Sepsis-3 definitions predict ICU mortality in a low-middle-income country

Eleven years impact of a stepwise educational program on healthcare associated infections and antibiotics consumption in an intensive care unit of a tertiary hospital in Brazil

BACKGROUND

Hospital acquired infections (HAI) and liberal use of broad-spectrum antibiotics are common in intensive care unit(ICU)s of low-middle income countries. We investigated the long-term association of a stepwise multifaceted educational program with the incidence of HAIs and antibiotics use in a Brazilian ICU. We also evaluated the program's cost impact.

METHODS

We retrieved data from a prospective daily collected database of a twelve bedrooms ICU, all admitted patients within a period of eleven years were enrolled.

FINDINGS

From 03/15/2007 to 09/11/2019, we admitted 3059 patients where 2406 (79%) survived the ICU stay. Median age was 51 years-old, and median SAPS3 was 53. The initial density of catheter related blood infection (4.3 events / 1000 patients-day), urinary tract infection (9.2 event / 1000 patients-day) and ventilator associated pneumonia (54.9 events / 1000 patients-day) felt during the observed period to (0.35 events / 1000 patients-day), (0 events / 1000 patients-day), and (1.5 events / 1000 patients-day) respectively. The days of antibiotic therapy also decreased from 797.9 days of therapy / 1000 patients day to 292.3 days of therapy / 1000 patients day. The total cost per patient also decreased. The adjusted mortality rate was steady during the studied period from 23.2% to 22.9%.

INTERPRETATION

A stepwise multifaceted educational program is an effective way to reduce hospital-associated infections, improve the rational use of antibiotics, and reduce costs. This impact occurred in a long term, and is probably consistent.

Diagnostic and Prognostic Roles of Procalcitonin and Other Tools in Community-Acquired Pneumonia: A Narrative Review

Community-acquired pneumonia (CAP) is among the most common causes of death and one of the leading healthcare concerns worldwide. It can evolve into sepsis and septic shock, which have a high mortality rate, especially in critical patients and comorbidities. The definitions of sepsis were revised in the last decade as "life-threatening organ dysfunction caused by a dysregulated host response to infection". Procalcitonin (PCT), C-reactive protein (CRP), and complete blood count, including white blood cells, are among the most commonly analyzed sepsis-specific biomarkers also used in pneumonia in a broad range of studies. It appears to be a reliable diagnostic tool to expedite care of these patients with severe infections in the acute setting. PCT was found to be superior to most other acute phase reactants and indicators, including CRP as a predictor of pneumonia, bacteremia, sepsis, and poor outcome, although conflicting results exist. In addition, PCT use is beneficial to judge timing for the cessation of antibiotic treatment in most severe infectious states. The clinicians should be aware of strengths and weaknesses of known and potential biomarkers in expedient recognition and management of severe infections. This manuscript is intended to present an overview of the definitions, complications, and outcomes of CAP and sepsis in adults, with special regard to PCT and other important markers.

Energetic dysfunction in sepsis: a narrative review

Background

Growing evidence associates organ dysfunction(s) with impaired metabolism in sepsis. Recent research has increased our understanding of the role of substrate utilization and mitochondrial dysfunction in the pathophysiology of sepsis-related organ dysfunction. The purpose of this review is to present this evidence as a coherent whole and to highlight future research directions.

Main text

Sepsis is characterized by systemic and organ-specific changes in metabolism. Alterations of oxygen consumption, increased levels of circulating substrates, impaired glucose and lipid oxidation, and mitochondrial dysfunction are all associated with organ dysfunction and poor outcomes in both animal models and patients. The pathophysiological relevance of bioenergetics and metabolism in the specific examples of sepsis-related immunodeficiency, cerebral dysfunction, cardiomyopathy, acute kidney injury and diaphragmatic failure is also described.

Conclusions

Recent understandings in substrate utilization and mitochondrial dysfunction may pave the way for new diagnostic and therapeutic approaches. These findings could help physicians to identify distinct subgroups of sepsis and to develop personalized treatment strategies. Implications for their use as bioenergetic targets to identify metabolism- and mitochondria-targeted treatments need to be evaluated in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00893-7.

The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis

Objective

To identify priorities for administrative, epidemiologic and diagnostic research in sepsis.

Design

As a follow-up to a previous consensus statement about sepsis research, members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis.

Methods

Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified through a consensus process.

Results

The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?; (2) What is the epidemiology of sepsis susceptibility and response to treatment?; (3) What information identifies organ dysfunction?; (4) How can we screen for sepsis in various settings?; (5) How do we identify septic shock?; and (6) What in-hospital clinical information is associated with important outcomes in patients with sepsis?

Conclusions

There is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritize initiatives to improve an understanding of individual patient and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care.

Superiority of Sepsis-3 to Sepsis-2 in the Early Detection of Severe Early Postoperative Sepsis After Living Donor Liver Transplantation

BACKGROUND

To date, the utility of Sepsis-3 compared to Sepsis-2 in living donor liver transplantation (LDLT) recipients has not been evaluated. We assessed the utility of Sepsis-3 compared to Sepsis-2 and verified the following hypotheses: 1. Sepsis-3-based sepsis (S3BS) corresponds to Sepsis-2-based severe sepsis (S2BSS), and 2. S3BS enables earlier diagnosis of early postoperative sepsis (within 21 postoperative days; EPoS) compared to S2BSS.

