibiotic use.

CONCLUSION

An automated sepsis decompensation detection system has the potential to improve clinical and financial outcomes such as LOS and total direct cost. Further evaluation is needed to validate generalizability and to understand the relative importance of individual elements of the intervention.

Low expression of microRNA-328 can predict sepsis and alleviate sepsis-induced cardiac dysfunction and inflammatory response

Sepsis often leads to cardiac dysfunction and inflammation. This study investigated the clinical value of microRNA-328 (miR-328) in sepsis and its role in cardiac dysfunction and inflammation caused by sepsis. The expression level of miR-328 in the serum of the subjects was detected by qRT-PCR. Receiver operating characteristic (ROC) curve measured the diagnostic value of miR-328 in sepsis. Rat sepsis model was established to detect left ventricular systolic pressure (LVSP), left ventricular end-diastolic pressure (LVEDP), and maximal rate of increase/decrease of left ventricular pressure (±dp/dt_max). Myocardial injury markers serum cardiac troponin I (cTnI), myocardial kinase isoenzyme (CK-MB), and inflammatory factors were detected by enzyme-linked immunosorbent assay (ELISA). miR-328 expression was assessed in serum of sepsis patients and in rat models of sepsis. The AUC of ROC curve was 0.926, sensitivity 87.60%, and specificity 86.36%. Compared with the sham group, LVSP and +dp/dt_max were decreased in the rat model of sepsis. LVEDP, -dp/dt_max, cTnI, CK-MB, tumor necrosis factor-α, interleukin (IL)-6, and IL-1β were upregulated in the rat model of sepsis. The low expression of miR-328 reversed these indicators. miR-328 is a diagnostic marker for patients with sepsis, and decreasing the expression level of miR-328 can ameliorate cardiac dysfunction and cardiac inflammation in sepsis.

Enhancing sepsis management through machine learning techniques: A review

Sepsis is a major public health problem and a leading cause of death in the world, where delay in the beginning of treatment, along with clinical guidelines non-adherence have been proved to be associated with higher mortality. Machine Learning is increasingly being adopted in developing innovative Clinical Decision Support Systems in many areas of medicine, showing a great potential for automatic prediction of diverse patient conditions, as well as assistance in clinical decision making. In this context, this work conducts a narrative review to provide an overview of how specific Machine Learning techniques can be used to improve sepsis management, discussing the main tasks addressed, the most popular methods and techniques, as well as the obtained results, in terms of both intelligent system accuracy and clinical outcomes improvement.

Costs and length of sepsis-related hospitalizations in Taiwan

To investigate the healthcare expenditures and length of stay (LOS) of sepsis-related hospitalizations in Taiwan.This is a retrospective claim database study. Data were obtained from the two-million-sample longitudinal health and welfare database (LHWD). Adult patients hospitalized with sepsis between 2010 and 2014 were identified by International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) codes, and these patients were divided into three levels of sepsis severity. The amount and distribution of their total medical expenditures were investigated.In total, 62,517 patients with 97,790 sepsis-related hospitalizations were included in the present study. It was found that ward fees and medicines comprised the largest component of expenses for sepsis-related hospitalizations. In addition, our study results indicated that the median sepsis-related hospitalization cost was 66.4 thousand New Taiwan Dollar (NT dollars) in 2014, and a significant temporal change was found between 2010 and 2014. The median LOS in a hospital and in an intensive care unit were 11 and 7 days, respectively. Both expenditures and LOS were found to increase with sepsis severity.This study provides an updated and better understanding of the costs and LOS of sepsis-related hospitalizations in Taiwan. It was found that ward fees and medicine fees were the major components of hospital costs.

Incidence and Outcomes of Sepsis in Korea: A Nationwide Cohort Study From 2007 to 2016

OBJECTIVES

This study aimed to estimate the incidence and clinical outcomes of sepsis in Korea from 2007 to 2016.

DESIGN

Retrospective observational study.

SETTING

Nationwide study with population-based healthcare reimbursement claims database.

PATIENTS

Using data from the National Health Insurance Service of Korea, patients who were hospitalized with a diagnosis of sepsis from 2007 to 2016 were analyzed. The incidence of sepsis was calculated using mid-year census population and analyzed according to year, age, and sex. The Elixhauser Comorbidity Index score was calculated to adjust for the impact of comorbidities on clinical outcome. In-hospital mortality, hospital length of stay, ICU admission rates, and risk factors for in-hospital mortality were also analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The incidence of sepsis increased from 173.8 per 100,000 population in 2007 to 233.6 per 100,000 population in 2016. In-hospital mortality decreased from 30.9% in 2007 to 22.6% in 2016 (p < 0.0001). From 2007 to 2016, hospital length of stay and ICU admission rates associated with sepsis decreased from 26.0 ± 33.5 days to 21.3 ± 24.4 days (p < 0.0001) and from 16.2% to 12.7% (p < 0.0001), respectively. Male sex, age greater than 50 years, Elixhauser Comorbidity Index greater than 10, and mechanical ventilation were identified as risk factors for in-hospital mortality after adjusting for baseline characteristics.

