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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Tak for opmærksomheden

dphenriksen@health.sdu.dk