Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data

Association Between the Sequence of β-Lactam and Vancomycin Administration and Mortality in Patients With Suspected Sepsis

BACKGROUND

Timely antibiotic initiation is critical to sepsis management, but there are limited data on the impact of giving β-lactams first versus vancomycin first among patients prescribed both agents.

METHODS

We retrospectively analyzed all adults admitted to 5 US hospitals from 2015-2022 with suspected sepsis (blood culture collected, antibiotics administered, and organ dysfunction) treated with vancomycin and a broad-spectrum β-lactam within 24 hours of arrival. We estimated associations between β-lactam- versus vancomycin-first strategies and in-hospital mortality using inverse probability weighting (IPW) to adjust for potential confounders.

RESULTS

Among 25 391 patients with suspected sepsis, 21 449 (84.4%) received β-lactams first and 3942 (15.6%) received vancomycin first. Compared with the β-lactam-first group, patients administered vancomycin first tended to be less severely ill, had more skin/musculoskeletal infections (20.0% vs 7.8%), and received β-lactams a median of 3.5 hours later relative to emergency department arrival. On IPW analysis, the β-lactam-first strategy was associated with lower mortality (adjusted odds ratio [aOR]: .89; 95% CI: .80-.99). Point estimates were directionally similar but nonsignificant in a sensitivity analysis using propensity score matching rather than IPW (aOR: .94; 95% CI: .82-1.07) and in subgroups of patients with positive blood cultures, methicillin-resistant Staphylococcus aureus cultures, and those administered antipseudomonal β-lactams.

CONCLUSIONS

Among patients with suspected sepsis prescribed vancomycin and β-lactam therapy, β-lactam administration before vancomycin was associated with a modest reduction in in-hospital mortality. These findings support prioritizing β-lactam therapy in most patients with sepsis but merit confirmation in randomized trials given the risk of residual confounding in observational analyses.

Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes

Importance

The Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) is supported by observational studies that report SEP-1 compliance is associated with lower mortality. Most studies, however, adjusted for limited confounders and provided little insight into why bundle-compliant care was not provided.

Objectives

To identify the clinical factors that complicate the diagnosis and management of sepsis and assess their association with SEP-1 compliance and mortality.

Design, Setting, and Participants

This retrospective cohort study was conducted among 590 adults with sepsis in the emergency department of 4 academic hospitals from January 1, 2019, to December 31, 2022. Patients' medical records were reviewed between September 2022 and December 2023.

Main Outcomes and Measures

Study outcomes were (1) characteristics of patients who received SEP-1-compliant care vs characteristics of patients who received noncompliant care and (2) association between SEP-1 compliance and hospital mortality using multivariable models to adjust for successively more potential confounders (first demographics and comorbidities, then infection source, then severity of illness, and then clinical markers of complexity).

Results

Of 590 patients with sepsis (median age, 65 years [IQR, 53-77 years]; 329 men [55.8%]), 335 (56.8%) received SEP-1-compliant care, and 225 (43.2%) received noncompliant care. Compared with patients in the compliant group, patients in the noncompliant group were more likely to be 65 years or older (142 [55.7%] vs 158 [47.2%]; odds ratio [OR], 1.41 [95% CI, 1.01-1.95]), to have multiple comorbidities (Elixhauser score >20: 99 [38.8%] vs 99 [29.6%]; OR, 1.51 [95% CI, 1.07-2.13]), and to have a higher incidence of septic shock (107 [42.0%] vs 107 [31.9%]; OR, 1.54 [95% CI, 1.10-2.16]), kidney dysfunction (87 [34.1%] vs 80 [23.9%]; OR, 1.65 [95% CI, 1.15-2.37]), and thrombocytopenia (43 [16.9%] vs 37 [11.0%]; OR, 1.16 [95% CI, 1.02-2.62]) on presentation. Compared with patients in the compliant group, those in the noncompliant group also had more nonfebrile presentations (136 [53.3%] vs 121 [36.1%]; OR, 2.02 [95% CI, 1.45-2.82]), impaired mental status (92 [36.1%] vs 94 [28.1%]; OR, 1.45 [95% CI, 1.02-2.05]), need for bedside procedures (57 [22.4%] vs 41 [12.2%]; OR, 2.06 [95% CI, 1.33-3.21]), acute concurrent noninfectious illnesses (140 [54.9%] vs 151 [45.1%]; OR, 1.48 [95% CI, 1.07-2.06]), and noninfectious illness as the primary factor associated with their presentation (84 [32.9%] vs 71 [21.2%]; OR, 1.82 [95% CI, 1.08-3.08]). SEP-1 compliance was associated with lower crude mortality rates compared with noncompliance (40 [11.9%] vs 41 [16.1%]; unadjusted OR, 0.60 [95% CI, 0.37-0.98]), but there was no statistically significant difference between groups after successively adjusting for demographics and comorbidities (adjusted OR [AOR], 0.71 [95% CI, 0.42-1.18]), infection source (AOR, 0.71 [95% CI, 0.43-1.20]), severity of illness (AOR, 0.86 [95% CI, 0.50-1.49]), and clinical markers of complexity (AOR, 1.08 [95% CI, 0.61-1.91]).

Conclusions and Relevance

In this cohort study of adults with sepsis, complex clinical presentations were more common among patients whose treatment was noncompliant with SEP-1. These nuances are poorly captured in most observational studies but confound the association between SEP-1 compliance and mortality.

Fluid Resuscitation and Initial Management in Patients Presenting with Sepsis in the General Ward

The optimal management of hospital-presenting sepsis remains poorly understood. We investigated the initial management in patients presenting with sepsis in the general ward, the association between fluid resuscitation and clinical outcomes, and the factors affecting fluid resuscitation. A retrospective study was conducted on patients who presented with sepsis-induced hypotension in the general ward. Patients were divided into Less 30 (fluid resuscitation less than 30 mL/kg) and More 30 (fluid resuscitation 30 mL/kg or more) groups. Multivariable logistic regression analysis was performed. The median resuscitation fluid volume was 500 mL (9.2 mL/kg) and 2000 mL (35.9 mL/kg) in the Less 30 (n = 79) and More 30 (n = 11) groups, respectively. The intensive care unit (ICU) mortality was similar between the two groups (43.0% vs. 45.5%). Twenty-two patients received continuous renal replacement therapy (CRRT) in the Less 30 group, whereas none received it in the More 30 group (27.8% vs. 0%). Fluid resuscitation ≥30 mL/kg was not associated with ICU mortality. Low body weight and systolic blood pressure were associated with fluid resuscitation ≥30 mL/kg. Most hospital-presenting sepsis patients received less than 30 mL/kg of fluid, and fluid resuscitation was not associated with ICU mortality.

The Complete Blood Count Sepsis Index Using Monocyte Distribution Width for Early Detection of Sepsis in Patients Without Obvious Signs

OBJECTIVES

Exploiting the complete blood count (CBC) with differential (CBC-diff) for early sepsis detection has practical value for emergency department (ED) care, especially for those without obvious presentations. The objective of this study was to develop the CBC Sepsis Index (CBC-SI) that incorporates monocyte distribution width (MDW) to enhance rapid sepsis screening.

DESIGN

A retrospective observational study.

SETTING

The ED of the University of Kansas Medical Center, United States.

PATIENTS

All adult patients (age 18 or over) presenting to the ED between August 8, 2020, and April 1, 2022, that received a CBC-diff as part of routine clinical care.

INTERVENTIONS

MDW, WBC count, and neutrophil-to-lymphocyte ratio were used to develop a CBC-SI (0 low to 5 high risk) for early sepsis detection. The diagnostic performance of CBC-SI was evaluated for patients with and without obvious early signs of sepsis.

MEASUREMENTS AND MAIN RESULTS

In a cohort of 51,407 ED visits, 1,683 (3.3%) met sepsis criteria; 1,343 (79.8%) septic patients presented with obvious signs and 340 (20.2%) without. The overall area under the curve of the CBC-SI was 0.83 (95% CI, 0.81-0.85). A CBC-SI of greater than or equal to 1 point exhibited a sensitivity of 83.1% (95% CI, 79.9-86.2%) and specificity of 64.8% (95% CI, 64.0-65.5%). Superior performance was observed in the patient subgroup presenting without obvious signs; greater than or equal to 1 point, 81.1% (95% CI, 73.2-88.9%) sensitivity and 69.1% (95% CI, 68.3-69.9%) specificity. Septic patients without obvious signs exhibited delays in antibiotic administration from arrival (median 4.7 vs. 3.4 hr; p < 0.001) and higher rates of ICU admission (43.8% vs. 27.9%; p < 0.001) and in-hospital mortality (14.7% vs. 9.8%; p = 0.011) compared with the septic subgroup presenting with obvious signs.

CONCLUSIONS

The CBC-SI demonstrated strong performance for early sepsis detection. Its performance was best for nonobvious presentations, suggesting highest utility in a subgroup that is most susceptible to delayed interventions and poorer outcomes.

Adjudication of Codes for Identifying Sepsis in Hospital Administrative Data by Expert Consensus

OBJECTIVES

Refine the administrative data definition of sepsis in hospitalized patients, including less severe cases.

