Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: We could go faster

Purpose

The aim of this study is to evaluate the feasibility of applying sepsis bundles in the intensive care unit (ICU) and their effect on outcomes.

Methods

In this prospective, observational study in a 31-bed capacity department of intensive care, we measured the time taken to perform sepsis bundle interventions in 69 consecutive patients with severe sepsis or septic shock.

Results

Compliance with the 6-hour bundle was obtained in 44 (72%) of 61 patients; these patients had a lower mortality rate (16% vs 41%, P = .04) and shorter ICU stay (median [range], 5 [3-10] vs 9 [6-19] days, P = .01) than other patients. Compliance with the 24-hour bundle was obtained in 30 (67%) of 44 eligible patients. The mortality rate and duration of ICU stay were not significantly lower in the 24-hour compliant as compared with the noncompliant group (23% vs 33% and 6 [4-11] vs 9 [6-25] days, respectively; P value is not significant). Patients who complied with the 24-hour sepsis bundle after only 12 hours had a lower mortality rate (10% vs 39%, P = .036) and shorter stay (6 [4-10] vs 9 [6-25] days, P = .055) than those who were compliant after 24 hours.

Conclusions

Correct application of the sepsis bundles was associated with reduced mortality and length of ICU stay. Earlier implementation of the 24-hour management bundle could result in better outcomes.     

Impact of serial measurements of lysophosphatidylcholine on 28-day mortality prediction in patients admitted to the intensive care unit with severe sepsis or septic shock

Purpose

The purpose of this study is to investigate the effect of serial lysophosphatidylcholine (LPC) measurement on 28-day mortality prediction in patients with severe sepsis or septic shock admitted to the medical intensive care unit (ICU).

Methods

This is a prospective observational study of 74 ICU patients in a tertiary hospital. Serum LPC, white blood cell, C-reactive protein, and procalcitonin (PCT) levels were measured at baseline (day 1 of enrollment) and day 7. The LPC concentrations were compared with inflammatory markers using their absolute levels and relative changes.

Results

The LPC concentration on day 7 was significantly lower in nonsurvivors than in survivors (68.45 ± 42.36 μmol/L and 99.76 ± 73.65 μmol/L; P = .04). A decreased LPC concentration on day 7 to its baseline as well as a sustained high concentration of PCT on day 7 at more than 50% of its baseline value was useful for predicting the 28-day mortality. Prognostic utility was substantially improved when combined LPC and PCT criteria were applied to 28-day mortality outcome predictions. Furthermore, LPC concentrations increased over time in patients with appropriate antibiotics but not in those with inappropriate antibiotics.

Conclusions

Serial measurements of LPC help in the prediction of 28-day mortality in ICU patients with severe sepsis or septic shock.     

One-year mortality of bloodstream infection-associated sepsis and septic shock among patients presenting to a regional critical care system

Objective The long-term mortality outcome associated with sepsis and septic shock has not been well defined in a nonselected critically ill population. This study investigated the occurrence and the role of bloodstream infection (BSI) associated sepsis and septic shock at time of intensive care unit (ICU) admission on the 1-year mortality of patients admitted to a regional critical care system.Design and setting Population-based inception cohort in all adult multidisciplinary and cardiovascular ICUs in the Calgary Health Region (population approx. 1 million) between 1 July 1999 and 31 March 2002.Patients and participants Adults (18 years; n=4,845) who had at least one ICU admission to CHR ICUs.Results In 251 (5%) patients there was BSI-associated sepsis at presentation to ICU, and 159 of these also had septic shock. The 28-day, 90-day, and 1-year mortality rates overall were 18%, 21%, and 24%: 23%, 30%, and 36% for BSI-associated sepsis without shock, and 51%, 57%, and 61% with shock, respectively. Surgical diagnosis, BSI-associated sepsis, and increasing age were independently associated with late (28-day to 1-year) mortality whereas higher APACHE II and TISS scores were associated with reduced odds in logistic regression analysis.Conclusions BSI-associated sepsis and septic shock are associated with increased risk of mortality persisting after 28-days up to 1 year or more. Follow-up duration beyond 28 days better defines the burden of illness associated with these syndromes.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at .     

