Surviving Sepsis Campaign Recommendations Research Articles

Real-World Implications of Updated Surviving Sepsis Campaign Antibiotic Timing Recommendations.

To evaluate real-world implications of updated Surviving Sepsis Campaign (SSC) recommendations for antibiotic timing. Retrospective cohort study. Twelve hospitals in the Southeastern United States between 2017 and 2021. One hundred sixty-six thousand five hundred fifty-nine adult hospitalized patients treated in the emergency department for suspected serious infection. None. We determined the number and characteristics of patients affected by updated SSC recommendations for initiation of antibiotics that incorporate a risk- and probability-stratified approach. Using an infection prediction model with a cutoff of 0.5 to classify possible vs. probable infection, we found that 30% of the suspected infection cohort would be classified as shock absent, possible infection and thus eligible for the new 3-hour antibiotic recommendation. In real-world practice, this group had a conservative time to antibiotics (median, 5.5 hr; interquartile range [IQR], 3.2-9.8 hr) and low mortality (2%). Patients categorized as shock absent, probable infection had a median time to antibiotics of 3.2 hours (IQR, 2.1-5.1 hr) and mortality of 3%. Patients categorized as shock present, the probable infection had a median time to antibiotics 2.7 hours (IQR, 1.7-4.6 hr) and mortality of 17%, and patients categorized as shock present, the possible infection had a median time to antibiotics 6.9 hours (IQR, 3.5-16.3 hr) and mortality of 12%. These data support recently updated SSC recommendations to align antibiotic timing targets with risk and probability stratifications. Our results provide empirical support that clinicians and hospitals should not be held to 1-hour targets for patients without shock and with only possible sepsis.

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis.

To estimate the effect of sepsis order set usage on hospital mortality. Retrospective cohort study. Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis. Hospital mortality. The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68-221] vs 179 [98-379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0-15.0] vs 7.6 [2.5-21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8-9.0] vs 6.0 [3.2-12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66-0.73). In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

Impact of parental and healthcare professional concern on the diagnosis of pediatric sepsis: a diagnostic accuracy study.

The Surviving Sepsis Campaign recommends systematic screening for sepsis. Although many sepsis screening tools include parent or healthcare professional concern, there remains a lack of evidence to support this practice. We aimed to test the diagnostic accuracy of parent and healthcare professional concern in relation to illness severity, to diagnose sepsis in children. This prospective multicenter study measured the level of concern for illness severity as perceived by the parent, treating nurse and doctor using a cross-sectional survey. The primary outcome was sepsis, defined as a pSOFA score >0. The unadjusted area under receiver-operating characteristic curves (AUC) and adjusted Odds Ratios (aOR) were calculated. Two specialised pediatric Emergency Departments in Queensland. Children aged 30 days to 18 years old that were evaluated for sepsis. None. 492 children were included in the study, of which 118 (23.9%) had sepsis. Parent concern was not associated with sepsis (AUC 0.53, 95% CI: 0.46-0.61, aOR: 1.18; 0.89-1.58) but was for PICU admission (OR: 1.88, 95% CI: 1.17-3.19) and bacterial infection (aOR: 1.47, 95% CI: 1.14-1.92). Healthcare professional concern was associated with sepsis in both unadjusted and adjusted models (nurses: AUC 0.57, 95% CI-0.50, 0.63, aOR: 1.29, 95% CI: 1.02-1.63; doctors: AUC 0.63, 95% CI: 0.55, 0.70, aOR: 1.61, 95% CI: 1.14-2.19). While our study does not support the broad use of parent or healthcare professional concern in isolation as a pediatric sepsis screening tool, measures of concern may be valuable as an adjunct in combination with other clinical data to support sepsis recognition. ACTRN12620001340921.

