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Daniel Pilsgaard HenriksenMD, PhD
Dept. of Clinical Chemistry and Pharmacology, OUH
Research Unit of Emergency Medicine, SDU
12 November 2014
Community-acquired sepsis among acutely hospitalized medical patients
- Incidence, risk factors, and long-term prognosis
Supervisors
Hanne Madsen, MD Ph.D. Dept. of Respiratory Medicine, OUH
Court Pedersen, MD Professor DMSci Dept. of Infectious Diseases, OUH
Annmarie Touborg Lassen, MD Professor Ph.D. DMSci Dept. of Emergency Medicine, OUH
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Introduction
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Definitions
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Raven MC, Lowe RA, Maselli J, Hsia RY (2013) Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. JAMA 309: 1145–1153. doi:10.1001/jama.2013.1948.
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Problems with discharge diagnoses
Difficult to differentiate between community-acquired and hospital-acquired sepsis Summary of an entire course of admission
Difficult to differentiate between the severity of sepsis Tends to underestimate the incidence of sepsis Tends to identfy the more severely ill severe sepsis
patients
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Aims
Based on symptoms and clinical findings to identify patients admitted to the medical ED at Odense University Hospital in a one-year period (September 2010 – August 2011) we aimed to: Determine to which degree discharge diagnoses of infection
could accurately identify community-acquired infections in an ED setting; and to assess if the sites of infection, baseline patient characteristics and disease severity affect the validity of the discharge diagnoses. (Study I)
Estimate the incidence rates of community-acquired sepsis, severe sepsis, septic shock, and sepsis of any severity. (Study II)
Examine the risk factors for hospitalization with community-acquired sepsis and severe sepsis, and sepsis of any severity in a population-based setting. (Study III)
Examine the association between long-term mortality and community-acquired sepsis, severe sepsis, septic shock, and sepsis of any severity, in a population-based setting. (Study IV)
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Materiale
Patienter indlagt akut i medicinsk regi OUH 1/9 2010-31/8 2011 Akut Modtageafdelingen Medicinsk Intensiv afdeling Døde i skadestuen af formodet medicinsk årsag
Registrering af vitalværdier og andre klinisk relevante data ankomst første 24 timer.
30 dage – journalgennemgang Infektion og fokus
Electronic Patient Records, OUH
Laboratory informations systems, OUH
Blood Gas Analyzer, Medical ED, OUH
Microbiology information system, OUH
Danish Civil Registration System
Funen Patient Administrative System
Danish National Patient Register
The Danish National Registry of Alcohol Treatment
Odense University Pharmacoepidemiological Database
Danish National Cancer Register
Cohort of acutely
admittedpatients
Cohort of acutely
admittedpatients
Hospital Based Databases Population-based Registers
SIRSOrgan dysfunctionBacteremia
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Demographic characteristics Study II, III, and IV
Among 8,358 admissions to the medical ED or directly to the medical ICU, 1,713 patients presented with an incident admission of sepsis of any severity within the study period Median age 72 years (5-95% range: 26-91 years) 793 (46.3%) were males 728 (42.5%) presented with severe comorbidity 621 (36.3%) with sepsis 1071 (62.5%) with severe sepsis 21 (1.2%) with septic shock.
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• Sepsis of any severity: 731/100,000 pyar (95%CI: 697-767) • Sepsis: 265/100,000 pyar (95%CI: 245-287• Severe sepsis: 457/100,000 pyar (95%CI: 430-485) • Septic shock: 9/100,000 pyar (95%CI: 6-14)
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Discharge diagnosesIncidence: 150-300/100,000 population
Discharge diagnosesIncidence: 150-300/100,000 population
Risk factors for Hospitalization with Community-acquired Sepsis – a Population-based Case-Control Study. Henriksen DP, Pottegård A, Laursen CB, Jensen TG, Hallas J, Pedersen C, Lassen AT. (In review – Critical Care).
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Aim
Assess risk factors using symptoms and clinical findings to identify sepsis
Difference in risk factors of sepsis and severe sepsis?
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Sepsis Adj. ORa [95%CI]
Severe sepsis Adj. OR [95%CI]c
Male gender 0.89 [0.76 - 1.05] 1.07 [0.95 - 1.22]
Age, 65-84 years 2.15 [1.78 - 2.60] 3.93 [3.39 - 4.56]
Age, 85+ years 3.66 [2.74 - 4.88] 7.84 [6.38 - 9.63]
Immunosuppression 5.03 [3.98 - 6.34] 4.45 [3.73 - 5.30]
Alcoholism-related conditions 2.64 [1.94 - 3.59] 2.93 [2.34 - 3.67]
Comorbidities
Psychotic disorder 1.35 [0.97 - 1.88] 2.26 [1.83 - 2.78]
Neurological 1.90 [1.52 - 2.38] 1.93 [1.65 - 2.25]
Respiratory 3.70 [3.01 - 4.54] 3.29 [2.82 - 3.84]
Cardiovascular 1.46 [1.15 - 1.86] 1.65 [1.40 - 1.94]
Diabetes 1.33 [1.01 - 1.75] 2.02 [1.70 - 2.41]
Cancer 1.30 [0.99 - 1.72] 1.47 [1.22 - 1.78]
Gastrointestinal 1.39 [1.02 - 1.91] 1.82 [1.48 - 2.24]
Renal 0.89 [0.76 - 1.05] 1.07 [0.95 - 1.22]
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Conclusions
Several independent risk factors. A large difference in the risk factors’ strength of
association in the different age categories. No difference in the risk factors’ strength of association
when stratifying on sepsis severity.
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Association between disease severity and long-term mortality in patients hospitalized with sepsis, a population-based cohort study. Henriksen DP, Pottegård A, Laursen CB, Jensen TG, Hallas J, Pedersen C, Lassen AT. (submitted – Critical Care)
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Aim
Long-term mortality of sepsis of any severity Difference in long-term mortality of sepsis and severe
sepsis
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Absolute mortality measures
Cumulative all-cause mortality, % (95%CI)30 daysSepsis 6.1% (4.4-8.3%)Severe sepsis 18.8% (16.5-21.2%)Septic shock 38.1% (18.1-61.6%)
Sepsis, any severity 14.4% (12.8-16.2%)
3 yearsSepsis 31.4% (27.8-35.2%)Severe sepsis 50.0% (46.9-53.0%)
Septic shock 71.4% (47.8-88.7%)Sepsis, any severity 43.5% (41.1-45.9%)
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Adjusted† HR (95%CI)Intermediate-term mortality
31-180 daysSepsis 3.6 (2.6-4.8)Severe sepsis 7.8 (6.5-9.3)Sepsis of any severity 7.1 (6.0-8.5)
Long-term mortality181-365 daysSepsis 2.5 (1.7-3.5)Severe sepsis 2.7 (2.1-3.6)Sepsis of any severity 2.8 (2.3-3.5)366-730 days (1 year - 2 years)Sepsis 1.7 (1.3-2.3)Severe sepsis 2.2 (1.8-2.8)Sepsis of any severity 2.1 (1.8-2.6)731-1096 days (2 years - 3 years)Sepsis 2.2 (1.5-3.2)Severe sepsis 2.1 (1.5-3.0)Sepsis of any severity 2.2 (1.7-2.9)
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Conclusions
Three years post-sepsis admission Two-fold higher risk of mortality
Intermediate-term mortality: Sepsis severity matters Long-term mortality: Sepsis severity does not matter
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