IntroductionCulture-negative sepsis is a common but relatively understudied condition. The aim of this study was to compare the characteristics and outcomes of culture-negative versus culture-positive severe sepsis.MethodsThis was a prospective observational cohort study of 1001 patients who were admitted to the medical intensive care unit (ICU) of a university hospital from 2004 to 2009 with severe sepsis. Patients with documented fungal, viral, and parasitic infections were excluded.ResultsThere were 415 culture-negative patients (41.5%) and 586 culture-positive patients (58.5%). Gram-positive bacteria were isolated in 257 patients, and gram-negative bacteria in 390 patients. Culture-negative patients were more often women and had fewer comorbidities, less tachycardia, higher blood pressure, lower procalcitonin levels, lower Acute Physiology and Chronic Health Evaluation II (median 25.0 (interquartile range 19.0 to 32.0) versus 27.0 (21.0 to 33.0), P = 0.001) and Sequential Organ Failure Assessment scores, less cardiovascular, central nervous system, and coagulation failures, and less need for vasoactive agents than culture-positive patients. The lungs were a more common site of infection, while urinary tract, soft tissue and skin infections, infective endocarditis and primary bacteremia were less common in culture-negative than in culture-positive patients. Culture-negative patients had a shorter duration of hospital stay (12 days (7.0 to 21.0) versus 15.0 (7.0 to27.0), P = 0.02) and lower ICU mortality than culture-positive patients. Hospital mortality was lower in the culture-negative group (35.9%) than in the culture-positive group (44.0%, P = 0.01), the culture-positive subgroup, which received early appropriate antibiotics (41.9%, P = 0.11), and the culture-positive subgroup, which did not (55.5%, P < 0.001). After adjusting for covariates, culture positivity was not independently associated with mortality on multivariable analysis.ConclusionsSignificant differences between culture-negative and culture-positive sepsis are identified, with the former group having fewer comorbidities, milder severity of illness, shorter hospitalizations, and lower mortality.

There was a lack of commitment by doctors on orders for DNR/CPR and to limit life-sustaining therapies, infrequent discussions with patients on end-of-life decisions, and excessive burdensome interventions with inadequate palliative care for the dying. These findings may reflect certain Asian cultural biases. More work is required to improve our quality of end-of-life care.

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Study Objectives: The Berlin questionnaire is a self-administered questionnaire that was developed to identify subjects with obstructive sleep apnea (OSA) in primary care settings. This study evaluated the performance of the questionnaire to predict OSA in the general population. Methods: A sample of 242 subjects in a population-based cohort completed a home-based sleep study with an Embletta device (type 3 monitor). Subjects completed the Berlin questionnaire on the evening just prior to the sleep study. The sleep studies were manually scored according to the 2012 American Academy of Sleep Medicine (AASM) criteria. Results: The prevalence of moderate-to-severe and severe OSA defined as apnea-hypopnea index (AHI) of ≥ 15 and ≥ 30 was 28.1% and 10.7%, respectively. Seventy-nine subjects (32.6%) were classified as high risk according to the Berlin questionnaire. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the questionnaire to predict an AHI ≥ 15 was 58.8%, 77.6%, 82.9%, and 50.6%, respectively. The area under the receiving operator characteristic (ROC) curve for moderate-to-severe OSA was 0.682. When used to predict an AHI ≥ 30, the sensitivity of the questionnaire increased to 76.9% with a small drop in specificity to 72.7%. The corresponding NPV, PPV, and area under the ROC curve of the questionnaire to predict severe OSA were 96.3%, 25.3%, and 0.748, respectively. Conclusions: The Berlin questionnaire may have utility in the general population setting as a screening tool for OSA in view of its good sensitivity and high NPV in ruling out severe OSA.

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