DESIGN AND SETTING

For each of 1928 infection and 108 organ dysfunction codes used in Canadian hospital abstracts, experts reached consensus on the likelihood that it could relate to sepsis. We developed a new algorithm, called AlgorithmL, that requires at least one infection and one organ dysfunction code adjudicated as likely or very likely to be related to sepsis. AlgorithmL was compared with four previously described algorithms, regarding included codes, population-based incidence, and hospital mortality rates-separately for ICU and non-ICU cohorts in a large Canadian city. We also compared sepsis identification from these code-based algorithms with the Centers for Disease Control's Adult Sepsis Event (ASE) definition.

SUBJECTS

Among Calgary's adult population of 1.033 million there were 61,632 eligible hospitalizations.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

AlgorithmL includes 720 infection codes and 50 organ dysfunction codes. Comparison algorithms varied from 42-941 infection codes to 2-36 organ codes. There was substantial nonoverlap of codes in AlgorithmL vs. the comparators. Annual sepsis incidence rates (per 100,000 population) based on AlgorithmL were 91 in the ICU and 291 in the non-ICU cohort. Incidences based on comparators ranged from 28-77 for ICU to 11-266 for non-ICU cohorts. Hospital sepsis mortality rates based on AlgorithmL were 24% in ICU and 17% in non-ICU cohorts; based on comparators, they ranged 27-38% in the ICU cohort and 18-47% for the non-ICU cohort. Of AlgorithmL-identified cases, 41% met the ASE criteria, compared with 42-82% for the comparator algorithms.

CONCLUSIONS

Compared with other code-based algorithms, AlgorithmL includes more infection and organ dysfunction codes. AlgorithmL incidence rates are higher; hospital mortality rates are lower. AlgorithmL may more fully encompass the full range of sepsis severity.

Analysis of factors associated with mortality due to sepsis resulting from device-related infections

INTRODUCTION

Health care-associated infections (HAIs) contribute to morbidity and mortality and to the dissemination of multidrug-resistant organisms. Children admitted to the intensive care unit undergo invasive procedures that increase their risk of developing HAIs and sepsis. The aim of the study was to analyse factors associated with mortality due to sepsis arising from HAIs.

PATIENTS AND METHODS

We conducted a case-control study in a 7-bed multipurpose paediatric intensive care unit in a tertiary care teaching hospital. The sample consisted of 90 children admitted between January 2014 and December 2018. The case group consisted of patients who died from sepsis associated with the main health care-associated infections; the control group consisted of patients who survived sepsis associated with the same infections.

RESULTS

Death was associated with age less than or equal to 12 months, presence of comorbidity, congenital disease, recurrent ventilator-associated pneumonia and septic shock. In the multiple regression analysis, heart disease (OR, 12.48; CI 2.55-60.93; P = .002), infection by carbapenem-resistant bacteria (OR, 31.51; CI 4.01-247.25; P = .001), cancer (OR, 58.23; CI 4.54-746.27; P = .002), and treatment with adrenaline (OR, 13.14; CI 1.35-128.02; P = .003) continued to be significantly associated with death.

CONCLUSIONS

Hospital sepsis secondary to carbapenem-resistant bacteria contributed to a high mortality rate in this cohort. Children with heart disease or neoplasia or who needed vasopressor drugs had poorer outcomes.

Diagnostic and prognostic value of heparin-binding protein in sepsis: A systematic review and meta-analysis

BACKGROUND

Sepsis remains a leading cause of death worldwide. In this context, heparin-binding protein (HBP) has emerged as a possible biomarker, drawing significant attention for its diagnostic and prognostic usefulness in septic patients. Despite this advancement, the literature yields conflicting results. This study is intended to critically evaluate the diagnostic and prognostic value of HBP in critically ill septic patients.

METHODS

We searched multiple databases, including PubMed, SCOPUS, Web of Science, and EBSCO, to identify relevant studies on April 27, 2023. We included studies investigating sepsis or its severe outcomes that reported HBP levels and the required data to create 2 × 2 tables. We used R version 4.2.2 and R Studio to analyze the pooled diagnostic accuracy outcomes. The diagmeta package was utilized to calculate the optimum cutoff value.

RESULTS

In our meta-analysis, we incorporated 28 studies including 5508 patients. The analysis revealed that HBP has a sensitivity of 0.71 (95% CI: 0.60; 0.79) and a specificity of 0.68 (95% CI: 0.51; 0.81) in diagnosing sepsis, respectively. HBP demonstrated moderate prognostic accuracy for mortality at a cutoff value of 161.415 ng/mL, with a sensitivity and specificity of 72%, and for severe sepsis outcomes at a cutoff value of 58.907 ng/mL, with a sensitivity and specificity of 71%.

CONCLUSION

Our findings indicate a relatively moderate diagnostic and prognostic accuracy of HBP for sepsis. Future studies are required to verify the accuracy of HBP as a biomarker for sepsis.

Trends in Empiric Broad-Spectrum Antibiotic Use for Suspected Community-Onset Sepsis in US Hospitals

Importance

Little is known about the degree to which suspected sepsis drives broad-spectrum antibiotic use in hospitals, what proportion of antibiotic courses are unnecessarily broad in retrospect, and whether these patterns are changing over time.

Objective

To describe trends in empiric broad-spectrum antibiotic use for suspected community-onset sepsis.

Design, Setting, and Participants

This cross-sectional study used clinical data from adults admitted to 241 US hospitals in the PINC AI Healthcare Database. Eligible participants were aged 18 years or more and were admitted between 2017 and 2021 with suspected community-onset sepsis, defined by a blood culture draw, lactate measurement, and intravenous antibiotic administration on admission.

Exposures

Empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) and/or antipseudomonal β-lactam agent use.

Main Outcomes and Measures

Annual rates of empiric anti-MRSA and/or antipseudomonal β-lactam agent use and the proportion that were likely unnecessary in retrospect based on the absence of β-lactam resistant gram-positive or ceftriaxone-resistant gram-negative pathogens from clinical cultures obtained through hospital day 4. Annual trends were calculated using mixed-effects logistic regression models, adjusting for patient and hospital characteristics.

Results

Among 6 272 538 hospitalizations (median [IQR] age, 66 [53-78] years; 443 465 male [49.6%]; 106 095 Black [11.9%], 65 763 Hispanic [7.4%], 653 907 White [73.1%]), 894 724 (14.3%) had suspected community-onset sepsis, of whom 582 585 (65.1%) received either empiric anti-MRSA (379 987 [42.5%]) or antipseudomonal β-lactam therapy (513 811 [57.4%]); 311 213 (34.8%) received both. Patients with suspected community-onset sepsis accounted for 1 573 673 of 3 141 300 (50.1%) of total inpatient anti-MRSA antibiotic days and 2 569 518 of 5 211 745 (49.3%) of total antipseudomonal β-lactam days. Between 2017 and 2021, the proportion of patients with suspected sepsis administered anti-MRSA or antipseudomonal therapy increased from 63.0% (82 731 of 131 275 patients) to 66.7% (101 003 of 151 435 patients) (adjusted OR [aOR] per year, 1.03; 95% CI, 1.03-1.04). However, resistant organisms were isolated in only 65 434 cases (7.3%) (30 617 gram-positive [3.4%], 38 844 gram-negative [4.3%]) and the proportion of patients who had any resistant organism decreased from 9.6% to 7.3% (aOR per year, 0.87; 95% CI, 0.87-0.88). Most patients with suspected sepsis treated with empiric anti-MRSA and/or antipseudomonal therapy had no resistant organisms (527 356 of 582 585 patients [90.5%]); this proportion increased from 88.0% in 2017 to 91.6% in 2021 (aOR per year, 1.12; 95% CI, 1.11-1.13).

Conclusions and Relevance

In this cross-sectional study of adults admitted to 241 US hospitals, empiric broad-spectrum antibiotic use for suspected community-onset sepsis accounted for half of all anti-MRSA or antipseudomonal therapy; the use of these types of antibiotics increased between 2017 and 2021 despite resistant organisms being isolated in less than 10% of patients treated with broad-spectrum agents.

Hospital-Onset Sepsis Warrants Expanded Investigation and Consideration as a Unique Clinical Entity

Sepsis causes more than a quarter million deaths among hospitalized adults in the United States each year. Although most cases of sepsis are present on admission, up to one-quarter of patients with sepsis develop this highly morbid and mortal condition while hospitalized. Compared with patients with community-onset sepsis (COS), patients with hospital-onset sepsis (HOS) are twice as likely to require mechanical ventilation and ICU admission, have more than two times longer ICU and hospital length of stay, accrue five times higher hospital costs, and are twice as likely to die. Patients with HOS differ from those with COS with respect to underlying comorbidities, admitting diagnosis, clinical manifestations of infection, and severity of illness. Despite the differences between these patient populations, patients with HOS sepsis are understudied and warrant expanded investigation. Here, we outline important knowledge gaps in the recognition and management of HOS in adults and propose associated research priorities for investigators. Of particular importance are questions regarding standardization of research and clinical case identification, understanding of clinical heterogeneity among patients with HOS, development of tailored management recommendations, identification of impactful prevention strategies, optimization of care delivery and quality metrics, identification and correction of disparities in care and outcomes, and how to ensure goal-concordant care for patients with HOS.

