Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study. Crit Care Med. 2013;41:1450-1457. [PMID: 23507718 DOI: 10.1097/ccm.0b013e31827caa89]

Interpretive machine learning predicts short-term mortality risk in elderly sepsis patients

Backgrounds

Sepsis is a leading cause of in-hospital mortality. However, its prevalence is increasing among the elderly population. Therefore, early identification and prediction of the risk of death in elderly patients with sepsis is crucial. The objective of this study was to create a machine learning model that can predict short-term mortality risk in elderly patients with severe sepsis in a clear and concise manner.

Methods

Data was collected from the MIMIC-IV (2.2). It was randomly divided into a training set and a validation set using a 7:3 ratio. Mortality predictors were determined through Recursive Feature Elimination (RFE). A prediction model for 28 days of ICU stay was built using six machine-learning algorithms. To create a comprehensive and nuanced model resolution, Shapley Additive Explanations (SHAP) and Local Interpretable Model-Agnostic Explanations (LIME) were used to systematically interpret the models at both a global and detailed level.

Results

The study involved the analysis of 4,056 elderly patients with sepsis. A feature recursive elimination algorithm was utilized to select eight variables out of 49 for model development. Six machine learning models were assessed, and the Extreme Gradient Boosting (XGBoost) model was found to perform the best. The validation set achieved an AUC of 0.88 (95% CI: 0.86-0.90) and an accuracy of 0.84 (95% CI: 0.81-0.86) for this model. To examine the roles of the eight key variables in the model, SHAP analysis was employed. The global ranking order was made evident, and through the use of LIME analysis, the weights of each feature range in the prediction model were determined.

Conclusion

The study's machine learning prediction model is a dependable tool for forecasting the prognosis of elderly patients with severe sepsis.

Chloramphenicol versus ceftriaxone for the treatment of pneumonia and sepsis in elderly patients with advanced dementia and functional disability. A propensity-weighted retrospective cohort study

BACKGROUND

Sepsis and pneumonia in the elderly comprise a significant portion of medical admissions. Chloramphenicol has been used in Israel for treatment of bacterial infections, without evidence regarding its efficacy and safety.

OBJECTIVES

We aimed to examine whether chloramphenicol was associated with similar outcomes to ceftriaxone, for treatment of sepsis and pneumonia in the elderly with dementia and functional disability.

METHODS

Patients over 75, with dementia and functional disability, admitted to the internal medicine ward at Beilinson Hospital between 2011 and 2021, with community-acquired aspiration pneumonia or sepsis of undetermined source were included. Patients with mild dementia and independent in their activities of daily living were excluded. Primary outcome was 30- and 90-day all-cause mortality. A propensity-weighted multivariable model was constructed using inverse probability of treatment weighting. Results were expressed as OR with 95% CI.

RESULTS

In total, 1558 patients were included: 512 treated with chloramphenicol and 1046 with ceftriaxone. The cohort consisted of elderly patients (mean age 87 ± 6.2 years) with comorbidities; 30- and 90-day all-cause mortality were similar [222/512 (43.3%) versus 439/1046 (41.9%) P = 0.602, and 261/512 (50.9%) versus 556/1046 (53.1%) P = 0.419, respectively]. Propensity-weighted, logistic multivariable analysis for 30- and 90-day all-cause mortality revealed similar mortality rates for chloramphenicol and ceftriaxone (OR 1.049 95% CI 0.217-1.158, OR 0.923 95% CI 0.734-1.112, respectively).

CONCLUSION

In this retrospective cohort of elderly debilitated patients hospitalized with pneumonia and sepsis, we found no difference in 30- and 90-day mortality between those treated with chloramphenicol or ceftriaxone. Further studies should determine the efficacy and safety of chloramphenicol in this population.

The Study of the Feasibility of Ultrasound-guided Catheterization of the Right Brachiocephalic Vein in Adult Patients: A Prospective Observational Study

Background

The brachiocephalic vein (BCV) is a feasible option for central venous access in the pediatric population and is rapidly developing as an alternative site for insertion of the central line in young children with faster insertion times, fewer attempts, and lower rates of complications. However, studies demonstrating the feasibility of BCV catheterization in adult patients are insufficient. The current study sought to assess the safety and effectiveness of ultrasound-guided supraclavicular right BCV cannulations in adults.

Methods

A linear array Ultrasound (US) probe was used to obtain a longitudinal picture of the BCV beginning at the junction of the internal jugular vein and the subclavian vein in the supraclavicular region. Under US supervision, the needle was guided into the BCV using the in-plane approach. A prospective study was performed on 80 adult patients scheduled for elective and emergency operative procedures under general anesthesia requiring a central venous catheter (CVC). Success rates and complications that occurred during catheter insertion were analyzed.

Results

CVC placement was successful in all adults. The procedure was successful at the first attempt in 74 cases (92.5%) and after 2 attempts in six patients (7.5%). The time to guide wire insertion was 31.26 s (19-58 s), and catheter insertion took 88.44 s (63-145 s). The mean length of catheter insertion was 10.46 cm. No complications were noted.

Conclusion

Ultrasound-guided supraclavicular BCV catheterization offers a new and safe method for central venous line catheterization in adults. However, larger trials and meta-analyses are needed to confirm these findings and evaluate the safety of this technique.

COMPARISON AMONG PRESEPSIN, PROCALCITONIN, AND C-REACTIVE PROTEIN IN PREDICTING BLOOD CULTURE POSITIVITY AND PATHOGEN IN SEPSIS PATIENTS

ABSTRACT

Background: Sepsis is caused by the invasion of the bloodstream by microorganisms from local sites of infection, leading to high mortality. This study aimed to compare the predictive ability of the biomarkers presepsin, procalcitonin (PCT), and C-reactive protein for bacteraemia. Methods: In this retrospective, multicentre study, a dataset of patients with sepsis who were prospectively enrolled between November 2017 and June 2021 was analyzed. The performances of the biomarkers for predicting positive blood cultures and infection with specific pathogens were assessed by the areas under the receiver operating characteristic curves (AUCs). The independent effects of the pathogen and foci of infection on presepsin and PCT levels were assessed by linear logistic regression models. Results: A total of 577 patients with 170 positive blood cultures (29.5%) were enrolled. The AUC achieved using PCT levels (0.856) was significantly higher than that achieved using presepsin (0.786, P = 0.0200) and C-reactive protein (0.550, P < 0.0001) levels in predicting bacteraemia. The combined analysis of PCT and presepsin levels led to a significantly higher AUC than the analysis of PCT levels alone for predicting blood culture positivity (0.877 vs. 0.856, P = 0.0344) and gram-negative bacteraemia (0.900 vs. 0.875, P = 0.0216). In a linear regression model, the elevated concentrations of presepsin and PCT were both independently related to Escherichia coli , Klebsiella species, Pseudomonas species, and Streptococcus species infections and Sequential Organ Failure Assessment score. Presepsin levels were also associated with Acinetobacter species and abdominal infection, and PCT levels were positively associated with other Enterobacteriaceae and negatively associated with respiratory infection. Combined analysis of presepsin and PCT levels provided a high sensitivity and specificity in identifying E. coli or Klebsiella species infection. Conclusions: Presepsin and PCT were promising markers for predicting bacteraemia and common pathogens at the time of sepsis onset with a synergistic effect.

Are patient volume and care level in teaching hospitals variables affecting clinical outcomes in adult intensive care units?

Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical.

OBJECTIVE

To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals.