METHODS

We evaluated 66 LDLT recipients in our institution. Patients with EPoS, who were diagnosed with S3BS and S2BSS, were extracted, and the postoperative day of diagnosing S3BS and S2BSS was identified.

RESULTS

EPoS was diagnosed in 14 patients with S3BS (21.2%) and in 15 with S2BSS (22.7%). All but 1 patient with S2BSS corresponded to those with S3BS, with 98.4% overlap. Among the overlapping 14 patients, the comparison between the postoperative days when S3BS and S2BSS occurred demonstrated that S3BS was diagnosed earlier in 7 patients (50%) and on the same day in 4 (28.6%), and S2BSS was diagnosed earlier in 3 (21.4%). Especially in cases with a change in the sequential organ failure assessment (SOFA) immediately after S3BS onset compared to before (ΔSOFA) of ≥ 4 points (n = 6), S3BS was diagnosed earlier in 5 cases (83.3%); in cases with ΔSOFA of 2 to 3 points (n = 8), S3BS was diagnosed earlier only in 2 cases (25.0%). Thus, early diagnosis of S3BS was significantly more common in cases with ≥ 4 points of ΔSOFA (P = .02).

CONCLUSIONS

S3BS nearly corresponds to S2BSS and can enable earlier detection of EPoS, especially with a high ΔSOFA.

Noninvasive ventilation in critically ill very old patients with pneumonia: A multicenter retrospective cohort study

Background

Very old patients (≥ 80 years-old, VOP) are increasingly admitted to intensive care units (ICUs). Community-acquired pneumonia (CAP) is a common reason for admission and the best strategy of support for respiratory failure in this scenario is not fully known. We evaluated whether noninvasive ventilation (NIV) would be beneficial compared to invasive mechanical ventilation (IMV) regarding hospital mortality.

Methods

Multicenter cohort study of VOPs admitted with CAP in need of IMV or NIV to 11 Brazilian ICUs from 2009 through 2012. We used logistic regression models to evaluate the association between the initial ventilatory strategy (NIV vs. IMV) and hospital mortality adjusting for confounding factors. We evaluated effect modification with interaction terms in pre-specified sub-groups.

Results

Of 369 VOPs admitted for CAP with respiratory failure, 232 (63%) received NIV and 137 (37%) received IMV as initial ventilatory strategy. IMV patients were sicker at baseline (median SOFA 8 vs. 4). Hospital mortality was 114/232 (49%) for NIV and 90/137 (66%) for IMV. For the comparison NIV vs. IMV (reference), the crude odds ratio (OR) was 0.50 (95% CI, 0.33–0.78, p = 0.002). This association was largely confounded by antecedent characteristics and non-respiratory SOFA (_adjOR = 0.70, 95% CI, 0.41–1.20, p = 0.196). The fully adjusted model, additionally including P_ao₂/F_io₂ ratio, pH and P_aco₂, yielded an _adjOR of 0.81 (95% CI, 0.46–1.41, p = 0.452). There was no strong evidence of effect modification among relevant subgroups, such as P_ao₂/F_io₂ ratio ≤ 150 (p = 0.30), acute respiratory acidosis (p = 0.42) and non-respiratory SOFA ≥ 4 (p = 0.53).

Conclusions

NIV was not associated with lower hospital mortality when compared to IMV in critically ill VOP admitted with CAP, but there was no strong signal of harm from its use. The main confounders of this association were both the severity of respiratory dysfunction and of extra-respiratory organ failures.

qSOFA Score Is Useful to Assess Disease Severity in Patients With Heart Failure in the Setting of a Heart Failure Unit (HFU)

Aims: There is no gold standard to predict outcome in acute decompensated heart failure (ADHF). Several scores for mortality prediction of patients with ADHF have been developed and mostly consist of complex regression models. None of these models has been widely adopted by clinicians. The quick SOFA score (qSOFA) is a simple score including three parameters (systolic blood pressure ≤ 100 mmHg, respiratory rate ≥22 breathes/min, and GCS <15) and is validated for discrimination of mortality risk in septic patients. Here, we adapted qSOFA score to patients admitted to a Heart Failure Unit (HFU) and assessed the prognostic accuracy.

Methods and Results: qSOFA, SOFA score, and SIRS criteria were assessed at admission. Clinical, laboratory, and echocardiographic parameters were recorded. A follow-up was performed 30 days after discharge. Primary outcome was all-cause mortality or readmission to hospital due do worsening of heart failure symptoms. Of 240 patients (73% male, 16–93 years), 25 patients (10%) had a qSOFA ≥2 points and 126 patients (53%) fulfilled none of qSOFA criteria. Within 30 days, the primary endpoint occurred in 46 patients (19%). Seventeen patients (7%) died and 34 patients (14%) were readmitted to hospital due to worsening heart failure. Patients with qSOFA ≥2 reached this endpoint more frequently (48 vs. 19%, p = 0.002), had more often dyspnea NYHA III-IV (OR 2.4, p = 0.005) and a higher risk for multi organ failure during hospital stay (28 vs. 9%, P = 0.005).

Conclusions: qSOFA is useful to identify patients with heart failure at high risk for worse outcome and to operationalize severity of decompensation.

