Recent Articles on Sepsis Recognition and Early Treatment

  1. Sepsis Screening: Current Evidence and Available Tools.

Author(s): Villegas, Natacha; Moore, Laura J

Source: Surgical infections; ; vol. 19 (no. 2); p. 126-130

Publication Type(s): Journal Article

PubMedID: 29315023

Abstract: BACKGROUND Early recognition of sepsis is challenging, especially in the surgical patient. Because of the non-specific nature of the initial signs and symptoms, delays in recognition are all too common. To improve the early identification of sepsis, screening tools have been developed, and several papers have described their results. This article reviews the available sepsis screening tools. METHODS A PubMed search was performed using the search terms “sepsis” and “shock,” “electronic alert,” “clinical decision support,” and “early warning systems.” The papers found were reviewed to determine their relevance to the topic of sepsis screening, and outcome data were extracted from appropriate papers. RESULTS Multiple sepsis screening tools were identified with differing performance characteristics. These tools are reviewed individually along with a summary of their sensitivity, specificity, and positive and negative predictive values. CONCLUSIONS Clearly, sepsis screening has the potential to improve patient outcomes by aiding clinicians in the early recognition of the condition, enabling early implementation of evidence-based therapies. However, significant challenges remain, including identifying an optimal screening tool. Continued research is needed into the development and integration of automated screening tools that will be effective in a variety of clinical settings.

Database: Medline

 

  1. Prehospital recognition and antibiotics for 999 patients with sepsis: protocol for a feasibility study.

Author(s): Moore, Chris; Bulger, Jenna; Morgan, Matt; Driscoll, Timothy; Porter, Alison; Islam, Saiful; Smyth, Mike; Perkins, Gavin; Sewell, Bernadette; Rainer, Timothy; Nanayakkara, Prabath; Okolie, Chukwudi; Allen, Susan; Fegan, Greg; Davies, Jan; Foster, Theresa; Francis, Nick; Smith, Fang Gao; Ellis, Gemma; Shanahan, Tracy; Howe, Robin; Snooks, Helen

Source: Pilot and feasibility studies; 2018; vol. 4 ; p. 64

Publication Date: 2018

Publication Type(s): Journal Article

PubMedID: 29564147

Abstract: Background Sepsis is a common condition which kills between 36,000 and 64,000 people every year in the UK. Early recognition and management of sepsis has been shown to reduce mortality and improve the health and well-being of people with sepsis. Paramedics frequently come into contact with patients with sepsis and are well placed to provide early diagnosis and treatment. We aim to determine the feasibility of undertaking a fully powered randomised controlled trial (RCT) to test the clinical and cost-effectiveness of paramedics obtaining blood cultures from and administering IV antibiotics to patients with sepsis, so we can make a decision about whether to proceed to a fully powered randomised controlled trial, which will answer questions regarding safety and effectiveness for patients and benefit to the National Health Service (NHS).Methods/design This is an individually randomised, two-arm feasibility study for a randomised controlled trial with a 1:1 ratio. Sixty paramedics will receive training to assist them to recognise sepsis using a screening tool, obtain blood cultures, and provide IV antibiotics. If sepsis is suspected, paramedics will randomly allocate patients to intervention or usual care using their next sequential individually issued scratch card. Patients will be followed up at 90 days using linked anonymised data to capture length of hospital admission and mortality. We will also collect self-reported health-related quality of life (using SF-12) at this time. We will interview ten patients by telephone and hold a focus group with paramedics, to find out what they think about the intervention. DiscussionAt the end of this study, we will make a recommendation about whether a full randomised controlled trial of paramedics obtaining blood cultures and administering IV antibiotics for sepsis is warranted, and if so, we will develop a proposal for research funding in order to take the work forward. Trial registrationISRCTN, ISRCTN36856873.

Database: Medline

 

  1. Raising Awareness for Sepsis, Sepsis Screening, Early Recognition, and Treatment in the Emergency Department.

Author(s): Walters, Elizabeth

Source: Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association; May 2018; vol. 44 (no. 3); p. 224-227

Publication Date: May 2018

Publication Type(s): Journal Article

PubMedID: 29126558

Database: Medline

 

  1. Barriers to implementing the Sepsis Six guidelines in an acute hospital setting.

Author(s): Breen, Sarah-Jane; Rees, Sharon

Source: British journal of nursing (Mark Allen Publishing); May 2018; vol. 27 (no. 9); p. 473-478

Publication Date: May 2018

Publication Type(s): Journal Article

PubMedID: 29749778

Abstract: AIM To identify the barriers to implementation of the Sepsis Six pathway. BACKGROUND Research has suggested that compliance with the Sepsis Six pathway remains low. METHODS A convenience sample of doctors and nurses from one emergency department, two medical wards and two surgical wards were asked to complete a survey questionnaire. RESULTS Data from 108 respondents were available for analysis. Doctors and nurses agreed that lack of sepsis recognition during observation rounds and failure to associate sepsis with deranged temperature and blood results acted as barriers to the identification of sepsis. Doctors and nurses agreed that nursing delays and knowledge deficits were the top barriers leading to delay in sepsis treatment. CONCLUSION Knowledge deficits, lack of resources and practical issues were barriers identified in this survey. This will inform the educational and process needs of both doctors and nurses in order to improve sepsis care.

