Variations in infection sites and mortality rates among patients in intensive care units with severe sepsis and septic shock in Japan

Toshikazu Abe,Yutaka Umemura,Hiroto Ikeda,Yuichiro Sakamoto,Gautam A Deshpande,Toshihiko Mayumi,Shigeki Kushimoto,Masashi Ueyama,Joji Kotani,Ryosuke Tsuruta,Takehiro Sugiyama,Toru Hifumi,Tomohiko Masuno,Satoshi Fujimi,Kohji Okamoto,Seitaro Fujishima,Yasuhiro Otomo,Junichi Sasaki,Masatoshi Uchida,Akiyoshi Hagiwara,Daizoh Saitoh,Norio Yamashita,Ikuo Nagata ,Taka‐Aki Nakada ,Shin Ichiro Shiraishi ,Hiroshi Ogura,Takehiko Tarui,Atsushi Shiraishi,Yasukazu Shiino,Kiyotsugu Takuma,Naoshi Takeyama,Kazuma Yamakawa,Satoshi Gando

doi:10.1186/s40560-019-0383-3

Abstract

BackgroundAccurate and early identification of infection sites might help to drive crucial decisions regarding the treatment of sepsis. We aimed to determine the clinical and etiological features of infection according to sites among patients with severe sepsis in Japan.MethodsThis secondary analysis of a multicenter, prospective cohort study included 59 intensive care units (ICU) and proceeded between January 2016 and March 2017. The study cohort comprised 1184 adults (≥ 16 years) who were admitted to an ICU with severe sepsis and septic shock diagnosed according to the sepsis-2 criteria. Sites of infection diagnosed by physicians in charge at the time of arrival comprised the lung, abdomen, urinary tract, soft tissue, bloodstream, central nervous system (CNS), and undifferentiated infections. The primary outcome was in-hospital mortality.ResultsThe most common sites of infection were the lungs (31.0%), followed by intra-abdominal sites (26.3%), the urinary tract (18.4%), and soft tissue (10.9%). The characteristics of the patients with severe sepsis across seven major suspected infection sites were heterogeneous. Septic shock was more frequent among patients with intra-abdominal (72.2%) and urinary tract (70.2%) infections than other sites. The in-hospital mortality rate due to severe sepsis and septic shock of a pooled sample was 23.4% (range, 11.9% [urinary tract infection] to 47.6% [CNS infection]). After adjusting for clinical background, sepsis severity, and stratification according to the presence or absence of shock, variations in hospital mortality across seven major sites of infection remained essentially unchanged from those for crude in-hospital mortality; adjusted in-hospital mortality rates ranged from 7.7% (95%CI, − 0.3 to 15.8) for urinary tract infection without shock to 58.3% (95%CI, 21.0–95.7) for CNS infection with shock in a generalized estimating equation model. Intra-abdominal and urinary tract infections were statistically associated with less in-hospital mortality than pneumonia. Infections of the CNS were statistically associated with higher in-hospital mortality rates than pneumonia in a logistic regression model, but not in the generalized estimating equation model.ConclusionsIn-hospital mortality and clinical features of patients with severe sepsis and septic shock were heterogeneous according to sites of infection.

Highlights

Sepsis remains a major lethal healthcare problem, with a reported mortality of > 25% [1]
After adjusting for clinical background, sepsis severity, and stratification according to the presence or absence of shock, variations in hospital mortality across seven major sites of infection remained essentially unchanged from those for crude in-hospital mortality; adjusted in-hospital mortality rates ranged from 7.7% (95%confidence intervals (CI), − 0.3 to 15.8) for urinary tract infection without shock to 58.3% (95%CI, 21.0–95.7) for central nervous system (CNS) infection with shock in a generalized estimating equation model
In-hospital mortality and clinical features of patients with severe sepsis and septic shock were heterogeneous according to sites of infection

Summary

Introduction

Sepsis remains a major lethal healthcare problem, with a reported mortality of > 25% [1]. Some authors have suggested that understanding clinical differences based on infection sites could aid clinicians to appropriately stratify risk, help guide clinical decisions regarding treatment, and facilitate understanding of variations in host responses [8, 9]. Few studies have described differences in clinical characteristics and in-hospital mortality based on infection sites that might be important [6, 7]. The present study aimed to identify the clinical and etiological features and outcomes of severe sepsis based on infection sites to help guide clinical decisions.

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Discussion

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