Sepsis Current Awareness Bulletin - July 2021 - Royal United Hospitals ...
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Sepsis
Current Awareness Bulletin
July 2021
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Email: ruh-tr.library@nhs.netTitle: A Wrinkle in Time to Antibiotics in Sepsis: When Should ONE Hour Be the Goal?
Citation: Journal of Pediatrics; Jun 2021; vol. 233 ; p. 13-15
Author(s): Chiotos ; Weiss, Scott L.
Title: Albumin replacement therapy in immunocompromised patients with sepsis –
Secondary analysis of the ALBIOS trial
Citation: Journal of Critical Care; Jun 2021; vol. 63 ; p. 83
Author(s): Cortegiani, Andrea; Grasselli, Giacomo; Meessen, Jennifer; Moscarelli,
Alessandra; Ippolito, Mariachiara; Turvani, Fabrizio; Bonenti, Chiara Maria; Romagnoli,
Stefano; Volta, Carlo Alberto; Bellani, Giacomo; Giarratano, Antonino; Latini, Roberto;
Pesenti, Antonio; Caironi, Pietro
Background: The best fluid replacement strategy and the role of albumin in
immunocompromised patients with sepsis is unclear.
Methods: We performed a secondary analysis of immunocompromised patients enrolled in
the ALBIOS trial which randomized patients with severe sepsis or septic shock to receive
either 20% albumin (target 30 g per liter or more) and crystalloid or crystalloid alone during
ICU stay.
Results: Of 1818 patients originally enrolled, 304 (16.4%) were immunocompromised. One-
hundred-thirty-nine (45.7%) patients were randomized in the albumin while 165 (54.2%) in
the crystalloid group. At 90 days, 69 (49.6%) in the albumin group and 89 (53.9%) in the
crystalloids group died (hazard ratio - HR - 0.94; 95% CI 0.69–1.29). No differences were
observed with regards to 28-day mortality, SOFA score (and sub-scores), length of stay in
the ICU and in the hospital, proportion of patients who had developed acute kidney injury or
received renal replacement therapy, duration of mechanical ventilation. Albumin was not
independently associated with a higher or lower 90-day mortality (HR 0.979, 95% CI 0.709–
1.352) as compared to crystalloid.
Conclusion: Albumin replacement during the ICU stay, as compared with crystalloids alone,
did not affect clinical outcomes in a cohort of immunocompromised patients with sepsis.
Title: Association of Annual Intensive Care Unit Sepsis Caseload With Hospital
Mortality From Sepsis in the United Kingdom, 2010-2016.
Citation: JAMA Network Open; Jun 2021; vol. 4 (no. 6)
Author(s): Maharaj ; McGuire, Alistair; Street, Andrew
Abstract: This cohort study assesses the association between the annual volume of
patients with sepsis treated in intensive care units of UK hospitals and hospital mortality from
sepsis between 2010 and 2016.
Key Points: Question: Is there an association between the annual volume of sepsis cases
in an intensive care unit (ICU) and hospital mortality from sepsis?
Findings: In this cohort study of 273 001 patients with sepsis at 231 ICUs in the UK, a
higher annual sepsis case volume in the ICU was associated with significantly lower hospital
mortality, and this association had no significant interaction with illness severity. A lower
volume threshold of 215 treated patients was identified, above which hospital mortality
decreased significantly.
2Meaning: The findings suggest that patients with sepsis in the UK have higher odds of
survival if treated in an ICU with a higher sepsis case volume.
Importance: Sepsis is associated with a high burden of inpatient mortality. Treatment in
intensive care units (ICUs) that have more experience treating patients with sepsis may be
associated with lower mortality. Objective: To assess the association between the volume of
patients with sepsis receiving care in an ICU and hospital mortality from sepsis in the UK.
Design, Setting, and Participants: This retrospective cohort study used data from adult
patients with sepsis from 231 UK ICUs between 2010 and 2016. Demographic and clinical
data were extracted from the Intensive Care National Audit & Research Centre (ICNARC)
Case Mix Programme database. Data were analyzed from January 1, 2010, to December
31, 2016.
Exposures: Annual sepsis case volume in an ICU in the year of a patient's admission.
Main Outcomes and Measures: Hospital mortality after ICU admission for sepsis assessed
using a mixed-effects logistic model in a 3-level hierarchical structure based on the number
of individual patients nested in years nested within ICUs.
