Met Criteria For Sepsis Research Articles

1057 WHAT IS THE ANTIBIOTIC OF CHOICE FOR OBSTRUCTING STONE PATIENTS WITH SEPSIS? A CONDITION-SPECIFIC ANTIBIOGRAM

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Kidney & Bladder (I)1 Apr 20131057 WHAT IS THE ANTIBIOTIC OF CHOICE FOR OBSTRUCTING STONE PATIENTS WITH SEPSIS? A CONDITION-SPECIFIC ANTIBIOGRAM Zachariah Goldsmith, Olugbemisola Oredein-Mccoy, Leah Gerber, Agnes Wang, Muhammad Iqbal, Gaston Astroza, Andreas Neisius, Ramy Youssef, Nicholas Kuntz, Luke Chen, Glenn Preminger, and Michael Lipkin Zachariah GoldsmithZachariah Goldsmith DURHAM, NC More articles by this author , Olugbemisola Oredein-MccoyOlugbemisola Oredein-Mccoy DURHAM, NC More articles by this author , Leah GerberLeah Gerber DURHAM, NC More articles by this author , Agnes WangAgnes Wang DURHAM, NC More articles by this author , Muhammad IqbalMuhammad Iqbal DURHAM, NC More articles by this author , Gaston AstrozaGaston Astroza DURHAM, NC More articles by this author , Andreas NeisiusAndreas Neisius DURHAM, NC More articles by this author , Ramy YoussefRamy Youssef DURHAM, NC More articles by this author , Nicholas KuntzNicholas Kuntz DURHAM, NC More articles by this author , Luke ChenLuke Chen DURHAM, NC More articles by this author , Glenn PremingerGlenn Preminger DURHAM, NC More articles by this author , and Michael LipkinMichael Lipkin DURHAM, NC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.643AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Appropriate antibiotic therapy is an important factor which determines the clinical outcomes of patients with sepsis. However, the epidemiology and antibiograms of pathogens causing sepsis in patients with obstructing urolithiasis have yet to be completely defined. METHODS Patients diagnosed with obstructing urolithiasis and meeting sepsis criteria were retrospectively identified from a large health system database, including a tertiary referral center and two community hospitals in North Carolina from 1995 to 2011. Urine cultures, blood cultures, and antibiotic-sensitivity results were reviewed. RESULTS 127 patients were reviewed. Bacterial isolates were identified from the urine in 105 patients (83%), and from blood for 58 (53%) patients. E. coli was the most common pathogen, followed by K. pneumonia, and yeast species. Notably, 53.5% of E coli isolates demonstrated resistance to at least one antibiotic, and 39.5% of E. coli showed fluoroquinolone resistance. The prevalence of resistance was stable between the time periods of 1995-2005 and 2006-2011 for fluoroquinolones (p = 0.15), piperacillin/tazobactam (p = 0.45), and ceftriaxone (p = 0.67). CONCLUSIONS E. coli is the most common micro-organism in patients with obstructing urolithiasis and sepsis. The overall high rates of resistance to fluoroquinolones support the use of piperacillin/tazobactam or ceftriaxone as an empiric agent of choice. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e433 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zachariah Goldsmith DURHAM, NC More articles by this author Olugbemisola Oredein-Mccoy DURHAM, NC More articles by this author Leah Gerber DURHAM, NC More articles by this author Agnes Wang DURHAM, NC More articles by this author Muhammad Iqbal DURHAM, NC More articles by this author Gaston Astroza DURHAM, NC More articles by this author Andreas Neisius DURHAM, NC More articles by this author Ramy Youssef DURHAM, NC More articles by this author Nicholas Kuntz DURHAM, NC More articles by this author Luke Chen DURHAM, NC More articles by this author Glenn Preminger DURHAM, NC More articles by this author Michael Lipkin DURHAM, NC More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