METHODS

In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital.

CONCLUSION

Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.

Immune dysregulation and RNA N6-methyladenosine modification in sepsis

Sepsis is defined as life-threatening organ dysfunction caused by the host immune dysregulation to infection. It is a highly heterogeneous syndrome with complex pathophysiological mechanisms. The host immune response to sepsis can be divided into hyper-inflammatory and immune-suppressive phases which could exist simultaneously. In the initial stage, systemic immune response is activated after exposure to pathogens. Both innate and adaptive immune cells undergo epigenomic, transcriptomic, and functional reprogramming, resulting in systemic and persistent inflammatory responses. Following the hyper-inflammatory phase, the body is in a state of continuous immunosuppression, which is related to immune cell apoptosis, metabolic failure, and epigenetic reprogramming. Immunosuppression leads to increased susceptibility to secondary infections in patients with sepsis. RNA N6-Methyladenosine (m6A) has been recognized as an indispensable epitranscriptomic modification involved in both physiological and pathological processes. Recent studies suggest that m6A could reprogram both innate and adaptive immune cells through posttranscriptional regulation of RNA metabolism. Dysregulated m6A modifications contribute to the pathogenesis of immune-related diseases. In this review, we summarize immune cell changes and the potential role of m6A modification in sepsis. This article is categorized under: RNA in Disease and Development > RNA in Disease RNA Processing > RNA Editing and Modification.

CD19+CD24hiCD38hi regulatory B cells deficiency revealed severity and poor prognosis in patients with sepsis

Background

Sepsis still remains a major challenge in intensive care medicine with unacceptably high mortality among patients with septic shock. Due to current limitations of human CD19⁺CD24^hiCD38^hi Breg cells (Bregs) studies among sepsis, here, we tried to evaluate Bregs in severity and prognostic value in patients with sepsis.

Methods

Peripheral blood from 58 patients with sepsis and 22 healthy controls was analyzed using flow cytometry to evaluate the frequency and number of Bregs. All cases were divided into non-survived or survived group after 28 days followed up. Spearman's correlation analysis was performed on Bregs frequency and clinical indices. The area under the curve was acquired using the receiver operating characteristic analysis to assess the sensitivity and specificity of Bregs for outcome of sepsis. Survival curve analysis and binary logistic regression were applied to estimate the value of Bregs in prognosis among cases with sepsis.

Results

Sepsis patients had decreased proportions and number of Bregs. Sepsis patients with low frequency of Bregs were associated with an increased risk of septic shock. Bregs frequency is inversely associated with lactate, SOFA, and APACHE II and positively correlated with Tregs frequency. Low levels of Bregs closely correlated with septic outcomes. Numbers of Bregs were prediction factors for poor prognosis.

Conclusions

Frequency and number of Bregs decreased, and Bregs deficiency revealed poor prognosis in patients with sepsis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12865-022-00528-x.

Burden of bacterial bloodstream infections and recent advances for diagnosis

Bloodstream infections (BSIs) and subsequent organ dysfunction (sepsis and septic shock) are conditions that rank among the top reasons for human mortality and have a great impact on healthcare systems. Their treatment mainly relies on the administration of broad-spectrum antimicrobials since the standard blood culture-based diagnostic methods remain time-consuming for the pathogen's identification. Consequently, the routine use of these antibiotics may lead to downstream antimicrobial resistance and failure in treatment outcomes. Recently, significant advances have been made in improving several methodologies for the identification of pathogens directly in whole blood especially regarding specificity and time to detection. Nevertheless, for the widespread implementation of these novel methods in healthcare facilities, further improvements are still needed concerning the sensitivity and cost-effectiveness to allow a faster and more appropriate antimicrobial therapy. This review is focused on the problem of BSIs and sepsis addressing several aspects like their origin, challenges, and causative agents. Also, it highlights current and emerging diagnostics technologies, discussing their strengths and weaknesses.

Optimization of sepsis therapy based on patient-specific digital precision diagnostics using next generation sequencing (DigiSep-Trial)-study protocol for a randomized, controlled, interventional, open-label, multicenter trial

Background

Sepsis is triggered by an infection and represents one of the greatest challenges of modern intensive care medicine. With regard to a targeted antimicrobial treatment strategy, the earliest possible pathogen detection is of crucial importance. Until now, culture-based detection methods represent the diagnostic gold standard, although they are characterized by numerous limitations. Culture-independent molecular diagnostic procedures represent a promising alternative. In particular, the plasmatic detection of circulating, cell-free DNA by next-generation sequencing (NGS) has shown to be suitable for identifying disease-causing pathogens in patients with bloodstream infections.

Methods

The DigiSep-Trial is a randomized, controlled, interventional, open-label, multicenter trial characterizing the effect of the combination of NGS-based digital precision diagnostics with standard-of-care microbiological analyses compared to solely standard-of-care microbiological analyses in the clinical picture of sepsis/septic shock. Additional anti-infective expert consultations are provided for both study groups. In 410 patients (n = 205 per arm) with sepsis/septic shock, the study examines whether the so-called DOOR-RADAR (Desirability of Outcome Ranking/Response Adjusted for Duration of Antibiotic Risk) score (representing a combined endpoint including the criteria (1) intensive/intermediate care unit length of stay, (2) consumption of antibiotics, (3) mortality, and (4) acute kidney injury (AKI)) can be improved by an additional NGS-based diagnostic concept. We also aim to investigate the cost-effectiveness of this new diagnostic procedure. It is postulated that intensive/intermediate care unit length of stay, mortality rate, incidence of AKI, the duration of antimicrobial therapy as well as the costs caused by complications and outpatient aftercare can be reduced. Moreover, a significant improvement in patient’s quality of life is expected.

Discussion

The authors´ previous work suggests that NGS-based diagnostics have a higher specificity and sensitivity compared to standard-of-care microbiological analyses for detecting bloodstream infections. In combination with the here presented DigiSep-Trial, this work provides the optimal basis to establish a new NGS-driven concept as part of the national standard based on the best possible evidence.

Trial registrations

DRKS-ID DRKS00022782. Registered on August 25, 2020

ClinicalTrials.govNCT04571801. Registered October 1, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05667-x.

Risk factors of septic shock development and thirty-day mortality with a predictive model in adult candidemia patients in intensive care units

BACKGROUND

This study aimed to investigate factors associated with septic shock development and 30-day mortality outcome with a prediction model among adult candidemia patients in the intensive care unit (ICU).

METHODS

A retrospective study was conducted among patients admitted to the ICU from 2009 to 2018 at a tertiary care medical centre. The study subjects included adult patients ≥ 19 years with candidemia treated with antifungal agent for ≥ 3 days. Clinical variables were collected and analysed.

RESULTS

A total of 126 patients were included in the study. Of these patients, 32 patients (25.4%) had septic shock. Multivariate logistic regression analysis revealed that chronic liver disease was associated with septic shock (odds ratio [OR] 3.372, 95% confidence interval [CI] 1.057 - 10.057). The rate of 30-day mortality was 35.7% and the associated mortality risk factors were malignancy (OR 8.251, 95% CI 2.227 - 30.573), chronic liver disease (OR 3.605, 95% CI 0.913 - 14.227), haemodialysis (OR 8.479, 95% CI 1.801 - 39.924), mycological failure (OR 29.675, 95% CI 7.012 - 125.578), and septic shock (OR 3.980, 95% CI 1.238 - 12.796). A predictive model for 30-day mortality was created based on the mortality risk factor scores, which had an area of 0.862 under the receiver operating characteristic curve.

