14 latest sepsis findings

Sepsis, a complication caused by the body's response to infection, can lead to organ failure and death, according to the CDC.

Read on for 14 recent findings on sepsis.

1. A study published in the Journal of Critical Care found that an educational program for the identification and treatment of sepsis implemented in coordination with rapid response care teams can result in a 10 percent reduction in sepsis deaths. Researchers reviewed data on sepsis patients treated at UF Health Jacksonville (Fla.) between Oct. 1, 2013, and Nov. 10, 2015.

2. Administering antibiotics earlier, along with completing a three-hour bundle of care, helped improve outcomes for sepsis patients as compared to administering intravenous fluids earlier, according to a study published in the New England Journal of Medicine. Researchers examined data from patients with sepsis and septic shock reported to the New York State Department of Health from April 1, 2014, to June 30, 2016.

3. Children who develop sepsis tend to feel the effects of the infection on their physical, social and emotional well-being until months after hospital discharge. For the study, researchers reviewed EHRs and identified 778 children at Seattle Children's Hospital between 2012 and 2015 who were diagnosed with sepsis within four hours of arrival. The research was presented at the 2017 Pediatric Academic Societies Meeting, May 6 to May 9, in San Francisco.

4. People who take short-term prescribed steroid pills may be at risk of developing serious conditions that could turn life-threatening, including sepsis, according to a paper published in The BMJ. The study included data from 1.5 million non-elderly adults with private insurance in the United States.

5. A study published in the Journal of the American Medical Association shows that septic shock patients treated at a hospital with an insufficient supply of the drug norepinephrine were more likely to die than those treated at a hospital not experiencing the effects of the 2011 norepinephrine drug shortage. For the study, researchers examined data on 27,835 septic shock patients treated at 26 hospitals between 2008 and 2013.

6. Researchers found a biomarker that may forecast death in sepsis patients, according to a study published in Science Advances. Researchers identified the biomarker — methylthioadenosine — after examining genetic pathways in mice infected with Salmonella bacteria, which is known to incite sepsis. They then detected the biomarker in sepsis patients.

7. A study published in Cell Chemical Biology found non-steroidal anti-inflammatory drugs to be a potentially effective treatment for sepsis. The researchers screened 1,280 existing drugs approved by the Food and Drug Administration for the ability to inhibit caspase, a family of enzymes that play a key role in aggressive immune responses, like sepsis.

8. Sepsis accounts for more readmissions than any of the four conditions CMS tracks for reimbursement purposes: heart attack, heart failure, chronic obstructive pulmonary disease, and pneumonia, according to a research letter published in JAMA. For the study, researchers analyzed data from the 2013 Nationwide Readmissions Database, which documents acute care hospitalizations from 21 states.

9. Procalcitonin, or PCT, screening on the first day of an intensive care unit patient's admission reduced hospital stays by an average of 1.2 days, as compared to patients who were not screened, according to a new study in CHEST. Researchers examined 15.04 million patient cases of which 730,088 had a potential sepsis, systemic inflammatory response syndrome, septicemia or shock-related diagnosis on admission or discharge.

10. A certain type of sugar in the body may restore the ability of cells to respond to infections after sepsis has compromised the immune system, according to a study published in Cell. Researchers introduced beta-glucan into blood samples of subjects with compromised immune systems and the sugar reactivated the immunoresponse of the macrophages.

11. Antibiotics during hospitalization could increase the risk of sepsis following discharge, according to study results presented at the IDWeek 2016 meeting in New Orleans in October. Researchers analyzed adult hospitalization and pharmacy data from the Truven Health MarketScan Hospital Drug Database, 2006-2010. In all, researchers examined 9.4 million adult patient visits.

12. Disinfecting the hospital room environment with an ultraviolet air sterilizer can reduce the occurrence of sepsis and mortality in cardiac surgery patients. Researchers monitored the outcomes of 1,097 patients admitted to ICUs after undergoing cardiac surgery, of which 522 were randomly admitted to an ICU sterilized with UV air purification system. The study results were presented at the 2016 Congress of the Acute Cardiovascular Care Association in Lisbon, Portugal in October.

13. Early detection of sepsis by hospital ward nurses can help reduce the disease's progression and improve survival for patients, a study in Critical Care shows. The study examined the efficacy of an intervention at a community hospital in Norway. There were 472 patients in the pre-intervention group and 409 patients in the post-intervention group.

14. U.K.-based University of Birmingham researchers identified three biomarkers that can be used to accurately predict the risk of sepsis for burn patients. The biomarkers are a neutrophil function, elevated immature granulocyte count and plasma cell-free DNA as markers indicative of an onset of sepsis. The researchers published their findings in Annals of Surgery.