Association Between Medicare's Sepsis Reporting Policy (SEP-1) and the Documentation of a Sepsis Diagnosis in the Clinical Record

STUDY DESIGN

Interrupted time series analysis of a retrospective, electronic health record cohort.

OBJECTIVE

To determine the association between the implementation of Medicare's sepsis reporting measure (SEP-1) and sepsis diagnosis rates as assessed in clinical documentation.

BACKGROUND

The role of health policy in the effort to improve sepsis diagnosis remains unclear.

PATIENTS AND METHODS

Adult patients hospitalized with suspected infection and organ dysfunction within 6 hours of presentation to the emergency department, admitted to one of 11 hospitals in a multi-hospital health system from January 2013 to December 2017. Clinician-diagnosed sepsis, as reflected by the inclusion of the terms "sepsis" or "septic" in the text of clinical notes in the first two calendar days following presentation.

RESULTS

Among 44,074 adult patients with sepsis admitted to 11 hospitals over 5 years, the proportion with sepsis documentation was 32.2% just before the implementation of SEP-1 in the third quarter of 2015 and increased to 37.3% by the fourth quarter of 2017. Of the 9 post-SEP-1 quarters, 8 had odds ratios for a sepsis diagnosis >1 (overall range: 0.98-1.26; P value for a joint test of statistical significance = 0.005). The effects were clinically modest, with a maximum effect of an absolute increase of 4.2% (95% CI: 0.9-7.8) at the end of the study period. The effect was greater in patients who did not require vasopressors compared with patients who required vasopressors ( P value for test of interaction = 0.02).

CONCLUSIONS

SEP-1 implementation was associated with modest increases in sepsis diagnosis rates, primarily among patients who did not require vasoactive medications.

Incidence and mortality of community-acquired and nosocomial infections in Japan: a nationwide medical claims database study

BACKGROUND

It is important to determine the prevalence and prognosis of community-acquired infection (CAI) and nosocomial infection (NI) to develop treatment strategies and appropriate medical policies in aging society.

METHODS

Patients hospitalized between January 2010 and December 2019, for whom culture tests were performed and antibiotics were administered, were selected using a national claims-based database. The annual trends in incidence and in-hospital mortality were calculated and evaluated by dividing the patients into four age groups.

RESULTS

Of the 73,962,409 inpatients registered in the database, 9.7% and 4.7% had CAI and NI, respectively. These incidences tended to increase across the years in both the groups. Among the patients hospitalized with infectious diseases, there was a significant increase in patients aged ≥ 85 years (CAI: + 1.04%/year and NI: + 0.94%/year, P < 0.001), while there was a significant decrease in hospitalization of patients aged ≤ 64 years (CAI: -1.63%/year and NI: -0.94%/year, P < 0.001). In-hospital mortality was significantly higher in the NI than in the CAI group (CAI: 8.3%; NI: 14.5%, adjusted mean difference 4.7%). The NI group had higher organ support, medical cost per patient, and longer duration of hospital stay. A decreasing trend in mortality was observed in both the groups (CAI: -0.53%/year and NI: -0.72%/year, P < 0.001).

CONCLUSION

The present analysis of a large Japanese claims database showed that NI is a significant burden on hospitalized patients in aging societies, emphasizing the need to address particularly on NI.

Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper

The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.

ICU-acquired infections in immunocompromised patients

Immunocompromised patients account for an increasing proportion of the typical intensive care unit (ICU) case-mix. Because of the increased availability of new drugs for cancer and auto-immune diseases, and improvement in the care of the most severely immunocompromised ICU patients (including those with hematologic malignancies), critically ill immunocompromised patients form a highly heterogeneous patient population. Furthermore, a large number of ICU patients with no apparent immunosuppression also harbor underlying conditions altering their immune response, or develop ICU-acquired immune deficiencies as a result of sepsis, trauma or major surgery. While infections are associated with significant morbidity and mortality in immunocompromised critically ill patients, little specific data are available on the incidence, microbiology, management and outcomes of ICU-acquired infections in this population. As a result, immunocompromised patients are usually excluded from trials and guidelines on the management of ICU-acquired infections. The most common ICU-acquired infections in immunocompromised patients are ventilator-associated lower respiratory tract infections (which include ventilator-associated pneumonia and tracheobronchitis) and bloodstream infections. Recently, several large observational studies have shed light on some of the epidemiological specificities of these infections-as well as on the dynamics of colonization and infection with multidrug-resistant bacteria-in these patients, and these will be discussed in this review. Immunocompromised patients are also at higher risk than non-immunocompromised hosts of fungal and viral infections, and the diagnostic and therapeutic management of these infections will be covered. Finally, we will suggest some important areas of future investigation.

In vivo functional immunoprotection correlates for vaccines against invasive bacteria

Vaccination has significantly reduced the incidence of invasive infections caused by several bacterial pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. However, no vaccines are available for many other invasive pathogens. A major hurdle in vaccine development is the lack of functional markers to quantify vaccine immunity in eliminating pathogens during the process of infection. Based on our recent discovery of the liver as the major organ of vaccine-induced clearance of blood-borne virulent bacteria, we here describe a new vaccine evaluation system that quantitatively characterizes the key features of effective vaccines in shuffling virulent bacteria from the blood circulation to the liver resident macrophage Kupffer cells (KCs) and sinusoidal endothelial cells (LSECs) in mouse septic infection model. This system consists of three related correlates or assays: pathogen clearance from the bloodstream, pathogen trapping in the liver, and pathogen capture by KCs/LSECs. These readouts were consistently associated with the serotype-specific immunoprotection levels of the 13-valent pneumococcal polysaccharide conjugate vaccine (PCV13) against lethal infection of S. pneumoniae, a major invasive Gram-positive pathogen of community-acquired infections in humans. Furthermore, the reliability and sensitivity of these correlates in reflecting vaccine efficacy were verified with whole cell vaccines of Klebsiella pneumoniae and Escherichia coli, two major Gram-negative pathogens in hospital-acquired invasive infections. This system may be used as effective readouts to evaluate the immunoprotective potential of vaccine candidates in the preclinical phase by filling the current technical gap in vaccine evaluation between the conventional in vitro approaches (e.g. antibody production and pathogen neutralization/opsonophagocytosis) and survival of immunized animals.

Previously healthy adults among septic patients: Population-level epidemiology and outcomes

PURPOSE

Previously healthy adults with community-onset sepsis were recently reported to have, counterintuitively, higher short-term mortality than those with comorbid conditions. However, the population-level generalizability of this finding and its applicability to all hospitalized septic patients are unclear.

METHODS

We used a statewide dataset to identify hospitalizations aged ≥18 years with a diagnosis of sepsis in Texas during 2018-2019. Comorbidities were defined as those included in the Charlson Comorbidity Index and other prevalent conditions associated with mortality. Hierarchical models were used to estimate the association of comorbid state with short-term mortality (defined as in-hospital mortality or discharge to hospice), overall and in community-onset and hospital-onset sepsis.

RESULTS

Among 120,371 sepsis hospitalizations, 6611 (5.5%) were previously healthy and 105,455 (87.6%) had community-onset sepsis. Short-term mortality among the previously healthy and those with comorbidities was 11.7% vs 28.2% overall, 11.0% vs 25.2% in community-onset sepsis, and 22.0% vs 48.7% in hospital-onset sepsis, respectively. On adjusted analysis, being previously healthy remained associated with lower short-term mortality overall (adjusted odds ratio 0.62 [95% CI 0.57-0.69]), with findings consistent with the primary analysis in community-onset sepsis, hospital-onset sepsis.

CONCLUSIONS

Previously healthy septic patients had lower short-term mortality compared to those with comorbid conditions.

Predicting mortality in pediatric sepsis: A nationwide data analysis using a pediatric sepsis surveillance method

INTRODUCTION

A sepsis surveillance method using electronic health records is increasingly used to describe the epidemiology of adult sepsis. However, its application in pediatric populations has been limited, and real-world epidemiology of pediatric sepsis remains unknown. We aimed to determine whether this surveillance method could identify children with sepsis at high-risk of mortality.

PATIENTS AND METHODS

From a nationwide inpatient database in Japan, we included children who underwent blood culture and received antimicrobials for ≥ 4 days between 2014 and 2021. We stratified these children into those with sepsis or without sepsis by the presence of organ dysfunction. We evaluated the discrimination for in-hospital mortality by the sepsis diagnosis and the number of organ dysfunction.

RESULTS

Among 6553 eligible children, in-hospital mortality was 7.2 % in 875 children with sepsis and 0.2 % in 5678 children without sepsis. Sepsis diagnosis discriminated in-hospital mortality with a sensitivity of 0.84 and a specificity of 0.87. The area under the curve for mortality based on the number of organ dysfunction was 0.88 (95 % confidence interval:0.84 to 0.93). In-hospital mortality incrementally increased with the number of organ dysfunction; zero, 0.2 %; one, 3.4 %; two, 12.7 %; three, 20.9 %; four, 33.3 %; and five, 50.0 %.

