scholarly journals Treatment variables associated with outcome in emergency department patients with suspected sepsis

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Narani Sivayoham ◽  
Lesley A. Blake ◽  
Shafi E. Tharimoopantavida ◽  
Saad Chughtai ◽  
Adil N. Hussain ◽  
...  
Keyword(s):  
Emergency Department ◽  
Independent Predictor ◽  
Severity Of Illness ◽  
Primary Outcome Measure ◽  
Number Needed To Treat ◽  
Suspected Sepsis ◽  
Suspected Infection ◽  
Predictors Of Mortality ◽  
Refractory Hypotension ◽  
Time To Antibiotics

Abstract Background Early treatment is advocated in the management of patients with suspected sepsis in the emergency department (ED). We sought to understand the association between the ED treatments and outcome in patients admitted with suspected sepsis. The treatments studied were: (i) the time to antibiotics, where time zero is the time the patient was booked in which is also the triage time; (ii) the volume of intravenous fluid (IVF); (iii) mean arterial pressure (MAP) after 2000 ml of IVF and (iv) the final MAP in the ED. Methods We performed a retrospective analysis of the ED database of patients aged ≥ 18 year who met two SIRS criteria or one red flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted between 8th February 2016 and 31st August 2017. The primary outcome measure was all-cause in-hospital mortality. The four treatments stated above were controlled for severity of illness and subject to multivariate logistic regression and Cox proportional-hazard regression to identify independent predictors of mortality. Results Of the 2,066 patients studied 272 (13.2%) died in hospital. The median time to antibiotics was 48 (interquartile range 30–82) minutes. The time to antibiotics was an independent predictor of mortality only in those who developed refractory hypotension (RH); antibiotics administered more than 55 mins after arrival was associated with an odds ratio (OR) for mortality of 2.75 [95% confidence interval (CI) 1.22–6.14]. The number-needed-to-treat was 4. IVF > 2000 ml (95% CI > 500– > 2100), except in RH, and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality. The OR for mortality of IVF > 2,000 ml in non-RH was 1.80 (95% CI 1.15–2.82); Number-needed-to-harm was 14. The OR for morality for a MAP ≤ 66 mmHg after 2000 ml of IVF was 3.42 (95% CI 2.10–5.57). A final MAP < 75 mmHg in the ED was associated with, but not an independent predictor of mortality. An initial systolic blood pressure of < 100 mmHg has a sensitivity of 63.3% and specificity of 88.4% for the development of RH. Conclusion In this study, antibiotics were found to be time-critical in RH. Intravenous fluids > 2000 ml (except in RH) and a MAP ≤ 66 mmHg after 2000 ml of IVF were also independent predictors of mortality.

scholarly journals The REDS score: a new scoring system to risk-stratify emergency department suspected sepsis: a derivation and validation study

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e030922 ◽  
Author(s):  
Narani Sivayoham ◽  
Lesley A Blake ◽  
Shafi E Tharimoopantavida ◽  
Saad Chughtai ◽  
Adil N Hussain ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Prediction Rule ◽  
Clinical Prediction Rule ◽  
Risk Category ◽  
Suspected Sepsis ◽  
Suspected Infection ◽  
Derivation Cohort ◽  
High Risk Category ◽  
Component Scores

ObjectiveTo derive and validate a new clinical prediction rule to risk-stratify emergency department (ED) patients admitted with suspected sepsis.DesignRetrospective prognostic study of prospectively collected data.SettingED.ParticipantsPatients aged ≥18 years who met two Systemic Inflammatory Response Syndrome criteria or one Red Flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted.Primary outcome measureIn-hospital all-cause mortality.MethodThe data were divided into derivation and validation cohorts. The simplified-Mortality in Severe Sepsis in the ED score and quick-SOFA scores, refractory hypotension and lactate were collectively termed ‘component scores’ and cumulatively termed the ‘Risk-stratification of ED suspected Sepsis (REDS) score’. Each patient in the derivation cohort received a score (0–3) for each component score. The REDS score ranged from 0 to 12. The component scores were subject to univariate and multivariate logistic regression analyses. The receiver operator characteristic (ROC) curves for the REDS and the components scores were constructed and their cut-off points identified. Scores above the cut-off points were deemed high-risk. The area under the ROC (AUROC) curves and sensitivity for mortality of the high-risk category of the REDS score and component scores were compared. The REDS score was internally validated.Results2115 patients of whom 282 (13.3%) died in hospital. Derivation cohort: 1078 patients with 140 deaths (13%). The AUROC curve with 95% CI, cut-off point and sensitivity for mortality (95% CI) of the high-risk category of the REDS score were: derivation: 0.78 (0.75 to 0.80); ≥3; 85.0 (78 to 90.5). Validation: 0.74 (0.71 to 0.76); ≥3; 84.5 (77.5 to 90.0). The AUROC curve and the sensitivity for mortality of the REDS score was better than that of the component scores. Specificity and mortality rates for REDS scores of ≥3, ≥5 and ≥7 were 54.8%, 88.8% and 96.9% and 21.8%, 36.0% and 49.1%, respectively.ConclusionThe REDS score is a simple and objective score to risk-stratify ED patients with suspected sepsis.