CONCLUSIONS

The incidence of sepsis in Korea increased from 2007 to 2016, while the associated in-hospital mortality, hospital length of stay, and ICU admission rates decreased.

Epidemiological Trend of Sepsis in Patients with Hospital Admissions Related to Hepatitis C in Spain (2000-2015): A Nationwide Study

Background: Hepatitis C virus (HCV) infection predisposes patients to other infectious diseases, such as sepsis. We aimed to analyze epidemiological trends of sepsis-related admissions, deaths, and costs in hospital admissions with chronic hepatitis C who had a hospital admission in Spain. Methods: We performed a retrospective study of all hospitalizations involving chronic hepatitis C in the Spanish Minimum Basic Data Set (MBDS) between 2000 and 2015. This period was divided into four calendar periods (2000–2004, 2005–2007, 2008–2011, and 2012–2015). Results: We selected 868,523 hospital admissions of patients with chronic hepatitis C over 16 years in the Spanish MBDS. Among them, we found 70,976 (8.17%) hospital admissions of patients who developed sepsis, of which 13,915 (19.61%) died during admission. We found an upward trend, from 2000–2003 to 2012–2015, in the rate of sepsis-related admission (from 6.18% to 10.64%; p < 0.001), the risk of sepsis-related admission (from 1.31 to 1.55; p < 0.001), and the sepsis-related cost per hospital admission (from 7198€ to above 9497€; p < 0.001). However, we found a downward trend during the same study period in the sepsis case-fatality rate (from 21.99% to 18.16%; p < 0.001), the risk of sepsis-related death (from 0.81 to 0.56; p < 0.001), and the length of hospital stay (LOHS) (from 16.9 to 13.9; p < 0.001). Moreover, the rate of bacterial Gram-positive and candidiasis infections decreased, while Gram-negative microorganisms increased from 2000–2003 to 2012–2015. Conclusions: Sepsis, in chronic hepatitis C patients admitted to the hospital, has increased the period 2000–2015 and has been an increasing burden for the Spanish public health system. However, there has also been a significant reduction in lethality and LOHS during the study period. In addition, the most prevalent specific microorganisms have also changed in this period.

Heart Rate Variability, Clinical and Laboratory Measures to Predict Future Deterioration in Patients Presenting With Sepsis

BACKGROUND

Risk stratification of patients presenting to the emergency department (ED) with sepsis can be challenging. We derived and evaluated performance of a predictive model containing clinical, laboratory, and heart rate variability (HRV) measures to quantify risk of deterioration in this population.

METHODS

ED patients aged 21 and older satisfying the 1992 consensus conference criteria for sepsis and able to consent (directly or through a surrogate) were enrolled (n = 1,247). Patients had clinical, laboratory, and HRV data recorded within 1 h of ED presentation, and were followed to identify deterioration within 72 h.

RESULTS

Eight hundred thirty-two patients had complete data, of whom 68 (8%) reached at least one endpoint. Optimal predictive performance was derived from a combination of laboratory values and HRV metrics with an area under the receiver-operating curve (AUROC) of 0.80 (95% CI, 0.65-0.92). This combination of variables was superior to clinical (AUROC = 0.69, 95% CI, 0.54-0.83), laboratory (AUROC = 0.77, 95% CI, 0.63-0.90), and HRV measures (AUROC = 0.76, 95% CI, 0.61-0.90) alone. The HRV+LAB model identified a high-risk cohort of patients (14% of all patients) with a 4.3-fold (95% CI, 3.2-5.4) increased risk of deterioration (incidence of deterioration: 35%), as well as a low-risk group (61% of all patients) with 0.2-fold (95% CI 0.1-0.4) risk of deterioration (incidence of deterioration: 2%).

CONCLUSIONS

A model that combines HRV and laboratory values may help ED physicians evaluate risk of deterioration in patients with sepsis and merits validation and further evaluation.