Predictive accuracy of Sepsis-3 definitions for mortality among adult critically ill patients with suspected infection

Background:

Sepsis-3 definitions have been published recently; however, their diagnostic value remains controversial. This study was to assess the accuracy of Sepsis-3 definitions compared to Sepsis-1 definitions by stratifying mortality among adult critically ill patients with suspected infection.

Methods:

A multicenter, prospective cohort study was conducted from November 10, 2017 to October 10, 2018, in five Intensive Care Units (ICUs) at four teaching hospitals. Thirty-day mortality was compared across categories for both Sepsis-3 definitions and Sepsis-1 definitions, which were evaluated by logistic regression analysis followed by measurement of the area under the receiver operating characteristic curve (AUROC) for predicting 30-day mortality rates.

Results:

Of the 749 enrolled patients, 644 (85.9%) were diagnosed with sepsis according to the Sepsis-1 definitions. Among those patients, 362 were diagnosed with septic shock (362/749, 48.3%). However, according to the Sepsis-3 definitions, there were 483 patients with a diagnosis of sepsis (483/749, 64.5%), among whom 299 patients were diagnosed with septic shock (299/749, 39.9%). According to the Sepsis-3 definitions, sepsis (sepsis and septic shock) patients had higher 30-day mortality (41.8%) than sepsis patients according to the Sepsis-1 definitions (31.8%, χ² = 5.552, P = 0.020). The AUROC of systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) scores with regard to 30-day mortality rates were 0.609 (0.566–0.652) and 0.694 (0.654–0.733), respectively. However, the AUROC of SOFA scores (0.828 [0.795–0.862]) were significantly higher than that of SIRS or qSOFA scores (P < 0.001).

Conclusion:

In adult critically ill patients with suspected infection, the Sepsis-3 definitions were relatively accurate in stratifying mortality and were superior to the Sepsis-1 definitions.

Trial Registration:

www.chictr.org.cn (ChiCTR-OOC-17013223).

Validation of prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among cardiac-, thoracic-, and vascular-surgery patients admitted to a cardiothoracic intensive care unit

SEPSIS-3 DEFINITION: Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. The clinical criteria of sepsis include organ dysfunction, which is defined as an increase of two points or more on the sequential organ failure assessment (SOFA). For patients with infection, an increase of 2 SOFA points yields an overall mortality rate of 10%. Patients with suspected infection who are likely to have a prolonged intensive care unit (ICU) stay or to have in-hospital mortality can be promptly identified at the bedside with a quick SOFA (qSOFA) score of 2 or higher.

IMPORTANCE

The sepsis-3 criteria have emphasized the value of a change of two or more points on the SOFA, introduced the qSOFA, and removed the systemic inflammatory response syndrome (SIRS) criteria from the sepsis definition.

OBJECTIVE

To externally validate and assess the discriminatory capacities of an increase in the SOFA score by two or more points, the presence of two or more SIRS criteria, or a qSOFA score of 2 or more points for outcomes in 5109 patients, the vast majority of whom were postcardiac surgery patients who were admitted to a Cardiothoracic Surgical ICU in Singapore.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis of 5109 patients with an infection-related primary admission diagnosis in the cardiothoracic intensive care unit (CTICU) at the National University Hospital (NUH) in Singapore from 2010 to 2016.

EXPOSURES

The SOFA, qSOFA, and SIRS criteria were applied to the data representing the worst condition within 24 hours of ICU admission.

MAIN OUTCOMES AND MEASURES

The primary outcome was in-hospital mortality. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

In 5109 patients, the average mortality of patients with an increase in the SOFA scores of less than 2 points was 3.5% (n = 64), and it was 6% (n = 199) for those with an increase in the SOFA scores of 2 or more points. The mortality of patients with an increase in the qSOFA scores of less than 2 points was 2.6% (n = 7), and it was 5.3% (n = 256) for those with an increase in the qSOFA scores of 2 or more points. The mortality of patients with an increase in the SIRS criteria of less than 2 points was 3.6% (n = 30), and it was 5.4% (n = 233) for those with an increase in the SIRS criteria of 2 or more points. The AUROC of in-hospital mortality of patients with an increase in the SOFA, qSOFA, and SIRS criteria of 2 or more points was 0.96, 0.95, and 0.95, respectively.

CONCLUSIONS AND RELEVANCE

In adults with suspected infection admitted to the CTICU in NUH, the change in in-hospital mortality between patients with an increase in SOFA scores of less than 2 and those with an increase of 2 or more was 2.5 percentage points. In contrast to other studies, the absolute change in mortality was nearly the same compared to the qSOFA and SIRS criteria, and the qSOFA score had the greatest percentage increase of 104%, compared to 71% for the SOFA score and 50% for the SIRS criteria. Besides, from the perspective of discriminatory capacities, an increase in SOFA scores of 2 or more did not demonstrate significantly greater prognostic accuracy for in-hospital mortality than equivalent increases in qSOFA scores or SIRS criteria. These findings suggest distinctive characteristics of the study population in the CTICU that are different from the general population.

Imbalance of Circulating Innate Lymphoid Cell Subpopulations in Patients With Septic Shock

Background: Septic shock, a major cause of death in critical care, is the clinical translation of a cytokine storm in response to infection. It can be complicated by sepsis-induced immunosuppression, exemplified by blood lymphopenia, an excess of circulating Treg lymphocytes, and decreased HLA-DR expression on circulating monocytes. Such immunosuppression is associated with secondary infections, and higher mortality. The effect of these biological modifications on circulating innate lymphoid cells (ILCs) has been little studied.