scholarly journals Role of presepsin for the evaluation of sepsis in the emergency department

2014 ◽  
Vol 0 (0) ◽  
Author(s):  
Elisa Pizzolato ◽  
Marco Ulla ◽  
Claudia Galluzzo ◽  
Manuela Lucchiari ◽  
Tilde Manetta ◽  
...  
Keyword(s):  
Emergency Department ◽  
Septic Shock ◽  
Early Diagnosis ◽  
Bacterial Infections ◽  
Acute Phase Proteins ◽  
Great Sensitivity ◽  
Healthy Population ◽  
Suspected Sepsis ◽  
Gold Standard Method ◽  
Suspected Infection

AbstractSepsis, severe sepsis and septic shock are among the most common conditions handled in the emergency department (ED). According to new Sepsis Guidelines, early diagnosis and treatment are the keys to improve survival. Plasma C-reactive protein (CRP) and procalcitonin (PCT) levels, when associated with documented or suspected infection, are now part of the definitions of sepsis. Blood culture is the gold standard method for detecting microorganisms but it requires too much time for results to be known. Sensitive biomarkers are required for early diagnosis and as indexes of prognosis sepsis. CRP is one of the acute phase proteins synthesized by the liver: it has a great sensitivity but a very poor specificity for bacterial infections. Moreover, the evolution of sepsis does not correlate with CRP plasma changes. In recent years PCT has been widely used for sepsis differential diagnosis, because of its close correlation with infections, but it still retains some limitations and false positivity (such as in multiple trauma and burns). Soluble CD14 subtype (sCD14-ST), also known as presepsin, is a novel and promising biomarker that has been shown to increase significantly in patients with sepsis, in comparison to the healthy population. Studies pointed out the capability of this biomarker for diagnosing sepsis, assessing the severity of the disease and providing a prognostic evaluation of patient outcome. In this mini review we mainly focused on presepsin: we evaluate its diagnostic and prognostic roles in patients presenting to the ED with systemic inflammatory response syndrome (SIRS), suspected sepsis or septic shock.

scholarly journals The Usefulness of C-Reactive Protein, Procalcitonin, and PELOD-2 Score as a Predictive Factor of Mortality in Sepsis

2020 ◽  
Vol 12 (2) ◽  
pp. 102-8
Author(s):  
Munar Lubis ◽  
Aridamuriany Dwiputri Lubis ◽  
Badai Buana Nasution
Keyword(s):  
Predictive Factor ◽  
Independent Predictor ◽  
Multivariate Logistic Regression Analysis ◽  
Pediatric Intensive Care ◽  
C Reactive Protein ◽  
Suspected Sepsis ◽  
Predictors Of Mortality ◽  
Reactive Protein ◽  
Logistic Organ Dysfunction ◽  
Pediatric Sepsis