Systemic inflammatory response syndrome,sepsis, severe sepsis and septic shock: Incidence,morbidities and outcomes in surgical ICU patients

Objectives To determine the incidence of systemic inflammatory response syndrome (SIRS), sepsis and severe sepsis in surgical ICU patients and define patient characteristics associated with their acquisition and outcome.Design One-month prospective study of critically ill patients with a 28 day in-hospital follow up.Setting Surgical intensive care unit (SICU) at a tertiary care institution.Methods All patients (n=170) admitted to the SICU between April 1 and April 30, 1992 were prospectively followed for 28 days. Daily surveillance was performed by two dedicated, specifically-trained research nurses. Medical and nursing chart reviews were performed, and follow up information at six and twelve months was obtained.Results The in-hospital surveillance represented 2246 patient-days, including 658 ICU patient-days. Overall, 158 patients (93%) had SIRS for an incidence of 542 episodes/1000 patients-days. The incidence of SIRS in the ICU was even higher (840 episodes/1000 patients-days). A total of 83 patients (49%) had sepsis; among them 28 developed severe sepsis. Importantly, 13 patients had severe sepsis after discharge from the ICU. Patient groups were comparable with respect to age, sex ratio, and type of surgery performed. Apach II score on admission to the ICU and ASA score at time of surgery were significantly higher (p<0.05) only for patients who subsequently developed severe sepsis. The crude mortality at 28 days was 8.2% (14/170); it markedly differed among patient groups: 6% for those with SIRS vs. 35% for patients with severe sepsis. Patients with sepsis and severe sepsis had a longer mean length of ICU stay (2.1±0.2 and 7.5±1.5, respectively) than those with SIRS (1.45±0.1) or control patients (1.16±0.1). Total length of hospital stay also markedly differed among groups (35±9 (severe sepsis), 24±2 (sepsis), 11±0.8 (SIRS), and 9±0.1 (controls, respectively).Conclusions Almost everyone in the SICU had SIRS. Therefore, because of its poor specificity, SIRS was not helpful predicting severe sepsis and septic shock. Patients who developed sepsis or severe sepsis had higher crude mortality and length of stay than those who did not. Studies designed to identify those who develop complications of SIRS would be very useful.     

Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies

Objective To compare the characteristics and outcome of patients with hematological malignancies referred to the ICU with severe sepsis and septic shock who had or had not received recent intravenous chemotherapy, defined as within 3 weeks prior to ICU admission. Design and setting Retrospective observational cohort study on prospectively collected data in a medical ICU of a university hospital. Patients 186 ICU patients with hematological malignancies with severe sepsis or septic shock (2000–2006). Measurements and results There were 77 patients admitted with severe sepsis and 109 with septic shock; 91 (49%) had received recent intravenous chemotherapy. Patients with recent chemotherapy more often had a high-grade malignancy and were more often neutropenic, less often had pulmonary infiltrates, and less often required mechanical ventilation. ICU, 28-day, in-hospital, and 6-month mortality rates were 33% vs. 48.4%, 40.7% vs. 57.4%, 45.1% vs. 58.9%, and 50.5% vs. 63.2% in patients with and without recent chemotherapy, respectively. Logistic regression identified four variables independently associated with 28-day mortality: SOFA score at ICU admission, pulmonary site of infection, and fungal infection were associated with worse outcome whereas previous intravenous chemotherapy was protective at borderline significance. After adjustment with a propensity score for recent chemotherapy, chemotherapy was not associated with outcome. Conclusions Patients referred to the ICU with severe sepsis and septic shock complicating active chemotherapeutic treatment have better prognosis than commonly perceived. This article is discussed in the editorial available at: .     

Analysis of prognostic factors in patients with sepsis and septic shock in intensive care unit北大核心CSCD

