Objective
To determine if time to initial antimicrobial is associated with
progression of severe sepsis to septic shock.
Design
Retrospective cohort
Setting
656 bed urban academic medical center
Patients
Emergency department patients ≥18 years of age with severe
sepsis and/or septic shock and antimicrobial administration within 24 hours.
Patients with shock on presentation were excluded.
Interventions
N/A.
Measurements and Main Results
We identified 3,929 severe sepsis patients, with overall mortality
12.8%. 984 (25.0%) patients progressed to septic shock. The
median time to antimicrobial was 3.77 hours (IQR = 1.96 –
6.42) in those who progressed vs 2.76 hours (IQR = 1.60 –
4.82) in those who did not (p < 0.001). Multivariate logistic
regression demonstrated that male sex (OR = 1.18; 95% CI,
1.01–1.36), Charlson Comorbidity Index (OR = 1.18;
95% CI, 1.11–1.27), number of infections (OR = 1.05;
95% CI, 1.02–1.08), and time to first antimicrobial (OR
= 1.08; 95% CI, 1.06–1.10) were associated with
progression. Each hour until initial antimicrobial administration was
associated with a 8.0% increase in progression to septic shock.
Additionally, time to broad spectrum antimicrobial was associated with
progression (OR = 1.06; 95% CI, 1.05–1.08). Time to
initial antimicrobial was also associated with in-hospital mortality (OR
= 1.05; 95% CI, 1.03–1.07).
Conclusions
This study emphasizes the importance of early, broad spectrum
antimicrobial administration in severe sepsis patients admitted through the
emergency department, as longer time to initial antimicrobial administration
is associated with increased progression of severe sepsis to septic shock
and increased mortality.
Severe sepsis continues to be an underdiagnosed and undertreated condition. Patients who were diagnosed had higher treatment rates yet experienced worse outcomes. Continued investigation is needed to identify factors contributing to diagnosis, treatment, and outcomes in patients with severe sepsis.
Background. Sacral neuromodulation has become a widely used treatment for lower urinary tract symptom and dysfunction. It has been observed to benefit sexual function in the domains of arousal and desire. Studies have yet to report markedly increased arousal symptoms as an adverse effect. Case. We present the case of a 57-year-old woman who developed symptomatic persistent genital arousal following implantation of a neuromodulator. Despite device reprogramming, a trial of the device being shut off, and eventual device removal, she continued to have residual new-onset undesired genital hyper-arousal symptoms. Conclusion. Our patient demonstrated markedly increased and persistent arousal symptoms that may be the result of upregulated or alternative activation of sacral nerve pathways. While other case reports describe improvement in persistent genital arousal disorder symptoms through neuromodulation, no studies mention hyperarousal symptoms as an adverse side effect after sacral neuromodulator placement nor persistence despite removal of the implant.
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