BACKGROUND: Sepsis in children is a significant cause of morbidity and mortality in the pediatric intensive care unit (PICU). Assessment of pediatric sepsis using serial Pediatric Logistic Organ Dysfunction (PELOD)-2 score can be used as a prognostic factor. The use of biomarkers of sepsis is also used for diagnosis and predicting outcomes. Many studies have suggested that C-reactive protein (CRP) and procalcitonin (PCT) can be used to predict mortality.METHODS: A prospective cohort study was conducted to evaluate CRP, PCT, PELOD-2 score and its combination as a predictive factor of mortality in sepsis. All patients admitted to PICU Haji Adam Malik General Hospital, Medan, from April to November 2019 with suspected sepsis were included in this study. Blood examination and PELOD-2 scores were examined in the first 24 hours.RESULTS: A total of 79 children were included with a mortality rate 55.7%. The CRP, PCT, and PELOD-2 score were higher in nonsurvivor (2.8 (0.5-22.4) mg/dL; 9.36 (0.13-79.8) ng/mL; 9 (3-21), respectively). In multivariate logistic regression analysis, neither CRP nor PCT values could be independent predictors of mortality. The PELOD-2 score can be an independent predictor for mortality at a cut-off score of 7 (OR: 3.47 (95% CI: 1.68-7.19)). The combination of PELOD-2 and CRP scores as predictors of mortality showed lower values than PELOD-2 and PCT scores (0.80 vs. 0.95). The combination of all parameters only adds 1% of the predicted mortality value.CONCLUSION: PELOD-2 score with PCT value are recommended to predict mortality children with sepsis.KEYWORDS: sepsis, mortality, C-reactive protein, procalcitonin, PELOD-2 score

A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis

2020 ◽  
Vol 222 (Supplement_2) ◽  
pp. S110-S118
Author(s):  
Jeremy Weinberger ◽  
Chanu Rhee ◽  
Michael Klompas
Keyword(s):  
Septic Shock ◽  
Severity Of Illness ◽  
Signs And Symptoms ◽  
Suspected Sepsis ◽  
Antibiotic Overuse ◽  
Time To Antibiotics ◽  
Precise Relationship ◽  
Inflated Estimate ◽  
Almost All ◽  
Sepsis And Septic Shock

Abstract The Surviving Sepsis Campaign recommends immediate antibiotics for all patients with suspected sepsis and septic shock, ideally within 1 hour of recognition. Immediate antibiotic treatment is lifesaving for some patients, but a substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions. Aggressive time-to-antibiotic targets risk promoting antibiotic overuse and antibiotic-associated harms for this subset of the population. An accurate understanding of the precise relationship between time-to-antibiotics and mortality for patients with possible sepsis is therefore critical to finding the best balance between assuring immediate antibiotics for those patients who truly need them versus allowing clinicians some time for rapid investigation to minimize the risk of overtreatment and antibiotic-associated harms for patients who are not infected. More than 30 papers have been published assessing the relationship between time-to-antibiotics and outcomes, almost all of which are observational cohort studies. Most report significant associations but all have important limitations. Key limitations include focusing just on the sickest subset of patients (only patients requiring intensive care and/or patients with septic shock), blending together mortality estimates from patients with very long intervals until antibiotics with patients with shorter intervals and reporting a single blended (and thus inflated) estimate for the average increase in mortality associated with each hour until antibiotics, and failure to control for large potential confounders including patients’ presenting signs and symptoms and granular measures of comorbidities and severity of illness. In this study, we elaborate on these potential sources of bias and try to distill a better understanding of what the true relationship between time-to-antibiotics and mortality may be for patients with suspected sepsis or septic shock.

scholarly journals Evaluation of the Angus ICD9-CM Sepsis Abstraction Criteria

2017 ◽  
Author(s):  
Steven Horng ◽  
Larry A. Nathanson ◽  
David A. Sontag ◽  
Nathan I. Shapiro
Keyword(s):  
Emergency Department ◽  
Outcome Measure ◽  
High Specificity ◽  
International Classification Of Diseases ◽  
The United States ◽  
Primary Outcome Measure ◽  
Suspected Infection ◽  
True Incidence ◽  
Classification Of Diseases ◽  
Observational Cohort