CONCLUSIONS

The surveillance method effectively identified children with sepsis with high-risk of mortality and demonstrated strong discrimination of mortality.

Call for a Singapore National Action Plan for Sepsis (SNAPS): Stop sepsis, save lives

Sepsis is a life-threatening organ dysfunction syndrome caused by a dysregulated host response to an infection.1 It affects up to 48.9 million people globally every year and causes 11 million sepsis-related deaths, accounting for 1 in every 5 deaths worldwide.2 The huge disease burden leads to significant consumption of healthcare resources due to longer hospitalisation and the need for intensive care.3 The resultant economic impact is tremendous; for instance, the 1-year incremental costs of sepsis to the healthcare system in Ontario, Canada approximates CAD 1 billion.3 In addition to the complexity of care required for sepsis, the higher healthcare costs incurred may be explained by the post-sepsis syndrome. Sequelae of sepsis include physical, psychological and medical complications.4

Validation of an ICD-Based Algorithm to Identify Sepsis: A Retrospective Study

Background

Sepsis surveillance was important for resources allocation, prevention, and development of health policy.

Objective

The aim of the study was to validate a modified International Classification of Diseases (ICD)-10 based algorithm for identifying hospitalized patients with sepsis.

Methods

We retrospectively analyzed a prospective, single-center cohort of adult patients who were consecutively admitted to one medical ICU ward and ten non-ICU wards with suspected or confirmed infections during a 6-month period. A modified ICD-10 based algorithm was validated against a reference standard of Sequential Organ Failure Assessment (SOFA) score based on Sepsis-3. Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), and areas under the receiver operating characteristic curves (AUROCs) were calculated for modified ICD-10 criteria, eSOFA criteria, Martin's criteria, and Angus's criteria.

Results

Of the 547 patients in the cohort, 332 (61%) patients met Sepsis-3 criteria and 274 (50%) met modified ICD-10 criteria. In the ICU setting, modified ICD-10 criteria had SE (84.47%), SP (88.57%), PPV (95.60), and NPV (65.96). In non-ICU settings, modified ICD-10 had SE (64.19%), SP (80.00%), PPV (80.33), and NPV (63.72). In the whole cohort, the AUROCs of modified ICD-10 criteria, eSOFA, Angus's criteria, and Martin's criteria were 0.76, 0.75, 0.62, and 0.62, respectively.

Conclusion

This study demonstrated that modified ICD-10 criteria had higher validity compared with Angus's criteria and Martin's criteria. Validity of the modified ICD-10 criteria was similar to eSOFA criteria. Modified ICD-10 algorithm can be used to provide an accurate estimate of population-based sepsis burden of China.

Exploiting Electronic Data to Advance Knowledge and Management of Severe Infections

Purpose of Review

To identify opportunities and recent advances in the use of multicentric digital data sources and networks to investigate the epidemiology and management of patients with infections admitted to intensive care units (ICUs).

Recent Findings

Electronic surveillance systems for a range of serious infections have been reported from large cohorts with evident improvements in efficiency, objectivity, and comprehensiveness of coverage as compared to traditional methods. Electronic data, most notably from electronic health records, has been used to define the epidemiology and outcomes of severe infections in several settings and conditions and has facilitated population-based evaluation. Automated alerts and notifications hold promise to identify patients at risk for sepsis and bloodstream infection although demonstration of efficacy in interventional trials is needed.

Summary

Exploitation of electronic data in ICUs has led to a better understanding of the epidemiology of severe infections and holds promise for future interventional clinical trials.

Association between hospital onset of infection and outcomes in sepsis patients - A propensity score matched cohort study based on health claims data in Germany

BACKGROUND

Hospital-acquired infections are a common source of sepsis. Hospital onset of sepsis was found to be associated with higher acute mortality and hospital costs, yet its impact on long-term patient-relevant outcomes and costs is unknown.

OBJECTIVE

We aimed to assess the association between sepsis origin and acute and long-term outcomes based on a nationwide population-based cohort of sepsis patients in Germany.

METHODS

This retrospective cohort study used nationwide health claims data from 23 million health insurance beneficiaries. Sepsis patients with hospital-acquired infections (HAI) were identified by ICD-10-codes in a cohort of adult patients with hospital-treated sepsis between 2013 and 2014. Cases without these ICD-10-codes were considered as sepsis cases with community-acquired infection (CAI) and were matched with HAI sepsis patients by propensity score matching. Outcomes included in-hospital/12-month mortality and costs, as well as readmissions and nursing care dependency until 12 months postsepsis.

RESULTS

We matched 33,110 HAI sepsis patients with 28,614 CAI sepsis patients and 22,234 HAI sepsis hospital survivors with 19,364 CAI sepsis hospital survivors. HAI sepsis patients had a higher hospital mortality than CAI sepsis patients (32.8% vs. 25.4%, RR 1.3, p < .001). Similarly, 12-months postacute mortality was higher (37.2% vs. 30.1%, RR=1.2, p < .001). Hospital and 12-month health care costs were 178% and 22% higher in HAI patients than in CAI patients, respectively. Twelve months postsepsis, HAI sepsis survivors were more often newly dependent on nursing care (33.4% vs. 24.0%, RR=1.4, p < .001) and experienced 5% more hospital readmissions (mean number of readmissions: 2.1 vs. 2.0, p < .001).

CONCLUSIONS

HAI sepsis patients face an increased risk of adverse outcomes both during the acute sepsis episode and in the long-term. Measures to prevent HAI and its progression into sepsis may be an opportunity to mitigate the burden of long-term impairments and costs of sepsis, e.g., by early detection of HAI progressing into sepsis, particularly in normal wards; adequate sepsis management and adherence to sepsis bundles in hospital-acquired sepsis; and an improved infection prevention and control.

The Clinical Value of Comprehensive Nursing Intervention in Preventing Severe Lymphopenia and Improving the Survival Rate Among Patients with Sepsis

Background

Intensive care unit (ICU) patients with sepsis who experience severe lymphopenia are at a higher risk of mortality, and they serve as a more accurate indicator of bacteremia compared to traditional infection markers.

Aim

Our study aimed to examine the influence of severe lymphopenia on ICU mortality and outcomes in sepsis patients, while also evaluating the clinical significance of comprehensive nursing intervention in preventing severe lymphopenia.

Methods

Patients with sepsis in the ICU at our hospital between January 2015 and January 2021 were split into a control group and a test group.The control group received regular nursing care, while the test group was provided with comprehensive nursing care in addition to the control group. The results encompassed mortality rates of 28 days, mortality rates of 1 year, and lengths of stay in the ICU.

Results

Our attention was directed towards day 4 absolute lymphocyte counts, taking into account the receiver operating characteristic (ROC) outcome. Patients with severe lymphopenia were older, more patients with 2 above comorbidities, higher co-infection rates and SOFA score. In addition, patients with severe lymphopenia required longer days stay in ICU (P<0.001), and presented with higher 28-day mortality (P=0.038) and 1-year mortality (P=0.004). Patients in control group have a higher incidence of severe lymphopenia (P=0.006), 28-day mortality (P=0.015) and 1-year mortality (P=0.019) compared with the test group.

Conclusion

Comprehensive nursing intervention can prevent the occurrence of severe lymphopenia, improve patients satisfaction and reduce mortality.

System Failure: The Geographic Distribution of Sepsis-Associated Death in the USA and Factors Contributing to the Mortality Burden of Black Communities

Sepsis is deadly and costly to health care systems, but these costs are disproportionately born by Black patients. Little empirical work has established the geographic patterning of sepsis or its area-level correlates. This study illustrates the geography of sepsis-associated death and racial composition of US counties with area socioeconomic indicators, health care access, and population health. Cartographic and spatially explicit analyses utilize mortality data from the National Cancer Institute and county data from the American Community Survey, Area Health Resource File, and County Health Rankings. Death rates are highest in the South, Southeast, and Appalachia. Counties disproportionately populated by Black people have higher death rates and associated risk indicators including poor air quality and vaccination coverage, socioeconomic distress, and impaired access to high-quality health care. Spatial Durbin error models suggest that conditions in nearby counties may also influence death rates within focal counties. Racial disparities in sepsis-associated death can be narrowed with improved health care equity-including immunization coverage-and by reducing socioeconomic distress in Black communities. Policy options for achieving these ends are discussed.