Methods: We prospectively enrolled patients with septic shock (Sepsis-3 definition) in the intensive care unit (ICU) of Timone CHU Hospital. ICU controls (trauma, cardiac arrest, neurological dysfunction) were recruited at the same time (NCT03297203). We performed immunophenotyping of adaptive lymphocytes (CD3⁺ T cells, CD19⁺ B cells, CD4⁺CD25⁺FoxP3⁺ Treg lymphocytes), ILCs (CD3⁻CD56⁺ NK cells and helper ILCs – ILC1, ILC2, and ILC3), and monocytes by flow cytometry on fresh blood samples collected between 24 and 72 h after admission.

Results: We investigated adaptive and innate circulating lymphoid cells in the peripheral blood of 18 patients in septic shock, 15 ICU controls, and 30 healthy subjects. As expected, the peripheral blood lymphocytes of all ICU patients showed lymphopenia, which was not specific to sepsis, whereas those of the healthy volunteers did not. Circulating CD3⁺ T cells and CD3⁻CD56⁺ NK cells were mainly concerned. There was a tendency toward fewer Treg lymphocytes and lower HLA-DR expression on monocytes in ICU patients with sepsis. Although the ILC1 count was higher in septic patients than healthy subjects, ILC2, and ILC3 counts were lower in both ICU groups. However, ILC3s within the total ILCs were overrepresented in patients with septic shock. The depression of immune responses has been correlated with the occurrence of secondary infections. We did not find any differences in ILC distribution according to this criterion.

Conclusion: All ICU patients exhibit lymphopenia, regardless of the nature (septic or sterile) of the initial medical condition. Specific distribution of circulating ILCs, with an excess of ILC1, and a lack of ILC3, may characterize septic shock during the first 3 days of the disease.

Robustness of sepsis-3 criteria in critically ill patients

Background

Early recognition of sepsis is challenging, and diagnostic criteria have changed repeatedly. We assessed the robustness of sepsis-3 criteria in intensive care unit (ICU) patients.

Methods

We studied the apparent incidence and associated mortality of sepsis-3 among patients who were prospectively enrolled in the Molecular Diagnosis and Risk Stratification of Sepsis (MARS) cohort in the Netherlands, and explored the effects of minor variations in the precise definition and timing of diagnostic criteria for organ failure.

Results

Among 1081 patients with suspected infection upon ICU admission, 648 (60%) were considered to have sepsis according to prospective adjudication in the MARS study, whereas 976 (90%) met sepsis-3 criteria, yielding only 64% agreement at the individual patient level. Among 501 subjects developing ICU-acquired infection, these rates were 270 (54%) and 260 (52%), respectively (yielding 58% agreement). Hospital mortality was 234 (36%) vs 277 (28%) for those meeting MARS-sepsis or sepsis-3 criteria upon presentation (p < 0.001), and 121 (45%) vs 103 (40%) for those having sepsis onset in the ICU (p < 0.001). Minor variations in timing and interpretation of organ failure criteria had a considerable effect on the apparent prevalence of sepsis-3, which ranged from 68 to 96% among those with infection at admission, and from 22 to 99% among ICU-acquired cases.

Conclusion

The sepsis-3 definition lacks robustness as well as discriminatory ability, since nearly all patients presenting to ICU with suspected infection fulfill its criteria. These should therefore be specified in greater detail, and applied more consistently, during future sepsis studies.

Trial registration

The MARS study is registered at ClinicalTrials.gov (identifier NCT 01905033).

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0400-6) contains supplementary material, which is available to authorized users.

Sepsis: evolving concepts and challenges

Sepsis remains a major cause of morbidity and mortality worldwide, with increased burden in low- and middle-resource settings. The role of the inflammatory response in the pathogenesis of the syndrome has supported the modern concept of sepsis. Nevertheless, a definition of sepsis and the criteria for its recognition is a continuous process, which reflects the growing knowledge of its mechanisms and the success and failure of diagnostic and therapeutic interventions. Here we review the evolving concepts of sepsis, from the "systemic inflammatory response syndrome triggered by infection" (Sepsis-1) to "a severe, potentially fatal, organic dysfunction caused by an inadequate or dysregulated host response to infection" (Sepsis-3). We focused in the pathophysiology behind the concept and the criteria for recognition and diagnosis of sepsis. A major challenge in evaluating the host response in sepsis is to characterize what is protective and what is harmful, and we discuss that, at least in part, the apparent dysregulated host response may be an effort to adapt to a hostile environment. The new criteria for recognition and diagnosis of sepsis were derived from robust databases, restricted, however, to developed countries. Since then, the criteria have been supported in different clinical settings and in different economic and epidemiological contexts, but still raise discussion regarding their use for the identification versus the prognostication of the septic patient. Clinicians should not be restricted to definition criteria when evaluating patients with infection and should wisely use the broad array of information obtained by rigorous clinical observation.

Nursing Activities Score: qual periodicidade ideal para avaliação da carga de trabalho?