Management of critical patient infected with extended spectrum beta-lactamase (ESBL) producing Escherichia Coli

Introduction : Antibiotics has been widely used in medical practices nowadays. Antibiotics usage is often massively performed and sometimes not as indicated. Un-judicious and overuse of antibiotics that is not correlated with clinical pathways could result in antimicrobial resistance. Extended Spectrum Beta-Lactamase (ESBL) is an enzyme that has a capability of hydrolysing and deactivate Penicillin group antibiotics, 1st, 2nd, 3rd generation cephalosporin, as well as Monobactam antibiotics, further will cause resistance to those antibiotics. These matters will make it difficult to choose antibiotics. This article will discuss patients with Escherichia coli infection with ESBL in septic shock and its management. Case Presentation: Thirty five years old female with BMI 22 Kg/m2 was admitted to ICU with septic shock caused by infected sacral pressure sore. She has a history of traffic accidents and was mechanical ventilated 6 months ago. We performed septic shock management according to the Surviving Sepsis Campaign recommendation along with other supportive management. Macro (temperature, heart rate, mean arterial blood pressure) and micro haemodynamic (lactate, pCO2 gap, central venous pressure, vena cava inferior diameter) changed on day 3. We change the antibiotic according to the culture result. Escherichia Coli was found in blood culture with ESBL. The antibiotics were Amikacin combined with Tigecycline. Improvement was seen on the fifth day, then stopped the vasopressor, on day six weaned the mechanical ventilation. Conclusion: Resuscitation and rapid source control of infection focus, combined with appropriate antibiotic choice become the key principle in managing patients with septic shock caused by Escherichia coli with ESBL.

Usefulness of pancreatic stone protein measurement to screen and diagnose sepsis in the context of the Surviving Sepsis Campaign recommendations.

Sepsis occurs yearly in 48.9 million people worldwide of whom 11 million will die. Sepsis is defined as a life-threatening dysregulated reaction of the body in response to a bacterial infection, leading to organ dysfunction. The Surviving Sepsis Campaign (SSC) made numerous recommendations for sepsis diagnosis and treatment using an evidence-based medicine approach. Frequently, levels of evidence of these recommendations are poor and lack clear clinical guidance. Interestingly, the SSC guidelines strongly recommend, with a moderate quality of evidence, screening of nosocomial sepsis in acutely ill hospitalized “high-risk patients”. The definition of acutely ill and high-risk patients is not specified, nor it is indicated which tools should be used. The diagnosis of infection and the subsequent administration of antibiotics relies solely on rapid clinical assessment, as recommended by the Best Practice Statement. Again, the elements used for clinical assessment are poorly defined, encompassing patient history, clinical examination, and tests for both infectious and non-infectious causes of acute illness. In the real world, only 30 to 40% of empiric broad-spectrum antibiotic administrations are appropriate, contributing to the emergence of antimicrobial resistant bacteria, toxicity related to antibiotic administration, and costs. The aim of this review article is to show that the use of biomarkers, such as the Pancreatic Stone Protein (PSP) as an example, helps in guiding the clinician to diagnose and manage sepsis. Over 600 peer-reviewed publications have studied the physiology of PSP and more than 50 evaluated its usefulness to screen for the development of nosocomial sepsis and diagnose sepsis.

1207: ANTIBIOTIC ADMINISTRATION TIMES BEFORE AND AFTER ADDITION TO THE AUTOMATED DISPENSING CABINETS

Introduction: The Surviving Sepsis Campaign guidelines recommend prompt intravenous antibiotic administration within one hour for patients with septic shock or a high likelihood of sepsis. To improve timeliness of antibiotic administration, piperacillin-tazobactam and cefepime were stocked in the automated dispensing cabinets (ADCs) in five intensive care units (ICU).The aim of this study was to evaluate the time from order entry of piperacillin-tazobactam or cefepime to administration in ICU patients before and after addition to the ADC. Methods: This was a retrospective study of adult, presumed septic patients who received their first dose of piperacillin-tazobactam or cefepime in an ICU. Patients included from March 23, 2019 – March 23, 2020 received antibiotics from the inpatient pharmacy (Pre-ADC) and those from March 25, 2020 – March 25, 2021 received piperacillin-tazobactam and cefepime from the ICU ADCs (Post-ADC). The primary outcome was time from antibiotic order entry to administration. Secondary outcomes included time from order entry to pharmacy verification, in-hospital mortality, and hospital length of stay. Results: One thousand eight hundred and three patients were included with 903 patients in the Pre-ADC group and 900 in the Post-ADC group. Baseline characteristics were similar, and respiratory infection was the most common antibiotic indication (37% Pre-ADC vs. 36% Post-ADC). Additionally, more Post-ADC patients had isolation precautions at the time of antibiotic administration (15% Pre-ADC vs. 19% Post-ADC, p=0.04). The median (IQR) time (minutes) from order of antibiotics to administration was shorter in the Pre-ADC group at 57 (32-97) vs. 75 (43-126) Post-ADC (p < 0.001). Median (IQR) time (minutes) from pharmacy verification to nursing administration was 51 (28-91) Pre-ADC vs. 75 (43-126) Post-ADC, p< 0.001. Hospital length of stay and mortality were similar between the groups. Conclusions: Adding piperacillin-tazobactam and cefepime to the ICU ADCs did not result in earlier antibiotic administration in presumed septic patients. Due to the timing of this study, the COVID-19 pandemic and isolation precautions likely confounded the results. Further investigation of antibiotic administration barriers is needed to optimize patient care and meet Surviving Sepsis Campaign recommendations.