Objective To investigate the risk factors of death in patients with sepsis and septic shock and analyze the prognostic factors of patients in ICU. Methods A total of 168 patients with sepsis and septic shock in ICU from June 2016 to October 2018 were enrolled. The patients were stratified in terms of survival time (60 days or not). General clinical data, length of hospital stay, APACHE II score, underlying diseases, and laboratory data were used to analyze the independent risk factors of patient mortality. Results Of the 168 patients enrolled, 66 (39.3%) died within 60 days of discharge and 102 survived. Survivor and non-survivor groups did not show significant difference in gender, age, and length of hospital stay. APACHE II score in the non-survivor group was significantly higher than survivor group (P＜0.05). Considering the underlying diseases in the non-survivor group and survivor group, chronic obstructive pulmonary disease was found in 44 and 56 cases;hypertension in 63 and 69 cases;chronic liver disease in 34 and 30 cases;tumor in 21 and 18 cases, respectively (P＜0.05). The prevalence of coronary atherosclerotic heart disease, chronic renal insufficiency, diabetes mellitus, and stroke did not show significant difference between the two groups. The patients in both survivor group and non-survivor group did not show significant difference in C-reactive protein, white blood cell count, oxygenation index, blood lactate, serum creatinine, and platelet count within 36 hours in ICU. After 37-48 hours of treatment, C-reactive protein level was significantly higher in survivor group than non-survivor group (P＜0.05). Conclusion Underlying chronic obstructive pulmonary disease, tumor, hypertension, chronic liver disease, high C-reactive protein level after treatment for 37-48 hours, and high APACHE II score are independent risk factors for death of septic patients in ICU. © 2019, Editorial Department of Chinese Journal of Infection. All rights reserved.     

重症肺炎及感染性休克的集束治疗

目的 探讨国内严重感染集束治疗的疗效.方法 在广州医学院附属第二医院呼吸重症监护病房中选用43例重症肺炎及感染性休克患者,进行14个月(2006年11月1日至2007年12月31日)前瞻性观察研究.患者入进标准参照2001年国际脓毒症会议.分教育、试验和运作3个连续阶段实施6 h严重感染集束治疗和24 h严重感染集束治疗.历史对照期内(2004年1月1日至2006年10月31日)合格患者门入对照组.计最资料以(x±s)表示,计数资料以率表爪.采用γ2检验、独立样本t榆验、配对t检验、单因素和多冈素Logistic回归分析,P＜0.05为差异具有统计学意义.结果 1)对照组和集束治疗组问的基础特征差异基本上无统计学意义.2)血清乳酸测定率、休克业组液体复苏率及6 h内所输入液体量、血糖榨制,与对照组相比较,其差异均有统计学意义(P值分别是0.024,0.009,0.045和0.000).3)72 h时,集束治疗组呼吸频率和氧合指数,与对照组相比较,其差异均有统计学意义(P值分别是0.033和0.041);集束治疗组中休克业绀急性生理和慢性疾病评分(A-PACHE)Ⅱ分值和预计死亡率的下降值,与对照组中休克业组比较,其差异均有统计学意义(P值分别是0.017和0.040).4)与对照组比较,集束治疗组病死率绝对值下降23.30%(P=0.019).结论 严重感染集束治疗能显著降低重症肺炎及感染性休克患者病死率.     

N末端前B型利钠肽对严重感染及感染性休克患者预后的预测作用

目的 评价N末端前B型利钠肽(NT-proBNP)对严重感染及感染性休克患者预后的预测作用.方法 采用前瞻性研究方法,收集并观察50例严重感染及感染性休克患者的临床资料.于入重症监护病房(ICU)0、24、48、72 h测定血浆NT-proBNP水平,根据住院30 d死亡情况分为死亡组与存活组并进行比较.用受试者工作特征曲线(ROC曲线)评价血浆NT-proBNP水平对死亡的预测作用;采用线性回归分析评价血浆NT-proBNP的干扰因素.结果 死亡组(20例)血浆NT-proBNP水平(μg/L)在入ICU 0 h[20.86(14.28,23.92)]时明显高于存活组[30例,10.02(5.58,16.41),P＜0.01],且这种差异持续至72 h[19.68(13.90,24.02)比9.24(4.30,11.81),P＜0.01],但组内各时间点之间比较均无明显差异;ROC曲线下面积(AUC)为0.842,95%可信区间(95%CI)为0.764～0.922,P＜0.01.以入ICU时血浆NT-proBNP水平＞13.30μg/L作为判断死亡的最佳临界值,其敏感性为80.6%,特异性为70.2%.线性回归分析发现,氧合指数(PaO2/FiO2,r=-0.839,P=0.003)、血小板计数(PLT,r=-0.803,P=0.032)和入ICU 0 h时感染相关器官功能衰竭评分(SOFA,r=0.874,P＜0.001)是NT-proBNP的独立相关因素.结论 血浆NT-proBNP水平可以预测严重感染及感染性休克患者的预后.     

