Suspected Sepsis Research Articles

A Quantitative Study of Decision Thresholds for Initiation of Antibiotics in Suspected Sepsis.

Clinicians' decision thresholds for initiating antibiotics in patients with suspected sepsis have not been quantified. We aimed to define an average threshold of infection likelihood at which clinicians initiate antibiotics when treating a patient with suspected infection and to evaluate the influence of severity of illness and clinician-related factors on the threshold. This was a prospective survey of 153 clinicians responding to 8 clinical vignettes constructed from real-world data from 3 health care systems in the United States. We treated each hour in the vignette as a decision to treat or not treat with antibiotics and assigned an infection probability to each hour using a previously developed infection prediction model. We then estimated decision thresholds using regression models based on the timing of antibiotic initiation. We compared thresholds across categories of severity of illness and clinician-related factors. Overall, the treatment threshold occurred at a 69% probability of infection, but the threshold varied significantly across severity of illness categories-when patients had high severity of illness, the treatment threshold occurred at a 55% probability of infection; when patients had intermediate severity, the threshold for antibiotic initiation occurred at an infection probability of 69%, and the threshold was 84% when patients had low severity of illness (P < 0.001 for group differences). Thresholds differed significantly across specialty, highest among infectious disease and lowest among emergency medicine clinicians and across years of experience, decreasing with increasing years of experience. The threshold infection probability above which physicians choose to initiate antibiotics in suspected sepsis depends on illness severity as well as clinician factors. Incorporating these context-dependent thresholds into discriminating and well-calibrated models will inform the development of future sepsis clinical decision support systems. Clinician-related differences in treatment thresholds suggests potential unwarranted variation and opportunities for performance improvement. Decision making about antibiotic initiation in suspected sepsis occurs under uncertainty, and little is known about clinicians' thresholds for treatment.In this prospective study, 153 clinicians from 3 health care systems reviewed 8 real-world clinical vignettes representing patients with sepsis and indicated the time that they would initiate antibiotics.Using a model-based approach, we estimated decision thresholds and found that thresholds differed significantly across illness severity categories and by clinician specialty and years of experience.

Cerebrovascular Events in Suspected Sepsis: Retrospective Prevalence Study in Critically Ill Patients Undergoing Full-Body Computed Tomography.

PurposeThis study aimed at retrospectively evaluating full-body computed tomography (CT) examinations for the prevalence of cerebrovascular events in patients with suspected sepsis treated in the intensive care unit (ICU).MethodsAll full-body CT examinations, i.e., both cranial CT (cCT) and body CT including chest, abdomen and pelvis, for focus search in septic patients over a 12-months period were identified from three ICUs, using full-text search. From this retrospective cohort, we fully analyzed 278 cCT examinations for the occurrence of acute cerebral findings. All acute cerebrovascular events were independently reviewed by two blinded readers. Clinical and laboratory findings were extracted. The data were statistically analyzed using contingency tests.ResultsIn our population of patients with suspected sepsis, 10.8% (n = 30/278) were identified to have major cerebral events, including 7.2% (n = 20/278) major cerebrovascular events and 4.3% (n = 12/278) generalized parenchymal damage. 13.4% (n = 22/163) of patients with a severe coma as compared with non-severe coma, 4.4% (n = 3/68), showed a major cerebral event (p = 0.04). Patients referred from the cardiology/nephrology ICU ward showed major cerebral events in 16.3% (n = 22/135), as compared with 4.9% (n = 3/61) in patients from pulmonary ICU and 6.1% (n = 5/82) major cerebral events with surgical referral (p = 0.02).ConclusionOur study provides further evidence that septic patients may suffer from cerebral events with relevance to their prognosis. Severe coma and the referring ward were associated with acute cerebral conditions. Full-body CT has the advantage of both detecting of septic foci and possibly identifying ischemic or hemorrhagic stroke in this vulnerable patient population.