Surviving Sepsis Guideline-Directed Fluid Resuscitation: An Assessment of Practice Patterns and Impact on Patient Outcomes.

IMPORTANCE:Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage.OBJECTIVES:Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation.DESIGN:Large, multisite retrospective cohort study.SETTING AND PARTICIPANTS:The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis.MAIN OUTCOMES AND MEASURES:Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0–29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay.RESULTS:We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight).CONCLUSIONS AND RELEVANCE:IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.

The Use of Intravenous Sodium Bicarbonate in the Treatment of Metabolic Acidosis with Septic Shock

Background: Acute metabolic acidemia, defined as a decrease in blood pH originating from a primary reduction in bicarbonate concentration that is accompanied by an appropriate secondary reduction in PaCO2 and is present for up to a few days, can impair hemodynamics and increase mortality, particularly when severe (arterial blood pH&lt;7.20). Septic shock constitutes an important cause of morbidity and mortality in the critically ill patient. The Surviving Sepsis Campaign recommends against treatment with bicarbonate in patients with lactic acidosis due to hypo perfusion when pH is &gt;7.15 but does not explicate what should be done in cases with lower pH. Methodology: Prospective randomized, Double-blind controlled study was conducted in ICU of Bangalore Medical College and Research Institute, Bangalore for a period of 4 months (November 2020 to February 2021). Sample size calculation was based on previous prospective, randomized double bind, controlled study by Jung B et al, calculated to be 27 in each group. Results: Mean age of subjects in Study group was 43.7 ± 14.0 years and in control group was 43.3 ± 17.1 years. A statistically significant difference was found in mean final pH and HCO3 levels and with respect to need for ventilation and Multi Organ Dysfunction Syndrome among the groups. Conclusion: Metabolic acidosis is a common acid-base disorder and its management should be directed by the current guidelines of therapy. Rational treatment of metabolic acidosis in sepsis is directed towards addressing the underlying causes of acidosis and optimizing tissue oxygen delivery through optimization of cardiopulmonary parameters. Limitations of the previous studies prevent reaching definite conclusions and further investigations are required in order to ensure the validity of this therapeutic approach.

Updates in Sepsis Management Show Thoughtful Approach

Updates in Sepsis Management Show Thoughtful Approach

Surgical mask on top of high-flow nasal cannula improves oxygenation in critically ill COVID-19 patients with hypoxemic respiratory failure

ObjectiveCritically ill patients admitted in ICU because of COVID-19 infection display severe hypoxemic respiratory failure. The Surviving Sepsis Campaign recommends oxygenation through high-flow nasal cannula over non-invasive ventilation. The primary outcome of our study was to evaluate the effect of the addition of a surgical mask on a high-flow nasal cannula system on oxygenation parameters in hypoxemic COVID-19 patients admitted in ICU who do not require urgent intubation. The secondary outcomes were relevant changes in PaCO2 associated with clinical modifications and patient’s feelings.DesignWe prospectively assessed 21 patients admitted in our mixed Intensive Care Unit of the Cliniques Universitaires Saint Luc.Main resultsWhile FiO2 was unchanged, we demonstrate a significant increase of PaO2 (from 59 (± 6), to 79 mmHg (± 16), p < 0.001), PaO2/FiO2 from 83 (± 22), to 111 (± 38), p < 0.001) and SaO2 (from 91% (± 1.5), to 94% (± 1.6), p < 0.001), while the patients were under the surgical mask. The SpO2 returned to pre-treatment values when the surgical mask was removed confirming the effect of the device rather than a spontaneous positive evolution.ConclusionA surgical mask placed on patient’s face already treated by a High-flow nasal cannula device improves COVID-19 patient’s oxygenation admitted in Intensive Care Unit for severe hypoxemic respiratory failure without any clinically relevant side.

