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Hechtman RK, Kipnis P, Cano J, Seelye S, Liu VX, Prescott HC. Heterogeneity of Benefit from Earlier Time-to-Antibiotics for Sepsis. Am J Respir Crit Care Med 2024; 209:852-860. [PMID: 38261986 PMCID: PMC10995570 DOI: 10.1164/rccm.202310-1800oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024] Open
Abstract
Rationale: Shorter time-to-antibiotics improves survival from sepsis, particularly among patients in shock. There may be other subgroups for whom faster antibiotics are particularly beneficial.Objectives: Identify patient characteristics associated with greater benefit from shorter time-to-antibiotics.Methods: Observational cohort study of patients hospitalized with community-onset sepsis at 173 hospitals and treated with antimicrobials within 12 hours. We used three approaches to evaluate heterogeneity of benefit from shorter time-to-antibiotics: 1) conditional average treatment effects of shorter (⩽3 h) versus longer (>3-12 h) time-to-antibiotics on 30-day mortality using multivariable Poisson regression; 2) causal forest to identify characteristics associated with greatest benefit from shorter time-to-antibiotics; and 3) logistic regression with time-to-antibiotics modeled as a spline.Measurements and Main Results: Among 273,255 patients with community-onset sepsis, 131,094 (48.0%) received antibiotics within 3 hours. In Poisson models, shorter time-to-antibiotics was associated with greater absolute mortality reduction among patients with metastatic cancer (5.0% [95% confidence interval; CI: 4.3-5.7] vs. 0.4% [95% CI: 0.2-0.6] for patients without cancer, P < 0.001); patients with shock (7.0% [95% CI: 5.8-8.2%] vs. 2.8% [95% CI: 2.7-3.5%] for patients without shock, P = 0.005); and patients with more acute organ dysfunctions (4.8% [95% CI: 3.9-5.6%] for three or more dysfunctions vs. 0.5% [95% CI: 0.3-0.8] for one dysfunction, P < 0.001). In causal forest, metastatic cancer and shock were associated with greatest benefit from shorter time-to-antibiotics. Spline analysis confirmed differential nonlinear associations of time-to-antibiotics with mortality in patients with metastatic cancer and shock.Conclusions: In patients with community-onset sepsis, the mortality benefit of shorter time-to-antibiotics varied by patient characteristics. These findings suggest that shorter time-to-antibiotics for sepsis is particularly important among patients with cancer and/or shock.
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Affiliation(s)
- Rachel K. Hechtman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Jennifer Cano
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sarah Seelye
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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2
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Bode C, Weis S, Sauer A, Wendel-Garcia P, David S. Targeting the host response in sepsis: current approaches and future evidence. Crit Care 2023; 27:478. [PMID: 38057824 PMCID: PMC10698949 DOI: 10.1186/s13054-023-04762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023] Open
Abstract
Sepsis, a dysregulated host response to infection characterized by organ failure, is one of the leading causes of death worldwide. Disbalances of the immune response play an important role in its pathophysiology. Patients may develop simultaneously or concomitantly states of systemic or local hyperinflammation and immunosuppression. Although a variety of effective immunomodulatory treatments are generally available, attempts to inhibit or stimulate the immune system in sepsis have failed so far to improve patients' outcome. The underlying reason is likely multifaceted including failure to identify responders to a specific immune intervention and the complex pathophysiology of organ dysfunction that is not exclusively caused by immunopathology but also includes dysfunction of the coagulation system, parenchymal organs, and the endothelium. Increasing evidence suggests that stratification of the heterogeneous population of septic patients with consideration of their host response might led to treatments that are more effective. The purpose of this review is to provide an overview of current studies aimed at optimizing the many facets of host response and to discuss future perspectives for precision medicine approaches in sepsis.