Results: Among 273 001 patients included in the analysis, the median age was 66 years
(interquartile range, 53-76 years), 148 149 (54.3%) were male, and 248 275 (91.0%) were
White. The mean ICNARC-2018 illness severity score was 21.0 (95% CI, 20.9-21.0). Septic
shock accounted for 19.3% of patient admissions, and 54.3% of patients required
mechanical ventilation. The median annual sepsis volume per ICU was 242 cases
(interquartile range, 177-334 cases). The study identified a significant association between
the volume of sepsis cases in the ICU and mortality from sepsis; in the logistic regression
model, hospital mortality was significantly lower among patients admitted to ICUs in the
highest quartile of sepsis volume compared with the lowest quartile (odds ratio [OR], 0.89;
95% CI, 0.82-0.96; P =.002). With volume modeled as a restricted cubic spline, treatment in
a larger ICU was associated with lower hospital mortality. A lower annual volume threshold
of 215 patients above which hospital mortality decreased significantly was found; 38.8% of
patients were treated in ICUs below this threshold volume. There was no significant
interaction between ICU volume and severity of illness as described by the ICNARC-2018
score (β [SE], –0.00014 [0.00024]; P =.57).
Conclusions and Relevance: The findings suggest that patients with sepsis in the UK have
higher odds of survival if they are treated in an ICU with a larger sepsis case volume. The
benefit of a high sepsis case volume was not associated with the severity of the sepsis
episode.
Title: Association of Positive Fluid Balance at Discharge After Sepsis Management
With 30-Day Readmission.
Citation: JAMA Network Open; Jun 2021; vol. 4 (no. 6)
Author(s): Yoo ; Zhu, Shiyun; Lu, Yun; Greene, John D.; Hammer, Helen L.; Iberti, Colin T.;
Nemazie, Siamack; Ananias, Martin P.; McCarthy, Caitlin M.; O'Malley, Robert M.; Young,
Karlyn L.; Reed, Karolin O.; Martinez, Robert A.; Cheung, Kawai; Liu, Vincent X.
Key Points: Question: For non–critically ill patients hospitalized with sepsis, is there an
association between positive fluid balance at the time of discharge and 30-day readmission?
Findings: In this cohort study that included 57 032 adults hospitalized with sepsis, no
association was found between net fluid balance at the time of discharge and 30-day
readmission. Findings may be limited by incomplete capture of intake and output net fluid
balance and residual confounding.
3Meaning: No association was found between positive fluid balance and readmission in this
large observational study of non–critically ill patients with sepsis, but further investigation is
needed.
Importance: Although early fluid administration has been shown to lower sepsis mortality,
positive fluid balance has been associated with adverse outcomes. Little is known about
associations in non–intensive care unit settings, with growing concern about readmission
from excess fluid accumulation in patients with sepsis.
Objective: To evaluate whether positive fluid balance among non–critically ill patients with
sepsis was associated with increased readmission risk, including readmission for heart
failure.
Design, Setting, and Participants: This multicenter retrospective cohort study was
conducted between January 1, 2012, and December 31, 2017, among 57 032 non–critically
ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser
Permanente Northern California is an integrated health care system with a community-based
population of more than 4.4 million members. Statistical analysis was performed from
January 1 to December 31, 2019.
Exposures: Intake and output net fluid balance (I/O) measured daily and cumulatively at
discharge (positive vs negative).
Main Outcomes and Measures: The primary outcome was 30-day readmission. The
secondary outcomes were readmission stratified by category and mortality after living
discharge.
Results: The cohort included 57 032 patients who were hospitalized for sepsis (28 779
women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O
(40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased
comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease,
diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719
patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in
readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05).
No association was detected between readmission and I/O using continuous, splined, and
quadratic function transformations. Positive I/O was associated with decreased heart failure–
related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23
[95% CI, 1.15-1.31]).
Conclusions and Relevance: In this large observational study of non–critically ill patients
hospitalized with sepsis, there was no association between positive fluid balance at the time
of discharge and readmission. However, these findings may have been limited by variable
recording and documentation of fluid intake and output; additional studies are needed to
examine the association of fluid status with outcomes in patients with sepsis to reduce
readmission risk. This cohort study evaluates whether positive fluid balance among non–
critically ill patients with sepsis was associated with increased readmission risk, including
readmission for heart failure.
Title: Biomarkers for the Diagnosis of Neonatal Sepsis
Citation: Clinics in Perinatology; Jun 2021; vol. 48 (no. 2); p. 215-227
Author(s): Cantey J.B.; Lee J.H.
Title: Blood lactate levels in sepsis: in 8 questions
Citation: Current opinion in critical care; Jun 2021; vol. 27 (no. 3); p. 298-302
4Author(s): Vincent J.-L.; Bakker J.
Purpose Of Review: Blood lactate concentrations are frequently measured in critically ill
patients and have important prognostic value. Here, we review some key questions related
to their clinical use in sepsis.