Quality of evidence supporting Surviving Sepsis Campaign Recommendations

IntroductionThe Surviving Sepsis Campaign (SSC) guidelines, released in 2017, are a combination of expert opinion and evidence-based medicine, adopted by many institutions as a standard of practice. The aim was to analyse the quality of evidence supporting recommendations on the management of sepsis. MethodsThe strength and quality of evidence (high, moderate, low-very low and best practice statements) of each recommendation were extracted. Randomised controlled trials were required to qualify as high-quality evidence. ResultsA total of 96 recommendations were formulated, and 87 were included. Among thirty-one (43%) strong recommendations, only 15.2% were supported by high-quality evidence. Overall, thirty-seven (42.5%) recommendations were based on low-quality evidence, followed by 28 (32.2%) based on moderate-quality, 15 (17.2%) were best practice statements and only seven (8.0%) were supported by high-quality evidence. Randomised controlled trials supported 21.4%, 9.5% and 8.6% recommendations on mechanical ventilation, resuscitation, and management/adjuvant therapy, respectively. In contrast, none high-quality evidence recommendation supported antimicrobial/source control (82.4% were low-very low evidence or best practice statements), and nutrition. ConclusionsIn the SSC guidelines most recommendations were informed by indirect evidence and non-systematic observations. While awaiting trials results, Delphi-like approaches or multi-criteria decision analyses should guide recommendations.

Delayed vasopressor initiation is associated with increased mortality in patients with septic shock

Despite significant advancements in the management of septic shock, mortality rates remain high. Systemic vasodilation leading to inadequate tissue perfusion and in turn multi-organ failure leads to death. Strategic sepsis bundles were introduced by the 2016 Surviving Sepsis Campaign (SSC) and recommend antibiotics within 1 hour of onset and early and aggressive fluid resuscitation, as well as three and six-hour bundles to allow for re-evaluation. Vasopressor initiation to correct hemodynamic instability that is unresponsive to fluid resuscitation can occur at any number of points during resuscitation per the SSC recommendations. Despite the crucial role of vasopressors in maintaining hemodynamic stability, there is limited data to show how the timing of vasopressor initiation affects outcomes, though some studies have shown mortality benefit with early administration of vasopressors in septic shock.

Adherence to Surviving Sepsis campaign 3-hour bundles improves survival in non-critically ill patients with cirrhosis and sepsis

Background and Aims: Sepsis is a common and life-threatening complication in cirrhosis. Surviving Sepsis Campaign recommendations suggest early administration of treatment bundles for sepsis, which reduces mortality in general population. However, no data is currently available in patients with cirrhosis. The aim of this study was to evaluate whether the adherence to 3-hour bundles could modify clinical outcomes in patients with cirrhosis and sepsis.

Antibiotic Delays and Feasibility of a 1-Hour-From-Triage Antibiotic Requirement: Analysis of an Emergency Department Sepsis Quality Improvement Database

We identify factors associated with delayed emergency department (ED) antibiotics and determine feasibility of a 1-hour-from-triage antibiotic requirement in sepsis. We studied all ED adult septic patients in accordance with Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures in 2 consecutive 12-month intervals. During the second interval, a quality improvement intervention was conducted: a sepsis screening protocol plus case-specific feedback to clinicians. Data were abstracted retrospectively through electronic query and chart review. Primary outcomes were antibiotic delay greater than 3 hours from documented onset of hypoperfusion (per Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock National Quality Measures) and antibiotic delay greater than 1 hour from triage (per 2018 Surviving Sepsis Campaign recommendations). We identified 297 and 357 septic patients before and during the quality improvement intervention, respectively. Before and during quality improvement intervention, antibiotic delay in accordance with Centers for Medicare & Medicaid Services measures occurred in 30% and 21% of cases (-9% [95% confidence interval -16% to -2%]); and in accordance with 2018 Surviving Sepsis Campaign recommendations, 85% and 71% (-14% [95% confidence interval -20% to -8%]). Four factors were independently associated with both definitions of antibiotic delay: vague (ie, nonexplicitly infectious) presenting symptoms, triage location to nonacute areas, care before the quality improvement intervention, and lower Sequential [Sepsis-related] Organ Failure Assessment scores. Most patients did not receive antibiotics within 1 hour of triage, with the exception of a small subset post-quality improvement intervention who presented with explicit infectious symptoms and triage hypotension. The quality improvement intervention significantly reduced antibiotic delays, yet most septic patients did not receive antibiotics within 1 hour of triage. Compliance with the 2018 Surviving Sepsis Campaign would require a wholesale alteration in the management of ED patients with either vague symptoms or absence of triage hypotension.