Association of Time of Day with Delays in Antimicrobial Initiation among Ward Patients with Hospital-Onset Sepsis

Rationale: Although the mainstay of sepsis treatment is timely initiation of broad-spectrum antimicrobials, treatment delays are common, especially among patients who develop hospital-onset sepsis. The time of day has been associated with suboptimal clinical care in several contexts, but its association with treatment initiation among patients with hospital-onset sepsis is unknown. Objectives: Assess the association of time of day with antimicrobial initiation among ward patients with hospital-onset sepsis. Methods: This retrospective cohort study included ward patients who developed hospital-onset sepsis while admitted to five acute care hospitals in a single health system from July 2017 through December 2019. Hospital-onset sepsis was defined by the Centers for Disease Control and Prevention Adult Sepsis Event criteria. We estimated the association between the hour of day and antimicrobial initiation among patients with hospital-onset sepsis using a discrete-time time-to-event model, accounting for time elapsed from sepsis onset. In a secondary analysis, we fit a quantile regression model to estimate the association between the hour of day of sepsis onset and time to antimicrobial initiation. Results: Among 1,672 patients with hospital-onset sepsis, the probability of antimicrobial initiation at any given hour varied nearly fivefold throughout the day, ranging from 3.0% (95% confidence interval [CI], 1.8-4.1%) at 7 a.m. to 13.9% (95% CI, 11.3-16.5%) at 6 p.m., with nadirs at 7 a.m. and 7 p.m. and progressive decline throughout the night shift (13.4% [95% CI, 10.7-16.0%] at 9 p.m. to 3.2% [95% CI, 2.0-4.0] at 6 a.m.). The standardized predicted median time to antimicrobial initiation was 3.2 hours (interquartile range [IQR], 2.5-3.8 h) for sepsis onset during the day shift (7 a.m.-7 p.m.) and 12.9 hours (IQR, 10.9-14.9 h) during the night shift (7 p.m.-7 a.m.). Conclusions: The probability of antimicrobial initiation among patients with new hospital-onset sepsis declined at shift changes and overnight. Time to antimicrobial initiation for patients with sepsis onset overnight was four times longer than for patients with onset during the day. These findings indicate that time of day is associated with important care processes for ward patients with hospital-onset sepsis. Future work should validate these findings in other settings and elucidate underlying mechanisms to inform quality-enhancing interventions.

Epidemiology, Resistance Profiles, and Outcomes of Bloodstream Infections in Community-Onset Sepsis in the United States

OBJECTIVES

To describe frequency of positive blood cultures, patterns of pathogens' characteristics and their resistance profile in patients with blood cultures drawn due to a presumed diagnosis of community-onset sepsis, and to examine the association between blood culture-positive pathogens and hospital mortality.

DESIGN

Retrospective cohort study.

SETTING

Two hundred one U.S. hospitals from 2016 to 2020 using the Premier Healthcare Database.

SUBJECTS

Adult patients presenting with community-onset sepsis who had blood cultures collected within 2 days of hospital admission. We defined sepsis using the U.S. Centers for Disease Control Adult Sepsis Event Surveillance criteria.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 147,061 patients with community-onset sepsis. The number of blood culture-positive sepsis episodes was 21,167 (14%) and the number of nonblood culture-positive sepsis episodes was 20,326 (14%). Among patients with blood culture-positive sepsis, Gram-negative rods were isolated in 55% of patients, Gram-positive cocci were isolated in 47%. Of those, methicillin-resistant Staphylococcus aureus (MRSA) was 11%, ceftriaxone-resistant Enterobacterales /extended-spectrum β-lactamase was 7%, and carbapenem-resistant Enterobacterales was 1.3%. The crude in-hospital mortality was 17% for culture-negative sepsis, 13% for nonblood culture-positive sepsis, and 17% for blood culture-positive sepsis. In multilevel logistic regression models, compared with culture-negative sepsis, blood culture-positive sepsis (adjusted odds ratio [aOR], 0.89; 95% CI, 0.85-0.94) and nonblood culture-positive sepsis (aOR, 0.82; 95% CI, 0.78-0.87) were associated with lower odds of in-hospital mortality. Acinetobacter species, Pseudomonas aeruginosa , methicillin-sensitive Staphylococcus aureus , and MRSA were associated with higher in-hospital mortality, whereas Escherichia coli , Klebsiella species, Proteus species, and Streptococcus species were associated with lower in-hospital mortality.

CONCLUSIONS

In patients hospitalized with community-onset sepsis, the prevalence of blood culture-positive sepsis was 14%. Among positive blood culture sepsis resistant organisms were infrequent. Compared with culture-negative sepsis, blood culture-positive sepsis and nonblood culture-positive sepsis were associated with lower in-hospital mortality.

Acinetobacter baumannii Early-Onset Sepsis After Home Delivery Into Toilet Water

Early-onset sepsis (EOS) is an important cause of morbidity and mortality in newborns, usually caused by pathogens acquired intrapartum. We present the case of a term neonate born by home delivery in the toilet, after an unsupervised pregnancy. He developed a culture-proven early-onset sepsis caused by Acinetobacter baumannii. This was the first case of neonatal sepsis by this pathogen in our unit. The microorganism was susceptible to all antibiotics tested. The neonate was treated empirically with ampicillin and cefotaxime and completed 21 days of directed therapy with meropenem, as meningitis could not be excluded. During the clinical course, the newborn developed severe and persistent thrombocytopenia and neutropenia. In this report, we discuss the etiology behind this clinical presentation. We intend to raise awareness for the consideration of Acinetobacter baumannii as a potential pathogen in EOS, particularly in the presence of adverse birth circumstances.

Sepsis Prediction Model for Determining Sepsis vs SIRS, qSOFA, and SOFA

Importance

The Sepsis Prediction Model (SPM) is a proprietary decision support tool created by Epic Systems; it generates a predicting sepsis score (PSS). The model has not undergone validation against existing sepsis prediction tools, such as Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), or quick Sepsis-Related Organ Failure Asessement (qSOFA).

Objective

To assess the validity and timeliness of the SPM compared with SIRS, qSOFA, and SOFA.

Design, Setting, and Participants

This retrospective cohort study included all adults admitted to 5 acute care hospitals in a single US health system between June 5, 2019, and December 31, 2020. Data analysis was conducted from March 2021 to February 2023.

Main Outcomes and Measures

A sepsis event was defined as receipt of 4 or more days of antimicrobials, blood cultures collected within ±48 hours of initial antimicrobial, and at least 1 organ dysfunction as defined by the organ dysfunction criteria optimized for the electronic health record (eSOFA). Time zero was defined as 15 minutes prior to qualifying antimicrobial or blood culture order.

Results

Of 60 507 total admissions, 1663 (2.7%) met sepsis criteria, with 1324 electronic health record-confirmed sepsis (699 [52.8%] male patients; 298 [22.5%] Black patients; 46 [3.5%] Hispanic/Latinx patients; 945 [71.4%] White patients), 339 COVID-19 sepsis (183 [54.0%] male patients; 98 [28.9%] Black patients; 36 [10.6%] Hispanic/Latinx patients; and 189 [55.8%] White patients), and 58 844 (97.3%; 26 632 [45.2%] male patients; 12 698 [21.6%] Black patients; 3367 [5.7%] Hispanic/Latinx patients; 40 491 White patients) did not meet sepsis criteria. The median (IQR) age was 63 (51 to 73) years for electronic health record-confirmed sepsis, 69 (60 to 77) years for COVID-19 sepsis, and 60 (42 to 72) years for nonsepsis admissions. Within the vendor recommended threshold PSS range of 5 to 8, PSS of 8 or greater had the highest balanced accuracy for classifying a sepsis admission at 0.79 (95% CI, 0.78 to 0.80). Change in SOFA score of 2 or more had the highest sensitivity, at 0.97 (95% CI, 0.97 to 0.98). At a PSS of 8 or greater, median (IQR) time to score positivity from time zero was 68.00 (6.75 to 605.75) minutes. For SIRS, qSOFA, and SOFA, median (IQR) time to score positivity was 7.00 (-105.00 to 08.00) minutes, 74.00 (-22.25 to 599.25) minutes, and 28.00 (-108.50 to 134.00) minutes, respectively.

Conclusions and Relevance

In this cohort study of hospital admissions, balanced accuracy of the SPM outperformed other models at higher threshold PSS; however, application of the SPM in a clinical setting was limited by poor timeliness as a sepsis screening tool as compared to SIRS and SOFA.

The impact of comorbidities and COVID-19 on the evolution of community onset sepsis

Sepsis is a disease with high mortality and morbidity despite advances in diagnostic procedures and therapeutic strategies. The aim of this study was to evaluate the profile and outcomes of community-onset sepsis. This retrospective, multicenter study included five 24-h health care units and was conducted from January 2018 to December 2021. Patients were diagnosed with sepsis or septic shock according to the Sepsis 3.0 criterion. A total of 2630 patients diagnosed as having sepsis (68.4%, 1800) or septic shock (31.6%, 830) in the 24-h health care unit were included; 43.76% of the patients were admitted to the intensive care unit, 12.2% died, 4.1% had sepsis and 30% had septic shock. The comorbidities that were independent predictors of septic shock were chronic kidney disease on dialysis (CKD-d), bone marrow transplantation and neoplasia. CKD and neoplasia were also independent predictors of mortality, with ORs of 2.00 (CI 1.10-3.68) p = 0.023 and 1.74 (CI 1.319-2.298) p =  < 0.0001, respectively. Mortality according to the focus of primary infection was as follows: pulmonary 40.1%; COVID-19 35.7%; abdominal 8.1% and urinary 6.2%. Mortality due to the COVID-19 outbreak had an OR of 4.94 (CI 3.08-8.13) p ≤ 0.0001. Even though community-onset sepsis can be potentially fatal, this study revealed that some comorbidities lead to an increased risk of septic shock (d-CKD and neoplasia) and mortality. COVID-19 infection as the primary focus was an independent predictor of mortality in patients with sepsis when compared to other foci.