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Introduction: Severe sepsis in children causes over 4,000 deaths & costs nearly $2B annually (Goldstein, 2005). Additionally, there exists significant variability in the recognition, evaluation & management of sepsis (Carcillo, 2006). 1st generation definitions & criteria for pediatric SIRS, sepsis(S), severe sepsis (SS), & septic shock (SSh) [2005 Sepsis] were published. SS was further parsed into cardiovascular (CV), respiratory (Resp) & Other (Oth). In 2009, an update further delineated pediatric practice parameters. As guidelines continue to be developed, the need for iterative derivation & validation is necessary to optimize efficiency. Hypothesis: We hypothesized that the efficacy of sepsis evaluation in the Pediatric Intensive Care Unit (PICU) can be quantified using the 2005 sepsis criteria. Methods: We reviewed all PICU admissions < 18 yrs old from Jul-Dec 2011 with length of stay > 3 days. Each SIRS event was analyzed independently. The 2005 criteria were used to define SIRS, S, & SS. Additionally, we defined Clinical Sepsis (CS) as treatment with IV antibiotics for > 2days. Multiple organ system failure (MOSF) was identified when 2+ SS domains were satisfied. Results: There were 384 evaluations in 150 patients & SIRS was identified in 239 (62%). SIRS eventuated in S & SS in 109(28%) & 140(37%) cases, respectively. Of the 140 cases of SS, CV, Resp & Oth accounted for 49%, 41%, & 10%, respectively. MOSF occurred in 47% of SS cases. CS occurred in 22% of evaluations. Of the 109 evaluations that met sepsis criteria, 56(51%) were treated for 2+ days. In contrast, 83 evaluations were treated for CS, 56 (67%) met sepsis criteria. Finally, WBC abnormality (vs temperature, HR & RR) was associated with the highest AUC-ROC (SEM) when S 0.68(0.027), MOSF 0.723(0.034) & CS 0.591(0.031) were outcomes. Conclusions: There is significant incoherence between the guidelines & clinical practice. Half of the evaluations meeting criteria were not treated. Conversely, one-third of those clinically treated did not meet criteria. Further efforts are underway to optimize the predictive value of the guidelines to treat those most at risk & minimize wasteful evaluations in PICU patients with non-infectious SIRS.

Negative pressure wound therapy in acute, contaminated wounds: documenting its safety and efficacy to support current global practice

Negative pressure wound therapy (NPWT) is in widespread use and its role in wound care is expanding worldwide. It is estimated that 300 million acute wounds are treated globally each year. Currently, sporadic data exist to support NPWT in acutely contaminated wounds. Despite lack of data, use of negative pressure wound therapy in such cases is increasing across the globe. We retrospectively reviewed 86 consecutive patients, totalling 97 contaminated wounds. All wounds were Class IV based on US Center for Disease Control criteria. Sepsis criteria were present in 78/86 (91%) of patients. All patients were managed with NPWT. Wound type, degree of tissue destruction, presence of infection, wound dimension, timing of initial NPWT, type and timing of wound closure and patient comorbidities were recorded. Outcome endpoints included durability of wound closure and death. Wound location was 41/97 (42%) in the torso; 56/97 (58%) at the extremities. Tissue necrosis was present in 84/97 (87%) of wounds. Infection was present in 86/97 (89%) of wounds. Average wound size was 619 cm(2) when square surface area measured; 786 cm(3) when volume measurements taken. Mean time to wound closure was 17 days, median 10 days and mode 6 days. Durability of wound closure 73/79 (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT. Contemporary NPWT related acute wound care is expanding empirically, in quantity and scope across the globe. However, several areas of concern are known regarding this contemporary use of NPWT in acute wounds. Thus, it is important to assess the safety and efficacy of such expanded empiric NPWT practice. Based on our findings with NPWT in the largest known patient cohort of this type, NPWT appears safe and effective in managing acute, contaminated wounds including patients meeting sepsis criteria. These findings provide evidence-based support for current worldwide empiric NPWT-related acute wound care.

A comparison of zinc metabolism, inflammation, and disease severity in critically ill infected and noninfected adults early after intensive care unit admission

Zinc deficiency is a cause of immune dysfunction and infection. Previous human studies have shown that the activation of the acute phase response alters zinc metabolism. Whether the alteration in zinc metabolism is predictive of disease severity in the setting of critical illness is unclear. We sought to determine whether differences occur in zinc metabolism at the onset of critical illness between infected (septic) and noninfected subjects. We conducted this prospective study in an adult medical intensive care unit (MICU) at a tertiary care hospital. Subjects were enrolled within 24 h of intensive care unit admission. Subjects who did not meet sepsis criteria were considered for the critically ill control (CIC) arm. After patient consent, blood was immediately collected to measure plasma zinc and cytokine concentrations and zinc transporter gene expression in peripheral blood monocytes. Clinical data during the MICU stay were also recorded. A total of 56 patients were evaluated (22 septic, 22 CIC, and 12 healthy subjects). Plasma zinc concentrations were below normal in CIC patients and further reduced in the septic cohort (57.2 ± 18.2 compared with 45.5 ± 18.1 μg/dL). Cytokine concentrations increased with decreasing plasma zinc concentrations (P = 0.05). SLC39A8 gene expression was highest in patients with the lowest plasma zinc concentrations and the highest severity of illness. The alteration of zinc metabolism was more pronounced in septic patients than in noninfected critically ill patients. Specifically, sepsis was associated with lower plasma zinc concentrations and higher SLC39A8 mRNA expression, which correlated with an increased severity of illness, including cardiovascular dysfunction.