Audit of Antibiotic Prescription in Suspected Neonatal Sepsis at an Indian Tertiary Care Hospital

Neonatal sepsis is one of the most typical causes of neonatal morbidity and mortality in the developing world. Rational use of antibacterial is a priority to prevent the emergence of resistance and to reduce the burden of treatment failure. This study was a prospective, cross-sectional study that collected data from 148 records of clinically suspected neonatal sepsis in a tertiary care hospital between January to December 2017. The isolated organisms, prescribing patterns, approval status, and list of antibacterial in WHO Essential Medicines List/NLEM were analyzed and presented as percentages, mean and standard deviations using appropriate tables and graphs. Of the 430 antibacterials examined, single-drug formulations were most commonly prescribed [400(93.02%)]; 298(69.30%) and 427(99.30%) were approved by DCGI and USFDA, respectively; 275(63.95%) antibacterials were included in both WHO and NLEM. The most common isolated organisms were gram-negative (64.1%). The most common class of antibacterial prescribed was beta-lactams (ATC class: J01D and J01C) [251(58.37%)] followed by aminoglycosides (ATC class: J01G) [124(28.84%)] irrespective of culture and sensitivity and their generic names prescribed almost 50% (216) of drugs. Regarding outcome, 87.16% of cases recovered well. In conclusion, the rationality of antibacterial drug usage in suspected cases of neonatal sepsis was followed the majority of times, leading to better patient care and outcome.

Augmented Renal Clearance of Vancomycin in Suspected Sepsis: Single-Center, Retrospective Pediatric Cohort.

To identify associations between augmented renal clearance (ARC) in pediatric patients treated for suspected sepsis and vancomycin pharmacokinetics. ARC has been associated with lower serum drug levels in both adult and pediatric cohorts for multiple drugs. We hypothesize that presence of ARC is associated with subtherapeutic initial vancomycin trough level (VTL). Retrospective study, with patients divided into two groups based on the presence of ARC (estimated glomerular filtration rate [eGFR] above 130 mL/min/1.73 m2) in comparison with VTL. Multivariable logistic regression analysis was performed to evaluate the association between eGFR and subtherapeutic VTL. Tertiary children's hospital. Hospitalized children (0-18 yr) initiated on empiric vancomycin therapy for suspected sepsis. Retrospective measurement of VTL, eGFR, and clinical variables. Seventy-three patients were treated with empiric vancomycin for sepsis. ARC was present in 32 patients (44%). Subtherapeutic first VTL was present in 40 patients (55%). Higher eGFR was independently associated with subtherapeutic VTL in the multivariable logistic regression analysis. Subtherapeutic VTL is associated with ARC in our single-center retrospective cohort of children with suspected sepsis. This problem may present a potential risk of treatment failure in Gram-positive sepsis or longer time to clinical response. Prospective studies to investigate the clinical significance and effect of optimizing vancomycin dose in patients with ARC are recommended.

Sequence-Based Genotyping of Extra-Intestinal Pathogenic Escherichia Coli Isolates from Patients with Suspected Community-Onset Sepsis, Sweden

Sequence-Based Genotyping of Extra-Intestinal Pathogenic Escherichia Coli Isolates from Patients with Suspected Community-Onset Sepsis, Sweden

1144. Evaluation of Procalcitnonin Usage in Neonates Presenting with Fever or Suspected Sepsis

BackgroundClinical evaluation alone is not effective in identifying serious bacterial infections (SBI) in neonates presenting with suspected sepsis and fever. A clinical decision making tool to aide in evaluating neonates presenting to the pediatric emergency department (PED) uses urinalysis, absolute neutrophil count (ANC), and procalcitonin (PCT) and together has high negative predictive value (NPV) for SBI. Use may decrease invasive testing, antibiotic exposure, and rates of admission. The tool was incorporated into hospital guidelines in October 2020. The purpose is to assess implementation and prediction of SBIs.MethodsThis is a single-center quality improvement study at an academic medical center. Neonates less than 60 days presenting with fever or suspected sepsis were included in the baseline group from October 2019- March 2020 or the post-implementation group from October 2020- March 2021. Exclusion criteria were receiving antibiotics 48 hours before PED visit, pre-existing medical conditions, indwelling devices, soft-tissue infections, and ≤ 36 weeks gestation. Implementation and guideline compliance was assessed in neonates aged 29-60 days as the primary outcome. Secondary endpoints include initiation of empiric antibiotics, rates of admission, rates of re-presentation within 30 days, and rates of lumbar punctures in all included patients.ResultsThe baseline group had 29 patients and the post-implementation group had 35 patients who met inclusion/exclusion criteria. Baseline characteristics were similar with higher SBI rates in the post-implementation group having 8 SBIs while the baseline group had 4. There were 16 patients aged 29-60 days in the baseline (55%) and 17 in the post-implementation groups (49%). Complete labs were available for 9 patients (53%) and guideline compliance was 89%. NPV in neonates aged 0-60 days with negative urinalysis, ANC, and PCT was 100%. Rates of secondary endpoints were slightly higher in the post-implementation group along with higher rates of infections.ConclusionHigh NPV in this small cohort is an indication for continued use of this tool in neonates presenting to the PED with suspected sepsis or fever. Further education to increase use and expansion to all neonates should be considered based on overall NPV and previous studies.Disclosures All Authors: No reported disclosures