CONCLUSIONS

Adult candidemia patients in the ICU who have chronic liver disease may be at higher risk of developing septic shock. Furthermore, our predictive model for 30-day mortality based on the mortality risk factors may be useful for clinical assessment.

Point-of-care Ultrasound-guided Central Venous Catheter Confirmation in Ultrasound Nonexperts

OBJECTIVE

Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts.

METHODS

We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.

RESULTS

Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients.

CONCLUSION

Thirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.

Central Venous Catheter Adverse Events Are not Associated with Crowding Indicators

Objective

Crowding in the emergency department (ED) impacts a number of important quality and safety metrics. We studied ED crowding measures associated with adverse events (AE) resulting from central venous catheters (CVC) inserted in the ED, as well as the relationship between crowding and the frequency of CVC insertions in an ED cohort admitted to the intensive care unit (ICU).

Methods

We conducted a retrospective observational study from 2008–2010 in an academic tertiary care center. Participants undergoing CVC in the ED or admitted to an ICU were categorized by quartile based on the following: National Emergency Department Overcrowding Scale (NEDOCS); waiting room patients (WR); ED patients awaiting inpatient beds (boarders); and ED occupancy (EDO). Main outcomes were the occurrence of an AE during CVC insertion in the ED, and deferred procedures assessed by frequency of CVC insertions in ED patients admitted to the ICU.

Results

Of 2,284 ED patients who had a CVC inserted, 293 (13%) suffered an AE. There was no association between AEs from ED CVCs and crowding scales when comparing the highest crowding level or quartile to all other quartiles: NEDOCS (dangerous crowding [13.1%] vs other levels [13.0%], P = 0.98); number of WR patients (14.0% vs 12.7%, P = 0.81); EDO (13.0% vs 12.9%, P = 0.99); and number of boarding patients (12.0% vs 13.3%), P = 0.21). In a cohort of ED patients admitted to the ICU, there was no association between CVC placement rates in the ED and crowding scales comparing the highest vs all other quartiles: NEDOCS (dangerous crowding 16% vs all others 16%, P = 0.97); WR patients (16% vs 16%, P = 0.82), EDO (15% vs. 17%, P = 0.15); and number of boarding patients (17% vs 16%, P = 0.08).

Conclusion

In a large, academic tertiary-care center, frequency of CVC insertion in the ED and related AEs were not associated with measures of crowding. These findings add to the evidence that the negative effects of crowding, which impact all ED patients and measures of ED performance, are less likely to impair the delivery of prioritized time-critical interventions.

Lactate/albumin ratio: An early prognostic marker in critically ill patients

OBJECTIVES

We investigate the clinical utility of the lactate/albumin (L/A) ratio as an early prognostic marker of ICU mortality in a large cohort of unselected critically ill patients.

METHODS

A retrospective single-center study using data from the Multiparameter Intelligent Monitoring Intensive Care III (MIMIC-III) database collected between 2001 and 2012. We screened adult patients (age ≥ 15) with measured lactate and albumin on the first day of ICU stay to evaluate the prognostic performance of the lactate and lactate/albumin (L/A) ratio for ICU mortality prediction.

RESULTS

The overall ICU mortality in the 6414 eligible ICU patients was 16.4%. L/A showed a receiver-operating characteristics area under the curve (ROC-AUC) value of 0.69 (95% CI: 0.67, 0.70) to predict ICU mortality, higher than lactate 0.67 (95%CI: 0.65, 0.69). Regardless of the lactate level, L/A yielded better ROC-AUC compared to the lactate level [normal lactate (<2.0 mmol/L): 0.63 vs 0.60; intermediate lactate (2.0 mmol/L ≤ lactate <4.0 mmol/L): 0.58 vs 0.56; high lactate (≥4.0 mmol/L): 0.67 vs 0.66]. L/A was a better prognostic marker for ICU mortality in patients with decreased lactate elimination [hepatic dysfunction: 0.72 vs 0.70; renal dysfunction 0.70 vs 0.68]. The L/A ratio ROC-AUC was better in patients with sepsis (0.68 vs 0.66) and those who developed severe sepsis or septic shock (0.68 vs 0.66).

CONCLUSIONS

The performance of L/A and lactate were equivalent in predicting ICU mortality and can be used as early prognostic markers for ICU patients with different initial lactate level and the presence of hepatic or renal dysfunction.

Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters

PURPOSE

Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography.

METHODS

We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS.

RESULTS

Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion "most of the time" or "always," none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion.

CONCLUSIONS

Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.

A novel flow cytometry assay based on bacteriophage-derived proteins for Staphylococcus detection in blood

Bloodstream infections (BSIs) are considered a major cause of death worldwide. Staphylococcus spp. are one of the most BSIs prevalent bacteria, classified as high priority due to the increasing multidrug resistant strains. Thus, a fast, specific and sensitive method for detection of these pathogens is of extreme importance. In this study, we have designed a novel assay for detection of Staphylococcus in blood culture samples, which combines the advantages of a phage endolysin cell wall binding domain (CBD) as a specific probe with the accuracy and high-throughput of flow cytometry techniques. In order to select the biorecognition molecule, three different truncations of the C-terminus of Staphylococcus phage endolysin E-LM12, namely the amidase (AMI), SH3 and amidase+SH3 (AMI_SH3) were cloned fused with a green fluorescent protein. From these, a higher binding efficiency to Staphylococcus cells was observed for AMI_SH3, indicating that the amidase domain possibly contributes to a more efficient binding of the SH3 domain. The novel phage endolysin-based flow cytometry assay provided highly reliable and specific detection of 1-5 CFU of Staphylococcus in 10 mL of spiked blood, after 16 hours of enrichment culture. Overall, the method developed herein presents advantages over the standard BSIs diagnostic methods, potentially contributing to an early and effective treatment of BSIs.

ICU Utilization for Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease Receiving Noninvasive Ventilation

OBJECTIVES

We investigated whether patients with chronic obstructive pulmonary disease could safely receive noninvasive ventilation outside of the ICU.

DESIGN

Retrospective cohort study.

SETTING

Twelve states with ICU utilization flag from the State Inpatient Database from 2014.

PATIENTS

Patients greater than or equal to 18 years old with primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease and secondary diagnosis of respiratory failure who received noninvasive ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multilevel logistic regression models were used to obtain hospital-level ICU utilization rates. We risk-adjusted using both patient/hospital characteristics. The primary outcome was in-hospital mortality; secondary outcomes were invasive monitoring (arterial/central catheters), hospital length of stay, and cost. We examined 5,081 hospitalizations from 424 hospitals with ICU utilization ranging from 0.05 to 0.98. The overall median in-hospital mortality was 2.62% (interquartile range, 1.72-3.88%). ICU utilization was not significantly associated with in-hospital mortality (β = 0.01; p = 0.05) or length of stay (β = 0.18; p = 0.41), which was confirmed by Spearman correlation (ρ = 0.06; p = 0.20 and ρ = 0.02; p = 0.64, respectively). However, lower ICU utilization was associated with lower rates of invasive monitor placement by linear regression (β = 0.05; p < 0.001) and Spearman correlation (ρ = 0.28; p < 0.001). Lower ICU utilization was also associated with significantly lower cost by linear regression (β = 14.91; p = 0.02) but not by Spearman correlation (ρ = 0.09; p = 0.07).