Journal Scan: Etomidate-Induced Adrenal Suppression: Is It Time to Abandon Old Faithful?

Journal Scan: Etomidate-Induced Adrenal Suppression: Is It Time to Abandon Old Faithful?

Assessment of disease-severity scoring systems for patients with sepsis in general internal medicine departments

IntroductionDue to the increasing burden on hospital systems, most elderly patients with non-surgical sepsis are admitted to general internal medicine departments. Disease-severity scoring systems are used for stratification of patients for utilization management, performance assessment, and clinical research. Some widely used scoring systems for septic patients are inappropriate when rating non-surgical patients in a non-intensive care unit (ICU) environment mainly because their calculations require types of data that are frequently unavailable. This study aimed to assess the fitness of four scoring systems for septic patients hospitalized in general internal medicine departments: modified early warning score (MEWS), simple clinical score (SCS), mortality in emergency department sepsis (MEDS) score, and rapid emergency medicine score (REMS).MethodsWe prospectively collected computerized data of septic patients admitted to general internal medicine departments in our community-based university hospital. We followed 28-day in-hospital mortality, overall in-hospital mortality, and 30- and 60-day mortality. Using a logistic regression procedure we calculated the area under ROC curve (AUC) for every scoring system.ResultsBetween February 1st, 2008 and April 30th, 2009 we gathered data of 1,072 patients meeting sepsis criteria on admission to general internal medicine departments. The 28-day mortality was 19.4%. The AUC for the MEWS was 0.65-0.70, for the SCS 0.76-0.79, for the MEDS 0.73-0.75, and for the REMS, 0.74-0.79. Using Hosmer-Lemeshow statistics, a lack of fit was found for the MEDS model. All scoring systems performed better than calculations based on sepsis severity.ConclusionsThe SCS and REMS are the most appropriate clinical scores to predict the mortality of patients with sepsis in general internal medicine departments.

Novel Influenza A(H1N1) Virus Among Gravid Admissions

Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population. We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957. Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17% (n = 3). Demographically, 2 patients were health care workers (11%); 15 were black (83%); 2, Hispanic (11%); and 1, white (6%). None reported recent travel. Half of the patients presented with gastrointestinal or abdominal complaints; 13 patients met sepsis criteria (72%). The most common comorbidities were asthma, sickle cell disease, and diabetes. Fourteen patients tested positive for H1N1 on DAT (initial or repeated) (78%); in the other 4 cases, H1N1 was identified by viral culture or rRT-PCR (22%). Seven patients delivered during hospitalization (39%), 6 prematurely and 4 via emergency cesarean delivery. There were 2 fetal deaths (11%). No maternal mortality was recorded. Admitted pregnant patients with H1N1 are at risk for obstetrical complications including fetal distress, premature delivery, emergency cesarean delivery, and fetal death. A high number of patients presented with gastrointestinal and abdominal complaints. Early antiviral treatment may improve maternal outcomes.

The Association of Race and Survival from Sepsis after Injury

Genetic variation is associated with outcome disparity in critical illness. We sought to determine if race is independently associated with the development of posttraumatic sepsis and subsequent related mortality. Our Intensive Care Unit database was queried for admissions from January 1, 2000 to June 30, 2007. Patients were prospectively followed for sepsis (Any four of the following symptoms: temperature > or =38 degrees C, heart rate (HR) > or =90 b/m, RR > or =20 b/m (or PaCO2 < or =32 mm Hg), white blood cell count (WBC) > or =12, or vasopressor requirement all with an infectious source). White, Black, Hispanic, and Asian groups were defined. "Other" race was excluded. Most of the 3998 study patients were male (3157, 79.0%). Blunt trauma (2661, 66.6%) predominated. Six-hundred-seventy-seven (16.9%) met sepsis criteria. Mortality was 14.0 per cent (560). Sepsis was increased in Asians versus all others combined (23.7% vs. 16.1%). Race was independently associated with sepsis (adjusted odds ratio (OR) 1.12 (1.01-1.24), P value = 0.03). Sepsis associated mortality was 36.9 per cent (250/677). Black race demonstrated an increased survival versus all others after sepsis (25.4% vs. 37.7%) but this was not statistically significant (adjusted OR 0.96 (0.73-1.18), P value = 0.71). Race is independently associated with posttraumatic sepsis and possibly subsequent sepsis associated mortality. Further related study is needed with the ultimate goal of genetically based treatments for the prevention and treatment of sepsis after injury.