197. A Predictive Model for the Prompt Identification of Suspected Sepsis Patients with High Death Risk

Abstract Background How to improve the high mortality rate of sepsis? The prompt identification of at-risk patients, and the interdisciplinary sepsis treatment protocol implementation are interventions that can reverse such unacceptable outcome. The objective of our study is to summarize main results of the protocol for the management of sepsis and septic shock, implemented at Biocor Instituto, a general hospital in Belo Horizonte, a 3,000,000 inhabitants city from Brazil. Methods Prospective cohort study of patients with sepsis, evaluated between May/2018-Apr/2020. Univariate and multivariate analysis by logistic regression to identify risk factors for hospital death. Results Over 28 months, 220 patients were included in sepsis protocol: 121 hospital deaths, a crude mortality = 121/220 = 55% (95%C.I. = [48%;62%]). 136 patients (62%) came from the emergency room. In 97 cases (44%) it was possible to isolate 111 microorganisms, with a predominance of Klebsiella, E.coli, and S.aureus. 75% of the cases (165) had definition of APACHE, with the absolute majority of these (88%) having APACHE between 25 and 40. Most patients (52%) received antibiotic (ATB) in 15 minutes and only 4% received ATB after 60 minutes of waiting time. In 198 patients (90%) it was possible to identify the focus of sepsis, with a predominance of pulmonary (47%), urinary (21%) and abdominal (15%). Hospital mortality varied from 30 to 62%, when the focus was pulmonary (p-value = 0.045). In univariate analysis (Figure 1), pulmonary sepsis, creatinine, lactate, and APACHE were significantly associated with hospital death. The time for ATB administration was typically close to 20 minutes, and time to receive the therapeutic antibiotic were not associated with the patient’s death. By using the logistic model (Figure 2) to assign cases of predicted hospital death for probabilities &amp;gt;= 0.5 and controls for probabilities &amp;lt; 0.5, the prediction model had a sensitivity of 0.68 (0.59–0.76), a specificity of 0.58 (0.48–0.67), an area under the curve of the receiver operating characteristic curve of 0.75 (0.68–0.82). There was no significant difference between observed versus expected mortality by APACHE (Figure 3). Figure 1. Univariate analysis to identify risk factors for hospital death. Figure 2. Logistic model for predicting hospital death. Figure 3. Observed X Expected/severity-adjusted mortality (APACHE). Conclusion The logistic model developed uses only creatinine and lactate data to predict suspected sepsis patients with high death risk. Disclosures All Authors: No reported disclosures

Utility of a Cell-Direct Polymerase Chain Reaction-Based Nucleic Acid Lateral Flow Immunoassay for Detection of Bacteria in Peripheral Blood Leukocytes of Suspected Sepsis Cases.

BackgroundThe detection of the pathogens in the blood is essential for the management of septic patients; however, conventional blood culture takes 2–3 days. Therefore, rapid and convenient methods may be useful to aid clinical decision-making.MethodsBlood samples with sepsis clinically diagnosed in cases that fulfilled the diagnostic criteria were used and analyzed the utility of a novel bacterial nucleic acid identification test using a cell-direct polymerase chain reaction (cdPCR)-based nucleic acid lateral flow immunoassay (NALFIA) which were named as “DiagnoSep” to detect representative bacteria in peripheral blood leukocytes in patients admitted to our hospital and compared the conventional blood culture results simultaneously taken from the patients.ResultsWe analyzed the total 42 samples in the terms of this study and found 18 (42.8%) were positive on cdPCR-NALFIA, and 24 (57.1%) were positive on blood cultures. Although the positive rate was higher with blood cultures, 15 samples showed positive results from both blood cultures and cdPCR-NALFIA, and the identified bacteria agreed for 10 samples. Of the 18 cdPCR-NALFIA-positive cases, the results for 8 samples differed from the results of blood cultures; four of them had an implanted pacemaker or prosthetic joint and were positive for Staphylococcus aureus or Staphylococcus epidermidis on cdPCR-NALFIA.ConclusionBlood culture tests are probably the gold standard in identifying causative organisms in sepsis, but the rapid results from cdPCR-NALFIA simultaneously used with blood culture may make it an important auxiliary diagnostic tool for identifying infecting organisms and lead to the improvement of mortality of the septic patients, because these combined results provide the wide information on the possible pathogens in early phase.