Database: Medline

 

  1. The New York Sepsis Severity Score: Development of a Risk-Adjusted Severity Model for Sepsis.

Author(s): Phillips, Gary S; Osborn, Tiffany M; Terry, Kathleen M; Gesten, Foster; Levy, Mitchell M; Lemeshow, Stanley

Source: Critical care medicine; May 2018; vol. 46 (no. 5); p. 674-683

Publication Date: May 2018

Publication Type(s): Journal Article

PubMedID: 29206765

Abstract: OBJECTIVES In accordance with Rory’s Regulations, hospitals across New York State developed and implemented protocols for sepsis recognition and treatment to reduce variations in evidence informed care and preventable mortality. The New York Department of Health sought to develop a risk assessment model for accurate and standardized hospital mortality comparisons of adult septic patients across institutions using case-mix adjustment. DESIGN Retrospective evaluation of prospectively collected data. PATIENTS Data from 43,204 severe sepsis and septic shock patients from 179 hospitals across New York State were evaluated. SETTINGS Prospective data were submitted to a database from January 1, 2015, to December 31, 2015.INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Maximum likelihood logistic regression was used to estimate model coefficients used in the New York State risk model. The mortality probability was estimated using a logistic regression model. Variables to be included in the model were determined as part of the model-building process. Interactions between variables were included if they made clinical sense and if their p values were less than 0.05. Model development used a random sample of 90% of available patients and was validated using the remaining 10%. Hosmer-Lemeshow goodness of fit p values were considerably greater than 0.05, suggesting good calibration. Areas under the receiver operator curve in the developmental and validation subsets were 0.770 (95% CI, 0.765-0.775) and 0.773 (95% CI, 0.758-0.787), respectively, indicating good discrimination. Development and validation datasets had similar distributions of estimated mortality probabilities. Mortality increased with rising age, comorbidities, and lactate. CONCLUSIONS The New York Sepsis Severity Score accurately estimated the probability of hospital mortality in severe sepsis and septic shock patients. It performed well with respect to calibration and discrimination. This sepsis-specific model provides an accurate, comprehensive method for standardized mortality comparison of adult patients with severe sepsis and septic shock.

Database: Medline

 

  1. A Novel Combination of Biomarkers to Herald the Onset of Sepsis Prior to the Manifestation of Symptoms.

Author(s): Dolin, Hallie H; Papadimos, Thomas J; Stepkowski, Stanislaw; Chen, Xiaohuan; Pan, Zhixing K

Source: Shock (Augusta, Ga.); Apr 2018; vol. 49 (no. 4); p. 364-370

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29016484

Abstract: Sepsis, which kills over 200,000 patients and costs over $20 billion in the United States alone, presents a constant but preventable challenge in the healthcare system. Among the more challenging problems that it presents is misdiagnosis due to conflation with other inflammatory processes, as its mechanisms are identical to those of other inflammatory states. Unfortunately, current biomarker tests can only assess the severity and mortality risk of each case, whereas no single test exists that can predict sepsis prior to the onset of symptoms for the purpose of pre-emptive care and monitoring. We propose that a single test utilizing three, rather than two, biomarkers that appear most quickly in the blood and are the most specific for sepsis rather than trauma, may improve diagnostic accuracy and lead to lessened patient morbidity and mortality. Such a test would vastly improve patient outcomes and quality of life, prevent complications for sepsis survivors, and prevent hospital readmissions, saving the American healthcare system money. This review summarizes the current use of sepsis biomarkers to prognosticate morbidity and mortality, and rejects the current single-biomarker and even combination biomarker tests as non-specific and inaccurate for current patient needs/pro-inflammatory cytokines, general markers of inflammation, and proteins specific to myeloid cells (and therefore to infection) are discussed. Ultimately, the review suggests a three-biomarker test of procalcitonin (PCT), interleukin-6 (IL-6), and soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) to diagnose sepsis before the onset of symptoms.

Database: Medline

 

  1. Sepsis: recognition, diagnosis and early management: © NICE (2017) Sepsis: recognition, diagnosis and early management.

Author(s):

Source: BJU international; Apr 2018; vol. 121 (no. 4); p. 497-514

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29603898

Database: Medline

 

  1. Sepsis recognition tools in acute ambulatory care: associations with process of care and clinical outcomes in a service evaluation of an Emergency Multidisciplinary Unit in Oxfordshire.