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Objective To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.Design The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.Participants Participants included 44 critical care and infectious disease experts representing 11 international organizations.Results A total of 46 recommendations plus pediatric management considerations.Conclusions Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.Electronic Supplementary Material Supplementary material is available in the online version of this articel at This article is published jointly with Critical Care MedicineChairs: R. Phillip Dellinger, MD*; Henry Masur, MD; Jean M. Carlet, MD; Herwig Gerlach, MD, PhD**. Committee members: Richard J. Beale, MD**; Marc Bonten, MD; Christian Brun-Buisson, MD; Thierry Calandra, MD; Joseph A. Carcillo, MD; Jonathan Cohen, MD**; Catherine Cordonnier, MD; E. Patchen Dellinger, MD; Jean-Francois Dhainaut, MD, PhD; Roger G. Finch, MD; Simon Finfer, MD; Francois A. Fourrier, MD; Juan Gea-Banacloche MD; Maurene A. Harvey, RN, MPH**; Jan A. Hazelzet, MD; Steven M. Hollenberg, MD; James H. Jorgensen, PhD; Didier Keh, MD; Mitchell M. Levy*, MD; Ronald V. Maier, MD; Dennis G. Maki, MD; John J. Marini, MD; John C. Marshall, MD; Steven M. Opal, MD; Tiffany M. Osborn, MD; Margaret M. Parker, MD**; Joseph E. Parrillo, MD; Graham Ramsay, MD*; Andrew Rhodes, MD; Jonathan E. Sevransky, MD; Charles L. Sprung, MD, JD**; Antoni Torres, MD; Jeffery S. Vender, MD; Jean-Louis Vincent, MD, PhD**; Janice L. Zimmerman, MD. Associate members: E. David Bennett, MD; Pierre-Yves Bochud, MD; Alain Cariou, MD; Glenn S. Murphy, MD; Martin Nitsun, MD; Joseph W. Szokol, MD; Stephen Trzeciak, MD; Christophe Vinsonneau, MD. *Executive Committee, Surviving Sepsis Campaign. **Steering Committee, Surviving Sepsis Campaign.Sponsoring organizations: American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; American Thoracic Society; Australian and New Zealand Intensive Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Society of Critical Care Medicine; Surgical Infection Society.The Surviving Sepsis Campaign is administered jointly by the European Society of Intensive Care Medicine, International Sepsis Forum, and the Society of Critical Care Medicine, and is supported in part by unrestricted educational grants from Baxter Bioscience, Edwards Lifesciences, and Eli Lilly and Company (majority sponsor).The authors and the publisher have exercised great care to ensure that drug dosages, formulas, and other information presented in this book are accurate and in accord with the professional standards in effect at the time of publication. Readers are, however, advised to always check the manufacturers product information sheet that is packaged with the respective products to be fully informed of changes in recommended dosages, contraindications, and the like before prescribing or administering any drug.     

不同液体管理策略对感染性休克患者病死率的影响

目的 探讨感染性休克不同时期采用不同液体管理策略对患者病死率的影响.方法 回顾性分析2007年3月至2009年12月江苏省苏北人民医院重症监护病房(ICU)107例感染性休克患者的临床资料,按28 d预后分为存活组(68例)和死亡组(39例);比较两组急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分、感染相关器官功能衰竭评分系统(SOFA)评分、1周内每日液体出入量及平衡、24 h早期目标导向治疗(EGDT)和24 h后保守性液体管理(CLFM)等数据,对影响患者预后的因素进行Logistic回归分析,确定和描述感染性休克患者的预后与24 h EGDT和24 h后CLFM策略间的关系.结果 单因素相关分析显示,两组7 d氧合指数、24 h乳酸清除率、急性肺损伤发生、机械通气时间、ICU住院时间、总住院时间、液体管理指标比较差异均有统计学意义.多元回归分析显示,未达到24 h EGDT、24 h后未达到CLFM、1周液体负平衡＜2000 ml和1周液体总入量＞20000 ml是感染性休克患者死亡的独立危险因素,其优势比(OR)分别为4.159、4.431、23.788、4.353,P值分别为0.035、0.019、0.000、0.025.达到24 h EGDT且24 h后实行CLFM策略的感染性休克患者28 d病死率(12.5%)明显低于达到24 h EGDT且24 h后实行开放性液体管理(LLFM)策略者(46.2%),以及未达到24 h EGDT且24 h后实行CLFM策略或LLFM策略者(30.0%、76.2%,P＜0.05或P＜0.01).结论 感染性休克早期达到24 h EGDT且24 h后采取CLFM策略可降低患者的病死率.