Which Biomarkers Can Be Used as Diagnostic Tools for Infection in Suspected Sepsis?

The diagnosis of infection in patients with suspected sepsis is frequently difficult to achieve with a reasonable degree of certainty. Currently, the diagnosis of infection still relies on a combination of systemic manifestations, manifestations of organ dysfunction, and microbiological documentation. In addition, the microbiologic confirmation of infection is obtained only after 2 to 3 days of empiric antibiotic therapy. These criteria are far from perfect being at least in part responsible for the overuse and misuse of antibiotics, in the community and in hospital, and probably the main drive for antibiotic resistance. Biomarkers have been studied and used in several clinical settings as surrogate markers of infection to improve their diagnostic accuracy as well as in the assessment of response to antibiotics and in antibiotic stewardship programs. The aim of this review is to provide a clear overview of the current evidence of usefulness of biomarkers in several clinical scenarios, namely, to diagnose infection to prescribe antibiotics, to exclude infection to withhold antibiotics, and to identify the causative pathogen to target antimicrobial treatment. In recent years, new evidence with "old" biomarkers, like C-reactive protein and procalcitonin, as well as new biomarkers and molecular tests, as breathomics or bacterial DNA identification by polymerase chain reaction, increased markedly in different areas adding useful information for clinical decision making at the bedside when adequately used. The recent evidence shows that the information given by biomarkers can support the suspicion of infection and pathogen identification but also, and not less important, can exclude its diagnosis. Although the ideal biomarker has not yet been found, there are various promising biomarkers that represent true evolutions in the diagnosis of infection in patients with suspected sepsis.

Reduction of Duration of Antibiotic Therapy for Suspected Early-Onset Sepsis in Late-Preterm and Term Newborns After Implementation of a Procalcitonin-Guided Algorithm: A Population-Based Study in Central Switzerland

Background: Suspected early-onset sepsis (EOS) is the main reason for antibiotic therapy at the start of life. Prolonged antibiotic therapy for culture-negative sepsis is often reported. Antibiotic stewardship is mandatory due to the potential negative effects of unnecessary antibiotics. Procalcitonin (PCT)-guided therapy is one possible strategy with published evidence to shorten antibiotic therapy. The aim of this study is to analyze the feasibility and the performance of the published PCT-algorithm in the clinical setting without study support.Methods: This is a retrospective, population-based study regarding duration of antibiotic therapy for suspected EOS in Central Switzerland between 2014 and 2018. All neonates >34 0/7 weeks of gestational age started on antibiotic therapy for suspected EOS within the first 3 calendar days of life were included. The Procalcitonin-guided algorithm according to the NeoPInS study was used as strategy to determine duration of antibiotic therapy.Results: In a population-based cohort of 35,642 life born neonates, the duration of antibiotic therapy of 879 neonates (2.5% of the cohort) treated for suspected EOS was 4 calendar days (median, IQR 2–5). We observed a statistically significant reduction from 4 (median, IQR 3–6) to 3 calendar days (median, IQR 2–4) from 2014 to 2018. Duration of antibiotic therapy was independent of gestational age (late-preterm vs. term neonates), of the presence of risk factors or clinical signs, but dependent on the presence of abnormal laboratory measurements (C-reactive protein > 10 mg/l or leukocytopenia <5 Giga/l) before start of antibiotic therapy (p < 0.01).Conclusions: PCT-guided therapy using the NeoPInS algorithm is feasible and may lead to reduced duration of antibiotic therapy for suspected EOS as reported in the original study. We observed a learning curve to the new algorithm which may be explained as change process. The use of biomarker to guide duration of antibiotic therapy for suspected EOS may have unintended consequences with prolongation of antibiotic therapy in some cases.