Early Antimicrobial Therapy for Sepsis: Does Each Hour Really Count?

For the last decades, the timing of antimicrobial therapy has remained a hotly debated topic in sepsis as well as other infectious diseases like community-acquired pneumonia (CAP) or bacterial meningitis (CABM). In CAP, a relationship between the time to antibiotic administration and mortality was found only in the largest cohort, but all these studies were retrospective and of low quality. In CABM, the level of evidence remains also limited, but there is now a good body of evidence linking the delay to antibiotic administration to unfavorable outcome. The European guidelines strongly suggest that time period should not exceed 1 hour. Finally, in sepsis, if the 1-hour cut-off remains debatable for sepsis patients, early administration (within 3 hours) is recommended in sepsis and sepsis shock as suggested by the surviving sepsis campaign recommendations. To conclude, all these data are in favor of a potential link between the time to antibiotic administration and survival, but we still miss randomized controlled studies to give a definite answer.

Activation of code sepsis in the emergency department is associated with a decrease in mortality

ObjectivesTo evaluate the impact of a code sepsis (CS) activation, complying with recommendations, the evolution of patients with severe sepsis in the emergency room and determine independent factors associated to mortality. MethodAll patients attending the emergency room with severe sepsis during a 6-month period were included. Complying with Surviving Sepsis Campaign recommendations, patients’ average stay, intensive care admissions and 30-day mortality were assessed. Two groups were compared: CS activation (A) and no activation (NA). ResultsA total of 114 episodes were found, 61.4% belonging to group A and 38.6% to NA. Patients in group A presented hypotension more frequently (61.5% vs. 34.4%; p=.005). Patients in group NA more frequently had lactate levels of >3mmol/l (48.3% vs. 80%; p=.01), and abdominal focus of sepsis (34.3% vs. 13%; p=.01). In group A, blood cultures were more frequently drawn in the first hour (95% vs. 41.7%; p<.001), early antibiotic was administered (76.9% vs. 25%; p=.005) and fluid replacement carried out (54.5% vs. 18.2%; p=.01). Global achievement of CS objectives was higher in group A (31.4% vs. 9.1%; p=.006). In group NA more patients were admitted to the intensive care unit (10% vs. 36.4%; p<.001), had longer average stays (10.2 days SD 6.9 vs. 14.4 days SD 5.8; p<.001) and a higher mortality rate (4.3% vs. 34.1%; p<.001).CRP >200mg/l (OR 33.7; p<.001) and the no activation of CS (OR 13.3; p=.001) resulted in being independent factors associated with mortality. ConclusionsThe implementation of a CS improves compliance with SSC recommendations and decreases intensive care admissions, average stays and mortality.

Beta-blockers in Septic Shock

The therapy of patients suffering from sepsis and septic shock is one of the greatest challenges in critical care medicine. In the initial phase of septic shock patients often present with hyperdynamic circulatory conditions with elevated cardiac index, tachycardia and progressive hemodynamic instability. The type of tachycardia differs from atrial fibrillation or flatter to sinus tachycardia. The latter might be persistent even in case of adequate volume therapy according to the surviving sepsis campaign recommendations and may represent an independent pathology due to adrenergic overstimulation. Despite predominantly β2-mediated immunomodulatory effects the administration of a selective β1-adrenergic blocker may be beneficial in some cases. On the other hand, incautious administration of beta-blockers especially in case of insufficient volume replacement may result in direct negative inotropic effects rapidly aggravating hypotension and shock. This review focused on pharmacology of the β-adrenergic system, the pathophysiological rationale and current literature on clinical practice of the use of beta-blockers in sepsis and septic shock.

