Diagnosis and management of sepsis in the older adult

Goodacre, Steve; Fuller, Gordon; Conroy, Simon; Hendrikse, Clint

doi:10.1136/bmj-2023-075585

Cited by 7 publications

(6 citation statements)

References 43 publications

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“…If the sepsis-3 definition identifies patients at risk of mortality due to underlying comorbidities rather than acute infection, then the effect of early antibiotic treatment will be attenuated. 79 Widespread use of NEWS2 across the NHS may have influenced paramedic assessment of diagnostic impression, particularly in terms of differentiating sepsis from other infections. This may mean that paramedic diagnostic impression and NEWS2 scores are correlated to a degree.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

Goodacre,

Sutton,

Ennis

et al. 2024

Health Technol Assess

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Background Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department. Objectives To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment. Design Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness. Setting Two ambulance services and four acute hospitals in England. Participants Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded. Interventions Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation. Main outcome measures Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained. Results Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed. Limitations We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling. Conclusions No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis. Study registration This study is registered as Research Registry (reference: researchregistry5268). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

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Section: Strengths and Limitationsmentioning

confidence: 99%

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

Goodacre,

Sutton,

Ennis

et al. 2024

Health Technol Assess

Self Cite

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“…In 2021–22, England and Wales reported over 100,000 emergency admissions with sepsis, with a mean patient age of 71 years [ 5 ]. In England, sepsis represented one-third of admissions to adult ICUs [ 6 ] and in China sepsis affected a fifth of patients admitted to the ICU [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…Dehydration is common in older adults, often necessitating an initial 500 mL crystalloid bolus. However, protocolized resuscitation, such as 30 mL/kg of intravenous crystalloid within 3 h, may be detrimental in patients with cardiac impairment or chronic kidney disease [ 5 ]. Excessive fluid therapy can lead to impaired outcomes, emphasizing the need for a dynamic evaluation of fluid response.…”

Section: Introductionmentioning

confidence: 99%

The critically ill older patient with sepsis: a narrative review

Ibarz,

Haas,

Ceccato

et al. 2024

Ann. Intensive Care

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Sepsis is a significant public health concern, particularly affecting individuals above 70 years in developed countries. This is a crucial fact due to the increasing aging population, their heightened vulnerability to sepsis, and the associated high mortality rates. However, the morbidity and long-term outcomes are even more notable. While many patients respond well to timely and appropriate interventions, it is imperative to enhance efforts in identifying, documenting, preventing, and treating sepsis. Managing sepsis in older patients poses greater challenges and necessitates a comprehensive understanding of predisposing factors and a heightened suspicion for diagnosing infections and assessing the risk of sudden deterioration into sepsis. Despite age often being considered an independent risk factor for mortality and morbidity, recent research emphasizes the pivotal roles of frailty, disease severity, and comorbid conditions in influencing health outcomes. In addition, it is important to inquire about the patient's preferences and establish a personalized treatment plan that considers their potential for recovery with quality of life and functional outcomes. This review provides a summary of the most crucial aspects to consider when dealing with an old critically ill patient with sepsis.

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“…Elderly people have decreased immune function and responses, known as immunosenescence, which occurs through multiple mechanisms, including decreased cytokine production, altered toll-like receptor expression, thymic involution, and decreased B cells antibody affinity, all of which predispose elderly patients to infection with a more severe outcome [ 7 , 8 ]. Furthermore, elderly patients with multiple comorbidities frequently present with atypical and nonspecific symptoms while they have infection, such as lack of fever or chills, making prompt diagnosis and management initiation more challenging [ 7 , 9 ]. Nearly half of all sepsis diagnoses are estimated to be made in the elderly population [ 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

Risk Factors and Outcomes of Community-Acquired Carbapenem-Resistant Klebsiella pneumoniae Infection in Elderly Patients

Chen,

Tsai,

Lai

et al. 2024

Antibiotics

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The increasing prevalence of carbapenem-resistant Klebsiella pneumoniae (CRKP) infections is a global concern. Elderly patients have a diminished immune response and functional reserve, and are thus more vulnerable to bacterial infection. This study aimed to investigate the risk factors and outcomes in elderly patients with community-acquired CRKP infections. We performed a retrospective cohort study in a tertiary medical center between 1 January 2021, and 31 December 2021. All elderly patients who visited the emergency department during this period with culture-positive K. pneumoniae were enrolled, and their baseline demographics, laboratory profiles, management strategies, and outcomes were recorded and analyzed. We identified 528 elderly patients with K. pneumonia infection, and the proportion of patients with CRKP infection was 10.2% (54/528). Recent intensive care unit (ICU) admission and prior carbapenem use are independent risk factors for CRKP infection in elderly patients. Compared to patients with carbapenem-sensitive K. pneumoniae infection, those with CRKP infection had a significantly higher risk of adverse outcomes, including ICU care, respiratory failure, septic shock, and 90-day mortality. CRKP infection was also identified as an independent risk factor for 90-day mortality. Clinicians should be aware of the increasing prevalence of CRKP infections in elderly patients and judiciously choose appropriate antibiotics for these patients.

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Diagnosis and management of sepsis in the older adult

Cited by 7 publications

References 43 publications

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

The critically ill older patient with sepsis: a narrative review

Risk Factors and Outcomes of Community-Acquired Carbapenem-Resistant Klebsiella pneumoniae Infection in Elderly Patients

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