Integrin ανβ3 modulates lipopolysaccharide-induced hyperpermeability in cardiac microvascular endothelial cells

Previous studies suggest an association of cardiac microvascular endothelial cells (CMECs) hyperpermeability with sepsis-related cardiac injury. Our results showed that CMECs permeability was dependent upon concentration and time of lipopolysaccharides (LPS) stimulation. Integrin ανβ3 expression decreased after LPS stimulation. Pretreatment with anti-integrin ανβ3 antibody enhanced LPS-induced hyperpermeability. Upregulation of integrin ανβ3 decreased LPS-induced hyperpermeability. F-actin remodeling was enhanced after LPS stimulation and was inhibited by up-regulation of integrin ανβ3. Inhibition of Src or Rac1 reduced CMECs permeability after LPS stimulation, but there were no differences in the phosphorylation of Src and Rac1 when over-expressing or blocking integrin β3. After pretreatment with Src or Rac1 inhibitor, no significant difference was found in the expression of integrin ανβ3 in LPS-induced CMECs. These finding suggested that integrin ανβ3 overexpression decreased LPS-stimulated CMECS permeability by inhibition of cytoskeletal remodeling, but the mechanism might not be mediated via Src/Rac1 signaling.

Cost Impact Model of a Novel Multi-mRNA Host Response Assay for Diagnosis and Risk Assessment of Acute Respiratory Tract Infections and Sepsis in the Emergency Department

BACKGROUND

Early identification of acute infections and sepsis remains an unmet medical need. While early detection and initiation of treatment reduces mortality, inappropriate treatment leads to adverse events and the development of antimicrobial resistance. Current diagnostic and prognostic solutions, including procalcitonin, lack required accuracy. A novel blood-based host response test, HostDx™ Sepsis by Inflammatix, Inc., assesses the likelihood of a bacterial infection, the likelihood of a viral infection, and the severity of the condition.

OBJECTIVES

We estimated the economic impact of adopting HostDx Sepsis testing among patients with suspected acute respiratory tract infection (ARTI) in the emergency department (ED).

METHODS

Our cost impact model estimated costs for adult ED patients with suspected ARTI under the standard of care versus with the adoption of HostDx Sepsis from the perspective of US payers. Included costs were those assumed to be associated with an episode of sepsis diagnosis, management, and treatment. Projected accuracies for test predictions, disease prevalence, and clinical parameters was derived from patient-level meta-analysis data of randomized trials, supplemented with published performance data for HostDx Sepsis. One-way sensitivity analysis was performed on key input parameters.

RESULTS

Compared to standard of care including procalcitonin, the superior test characteristics of HostDx Sepsis resulted in an average cost savings of approximately US$1974 per patient (-31.3%) exclusive of the cost of HostDx Sepsis. Reductions in hospital days (-0.80 days, -36.7%), antibiotic days (-1.49 days, -29.5%), and percent 30-day mortality (-1.67%, -13.64%) were driven by HostDx Sepsis providing fewer "noninformative" moderate risk predictions and more "certain" low- or high-risk predictions compared to standard of care, especially for patients who were not severely ill. These results were robust to changes in key parameters, including disease prevalence.

CONCLUSIONS

Our model shows substantial savings associated with introduction of HostDx Sepsis among patients with ARTIs in EDs. These results need confirmation in interventional trials.

Trends and Outcomes in Sepsis Hospitalizations With and Without Atrial Fibrillation: A Nationwide Inpatient Analysis

OBJECTIVES

Atrial fibrillation is frequently seen in sepsis-related hospitalizations. However, large-scale contemporary data from the United States comparing outcomes among sepsis-related hospitalizations with versus without atrial fibrillation are limited. The aim of our study was to assess the frequency of atrial fibrillation and its impact on outcomes of sepsis-related hospitalizations.

DESIGN

Retrospective cohort study.

SETTING

The National Inpatient Sample databases (2010-2014).

PATIENTS

Primary discharge diagnosis of sepsis with and without atrial fibrillation were identified using prior validated International Classification of Diseases, 9th Edition, Clinical Modification codes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Overall, 5,808,166 hospitalizations with the primary diagnosis of sepsis, of which 19.4% (1,126,433) were associated with atrial fibrillation. The sepsis-atrial fibrillation cohort consisted of older (median [interquartile range] age of 79 yr [70-86 yr] vs 67 yr [53-79 yr]; p < 0.001) white (80.9% vs 68.8%; p < 0.001) male (51.1% vs 47.5%; p < 0.001) patients with an extended length of stay (median [interquartile range] 6 d [4-11 d] vs 5 d [3-9 d]; p < 0.001) and higher hospitalization charges (median [interquartile range] $44,765 [$23,234-$88,657] vs $35,737 [$18,767-$72,220]; p < 0.001) as compared with the nonatrial fibrillation cohort. The all-cause mortality rate in the sepsis-atrial fibrillation cohort was significantly higher (18.4% and 11.9%; p = 0.001) as compared with those without atrial fibrillation. Although all-cause mortality (20.4% vs 16.6%) and length of stay (median [interquartile range] 7 d [4-11 d] vs 6 d [4-10 d]) decreased between 2010 and 2014, hospitalization charges increased (median [interquartile range] $41,783 [$21,430-$84,465] vs $46,251 [$24,157-$89,995]) in the sepsis-atrial fibrillation cohort. The greatest predictors of mortality in the atrial fibrillation-sepsis cohort were African American race, female gender, advanced age, and the presence of medical comorbidities.