Recent Findings: Despite the metabolic hurdles, measuring lactate concentrations remains
very informative in clinical practice. Although blood lactate levels change too slowly to
represent the only guide to resuscitation, serial lactate levels can help to define the patient's
trajectory and encourage a review of the therapeutic strategy if they remain stable or
increase over time.
Summary: Lactate concentrations respond too slowly to be used to guide acute changes in
therapy, but can help evaluate overall response. Hyperlactatemia should not be considered
as a problem in itself, but as a warning of altered cell function. Copyright © 2021 Wolters
Kluwer Health, Inc. All rights reserved.
Title: Coagulopathy and sepsis: Pathophysiology, clinical manifestations and
treatment.
Citation: Blood reviews; Jun 2021 ; p. 100864
Author(s): Giustozzi, Michela; Ehrlinder, Hanne; Bongiovanni, Dario; Borovac, Josip A;
Guerreiro, Rui Azevedo; Gąsecka, Aleksandra; Papakonstantinou, Panteleimon E; Parker,
William A E
Abstract: Sepsis is a complex syndrome with a high incidence, increasing by 8.7% annually
over the last 20 years. Coagulopathy is a leading factor associated with mortality in patients
with sepsis and range from slight thrombocytopenia to fatal disorders, such as disseminated
intravascular coagulation (DIC). Platelet reactivity increases during sepsis but prospective
trials of antiplatelet therapy during sepsis have been disappointing. Thrombocytopenia is a
known predictor of worse prognosis during sepsis. The mechanisms underlying
thrombocytopenia in sepsis have yet to be fully understood but likely involves decreased
platelet production, platelet sequestration and increased consumption. DIC is an acquired
thrombohemorrhagic syndrome, resulting in intravascular fibrin formation, microangiopathic
thrombosis, and subsequent depletion of coagulation factors and platelets. DIC can be
resolved with treatment of the underlying disorder, which is considered the cornerstone in
the management of this syndrome. This review presents the current knowledge on the
pathophysiology, diagnosis, and treatment of sepsis-associated coagulopathies.
Title: Delayed Administration of Antibiotics Beyond the First Hour of Recognition Is
Associated with Increased Mortality Rates in Children with Sepsis/Severe Sepsis and
Septic Shock.
Citation: Journal of Pediatrics; Jun 2021; vol. 233 ; p. 183-183
Author(s): Sankar ; Garg, Mohil; Ghimire, Jagat Jeevan; Sankar, M. Jeeva; Lodha, Rakesh;
Kabra, Sushil K.
Objective: To compare the risk of mortality and other clinical outcomes in children with
sepsis, severe sepsis, or septic shock who received antibiotics within the first hour of
recognition (early antibiotics group) with those who received antibiotics after the first hour
(delayed antibiotics group).
5Study Design: In this prospective cohort study, we enrolled children
(SQSTM1). Pharmacological modulation of the immunocoagulation pathways emerge as
novel and potential therapeutic strategies for sepsis.
Title: Global incidence and mortality of neonatal sepsis: A systematic review and
meta-analysis
Citation: Archives of Disease in Childhood; 2021
Author(s): Fleischmann C.; Reichert F.; Horner R.; Harder T.; Markwart R.; Trondle M.;
Savova Y.; Eckmanns T.; Cassini A.; Allegranzi B.; Kissoon N.; Schlattmann P.; Reinhart K.
Background: Neonates are at major risk of sepsis, but data on neonatal sepsis incidence
are scarce. We aimed to assess the incidence and mortality of neonatal sepsis worldwide.
Method(s): We performed a systematic review and meta-analysis. 13 databases were
searched for the period January 1979-May 2019, updating the search of a previous
systematic review and extending it in order to increase data inputs from low-income and
middle-income countries (LMICs). We included studies on the population-level neonatal
sepsis incidence that used a clinical sepsis definition, such as the 2005 consensus definition,
or relevant ICD codes. We performed a random-effects meta-analysis on neonatal sepsis
incidence and mortality, stratified according to sepsis onset, birth weight, prematurity, study
setting, WHO region and World Bank income level.
Result(s): The search yielded 4737 publications, of which 26 were included. They
accounted for 2 797 879 live births and 29 608 sepsis cases in 14 countries, most of which
were middle-income countries. Random-effects estimator for neonatal sepsis incidence in
the overall time frame was 2824 (95% CI 1892 to 4194) cases per 100 000 live births, of
which an estimated 17.6% 9 (95% CI 10.3% to 28.6%) died. In the last decade (2009-2018),
the incidence was 3930 (95% CI 1937 to 7812) per 100 000 live births based on four studies
from LMICs. In the overall time frame, estimated incidence and mortality was higher in early-
onset than late-onset neonatal sepsis cases. There was substantial between-study
heterogeneity in all analyses. Studies were at moderate to high risk of bias.