Epidemiology of Sepsis in US Children and Young Adults

Background

Most multicenter studies of US pediatric sepsis epidemiology use administrative data or focus on pediatric intensive care units. We conducted a detailed medical record review to describe sepsis epidemiology in children and young adults.

Methods

In a convenience sample of hospitals in 10 states, patients aged 30 days-21 years, discharged during 1 October 2014-30 September 2015, with explicit diagnosis codes for severe sepsis or septic shock, were included. Medical records were reviewed for patients with documentation of sepsis, septic shock, or similar terms. We analyzed overall and age group-specific patient characteristics.

Results

Of 736 patients in 26 hospitals, 442 (60.1%) had underlying conditions. Most patients (613 [83.3%]) had community-onset sepsis, although most community-onset sepsis was healthcare associated (344 [56.1%]). Two hundred forty-one patients (32.7%) had outpatient visits 1-7 days before sepsis hospitalization, of whom 125 (51.9%) received antimicrobials ≤30 days before sepsis hospitalization. Age group-related differences included common underlying conditions (<5 years: prematurity vs 5-12 years: chronic pulmonary disease vs 13-21 years: chronic immunocompromise); medical device presence ≤30 days before sepsis hospitalization (1-4 years: 46.9% vs 30 days-11 months: 23.3%); percentage with hospital-onset sepsis (<5 years: 19.6% vs ≥5 years: 12.0%); and percentage with sepsis-associated pathogens (30 days-11 months: 65.6% vs 13-21 years: 49.3%).

Conclusions

Our data suggest potential opportunities to raise sepsis awareness among outpatient providers to facilitate prevention, early recognition, and intervention in some patients. Consideration of age-specific differences may be important as approaches are developed to improve sepsis prevention, risk prediction, recognition, and management.

Nurses' knowledge and confidence in recognizing and managing patients with sepsis: A multi-site cross-sectional study

AIMS

(1) To examine registered nurses' knowledge and confidence in recognizing and managing to patients with sepsis and (2) identify nurse and workplace factors that influence their knowledge on sepsis.

DESIGN

A multi-site, cross-sectional survey.

METHODS

An online survey was developed and content validated. Data was collected from registered nurses working in the inpatient wards and emergency departments of three hospitals of a single healthcare cluster in Singapore during August 2021. Statistical analyses of closed-ended responses and content analysis of open-ended responses were undertaken.

RESULTS

A total of 709 nurses completed the survey. Nurses possessed moderate levels of knowledge about sepsis (mean score = 10.56/15; SD = 2.01) and confidence in recognizing and responding to patients with sepsis (mean score = 18.46/25; SD = 2.79). However, only 369 (52.0%) could correctly define sepsis. Nurses' job grade, nursing education level and clinical work area were significant predictors of nurses' sepsis knowledge. Specifically, nurses with higher job grade, higher nursing education level or those working in acute care areas (i.e. emergency department, high dependency units or intensive care units) were more likely to obtain higher total sepsis knowledge scores. A weak positive correlation was observed between sepsis knowledge test scores and self-confidence (r = .184). Open comments revealed that participants desired for more sepsis education and training opportunities and the implementation of sepsis screening tool and sepsis care protocol.

CONCLUSION

A stronger foundation in sepsis education and training programs and the implementation of sepsis screening tools and care bundles are needed to enhance nurses' knowledge and confidence in recognizing and managing patients with sepsis.

IMPACT

The findings of this study are beneficial to administrators, educators and researchers in designing interventions to support nurses in their role in recognizing and responding to sepsis.

Update on Sepsis Epidemiology in the Era of COVID-19

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

Prognostic Accuracy of the Different Scoring Systems for Assessing Coagulopathy in Sepsis: A Retrospective Study

There is no gold standard for the diagnosis of coagulation dysfunction in sepsis, and the use of the current scoring systems is still controversial. The purpose of this study was to assess the performance of sepsis-induced coagulopathy (SIC), the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), and the International Society on Thrombosis and Haemostasis overt DIC (ISTH overt-DIC). The relationship between each scoring system and 28-day all-cause mortality was examined. Among 452 patients (mean age, 65 [48,76] years), 306 [66.7%] were men, the median SOFA score was 6 [4,9], and the median APACHE II score was 15 [11,22]. A total of 132 patients (29.2%) died within 28 days. Both the diagnosis of SIC (AUROC, 0.779 [95% CI, 0.728-0.830], P < 0.001) and ISTH overt-DIC (AUROC, 0.782 [95% CI, 0.732-0.833], P < 0.001) performed equally well in the discrimination of 28-day all-cause mortality (between-group difference: SIC versus ISTH overt-DIC, -0.003 [95% CI, -0.025-0.018], P = 0.766). However, the SIC demonstrated greater calibration for 28-day all-cause mortality than ISTH overt-DIC (the coincidence of the calibration curve of the former is higher than that of the latter). The diagnosis of JAAM DIC was not independently associated with 28-day all-cause mortality in sepsis (RR, 1.115, [95% CI 0.660-1.182], P = 0.684). The SIC scoring system demonstrated superior prognostic prediction ability in comparison with the others and is the most appropriate standard for diagnosing coagulopathy in sepsis.

Improving Sepsis Management Through the Emergency Quality Network Sepsis Initiative

BACKGROUND

Public reporting of the Centers for Medicare & Medicaid (CMS) SEP-1 sepsis quality measure is often too late and without the data granularity to inform real-time quality improvement (QI). In response, the American College of Emergency Physicians (ACEP) Emergency Quality Network (E-QUAL) Sepsis Initiative sought to support QI efforts through benchmarking of preliminary draft SEP-1 scores for emergency department (ED) patients. This study sought to determine the anticipatory value of these preliminary SEP-1 benchmarking scores and publicly reported performance.

METHODS

Cross-sectional analysis was performed on QI data collected from hospital-based ED sites participating in the E-QUAL Sepsis Collaborative in 2017 and 2018. Participating EDs submitted SEP-1 benchmarking scores semiannually, which were compared to publicly reported CMS SEP-1 data. EDs also reported implementation data on a variety of sepsis-related QI activities for comparison based on SEP-1 performance.

RESULTS

Among 220 EDs participating in E-QUAL, SEP-1 benchmarking scores showed weak but statistically significant correlation with CMS SEP-1 scores (r = 0.189, p = 0.01). Mean E-QUAL SEP-1 benchmarking scores were higher than mean CMS SEP-1 scores (74.1% vs. 57.2%), with 83.2% of sites reporting a benchmarking score higher than the CMS SEP-1 score. EDs with SEP-1 scores in the bottom 20% reported completion of more sepsis-related QI activities than EDs with average or top 20% SEP-1 scores.

CONCLUSION

Preliminary benchmarking results demonstrate a weak, statistically significant correlation with subsequent publicly reported CMS SEP-1 scores and suggest that ED performance in sepsis care may exceed overall hospital performance inclusive of all inpatients. Sepsis quality measurement and sepsis QI efforts may be best guided by separating ED sepsis cases from in-hospital sepsis cases as is done for other acute time-sensitive conditions.

Mortality of patients with hospital-onset sepsis in hospitals with all-day and non-all-day rapid response teams: a prospective nationwide multicenter cohort study

Background

Hospital-onset sepsis is associated with a higher in-hospital mortality rate than community-onset sepsis. Many hospitals have implemented rapid response teams (RRTs) for early detection and timely management of at-risk hospitalized patients. However, the effectiveness of an all-day RRT over a non-all-day RRT in reducing the risk of in-hospital mortality in patient with hospital-onset sepsis is unclear. We aimed to determine the effect of the RRT’s operating hours on in-hospital mortality in inpatient patients with sepsis.

Methods

We conducted a nationwide cohort study of adult patients with hospital-onset sepsis prospectively collected from the Korean Sepsis Alliance (KSA) Database from 16 tertiary referral or university-affiliated hospitals in South Korea between September of 2019 and February of 2020. RRT was implemented in 11 hospitals, of which 5 (45.5%) operated 24-h RRT (all-day RRT) and the remaining 6 (54.5%) had part-day RRT (non-all-day RRT). The primary outcome was in-hospital mortality between the two groups.

Results

Of the 405 patients with hospital-onset sepsis, 206 (50.9%) were admitted to hospitals operating all-day RRT, whereas 199 (49.1%) were hospitalized in hospitals with non-all-day RRT. A total of 73 of the 206 patients in the all-day group (35.4%) and 85 of the 199 patients in the non-all-day group (42.7%) died in the hospital (P = 0.133). After adjustments for co-variables, the implementation of all-day RRT was associated with a significant reduction in in-hospital mortality (adjusted odds ratio 0.57; 95% confidence interval 0.35–0.93; P = 0.024).