CONCLUSIONS

There is wide variability in the rate of ICU utilization for noninvasive ventilation across hospitals. Chronic obstructive pulmonary disease patients receiving noninvasive ventilation had similar in-hospital mortality across the ICU utilization spectrum but a lower rate of receiving invasive monitors and probably lower cost when treated in lower ICU-utilizing hospitals. Although the results suggest that noninvasive ventilation can be delivered safely outside of the ICU, we advocate for hospital-specific risk assessment if a hospital were considering changing its noninvasive ventilation delivery policy.

Rapid diagnosis and comprehensive bacteria profiling of sepsis based on cell-free DNA

Background

Sepsis remains a major challenge in intensive care units, causing unacceptably high mortality rates due to the lack of rapid diagnostic tools with sufficient sensitivity. Therefore, there is an urgent need to replace time-consuming blood cultures with a new method. Ideally, such a method also provides comprehensive profiling of pathogenic bacteria to facilitate the treatment decision.

Methods

We developed a Random Forest with balanced subsampling to screen for pathogenic bacteria and diagnose sepsis based on cell-free DNA (cfDNA) sequencing data in a small blood sample. In addition, we constructed a bacterial co-occurrence network, based on a set of normal and sepsis samples, to infer unobserved bacteria.

Results

Based solely on cfDNA sequencing information from three independent datasets of sepsis, we distinguish sepsis from healthy samples with a satisfactory performance. This strategy also provides comprehensive bacteria profiling, permitting doctors to choose the best treatment strategy for a sepsis case.

Conclusions

The combination of sepsis identification and bacteria-inferring strategies is a success for noninvasive cfDNA-based diagnosis, which has the potential to greatly enhance efficiency in disease detection and provide a comprehensive understanding of pathogens. For comparison, where a culture-based analysis of pathogens takes up to 5 days and is effective for only a third to a half of patients, cfDNA sequencing can be completed in just 1 day and our method can identify the majority of pathogens in all patients.

The Impact of Transit Times on the Detection of Bacterial Pathogens in Blood Cultures: A College of American Pathologists Q-Probes Study of 36 Institutions

CONTEXT.—

Consolidation of clinical microbiology laboratory services has resulted in extended transit time for blood cultures from service points distant from the laboratory. Sepsis is critical; delays in identification of etiologic agents of diseases could adversely impact patient care.

OBJECTIVE.—

To examine the effect of total preanalytic time and blood culture volume on the instrument time-to-detection for bacterial pathogens in blood cultures. A secondary objective was to obtain relevant blood culture information by questionnaire.

DESIGN.—

Participants in this Q-Probes study recorded date, time, and volume information for the first 50 positive blood cultures collected during the 12-week study period. Additional information regarding blood culture collection practices was obtained through questionnaire.

RESULTS.—

Prolonged overall time-to-detection was secondary to prolonged preanalytic time, particularly prolonged transit time, rather than slower organism growth once bottles were placed on the instrument. Among 1578 blood cultures, the overall time from collection to positive result was significantly less for blood cultures collected on-site than for off-site locations. Most institutions lack sufficient training programs and do not monitor preanalytic time metrics associated with blood cultures. Four hundred fifty-six of the 1580 blood cultures with blood volume adequacy reported (28.9%) were inadequately filled.

CONCLUSIONS.—

Overall process time (specimen collection to positive blood culture detection) is predicted to be higher for blood cultures collected off-site. Transit time is a variable that can be reduced to decrease overall time to detection. Thus, improved training and closer attention to preanalytic metrics associated with blood cultures could decrease hospital stays and mortality rates.

Comparative-effectiveness of ceftaroline and daptomycin as first-line MRSA therapy for patients with sepsis admitted to hospitals in the United States Veterans Health Care System

Objectives: This study compared hospital readmission and mortality for patients with sepsis who received ceftaroline or daptomycin as first-line MRSA therapy.Methods: This retrospective comparative-effectiveness study included adults ≥18 years old hospitalized in the United States Veterans Health Care System with sepsis between 10/1/2010-9/30/2014, who received ceftaroline or daptomycin within 14 days of hospital admission as the first antibiotic effective against methicillin resistant Staphylococcus aureus (MRSA). Patients with pneumonia, and those who received both study drugs, were excluded. Baseline characteristics were compared using Chi-square, Fischer's exact, Student's t, and Wilcoxon Rank Sum tests. Patient outcomes were compared with multivariable logistic regression models.Results: 409 patients were included (ceftaroline = 67, daptomycin = 342). Ceftaroline patients were older, less likely to be Black, more likely to have diabetes with complications, and had higher Charlson comorbidity scores. Median (interquartile range) time from admission to drug initiation was 1 (0-1) day for ceftaroline and 1 (1-3) day for daptomycin (p = 0.01). Unadjusted hospital readmission rates for ceftaroline and daptomycin, respectively, were: 30-day (25%/37%, p = 0.06), 60-day (27%/44%, p = 0.008), and 90-day (28%/46%, p = 0.01). Unadjusted mortality rates were: in-hospital (7%/12%, p = 0.4), 30-day (3%/9%, p = 0.1), 60-day (6%/12%, p = 0.2), and 90-day (7%/15%, p = 0.1). In multivariable models with all divergent baseline characteristics included as covariates, patients treated with ceftaroline were less likely to experience (OR, 95% CI): 30/60/90-day hospital readmission (0.54, 0.29-0.98; 0.42, 0.23-0.76; 0.42, 0.23-0.75) and 30/60/90-day mortality (0.23, 0.04-0.82; 0.34, 0.10-0.93; 0.34, 0.11-0.86).Conclusion: In patients with sepsis, ceftaroline was associated with fewer hospital readmissions and lower mortality as compared to daptomycin. Prospective investigations in larger, more generalized cohorts are needed to examine outcomes with specific MRSA therapies.

Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Diabetic Ketoacidosis

BACKGROUND

Diabetic ketoacidosis entails a huge health burden among patients with diabetes. Atrial fibrillation (AF) is the most common type of heart arrhythmia. This study aimed to evaluate the impact of AF on clinical outcomes in patients with diabetic ketoacidosis.

METHODS

Using the 2012-2014 National Inpatient Sample database, we identified adult patients hospitalized with diabetic ketoacidosis as the principal discharge diagnosis. The identified admissions were stratified into 2 cohorts based on the AF presence. We used multivariable regression models and propensity score matching models to evaluate in-hospital mortality, length of stay, comorbidities, and in-hospital complications.

RESULTS

The study included 478,890 adult patients who were admitted for diabetic ketoacidosis in the year 2012-2014. A total of 467,780 (97.68%) had no AF and 11,125 (2.32%) had AF. In both multivariable regression models and propensity score matching models, compared with nonatrial fibrillation group, the AF group had higher in-hospital mortality rates (2.36 [1.69-3.32], P < 0.001) and longer length of stay (5.5 versus 3.3 days, P < 0.001). AF was also associated with a significantly higher incidence of complications including septic shock, pulmonary failure, mechanical ventilation, neurological failure, cerebral edema, acute kidney injury, acute hematologic failure, and cardiac arrest.

CONCLUSIONS

Among patients who were hospitalized for diabetic ketoacidosis, comorbid AF led to increasing in-hospital mortality rates and longer length of stay. A potential explanation was that AF increased the risk of in-hospital complications including respiratory failure with a more frequent requirement for mechanical ventilation, cardiac arrest, and metabolic encephalopathy.