Written by Anuja Vaidya 

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Prompt sepsis treatment less likely when ERs overcrowded

ATS 2017, WASHINGTON, DC -- According to a new study, patients with sepsis, a life-threatening complication of an infection, had delays approaching one hour in being given antibiotics when seen in emergency rooms that were overcrowded. The study was presented at the 2017 American Thoracic Society International Conference.

"Prompt initiation of appropriate antibiotics is the cornerstone of high-quality sepsis care, a fact emphasized in Medicare quality measures and international guidelines," said lead author Ithan Peltan, MD, MSc, from Intermountain Medical Center and the University of Utah School of Medicine, Salt Lake City, Utah. "I wanted to understand how strains on hospital resources influence timely antibiotics."

Dr. Peltan pointed out that each one-hour delay in antibiotics is associated with a 7-10 percent increase in the odds of dying from sepsis.

Dr. Peltan and colleagues looked back at the medical records of patients admitted to an intensive care unit after being seen in the emergency departments of two community hospitals and two tertiary referral centers in Utah between July 2013 and December 2015. Patients whose records were in the hospitals' joint sepsis registry were eligible for study inclusion if they exhibited sepsis on ER arrival. Emergency department workload was measured based on the ratio of registered patients to available beds. They identified overcrowding as the presence of more registered ER patients than available beds and conducted statistical analyses that examined the association between emergency dept. crowding and door-to-antibiotic time after adjusting for a number of variables including (but not limited to) nighttime ER arrival and indicators of illness severity.

The researchers found that of 945 patients studied, 128 (14 percent) arrived when registered emergency department patients already exceeded the ERs' licensed beds. Patients received antibiotics within three hours in 83 percent of all cases in uncrowded ERs, but 72 percent of the time when the ER was crowded. In the adjusted analysis, patients who presented to a crowded ER rather than an empty ER waited an extra 47 minutes for antibiotics and were three times less likely to start antibiotics within three hours, the initiation window recommended by Medicare and international guidelines.

"Our findings suggest adequate staff and diagnostic resources are critical to effective sepsis care," said Dr. Peltan. "Hospitals should also consider sepsis care reorganization to bypass competing demands on clinicians and diagnostic resources."

He added: "In many emergency departments, protocols coupling pre-hospital notification and a multi-disciplinary rapid response team help ensure time-dependent therapies for stroke, heart attack and trauma patients. I suspect similar protocols could improve timely care for sepsis."

Abstract 5505

Increasing ED Workload Is Associated with Delayed Antibiotic Initiation for Sepsis

Authors: I.D. Peltan1, J.R. Bledsoe2, T.A. Oniki2, A.R. Jephson2, T.L. Allen1, S.M. Brown1; 1Intermountain Medical Center and University of Utah School of Medicine - Salt Lake City, UT/US, 2Intermountain Medical Center - Salt Lake City, UT/US

Rationale: Prompt antibiotic initiation is associated with improved mortality in sepsis and septic shock, but determinants of door-to-antibiotic time are poorly understood. We investigated the influence of emergency department (ED) workload on door-to-antibiotic time for septic patients.

Methods: We conducted a retrospective cohort study of patients admitted to an intensive care unit after presenting to the EDs of two community hospitals and two tertiary referral centers in Utah between July 2013 and December 2015. Patients entered in the hospitals' joint sepsis registry were eligible for inclusion if they exhibited sepsis on admission, as defined by antibiotic initiation in the ED and an increase in the SOFA score ?2 compared to baseline. ED workload was quantified by the ED occupancy rate (the ratio of registered patients to available ED beds). Occupancy rate ?1 defined ED crowding. We employed multivariable regression to examine the association between ED workload and door-to-antibiotic time after adjustment for patient age, sex, comorbidities (Charlson score), nighttime ED arrival (10 pm-6:59 am), and indicators of illness severity (APACHE II score, arrival shock, and acuity score).

Results: Of 945 eligible patients with complete data for multivariable regression, 128 (14%) arrived when registered ED patients already exceeded licensed ED beds (occupancy rate ?1). Aside from a decreased median ED length of stay (222 [168-286] vs. 244 [188-312] minutes, p=0.016) and higher probability of nighttime admission (19% vs. 5%, p<0.001) when EDs were not crowded, demographic and clinical characteristics were similar in patients presenting to uncrowded versus crowded EDs. Overall median door-to-antibiotic time was 115 minutes (IQR 77-162) when occupancy rate was <1 and 139 (90-187) minutes when occupancy rate was ?1 (p=0.003). Patients received antibiotics within 3 hours in 83% of cases when the ED occupancy rate was <1 and 72% of cases when it was not (p=0.003). After multivariable adjustment, the ED occupancy rate remained a strong predictor of door-to-antibiotic time (β=47 minutes, 95% CI 32-63, p<0.001). Increasing ED occupancy rates were also associated with a decreased adjusted odds (OR 0.27, 95% CI 0.15-0.49, p<0.001) of receiving antibiotics within 3 hours as recommended by international guidelines (Figure 1).