CONCLUSIONS

The presence of atrial fibrillation among sepsis-related hospitalizations is a marker of poor prognosis and increased mortality. Although we observed rising trends in sepsis and sepsis-atrial fibrillation-related hospitalizations during the study period, the rate and odds of mortality progressively decreased.

Effect of a sepsis prediction algorithm on patient mortality, length of stay and readmission: a prospective multicentre clinical outcomes evaluation of real-world patient data from US hospitals

BACKGROUND

Severe sepsis and septic shock are among the leading causes of death in the USA. While early prediction of severe sepsis can reduce adverse patient outcomes, sepsis remains one of the most expensive conditions to diagnose and treat.

OBJECTIVE

The purpose of this study was to evaluate the effect of a machine learning algorithm for severe sepsis prediction on in-hospital mortality, hospital length of stay and 30-day readmission.

DESIGN

Prospective clinical outcomes evaluation.

SETTING

Evaluation was performed on a multiyear, multicentre clinical data set of real-world data containing 75 147 patient encounters from nine hospitals across the continental USA, ranging from community hospitals to large academic medical centres.

PARTICIPANTS

Analyses were performed for 17 758 adult patients who met two or more systemic inflammatory response syndrome criteria at any point during their stay ('sepsis-related' patients).

INTERVENTIONS

Machine learning algorithm for severe sepsis prediction.

OUTCOME MEASURES

In-hospital mortality, length of stay and 30-day readmission rates.

RESULTS

Hospitals saw an average 39.5% reduction of in-hospital mortality, a 32.3% reduction in hospital length of stay and a 22.7% reduction in 30-day readmission rate for sepsis-related patient stays when using the machine learning algorithm in clinical outcomes analysis.

CONCLUSIONS

Reductions of in-hospital mortality, hospital length of stay and 30-day readmissions were observed in real-world clinical use of the machine learning-based algorithm. The predictive algorithm may be successfully used to improve sepsis-related outcomes in live clinical settings.

TRIAL REGISTRATION NUMBER

NCT03960203.

Predictors of Urinary Infections and Urosepsis After Ureteroscopy for Stone Disease: a Systematic Review from EAU Section of Urolithiasis (EULIS)

PURPOSE OF REVIEW

To present the latest evidence related to the predictors of urinary tract infections (UTIs) and urosepsis after ureteroscopy (URS) for stone disease.

RECENT FINDINGS

Our review suggests that almost half of all post-URS complications are related to infectious complications although reported rates of urosepsis were low. The use of antibiotic prophylaxis, treatment of pre-operative UTI, and low procedural time seem to reduce this risk. However, the risk is higher in patients with higher Charlson comorbidity index, elderly patients, female gender, long duration of pre-procedural indwelling ureteric stents and patients with a neurogenic bladder and with high BMI. Infectious complications following ureteroscopy can be a source of morbidity and potential mortality. Although majority of these are minor, efforts must be taken to minimise them especially in high-risk patients. This includes the use of prophylactic antibiotics, limiting stent dwell and procedural time, prompt identification and treatment of UTI and urosepsis, and careful planning in patients with large stone burden and multiple comorbidities.

Long-term mortality and outcome in hospital survivors of septic shock, sepsis, and severe infections: The importance of aftercare

Patients with severe infections and especially sepsis have a high in-hospital mortality, but even hospital survivors face long-term sequelae, decreased health-related quality of life, and high risk of death, suggesting a great need for specialized aftercare. However, data regarding a potential benefit of post-discharge rehabilitation in these patients are scarce. In this retrospective matched cohort study the claim data of a large German statutory health care insurer was analyzed. 83,974 hospital survivors having suffered from septic shock, sepsis, and severe infections within the years 2009–2016 were identified using an ICD abstraction strategy closely matched to the current Sepsis-3 definition. Cases were analyzed and compared with their matched pairs to determine their 5-year mortality and the impact of post-discharge rehabilitation. Five years after hospital discharge, mortality of initial hospital survivors were still increased after septic shock (HR_adj 2.03, 95%-CI 1.87 to 2.19; P<0.001), sepsis (HR_adj 1.73, 95%-CI 1.71 to 1.76; P<0.001), and also in survivors of severe infections without organ dysfunction (HR_adj 1.70, 95%-CI 1.65 to 1.74; P<0.001) compared to matched controls without infectious diseases. Strikingly, patients treated in rehabilitation facilities showed a significantly improved 5-year survival after suffering from sepsis or septic shock (HR_adj 0.81, 95%-CI 0.77 to 0.85; P<0.001) as well as severe infections without organ dysfunction (HR_adj 0.81, 95%-CI 0.73 to 0.90; P<0.001) compared to matched patients discharged to home or self-care. Long-term mortality and morbidity of hospital survivors are markedly increased after septic shock, sepsis and severe infections without organ dysfunction, but best 5-year survival was recorded in patients discharged to a rehabilitation facility in all three groups. Thus, our data suggest that specialized aftercare programs may help to improve long-term outcome in these patients and warrants more vigilance in future investigations.