Impact of post-sepsis cardiovascular complications on mortality in sepsis survivors: a population-based study

BACKGROUND

It remains unclear whether sepsis-related cardiovascular complications have an adverse impact on survival independent of pre-existing comorbidities. To investigate the survival impact of post-sepsis cardiovascular complications among sepsis survivors, we conducted a population-based study using the National Health Insurance Database of Taiwan.

METHODS

We identified sepsis patients from the National Health Insurance Research Database of Taiwan using ICD-9-CM codes involving infection and organ dysfunction between 2000 and 2011. Post-sepsis incident myocardial infarction (MI) and stroke were ascertained by ICD-9-CM codes and antiplatelet treatment. We constructed a non-sepsis comparison cohort using propensity score matching to ascertain the association between sepsis and cardiovascular complications. Furthermore, we compared the 180-day mortality and 365-day mortality between patients surviving sepsis with or without post-sepsis MI or stroke within 70 days of hospital discharge. We constructed Cox regression models adjusting for pre-existing comorbidities to evaluate the independent survival impact of post-sepsis MI or stroke among sepsis survivors.

RESULTS

We identified 42,316 patients hospitalized for sepsis, from which we matched 42,151 patients 1:1 with 42,151 patients hospitalized without sepsis. Compared to patients hospitalized without sepsis, patients hospitalized with sepsis had an increased risk of MI or stroke (adjusted odds ratio 1.72, 95% CI 1.60-1.85). Among 42,316 patients hospitalized for sepsis, 486 (1.15%) patients developed incident stroke and 108 (0.26%) developed incident MI within 70 days of hospital discharge. Compared to sepsis survivors without cardiovascular complications, sepsis survivors with incident MI or stroke had a higher mortality rate at 180 days (11.68% vs. 4.44%, P = 0.003) and at 365 days (16.75% vs. 7.11%, P = 0.005). Adjusting for age, sex, and comorbidities, post-sepsis MI or stroke was independently associated with increased 180-day (adjusted hazard ratio [HR] 2.16, 95% CI 1.69-2.76) and 365-day (adjusted HR 1.90, 95% CI 1.54-2.32) mortality.

CONCLUSIONS

Compared to sepsis patients without incident MI or stroke, sepsis patients with incident MI or stroke following hospital discharge had an increased risk of mortality for up to 365 days of follow-up. This increased risk cannot be explained by pre-sepsis comorbidities.

Does Use of Electronic Alerts for Systemic Inflammatory Response Syndrome (SIRS) to Identify Patients With Sepsis Improve Mortality?

PURPOSE

The objective of this study was to assess whether earlier antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) and evidence of organ dysfunction identified through electronic alerts improves patient mortality.

METHODS

This is a retrospective observational cohort study of adult patients admitted across 5 acute-care hospitals. Mortality, Premier CareScience^TM Analytics Expected Mortality Score, and clinical and demographic variables were obtained through the electronic medical record and Premier (Premier Healthcare Solutions, Inc, Charlotte NC) reports. Patients with 2 SIRS criteria and organ dysfunction were identified through an automated alert. Univariate and multivariate logistic regression was performed.

RESULTS

Of those with SIRS and organ dysfunction, 8146 patients were identified through the electronic Best Practice Alert (BPA). Overall 30-day mortality rate was 8.7%. There was no significant association between time to antibiotic administration from BPA alert and mortality (P = 0.21) after adjusting for factors that could influence mortality, including age, heart rate, blood pressure, plasma lactate levels, creatinine, bilirubin levels, and the CareScience^TM Predicted Mortality Risk Score. Female gender (odds ratio [OR] 1.31, 95% confidence interval [CI] 1.06-1.63) and facility were also independently associated with mortality.

CONCLUSION

The use of alerts in the electronic medical record may misclassify patients with SIRS as having sepsis. Time to antibiotic administration in patients meeting SIRS criteria and evidence of end-organ dysfunction through BPA alerts did not affect 30-day mortality rates across a health system. Patient severity of illness, gender, and facility also independently predicted mortality. There were higher rates of antibiotic use and Clostridioides difficile infection in patients with BPA alerts.

Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department

PROBLEM

Sepsis, a life-threatening condition, can rapidly progress to death. The Hospital Inpatient Quality Reporting program has implemented bundled care metrics for sepsis care, but timely completion of these interventions is challenging. Best-practice interventions could improve patient outcomes and reimbursement. The purpose of this project was to improve the timeliness of sepsis recognition and implementation of bundled care interventions in the emergency department.

METHODS

This evidence-based practice improvement project implemented a Detect, Act, Reassess, Titrate (DART)-based nursing protocol embedded within a checklist communication tool in the emergency department of a tertiary level-2 trauma center. Data comparisons between preintervention and post-DART protocol/checklist implementation included compliance with the individual Inpatient Quality Reporting 3-hour bundled elements, number of hospital days, and time to screen. Staff also completed a survey designed to assess their satisfaction with the DART algorithm/checklist. The Pearson χ² test was used to assess bundled-care intervention variables. Wilcoxon rank sum tests were used to explore hospitalization outcomes. Staff satisfaction survey results were summarized.

RESULTS

Improvement was statistically significant for lactate levels, blood cultures, and early antibiotic administration in the intervention period compared with baseline. Time to screen, ED length of stay, and number of hospital days improved between baseline and the intervention period, with an average number of hospital days decreasing by 2.5 days. Compliance with all Inpatient Quality Reporting metrics increased from 30% to 80%.

DISCUSSION

When the nurse-driven protocol and communication tool were implemented, compliance with time-sensitive sepsis bundled interventions improved significantly. The outcomes suggest nurse-driven protocols can improve sepsis outcomes.

Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis

Background

Septic shock is the most severe form of sepsis, in which profound underlying abnormalities in circulatory and cellular/metabolic parameters lead to substantially increased mortality. A clear understanding and up-to-date assessment of the burden and epidemiology of septic shock are needed to help guide resource allocation and thus ultimately improve patient care. The aim of this systematic review and meta-analysis was therefore to provide a recent evaluation of the frequency of septic shock in intensive care units (ICUs) and associated ICU and hospital mortality.

Methods

We searched MEDLINE, Embase, and the Cochrane Library from 1 January 2005 to 20 February 2018 for observational studies that reported on the frequency and mortality of septic shock. Four reviewers independently selected studies and extracted data. Disagreements were resolved via consensus. Random effects meta-analyses were performed to estimate pooled frequency of septic shock diagnosed at admission and during the ICU stay and to estimate septic shock mortality in the ICU, hospital, and at 28 or 30 days.

Results

The literature search identified 6291 records of which 71 articles met the inclusion criteria. The frequency of septic shock was estimated at 10.4% (95% CI 5.9 to 16.1%) in studies reporting values for patients diagnosed at ICU admission and at 8.3% (95% CI 6.1 to 10.7%) in studies reporting values for patients diagnosed at any time during the ICU stay. ICU mortality was 37.3% (95% CI 31.5 to 43.5%), hospital mortality 39.0% (95% CI 34.4 to 43.9%), and 28-/30-day mortality 36.7% (95% CI 32.8 to 40.8%). Significant between-study heterogeneity was observed.

Conclusions

Our literature review reaffirms the continued common occurrence of septic shock and estimates a high mortality of around 38%. The high level of heterogeneity observed in this review may be driven by variability in defining and applying the diagnostic criteria, as well as differences in treatment and care across settings and countries.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2478-6) contains supplementary material, which is available to authorized users.