Conclusion(s): Neonatal sepsis is common and often fatal. Its incidence remains unknown
in most countries and existing studies show marked heterogeneity, indicating the need to
increase the number of epidemiological studies, harmonise neonatal sepsis definitions and
improve the quality of research in this field. This can help to design and implement targeted
interventions, which are urgently needed to reduce the high incidence of neonatal sepsis
worldwide. Copyright © Author(s) (or their employer(s)) 2021. Re-use permitted under CC
BY. Published by BMJ.
Title: Impact of Body Mass Index on the Survival of Patients with Sepsis with Different
Modified NUTRIC Scores.
Citation: Nutrients; Jun 2021; vol. 13 (no. 6); p. 1873-1873
Author(s): Tsai ; Lin, Chiung-Yu; Chen, Yu-Mu; Chang, Yu-Ping; Hung, Kai-Yin; Chang, Ya-
Chun; Chen, Hung-Cheng; Huang, Kuo-Tung; Chen, Yung-Che; Wang, Yi-Hsi; Wang, Chin-
Chou; Lin, Meng-Chih; Fang, Wen-Feng
Abstract: Nutritional status affects the survival of patients with sepsis. This retrospective
study analyzed the impact of body mass index (BMI) and modified nutrition risk in critically ill
(mNUTRIC) scores on survival of these patients. Data of 1291 patients with sepsis admitted
to the intensive care unit (ICU) were extracted. The outcomes were mortality, duration of
7stay, ICU stay, and survival curve for 90-day mortality. Logistic regression analysis was
performed to examine the risk factors for mortality. Cytokine and biomarker levels were
analyzed in 165 patients. The 90-day survival of underweight patients with low mNUTRIC
scores was significantly better than that of normal-weight patients with low mNUTRIC scores
(70.8% vs. 58.3%, respectively; p = 0.048). Regression model analysis revealed that
underweight patients with low mNUTRIC scores had a lower risk of mortality (odds ratio =
0.557; p = 0.082). Moreover, normal-weight patients with low mNUTRIC scores had the
lowest human leukocyte antigen DR (HLA-DR) level on days 1 (underweight vs. normal
weight vs. overweight: 94.3 vs. 82.1 vs. 94.3, respectively; p = 0.007) and 3 (91.8 vs. 91.0
vs. 93.2, respectively; p = 0.047). Thus, being underweight may not always be harmful if
patients have optimal clinical nutritional status. Additionally, HLA-DR levels were the lowest
in patients with low survival.
Title: Impact of Right Ventricular Dysfunction on Short-term and Long-term Mortality
in Sepsis: A Meta-analysis of 1,373 Patients.
Citation: Chest; Jun 2021; vol. 159 (no. 6); p. 2254-2263
Author(s): Vallabhajosyula ; Shankar, Aditi; Vojjini, Rahul; Cheungpasitporn, Wisit;
Sundaragiri, Pranathi R.; DuBrock, Hilary M.; Sekiguchi, Hiroshi; Frantz, Robert P.; Cajigas,
Hector R.; Kane, Garvan C.; Oh, Jae K.
Background: Right ventricular (RV) dysfunction in sepsis and septic shock has been
infrequently studied and has uncertain prognostic significance.
Research Question: Does RV function impact mortality in sepsis and septic shock?
Study Design and Methods: We reviewed the published literature from January 1999 to
April 2020 for studies evaluating adult patients with sepsis and septic shock. Study definition
of RV dysfunction was used to classify patients. The primary outcome was all-cause
mortality divided into short-term mortality (ICU stay, hospital stay, or mortality ≤30 days) and
long-term mortality (>30 days). Effect estimates from the individual studies were extracted
and combined, using the random-effects, generic inverse variance method of DerSimonian
and Laird.
Results: Ten studies, 1,373 patients, were included; RV dysfunction was noted in 477
(34.7%). RV dysfunction was variably classified as decreased RV systolic motion, high
RV/left ventricular ratio and decreased RV ejection fraction. Septic shock, ARDS, and
mechanical ventilation were noted in 82.0%, 27.5%, and 78.4% of the population,
respectively. Patients with RV dysfunction had lower rates of mechanical ventilation
(71.9% vs 81.9%; P < .001), higher rates of acute hemodialysis (38.1% vs 22.4%; P = .04),
but comparable rates of septic shock and ARDS. Studies showed moderate (I2 = 58%) and
low (I2 = 49%) heterogeneity for short-term and long-term mortality, respectively. RV
dysfunction was associated with higher short-term (pooled OR, 2.42; 95%CI, 1.52-3.85; P =
.0002) (10 studies) and long-term (pooled OR, 2.26; 95%CI, 1.29-3.95; P = .004) (4 studies)
mortality.