Abstract：

Objective To find out the influential effect of different fluid management on mortality of patients with septic shock in different phases. Methods From March 2007 to December 2009, a retrospective controlled study was conducted on the clinical data of 107 adult patients with septic shock in the intensive care unit(ICU)of Subei Hospital of Jiangsu Province. The patients were divided into survival group(n=68)and non-survival group(n= 39)according to the final outcome. A number of demographic and variables were collected from the medical record. The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ)score, sequential organ failure assessment(SOFA), liquid intake and output volume and its balance daily within 1 week, 24-hour early goal-directed therapy(EGDT)and conservative late fluid management(CLFM)were compared between two groups. The Logistic regression statistics was used to determine the relationship between APACHE Ⅱ , SOFA, EGDT, CLFM and survival. Results The single variable analysis showed that there was significant difference in the parameters of oxygenation index in 7 days, arterial blood lactate clearance within 24 hours, acute lung injury, length of mechanical ventilation,length of ICU stay and in hospital, the goal of fluid management including 24-hour EGDT, 24-hour CLFM,fluid balance in 24 hours, total fluid input within 7 days, negative fluid balance and times during 7 days between two groups. Logistic regression showed that failure to achieve 24-hour EGDT and late CLFM, a negative balance of ＜2 000 ml, total fluid input of ＞20000 ml within 1 week were independent risk factors of death, and odds ratio(OR)was 4. 159, 4. 431, 23. 788 and 4. 353, respectively, the P value was 0. 035,0. 019, 0. 000, 0. 025, respectively. The 28-day mortality in 24-hour EGDT and CLFM group(12. 5 %)was significantly lower than that of 24-hour EGDT with liberal late fluid management(LLFM)group(46. 2%)and that in the group of patients in whom with failure to have 24-hour EGDT with CLFM or LLFM(30.0%,76.2%, P＜0. 05 or P＜0. 01). Conclusion Both early achievement of 24-hour EGDT and late CLFM for the patients with septic shock can lower mortality.     

Critically ill patients with cancer and sepsis: clinical course and prognostic factors

Purpose

The purposes of this study were to evaluate the clinical course and to identify independent predictors of mortality in patients with cancer with sepsis.

Materials and Methods

This is a secondary analysis of a prospective cohort study conducted at an oncological medical-surgical intensive care unit. Logistic regression was used to identify predictors of hospital mortality.

Results

A total of 563 patients (77% solid tumor, 23% hematologic malignancies) were included over a 55-month period. The most frequent sites of infection were the lung, abdomen, and urinary tract; 91% patients had severe sepsis/septic shock. Gram-negative bacteria were responsible for more than half of the episodes of infection; 38% of patients had polymicrobial infections. Intensive care unit, hospital, and 6-month mortality rates were 51%, 65%, and 72%, respectively. In multivariate analyses, sepsis in the context of medical complications; active disease; compromised performance status; presence of 3 to 4 systemic inflammatory response syndrome criteria; and the presence of respiratory, renal, and cardiovascular failures were associated with increased mortality. Adjusting for other covariates, patients with non–urinary tract infections, mostly represented by patients with pneumonia and abdominal infections, had worse outcomes.

Conclusions

Sepsis remains a frequent complication in patients with cancer and associated with high mortality. Our results can be of help to assist intensivists in clinical decisions and to improve characterization and risk stratification in these patients.     

Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock

Introduction

We sought to compare the outcomes of patients with cryptic versus overt shock treated with an emergency department (ED) based early sepsis resuscitation protocol.

Methods

Pre-planned secondary analysis of a large, multicenter ED-based randomized controlled trial of early sepsis resuscitation. All subjects were treated with a quantitative resuscitation protocol in the ED targeting 3 physiological variables: central venous pressure, mean arterial pressure and either central venous oxygen saturation or lactate clearance. The study protocol was continued until all endpoints were achieved or a maximum of 6 h. Outcomes data of patients who were enrolled with a lactate ≥4 mmol/L and normotension (cryptic shock) were compared to those enrolled with sustained hypotension after fluid challenge (overt shock). The primary outcome was in-hospital mortality.