Machine Learning Approaches to Predict In-Hospital Mortality among Neonates with Clinically Suspected Sepsis in the Neonatal Intensive Care Unit.

Background: preterm and critically ill neonates often experience clinically suspected sepsis during their prolonged hospitalization in the neonatal intensive care unit (NICU), which can be the initial sign of final adverse outcomes. Therefore, we aimed to utilize machine learning approaches to predict neonatal in-hospital mortality through data-driven learning. Methods: a total of 1095 neonates who experienced clinically suspected sepsis in a tertiary-level NICU in Taiwan between August 2017 and July 2020 were enrolled. Clinically suspected sepsis was defined based on clinical features and laboratory criteria and the administration of empiric antibiotics by clinicians. The variables used for analysis included patient demographics, clinical features, laboratory data, and medications. The machine learning methods used included deep neural network (DNN), k-nearest neighbors, support vector machine, random forest, and extreme gradient boost. The performance of these models was evaluated using the area under the receiver operating characteristic curve (AUC). Results: the final in-hospital mortality of this cohort was 8.2% (90 neonates died). A total of 765 (69.8%) and 330 (30.2%) patients were randomly assigned to the training and test sets, respectively. Regarding the efficacy of the single model that most accurately predicted the outcome, DNN exhibited the greatest AUC (0.923, 95% confidence interval [CI] 0.953–0.893) and the best accuracy (95.64%, 95% CI 96.76–94.52%), Cohen’s kappa coefficient value (0.74, 95% CI 0.79–0.69) and Matthews correlation coefficient value (0.75, 95% CI 0.80–0.70). The top three most influential variables in the DNN importance matrix plot were the requirement of ventilator support at the onset of suspected sepsis, the feeding conditions, and intravascular volume expansion. The model performance was indistinguishable between the training and test sets. Conclusions: the DNN model was successfully established to predict in-hospital mortality in neonates with clinically suspected sepsis, and the machine learning algorithm is applicable for clinicians to gain insights and have better communication with families in advance.

Vignettes Identify Variation in Antibiotic Use for Suspected Early Onset Sepsis.

There is widespread unwarranted antibiotic use and large individual provider variation in antibiotic use in NICUs. Vignette-based research methodology offers a unique method of studying variation in individual provider decisions. The objective with this study was to use a vignette-based survey to identify specific areas of provider antibiotic use variation in newborns being evaluated for early onset sepsis. This study was undertaken as part of a statewide multicenter neonatal antibiotic stewardship quality improvement project led by a perinatal quality improvement collaborative. A web-based vignette survey was administered to identify variation in decisions to start and discontinue antibiotics in cases of early onset sepsis. The largest variation was noted in 3 of the 6 vignette cases. These cases highlighted variation in (1) decisions to start antibiotics in a case describing a well-appearing newborn with risk factors and an elevated C-reactive protein, (2) decisions to start antibiotics in the case of a newborn with risk factors plus mild respiratory signs at birth, and (3) decisions to stop antibiotics in the case of the newborn with a history of sepsis risk factors and mild clinical respiratory signs that resolved after 72 hours. Clinical vignette assessment identified specific areas of variation in individual provider antibiotic use decisions in cases of suspected early onset sepsis. Vignettes are a valuable method of describing individual provider variation and highlighting antibiotic stewardship improvement opportunities in NICUs.

Reduction of Duration of Antibiotic Therapy for Suspected Early-Onset Sepsis in Late-Preterm and Term Newborns After Implementation of a Procalcitonin-Guided Algorithm: A Population-Based Study in Central Switzerland

Reduction of Duration of Antibiotic Therapy for Suspected Early-Onset Sepsis in Late-Preterm and Term Newborns After Implementation of a Procalcitonin-Guided Algorithm: A Population-Based Study in Central Switzerland

Toward More Rational Time-to-Antibiotic Metrics for Suspected Sepsis: Erratum.

Toward More Rational Time-to-Antibiotic Metrics for Suspected Sepsis: Erratum.