A Computerized Alert Screening For Severe Sepsis In Emergency Department Patients Increases Lactate Testing But Does Not Improve Inpatient Mortality

This study tested the hypothesis that lactate testing in ED sepsis patients could be increased using a computer alert that automatically recognizes systemic inflammatory response syndrome (SIRS) criteria and recommends lactate testing in cases of sepsis defined as ≥2 SIRS criteria plus physician suspicion of infection. Secondary outcomes included the effect of the alert on lactate testing among admitted sepsis patients, the proportion of admitted patients with lactate ≥4.0 mmol/L identified and the in-patient mortality difference before and after alert implementation. After a 6 month pre-alert phase, a computer alert was implemented that computed and displayed abnormal vital signs and white blood cell counts for all patients with >2 SIRS criteria and recommended testing lactate if an infection was suspected. Data for admitted patients was collected electronically on consecutive patients meeting sepsis criteria for 6 months before and 6 months after implementation of the alert. There were a total of 5,796 subjects enrolled. Among all septic patients, lactate testing increased from 5.2% in the pre-alert phase to 12.7% in the alert phase, a 7.5% (95% CI 6.0 to 9.0%) absolute increase in lactate testing, p<0.001. Among the 1,798 admitted patients with sepsis, lactate testing increased from 15.3% to 34.2%, an 18.9% (95% CI 15.0 to 22.8%) absolute increase, p<0.001. Among admitted patients with sepsis, there was a 1.9% (95% CI 0.03 to 3.8%, p = 0.05) increase in absolute number of patients with elevated lactate levels identified and a 0.5% (95% CI -1.6 to 2.6%, p=0.64) decrease in mortality. The proportion of ED patients who had lactate tested and the number of admitted patients identified with a lactate level ≥4.0 mmol/L improved significantly after the implementation of a computer alert identifying sepsis patients with >2 SIRS criteria while mortality among admitted sepsis patients remained unchanged.

Genomic expression profiling across the pediatric systemic inflammatory response syndrome, sepsis, and septic shock spectrum*

To advance our biological understanding of pediatric septic shock, we measured the genome-level expression profiles of critically ill children representing the systemic inflammatory response syndrome (SIRS), sepsis, and septic shock spectrum. Prospective observational study involving microarray-based bioinformatics. Multiple pediatric intensive care units in the United States. Children <or=10 years of age: 18 normal controls, 22 meeting criteria for SIRS, 32 meeting criteria for sepsis, and 67 meeting criteria for septic shock on day 1. The available day 3 samples included 20 patients still meeting sepsis criteria, 39 patients still meeting septic shock criteria, and 24 patients meeting the exclusive day 3 category, SIRS resolved. None other than standard care. Longitudinal analyses were focused on gene expression relative to control samples and patients having paired day 1 and day 3 samples. The longitudinal analysis focused on up-regulated genes revealed common patterns of up-regulated gene expression, primarily corresponding to inflammation and innate immunity, across all patient groups on day 1. These patterns of up-regulated gene expression persisted on day 3 in patients with septic shock, but not to the same degree in the other patient classes. The longitudinal analysis focused on down-regulated genes demonstrated gene repression corresponding to adaptive immunity-specific signaling pathways and was most prominent in patients with septic shock on days 1 and 3. Gene network analyses based on direct comparisons across the SIRS, sepsis, and septic shock spectrum, and all available patients in the database, demonstrated unique repression of gene networks in patients with septic shock corresponding to major histocompatibility complex antigen presentation. Finally, analyses focused on repression of genes corresponding to zinc-related biology demonstrated that this pattern of gene repression is unique to patients with septic shock. Although some common patterns of gene expression exist across the pediatric SIRS, sepsis, and septic shock spectrum, septic shock is particularly characterized by repression of genes corresponding to adaptive immunity and zinc-related biology.