Conclusions

In comparison with non-all-day RRTs, the availability of all-day RRTs was associated with reduced in-hospital mortality among patients with hospital-onset sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04149-z.

Nomogram for predicting the prognosis of tumor patients with sepsis after gastrointestinal surgery

BACKGROUND

There were few studies on the prognosis of tumor patients with sepsis after gastrointestinal surgery and there was no relevant nomogram for predicting the prognosis of these patients.

AIM

To establish a nomogram for predicting the prognosis of tumor patients with sepsis after gastrointestinal surgery in the intensive care unit (ICU).

METHODS

A total of 303 septic patients after gastrointestinal tumor surgery admitted to the ICU at Peking University Cancer Hospital from January 1, 2013 to December 31, 2020 were analysed retrospectively. The model for predicting the prognosis of septic patients was established by the R software package.

RESULTS

The most common infection site of sepsis after gastrointestinal surgery in the ICU was abdominal infection. The 90-d all-cause mortality rate was 10.2% in our study group. In multiple analyses, we found that there were statistically significant differences in tumor type, septic shock, the number of lymphocytes after ICU admission, serum creatinine and total operation times among tumor patients with sepsis after gastrointestinal surgery (P < 0.05). These five variables could be used to establish a nomogram for predicting the prognosis of these septic patients. The nomogram was verified, and the initial C-index was 0.861. After 1000 internal validations of the model, the C-index was 0.876, and the discrimination was good. The correction curve indicated that the actual value was in good agreement with the predicted value.

CONCLUSION

The nomogram based on these five factors (tumor type, septic shock, number of lymphocytes, serum creatinine, and total operation times) could accurately predict the prognosis of tumor patients with sepsis after gastrointestinal surgery.

Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis

Rationale: Patients with hospital-acquired sepsis (HAS) experience higher mortality and delayed care compared with those with community-acquired sepsis. Capacity strain, the extent to which demand for hospital resources exceeds availability, thus impacting patient care, is a possible mechanism underlying antimicrobial delays for HAS but has not been studied. Objectives: Assess the association of ward census with the timing of antimicrobial initiation among ward patients with HAS. Methods: This retrospective cohort study included adult patients hospitalized at five acute care hospitals between July 2017 and December 2019 who developed ward-onset HAS, distinguished from community-acquired sepsis by onset after 48 hours of hospitalization. The primary exposure was ward census, measured as the number of patients present in each ward at each hour, standardized by quarter and year. The primary outcome was time from sepsis onset to antimicrobial initiation. We used quantile regression to assess the association between ward census at sepsis onset and time to antimicrobial initiation among patients with HAS defined by Centers for Disease Control and Prevention Adult Sepsis Event criteria. We adjusted for hospital, year, quarter, age, sex, race, ethnicity, severity of illness, admission diagnosis, and service type. Results: A total of 1,672 hospitalizations included at least one ward-onset HAS episode. Median time to antimicrobial initiation after HAS onset was 4.1 hours (interquartile range, 0.4-22.3). Marginal adjusted time to antimicrobial initiation ranged from 3.6 hours (95% confidence interval [CI], 2.4-4.8 h) to 6.8 hours (95% CI, 5.3-8.4 h) at census levels 2 standard deviations (SDs) below and above the ward-specific mean, respectively. Each 1-SD increase in ward census at sepsis onset, representing a median of 2.4 patients, was associated with an increase in time to antimicrobial initiation of 0.80 hours (95% CI, 0.32-1.29 h). In sensitivity analyses, results were consistent across severity of illness and electronic health record-based sepsis definitions. Conclusions: Time to antimicrobial initiation increased with increasing census among ward patients with HAS. These findings suggest that delays in care for HAS may be related to ward capacity strain as measured by census. Additional work is needed to validate these findings and identify potential mechanisms operating through clinician behavior and care delivery processes.

TIME FROM HOSPITAL ADMISSION TO ONSET OF SEPTIC SHOCK IS ASSOCIATED WITH HIGHER IN-HOSPITAL MORTALITY

ABSTRACT

Objective: Several studies have shown septic shock developing later during the hospital stay is associated with higher mortality. However, the precise point at which time from hospital admission to the onset of septic shock (admission-shock-onset-time) becomes an independent prognostic marker of mortality remains unknown. This study evaluated the association between admission-shock-onset-time and in-hospital mortality among patients with septic shock and the optimal cutoff period to categorize early- and late-onset septic shock. Method: We conducted a single-center retrospective, observational cohort study at a quaternary academic hospital comprising adult patients with septic shock admitted to a medical intensive care unit (ICU) from January 2011 to December 2020. A multivariable additive logistic regression model was developed to assess if log-transformed admission-shock-onset-time was associated with in-hospital mortality. The thin plate spline function was used to describe the nonlinear relationship between the log-transformed admission-shock-onset-time and in-hospital mortality. The primary outcome was in-hospital mortality, and the secondary outcome was ICU mortality. Results: Two thousand five hundred twenty patients met the inclusion criteria with an overall in-hospital mortality of 37.3%. The log-transformed admission-shock-onset-time was associated with higher in-hospital and ICU mortality even after adjusting for clinical variables. The odds ratio for in-hospital mortality continued to increase throughout the observation period. The adjusted odds ratio exceeded 2 in between 20.1 and 54.6 h, and it surpassed 3 in between 54.6 and 148.4 h of the time from the hospital admission to shock onset. Conclusion: In-hospital mortality continued to rise as admission-shock-onset-time increased in patients with septic shock. No clear dichotomization between early and late septic shock could be ascertained, and this categorization may limit our understanding of the temporal relationship of shock onset to mortality.

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

Potential Interaction Between Sepsis and Acute Respiratory Distress Syndrome and Effect on the 6-Month Clinical Outcomes: A Preliminary Secondary Analysis of a Prospective Observational Study

BACKGROUND

This study aimed to investigate the effect of the potential interaction between sepsis and acute respiratory distress syndrome (ARDS) on the 6-month clinical outcomes.

METHODS

This secondary analysis of a prospective multicenter observational study included patients who were expected to receive mechanical ventilation for more than 48 h. Patients were stratified based on the incidence of sepsis and further subdivided according to the presence of ARDS. The primary endpoints for patients whose follow-up information was available included mortality (n = 162) and the occurrence of PICS (n = 96) at six months. The diagnosis of PICS was based on any of the following criteria: (1) decrease ≥ 10 points in the physical component score of the 36-item Short Form (SF36) questionnaire; (2) decrease ≥ 10 points in the mental component score of the SF-36; or (3) decline in the Short Memory Questionnaire (SMQ) score and SMQ score < 40 at six months after ICU admission. We conducted multivariate logistic regression analyses to assess the effect of the potential interaction between ARDS and sepsis on the 6-month clinical outcomes.

RESULTS

The mortality in the ARDS sub-group was higher than that in the non-ARDS subgroup [47% (7/15) versus 21% (18/85)] in the non-sepsis group. However, the mortality in the ARDS and non-ARDS subgroups was similar in the sepsis group. Multivariate logistic regression analyses revealed that ARDS was significantly associated with mortality in the non-sepsis group (adjusted OR: 5.25; 95% CI: 1.45-19.09; p = .012), but not in the sepsis group (P for interaction = .087). Multivariate logistic regression analyses showed ARDS was not associated with PICS occurrence in the non-sepsis and sepsis groups (P-value for the interaction = .039).

CONCLUSIONS

This hypothesis-generating study suggested that the effect of ARDS on the 6-month outcomes depended on the presence or absence of sepsis.

TRIAL REGISTRATION

Not applicable.

Hospital-onset sepsis and community-onset sepsis in critical care units in Japan: a retrospective cohort study based on a Japanese administrative claims database

Background

Hospital- and community-onset sepsis are significant sepsis subgroups. Japanese data comparing these subgroups are limited. This study aimed to describe the epidemiology of hospital- and community-onset sepsis in critical care units in Japan.

Methods

We performed a retrospective cohort study using the Japanese Diagnosis and Procedure Combination database. Adult patients admitted to critical care units with sepsis from April 2010 to March 2020 were included. Sepsis cases were identified based on ICD-10 codes for infectious diseases, procedure codes for blood culture tests, and medication codes for antimicrobials. Patients’ characteristics, in-hospital mortality, and resource utilization were assessed. The in-hospital mortality between groups was compared using the Poisson regression generalized linear mixed-effect model.

Results

Of 516,124 patients, 52,183 (10.1%) had hospital-onset sepsis and 463,940 (89.9%) had community-onset sepsis. Hospital-onset sepsis was characterized by younger age, infrequent emergency hospitalization, frequent surgery under general anesthesia, and frequent organ support upon critical care unit admission compared to community-onset sepsis. In-hospital mortality was higher for hospital-onset than for community-onset sepsis (35.5% versus 19.2%; unadjusted mean difference, 16.3% [95% confidence interval (CI) 15.9–16.7]; adjusted mean difference, 15.6% [95% CI 14.9–16.2]). Mean hospital length of stay was longer for hospital-onset than for community-onset sepsis (47 days versus 30 days; unadjusted mean difference, 17 days [95% CI 16–17]; adjusted mean difference, 13 days [95% CI 12–14]).