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Affiliation(s)
- Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Sebastian Weis
- Institute for Infectious Disease and Infection Control, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Friedrich-Schiller University Jena, Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll Institute-HKI, Jena, Germany
| | - Andrea Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Pedro Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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3
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Butler DA, Moolick K, McCray D, Gifford M. Compatibility of Omadacycline With Select Parenteral Products in Simulated Y-site Administration. Clin Ther 2023; 45:1137-1141. [PMID: 37777376 DOI: 10.1016/j.clinthera.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE Omadacycline is a broad-spectrum intravenous and oral tetracycline antibiotic approved for the treatment of community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections. Available information on the compatibility of intravenous omadacycline is limited to sterile water, 0.9% sodium chloride, and 5% dextrose via a dedicated line. The objective of this work was to determine the intravenous compatibility of omadacycline with commonly used intravenous fluids and medications using simulated Y-site administration. METHODS Omadacycline was prepared at concentrations consistent with a maintenance dose (1 mg/mL) and a loading dose (2 mg/mL) with 0.9% sodium chloride according to the prescribing information. Compatibility via simulated Y-site administration was assessed with selected crystalloids (lactated Ringer's solution, magnesium sulfate, and normal saline with potassium chloride) and intravenous medications (bumetanide, furosemide, heparin, and insulin). Y-site administration was simulated by mixing 5 mL of omadacycline with 5 mL of each parenteral product prepared at standard concentrations for infusion. Compatibility was assessed by using visual, Tyndall beam, microscopy, and spectrophotometry methods at 0, 30, and 60 minutes. FINDINGS Omadacycline appeared physically compatible with lactated Ringer's solution, magnesium sulfate, normal saline with potassium chloride, bumetanide, heparin, and insulin at standard infusion concentrations. However, although the lower concentrations of omadacycline 1 mg/mL and furosemide 2 mg/mL showed compatibility, higher concentrations of either agent in combination resulted in incompatibility. IMPLICATIONS Omadacycline appeared physically compatible with all products tested and incompatible with furosemide. Simultaneous administration of omadacycline with tested intravenous medications, except furosemide, is suggested to be safe.
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Affiliation(s)
- David A Butler
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA.
| | - Kelly Moolick
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Donavon McCray
- Department of Basic and Clinical Sciences, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Maxwell Gifford
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
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4
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Papathanakos G, Andrianopoulos I, Xenikakis M, Papathanasiou A, Koulenti D, Blot S, Koulouras V. Clinical Sepsis Phenotypes in Critically Ill Patients. Microorganisms 2023; 11:2165. [PMID: 37764009 PMCID: PMC10538192 DOI: 10.3390/microorganisms11092165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis, defined as the life-threatening dysregulated host response to an infection leading to organ dysfunction, is considered as one of the leading causes of mortality worldwide, especially in intensive care units (ICU). Moreover, sepsis remains an enigmatic clinical syndrome, with complex pathophysiology incompletely understood and a great heterogeneity both in terms of clinical expression, patient response to currently available therapeutic interventions and outcomes. This heterogeneity proves to be a major obstacle in our quest to deliver improved treatment in septic critical care patients; thus, identification of clinical phenotypes is absolutely necessary. Although this might be seen as an extremely difficult task, nowadays, artificial intelligence and machine learning techniques can be recruited to quantify similarities between individuals within sepsis population and differentiate them into distinct phenotypes regarding not only temperature, hemodynamics or type of organ dysfunction, but also fluid status/responsiveness, trajectories in ICU and outcome. Hopefully, we will eventually manage to determine both the subgroup of septic patients that will benefit from a therapeutic intervention and the correct timing of applying the intervention during the disease process.