Author(s): Camm, Christian Fielder; Hayward, Gail; Elias, Tania C N; Bowen, Jordan S T; Hassanzadeh, Roya; Fanshawe, Thomas; Pendlebury, Sarah T; Lasserson, Daniel S

Source: BMJ open; Apr 2018; vol. 8 (no. 4); p. e020497

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29632083

Abstract: OBJECTIVET o assess the performance of currently available sepsis recognition tools in patients referred to a community-based acute ambulatory care unit. DESIGN Service evaluation of consecutive patients over a 4-month period. SETTING Community-based acute ambulatory care unit. DATA COLLECTION AND OUTCOME MEASURES Observations, blood results and outcome data were analysed from patients with a suspected infection. Clinical features at first assessment were used to populate sepsis recognition tools including: systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), quick Sequential Organ Failure Assessment (qSOFA) and National Institute for Health and Care Excellence (NICE) criteria. Scores were assessed against the clinical need for escalated care (use of intravenous antibiotics, fluids, ongoing ambulatory care or hospital treatment) and poor clinical outcome (all-cause mortality and readmission at 30 days after index assessment).RESULTS Of 533 patients (median age 81 years), 316 had suspected infection with 120 patients requiring care escalated beyond simple community care. SIRS had the highest positive predictive value (50.9%, 95% CI 41.6% to 60.3%) and negative predictive value (68.9%, 95% CI 62.6% to 75.3%) for the need for escalated care. Both NEWS and SIRS were better at predicting the need for escalated care than qSOFA and NICE criteria in patients with suspected infection (all P<0.001). While new-onset confusion predicted the need for escalated care for infection in patients ≥85 years old (n=114), 23.7% of patients ≥85 years had new-onset confusion without evidence for infection. CONCLUSIONS Acute ambulatory care clinicians should use caution in applying the new NICE endorsed criteria for determining the need for intravenous therapy and hospital-based location of care. NICE criteria have poorer performance when compared against NEWS and SIRS and new-onset confusion was prevalent in patients aged ≥85 years without infection.

Database: Medline

 

  1. An Interpretable Machine Learning Model for Accurate Prediction of Sepsis in the ICU.

Author(s): Nemati, Shamim; Holder, Andre; Razmi, Fereshteh; Stanley, Matthew D; Clifford, Gari D; Buchman, Timothy G

Source: Critical care medicine; Apr 2018; vol. 46 (no. 4); p. 547-553

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29286945

Abstract: OBJECTIVES Sepsis is among the leading causes of morbidity, mortality, and cost overruns in critically ill patients. Early intervention with antibiotics improves survival in septic patients. However, no clinically validated system exists for real-time prediction of sepsis onset. We aimed to develop and validate an Artificial Intelligence Sepsis Expert algorithm for early prediction of sepsis. DESIGN Observational cohort study. SETTING Academic medical center from January 2013 to December 2015.PATIENTSOver 31,000 admissions to the ICUs at two Emory University hospitals (development cohort), in addition to over 52,000 ICU patients from the publicly available Medical Information Mart for Intensive Care-III ICU database (validation cohort). Patients who met the Third International Consensus Definitions for Sepsis (Sepsis-3) prior to or within 4 hours of their ICU admission were excluded, resulting in roughly 27,000 and 42,000 patients within our development and validation cohorts, respectively. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS High-resolution vital signs time series and electronic medical record data were extracted. A set of 65 features (variables) were calculated on hourly basis and passed to the Artificial Intelligence Sepsis Expert algorithm to predict onset of sepsis in the proceeding T hours (where T = 12, 8, 6, or 4). Artificial Intelligence Sepsis Expert was used to predict onset of sepsis in the proceeding T hours and to produce a list of the most significant contributing factors. For the 12-, 8-, 6-, and 4-hour ahead prediction of sepsis, Artificial Intelligence Sepsis Expert achieved area under the receiver operating characteristic in the range of 0.83-0.85. Performance of the Artificial Intelligence Sepsis Expert on the development and validation cohorts was indistinguishable. CONCLUSIONS Using data available in the ICU in real-time, Artificial Intelligence Sepsis Expert can accurately predict the onset of sepsis in an ICU patient 4-12 hours prior to clinical recognition. A prospective study is necessary to determine the clinical utility of the proposed sepsis prediction model.