AbstractObjectiveValidate the infection component of the Angus International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) sepsis abstraction criteriaDesignObservational cohort studySetting55,000 visits/year Adult Emergency Department (ED)PatientsAll consecutive ED patient visits between 12/16/2011 and 08/13/2012 were included in the study. Patients were excluded if there was a missing outcome measure.InterventionsNone.Measurements and Main ResultsThe primary outcome measure was suspected infection at conclusion of the ED work-up as judged by the physician. There were 34,796 patients who presented to the ED between 12/16/11 and 8/13/12, of which 31,755 (91%) patients were included and analyzed. The original Angus sepsis abstraction criteria had a sensitivity of 55%, specificity of 97%, PPV of 82%, NPV of 88%, accuracy of 87%, and a F1score of 0.66. The modified Angus sepsis abstraction criteria which includes codes added after the original publication had a sensitivity of 65%, specificity of 96%, PPV of 81%, NPV of 91%, accuracy of 89%, and F1score of 0.72.ConclusionsIn our study, the Angus abstraction criteria have high specificity (97%), but moderate sensitivity (55%) in identifying patients with suspected infection as defined by physician at the time of disposition from the emergency department. Given these findings, it is likely that we are underestimating the true incidence of sepsis in the United States and worldwide.

scholarly journals OP0240 EPIDEMIOLOGY, PREDICTORS OF MORTALITY AND ROLE OF PROPHYLAXIS FOR PNEUMOCYSTITIS JIROVECI PNEUMONIA AMONG RHEUMATIC PATIENTS: A TERRITORY-WIDE STUDY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 147-147
Author(s):  
C. W. S. Chan ◽  
H. Y. Chung ◽  
W. Y. Yeung ◽  
C. S. Lau ◽  
P. H. LI
Keyword(s):  
Lupus Erythematosus ◽  
Absolute Risk ◽  
Absolute Risk Reduction ◽  
Number Needed To Treat ◽  
Healthcare Database ◽  
Pneumocystis Jiroveci ◽  
Predictors Of Mortality ◽  
Prednisolone Dose ◽  
Rheumatic Patients

Background:Pneumocystis jiroveci pneumonia (PJP) is an opportunistic infection affecting immunocompromised individuals. Due to its high mortality, PJP prophylaxis is commonly recommended for many immunocompromising conditions. However, evidence regarding the burden and role of prophylaxis in PJP among rheumatic patients remains limited. There is lack of consensus for when and for whom to initiate prophylaxis. Delineating the epidemiology, predictors of mortality and efficacy of prophylaxis in PJP among rheumatic patients is urgently needed.Objectives:To delineate the epidemiology of PJP, identify predictors of mortality and evaluate the usefulness of prophylaxis in rheumatology patients.Methods:We performed a big-data cohort study based on the territory-wide healthcare database of the Hong Kong Hospital Authority. All patients with a diagnosis of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), immune-mediated myositis (IMM), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), or spondyloarthritis (SpA) between 2015-2019 were included. PJP were identified based on physician diagnosis and/or positive microbiological results from deep respiratory tract specimens. Prophylaxis was defined as prescription of a prophylactic dose of co-trimoxazole for at least 2 weeks and/or inhaled pentamidine. Prevalence of PJP, prophylaxis and mortality among rheumatic patients were calculated. Demographics, blood parameters and immunosuppressants use was also collected for multivariate analysis. Number needed to treat (NNT) analysis was performed based on absolute risk reduction of PJP in patients with and without prior PJP prophylaxis.Results:A total of 21,587 unique rheumatic patients were analysed (54% RA, 25% SLE, 13% SpA, 5% IMM, 2% AAV and 1% SSc). Between 2015-2019, 1141 (5.3%) patients were prescribed PJP prophylaxis and 48 (0.2%) developed PJP. None of those patients who developed PJP had received prophylaxis prior to infection. The risk of PJP was highest among SSc (1.8%), AAV (1.4%) and IMM (0.7%) patients, with NNT of SSc 36, AAV 48 and IMM 114. Within these disease entities, the majority of PJP occurred at prednisolone dose of 15mg/day (P15) or above (100% in SSc and IIM, 66.7% in AAV). Overall, PJP was associated with a mortality-rate of 39.6%. Glucocorticoid dose (daily prednisolone dose equivalent 29.1±23.5mg vs 11.4±7.2mg, P<0.01) and lymphopenia (0.44x109/L vs 0.90x109/L, P= 0.04) at PJP diagnosis were associated with PJP mortality in rheumatic patients.Conclusion:PJP is an uncommon but important infection in rheumatic patients associated with significant mortality. PJP prophylaxis is effective and should be considered in patients with SSc, AAV and IMM, especially in those receiving a steroid dose above P15.Disclosure of Interests:None declared

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