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Affiliation(s)
- Georgios Papathanakos
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Ioannis Andrianopoulos
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Menelaos Xenikakis
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Athanasios Papathanasiou
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia;
- Second Critical Care Department, Attikon University Hospital, Rimini Street, 12462 Athens, Greece
| | - Stijn Blot
- Department of Internal Medicine & Pediatrics, Ghent University, 9000 Ghent, Belgium;
| | - Vasilios Koulouras
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
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5
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Yang A, Kennedy JN, Reitz KM, Phillips G, Terry KM, Levy MM, Angus DC, Seymour CW. Time to treatment and mortality for clinical sepsis subtypes. Crit Care 2023; 27:236. [PMID: 37322546 PMCID: PMC10268363 DOI: 10.1186/s13054-023-04507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Sepsis is common, deadly, and heterogenous. Prior analyses of patients with sepsis and septic shock in New York State showed a risk-adjusted association between more rapid antibiotic administration and bundled care completion, but not an intravenous fluid bolus, with reduced in-hospital mortality. However, it is unknown if clinically identifiable sepsis subtypes modify these associations. METHODS Secondary analysis of patients with sepsis and septic shock enrolled in the New York State Department of Health cohort from January 1, 2015 to December 31, 2016. Patients were classified as clinical sepsis subtypes (α, β, γ, δ-types) using the Sepsis ENdotyping in Emergency CAre (SENECA) approach. Exposure variables included time to 3-h sepsis bundle completion, antibiotic administration, and intravenous fluid bolus completion. Then logistic regression models evaluated the interaction between exposures, clinical sepsis subtypes, and in-hospital mortality. RESULTS 55,169 hospitalizations from 155 hospitals were included (34% α, 30% β, 19% γ, 17% δ). The α-subtype had the lowest (N = 1,905, 10%) and δ-subtype had the highest (N = 3,776, 41%) in-hospital mortality. Each hour to completion of the 3-h bundle (aOR, 1.04 [95%CI, 1.02-1.05]) and antibiotic initiation (aOR, 1.03 [95%CI, 1.02-1.04]) was associated with increased risk-adjusted in-hospital mortality. The association differed across subtypes (p-interactions < 0.05). For example, the outcome association for the time to completion of the 3-h bundle was greater in the δ-subtype (aOR, 1.07 [95%CI, 1.05-1.10]) compared to α-subtype (aOR, 1.02 [95%CI, 0.99-1.04]). Time to intravenous fluid bolus completion was not associated with risk-adjusted in-hospital mortality (aOR, 0.99 [95%CI, 0.97-1.01]) and did not differ among subtypes (p-interaction = 0.41). CONCLUSION Timely completion of a 3-h sepsis bundle and antibiotic initiation was associated with reduced risk-adjusted in-hospital mortality, an association modified by clinically identifiable sepsis subtype.
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Affiliation(s)
- Anne Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh Medical Center, PA, Pittsburgh, USA.
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
| | - Jason N Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gary Phillips
- The Ohio State University, Center for Biostatistics, Columbus, OH, USA
| | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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6
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Hu W, Chen H, Wang H, Peng Q, Wang J, Huang W, Liu A, Xu J, Li Q, Pan C, Xie J, Huang Y. Identifying high-risk phenotypes and associated harms of delayed time-to-antibiotics in patients with ICU onset sepsis: A retrospective cohort study. J Crit Care 2023; 74:154221. [PMID: 36565649 DOI: 10.1016/j.jcrc.2022.154221] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/19/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To identify phenotypes of Intensive Care Unit (ICU) onset sepsis and its associated harms of delayed time-to-antibiotics. MATERIALS AND METHODS The Medical Information Mart for Intensive Care IV (MIMIC-IV) database was employed to identify patients with ICU onset sepsis. The primary exposure was time-to-antibiotics, as measured from sepsis recognition to first antibiotic administered. Latent profile analysis (LPA) was used to identify phenotypes of sepsis based on individual organ failure score derived from Sequential Organ Failure Assessment (SOFA). Interactions between phenotypes and time-to-antibiotics on 28-day mortality were explored. RESULTS 6246 patients were enrolled in final analysis. The overall 28-day mortality was 12.7%. Delayed time-to-antibiotics was associated with increased 28-day mortality in patients with ICU onset sepsis (HR 1.12, 95% CI 1.08-1.18). Four phenotypes of sepsis were identified: phenotype 1 was characterized by respiratory dysfunction, phenotype 2 was characterized by cardiovascular dysfunction, phenotype 3 was characterized by multiple organ dysfunction, and phenotype 4 was characterized by neurological dysfunction. The adjusted HR of 28-day mortality was 1.16 (95% CI 1.08-1.25) in phenotype 1, and 1.06 (95% CI 1.00-1.13) in phenotype 2, while no significant interaction was observed. CONCLUSIONS Septic patients with respiratory or cardiovascular dysfunction were associated with harms of delayed time-to-antibiotics.
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Affiliation(s)
- Wenhan Hu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Haofei Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Qingyun Peng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Jinlong Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Wei Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China.
| | - Airan Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Qing Li
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Chun Pan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, PR China.
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7
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Timing and Spectrum of Antibiotic Treatment for Suspected Sepsis and Septic Shock: Why so Controversial? Infect Dis Clin North Am 2022; 36:719-733. [PMID: 36328632 DOI: 10.1016/j.idc.2022.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sepsis guidelines and mandates encourage increasingly aggressive time-to-antibiotic targets for broad-spectrum antimicrobials for suspected sepsis and septic shock. This has caused considerable controversy due to weaknesses in the underlying evidence and fear that overly strict antibiotic deadlines may harm patients by perpetuating or escalating overtreatment. Indeed, a third or more of patients currently treated for sepsis and septic shock have noninfectious or nonbacterial conditions. These patients risk all the potential harms of antibiotics without their possible benefits. Updated Surviving Sepsis Campaign guidelines now emphasize the importance of tailoring antibiotics to each patient's likelihood of infection, risk for drug-resistant pathogens, and severity-of-illness.