Interpretation: In this meta-analysis of observational studies, RV dysfunction was
associated with higher short-term and long-term mortality in sepsis and septic shock.
Title: Improving the Accuracy of Sepsis Screening by Nurses in Hospitalized Older
Adults: A Pilot Interventional Study.
Citation: Journal of Gerontological Nursing; Jun 2021; vol. 47 (no. 6); p. 27-34
Author(s): Nieves, Aldrin U.; Love, Pamela J.; Estey, Alisa J.
8Abstract: The current quality improvement interventional study aimed to determine whether
an educational intervention focused on evidence-based practices of sepsis screening for
RNs would increase accuracy of sepsis screenings performed among older adult patients in
a 32-bed medical-surgical unit of a large urban trauma hospital. A total of 34 RNs
participated in this study. Sepsis screenings of participants were collected and audited
before and after the educational intervention to determine changes in sepsis screening
accuracy. A dependent samples t test was used to assess the statistical difference between
pre- and post-intervention sepsis screening scores. Results indicated that the educational
intervention effectively increased sepsis screening accuracy in older adult patients at the
study center (p = 0.007), with a mean increase of 22.06% accuracy. Accurate sepsis
screening is crucial for early sepsis diagnosis and treatment to improve the clinical outcomes
of older adult patients with sepsis, reduce health care costs, and decrease resource use.
Title: Looking to the future of physiologically informed sepsis resuscitation: The role
of dynamic fluid-responsive measurement.
Citation: Chest Physician; Jun 2021; vol. 16 (no. 6); p. 10-11
Author(s): Douglas, Ivor S.; Sahatjian, Jennifer A.; Hansell, Douglas M.
Title: Maternal sepsis update
Citation: Current opinion in anaesthesiology; Jun 2021; vol. 34 (no. 3); p. 254-259
Author(s): Abir G.; Bauer M.E.
Purpose Of Review: Maternal sepsis is the second leading cause of maternal death in the
United States. A significant number of these deaths are preventable and the purpose of this
review is to highlight causes such as delays in recognition and early treatment.
Recent Findings: Maternal sepsis can be difficult to diagnose due to significant overlap of
symptoms and signs of normal physiological changes of pregnancy, and current screening
tools perform poorly to identify sepsis in pregnant women. Surveillance should not only
include during pregnancy, but also throughout the postpartum period, up to 42 days
postpartum. Education and awareness to highlight this importance are not only vital for
obstetric healthcare provides, but also for nonobstetric healthcare providers, patients, and
support persons.
Summary: Through education and continual review and analysis of evidence-based
practice, a reduction in maternal morbidity and mortality secondary to maternal sepsis
should be attainable with dedication from all disciplines that care for obstetric and
postpartum patients. Education and vigilance also extend to patients and support persons
who should be empowered to escalate care when needed. Copyright © 2021 Wolters Kluwer
Health, Inc. All rights reserved.
Title: Non-invasive assessment of fluid responsiveness to guide fluid therapy in
patients with sepsis in the emergency department: a prospective cohort study.
Citation: Emergency Medicine Journal; Jun 2021; vol. 38 (no. 6); p. 416-422
Author(s): Koopmans ; Stolmeijer, Renate; Sijtsma, Ben C.; van Beest, Paul A.; Boerma,
Christiaan E.; Veeger, Nic J.; Avest, Ewoudter; Ter Avest, Ewoud
9Background: Little is known about optimal fluid therapy for patients with sepsis without shock who present to the ED. In this study, we aimed to quantify the effect of a fluid challenge on non-invasively measured Cardiac Index (CI) in patients presenting with sepsis without shock. Methods: In a prospective cohort study, CI, stroke volume (SV) and systemic vascular resistance (SVR) were measured non-invasively in 30 patients presenting with sepsis without shock to the ED of a large teaching hospital in the Netherlands between May 2018 and March 2019 using the ClearSight system. After baseline measurements were performed, a passive leg raise (PLR) was done to simulate a fluid bolus. Measurements were then repeated 30, 60, 90 and 120 s after PLR. Finally, a standardised 500 mL NaCl 0.9% intravenous bolus was administered after which final measurements were done. Fluid responsiveness was defined as >15% increase in CI after a standardised fluid challenge. Measurements and Main Results: Seven out of 30 (23%) patients demonstrated a >15% increase in CI after PLR and after a 500 mL fluid bolus. Fluid responders had a higher estimated glomerular filtration rate (eGFR) (64 (44-78) vs 37 (23-47), p=0.009) but otherwise similar patient and treatment characteristics as non-responders. Baseline measurements of cardiac output (CO), CI, SV and SVR were unrelated to PLR fluid responsiveness. The change in CI after PLR was strongly positive correlated to the change in CI after a 500 mL NaCl 0.9% fluid bolus (r=0.88, p
Title: Predicting mortality in adult patients with sepsis in the emergency department
by using combinations of biomarkers and clinical scoring systems: a systematic
review.