Resumo Objetivo: Comparar a carga de trabalho obtida a partir do Nursing Activities Score (NAS) pontuado três vezes ao dia, no final de cada turno de trabalho, e pontuado uma vez ao dia considerando as 24 horas. Métodos: Estudo longitudinal prospectivo, realizado com adultos internados em um Centro de Terapia Intensiva de um hospital público de alta complexidade do sul do Brasil. A coleta de dados foi realizada através do sistema Epimed Monitor®. No primeiro período do estudo (Período 1) a pontuação média do NAS foi obtida a partir de três avaliações diárias e no segundo período (Período 2) o NAS foi pontuado uma vez ao dia. A comparação das variáveis foi verificada por meio dos testes t-Studente Mann Whitney U. O estudo foi aprovado pelo Comitê de Ética em Pesquisa da instituição de origem. Resultados: Durante o estudo foram realizadas 1738 avaliações de NAS em 338 pacientes. A média de pontuação do NAS foi de 74±20,9% para o total de pacientes. Não houve diferença entre a média do Período 1 (74,1±20,8%) e a média do Período 2 (73,9±21%) (p= 0,806). O Período 2 teve mais avaliações na categoria de NAS <50% e menos avaliações na categoria de NAS 50,1-100% em relação ao Período 1 (p<0,001 e p= 0,029, respectivamente). Conclusão: A pontuação média do NAS é semelhante quando comparada a aferição realizada três vezes ao dia com a realizada uma vez ao dia considerando as 24 horas anteriores para avaliação de carga de trabalho de enfermagem.

Comparison of International Pediatric Sepsis Consensus Conference Versus Sepsis-3 Definitions for Children Presenting With Septic Shock to a Tertiary Care Center in India: A Retrospective Study

OBJECTIVES

To evaluate the proportion of children fulfilling "Sepsis-3" definition and International Pediatric Sepsis Consensus Conference definition among children diagnosed to have septic shock and compare the mortality risk between the two groups.

DESIGN

Retrospective chart review.

SETTING

PICU of a tertiary care teaching hospital from 2014 to 2017.

PATIENTS

Children (≤ 17 yr old) with a diagnosis of septic shock at admission or during PICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We applied both International Pediatric Sepsis Consensus Conference and the new "Sepsis-3" definition (sepsis with hypotension requiring vasopressors and a lactate value of ≥ 2 mmol/L) to identify cases of septic shock by these definitions. Key outcomes such as mortality, proportion attaining shock reversal at 24 hours and organ dysfunction were compared between those fulfilling "Sepsis-3" definitions ("Sepsis-3" group) and those fulfilling "International Pediatric Sepsis Consensus Conference" definition ("International Pediatric Sepsis Consensus Conference" group). A total of 216 patients fulfilled International Pediatric Sepsis Consensus Conference definitions of septic shock. Of these, only 104 (48%; 95% CI, 42-55) fulfilled "Sepsis-3" definition. Children fulfilling "Sepsis-3 plus International Pediatric Sepsis Consensus Conference definitions" ("Sepsis-3 and International Pediatric Sepsis Consensus Conference" group) had lower proportion with shock resolution (61% vs 82%; relative risk, 0.73; 95% CI, 0.62-0.88) and higher risk of multiple organ dysfunction (85% vs 68%; 1.24; 1.07-1.45) at 24 hours. The mortality was 48.5% in "Sepsis-3 and International Pediatric Sepsis Consensus Conference" group as compared with 37.5% in the "International Pediatric Sepsis Consensus Conference only" group (relative risk, 1.3; 95% CI, 0.94-1.75).

CONCLUSIONS

Less than half of children with septic shock identified by International Pediatric Sepsis Consensus Conference definitions were observed to fulfill the criteria for shock as per "Sepsis-3" definitions. Lack of difference in the risk of mortality between children who fulfilled "Sepsis-3" definition and those who did not fulfill the definition raises questions on the appropriateness of using this definition for diagnosis of septic shock in children.

Utility of qSOFA score in identifying patients at risk for poor outcome in Staphylococcus aureus bacteremia

Background

The prognostic capability of the quick Sequential Organ Failure Assessment (qSOFA) bedside scoring tool is uncertain in non-ICU patients with sepsis due to bacteremia given the low number of patients previously evaluated.

Methods

We performed a retrospective cohort study of adult hospitalized patients with Staphylococcus aureus bacteremia (SAB). Medical charts were reviewed to determine qSOFA score, systemic inflammatory response syndrome (SIRS) criteria, and Pitt bacteremia score (PBS) at initial presentation; their predictive values were compared for ICU admission within 48 h, ICU stay duration > 72 h, and 30-day mortality.

Results

Four hundred twenty-two patients were included; 22% had qSOFA score ≥2. Overall, mean age was 56y and 75% were male. More patients with qSOFA ≥2 had altered mentation (23% vs 5%, p < 0.0001), were infected with MRSA (42% vs 30%, p = 0.03), had endocarditis or pneumonia (29% vs 15%, p = 0.0028), and bacterial persistence ≥4d (34% vs 20%, p = 0.0039) compared to qSOFA <2 patients. Predictive performance based on AUROC was better (p < 0.0001) with qSOFA than SIRS criteria for all three outcomes, but similar to PBS ≥2. qSOFA≥2 was the strongest predictor for poor outcome by multivariable analysis and showed improved specificity but lower sensitivity than SIRS ≥2.

Conclusions

qSOFA is a simple 3-variable bedside tool for use at the time of sepsis presentation that is more specific than SIRS and simpler to calculate than PBS in identifying septic patients at high risk for poor outcomes later confirmed to have S. aureus bacteremia.