Database: Medline

 

  1. Clinical and epidemiological variability in severe sepsis: an ecological study.

Author(s): Vakkalanka, J Priyanka; Harland, Karisa K; Swanson, Morgan B; Mohr, Nicholas M

Source: Journal of epidemiology and community health; Apr 2018

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29636401

Abstract: BACKGROUND To assess clinical and epidemiological trends of severe sepsis. METHODS Ecological study of patients presenting to the emergency department with severe sepsis or septic shock between 2005 and 2013. Patients were identified using the state-wide hospital administrative database. Key outcomes included incidence rates (IRs) and mortality rates (per 1000 population) by age and medically underserved areas (MUAs), sepsis case fatality rate (deaths per 100 sepsis cases), and proportions of transfer and comorbidities. RESULTS There were 154 019 sepsis cases identified. In 2005, 85+ yo in non-MUAs had a 44% increase in IR compared with those in MUAs, and this difference rose to 74% by 2013. Mortality rates were 1.6 (95% CI 1.3 to 1.8) times greater among 85+ yo in non-MUAs. Mortality rates increased by 1.8% annually, while the sepsis case fatality rate decreased by 7.7%. The proportion of transfer among sepsis cases decreased by 2.1% per year (3.8% in non-MUAs, 0.7% in MUAs).CONCLUSIONS Sepsis incidence varies geographically, and access to healthcare is one proposed mechanism that may explain heterogeneity. Over time, we may be capturing higher acuity sepsis cases with better recognition and management, as well as observing differential diagnostic coding documentation by location.

Database: Medline

 

  1. Healthcare Utilization and Infection in the Week Prior to Sepsis Hospitalization.

Author(s): Liu, Vincent X; Escobar, Gabriel J; Chaudhary, Rakesh; Prescott, Hallie C

Source: Critical care medicine; Apr 2018; vol. 46 (no. 4); p. 513-516

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29309371

Abstract: OBJECTIVES To quantify healthcare utilization in the week preceding sepsis hospitalization to identify potential opportunities to improve the recognition and treatment of sepsis prior to admission. DESIGN Retrospective study. SETTING Two large integrated healthcare delivery systems in the United States. PARTICIPANTS Hospitalized sepsis patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We quantified clinician-based encounters in each of the 7 days preceding sepsis admission, as well as on the day of admission, and categorized them as: hospitalization, subacute nursing facility, emergency department, urgent care, primary care, and specialty care. We identified the proportion of encounters with diagnoses for acute infection based on 28 single-level Clinical Classification Software categories. We also quantified the use of antibiotics over the same interval and used linear regression to evaluate time trends. We included a total of 14,658 Kaiser Permanente Northern California sepsis hospitalizations and 31,369 Veterans Health Administration sepsis hospitalizations. Over 40% of patients in both cohorts required intensive care. A total of 7,747 Kaiser Permanente Northern California patients (52.9%) and 14,280 Veterans Health Administration patients (45.5%) were seen by a clinician in the week before sepsis. Prior to sepsis, utilization of subacute nursing facilities remained steady, whereas hospital utilization declined. Primary care, specialty care, and emergency department visits increased, particularly at admission day. Among those with a presepsis encounter, 2,648 Kaiser Permanente Northern California patients (34.2%) and 3,858 Veterans Health Administration patients (27.0%) had at least one acute infection diagnosis. An increasing percentage of outpatient encounters also had infectious diagnoses (3.3%/d; 95% CI, 1.5%-5.1%; p < 0.01), particularly in primary and specialty care settings. Prior to sepsis hospitalization, the use of antibiotics also increased steadily (2.1%/d; 95% CI, 1.1%-3.1%; p < 0.01). CONCLUSIONS Over 45% of sepsis patients had clinician-based encounters in the week prior to hospitalization with an increasing frequency of diagnoses for acute infection and antibiotic use in the outpatient setting. These presepsis encounters offer several potential opportunities to improve the recognition, risk stratification, and treatment prior to sepsis hospitalization.

Database: Medline

 

  1. Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign.

Author(s): Martischang, Romain; Pires, Daniela; Masson-Roy, Sarah; Saito, Hiroki; Pittet, Didier

Source: Critical care (London, England); Apr 2018; vol. 22 (no. 1); p. 92

Publication Date: Apr 2018

Publication Type(s): Editorial

PubMedID: 29653553

Abstract: Sepsis is estimated to affect more than 30 million patients with potentially five million deaths every year worldwide. Prevention of sepsis, as well as early recognition, diagnosis and treatment, can’t be overlooked to mitigate this global public health threat. World Health Organization (WHO) promotes hand hygiene in health care through its annual global campaign, SAVE LIVES: Clean Your Hands campaign on 5 May every year. The 2018 campaign targets sepsis with the overall theme “It’s in your hands; prevent sepsis in health care”.

Database: Medline

 

  1. Sepsis Rapid Response Teams.

Author(s): Ju, Tammy; Al-Mashat, Mustafa; Rivas, Lisbi; Sarani, Babak

Source: Critical care clinics; Apr 2018; vol. 34 (no. 2); p. 253-258

Publication Date: Apr 2018

Publication Type(s): Journal Article Review

PubMedID: 29482904

Abstract: Sepsis rapid response teams are being incorporated into hospitals around the world. Based on the concept of the medical emergency team, the sepsis rapid response team consists of a specifically trained team of health care providers educated in the early recognition, diagnosis, and treatment of patients at risk of having or who have sepsis. Using hospital-wide initiatives consisting of multidisciplinary education, training, and specific resource utilization, such teams have been found to improve patient outcomes.