Sepsis Patients in Critical Care Units with Obesity: Is Obesity Protective?

Obesity is becoming a global health issue and its prevalence is increasing. It is associated with an increased incidence of illness and sepsis. While obesity is associated with increased morbidity and mortality, obesity has been found to be associated with improvement in mortality outcomes in sepsis when compared to leaner patients, a phenomenon described as an obesity paradox. However, the effect of obesity on mortality in adults requiring treatment for sepsis is unclear. Studies evaluating this effect are inconsistent and there is an increased morbidity still associated with obesity. As well, there are many limitations to these studies confounding interpretation. Future prospective studies minimizing bias and confounding factors are suggested to address this important clinical issue.

Cell-free hemoglobin increases inflammation, lung apoptosis, and microvascular permeability in murine polymicrobial sepsis

Increased endothelial permeability is central to the pathogenesis of sepsis and leads to organ dysfunction and death but the endogenous mechanisms that drive increased endothelial permeability are not completely understood. We previously reported that cell-free hemoglobin (CFH), elevated in 80% of patients with sepsis, increases lung microvascular permeability in an ex vivo human lung model and cultured endothelial cells. In this study, we augmented a murine model of polymicrobial sepsis with elevated circulating CFH to test the hypothesis that CFH increases microvascular endothelial permeability by inducing endothelial apoptosis. Mice were treated with an intraperitoneal injection of cecal slurry with or without a single intravenous injection of CFH. Severity of illness, mortality, systemic and lung inflammation, endothelial injury and dysfunction and lung apoptosis were measured at selected time points. We found that CFH added to CS increased sepsis mortality, plasma inflammatory cytokines as well as lung apoptosis, edema and inflammation without affecting large vessel reactivity or vascular injury marker concentrations. These results suggest that CFH is an endogenous mediator of increased endothelial permeability and apoptosis in sepsis and may be a promising therapeutic target.

Sepsis trends: increasing incidence and decreasing mortality, or changing denominator?

Numerous studies suggest that the incidence of sepsis has been steadily increasing over the past several decades while mortality rates are falling. However, reliably assessing trends in sepsis epidemiology is challenging due to changing diagnosis and coding practices over time. Ongoing efforts by clinicians, administrators, policy makers, and patient advocates to increase sepsis awareness, screening, and recognition are leading to more patients being labeled with sepsis. Subjective clinical definitions and heterogeneous presentations also allow for wide discretion in diagnosing sepsis rather than specific infections alone or non-specific syndromes. These factors create a potential ascertainment bias whereby the inclusion of less severely ill patients in sepsis case counts over time leads to a perceived increase in sepsis incidence and decrease in sepsis mortality rates. Analyses that rely on administrative data alone are further confounded by changing coding practices in response to new policies, financial incentives, and efforts to improve documentation. An alternate strategy for measuring sepsis incidence, outcomes, and trends is to use objective and consistent clinical criteria rather than administrative codes or registries to identify sepsis. This is feasible using data routinely found in electronic health record systems, such as blood culture draws and sustained courses of antibiotics to identify infection and laboratory values, vasopressors, and mechanical ventilation to measure acute organ dysfunction. Recent surveillance studies using this approach suggest that sepsis incidence and mortality rates have been essentially stable over the past decade. In this review, we summarize the major epidemiologic studies of sepsis trends, potential biases in these analyses, and the recent change in the surveillance paradigm toward using objective clinical data from electronic health records to more accurately characterize sepsis trends.

Impact of the pre-illness lipid profile on sepsis mortality

PURPOSE

To determine if baseline lipid levels contribute to the relationship between lipid levels during sepsis and outcomes.

MATERIALS AND METHODS

We conducted a retrospective cohort study at a tertiary-care academic medical center. Multivariable logistic regression models were used to adjust for confounders. Both Systemic Inflammatory Response Syndrome (SIRS) and Sequential Organ Failure Assessment (SOFA) score-based definitions of sepsis were analyzed.