Results

A total of 300 subjects were enrolled, 53 in the cryptic shock group and 247 in the overt shock group. The demographics and baseline characteristics were similar between the groups. The primary endpoint of in-hospital mortality was observed in 11/53 (20%, 95% CI 11–34) in the cryptic shock group and 48/247 (19%, 95% CI 15–25) in the overt shock group, difference of 1% (95% CI −10 to 14; log rank test p = 0.81).

Conclusion

Severe sepsis with cryptic shock carries a mortality rate not significantly different from that of overt septic shock. These data suggest the need for early aggressive screening for and treatment of patients with an elevated serum lactate in the absence of hypotension.     

Absolute eosinophils count as a marker of mortality in patients with severe sepsis and septic shock in an intensive care unit

Introduction

Eosinophils in the circulating blood undergo apoptosis during sepsis syndromes induced by the action of certain cytokines.

Objective

The aim of the study was to evaluate the absolute eosinophils count (EC) as a marker of mortality in severe sepsis and septic shock.

Patients and Method

A prospective cohort study of patients with a diagnosis of sepsis or septic shock admitted to the intensive care unit (ICU) of the Dr Gustavo Fricke Hospital between January 2008 and December 2009 was conducted. Daily EC in all patients was analyzed. Receiver operating characteristic curve analysis was used to assess the performance of the diagnostic test.

Results

We studied a total of 240 patients. The median age was 62 years (interquartile range [IQR], 48-72 years), and 67 (27.9%) died. The median EC in patients who died was 43 (IQR, 14-121), whereas in surviving patients, it was 168 (IQR, 98-292) (P < .001). When the EC on the fifth day of hospital stay was assessed, an area under the curve (AUC) of 0.64 (95% confidence interval, 0.55-0.73) was observed. Eosinophils count at intensive care unit discharge showed an area under the curve of 0.81 (95% confidence interval, 0.76-0.87).

Discussion

Eosinophils counts were lower in patients who died of sepsis than in those who survived, but its clinical usefulness seems limited. Their role as an indicator of clinical stability seems to be important.     

Long-term costs and cost-effectiveness of adjunctive corticosteroids for patients with septic shock in New Zealand

ObjectiveThe aim of the study was to determine whether adjunctive hydrocortisone reduced healthcare expenditure and was cost-effective compared with placebo in New Zealand patients in the Adjunctive Glucocorticoid Therapy in Patients with Septic Shock (ADRENAL) trial.DesignThis is a health economic analysis using data linkage to New Zealand Ministry of Health databases to determine resource use, costs, and cost-effectiveness for a 24-month period.SettingThe study was conducted in New Zealand.Participants and interventionPatients with septic shock were randomised to receive a 7-day continuous infusion of 200 mg of hydrocortisone or placebo in the ADRENAL trial.Main outcome measuresHealthcare expenditure was associated with all hospital admissions, emergency department presentations, outpatient visits, and pharmacy expenditure. Effectiveness outcomes included mortality at 6 months and 24 months and quality of life at 6 months. Cost-effectiveness outcomes were assessed with reference to quality-adjusted life years gained at 6 months and life years gained at 24 months.ResultsOf 3800 patients in the ADRENAL trial, 419 (11.0%) were eligible, and 405 (96.7% of those eligible) were included. The mean total costs per patient over 24 months were $143,627 ± 100,890 and $143,772 ± 97,117 for the hydrocortisone and placebo groups, respectively (p = 0.99). Intensive care unit costs for the index admission were $50,492 and $62,288 per patient for the hydrocortisone and placebo groups, respectively (p = 0.09). The mean number of quality-adjusted life years gained at 6 months and mean number of life years gained at 24 months was not significantly different by treatment group, and the probability of hydrocortisone being cost-effective was 55% at 24 months.ConclusionsIn New Zealand, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes compared with placebo in patients with septic shock.     

Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock

Study objective

To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen.