Effectiveness of Treatments and Diagnostic Tools and Declining Mortality in Patients With Severe Sepsis: A 12-Year Population-Based Cohort Study

Sepsis is a major cause of morbidity and mortality worldwide. With the advance of medical care, the mortality of sepsis has decreased in the past decades. Many treatments and diagnostic tools still lack supporting evidence. We conducted a retrospective population-based cohort study with propensity score matched subcohorts based on a prospectively collected national longitudinal health insurance database in Taiwan. Severe sepsis-associated hospital admissions from 2000 to 2011 based on International Classification of Diseases, Ninth Revision, Clinical Modification codes of infections and acute organ dysfunction were identified. To compare the effectiveness of treatment and diagnostic tool, propensity scores were generated to match the comparable control groups. During the 12-year period, 33 375 patients and 50 465 hospitalizations of severe sepsis were identified. The age-standardized 28-day in-hospital mortality decreased significantly from 21% in 2008 to 15% in 2011 with increasingly implemented treatment and diagnostic tool. After propensity score matching, procalcitonin (odds ratio [OR]: 0.70, 95% confidence interval [95% CI]: 0.61-0.81) and lactate testing (OR: 0.90, 95% CI: 0.84-0.97, respectively), transfusion of packed red blood cell (OR: 0.60, 95% CI: 0.52-0.69), albumin (OR: 0.72, 95% CI: 0.55-0.93), balanced crystalloid (OR: 0.29, 95% CI: 0.20-0.41), and use of dopamine (OR: 0.44, 95% CI: 0.39-0.49) were found to be significantly associated with lower mortality rate. However, inconsistent findings need to be further validated.

Sepsis: Early Recognition and Optimized Treatment

Sepsis is a life-threatening condition caused by infection and represents a substantial global health burden. Recent epidemiological studies showed that sepsis mortality rates have decreased, but that the incidence has continued to increase. Although a mortality benefit from early-goal directed therapy (EGDT) in patients with severe sepsis or septic shock was reported in 2001, three subsequent multicenter randomized studies showed no benefits of EGDT versus usual care. Nonetheless, the early administration of antibiotics and intravenous fluids is considered crucial for the treatment of sepsis. In 2016, new sepsis definitions (Sepsis-3) were issued, in which organ failure was emphasized and use of the terms "systemic inflammatory response syndrome" and "severe sepsis" was discouraged. However, early detection of sepsis with timely, appropriate interventions increases the likelihood of survival for patients with sepsis. Also, performance improvement programs have been associated with a significant increase in compliance with the sepsis bundles and a reduction in mortality. To improve sepsis management and reduce its burden, in 2017, the World Health Assembly and World Health Organization adopted a resolution that urged governments and healthcare workers to implement appropriate measures to address sepsis. Sepsis should be considered a medical emergency, and increasing the level of awareness of sepsis is essential.

Heart rate variability as predictor of mortality in sepsis: A systematic review

BACKGROUND

Autonomic dysregulation is one of the recognized pathophysiological mechanisms in sepsis, generating the hypothesis that heart rate variability (HRV) can be used to predict mortality in sepsis.

METHODS

This was a systematic review of studies evaluating HRV as a predictor of death in patients with sepsis. The search was performed by independent researchers in PubMed, LILACS and Cochrane, including papers in English, Portuguese or Spanish, indexed until August 20th, 2017 with at least 10 patients. Study quality was assessed by Newcastle-Ottawa Scale. To analyze the results, we divided the articles between those who measured HRV for short-term recordings (≤ 1 hour), and those who did long-term recordings (≥ 24 hours).

RESULTS

Nine studies were included with a total of 536 patients. All of them were observational studies. Studies quality varied from 4 to 7 stars in Newcastle-Ottawa Scale. The mortality rate in the studies ranged from 8 to 61%. Seven studies performed HRV analysis in short-term recordings. With the exception of one study that did not explain which group had the lowest results, all other studies showed reduction of several HRV parameters in the non-survivors in relation to the surviving septic patients. SDNN (Standard deviation of the Normal to Normal interval), TP (Total Power), VLF (Very Low Frequency Power), LF (Low Frequency Power), LF/HF (Low Frequency Power / High Frequency Power), nLF (Normalized Low Frequency Power), α1/α2 (short-term and long-term fractal scaling coefficients from DFA) and r-MSSD (Square root of the squared mean of the difference of successive NN-intervals) of the non-survivor group were reduced in relation to the survivors in at least one study. Two studies found that SDNN is associated with mortality in sepsis, even after adjusting for possible confounding factors. Three studies performed HRV analysis using long-term recordings. Only one of these studies found difference between surviving and non-surviving groups, and even so, in only one HRV parameter: LogHF.

CONCLUSIONS

Several HRV parameters are reduced in nonsurviving septic patients in short-term recording. Two studies have found that SDNN is associated with mortality in sepsis, even after adjusting for possible confounding factors.

[Assessment of an educational intervention regarding blood cultures as process indicators in an emergency department in Argentina]

OBJECTIVE

The aim of this study was to describe 2 process indicators related to taking blood cultures (BC) in an Adult Emergency Department of a tertiary university hospital in Buenos Aires,and to describe the changes after a series of educational activities for health professionals was implemented during May 2016 as regards the appropriate indication of BC and the proper collection technique.

MATERIALS AND METHODS

A retrospective cohort study was designed to assess its effectiveness, which consecutively included all patients admitted during 2015-2016. The BC request rate was used as a process indicator, and the percentage of contaminated BCs and the true positives rate were used as quality indicators. Both were measured monthly and prospectively during the period of study.

RESULTS

The annual adjusted rate of BC requests was 4.9% (95% CI 4.8-5) in 2015 and 2.9% (95% CI 2.8-2.9) in 2016. The rate of false positive (contaminated) BCs was 4.5% in 2015 and 4.3% after the educational intervention. The true positive BCs were 8.3% in 2015 and 12% post-intervention.

CONCLUSIONS

These findings prove how important and effective the educational interventions are.

[Reality and prospects of sepsis epidemiology research]

Current foreign and Russian literature for sepsis epidemiology is reviewed. There is advanced incidence of sepsis in developing countries among young people as a rule. Absent high-quality epidemiological studies lead to overdiagnosis of sepsis and increased morbidity. National and territorial screening and diagnostic programs for sepsis became possible with introduction of new recommendations 'Sepsis-3'. Thus, there is a possibility to systematize regular epidemiological studies devoted to sepsis.

Emerging Adjunctive Approach for the Treatment of Sepsis: Vitamin C and Thiamine

Evidence is emerging that parenteral administration of high-dose vitamin C and thiamine may be a beneficial adjuvant therapy of severe sepsis and septic shock. Despite modern practices in critical care medicine, sepsis and severe sepsis remain a leading cause of morbidity and mortality in the critical care unit.

Next-generation sequencing diagnostics of bacteremia in sepsis (Next GeneSiS-Trial): Study protocol of a prospective, observational, noninterventional, multicenter, clinical trial

BACKGROUND

Sepsis remains a major challenge, even in modern intensive care medicine. The identification of the causative pathogen is crucial for an early optimization of the antimicrobial treatment regime. In this context, culture-based diagnostic procedures (e.g., blood cultures) represent the standard of care, although they are associated with relevant limitations. Accordingly, culture-independent molecular diagnostic procedures might be of help for the identification of the causative pathogen in infected patients. The concept of an unbiased sequence analysis of circulating cell-free DNA (cfDNA) from plasma samples of septic patients by next-generation sequencing (NGS) has recently been identified to be a promising diagnostic platform for critically ill patients suffering from bloodstream infections. Although this new approach might be more sensitive and specific than culture-based state-of-the-art technologies, additional clinical trials are needed to exactly define the performance as well as clinical value of a NGS-based approach.