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8
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Li A, Ling L, Qin H, Arabi YM, Myatra SN, Egi M, Kim JH, Mat Nor MB, Son DN, Fang WF, Wahyuprajitno B, Hashmi M, Faruq MO, Patjanasoontorn B, Al Bahrani MJ, Shrestha BR, Shrestha U, Nafees KMK, Sann KK, Palo JEM, Mendsaikhan N, Konkayev A, Detleuxay K, Chan YH, Du B, Divatia JV, Koh Y, Gomersall CD, Phua J. Epidemiology, Management, and Outcomes of Sepsis in ICUs among Countries of Differing National Wealth across Asia. Am J Respir Crit Care Med 2022; 206:1107-1116. [PMID: 35763381 DOI: 10.1164/rccm.202112-2743oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: Directly comparative data on sepsis epidemiology and sepsis bundle implementation in countries of differing national wealth remain sparse. Objectives: To evaluate across countries/regions of differing income status in Asia 1) the prevalence, causes, and outcomes of sepsis as a reason for ICU admission and 2) sepsis bundle (antibiotic administration, blood culture, and lactate measurement) compliance and its association with hospital mortality. Methods: A prospective point prevalence study was conducted among 386 adult ICUs from 22 Asian countries/regions. Adult ICU participants admitted for sepsis on four separate days (representing the seasons of 2019) were recruited. Measurements and Main Results: The overall prevalence of sepsis in ICUs was 22.4% (20.9%, 24.5%, and 21.3% in low-income countries/regions [LICs]/lower middle-income countries/regions [LMICs], upper middle-income countries/regions, and high-income countries/regions [HICs], respectively; P < 0.001). Patients were younger and had lower severity of illness in LICs/LMICs. Hospital mortality was 32.6% and marginally significantly higher in LICs/LMICs than HICs on multivariable generalized mixed model analysis (adjusted odds ratio, 1.84; 95% confidence interval, 1.00-3.37; P = 0.049). Sepsis bundle compliance was 21.5% at 1 hour (26.0%, 22.1%, and 16.2% in LICs/LMICs, upper middle-income countries/regions, and HICs, respectively; P < 0.001) and 36.6% at 3 hours (39.3%, 32.8%, and 38.5%, respectively; P = 0.001). Delaying antibiotic administration beyond 3 hours was the only element independently associated with increased mortality (adjusted odds ratio, 2.53; 95% confidence interval, 2.07-3.08; P < 0.001). Conclusions: Sepsis is a common cause of admission to Asian ICUs. Mortality remains high and is higher in LICs/LMICs after controlling for confounders. Sepsis bundle compliance remains low. Delaying antibiotic administration beyond 3 hours from diagnosis is associated with increased mortality. Clinical trial registered with www.ctri.nic.in (CTRI/2019/01/016898).