Citation: BMC Emergency Medicine; Jun 2021; vol. 21 (no. 1); p. 1-11
Author(s): Tong-Minh ; Welten, Iris; Endeman, Henrik; Hagenaars, Tjebbe; Ramakers,
Christian; Gommers, Diederik; van Gorp, Eric; van der Does, Yuri
Background: Sepsis can be detected in an early stage in the emergency department (ED)
by biomarkers and clinical scoring systems. A combination of multiple biomarkers or
biomarker with clinical scoring system might result in a higher predictive value on mortality.
The goal of this systematic review is to evaluate the available literature on combinations of
biomarkers and clinical scoring systems on 1-month mortality in patients with sepsis in the
ED.
Methods: We performed a systematic search using MEDLINE, EMBASE and Google
Scholar. Articles were included if they evaluated at least one biomarker combined with
another biomarker or clinical scoring system and reported the prognostic accuracy on 28 or
30 day mortality by area under the curve (AUC) in patients with sepsis. We did not define
biomarker cut-off values in advance.
Results: We included 18 articles in which a total of 35 combinations of biomarkers and
clinical scoring systems were studied, of which 33 unique combinations. In total, seven
different clinical scoring systems and 21 different biomarkers were investigated. The
combination of procalcitonin (PCT), lactate, interleukin-6 (IL-6) and Simplified Acute
Physiology Score-2 (SAPS-2) resulted in the highest AUC on 1-month mortality.
Conclusion: The studies we found in this systematic review were too heterogeneous to
conclude that a certain combination it should be used in the ED to predict 1-month mortality
in patients with sepsis. Future studies should focus on clinical scoring systems which require
a limited amount of clinical parameters, such as the qSOFA score in combination with a
biomarker that is already routinely available in the ED.
Title: Preventing sepsis; how can artificial intelligence inform the clinical decision-
making process? A systematic review
Citation: International Journal of Medical Informatics; Jun 2021; vol. 150
Author(s): Hassan N.; Slight S.P.; Slight R.; Weiand D.; Vellinga A.; Morgan G.;
Aboushareb F.
Background and Objectives: Sepsis is a life-threatening condition that is associated with
increased mortality. Artificial intelligence tools can inform clinical decision making by flagging
patients at risk of developing infection and subsequent sepsis. This systematic review aims
to identify the optimal set of predictors used to train machine learning algorithms to predict
the likelihood of an infection and subsequent sepsis.
Method(s): This systematic review was registered in PROSPERO database
(CRD42020158685). We conducted a systematic literature review across 3 large databases:
Medline, Cumulative Index of Nursing and Allied Health Literature, and Embase. Quantitative
primary research studies that focused on sepsis prediction associated with bacterial infection
in adults in all care settings were eligible for inclusion.
Result(s): Seventeen articles met our inclusion criteria. We identified 194 predictors that
were used to train machine learning algorithms, with 13 predictors used on average across
11all included studies. The most prevalent predictors included age, gender, smoking, alcohol
intake, heart rate, blood pressure, lactate level, cardiovascular disease, endocrine disease,
cancer, chronic kidney disease (eGFR34-
week gestation was conducted using the Cochrane methodology. Databases PubMed,
CINAHL, Embase, Cochrane Central library and Google Scholar were searched in May
2019. Primary outcomes were antibiotics usage and laboratory tests for managing EOS.
Secondary outcomes included hospital admissions and readmissions, blood culture positive
EOS and mortality. The level of evidence (LOE) was summarized using the GRADE
guidelines.
12Results: A total of 387 articles were retrieved after initial search. Six high quality non-RCTs
fulfilled inclusion criteria. Meta-analysis (random effects model) showed that implementation
of sepsis calculator was associated with reduced antibiotic usage [N = 172,385; OR = 0.22
(0.14-0.36); p < .00001; heterogeneity (I2) = 97%, Number needed to treat (NNT): 22],
laboratory tests [N = 168,432; OR = 0.14 (0.08-0.27); p < .00001; I2 = 99%, NNT = 8], and
admissions to neonatal unit [N = 16,628; OR = 0.24 (0.11-0.51); p = .0002; I2 = 98%,
NNT = 7]; LOE: moderate. There was no difference in mortality, culture positive EOS, and
readmissions.