Comparison of 25-Hydroxyvitamin D Levels in Pediatric Hematologic Cancer with and without Suspected Sepsis

Vitamin D is known to play an important role in fighting infections through innate and adaptive immune systems. Children with cancer have a higher risk of suffering sepsis and vitamin D deficiency. Some studies on vitamin D levels in pediatric cancer with sepsis have shown varied results and remain controversial. This study aimed to analyze 25-hydroxyvitamin D levels in pediatric hematologic cancer with and without suspected sepsis. The study was an observational analytical study with a cross-sectional design. Samples were collected during April–September 2019 from the Pediatrics Outpatient Clinic of the Dr. Soetomo Hospital, Surabaya. The samples were a group of pediatric hematologic cancer consisted of 32 subjects with suspected sepsis and 30 without sepsis. Each group was measured the 25-hydroxyvitamin D levels, then differences in levels of 25-hydroxyvitamin D between groups were assessed. Vitamin D levels were measured using ADVIA Centaur. Both groups had low 25-hydroxyvitamin D levels with a deficiency state of 96.9% and 80% in the suspected sepsis group and group without sepsis. There were differences in levels of 25-hydroxyvitamin D in pediatric cancer with and without suspected sepsis (p=0.045). Lower vitamin D levels were found in the cancer group with suspected sepsis. Low vitamin D levels reduce T-helper 2 activity, decrease cellular immunity, and decrease phagocytic macrophages, leading to an easier entry of pathogens and bacteremia. There were significant differences in 25-hydroxyvitamin D levels in pediatric hematologic cancer with and without suspected sepsis.

Toward More Rational Time-to-Antibiotic Metrics for Suspected Sepsis*

Toward More Rational Time-to-Antibiotic Metrics for Suspected Sepsis*

The Association Between Antibiotic Delay Intervals and Hospital Mortality Among Patients Treated in the Emergency Department for Suspected Sepsis.

Rapid delivery of antibiotics is a cornerstone of sepsis therapy, although time targets for specific components of antibiotic delivery are unknown. We quantified time intervals comprising the task of antibiotic delivery and evaluated the association between interval delays and hospital mortality among patients treated in the emergency department for suspected sepsis. Retrospective cohort. Twelve hospitals in Southeastern United States from 2014 to 2017. Twenty-four thousand ninety-three encounters among 20,026 adults with suspected sepsis in 12 emergency departments. We divided antibiotic administration into two intervals: time from emergency department triage to antibiotic order (recognition delay) and time from antibiotic order to infusion (administration delay). We used generalized linear mixed models to evaluate associations between these intervals and hospital mortality. Median time from emergency department triage to antibiotic administration was 3.4 hours (interquartile range, 2.0-6.0 hr), separated into a median recognition delay (time from emergency department triage to antibiotic order) of 2.7 hours(interquartile range, 1.5-4.7 hr) and median administration delay (time from antibiotic order to infusion) of 0.6 hours (0.3-1.2 hr). Adjusting for other risk factors, both recognition delay and administration delay were associated with mortality, but pairwise comparison with a no-delay reference group was not significant for up to 6 hours of recognition delay or up to 1.5 hours of administration delay. Both recognition delays and administration delays were associated with increased hospital mortality, but only for longer delays. These results suggest that both metrics may be important to measure and improve for patients with suspected sepsis but do not support targets less than 1 hour.