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Affiliation(s)
- Andrew Li
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- Department of Intensive Care Medicine, Woodlands Health, Singapore, Singapore
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Hanyu Qin
- State Key Laboratory of Complex, Severe and Rare Disease, Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Moritoki Egi
- Department of Anesthesiology and Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | - Je Hyeong Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Ansan, South Korea
| | - Mohd Basri Mat Nor
- International Islamic University Malaysia Medical Centre, Kuantan, Malaysia
| | - Do Ngoc Son
- Critical Care Unit, Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Bambang Wahyuprajitno
- Department of Anesthesiology and Reanimation, Faculty of Medicine - University of Airlangga, Intensive Care Unit, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Mohammad Omar Faruq
- General Intensive Care Unit and Emergency Department, United Hospital Ltd., Dhaka, Bangladesh
| | - Boonsong Patjanasoontorn
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Babu Raja Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | - Ujma Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | | | - Kyi Kyi Sann
- Department of Anaesthesiology and Intensive Care Unit, Yangon General Hospital, University of Medicine 1, Yangon, Myanmar
| | | | - Naranpurev Mendsaikhan
- Anaesthesia and Critical Care Department, Mongolian National University of Health Science, Ulaanbaatar, Mongolia
| | - Aidos Konkayev
- Anaesthesiology and Intensive Care Department, Astana Medical University, Nur-Sultan, Kazakhstan
- Anaesthesia and Intensive Care Unit Department, Institution of Traumatology and Orthopedics, Nur-Sultan, Kazakhstan
| | - Khamsay Detleuxay
- Adult Intensive Care Unit, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bin Du
- State Key Laboratory of Complex, Severe and Rare Disease, Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; and
| | - Charles D Gomersall
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- FAST and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore, Singapore
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9
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Klompas M, Goldberg SA. Turning Back the Clock: Prehospital Antibiotics for Patients With Septic Shock. Crit Care Med 2022; 50:1537-1540. [PMID: 36106973 DOI: 10.1097/ccm.0000000000005655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
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10
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Ginestra JC, Kohn R, Hubbard RA, Crane-Droesch A, Halpern SD, Kerlin MP, Weissman GE. Association of Unit Census with Delays in Antimicrobial Initiation among Ward Patients with Hospital-acquired Sepsis. Ann Am Thorac Soc 2022; 19:1525-1533. [PMID: 35312462 PMCID: PMC9447380 DOI: 10.1513/annalsats.202112-1360oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/18/2022] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer C. Ginestra
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rachel Kohn
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Rebecca A. Hubbard
- Palliative and Advanced Illness Research (PAIR) Center
- Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Crane-Droesch
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
| | - Gary E. Weissman
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
- Palliative and Advanced Illness Research (PAIR) Center
- Leonard Davis Institute of Health Economics, and
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11
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Zhang Z, Chen L, Xu P, Wang Q, Zhang J, Chen K, Clements CM, Celi LA, Herasevich V, Hong Y. Effectiveness of automated alerting system compared to usual care for the management of sepsis. NPJ Digit Med 2022; 5:101. [PMID: 35854120 PMCID: PMC9296632 DOI: 10.1038/s41746-022-00650-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/04/2022] [Indexed: 01/18/2023] Open
Abstract
There is a large body of evidence showing that delayed initiation of sepsis bundle is associated with adverse clinical outcomes in patients with sepsis. However, it is controversial whether electronic automated alerts can help improve clinical outcomes of sepsis. Electronic databases are searched from inception to December 2021 for comparative effectiveness studies comparing automated alerts versus usual care for the management of sepsis. A total of 36 studies are eligible for analysis, including 6 randomized controlled trials and 30 non-randomized studies. There is significant heterogeneity in these studies concerning the study setting, design, and alerting methods. The Bayesian meta-analysis by using pooled effects of non-randomized studies as priors shows a beneficial effect of the alerting system (relative risk [RR]: 0.71; 95% credible interval: 0.62 to 0.81) in reducing mortality. The automated alerting system shows less beneficial effects in the intensive care unit (RR: 0.90; 95% CI: 0.73–1.11) than that in the emergency department (RR: 0.68; 95% CI: 0.51–0.90) and ward (RR: 0.71; 95% CI: 0.61–0.82). Furthermore, machine learning-based prediction methods can reduce mortality by a larger magnitude (RR: 0.56; 95% CI: 0.39–0.80) than rule-based methods (RR: 0.73; 95% CI: 0.63–0.85). The study shows a statistically significant beneficial effect of using the automated alerting system in the management of sepsis. Interestingly, machine learning monitoring systems coupled with better early interventions show promise, especially for patients outside of the intensive care unit.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Lin Chen
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People's Republic of China
| | - Ping Xu
- Emergency Department, Zigong Fourth People's Hospital, Zigong, Sichuan, China.,Institute of Medical Big Data, Zigong Academy of Artificial Intelligence and Big Data for Medical Science Artificial Intelligence, Zigong, Sichuan, China.,Key Laboratory of Sichuan Province, Zigong, China
| | - Qing Wang