MEASUREMENTS AND MAIN RESULTS

After adjusting for patient characteristics and severity of illness, baseline values for both low density lipoprotein (LDL) cholesterol and triglycerides were associated with mortality (LDL cholesterol odds ratio [OR] 0.44, 95% confidence interval [CI] 0.23-0.84, p = .013; triglyceride OR 0.54, 95% CI 0.37-0.78, p = .001) using a SIRS based definition of sepsis. An interaction existed between these two variables, which resulted in increased mortality with higher baseline low density lipoprotein (LDL) cholesterol values for individuals with triglycerides below 208 mg/dL and the opposite direction of association above this level (interaction OR 1.48, 95% CI 1.02-2.16, p = .039). When using a SOFA score-based definition, only triglycerides remained associated with the mortality (OR 0.55, 95% CI 0.35-0.86, p = .008).

CONCLUSIONS

Baseline lipid values, particularly triglyceride concentrations, are associated with hospital mortality in septic patients.

Incidence, trends, and outcomes of infection sites among hospitalizations of sepsis: A nationwide study

Purpose

To determine the trends of infection sites and outcome of sepsis using a national population-based database.

Materials and methods

Using the Nationwide Inpatient Sample database of the US, adult sepsis hospitalizations and infection sites were identified using a validated approach that selects admissions with explicit ICD-9-CM codes for sepsis and diagnosis/procedure codes for acute organ dysfunctions. The primary outcome was the trend of incidence and in-hospital mortality of specific infection sites in sepsis patients. The secondary outcome was the impact of specific infection sites on in-hospital mortality.

Results

During the 9-year period, we identified 7,860,687 admissions of adult sepsis. Genitourinary tract infection (36.7%), lower respiratory tract infection (36.6%), and systemic fungal infection (9.2%) were the leading three sites of infection in patients with sepsis. Intra-abdominal infection (30.7%), lower respiratory tract infection (27.7%), and biliary tract infection (25.5%) were associated with highest mortality rate. The incidences of all sites of infections were trending upward. Musculoskeletal infection (annual increase: 34.2%) and skin and skin structure infection (annual increase: 23.0%) had the steepest increase. Mortality from all sites of infection has decreased significantly (trend p<0.001). Skin and skin structure infection had the fastest declining rate (annual decrease: 5.5%) followed by primary bacteremia (annual decrease: 5.3%) and catheter related bloodstream infection (annual decrease: 4.8%).

Conclusions

The anatomic site of infection does have a differential impact on the mortality of septic patients. Intra-abdominal infection, lower respiratory tract infection, and biliary tract infection are associated with higher mortality in septic patients.

Epidemiology and outcomes of sepsis among hospitalizations with systemic lupus erythematosus admitted to the ICU: a population-based cohort study

Background

Sepsis is the most common cause of premature death among patients with systemic lupus erythematosus (SLE) aged ≤ 50 years in the United States, and infection is the most common cause of admission to the ICU among SLE patients. However, there are no population-level data on the patterns of the demand for critical care services among hospitalized septic patients with SLE or the outcomes of those admitted to the ICU.

Methods

We performed a retrospective cohort study, using the Texas Inpatient Public Use Data File, to identify SLE hospitalizations aged ≥ 18 years and the subgroups with sepsis and ICU admission during 2009–2014. The patterns of ICU admission among septic hospitalizations were examined. Logistic regression modeling was used to identify predictors of short-term mortality (defined as hospital death or discharge to hospice) among ICU admissions with sepsis and to estimate the risk-adjusted short-term mortality among ICU admissions with and without sepsis.

Results

Among 94,338 SLE hospitalizations, 17,037 (18.1%) had sepsis and 9409 (55.2%) of the latter were admitted to the ICU. Sepsis accounted for 51.5% of the growth in volume of ICU admissions among SLE hospitalizations during the study period. Among ICU admissions with sepsis, 25.3% were aged ≥ 65 years, 88.6% were female, and 64.4% were non-white minorities. The odds of short-term mortality among septic ICU admissions were increased among those lacking health insurance (adjusted odds ratio 1.40 [95% confidence interval 1.07–1.84]), while being unaffected by gender and race/ethnicity, and remaining unchanged over the study period. On adjusted analyses among ICU admissions, the short-term mortality among those with and without sepsis was 13% (95% CI 12.6–13.3) and 2.7% (95% CI 2.6–2.8), respectively. Sepsis was associated with 63.6% of all short-term mortality events.

Conclusions

Sepsis is a major, incremental driver of the demand for critical care services among SLE hospitalizations. Despite its relatively low mortality, sepsis was associated with most of the short-term deaths among ICU patients with SLE.

