References
Early Identification
- Bhattacharjee, P. et al. Identifying Patients with Sepsis on the Hospital Wards. Chest 2017.
- Data highlighting the benefits and limitations of the systemic inflammatory response syndrome(SIRS) criteria for screening patients with sepsis, such as its low specificity, as well as newly described scoring systems, including the proposed role of the quick sepsis-related organ failure assessment(qSOFA) score.
- Chen, H. et al. Early lactate measurement is associated with better outcomes in septic patients with an elevated serum lactate level.Crit Care 2019.
- A strong relationship between delayed initial lactate measurement and risk-adjusted 28-day mortality was noted. Further analysis demonstrated that repeating the measurement 3 h after the initial lactate measurement led to a significant difference.
- Delawder, J.M. et al. An Interdisciplinary Code Sepsis Team to Improve Sepsis-Bundle Compliance: A Quality Improvement Project. J Emerg Nurs. Jan 2020;46(1):91-98.
- Interprofessional teams can use existing knowledge, skills, and tools to improve sepsis-bundle compliance and mortality outcomes in patients with sepsis presenting to the emergency department.
- Scheer, C.S. et al. Impact of antibiotic administration on blood culture positivity at the beginning of sepsis: a prospective clinical cohort study.Clin Microbiol Infect 2019.
- Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. This strongly emphasizes the current recommendation to obtain blood cultures before antibiotic administration in patients with sepsis.
- Schorr, C. et al. Implementation of a multicenter performance improvement program for early detection and treatment of severe sepsis in general medical-surgical wards.J Hosp Med 2016.
- Based on our experience, we recommend a stepwise approach to implement such a program to improve outcomes and sustain improvements.
- Uffen, J.W. et al. Interventions for rapid recognition and treatment of sepsis in the emergency department: a narrative review.Clin Microbiol Infect 2021.
- The severity and poor outcome of sepsis as well as the frequency of its presentation in EDs make a structured, protocol-based approach towards these patients essential, preferably as part of a clinical pathway.
Initial Treatment
- Ballester, L. et al. Differences in Hypotensive vs. Non-Hypotensive Sepsis Management in the Emergency Department: Door-to-Antibiotic Time Impact on Sepsis Survival. Med Sci(Basel)2018.
- Initial management of patients with community-onset severe sepsis differed according to their clinical presentation. Initial hypotension was associated with early hemodynamic management and less ICU requirement. A non-significant delay was observed in the administration of antibiotics to initially non-hypotensive patients. The time of door-to-antibiotic administration was related to mortality.
- Liu, V.X. et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values. Am J Resp Crit Care Med 2016.
- Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values improved bundle compliance and was associated with decreased hospital mortality.
- Liu, V.X. et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med 2017.
- In a large, contemporary, and multicenter sample of patients with sepsis in the emergency department, hourly delays in antibiotic administration were associated with increased odds of hospital mortality even among patients who received antibiotics within 6 hours.
- Mohd, A.H. et. al. Prolonged vs Intermittent Infusions of β-Lactam Antibiotics in Adults With Sepsis or Septic Shock: A Systematic Review and Meta-Analysis. JAMA, 2024.
- Among adults in the intensive care unit who had sepsis or septic shock, the use of prolonged β-lactam antibiotic infusions was associated with a reduced risk of 90-day mortality compared with intermittent infusions. The current evidence presents a high degree of certainty for clinicians to consider prolonged infusions as a standard of care in the management of sepsis and septic shock.
- Munroe, E. et al. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. CHEST 2023.
- Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.
- Associated Podcast Episode: CHEST Journal Podcast - April 2024
- Peltan, I.D. et al. ED Door-to-Antibiotic Time and Long-term Mortality in Sepsis. Chest 2019.
- Delays in ED antibiotic initiation time are associated with clinically important increases in long-term, risk-adjusted sepsis mortality.
- Prescott, H.C. et al. Temporal trends in antimicrobial prescribing during hospitalization for potential infection and sepsis. JAMA IM 2022.
- In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.
- Seymour, C.W. et al. Time to treatment and mortality during mandated emergency care for sepsis. NewEngl J Med 2017.
- More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.(Funded by the National Institutes of Health and others).
- Taylor, S.P. et al. First-to-second antibiotic delay and hospital mortality among emergency department patients with suspected sepsisAm J Emerg Med 2021.
- First-to-second antibiotic delay of greater than one hour was associated with an increased risk of hospital death among patients meeting criteria for septic shock but not all patients with suspected sepsis. Tracking and improving first-to-second antibiotic delays may be considered in septic shock.
- Taylor, S.P. et. al. Real-World Implications of Updated Surviving Sepsis Campaign Antibiotic Timing Recommendations. Critical Care Medicine 2024.
- A retrospective cohort study of 12 hospitals between 2017 and 2021 evaluating the real-world implications of the updates Surviving Sepsis Campaign recommendations for antibiotic timing. This data supports the SSC recommendations to align antibiotic timing targets with risk and probability stratifications.
Early Fluid Management
- Acharya, P. et al. Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study. PLoS One 2021.
- The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.
- Kuttab, HI. et al. Evaluation and predictors of fluid resuscitation in patients with severe sepsis and septic shock. Crit Care Med 2019.
- Failure to reach 30 ml/kg/hr by 3 hours of sepsis onset was associated with increased odds of in-hospital mortality irrespective of comorbidities. Predictors of inadequate resuscitation can be identified, potentially leading to interventions to improve survival.
- Meyhoff, T.S. et al. Restriction of Intravenous Fluid in ICU Patients with Septic ShockNew England Journal of Medicine 2022.
- Among adult patients with septic shock in the ICU, intravenous fluid restriction did not result in fewer deaths at 90 days than standard intravenous fluid therapy.
- Zampieri, F.G. et al. Fluid Therapy for Critically Ill Adults with Sepsis. JAMA 2023.
- Fluids are an important component of treating patients who are critically ill with sepsis. Although optimal fluid management in these patients remains uncertain, clinicians should consider the risks and benefits of fluid administration in each phase of critical illness and facilitate fluid removal for patients recovering from acute respiratory distress syndrome.