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jianjun Zhang
- Emergency Department, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Kun Chen
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, People's Republic of China
| | - Casey M Clements
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Leo Anthony Celi
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, USA.,Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Vitaly Herasevich
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yucai Hong
- Department of Emergency Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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12
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Scheibner A, Betthauser KD, Bewley AF, Juang P, Lizza B, Micek S, Lyons PG. Machine learning to predict vasopressin responsiveness in patients with septic shock. Pharmacotherapy 2022; 42:460-471. [PMID: 35426141 DOI: 10.1002/phar.2683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES The objective of this study was to develop and externally validate a model to predict adjunctive vasopressin response in patients with septic shock being treated with norepinephrine for bedside use in the intensive care unit. DESIGN This was a retrospective analysis of two adult tertiary intensive care unit septic shock populations. SETTING Barnes-Jewish Hospital (BJH) from 2010 to 2017 and Beth Israel Deaconess Medical Center (BIDMC) from 2001 to 2012. PATIENTS Two septic shock populations (548 BJH patients and 464 BIDMC patients) that received vasopressin as second-line vasopressor. INTERVENTION Patients who were vasopressin responsive were compared with those who were nonresponsive. Vasopressin response was defined as survival with at least a 20% decrease in maximum daily norepinephrine requirements by one calendar day after vasopressin initiation, without a third-line vasopressor. MEASUREMENTS Two supervised machine learning models (gradient-boosting machine [XGBoost] and elastic net penalized logistic regression [EN]) were trained in 1000 bootstrap replications of the BJH data and externally validated in the BIDMC data to predict vasopressin responsiveness. MAIN RESULTS Vasopressin responsiveness was similar among each cohort (BJH 45% and BIDMC 39%). Mortality was lower for vasopressin responders compared with nonresponders in the BJH (51% vs. 73%) and BIDMC (45% vs. 83%) cohorts, respectively. Both models demonstrated modest discrimination in the training (XGBoost area under receiver operator curve [AUROC] 0.61 [95% confidence interval (CI) 0.61-0.61], EN 0.59 [95% CI 0.58-0.59]) and external validation (XGBoost 0.68 [95% CI 0.63-0.73], EN 0.64 [95% CI 0.59-0.69]) datasets. CONCLUSION Vasopressin nonresponsiveness is common and associated with increased mortality. The models' modest performances highlight the complexity of septic shock and indicate that more research will be required before clinical decision support tools can aid in anticipating patient-specific responsiveness to vasopressin.
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Affiliation(s)
- Aileen Scheibner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kevin D Betthauser
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Alice F Bewley
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul Juang
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA.,Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Bryan Lizza
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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13
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Heterogeneity in Clinical Presentations of Sepsis: Challenges and Implications for "One-Size-Fits-All" Time-to-Antibiotic Measures. Crit Care Med 2022; 50:886-889. [PMID: 35485589 DOI: 10.1097/ccm.0000000000005430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Chang JL, Pearson JC, Rhee C. Early Empirical Use of Broad-Spectrum Antibiotics in Sepsis. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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15
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Abstract
Despite its heterogeneous phenotypes, sepsis or life-threatening dysfunction in response to infection is often treated empirically. Identifying patient subgroups with unique pathophysiology and treatment response is critical to the advancement of sepsis care. However, phenotyping methods and results are as heterogeneous as the disease itself. This scoping review evaluates the prognostic capabilities and treatment implications of adult sepsis and septic shock phenotyping methods. DATA SOURCES Medline and Embase. STUDY SELECTION We included clinical studies that described sepsis or septic shock and used any clustering method to identify sepsis phenotypes. We excluded conference abstracts, literature reviews, comments, letters to the editor, and in vitro studies. We assessed study quality using a validated risk of bias tool for observational cohort and cross-sectional studies. DATA EXTRACTION We extracted population, methodology, validation, and phenotyping characteristics from 17 studies. DATA SYNTHESIS Sepsis phenotyping methods most frequently grouped patients based on the degree of inflammatory response and coagulopathy using clinical, nongenomic variables. Five articles clustered patients based on genomic or transcriptomic data. Seven articles generated patient subgroups with differential response to sepsis treatments. Cluster clinical characteristics and their associations with mortality and treatment response were heterogeneous across studies, and validity was evaluated in nine of 17 articles, hindering pooled analysis of results and derivation of universal truths regarding sepsis phenotypes, their prognostic capabilities, and their associations with treatment response. CONCLUSIONS Sepsis phenotyping methods can identify high-risk patients and those with high probability of responding well to targeted treatments. Research quality was fair, but achieving generalizability and clinical impact of sepsis phenotyping will require external validation and direct comparison with alternative approaches.