62. Factors Associated with 30-Day ED Readmission Following Initial ED Discharge for Suspected Sepsis

BackgroundGiven the increased mortality associated with delayed recognition of sepsis, emergency departments (ED) often use protocols to rapidly identify and treat suspected sepsis. However, screening criteria such as systemic inflammatory response syndrome (SIRS) lack specificity and may over-diagnose sepsis in patients otherwise stable for discharge. Our study describes outcomes and identifies factors associated with ED readmission in those initially discharged directly from the ED who met sepsis criteria.MethodsThis retrospective cohort study evaluated adult patients (≥ 18 years) seen in the ED at UTSW Medical Center from January to June 2018 who met all the following: ≥ 2 SIRS criteria; received ≥ 1 dose of intravenous (IV) broad-spectrum antibiotic(s) in the ED; were discharged home. A multivariable logistic regression model identified factors associated with 30-day re-admission to our ED, using clinically significant variables parsimoniously. A two-sided P value < 0.05 was considered significant.ResultsA total of 179 patients were included. Forty-four patients (25%) returned to the ED within 30 days of their initial visit; of those 44, 63.6% (28) returned for issues related to their prior visit, and 50% (22) were admitted to the hospital. Table 1 compares baseline demographics of patients with suspected sepsis readmitted to the ED with those not readmitted within 30 days after initial ED discharge. In univariable analysis, quick Sequential Organ Failure Assessment (qSOFA), and length of antibiotic therapy (ED plus discharge antibiotics) were associated with ED re-admission (table 1). Receipt of antibiotics on discharge was not significant. In the final multivariable analysis (table 2), initial qSOFA ≥ 2 alone was associated with increased risk of ED re-admission (OR 7.5, p=0.01).Table 1. Baseline demographics of patients readmitted and not readmitted to the ED within 30 days after ED discharge with suspected sepsis Table 2. Multivariable logistic regression of risk factors for patients readmitted and not readmitted to the ED within 30 days after ED discharge with suspected sepsis ConclusionIn this cohort, 25% of patients with suspected sepsis initially discharged from the ED were readmitted to our ED within 30 days. A qSOFA ≥ 2 at the initial ED visit was associated with increased risk of readmission, suggesting a potential use of qSOFA to triage those warranting admission or closer follow-up. Larger prospective studies are warranted in this understudied population of patients who meet screening sepsis criteria but are discharged from the ED.Disclosures All Authors: No reported disclosures

Thyroid Crisis and Septic Suspected Sepsis in the First Trimester of Pregnancy

A normal pregnancy with physiological and hormonal changes can change thyroid function, accordingly, there are difficulties to establish the diagnosis of thyroid abnormality. The prevalence of hyperthyroidism in pregnancy is 0.6%. Approximately 1-2% of hyperthyroidism develops into a thyroid crisis. Knowledge of the diagnosis of the thyroid crisis in a pregnant female is very important to avoid complications. The 22-year-old female of thirteen weeks presented with vomiting, since two days before hospitalized, weakness, and decreased consciousness. During treatment, patients had diarrhea, melena, and was irritable. Physical examination showed blood pressure of 136/112 mmHg, pulse of 110 times/minute, respiration of 24 times/minute, and temperature of 38.3oC. Exophthalmos was found at the patient's eyes, but there was no enlargement of the thyroid and the patient often screamed hysterically. Routine urine examination showed proteinuria 1+, blood 3+, leukocytes 1+ in urinalysis, FT4 35.18 pmol/L and TSH &lt;0.05 uIU/mL, leukocytes 15.2 x103/uL, SGOT 245 U/L, SGPT 366 U/L. The final diagnosis of this patient is a thyroid crisis and suspect sepsis in the first trimester of pregnancy. Thyroid Receptor Antibody (TRAb) examination should be performed to assure Graves disease or hyperthyroidism due to pregnancy (transient hyperthyroidism) as the cause.

Association of Acute Kidney Injury With Subsequent Sepsis in Critically Ill Children.

Acute kidney injury is a major cause of morbidity and mortality in critically ill children. A growing body of evidence has shown that acute kidney injury affects immune function, yet little is known about the association between acute kidney injury and subsequent infection in pediatric patients. Our objective was to examine the association of non-septic acute kidney injury with the development of subsequent sepsis in critically ill children. A single-center retrospective cohort study. The pediatric and cardiac ICUs at a tertiary pediatric care center. All patients 0-18 years old without a history of chronic kidney disease, who did not have sepsis prior to or within the initial 48 hours of ICU admission. None. We analyzed data for 5,538 children (median age, 5.3 yr; 58.2% male), and identified 255 (4.6%) with stage 2 or 3 acute kidney injury. Suspected sepsis occurred in 46 children (18%) with stage 2 or 3 acute kidney injury compared to 286 children (5.4%) with stage 1 or no acute kidney injury. On adjusted analysis, children with stage 2 or 3 acute kidney injury had 2.05 times greater odds of developing sepsis compared to those with stage 1 or no acute kidney injury (95% CI, 1.39-3.03; p < 0.001). Looking at acute kidney injury severity, children with stage 2 and 3 acute kidney injury had a 1.79-fold (95% CI, 1.15-2.79; p = 0.01) and 3.24-fold (95% CI, 1.55-6.80; p = 0.002) increased odds of developing suspected sepsis, respectively. Acute kidney injury is associated with an increased risk for subsequent infection in critically ill children. These results further support the concept of acute kidney injury as a clinically relevant immunocompromised state.