Conclusion

Patients with hospital-onset sepsis admitted to critical care units in Japan had a poorer prognosis and more resource utilization including organ support rate, number of days with critical care unit surcharge codes, and hospital length of stay than those with community-onset sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04013-0.

Monocyte distribution width as part of a broad pragmatic sepsis screen in the emergency department

STUDY OBJECTIVE

Enhancement of a routine complete blood count (CBC) for detection of sepsis in the emergency department (ED) has pragmatic utility for early management. This study evaluated the performance of monocyte distribution width (MDW) alone and in combination with other routine CBC parameters as a screen for sepsis and septic shock in ED patients.

METHODS

A prospective cohort analysis of adult patients with a CBC collected at an urban ED from January 2020 through July 2021. The performance of MDW, white blood count (WBC) count, and neutrophil-to-lymphocyte-ratio (NLR) to detect sepsis and septic shock (Sepsis-3 Criteria) was evaluated using diagnostic performance measures.

RESULTS

The cohort included 7952 ED patients, with 180 meeting criteria for sepsis; 43 with septic shock and 137 without shock. MDW was highest for patients with septic shock (median 24.8 U, interquartile range [IQR] 22.0-28.1) and trended downward for patients with sepsis without shock (23.9 U, IQR 20.2-26.8), infection (20.4 U, IQR 18.2-23.3), then controls (18.6 U, IQR 17.1-20.4). In isolation, MDW detected sepsis and septic shock with an area under the receiver operator characteristic curve (AUC) of 0.80 (95% confidence interval [CI] 0.77-0.84) and 0.85 (95% CI 0.80-0 .91), respectively. Optimal performance was achieved in combination with WBC count and NLR for detection of sepsis (AUC 0.86, 95% CI 0.83-0.89) and septic shock (0.86, 95% CI 0.80-0.92).

CONCLUSION

A CBC differential panel that includes MDW demonstrated strong performance characteristics in a broad ED population suggesting pragmatic value as a rapid screen for sepsis and septic shock.

Should hospital-onset Adult Sepsis Event surveillance be routine… or even mandatory?

Hospital-onset sepsis accounts for 10%-15% of all sepsis cases and is associated with very high mortality rates, yet to date most hospitals have paid little attention to tracking its incidence and outcomes. This contrasts sharply with the substantial effort that hospitals and regulatory agencies spend tracking and reporting a limited subset of healthcare-associated infections. The recent development of the Center for Disease Control and Prevention's hospital-onset Adult Sepsis Event (ASE) definition, however, provides a validated and standardized mechanism for facilities to identify patients with nosocomial sepsis using routinely available electronic health record data. Recent data have demonstrated that hospital-onset ASE surveillance identifies many infections that are largely missed by current reportable healthcare-associated infections and that are associated with much higher mortality rates. Expanding the breadth of surveillance to include these highly consequential infections could help identify new targets for prevention and quality improvement and ultimately catalyze better outcomes for hospitalized patients. More work is needed, however, to characterize the preventability of hospital-onset ASE, develop and validate robust case-mix adjustment tools, and facilitate widespread uptake in hospitals with limited resources.

A New Time-Window Prediction Model For Traumatic Hemorrhagic Shock Based on Interpretable Machine Learning

ABSTRACT

Early warning prediction of traumatic hemorrhagic shock (THS) can greatly reduce patient mortality and morbidity. We aimed to develop and validate models with different stepped feature sets to predict THS in advance. From the PLA General Hospital Emergency Rescue Database and Medical Information Mart for Intensive Care III, we identified 604 and 1,614 patients, respectively. Two popular machine learning algorithms (i.e., extreme gradient boosting [XGBoost] and logistic regression) were applied. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the performance of the models. By analyzing the feature importance based on XGBoost, we found that features in vital signs (VS), routine blood (RB), and blood gas analysis (BG) were the most relevant to THS (0.292, 0.249, and 0.225, respectively). Thus, the stepped relationships existing in them were revealed. Furthermore, the three stepped feature sets (i.e., VS, VS + RB, and VS + RB + sBG) were passed to the two machine learning algorithms to predict THS in the subsequent T hours (where T = 3, 2, 1, or 0.5), respectively. Results showed that the XGBoost model performance was significantly better than the logistic regression. The model using vital signs alone achieved good performance at the half-hour time window (AUROC = 0.935), and the performance was increased when laboratory results were added, especially when the time window was 1 h (AUROC = 0.950 and 0.968, respectively). These good-performing interpretable models demonstrated acceptable generalization ability in external validation, which could flexibly and rollingly predict THS T hours (where T = 0.5, 1) prior to clinical recognition. A prospective study is necessary to determine the clinical utility of the proposed THS prediction models.

Recent Advances in Bedside Device-Based Early Detection of Sepsis

Early detection of sepsis is challenging to achieve with current diagnostic methods, leading to expenditures of $27 billion annually in the United States with significant associated mortality. Various scoring systems have been proposed such as the sequential organ failure assessment (SOFA) and systemic inflammatory response syndrome (SIRS) criteria for identification of sepsis, but their sensitivities range from 60% to 70% when used in the emergency department triage. Other methods for the recognition of sepsis may rely on laboratory work, in addition to vitals monitoring, and are often outpaced by the development of sepsis. Automated alerts have not shown any reduction in mortality thus far. New technology may fill a critical gap in the early detection of sepsis. The ideal bedside screening device for would demonstrate rapid time to result, high portability, and high sensitivity to not miss cases, but also reasonable specificity to prevent provider fatigue from excessive false alerts. Non-invasive end-organ perfusion devices analyzing lactate and capillary refill time (CRT) tend to perform well in speed and portability, but may be less sensitive. Biomarker devices demonstrate a wider array of performance metrics. Those analyzing a single biomarker tend to be more sensitive but are less specific to the diagnosis of sepsis than technologies that assess multiple biomarkers, which in turn have lower sensitivity. Additionally, biomarker devices are generally invasive requiring blood samples, which may or may not be feasible in all patients especially when serial draws are needed. Sepsis is a complex disease process and most likely will require a combination of improved technology in addition to vital signs and high-risk patient history for better recognition. This review examines recent advances in the device-based early detection of sepsis between 2017 and 2020 with emphasis on bedside diagnostics, divided into markers of perfusion and biomarkers commonly implicated in sepsis.

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

OBJECTIVES

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

DESIGN

Retrospective cohort study.

SETTING

About 373 U.S. hospitals.

PATIENTS

Adults hospitalized between January 2009 and September 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Predictive factors of in-hospital mortality in patients with laboratory-confirmed Escherichia coli, Klebsiella species or Pseudomonas aeruginosa bloodstream infections

Gram-negative bloodstream infections (GNBSI) are confirmed by the presence of gram-negative bacteria in the bloodstream and pose a significant healthcare issue as they increase the risk of sepsis and mortality. In England, the aim is to reduce GNBSI cases and further deterioration through enhanced population surveillance of patients with a laboratory-confirmed GNBSI to inform on healthcare policies. The objective of this study was to evaluate the factors associated with in-hospital mortality in patients with a laboratory-confirmed Escherichia coli, Klebsiella or Pseudomonas aeruginosa GNBSIs, with data obtained from the enhanced data capture for the surveillance of GNBSIs. All patients with a laboratory-confirmed GNBSI at a single centre, admitted between April 2017 and March 2019, were included in this retrospective observational study. Demographic and recent exposure to healthcare risk factors were collected and assessed for the association with in-hospital mortality. In 1113 patients with laboratory-confirmed GNBSIs, the in-hospital mortality rate was 13%. Multivariable analysis confirmed that patients with respiratory (OR = 3.73, 95%CI = 2.05-6.76), gastrointestinal (2.61; 1.22-5.58) or skin (3.61; 1.24-10.54) infection primary focus had a greater risk of in-hospital mortality, compared to upper urinary tract infections. Increased risk of in-hospital mortality was also observed in patients with hospital-onset GNBSIs (OR = 1.87; 1.17-2.97) compared with community-onset healthcare acquired GNBSIs, or who were on dialysis at the time of the GNBSI (3.28; 1.01-10.14), as well as in patients who had recently been discharged from hospital (1.55; 1.01-2.38), or had a vascular device recently manipulated (2.41; 1.01-5.74). Results confirm that the data obtained from the enhanced data capture for GNBSIs in England can predict in-hospital mortality in patients with a GNBSI. Several factors associated with an increased risk of in-hospital mortality have been identified. Results should be reported back to clinicians in order to identify patients at a greater risk of dying in-hospital who may benefit from further monitoring.

A Transcriptomic Severity Metric That Predicts Clinical Outcomes in Critically Ill Surgical Sepsis Patients

Supplemental Digital Content is available in the text.

Clinically deployable methods for the rapid and accurate prediction of sepsis severity that could elicit a meaningful change in clinical practice are currently lacking. We evaluated a whole-blood, multiplex host-messenger RNA expression metric, Inflammatix-Severity-2, for identifying septic, hospitalized patients’ likelihood of 30-day mortality, development of chronic critical illness, discharge disposition, and/or secondary infections.