Database: Medline

 

  1. Role of point-of-care ultrasonography for management of sepsis and septic shock.

Author(s): Shrestha, Gentle Sunder; Srinivasan, Shrikanth

Source: Reviews on recent clinical trials; Apr 2018

Publication Date: Apr 2018

Publication Type(s): Journal Article

PubMedID: 29651944

Abstract: BACKGROUND Sepsis and septic shock remain a major cause of morbidity and mortality globally. In recent years, outcome of patients with sepsis and septic shock has gradually improved, in part due to early recognition and timely appropriate management. Bedside physical examination can be of limited value to identify the source of infection and to decide appropriate management. Moreover, the clinical status of these patients can change rapidly, as a part of disease progression or in response to treatment or intervention. METHODS Research articles, review papers and online contents related to point-of-care ultrasound for management of patients with sepsis and septic shock were reviewed. RESULTS Point-of-care ultrasonography can be a valuable bedside tool to rapidly identify the potential source of infection and associated organ dysfunction. It can also help to guide management to predict fluid responsiveness by assessing the variation of inferior venacava with respiration, ventricular size and aortic flow variation. Response to various interventions like fluid challenge or administration of inotropes can be assessed at bedside. Point-of-care ultrasound can also enhance safety and increase success of bedside procedures like central venous cannulation and drainage of pleural effusion. CONCLUSION Bedside ultrasound can help to individualize management of patients with sepsis and septic shock and my potentially improve patient outcome.

Database: Medline

 

  1. Sepsis as a model for improving diagnosis.

Author(s): Graber, Mark L; Patel, Monika; Claypool, Stephen

Source: Diagnosis (Berlin, Germany); Mar 2018; vol. 5 (no. 1); p. 3-10

Publication Date: Mar 2018

Publication Type(s): Journal Article Review

PubMedID: 29601298

Abstract: Diagnostic safety could theoretically be improved by high-level interventions, such as improving clinical reasoning or eliminating system-related defects in care, or by focusing more specifically on a single problem or disease. In this review, we consider how the timely diagnosis of sepsis has evolved and improved as an example of the disease-focused approach. This progress has involved clarifying and revising the definitions of sepsis, efforts to raise awareness, faster and more reliable laboratory tests and a host of practice-level improvements based on health services research findings and recommendations. We conclude that this multi-faceted approach incorporating elements of the ‘learning health system’ model has improved the early recognition and treatment of sepsis, and propose that this model could be productively applied to improve timely diagnosis in other time-sensitive conditions.

Database: Medline

 

  1. Recognition and clinical management of sepsis in frail older people.

Author(s): Lat, Sheryll; Mashlan, Wendy; Heffey, Susan; Jones, Bridie

Source: Nursing older people; Feb 2018; vol. 30 (no. 2); p. 35-38

Publication Date: Feb 2018

Publication Type(s): Journal Article

PubMedID: 29480658

Abstract:Sepsis is a common condition caused by the body’s immune and coagulation systems being ‘switched on’ by the presence of infection, either through bacteria or viruses in the blood. If untreated, sepsis can be life-threatening and is a leading cause of death in hospital patients worldwide. However, awareness of sepsis is low. This article provides an overview of the important role played by nurses in acute hospital settings in the early identification and treatment of suspected sepsis in frail older patients, and in escalating the care and management of deteriorating patients. It also explores recommendations in the 2016 National Institute for Health and Care Excellence guideline on sepsis recognition, diagnosis and early management.

Database: Medline

 

  1. CE: Managing Sepsis and Septic Shock: Current Guidelines and Definitions.

Author(s): Makic, Mary Beth Flynn; Bridges, Elizabeth

Source: The American journal of nursing; Feb 2018; vol. 118 (no. 2); p. 34-39

Publication Date: Feb 2018

Publication Type(s): Journal Article

PubMedID: 29329118

Abstract: Sepsis is a leading cause of critical illness and hospital mortality. Early recognition and intervention are essential for the survival of patients with this syndrome. In 2002, the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) launched the Surviving Sepsis Campaign (SSC) to reduce overall patient morbidity and mortality from sepsis and septic shock by driving practice initiatives based on current best evidence. The SSC guidelines have been updated every four years, with the most recent update completed in 2016. The new guidelines have increased the focus on early identification of infection, risks for sepsis and septic shock, rapid antibiotic administration, and aggressive fluid resuscitation to restore tissue perfusion. In 2014, the SCCM and the ESICM convened a task force of specialists to reexamine the definitions of terms used to identify patients along the sepsis continuum. In 2016, this task force published the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The new definitions and recommendations included tools, based on an updated understanding of the pathobiology of sepsis, that can be used to predict adverse outcomes in patients with infection. This article discusses the new SSC treatment guidelines, changes in the sepsis bundle interventions, and the Sepsis-3 definitions and tools, all of which enable nurses to improve patient outcomes through timely collaborative action.