Conclusion: Moderate quality evidence indicates that the implementation of a sepsis
calculator was associated with reduced usage of antibiotics, laboratory tests and admission
to neonatal unit with no increase in mortality and readmissions.
Title: Septic shock: Clinical indicators and implications to critical patient care
Citation: Journal of Clinical Nursing; Jun 2021; vol. 30 (no. 11-12); p. 1607
Author(s): Luciana Ramos Corrêa Pinto; Karina de Oliveira Azzolin; Amália de Fátima
Lucena; Moretti, Miriane M S; Haas, Jaqueline S; Moraes, Rafael B; Friedman, Gilberto
Aims and Objective: To identify clinical indicators of septic shock in critical care patients.
Background: The identification of clinical indicators of septic shock is relevant to avoid
clinical deterioration of patients with sepsis. However, the recognition of these factors,
especially by the nursing team, is still deficient and reinforces the need for studies that
investigate the subject in different realities such as that of Brazil.
Design: The study had a cross-sectional design based on STROBE guidelines (see
Appendix S1).
Methods: A sample of 392 patients with sepsis or septic shock was admitted to the
Intensive Care Unit of a Brazilian university hospital. Data were collected from medical
records of the Intrahospital Sepsis Combat Program referring to patients admitted between
January 2018–January 2019. Sociodemographic and clinical data were collected, as well as
information on the time from diagnosis of sepsis or septic shock to initiation of antibiotic
therapy, length of stay, and discharge or death outcomes. Data were statically analysed.
Results: Out of the total sample, 190 (49%) patients were admitted with septic shock.
Clinical indicators of septic shock were hypotension, mechanical ventilation, lactate levels
between 2.0–3.9 or >4, hypothermia 3 and admittance through the emergency unit. Among
patients with septic shock, 85 (44.7%) were discharged and 105 (55.2%) died in the
intensive care unit.
Conclusions: Patients with septic shock presented hyperlactataemia and greater organic
dysfunction as clinical indicators when compared to patients with sepsis. Mechanical
ventilation, chemotherapy and radiotherapy increased the risk of developing septic shock.
Relevance To Clinical Practice: Our results can support the nursing team by providing the
main clinical indicators of septic shock and contributing to the interprofessional team in the
prevention of septic shock.
Title: The Efficacy of vitamin C, thiamine, and corticosteroid therapy in adult sepsis
patients: a systematic review and meta-analysis.
Citation: Acute and critical care; Jun 2021
Author(s): Somagutta, Manoj Kumar Reddy; Pormento, Maria Kezia Lourdes; Khan,
Muhammad Adnan; Hamdan, Alaa; Hange, Namrata; Kc, Manish; Pagad, Sukrut; Jain, Molly
13Sanjay; Lingarajah, Sivasthikka; Sharma, Vishal; Kaur, Jaspreet; Emuze, Bernard; Batti, Erkan; Iloeje, Obumneme Jude Background: Previous studies have suggested favorable outcomes of hydrocortisone, ascorbic acid (vitamin C), and thiamine (HAT) therapy in patients with sepsis. However, similar results have not been duplicated in sequential studies. This meta-analysis aimed to reevaluate the value of HAT treatment in patients with sepsis. Methods: Electronic databases were searched up until October 2020 for any studies that compared the effect of HAT versus non-HAT use in patients with sepsis. Results: Data from 15 studies (eight randomized controlled trials [RCTs] and seven cohort studies) involving 67,349 patients were included. The results from the RCTs show no significant benefit of triple therapy on hospital mortality (risk ratio [RR], 0.99; P=0.92; I2=0%); intensive care unit (ICU) mortality (RR, 0.77; P=0.20; I2=58%); ICU length of stay (weighted mean difference [WMD], 0.11; P=0.86; I2=37%) or hospital length of stay (WMD: 0.57; P=0.49; I2=17%), and renal replacement therapy (RR, 0.64; P=0.44; I2=39%). The delta Sequential Organ Failure Assessment (SOFA) score favored treatment after a sensitivity analysis (WMD, -0.72; P=0.01; I2=32%). However, a significant effect was noted for the duration of vasopressor use (WMD, -25.49; P
Title: Time to antibiotic administration: Sepsis alerts called in emergency department
versus in the field via emergency medical services.