Conclusion: As measured by the ED occupancy rate, ED crowding was associated with a nearly one-hour delay in antibiotic administration for septic patients. Crowded EDs may particularly benefit from interventions to speed antibiotic initiation.

Funding: None

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Sepsis Linked to Long-Term Risk for Seizures

BOSTON — Patients who survive sepsis are at a significantly increased risk for seizures over the long term, new research suggests.

The retrospective cohort study showed a cumulative seizure rate of 6.67% among more than 842,000 patients who were hospitalized for sepsis 8 years earlier vs 1.27% for a matched, general population sample.

Confirmatory analysis using Medicare data showed an incidence rate ratio (IRR) of 2.18 for seizures among patients with sepsis after exclusion of those with stroke, traumatic brain injury, or central nervous system infection/neoplasm.

In addition, sepsis was significantly linked to status epilepticus resulting in hospitalization.

"Our findings support the hypothesis that sepsis could be associated with pathways leading to long-lasting brain injury, independent of other structural lesions," lead author, Michael Reznik, MD, Department of Neurology, Weill Cornell Medicine/Columbia University Medical Center, New York City, told attendees here at the American Academy of Neurology 2017 Annual Meeting (AAN).

Later, session co-moderator Walter Morgan, MD, Florida Hospital, Celebration, told Medscape Medical News that the study was intriguing but he is " interested now in knowing if there's any way we can start to predict these patients."

"If we can figure out how to analyze these cases more thoroughly, and perhaps predict which ones will be more likely to develop seizures down the line, that would be great," said Dr Morgan.

Who Is at Highest Risk?

Dr Reznik noted that common neurologic complications with sepsis include stroke, neuromuscular disease, and sepsis-associated encephalopathy, "which has led to the recognition of long-term cognitive dysfunction after sepsis."

The life-threatening inflammatory response to infection has also been linked previously with short-term risk for seizures.

For the current study, "we wanted to look at these patients and find out if there's a long-term risk of developing seizures after hospital discharge, and, if that is the case, what groups are at the highest risk?" said Dr Reznik.

The investigators assessed discharge claims data from 2005 to 2013 for 842,735 adult patients with sepsis (51% men; 65% white; mean age, 69.2 years) from emergency departments and acute care hospitals in New York, Florida, and California.

As part of the Healthcare Cost and Utilization Project, a personal linkage number is assigned that allows subsequent hospitalizations to be recorded anonymously. None of the patients had seizures before or during their initial hospitalization for sepsis.

The researchers also evaluated a cohort of patients hospitalized for diagnoses other than sepsis who were matched to the sepsis group by age, sex, race, insurance, the length of hospital stay and year of hospitalization, discharge location, and the presence of organ dysfunction.

In the sepsis group, 30,503 had follow-up seizures; 22.8% of these patients vs 16.2% of those without seizures had "sepsis with neurological dysfunction" at the time of their initial hospitalization.  

Significant Pathways

For the patients with sepsis, the crude rate of seizures after initial hospital discharge was 3.62% (95% confidence interval [CI], 3.58% - 3.66%).

The annual incidence of seizure was 1.29% (95% CI, 1.27% - 1.30%) for the sepsis group vs 0.16% (95% CI, 0.16% - 0.16%) among the three-state general population. In addition, the incidence rate for each of these groups was 1287.9 vs 158.9, respectively, per 100,000 person-years.

While the overall IRR was 4.98 (95% CI, 4.92 - 5.04) for the sepsis survivors vs the general population, the ratio dropped to 4.53 for patients with sepsis and no concurrent neurologic dysfunction — but it rose to 7.52 for those in the sepsis group who did have this type of dysfunction.

The 8-year IRRs for seizures were 7.52 and 4.53, respectively, for patients in the sepsis group with vs without neurologic dysfunction.

Sepsis was also associated with status epilepticus, according to prespecified sensitivity analysis (IRR, 5.42).

Next, the investigators conducted a confirmatory cohort analysis, assessing inpatient and outpatient claims from a 5% sample of Medicare beneficiaries. It showed that "hospitalization for sepsis was again associated with subsequent seizures" (unadjusted IRR, 2.72), reported Dr Reznik.