Database: Medline

 

  1. Rapid diagnosis of sepsis with TaqMan-Based multiplex real-time PCR.

Author(s): Liu, Chang-Feng; Shi, Xin-Ping; Chen, Yun; Jin, Ye; Zhang, Bing

Source: Journal of clinical laboratory analysis; Feb 2018; vol. 32 (no. 2)

Publication Date: Feb 2018

Publication Type(s): Journal Article

PubMedID: 28512861

Abstract: BACKGROUND The survival rate of septic patients mainly depends on a rapid and reliable diagnosis. A rapid, broad range, specific and sensitive quantitative diagnostic test is the urgent need. Thus, we developed a TaqMan-Based Multiplex real-time PCR assays to identify bloodstream pathogens within a few hours. METHODS Primers and TaqMan probes were designed to be complementary to conserved regions in the 16S rDNA gene of different kinds of bacteria. To evaluate accurately, sensitively, and specifically, the known bacteria samples (Standard strains, whole blood samples) are determined by TaqMan-Based Multiplex real-time PCR. In addition, 30 blood samples taken from patients with clinical symptoms of sepsis were tested by TaqMan-Based Multiplex real-time PCR and blood culture. RESULTS The mean frequency of positive for Multiplex real-time PCR was 96% at a concentration of 100 CFU/mL, and it was 100% at a concentration greater than 1000 CFU/mL. All the known blood samples and Standard strains were detected positively by TaqMan-Based Multiplex PCR, no PCR products were detected when DNAs from other bacterium were used in the multiplex assay. Among the 30 patients with clinical symptoms of sepsis, 18 patients were confirmed positive by Multiplex real-time PCR and seven patients were confirmed positive by blood culture. CONCLUSION TaqMan-Based Multiplex real-time PCR assay with highly sensitivity, specificity and broad detection range, is a rapid and accurate method in the detection of bacterial pathogens of sepsis and should have a promising usage in the diagnosis of sepsis.

Database: Medline

 

  1. Evaluation of a model to improve collection of blood cultures in patients with sepsis in the emergency room.

Author(s): Mariani, B; Corbella, M; Seminari, E; Sacco, L; Cambieri, P; Capra Marzani, F; Martino, I F; Bressan, M A; Muzzi, A; Marena, C; Tinelli, C; Marone, P

Source: European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology; Feb 2018; vol. 37 (no. 2); p. 241-246

Publication Date: Feb 2018

Publication Type(s): Journal Article

PubMedID: 29080931

Abstract: Sepsis begins outside of the hospital for nearly 80% of patients and the emergency room (ER) represents the first contact with the health care system. This study evaluates a project to improve collection of blood cultures (BCs) in patients with sepsis in the ER consisting of staff education and completion of the appropriate BC pre-analytical phase. A retrospective observational study performed to analyse the data on BC collection in the ER before and after a three-phase project. The first phase (1 January to 30 June 2015) before the intervention consisted of evaluation of data on BCs routinely collected in the ER. The second phase (1 July to 31 December 2015) was the intervention phase in which educational courses on sepsis recognition and on pre-analytical phase procedures (including direct incubation) were provided to ER staff. The third phase (1 January to 30 June 2016; after the intervention) again consisted of evaluation. Before the intervention, out of 24,738 admissions to the ER, 103 patients (0.4%) were identified as septic and had BCs drawn (359 BC bottles); 19 out of 103 patients (18.4%) had positive BCs. After the intervention, out of 24,702 admissions, 313 patients (1.3%) had BCs drawn (1,242 bottles); of these, 96 (30.7%) had positive BCs. Comparing the first and third periods, an increase in the percentage of patients with BCs collected (from 0.4% to 1.3% respectively, p < 0.0001) and an increase in the percentages of patients with true-positive BCs (from 0.08% to 0.39% of all patients evaluated respectively, p < 0.0001) were observed. The isolation of bacteria by BCs increased 3.25-fold after project implementation. These results can be principally ascribed to an improved awareness of sepsis in the staff associated with improved pre-analytical phase procedures in BC collection.