Systemic inflammatory response syndrome in Sepsis-3: a retrospective study

BACKGROUND

In the new Sepsis-3 definition, sepsis is defined as "life-threatening organ dysfunction due to a dysregulated host response to infection." We tested the predictive validity of the systematic inflammatory response syndrome (SIRS) criteria in patients in the Sepsis-3 cohort.

METHODS

Among 1243 electronic health records from 1 January to 31 December 2015 at Sichuan University West China Hospital, we identified patients with sepsis and septic shock according to the Sepsis-3 definition and divided them into 2 subsets: SIRS-positive and SIRS-negative. We compared their characteristics and outcomes as well as the predictive validity of the SIRS criteria for in-hospital mortality.

RESULTS

Of the 1243 patients, 631 were enrolled. Among these, 538 (85.3%) patients had SIRS-positive sepsis or septic shock, 168 (31.2%) of whom died, and 93 (14.7%) had SIRS-negative sepsis or septic shock, 20 (21.5%) of whom died (p = 0.06). Over a 1-year period, these groups had similar characteristics and changes in mortality. Among patients of the Sepsis-3 cohort admitted to the intensive care unit, the predictive validity for in-hospital mortality was lower for the SIRS criteria (area under the receiver operating characteristic curve [AUROC], 0.53; 95% confidence interval [95% CI], 0.49-0.57) than for the sequential (sepsis-related) organ failure assessment (SOFA) criteria (AUROC, 0.70; 95% CI, 0.66-0.74; p ≤ 0.01 for both). The SIRS score had poor predictive validity for the risk of in-hospital mortality.

CONCLUSIONS

In this cohort study of the new Sepsis-3 definition, we found that the SIRS criteria are weaker than the SOFA criteria with respect to their predictive efficacy for in-hospital death.

Severity scoring systems for pneumonia: current understanding and next steps

PURPOSE OF REVIEW

To describe the current understanding and clinical applicability of severity scoring systems in pneumonia management.

RECENT FINDINGS

Severity scores in community-acquired pneumonia are strong markers of mortality, but are not necessarily clinical decision-aid tools. The use of severity scores to support outpatient care in low-risk patients has moderate-to-strong evidence available in the literature, mainly for the pneumonia severity index, and must be applied together with clinical judgment. It is not clear that severity scores are helpful to guide empiric antibiotic treatment. The inclusion of biomarkers and performance status might improve the predictive performance of the well known severity scores in community-acquired pneumonia. We should improve our methods for score evaluation and move toward the development of decision-aid tools.

SUMMARY

The application of the available evidence favors the use of severity scoring systems to improve the delivery of care for pneumonia patients. The incorporation of new methodologies and the formulation of different questions other than mortality prediction might help the further development of severity scoring systems, and enhance their support to the clinical decision-making process for the pneumonia-management cascade.

Timing and Associated Factors for Sepsis-3 in Severe Trauma Patients: A 3-Year Single Trauma Center Experience

Background

We hypothesized that the recent change of sepsis definition by sepsis-3 would facilitate the measurement of timing of sepsis for trauma patients presenting with initial systemic inflammatory response syndrome. Moreover, we investigated factors associated with sepsis according to the sepsis-3 definition.

Methods

Trauma patients in a single level I trauma center were retrospectively reviewed from January 2014 to December 2016. Exclusion criteria were younger than 18 years, Injury Severity Score (ISS) <15, length of stay <8 days, transferred from other hospitals, uncertain trauma history, and incomplete medical records. A binary logistic regression test was used to identify the risk factors for sepsis-3.

Results

A total of 3,869 patients were considered and, after a process of exclusion, 422 patients were reviewed. Fifty patients (11.85%) were diagnosed with sepsis. The sepsis group presented with higher mortality (14 [28.0%] vs. 17 [4.6%], P<0.001) and longer intensive care unit stay (23 days [range, 11 to 35 days] vs. 3 days [range, 1 to 9 days], P<0.001). Multivariate analysis demonstrated that, in men, high lactate level and red blood cell transfusion within 24 hours were risk factors for sepsis. The median timing of sepsis-3 was at 8 hospital days and 4 postoperative days. The most common focus was the respiratory system.

Conclusions

Sepsis defined by sepsis-3 remains a critical issue in severe trauma patients. Male patients with higher ISS, lactate level, and red blood cell transfusion should be cared for with caution. Reassessment of sepsis should be considered at day 8 of hospital stay or day 4 postoperatively.

Prognostic value of the biomarkers serum amyloid A and nitric oxide in patients with sepsis

OBJECTIVE

Sepsis is a major cause of mortality among critically ill patients in the intensive care unit (ICU). Alterations in serum amyloid A (SAA) and nitric oxide (NO) levels have been associated with mortality in critically ill patients. In the present study, we investigated the predictive value of SAA and/or NO compared to traditional predictive markers such as C-reactive protein (CRP) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

METHODS

100 adult patients with sepsis and 25 without sepsis were enrolled in a prospective, randomized study in our ICU. The APACHE II score was calculated, and their peripheral venous blood SAA, NO and CRP levels were evaluated on days 1, 3, and 7 after sepsis was diagnosed. The patients were sorted based on incidence of septic shock into septic shock (A) and non-septic shock (B) groups. Comparative analyses of altered levels of these indicators between the two groups were performed, and correlations between SAA, NO, and the more traditional APACHE II score were probed. Patients were sorted based on survival status into death (D) and survival (S) groups based on death endpoint within 28 days after admission.