Potentially Preventable Intensive Care Unit Admissions in the United States, 2006-2015

Rationale: Increasing intensive care unit (ICU) beds and the critical care workforce are often advocated to address an aging and increasingly medically complex population. However, reducing potentially preventable ICU stays may be an alternative to ensure adequate capacity.Objectives: To determine the proportions of ICU admissions meeting two definitions of being potentially preventable using nationally representative U.S. claims databases.Methods: We analyzed claims from 2006 to 2015 from all Medicare Fee-for-Service (FFS) beneficiaries and from a large national payer offering a private insurance (PI) plan and a Medicare Advantage (MA) plan. Potentially preventable hospitalizations were identified using existing definitions for ambulatory care sensitive conditions (ACSCs) and life-limiting malignancies (LLMs).Results: We analyzed 420,369,434 person-years of insurance coverage, during which there were 99,793,416 acute inpatient hospitalizations, of which 16,646,977 (16.7%) were associated with an ICU admission. Of these, the proportions with an ACSC were 12.9%, 12.7%, and 15.8%, and with an LLM were 5.2%, 5.4%, and 6.4%, among those with PI, MA, and FFS, respectively. Over 10 years, the absolute percentages of ACSC-associated ICU stays declined (PI = -1.1%, MA -6.4%, FFS -6.4%; all P < 0.001 for all trends). Smaller changes were noted among LLM-associated ICU stays, declining in the MA cohort (-0.8%) and increasing in the FFS (+0.3%) and PI (+0.2%) populations (P < 0.001 for all trends).Conclusions: An appreciable proportion of U.S. ICU admissions may be preventable with community-based interventions. Investment in the outpatient infrastructure required to prevent these ICU admissions should be considered as a complementary, if not alternative, strategy to expanding ICU capacity to meet future demand.

Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019

Background

Sepsis syndrome is an emerging healthcare problem, especially in critically ill patients, regardless whether it's community- or hospital-acquired sepsis. This study evaluates the characteristics of these patients, in addition to the type, source, and outcome of sepsis and septic shock, in a university tertiary hospital in Palestine. It also studies the most common organisms encountered in these patients.

Materials and methods

This is retrospective observational chart review study of all adult admissions to the intensive care unit over a period of 2 years. The presence of sepsis and septic shock was assessed and documented based on the Third International Consensus Definitions (Sepsis-3). Data regarding demographics, severity, comorbidities, source of infection, microbiology, length of stay, and outcomes (dead/alive at discharge from ICU) were recorded.

Results

A total number of 174 patients were included. The mean age was 57.4 years, with cardiovascular diseases and diabetes being the leading comorbidities encountered in them. Respiratory infections were the most common site of sepsis, found in around 71% of patients, followed by urinary tract infections. More than 70% of cases were due to hospital-acquired infections (HAIs). Acinetobacter species were the most common gram-negative organisms encountered, while Enterococcus was the most common gram-positive organisms. Around 54% of patients had multidrug-resistant organisms. The average length of stay in the ICU was 8 days. The average mortality rate was 39.7%, which is higher among septic shock patients.

Conclusion

Both sepsis and septic shock carry high morbidity and mortality rates, and they are very frequent among critically ill patients. Special care and developing management bundles are crucial in controlling and preventing this threat.

How to cite this article

Rabee HA, Tanbour R, Nazzal Z, Hamshari Y, Habash Y, Anaya A, et al. Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019. Indian J Crit Care Med 2020;24(7):551–556.

The ability of an improved qSOFA score to predict acute sepsis severity and prognosis among adult patients

This study analyzed independent risk factors that could improve the qSOFA scoring system among sepsis patients.This retrospective study evaluated 821 patients (2015-2016) who fulfilled the 2001 International Sepsis Definitions Conference diagnostic criteria. Patients were classified based on their survival outcomes after 28 days, and the predictive values of various predictive scores at admission were compared.The independent risk factors for 28-day mortality were fibrinogen, plasma lactic acid, albumin, oxygenation index, and procalcitonin level >0.5 ng/mL (all P < .05). The "PqSOFA" score combined the qSOFA score with procalcitonin, which provided an area under the curve value of 0.751 (95% CI: 0.712-0.790) for predicting 28-day mortality. A cut-off score of 2 points provided sensitivity of 83.2%, specificity of 54.9%, negative predictive value (NPV) of 33.03%, positive predictive value (PPV) of 92.47%, positive-likelihood ratio (PLR) of 1.85, and negative-likelihood ratio (NLR) of 0.31. The area under the curve for predicting 28-day mortality was significantly greater for the PqSOFA score than for the qSOFA score (Z = 7.019, P < .0001). The PqSOFA score was comparable to the SOFA and APACHE II scores.The PqSOFA score independently predicted poor short-term outcomes among high-risk sepsis patients.

Epidemiological Characteristics of Postoperative Sepsis

BACKGROUND

Postoperative sepsis is a major type of sepsis. Sociodemographic characteristics, incidence trends, surgical procedures, comorbidities, and organ system dysfunctions related to the disease burden of postoperative sepsis episodes are unclear.