Incidence and mortality of severe sepsis in surgical intensive care patients: the influence of patient gender on disease process and outcome

Objective: Laboratory studies demonstrated significant detrimental effects of male sex-steroids (testosterone) on immune functions following hemorrhagic shock and soft-tissue trauma. Moreover, better survival of female mice subjected to severe sepsis was observed when compared to male animals. The aims of the present study were to evaluate whether or not gender differences regarding incidence and mortality of severe sepsis do exist in surgical intensive care patients and to elucidate the influence of patient age on incidence and mortality of severe sepsis/septic shock.¶Design: Data base review of prospectively collected data from surgical intensive care patients.¶Setting: Surgical intensive care unit of the department of surgery of a university hospital.¶Patients: Prospectively collected data of 4218 intensive care patients (2709 male, 1509 female).¶Results: Significantly fewer female patients were referred to the intensive care unit (6.6 % vs 10.8 % of all patients; P < 0.05) leading to a significantly smaller proportion of female intensive care patients (35.8 % vs 64.2 %). No gender differences regarding number of failing organs or surgical procedure (exception vascular surgery) were observed in patients with and without severe sepsis/septic shock, indicating that the patients studied are comparable regarding general health prior to admission to SICU. Among all female patients referred to SICU only 7.6 % developed severe sepsis/septic shock, while 10.4 % of all male patients suffered from severe sepsis or septic shock (P < 0.05). This gender difference results from a significantly lower incidence of severe sepsis/septic shock in female patients between 60 and 79 years. No gender difference regarding mortality rates of severe sepsis/septic shock was observed (men 64.9 %, women 65.5 %).¶Conclusions: Our results indicate a significantly smaller number of female patients requiring intensive care as well as a significantly lower incidence of severe sepsis/septic shock in female intensive care patients. Mortality from severe sepsis/septic shock, however, is not affected by gender.     

Endotoxaemia in patients with severe sepsis or septic shock

Objective: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. Design: Prospective review. Setting: A 15-bed general ICU in a university hospital. Patients: One hundred sixteen patients hospitalised in our ICU fulfilling Bone's criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). Interventions: None. Measurements and results: The clinical characteristics of the population were: age 63.6 ± 11.4 years; SAPS II: 45.4 ± 15.6; mechanical ventilation: 72.4 %; septic shock: 51.7 % (n = 60); bacteraemia: 28.4 % (n = 33); gram-negative bacteria (GNB) infection 47.4 % (n = 55); ICU mortality: 39.6 % (n = 46). Detectable endotoxin occurred in 61 patients (51.2 %; mean level: 310 ± 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3 % vs 16.3 %; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. Conclusion: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult. Received: 28 September 1999 Final revision received: 31 January 2000 Accepted: 1 February 2000     

Impact of cancer on mortality rates in patients with sepsis: A meta-analysis and meta-regression of current studies

BACKGROUNDResearch suggests that approximately 6% of adult patients admitted to hospitals in the United States present with sepsis and there has been a minimal change in the incidence of this condition in the last decade. Furthermore, patients with cancer generally have a higher incidence of sepsis due to immunosuppression caused by cancer or its treatment.AIMTo assess if cancer increases the mortality rates in sepsis patients by pooling evidence from contemporary studies.METHODSPubMed, Embase, and Google Scholar databases were searched from January 1, 2001 to December 15, 2021 for studies comparing outcomes of sepsis patients based on the presence of active cancer. Mortality data were pooled using a random-effects model, with the odds ratio (OR) and 95% confidence interval (CI) calculated. Meta-regression was conducted to assess the influence of confounders on mortality rates.RESULTSNine studies were included. The meta-analysis demonstrated a non-significant tendency towards increased risk of early mortality (OR = 2.77, 95%CI: 0.88-8.66, I² = 99%) and a statistically significantly increased risk of late mortality amongst sepsis patients with cancer as compared to non-cancer sepsis patients (OR = 2.46, 95%CI: 1.42-4.25, I² = 99%). Overall, cancer was found to significantly increase the risk of mortality in sepsis patients (OR = 2.7, 95%CI: 1.07-6.84, I² = 99%). Meta-analysis indicated a statistically significantly increased risk of mortality in patients with solid tumors as well as hematological malignancies. Meta-regression indicated that an increase in the prevalence of comorbid pulmonary and renal diseases increased the risk of mortality in cancer patients with sepsis. Mortality rates increased with an increase in the percentage of patients with urinary tract infections while an inverse relationship was seen for infections of cutaneous origin.CONCLUSIONContemporary evidence indicates that the presence of any cancer in sepsis patients significantly increases the risk of mortality. Scarce data suggest that mortality is equally increased for both solid and hematological cancers. Current evidence is limited by high heterogeneity and there is a need for further studies taking into account several confounding variables to present better evidence.