In the last post hoc subgroup analysis, which stratified by age, the IRRs were 2.83 for the sepsis group who were at least 65 years of age or older (95% CI, 2.78 - 2.88) and 10.33 for those younger than 65 years (95% CI, 10.17 - 10.49).

However, Dr Reznik noted that "this isn't to say that these younger patients are more likely to have seizures than anyone else. The actual incidence is higher in older patients."

The investigators write that the overall findings suggest that "sepsis is associated with pathways that lead to permanent neurological sequelae." Dr Reznik noted that questions going forward include determining risk factors and "Will there be brain-protective strategies on the horizon?"

"Be On the Lookout"

After the presentation, when Dr Reznik was asked whether any familial information was available for the patients, he answered, "No, unfortunately. That would be something great to have in a prospective study."

Dr Morgan later commented that he would be interested to know whether there were any particular exposures to medications, especially antibiotics, in these patients.

"It would be intriguing to know if we could start to look at predictive factors because it looks like there is obviously an increased risk of these patients developing seizures down the line," he said. "That's something we should be looking out for and something we're missing in the clinical setting."

He added that the issue is important to neurologists and clinicians in other fields, such as primary care. "We need to be on the lookout for this and start asking questions."

The study was supported by a grant from the National Institute of Neurological Disorders and Stroke and by the Michael Goldberg Research Fund. Dr Reznik and Dr Morgan have disclosed no relevant financial relationships.

American Academy of Neurology 2017 Annual Meeting (AAN). Emerging Science abstract S5.003. Presented April 23, 2017.

By: Deborah Brauser

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Sepsis can send a child to the brink of death within hours.

FORT WORTH, Texas — It might start out looking like not much more than an ordinary childhood fever.

But within days — within hours, sometimes — the complication known as sepsis can turn deadly. The patient’s blood pressure dives. Intense pain floods her body. Her organs begin to shut down.

The toll is frightening: Sepsis hospitalizes some 75,000 children and teens each year in the United States. Nearly 7,000 will die, according to one 2013 study. That’s more than three times as many annual deaths as are caused by paediatric cancers. And some of the children who survive sepsis may suffer long-term consequences, including organ damage and amputated limbs.

Now dozens of hospitals nationwide, including here in Fort Worth, are launching an all-out campaign against sepsis, an infection-related complication which can take hold after a viral illness — or an injury as innocuous as a scraped arm or a bug bite. Their ambitious goal: Reduce both childhood sepsis deaths and diagnoses of severe sepsis at participating hospitals by 75 percent by the end of 2020.

“You go big or you go home,” said Amy Knight, chief operating officer for the Children’s Hospital Association, which organized the sepsis collaboration.

The 44 hospitals participating in the effort so far — more are likely to join — have agreed to implement diagnostic and treatment protocols developed by dozens of experts. They will, for instance, screen all patients who show any signs that could be associated with sepsis and treat potential cases with quick infusions of antibiotics and intravenous fluids. And they’ll submit data on their cases to the collaboration — including how fast they got patients into treatment — in hopes of identifying best practices.

Some hospitals are also working on public education, such as teaching the warning signs of sepsis to parents of cancer patients, who are especially vulnerable to infection.

One key challenge: Training physicians and nurses to more quickly recognize the earlier stage, known as “warm sepsis,” which can masquerade as many other more common and far less worrisome childhood ills.

A child might develop a fever and a somewhat faster heart rate, but otherwise, has good color and is chatting with the doctor. “And 10 minutes later, their blood pressure is out the bottom and they are in dire straits,” said Dr. Joann Sanders, chief quality officer at Cook Children’s Health Care System here in Fort Worth. “A kid who is well into sepsis is not that hard to recognize. That warm sepsis kid — that’s your challenge.”

A terrifying brush with death

Sepsis moved with terrifying speed in the case of Chloe Miller, who was diagnosed with septic shock last fall at age 12.

Chloe had gone to school near her home in Silver Spring, Md., that Friday with no signs of illness, although the teachers reported that she seemed somewhat tired, recounted her dad, Mark Miller. Her parents have learned to stay particularly attuned to even subtle changes in Chloe, who has autism and a seizure disorder and can’t communicate verbally.

By Saturday, the preteen was running a fever of 104 degrees. Acetaminophen did bring it down. But she was sleeping for long stretches and becoming increasingly difficult to wake up. Alarmed, Chloe’s mother and grandmother decided to take her to a local emergency room late Saturday. They nearly had to carry her to the car.