METHODS

We analyzed epidemiological characteristics of postoperative sepsis based on the ICD-9-CM codes for the years 2002 to 2013 using the Longitudinal Health Insurance Databases of Taiwan's National Health Insurance Research Database.

RESULTS

We identified 5,221 patients with postoperative sepsis and 338,279 patients without postoperative sepsis. The incidence of postoperative sepsis increased annually with a crude mean of 0.06% for patients aged 45-64 and 0.34% over 65 years. Patients with postoperative sepsis indicated a high risk associated with the characteristics, male sex (OR:1.375), aged 45-64 or ≥ 65 years (OR:2.639 and 5.862), low income (OR:1.390), aged township (OR:1.269), agricultural town (OR:1.266), and remote township (OR:1.205). Splenic surgery (OR:7.723), Chronic renal disease (OR:1.733), cardiovascular dysfunction (OR:2.441), and organ system dysfunctions had the highest risk of postoperative sepsis.

CONCLUSION

Risk of postoperative sepsis was highest among men, older, and low income. Patients with splenic surgery, chronic renal comorbidity, and cardiovascular system dysfunction exhibited the highest risk for postoperative sepsis. The evaluation of high-risk factors assists in reducing the disease burden.

Epidemiology and Trends of Sepsis in Young Adults Aged 20-44 Years: A Nationwide Population-Based Study

Background: While sepsis may have especially marked impacts in young adults, there is limited population-based information on its epidemiology and trends. Methods: Population-based longitudinal study on sepsis in adults aged 20–44 years using the 2006–2015 Spanish national hospital discharge database. Cases are identified by an ICD-9-CM coding strategy. Primary endpoints are incidence and in-hospital mortality. Trends are assessed for annual percentage change (AAPC) in rates using Joinpoint regression models. Results: 28,351 cases are identified, representing 3.06‰ of all-cause hospitalisations and a crude incidence of 16.4 cases/100,000 population aged 20–44. The mean age is 36 years, 58% of cases are men, and around 60% have associated comorbidities. Seen in one third of cases, the source of infection is respiratory. Single organ dysfunction is recorded in 45% of cases. In-hospital mortality is 24% and associated with age, comorbidity and extent of organ dysfunction. Incidence rates increase over time in women (AAPC: 3.8% (95% CI: 2.1, 5.5)), whereas case-fatality decline with an overall AAPC of −5.9% (95% CI −6.6, −5.2). Our results indicate that sepsis is common in young adults and associated with high in-hospital mortality, though it shows a decreasing trend. The substantial increase in incidence rates in women needs further research.

Effects of Inotropes on the Mortality in Patients With Septic Shock

BACKGROUND

Although surviving sepsis campaign guidelines recommend the use of inotropes in the presence of myocardial dysfunction, the effects of inotropes, including epinephrine, dobutamine, and milrinone, on in-hospital mortality in patients with septic shock remains unclear.

MATERIALS AND METHODS

We conducted an international,2-center, retrospective cohort study. The Cox proportional hazards regression model with time-varying covariates was used to investigate whether epinephrine, milrinone, or dobutamine reduces in-hospital mortality in patients with septic shock. Sensitivity analysis was performed using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcome included atrial fibrillation (Afib) with a rapid ventricular response (RVR) in the intensive care unit (ICU) and ICU-free days.

RESULTS

A total of 417 patients with septic shock were included, 72 (17.3%) of whom received inotropes. The use of epinephrine and dobutamine was associated with significantly higher in-hospital mortality (epinephrine, hazard ratio [HR]: 4.79, 95% confidence interval [CI]: 2.12-10.82, P = .001; dobutamine, HR: 2.53, 95% CI: 1.30-4.95, P = .046). The effects of epinephrine and dobutamine were time- and dose-dependent. The use of milrinone was not associated with increased mortality (HR: 1.07, 95% CI: 0.42-2.68, P = .345). The use of epinephrine, dobutamine, and milrinone was associated with significantly increased odds of Afib with RVR (epinephrine, odds ratio [OR]: 3.88, 95% CI: 1.11-13.61, P = .034; dobutamine, OR: 3.95, 95% CI: 1.14-13.76; and milrinone, OR: 3.77, 95% CI: 1.05-13.59). On the other hand, the use of epinephrine, dobutamine, and milrinone was not associated with less ICU-free days (epinephrine, adjusted OR: 0.30, 95% CI: 0.09-1.01, P = .053; dobutamine, adjusted OR: 0.91, 95% CI: 0.29-2.84; and milrinone, adjusted OR: 0.60, 95% CI: 0.19-1.87).

CONCLUSION

The present study showed that the use of epinephrine and dobutamine was associated with significantly increased in-hospital mortality in patients with septic shock. These effects were both time- and dose-dependent. On the other hand, the use of milrinone was not associated with increased in-hospital mortality.