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16
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Rüddel H, Thomas-Rüddel DO, Reinhart K, Bach F, Gerlach H, Lindner M, Marshall JC, Simon P, Weiss M, Bloos F, Schwarzkopf D. Adverse effects of delayed antimicrobial treatment and surgical source control in adults with sepsis: results of a planned secondary analysis of a cluster-randomized controlled trial. Crit Care 2022; 26:51. [PMID: 35227308 PMCID: PMC8883454 DOI: 10.1186/s13054-022-03901-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/16/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain. METHODS We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing. RESULTS Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1-3 h, or 1 h versus 3-6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04). CONCLUSIONS Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov ( NCT01187134 ). Registered 23 August 2010, NCT01187134.
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Affiliation(s)
- Hendrik Rüddel
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel O Thomas-Rüddel
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Konrad Reinhart
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health, Campus Virchow-Klinikum, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Friedhelm Bach
- Department for Infectious Diseases, Protestant Hospital of Bethel Foundation University Hospital, University of Bielefeld, Bethesdaweg 10, 33617, Bielefeld, Germany
| | - Herwig Gerlach
- Department for Anaesthesia, Intensive Care Medicine and Pain Management, Vivantes - Klinikum Neukoelln, Rudower Strasse 48, 12351, Berlin, Germany
| | - Matthias Lindner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
| | - Philipp Simon
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Centre, Liebigstraße 20, 04103, Leipzig, Germany
| | - Manfred Weiss
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Frank Bloos
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel Schwarzkopf
- Integrated Research and Treatment Center - Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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17
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Alrashed MA, Kang N, Perona SJ, Torabi MR, Borgstorm MC. Evaluation of Intravenous Push Piperacillin-Tazobactam on Time to Antibiotic Administration in Emergency Department Patients with Sepsis. J Pharm Pract 2022:8971900211061937. [PMID: 35220826 DOI: 10.1177/08971900211061937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: The purpose of this study was to determine if intravenous push (IVP) administration of piperacillin-tazobactam reduced the time to antibiotic administration compared to intravenous piggyback (IVPB) in emergency department (ED) patients who present with sepsis. Methods: This was a retrospective cohort study of patients with sepsis who received piperacillin-tazobactam before and after implementation of an IVPB to IVP conversion protocol. Results: A total of 486 charts were reviewed and the final analysis included 127 patients in each group. The mean time to administration of piperacillin-tazobactam was 67 (± 48) minutes and 58 (± 36) minutes in the IVPB and IVP cohorts, respectively (P = NS). The time to administration of secondary antibiotics was reduced by 38 minutes in patients who received piperacillin-tazobactam by IVP (105 min ±69 vs 67 min ±37; P < .001). Nurse administration time was reduced by 11 min for piperacillin-tazobactam (54 min ±46 vs 43 min ±33; P = .034) and 40 min for secondary antibiotics (90 min ±67 vs 50 min ±32; P = < .001) in the IVP group. There was no difference in hypersensitivity reactions, hospital length of stay, or mortality. Conclusion: Conversion from piperacillin-tazobactam IVPB to IVP was associated with a reduction in time to piperacillin-tazobactam and secondary antibiotic administration in emergency department patients with sepsis. Further prospective research is needed to evaluate clinical outcomes associated with IVP administration.
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Affiliation(s)
- Mohammed A Alrashed
- 25336Northwest Medical Center, Tucson, AZ, USA.,College of Pharmacy, 15498University of Arizona, Tucson, AZ, USA
| | - Nayoung Kang
- 25336Northwest Medical Center, Tucson, AZ, USA.,College of Pharmacy, 15498University of Arizona, Tucson, AZ, USA
| | - Stephen J Perona
- 25336Northwest Medical Center, Tucson, AZ, USA.,College of Pharmacy, 15498University of Arizona, Tucson, AZ, USA
| | - Mohammad R Torabi
- College of Pharmacy, 15498University of Arizona, Tucson, AZ, USA.,Statistical Consulting Services, 15498University of Arizona, Tucson, AZ, USA
| | - Mark C Borgstorm
- College of Pharmacy, 15498University of Arizona, Tucson, AZ, USA.,Statistical Consulting Services, 15498University of Arizona, Tucson, AZ, USA
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18
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Affiliation(s)
- Sean R Townsend
- Division of Pulmonary, Critical Care Medicine, California Pacific Medical Center, San Francisco, CA
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA
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