The doctors and nurses there moved quickly, diagnosing Chloe with pneumonia and influenza and giving her antibiotics, intravenous fluids, and an escalating flow of oxygen for her alarmingly low blood pressure and oxygen readings, said Dr Christiane Corriveau, the critical care physician who treated Chloe once she arrived by ambulance at Children’s National Medical Center in Washington, D.C., in the wee hours of Sunday morning. “I think everybody was concerned that this was more than just pneumonia — that her body was being taken over by the infection,” she said.

Despite the aggressive treatment, Chloe was already entering the final and most life-threatening stage of sepsis, called septic shock.

Miller distinctly recalls how unresponsive his daughter was in the intensive care unit, not flinching when she got a shot or an intravenous line. Also, that her breathing was unnervingly fast: “In and out and in and out and in and out.”

After getting blood and platelet transfusions, antibiotics, fluids and heart medications, among other treatments, Chloe was improving by Monday, Corriveau said. By Tuesday, her breathing had eased and her “blood pressures were beautiful.”

Miller, who works at Children’s National in a fundraising role, recalls lots of updates as clinicians combated his daughter’s low blood pressure and other symptoms. But it wasn’t until the worst of the crisis had eased that he first heard the word “sepsis” and learned what that diagnosis meant.

“When they said, ‘She’s out of the woods,’ it really hit me just how life-threatening this was,” he said.

A simple screening that can save lives

Sepsis sometimes called blood poisoning, describes the body’s massive inflammatory response to an infection that infiltrates the bloodstream. The body marshals all its efforts to protect the heart, lungs, and other vital organs, said Dr Charles Macias, an emergency physician at Texas Children’s Hospital in Houston and one of the collaboration’s co-chairs.

A child’s heart rate typically increases, in order to pump more blood to boost oxygen levels to organs and other tissues, Macias said. The increased demand for oxygen speeds up his breathing. Blood pressure can drop, as some vessels may leak and others may dilate.

In 2012, a 12-year-old New York student named Rory Staunton developed sepsis and died several days after cutting his arm while playing basketball, heightening national attention to the issue. A few states, including New York, have since enacted protocols mandating that hospitals regularly screen patients for sepsis.  The Illinois version is dubbed Gabby’s Law, after a young girl who died from sepsis following a tick bite.

Some screening steps can be quite simple.

At Cook Children’s, a nurse will press down firmly on the child’s skin, for three seconds, said Stephanie Lavin, the hospital’s nurse quality leader for the sepsis initiative. The skin naturally turns lighter. But it should return to a normal shade within three seconds of releasing that pressure, she said. Any signs of poor blood flow — the jargon is capillary refill — indicates that the child is dehydrated or that blood has begun to shift away from the skin’s surface.

That skin check is part of Cook Children’s 18-point sepsis screening, a process that doesn’t take much longer than a minute and includes asking parents if their child has shown any signs of confusion. The screening is performed with any emergency room patient who complains of a fever or another symptom that could signal an underlying infection, such as abdominal pain.

Any child who scores 5 or higher on the 18-point scale gets oxygen, antibiotics, and intravenous fluids — even before the blood test results come back, according to Lavin. That turns out to be a lot of patients: About 150 to 190 a month in the ER are identified by that initial screen as potentially having sepsis.

Regular screening already is routine in some other departments, such as the surgery and cancer units. Beginning this spring, it will be expanded to nearly every unit of the hospital, Lavin said.

Some of the collaboration’s participants, including Cook Children’s, have already had been participating in smaller initiatives against sepsis. Other hospitals can join the national effort; the next deadline to sign up is June 30.

Rory’s mother, Orlaith Staunton, applauds the collaboration’s efforts. But she still advocates for a more standardized regulatory approach: She wants to require every hospital in the US to adhere to certain screening and treatment procedures.

Imagine, she said, that you’re driving down the road with an ill family member in the car. “This hospital happens to be very good at enforcing their own sepsis protocols. This one is not so good. I end up driving to the wrong hospital. Worst-case scenario, my child or my loved one dies,” said Staunton, who cofounded the Rory Staunton Foundation with her husband.

But Knight believes that the national collaborative model will work best because it lets medical experts learn from one another. At Cook Children’s, for instance, doctors and nurses continue to tweak their screening system, in order to most rapidly flag that “warm sepsis” patient.

“Will we bring kids into the hospital and watch them overnight who don’t have sepsis?” asked Sanders, the chief quality officer. “Probably. But I’d rather do that to 90 kids and catch the 10 kids who are in early sepsis, and save their lives.”Contact the Author

Charlotte Huff 

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