A Prospective Observational Study of the Effect of Etomidate on Septic Patient Mortality and Length of Stay

Etomidate is known to cause adrenal suppression after single-bolus administration. Some studies suggest that when etomidate is used as an induction agent for intubation of septic patients in the emergency department (ED), this adrenal suppression leads to increased mortality, vasopressor requirements, and length of hospital stay. The authors sought to determine differences in the in-hospital mortality and hospital length of stay (LOS) between septic patients given etomidate and patients given alternative or no induction agents for rapid-sequence intubation in our ED. This was a nonrandomized, prospective observational study of all patients meeting sepsis criteria who were intubated in an ED over a 9-month period. Times of patient presentation, intubation, admission, discharge, and/or death were recorded, as well as the intubation agent used, if any, and corticosteroid use. The authors also recorded relevant laboratory and demographic variables to determine severity of illness using the Mortality in Emergency Department Sepsis (MEDS) score. Mortality and survivor LOS between the patients given etomidate and those given alternative or no induction agents were compared. A total of 106 patients with sepsis were intubated over the study period. Of these, 74 patients received etomidate, while 32 patients received ketamine, benzodiazepines, propofol, or no induction agents. Age in years (median = 78; interquartile range [IQR] = 67 to 83), gender (45% male), MEDS score (median = 13; IQR = 10 to 15), and receipt of supplemental corticosteroids (56%) were statistically similar between the two groups. In-hospital mortality of patients given etomidate (38%; 95% confidence interval [CI] = 28% to 49%) was similar to those receiving alternatives (44%; 95% CI = 28% to 61%). Surviving patients had a median hospital LOS after receiving etomidate of 10 days compared to those receiving alternatives (7.5 days; p = 0.08). No statistically significant increase in hospital LOS or mortality in patients given etomidate for rapid-sequence intubation was found. Suggestions that the use of etomidate for intubation in the ED be abandoned are not supported by these data.

Early risk factors for sepsis in patients with severe blunt trauma

We studied 43 patients with blunt trauma (injury severity score, ≥25), age >14 years and length of the intensive care unit (ICU) stay >48 h in order to estimate the frequency of sepsis and to identify early risk factors related to its development. Clinical data were collected during the first 24 h and several inflammatory mediators were determined from serum samples of the first 2 days after injury. Twenty-one patients (48.8%) met sepsis criteria during their ICU stay, 9 (20.9%) fulfilled only criteria for sepsis; 6 (13.9%) fulfilled criteria for severe sepsis and another 6 (13.9%) criteria for septic shock. An APACHE II score ≥14, the presence of hypovolemic shock, the need for three or more units of blood to be transfused and the administration of a total volume of fluids ≥10 l were all factors associated significantly with the development of sepsis. In the multivariant analysis, the need for a total volume of fluids ≥10 l was the only independent risk factor (adjusted odds ratio=10.49, 95% CI, 2.34–47.02; P=0.002). No significant differences were documented in relation to the behaviour of the serum markers.

Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock.

IntroductionThere have been conflicting data regarding the relationship between sepsis-bundle adherence and mortality. Moreover, little is known about how this relationship may be moderated by the anatomic source of infection or the location of sepsis declaration.MethodsThis was a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock. The study included patients who presented to one of three Los Angeles County Department of Health Services (DHS) full-service hospitals January 2012 to December 2014. The primary outcome of interest was the association between sepsis-bundle adherence and in-hospital mortality. Secondary outcome measures included in-hospital mortality by source of infection, and the location of sepsis declaration.ResultsAmong the 4,582 patients identified with sepsis, overall mortality was lower among those who received bundle-adherent care compared to those who did not (17.9% vs. 20.4%; p=0.035). Seventy-five percent (n=3,459) of patients first met sepsis criteria in the ED, 9.6% (n=444) in the intensive care unit (ICU) and 14.8% (n=678) on the ward. Bundle adherence was associated with lower mortality for those declaring in the ICU (23.0% adherent [95% confidence interval{CI} {16.8–30.5}] vs. 31.4% non-adherent [95% CI {26.4–37.0}]; p=0.063), but not for those declaring in the ED (17.2% adherent [95% CI {15.8–18.7}] vs. 15.1% non-adherent [95% CI {13.0–17.5}]; p=0.133) or on the ward (24.8% adherent [95% CI {18.6–32.4}] vs. 24.4% non-adherent [95% CI {20.9–28.3}]; p=0.908). Pneumonia was the most common source of sepsis (32.6%), and patients with pneumonia had the highest mortality of all other subsets receiving bundle non-adherent care (28.9%; 95% CI [25.3–32.9]). Although overall mortality was lower among those who received bundle-adherent care compared to those who did not, when divided into subgroups by suspected source of infection, a statistically significant mortality benefit to bundle-adherent sepsis care was only seen in patients with pneumonia.ConclusionIn a large public healthcare system, adherence with severe sepsis/septic shock management bundles was found to be associated with improved survival. Bundle adherence seems to be most beneficial for patients with pneumonia. The overall improved survival in patients who received bundle-adherent care was driven by patients declaring in the ICU. Adherence was not associated with lower mortality in the large subset of patients who declared in the ED, nor in the smaller subset of patients who declared in the ward.