Database: Medline

 

  1. Impact of Pharmacist Intervention on Selection and Timing of Appropriate Antimicrobial Therapy in Septic Shock.

Author(s): Laine, Melanie E; Flynn, Jeremy D; Flannery, Alexander H

Source: Journal of pharmacy practice; Feb 2018; vol. 31 (no. 1); p. 46-51

Publication Date: Feb 2018

Publication Type(s): Journal Article

PubMedID: 29278987

Abstract: BACKGROUND Current guidelines for septic shock management recommend administration of appropriate, broad-spectrum antimicrobials within 1 hour of recognition. OBJECTIVE To evaluate the interventions pharmacists make as part of a sepsis response team and to determine if these interventions increase the proportion of patients with appropriate empiric antimicrobial therapy. METHODS A retrospective cohort study was undertaken reviewing adult patients in a large, academic medical center with confirmed septic shock who had an order for a “sepsis bundle,” which includes notification of a pharmacist to assess adequacy of empiric therapy. Pharmacist interventions with regard to selection of empiric antimicrobials were documented. The proportion of patients with initial successful selection of antimicrobial therapy (SSAT) before and after pharmacist intervention was assessed as well as the time to first antimicrobial administration and time to appropriate antimicrobial administration. RESULTS A total of 76 patients were included. Pharmacist intervention increased the proportion of patients with SSAT from 66% to 80% ( P = .04). Median time to first antimicrobial administration was 43 minutes, and time to appropriate antimicrobial therapy was 1 hour, 34 minutes for the entire cohort, with pharmacist intervention decreasing the latter time significantly in patients without SSAT on initiation of the “sepsis bundle” ( P < .001). CONCLUSION Pharmacist assessment of patients in septic shock offers the opportunity to improve SSAT. Systems designed to use a pharmacist responder for the care of patients with septic shock maximize the selection of antimicrobials, facilitate rapid administration, and improve surrogate outcomes for mortality in septic shock.

Database: Medline

 

  1. Computerised sepsis protocol management. Description of an early warning system.

Author(s): de Dios, Begoña; Borges, Marcio; Smith, Timothy D; Del Castillo, Alberto; Socias, Antonia; Gutiérrez, Leticia; Nicolás, Jordi; Lladó, Bartolomé; Roche, Jose A; Díaz, Maria P; Lladó, Yolanda; Equipo de Sepsis

Source: Enfermedades infecciosas y microbiologia clinica; Feb 2018; vol. 36 (no. 2); p. 84-90

Publication Date: Feb 2018

Publication Type(s): Journal Article

PubMedID: 28087145

Abstract: INTRODUCTION New strategies need to be developed for the early recognition and rapid response for the management of sepsis. To achieve this purpose, the Multidisciplinary Sepsis Team (MST) developed the Computerised Sepsis Protocol Management (PIMIS). The aim of this study was to evaluate the convenience of using PIMIS, as well as the activity of the MST. METHODS An analysis was performed on the data collected from solicited MST consultations (direct activation of PIMIS by attending physician or telephone request) and unsolicited ones (by referral from the microbiology laboratory or an automatic referral via the hospital vital signs recording software [SIDCV]), as well as the hospital department, source of infection, treatment recommendation, and acceptance of this. RESULTS Of the 1,581 first consultations, 65.1% were solicited consultations (84.1% activation of PIMIS and 15.9% by telephone). The majority of unsolicited consultations were generated by the microbiology laboratory (95.2%), and 4.8% from the SIDCV. Referral from solicited consultations were generated sooner (5.63days vs 8.47days; P<.001) and came from clinical specialties rather than from the surgical ward (73.0% vs 39.1%; P<.001). A recommendation was made for antimicrobial prescription change in 32% of first consultations. The treating physician accepted 78.1% of recommendations. CONCLUSIONS The high rate of solicited consultations and acceptance of recommended prescription changes suggest that a MST is seen as a helpful resource, and that PIMIS software is perceived to be useful and convenient to use, as it is the main source of referral.

Database: Medline

 

  1. Near-infrared spectroscopy to predict organ failure and outcome in sepsis: the Assessing Risk in Sepsis using a Tissue Oxygen Saturation (ARISTOS) study.

Author(s): Macdonald, Stephen P J; Kinnear, Frances B; Arendts, Glenn; Ho, Kwok M; Fatovich, Daniel M

Source: European journal of emergency medicine : official journal of the European Society for Emergency Medicine; Jan 2018