RESULTS

We observed that the difference in APACHE II score, SAA and CRP levels were statistically significantly (p < 0.05) between groups A and B on days 1, 3 and 7 post-diagnosis, while inter-group NO level significantly differed (p < 0.05) on days 1 and 3 post-diagnosis, no apparent difference was observed on day 7 post-diagnosis. For groups D and S, SAA, CRP and NO levels significantly differed (p < 0.05) on days 3 and 7 post-diagnosis, with no apparent difference on day 1. APACHE II score was significantly different on day 7 (p < 0.05), however the difference on days 1 and 3 were non-significant. We also demonstrated a positive correlation between APACHE II scores, SAA levels on days 1, 3, and 7, as well as NO levels on days 1 and 3. In addition, for the D and S groups, SAA at all time points, NO on day 3 and CRP on day 7 positively correlated with increased death events.

CONCLUSION

The dynamic monitoring of SAA and NO serum levels with APACHE II scores better reflect the severity of sepsis than traditional indicators like CRP and may serve as independent prognosticators of sepsis in critically ill patients, shorten time to diagnosis confirmation and improve therapeutic decision-making.

Surviving sepsis campaign: research priorities for sepsis and septic shock

Objective

To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock.

Design

A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion. The entire committee iteratively developed the entire document and recommendations.

Methods

Each committee member independently gave their top five priorities for sepsis research. A total of 88 suggestions (ESM 1 - supplemental table 1) were grouped into categories by the committee co-chairs, leading to the formation of seven subgroups: infection, fluids and vasoactive agents, adjunctive therapy, administration/epidemiology, scoring/identification, post-intensive care unit, and basic/translational science. Each subgroup had teleconferences to go over each priority followed by formal voting within each subgroup. The entire committee also voted on top priorities across all subgroups except for basic/translational science.

Results

The Surviving Sepsis Research Committee provides 26 priorities for sepsis and septic shock. Of these, the top six clinical priorities were identified and include the following questions: (1) can targeted/personalized/precision medicine approaches determine which therapies will work for which patients at which times?; (2) what are ideal endpoints for volume resuscitation and how should volume resuscitation be titrated?; (3) should rapid diagnostic tests be implemented in clinical practice?; (4) should empiric antibiotic combination therapy be used in sepsis or septic shock?; (5) what are the predictors of sepsis long-term morbidity and mortality?; and (6) what information identifies organ dysfunction?

Conclusions

While the Surviving Sepsis Campaign guidelines give multiple recommendations on the treatment of sepsis, significant knowledge gaps remain, both in bedside issues directly applicable to clinicians, as well as understanding the fundamental mechanisms underlying the development and progression of sepsis. The priorities identified represent a roadmap for research in sepsis and septic shock.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5175-z) contains supplementary material, which is available to authorized users.

Accuracy of SOFA, qSOFA, and SIRS scores for mortality in cancer patients admitted to an intensive care unit with suspected infection

PURPOSE

To compare the prognostic accuracy of Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) with systemic inflammatory response syndrome (SIRS) criteria in critically ill cancer patients with suspected infection.

METHODS

Data for 450 cancer patients admitted to an intensive care unit (ICU) in 2014 with a suspected infection were retrospectively analyzed. Sensitivity, specificity, and area under the receiver operating curve (AUC) values for SOFA, qSOFA, and SIRS criteria for ICU and hospital mortalities were calculated. Mortalities according to Sepsis-2 stratification (e.g., sepsis, severe sepsis, and septic shock) and Sepsis-3 stratification (e.g., infection, sepsis, and septic shock) were also compared.

RESULTS

SOFA outperformed SIRS in predicting mortalities for ICU [(AUC, 0.76; 95% confidence interval (CI) 95%, 0.71-0.81) vs. (AUC, 0.62; 95% CI, 0.56-0.67), p < .01] and hospital [(AUC, 0.69; 95% CI, 0.65-0.74) vs. (AUC, 0.58; 95% CI, 0.52-0.63), p < .01)] patients. Similarly, qSOFA outperformed SIRS for both settings [(AUC, 0.71; 95% CI, 0.65-0.76, p = .02) vs. (AUC, 0.69; 95% CI, 0.64-0.74; p < .01), respectively].

CONCLUSIONS

SOFA and qSOFA were more sensitive and accurate than SIRS in predicting ICU and hospital mortality for critically ill cancer patients with suspected infection.

Sepsis in tropical regions: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Sepsis and septic shock in the tropics are caused by a wide array of organisms. These infections are encountered mainly in low and middle-income countries (LMIC) where a lack of infrastructure and medical facilities contribute to the high morbidity and mortality. Published sepsis guidelines are based on studies primarily performed in high income countries and as such recommendations may or may not be relevant to practice in the tropics. Failure to adhere to guidelines, particularly among non-intensive care specialists even in high-income countries, is an area of concern for sepsis management. Additionally, inappropriate use of antimicrobials has led to significant antimicrobial resistance. Access to rapid, low-cost, and accurate diagnostic tests is critical in countries where tropical diseases are prevalent to facilitate early diagnosis and treatment. Implementation of performance improvement programs may improve outcomes for patients with sepsis and the addition of resuscitation and treatment bundles may further reduce mortality. Associated co-morbidities such as malnutrition and HIV influence outcomes and must be considered.

