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Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study.

ABSTRACT: A clinical suspicion of infection is mandatory for diagnosing sepsis in patients with a systemic inflammatory response syndrome. Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown. We therefore assessed the likelihood of infection in patients who were treated for sepsis upon admission to the ICU, and quantified the association between plausibility of infection and mortality.We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013. The likelihood of infection was categorized as none, possible, probable or definite by post-hoc assessment. We used multivariable competing risks survival analyses to determine the association of the plausibility of infection with mortality.Among 2579 patients treated for sepsis, 13% had a post-hoc infection likelihood of "none", and an additional 30% of only "possible". These percentages were largely similar for different suspected sites of infection. In crude analyses, the likelihood of infection was associated with increased length of stay and complications. In multivariable analysis, patients with an unlikely infection had a higher mortality rate compared to patients with a definite infection (subdistribution hazard ratio 1.23; 95% confidence interval 1.03-1.49).This study is the first prospective analysis to show that the clinical diagnosis of sepsis upon ICU admission corresponds poorly with the presence of infection on post-hoc assessment. A higher likelihood of infection does not adversely influence outcome in this population.ClinicalTrials.gov NCT01905033. Registered 11 July 2013.

SUBMITTER: Klein Klouwenberg PM

PROVIDER: S-EPMC4562354 | biostudies-literature | 2015 Sep

REPOSITORIES: biostudies-literature

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Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study.

Klein Klouwenberg Peter M C PM Cremer Olaf L OL van Vught Lonneke A LA Ong David S Y DS Frencken Jos F JF Schultz Marcus J MJ Bonten Marc J MJ van der Poll Tom T

Critical care (London, England) 20150907

<h4>Introduction</h4>A clinical suspicion of infection is mandatory for diagnosing sepsis in patients with a systemic inflammatory response syndrome. Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown. We therefore assessed the likelihood of infection in patients who were treated for sepsis upon admission to the ICU, and quantified the association between plausibility of infection and mortality.<h4>Methods</h4 ...[more]

PMID: 26346055

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Project description:BACKGROUND:Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00-06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity. METHODS:This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00-06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ? 90% or clustering of admissions (??0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity. RESULTS:Of 12,265 admissions, 34.7% (n?=?4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7-37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44-70) vs 60 (47-70) years, p?<?0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p?<?0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p?<?0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p?=?0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923-1.135, p?=?0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p?=?0.90) or hospital length of stay (LOS) (p?=?0.27), although ICU LOS was shorter (p?=?0.049). Early-morning admission (00:00-06:59 h) with ICU occupancy ? 90% was associated with short-term (??7 days) and all-cause ICU mortality. CONCLUSIONS:One-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity.

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Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study.

Publications

Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study.

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