Publication Date: Jan 2018

Publication Type(s): Journal Article

PubMedID: 29346183

Abstract: OBJECTIVES Sepsis is acute organ dysfunction in the setting of infection. An accurate diagnosis is important to guide treatment and disposition. Tissue oxygen saturation (StO2) can be estimated noninvasively by near-infrared spectroscopy (NIRS), and may be an indicator of microcirculatory dysfunction in early sepsis. We aimed to determine the utility of StO2 for sepsis recognition and outcome prediction among patients presenting to the emergency department (ED) with infection. PATIENTS AND METHODSA multicentre, prospective, observational cohort study recruited patients who were being admitted to hospital with infection. StO2 was measured in the ED using a handheld NIRS device, Inspectra 300. Outcomes were sepsis, defined as an increase in sequential organ failure assessment score of at least 2 points within 72 h, and composite in-hospital mortality/ICU admission at least 3 days. RESULTS A cohort of 323 participants, median age 64 (interquartile range: 47-77) years, was recruited at three Australian hospitals. 143 (44%) fulfilled the criteria for sepsis and 22 (7%) died within 30 days. The mean±SD StO2 was 74±8% in sepsis and 78±7% in nonsepsis (P<0.0001). StO2 correlated with the peak sequential organ failure assessment score (Spearman’s ρ -0.27, P<0.0001). Area under the receiver operating characteristic curve was 0.66 (95% confidence interval: 0.60-0.72) for sepsis and 0.66 (0.58-0.75) for the composite outcome. StO2 less than 75% had an odds ratio of 2.67 (1.45-4.94; P=0.002), for the composite outcome compared with StO2 at least 75%.CONCLUSIONNIRS-derived StO2 correlates with organ failure and is associated with outcome in sepsis. However, its ability to differentiate sepsis among ED patients with infection is limited. NIRS cannot be recommended for this purpose.

Database: Medline

 

  1. Pentraxin-3 as a marker of sepsis severity and predictor of mortality outcomes: A systematic review and meta-analysis.

Author(s): Lee, Yee Ting; Gong, Mengqi; Chau, Alex; Wong, Wing Tak; Bazoukis, George; Wong, Sunny Hei; Lampropoulos, Konstantinos; Xia, Yunlong; Li, Guangping; Wong, Martin C S; Liu, Tong; Wu, William K K; Tse, Gary; International Heath Informatics Study (IHIS) Network

Source: The Journal of infection; Jan 2018; vol. 76 (no. 1); p. 1-10

Publication Date: Jan 2018

Publication Type(s): Journal Article

PubMedID: 29174966

Abstract:OBJECTIVESPentraxin-3 (PTX-3) is a multi-functional pattern recognition molecule produced by various cell types of peripheral tissues in different infections. It is raised in sepsis, but its values in predicting disease severity or mortality outcomes have been controversial. Therefore, we conducted a systematic review and meta-analysis of these associations. METHODS PubMed and Embase were searched until July 18, 2017 for studies that evaluated the relationship between PTX-3 levels and disease severity or mortality in sepsis. RESULTS A total of 23 and 10 entries were retrieved from both databases, respectively, of which 16 studies were included in the final meta-analysis. A total of 3001 patients (56% male, mean age 63 ± 15 years; mean follow-up duration of 207 days) were analysed. PTX-3 was significantly higher in patients with more severe sepsis compared to those with less severe sepsis (standard mean difference = 18.5 ng/mL, standard error: 4.5 ng/mL, P < 0.0001) and higher in non-survivors compared to survivors (standard mean difference = 40.3 ng/mL, standard error: 6.8 ng/mL, P < 0.0001). Elevated PTX-3 levels significantly increased the risk of all-cause mortality (hazard ratio: 1.91, 95% CI: 1.53 to 2.46, P < 0.0001).CONCLUSIONSPTX-3 significantly predicts disease severity and mortality in sepsis.

Database: Medline

 

  1. Bacterial sepsis : Diagnostics and calculated antibiotic therapy.

Author(s): Richter, D C; Heininger, A; Brenner, T; Hochreiter, M; Bernhard, M; Briegel, J; Dubler, S; Grabein, B; Hecker, A; Kruger, W A; Mayer, K; Pletz, M W; Storzinger, D; Pinder, N; Hoppe-Tichy, T; Weiterer, S; Zimmermann, S; Brinkmann, A; Weigand, M A; Lichtenstern, C

Source: Der Anaesthesist; Jan 2018

Publication Date: Jan 2018

Publication Type(s): Journal Article Review

PubMedID: 29383395

Abstract: The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of β‑lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by “Free Access” [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).

Database: Medline

 

  1. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial.

Author(s): Alam, Nadia; Oskam, Erick; Stassen, Patricia M; Exter, Pieternel van; van de Ven, Peter M; Haak, Harm R; Holleman, Frits; Zanten, Arthur van; Leeuwen-Nguyen, Hien van; Bon, Victor; Duineveld, Bart A M; Nannan Panday, Rishi S; Kramer, Mark H H; Nanayakkara, Prabath W B; PHANTASi Trial Investigators and the ORCA (Onderzoeks Consortium Acute Geneeskunde) Research Consortium the Netherlands

Source: The Lancet. Respiratory medicine; Jan 2018; vol. 6 (no. 1); p. 40-50

Publication Date: Jan 2018

Publication Type(s): Research Support, Non-u.s. Gov’t Journal Article

PubMedID: 29196046

Abstract: BACKGROUND Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care. METHODS After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428.FINDINGS2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone. INTERPRETATION In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity. FUNDING The Nuts Ohra Foundation, Netherlands Society of Internal Medicine (NIV).

Database: Medline

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