Citation: American Journal of Emergency Medicine; Jun 2021; vol. 44 ; p. 291-295
Author(s): Mixon ; Dietrich, Scott; Floren, Michael; Rogoszewski, Ryan; Kane, Lindsay;
Nudell, Nikiah; Spears, Lindsey
Introduction: The Severe Sepsis and Septic Shock Early Management Bundle (SEP-1)
identifies patients with “severe sepsis” and mandates antibiotics within a specific time
window. Rapid time to administration of antibiotics may improve patient outcomes. The goal
of this investigation was to compare time to antibiotic administration when sepsis alerts are
called in the emergency department (ED) with those called in the field by emergency medical
services (EMS).
Methods: This was a multi-center, retrospective review of patients designated as sepsis
alerts in ED or via EMS in the field, presenting to four community emergency departments
over a six-month period.
Results: 507 patients were included, 419 in the ED alert group and 88 in the field alert
group. Mean time to antibiotic administration was significantly faster in the field alert group
when compared to the ED alert group (48.5 min vs 64.5 min, p < 0.001). Patients were more
likely to receive antibiotics within 60 min of ED arrival in the field alert group (59.1% vs
44%, p = 0.01). Secondary outcomes including mortality, hospital length of stay, intensive
care unit length of stay, sepsis diagnosis on admission, Clostridioides difficile infection rates,
fluid bolus utilization, anti-MRSA antibiotic utilization rates, and anti-Pseudomonal antibiotic
utilization rates were not found to be significantly different.
Conclusions: Sepsis alerts called in the field via EMS may decrease time to antibiotics and
increase the likelihood of antibiotic administration occurring within 60 min of arrival when
compared to those called in the ED.
Title: Treatment of suspected sepsis and septic shock in children with chronic
disease seen in the pediatric emergency department.
Citation: American Journal of Emergency Medicine; Jun 2021; vol. 44 ; p. 56-61
Author(s): Hegamyer ; Smith, Nadine; Thompson, Amy D.; Depiero, Andrew D.
Background: Research demonstrates that timely recognition and treatment of sepsis can
significantly improve pediatric patient outcomes, especially regarding time to intravenous
fluid (IVF) and antibiotic administration. Further research suggests that underlying chronic
disease in a septic pediatric patient puts them at higher risk for poor outcomes.
Objective: To compare treatment time for suspected sepsis and septic shock in pediatric
patients with chronic disease versus those without chronic disease seen in the Pediatric
Emergency Department (PED).
Methods: We reviewed patient data from a pediatric sepsis outcomes dataset collected at
two tertiary care pediatric hospital sites from January 2017-December 2018. Patients were
stratified into two groups: those with and without chronic disease, defined as any patient with
at least one of eight chronic health conditions.
Inclusion criteria: patients seen in the PED ultimately diagnosed with sepsis or septic
shock, patient age 0 to 20 years and time zero for identification of sepsis in the PED.
Exclusion criteria: time zero unavailable, inability to determine time of first IVF or antibiotic
administration or patient death within the PED. Primary analysis included comparison of time
zero to first IVF and antibiotic administration between each group.
Results: 312 patients met inclusion criteria. 169 individuals had chronic disease and 143 did
not. Median time to antibiotics in those with chronic disease was 41.9 min versus 43.0 min in
15patients without chronic disease (p = 0.181). Time to first IVF in those with chronic disease
was 22.0 min versus 12.0 min in those without (p = 0.010). Those with an indwelling
line/catheter (n = 40) received IVF slower than those without (n = 272), with no significant
difference in time to antibiotic administration by indwelling catheter status (p = 0.063). There
were no significant differences in the mode of identification of suspected sepsis or septic
shock between those with versus without chronic disease (p = 0.27).
Conclusions: Study findings suggest pediatric patients with chronic disease with suspected
sepsis or septic shock in the PED have a slower time to IVF administration but equivocal use
of sepsis recognition tools compared to patients without chronic disease.
Keywords: Antimicrobial therapy; Chronic disease; Fluid resuscitation; Intravenous access;
Pediatric; Sepsis.
Title: Using Readmission Rates as a Quality Indicator in Sepsis—Addressing the
Problem or Adding to It?
Citation: JAMA Network Open; Jun 2021; vol. 4 (no. 6)
Author(s): Levy
Sources Used:
The following databases are used in the creation of this bulletin: CINAHL, BNI, EMBASE &
Medline.
Disclaimer:
The results of your literature search are based on the request that you made, and consist of
a list of references, some with abstracts. Royal United Hospital Bath Healthcare Library will
endeavour to use the best, most appropriate and most recent sources available to it, but
accepts no liability for the information retrieved, which is subject to the content and accuracy
of databases, and the limitations of the search process. The library assumes no liability for
the interpretation or application of these results, which are not intended to provide advice or
recommendations on patient care.
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