La activación de un código sepsis en urgencias se asocia a una menor mortalidad

ObjectivesTo evaluate the impact of a code sepsis (CS) activation, complying with recommendations, the evolution of patients with severe sepsis in the emergency room and determine independent factors associated to mortality. MethodAll patients attending the emergency room with severe sepsis during a 6-month period were included. Complying with Surviving Sepsis Campaign recommendations, patients’ average stay, intensive care admissions and 30-day mortality were assessed. Two groups were compared: CS activation (A) and no activation (NA). ResultsA total of 114 episodes were found, 61.4% belonging to group A and 38.6% to NA. Patients in group A presented hypotension more frequently (61.5% vs 34.4%; P=.005). Patients in group NA more frequently had lactate levels of >3mmol/L (48.3% vs 80%; P=.01), and abdominal focus of sepsis (34.3% vs 13%; P=.01). In group A, blood cultures were more frequently drawn in the first hour (95% vs 41.7%; P<.001), early antibiotic was administered (76.9% vs 25%; p=.005) and fluid replacement carried out (54.5% vs 18.2%; P=.01). Global achievement of CS objectives was higher in group A (31.4% vs 9.1%; P=.006). In group NA more patients were admitted to the intensive care unit (10% vs 36.4%; P<.001), had longer average stays (10.2 days SD 6.9 vs 14.4 days SD 5.8; P<.001) and a higher mortality rate (4.3% vs 34.1%; P<.001).CRP>200mg/l (OR 33.7; P<.001) and the no activation of CS (OR 13.3; p=.001) resulted in being independent factors associated with mortality. ConclusionsThe implementation of a CS improves compliance with SSC recommendations and decreases intensive care admissions, average stays and mortality.

Resource availability for the management of maternal sepsis in Malawi, other low-income countries, and lower-middle-income countries.

To assess the availability of key resources for the management of maternal sepsis and evaluate the feasibility of implementing the Surviving Sepsis Campaign (SSC) recommendations in Malawi and other low-resource settings. A cross-sectional study was conducted at health facilities in Malawi, other low-income countries, and lower-middle-income countries during January-March 2016. English-speaking healthcare professionals (e.g. doctors, nurses, midwives, and administrators) completed a questionnaire/online survey to assess the availability of resources for the management of maternal sepsis. Healthcare centers (n=23) and hospitals (n=13) in Malawi showed shortages in the resources for basic monitoring (always available in 5 [21.7%] and 10 [76.9%] facilities, respectively) and basic infrastructure (2 [8.7%] and 7 [53.8%], respectively). The availability of antibiotics varied between Malawian healthcare centers (9 [39.1%]), Malawian hospitals (8 [61.5%]), hospitals in other low-income countries (10/17 [58.8%]), and hospitals in lower-middle-income countries (39/41 [95.1%]). The percentage of SSC recommendations that could be implemented was 33.3% at hospitals in Malawi, 30.3% at hospitals in other low-income countries, and 68.2% at hospitals in lower-middle-income countries. The implementation of existing SSC recommendations is unrealistic in low-income countries because of resource limitations. New maternal sepsis care bundles must be developed that are applicable to low-resource settings.

Impact of a Combination Antibiotic Bag on Compliance With Surviving Sepsis Campaign Goals in Emergency Department Patients With Severe Sepsis and Septic Shock.

Severe sepsis and septic shock represent common presentations in the emergency department (ED) and have high rates of mortality. Guideline-recommended goals of care have been shown to benefit these patients, but can be difficult to provide. To determine whether the use of a premixed bag consisting of 2 g cefepime and 1 g vancomycin in 1000 mL of normal saline increases the probability of patients receiving Surviving Sepsis Campaign (SSC) recommendations for the initiation of antimicrobials and fluid challenge. This was a 6-month retrospective analysis conducted to determine the impact of an intervention on time to antimicrobials and fluid administration in patients with severe sepsis and septic shock. Patients presenting to the ED who received a diagnosis of severe sepsis or septic shock and were administered 2 antibiotics were eligible for inclusion. The primary outcome assessed was compliance with SSC recommendations for antibiotic and fluid goals within 3 hours of ED arrival. A total of 160 patients were included. In the intervention group, 63.8% of patients met the primary outcome compared with 22.5% in the historical group (odds ratio = 2.32; 95% CI = 1.67-3.23). Time to administration of antibiotics was less with the combination antibiotic bag (CAB: median (IQR) = 72 (48-115) minutes; non-CAB: median (IQR) = 135 (102-244) minutes; P ≤ 0.001). This intervention significantly increased the proportion of patients provided with SSC goals of care. Such interventions have not been reported previously and could be meaningful in the management of severe sepsis and septic shock.