Glucose homeostasis in two degrees of sepsis lethality induced by caecum ligation and puncture in mice

Sepsis is associated with high mortality. Both critically ill humans and animal models of sepsis exhibit changes in their glucose homeostasis, that is, hypoglycaemia, with the progression of infection. However, the relationship between basal glycaemia, glucose tolerance and insulin sensitivity is not well understood. Thus, we aimed to evaluate this glucose homeostasis triad at the late stage of sepsis (24 h after surgery) in male Swiss mice subjected to lethal and sublethal sepsis by the caecal ligation and puncture (CLP) model. The percentage of survival 24 h after CLP procedure in the Lethal and Sublethal groups was around 66% and 100% respectively. Both Lethal and Sublethal groups became hypoglycaemic in fasting and fed states 24 h after surgery. The pronounced fed hypoglycaemia in the Lethal group was not due to worsening anorexic behaviour or hepatic inability to deliver glucose in relation to the Sublethal group. Reduction in insulin sensitivity in CLP mice occurred in a lethality-dependent manner and was not associated with glucose intolerance. Analysis of oral and intraperitoneal glucose tolerance tests, as well as the gastrointestinal motility data, indicated that CLP mice had reduced intestinal glucose absorption. Altogether, we suggest cessation of appetite and intestinal glucose malabsorption are key contributors to the hypoglycaemic state observed during experimental severe sepsis.

Does SOFA predict outcomes better than SIRS in Brazilian ICU patients with suspected infection? A retrospective cohort study

We compared the discriminatory capacity of the sequential organ failure assessment (SOFA) versus the systemic inflammatory response syndrome (SIRS) score for predicting ICU mortality, need for and length of mechanical ventilation, ICU stay, and hospitalization in patients with suspected infection admitted to a mixed Brazilian ICU. We performed a retrospective analysis of a longitudinal ICU database from a tertiary hospital in Southern Brazil. Patients were categorized according to whether they met the criteria for sepsis according to SOFA (variation ≥2 points over the baseline clinical condition) and SIRS (SIRS score ≥2 points). From January 2008 to December 2014, 1487 patients were admitted to the ICU due to suspected infection. SOFA ≥2 identified more septic patients than SIRS ≥2 (79.0% [n = 1175] vs. 68.5% [n = 1020], p < 0.001). There was no difference between the two scores in predicting ICU mortality (area under the receiver operating characteristic curve (AUROC) = 0.64 vs. 0.64, p = 0.99). SOFA ≥2 was marginally better than SIRS ≥2 in predicting need for mechanical ventilation (AUROC = 0.64 vs. 0.62, p = 0.001), ICU stay > 7 days (AUROC = 0.65 vs. 0.63, p = 0.004), and length of hospitalization >10 days (AUROC = 0.61 vs. 0.59, p < 0.001). There was no difference between the two scores in predicting mechanical ventilation >7 days.

Application of the Third International Consensus Definitions for Sepsis (Sepsis-3) Classification: a retrospective population-based cohort study

BACKGROUND

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) present clinical criteria for the classification of patients with sepsis. We investigated incidence and long-term outcomes of patients diagnosed with these classifications, which are currently unknown.

METHODS

We did a retrospective analysis using data from 30 239 participants from the USA who were aged at least 45 years and enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. Patients were enrolled between Jan 25, 2003, and Oct 30, 2007, and we identified hospital admissions from Feb 5, 2003, to Dec 31, 2012, and applied three classifications: infection and systemic inflammatory response syndrome (SIRS) criteria, elevated sepsis-related organ failure assessment (SOFA) score from Sepsis-3, and elevated quick SOFA (qSOFA) score from Sepsis-3. We estimated incidence during the study period, in-hospital mortality, and 1-year mortality.

FINDINGS

Of 2593 first infection events, 1526 met SIRS criteria, 1080 met SOFA criteria, and 378 met qSOFA criteria. Incidence was 8·2 events (95% CI 7·8-8·7) per 1000 person-years for SIRS, 5·8 events (5·4-6·1) per 1000 person-years for SOFA, and 2·0 events (1·8-2·2) per 1000 person-years for qSOFA. In-hospital mortality was higher for patients with an elevated qSOFA score (67 [23%] of 295 patients died) than for those with an elevated SOFA score (125 [13%] of 960 patients died) or who met SIRS criteria (128 [9%] of 1392 patients died). Mortality at 1 year after discharge was also highest for patients with an elevated qSOFA score (29·4 deaths [95% CI 22·3-38·7] per 100 person-years) compared with those with an elevated SOFA score (22·6 deaths [19·2-26·6] per 100 person-years) or those who met SIRS criteria (14·7 deaths [12·5-17·2] per 100 person-years).

INTERPRETATION

SIRS, SOFA, and qSOFA classifications identified different incidences and mortality. Our findings support the use of the SOFA and qSOFA classifications to identify patients with infection who are at elevated risk of poor outcomes. These classifications could be used in future epidemiological assessments and studies of patients with infection.

FUNDING

National Institute for Nursing Research, National Center for Research Resources, and National Institute of Neurological Disorders and Stroke.