METHODS

Next GeneSiS is a prospective, observational, noninterventional, multicenter study to assess the diagnostic performance of a NGS-based approach for the detection of relevant infecting organisms in patients with suspected or proven sepsis [according to recent sepsis definitions (sepsis-3)] by the use of the quantitative sepsis indicating quantifier (SIQ) score in comparison to standard (culture-based) microbiological diagnostics. The clinical value of this NGS-based approach will be estimated by a panel of independent clinical specialists, retrospectively identifying potential changes in patients' management based on NGS results. Further subgroup analyses will focus on the clinical value especially for patients suffering from a failure of empiric treatment within the first 3 days after onset [as assessed by death of the patient or lack of improvement of the patient's clinical condition (in terms of an inadequate decrease of SOFA-score) or persistent high procalcitonin levels].

DISCUSSION

This prospective, observational, noninterventional, multicenter study for the first time investigates the performance as well as the clinical value of a NGS-based approach for the detection of bacteremia in patients with sepsis and may therefore be a pivotal step toward the clinical use of NGS in this indication.

TRIAL REGISTRATION

DRKS-ID: DRKS00011911 (registered October 9, 2017) https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011911; ClinicalTrials.gov Identifier: NCT03356249 (registered November 29, 2017) https://clinicaltrials.gov/ct2/show/NCT03356249.

Epidemiology and Outcomes

Sepsis is a global public health concern. Internationally it contributes to more than 5 million deaths annually. Although rates are variable between countries, over the past 40 years reported incidence has continued to increase. Aside from potential differences in patient populations, the variation in reported rates also reflects differences in identification strategies, access to health care, and awareness of the diagnosis. Factors such as age, sex, socioeconomic status, comorbid disease, and type and site of infection impact the development of and outcomes from sepsis. Although advances have been made in treatment, its impact remains substantial.

Sepsis and Septic Shock Strategies

Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.

The Lactate/Albumin Ratio: A Valuable Tool for Risk Stratification in Septic Patients Admitted to ICU

The lactate/albumin ratio has been reported to be associated with mortality in pediatric patients with sepsis. We aimed to evaluate the lactate/albumin ratio for its prognostic relevance in a larger collective of critically ill (adult) patients admitted to an intensive care unit (ICU). A total of 348 medical patients admitted to a German ICU for sepsis between 2004 and 2009 were included. Follow-up of patients was performed retrospectively between May 2013 and November 2013. The association of the lactate/albumin ratio (cut-off 0.15) and both in-hospital and post-discharge mortality was investigated. An optimal cut-off was calculated by means of Youden’s index. The lactate/albumin ratio was elevated in non-survivors (p < 0.001). Patients with an increased lactate/albumin ratio were of similar age, but clinically in a poorer condition and had more pronounced laboratory signs of multi-organ failure. An increased lactate/albumin ratio was associated with adverse in-hospital mortality. An optimal cut-off of 0.15 was calculated and was associated with adverse long-term outcome even after correction for APACHE2 and SAPS2. We matched 99 patients with a lactate/albumin ratio >0.15 to case-controls with a lactate/albumin ratio <0.15 corrected for APACHE2 scores: The group with a lactate/albumin ratio >0.15 evidenced adverse in-hospital outcome in a paired analysis with a difference of 27% (95%CI 10–43%; p < 0.01). Regarding long-term mortality, again, patients in the group with a lactate/albumin ratio >0.15 showed adverse outcomes (p < 0.001). An increased lactate/albumin ratio was significantly associated with an adverse outcome in critically ill patients admitted to an ICU, even after correction for confounders. The lactate/albumin ratio might constitute an independent, readily available, and important parameter for risk stratification in the critically ill.

Heart rate variability as predictor of mortality in sepsis: A prospective cohort study

Background

Sepsis is a serious medical condition with increasing prevalence and high mortality. The role of the autonomic nervous system in pathophysiology of sepsis has been increasingly researched. The objective of this study is to evaluate the Heart rate variability (HRV) as a predictor of mortality in septic patients.

Methods

This was a prospective cohort of patients diagnosed with sepsis. Patient recruitment was carried out at ICU in tertiary university hospital between March 2012 and February 2014. Clinical data and laboratory exams were collected at admission. Each patient underwent a 20-minute Holter and a 24-hour Holter on the first day of enrollment. The primary outcome was the 28-day all-cause mortality.

Results

A total of 63 patients were included. Patients were categorized into nonsurvivor group (n = 16) or survivor group (n = 47) depending on this endpoint. Survivors were younger (48.6 years vs. 63.0 years), had better renal function and lower values in severity scores (APACHE II and SOFA) compared to nonsurvivors. In the 20-minute Holter, SDNN, Total Power, VLF Power, LF Power and LF/HF of nonsurvivors were significantly lower than those of survivors (p = <0.001, p = 0.003, p = 0.002, p = 0.006, p = 0.009 respectively). ROC curve of SDNN was built, showing area under the curve of 0.772 (0.638–0.906) for mortality. The value of 17ms was chosen as best SDNN cutoff to discriminate survivors and nonsurvivors. In the Cox proportional regression, adjusted for SOFA score and for APACHE II, a SDNN ≤ 17ms was associated with a greater risk of death, with hazard ratios of 6.3 (1.4–28.0; p = 0.015) and 5.5 (1,2–24,8; p = 0.027), respectively. The addition of the dichotomized SDNN to the SOFA model reduced AIC and increased the concordance statistic and the R², indicating that predictive power of the SDNN + SOFA model is better than predictive power of SOFA only.

Conclusions

Several HRV parameters are reduced in nonsurviving septic patients. SDNN ≤17 is a risk factor for death in septic patients, even after adjusting for severity scores.

Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization

OBJECTIVES

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low.

DESIGN

Retrospective chart review.

SETTING

Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system.

PATIENTS

All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate.

CONCLUSIONS

In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.

DATA SOURCES

PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.

STUDY SELECTION

Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.

DATA EXTRACTION

Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.

DATA SYNTHESIS

Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.

CONCLUSIONS

Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

Bone Failure in Critical Illness

OBJECTIVES

The origin of systemic inflammatory response syndrome and multiple organ dysfunction syndrome is poorly understood but remains a fundamental concern in the ICU. This paper provides a critical appraisal on whether bone failure may represent an unrecognized component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome.

DATA SOURCES, DATA SELECTION, AND DATA EXTRACTION

Search of the PubMed database and manual review of selected articles investigating bone pathophysiology in critical illness.

DATA SYNTHESIS

Bone hyperresorption is highly prevalent among critically ill patients. Bone breakdown releases numerous systemically active cytokines and bone-sequestered toxins, with the capacity to fuel inflammatory hypercytokinaemia and metabolic toxaemia. Anti-resorptive medication inhibits bone break down and preadmission anti-resorptive use is associated with superior survival among critically ill patients.

CONCLUSIONS

We propose that hyperresorptive bone failure is an unrecognised component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome that is causal to critical illness progression. If this hypothesis is valid, bone preservative strategies could reduce the risk of osteoporosis/fractures among ICU survivors, as well as decreasing critical illness mortality.

Sepsis and septic shock: Pathogenesis and treatment perspectives

The majority of bacteremias do not develop to sepsis: bacteria are cleared from the bloodstream. Oxygen released from erythrocytes and humoral immunity kill bacteria in the bloodstream. Sepsis develops if bacteria are resistant to oxidation and proliferate in erythrocytes. Bacteria provoke oxygen release from erythrocytes to arterial blood. Abundant release of oxygen to the plasma triggers a cascade of events that cause: 1. oxygen delivery failure to cells; 2. oxidation of plasma components that impairs humoral regulation and inactivates immune complexes; 3. disseminated intravascular coagulation and multiple organs' failure. Bacterial reservoir inside erythrocytes provides the long-term survival of bacteria and is the cause of ineffectiveness of antibiotics and host immune reactions. Treatment perspectives that include different aspects of sepsis development are discussed.

Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.

DATA SOURCES

PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.

STUDY SELECTION

Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.

DATA EXTRACTION

Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.

DATA SYNTHESIS

Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.

CONCLUSIONS

Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

Sepsis and Other Infectious Disease Emergencies in the Elderly

Waning immunity and declining anatomic and physiologic defenses render the elder vulnerable to a wide range of infectious diseases. Clinical presentations are often atypical and muted, favoring global changes in mental status and function over febrile responses or localizing symptoms. This review encompasses early recognition, evaluation, and appropriate management of these common infections specifically in the context of elders presenting to the emergency department. With enhanced understanding and appreciation of the unique aspects of infections in the elderly, emergency physicians can play an integral part in reducing the morbidity and mortality associated with these often debilitating and life-threatening diseases.

Next-generation sequencing diagnostics of bacteremia in septic patients

Background

Bloodstream infections remain one of the major challenges in intensive care units, leading to sepsis or even septic shock in many cases. Due to the lack of timely diagnostic approaches with sufficient sensitivity, mortality rates of sepsis are still unacceptably high. However a prompt diagnosis of the causative microorganism is critical to significantly improve outcome of bloodstream infections. Although various targeted molecular tests for blood samples are available, time-consuming blood culture-based approaches still represent the standard of care for the identification of bacteria.

Methods

Here we describe the establishment of a complete diagnostic workflow for the identification of infectious microorganisms from seven septic patients based on unbiased sequence analyses of free circulating DNA from plasma by next-generation sequencing.

Results

We found significant levels of DNA fragments derived from pathogenic bacteria in samples from septic patients. Quantitative evaluation of normalized read counts and introduction of a sepsis indicating quantifier (SIQ) score allowed for an unambiguous identification of Gram-positive as well as Gram-negative bacteria that exactly matched with blood cultures from corresponding patient samples. In addition, we also identified species from samples where blood cultures were negative. Reads of non-human origin also comprised fragments derived from antimicrobial resistance genes, showing that, in principle, prediction of specific types of resistance might be possible.

Conclusions

The complete workflow from sample preparation to species identification report could be accomplished in roughly 30 h, thus making this approach a promising diagnostic platform for critically ill patients suffering from bloodstream infections.

Electronic supplementary material

The online version of this article (doi:10.1186/s13073-016-0326-8) contains supplementary material, which is available to authorized users.

Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE

Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.

Mortality trends in U.S. adults with septic shock, 2005-2011: a serial cross-sectional analysis of nationally-representative data

Background

We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use.

Methods

We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality.

Results

From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; P_trend = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96–1.00; P < 0.001). In stratified analysis, the mortality trend was not significant in the subgroup with vasopressor use (from 42 % in 2005 to 40 % in 2011; P_trend =0.57); similarly, the adjusted mortality did not change significantly (OR, 1.01; 95 % CI, 0.97–1.05; P =0.62). By contrast, there was a downward trend in mortality in the subgroup without vasopressor use (from 47 % in 2005 to 43 % in 2011; P_trend =0.002); likewise, the adjusted mortality decreased significantly (OR, 0.97; 95 % CI, 0.95–0.99; P =0.002)

Conclusions

From 2005 to 2011, we found a modest decrease in in-hospital mortality among patients identified with septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1620-1) contains supplementary material, which is available to authorized users.

Mortality Associated with Severe Sepsis Among Age-Similar Women with and without Pregnancy-Associated Hospitalization in Texas: A Population-Based Study

Background

The reported mortality among women with pregnancy-associated severe sepsis (PASS) has been considerably lower than among severely septic patients in the general population, with the difference being attributed to the younger age and lack of chronic illness among the women with PASS. However, no comparative studies were reported to date between patients with PASS and age-similar women with severe sepsis not associated with pregnancy (NPSS).

Material/Methods

We used the Texas Inpatient Public Use Data File to compare the crude and adjusted hospital mortality between women with severe sepsis, aged 20–34 years, with and without pregnancy-associated hospitalizations during 2001–2010, following exclusion of those with reported chronic comorbidities, as well as alcohol and drug abuse.

Results

Crude hospital mortality among PASS vs. NPSS hospitalizations was lower for the whole cohort (6.7% vs. 14.1% [p<0.0001]) and those with ≥3 organ failures (17.6% vs. 33.2% [p=0.0100]). Adjusted PASS mortality (odds ratio [95% CI]) was 0.57 (0.38–0.86) [p=0.0070].

Conclusions

Hospital mortality was unexpectedly markedly and consistently lower among women with severe sepsis associated with pregnancy, as compared with contemporaneous, age-similar women with severe sepsis not associated with pregnancy, without reported chronic comorbidities. Further studies are warranted to examine the sources of the observed differences and to corroborate our findings.

Determinants of Home Discharge Among Survivors of Necrotizing Fasciitis: A Population-Level Analysis

BACKGROUND

The majority of patients with necrotizing fasciitis (NF) in the United Sates survive their illness, and there is increasing interest in addressing the ability of survivors to return to their community following hospitalization. However, there are no data on the factors affecting home discharge among survivors of NF.

METHODS

We used the Texas Inpatient Public Use Data File to conduct a retrospective population-based examination of hospitalizations with NF aged 15 years or older between 2001 and 2010. Multivariate logistic regression modeling was used to explore predictors of home discharge among hospital survivors.

RESULTS

There were 10,724 NF hospitalizations surviving to discharge during study period, of which 62.5% were discharged home. The following key predictors have adversely affected odds of home discharge (odds ratio and 95% confidence intervals): age ≥ 75 years (0.349 (0.292 - 0.417)), Medicare insurance (0.582 (0.510 - 0.663)), congestive heart failure (0.836 (0.719 - 0.972)), chronic liver disease (0.684 (0.522 - 0.895)), respiratory failure (0.464 (0.386 - 0.558)), neurological failure (0.573 (0.418 - 0.787)), and need for mechanical ventilation (0.339 (0.199 - 0.578)). Increased odds of home discharge were found among males (1.116 (1.058 - 1.285)), Hispanics (1.193 (1.056 - 1.349)), those lacking health insurance (2.161 (1.183 - 2.521)) or managed at a teaching hospital (1.264 (1.127 - 1.418)).

CONCLUSIONS

In this first population-level examination of the determinants of home discharge among survivors of NF, older age, Medicare insurance, selected comorbidities, and development of organ failure decreased patients' odds of home discharge. Unexpectedly, male gender, Hispanic ethnicity, lack of health insurance, and being managed at a teaching hospital were associated with favorable impact on patients' discharge disposition. Further studies are warranted in other populations and healthcare environments to corroborate the present findings and to refine our understanding of the factors affecting short-term outcomes among NF survivors.