Epidemiology of Hospital-Onset Versus Community-Onset Sepsis in U.S. Hospitals and Association With Mortality: A Retrospective Analysis Using Electronic Clinical Data

Abstract

Objectives: Prior studies have reported that hospital-onset sepsis is associated with higher mortality rates than community-onset sepsis. Most studies, however, have used inconsistent case-finding methods and applied limited risk-adjustment for potential confounders. We used consistent sepsis criteria and detailed electronic clinical data to elucidate the epidemiology and mortality associated with hospital-onset sepsis. Design: Retrospective cohort study. Setting: 136 U.S. hospitals in the Cerner HealthFacts dataset. Patients: Adults hospitalized in 2009–2015. Interventions: None. Measurements and Main Results: We identified sepsis using Centers for Disease Control and Prevention Adult Sepsis Event criteria and estimated the risk of in-hospital death for hospital-onset sepsis versus community-onset sepsis using logistic regression models. In patients admitted without community-onset sepsis, we estimated risk of death associated with hospital-onset sepsis using Cox regression models with sepsis as a time-varying covariate. Models were adjusted for baseline characteristics and severity of illness. Among 2.2 million hospitalizations, there were 95,154 sepsis cases: 83,620 (87.9%) community-onset sepsis and 11,534 (12.1%) hospital-onset sepsis (0.5% of hospitalized cohort). Compared to community-onset sepsis, hospital-onset sepsis patients were younger (median 66 vs 68 yr) but had more comorbidities (median Elixhauser score 14 vs 11), higher Sequential Organ Failure Assessment scores (median 4 vs 3), higher ICU admission rates (61% vs 44%), longer hospital length of stay (median 19 vs 8 d), and higher in-hospital mortality (33% vs 17%) (p < 0.001 for all comparisons). On multivariate analysis, hospital-onset sepsis was associated with higher mortality versus community-onset sepsis (odds ratio, 2.1; 95% CI, 2.0–2.2) and patients admitted without sepsis (hazard ratio, 3.0; 95% CI, 2.9–3.2). Conclusions: Hospital-onset sepsis complicated one in 200 hospitalizations and accounted for one in eight sepsis cases, with one in three patients dying in-hospital. Hospital-onset sepsis preferentially afflicted ill patients but even after risk-adjustment, they were twice as likely to die as community-onset sepsis patients; in patients admitted without sepsis, hospital-onset sepsis tripled the risk of death. Hospital-onset sepsis is an important target for surveillance, prevention, and quality improvement initiatives.

Validation of automated sepsis surveillance based on the Sepsis-3 clinical criteria against physician record review in a general hospital population: observational study using electronic health records data

“…In our study, the majority of patients presented with sepsis on admission, but the burden of HO sepsis was still substantial. Recent data have associated HO sepsis with mortality approximately twice as high compared with CO sepsis 25. Despite this, traditional surveillance programmes for healthcare-associated infections, such as CDC/National Healthcare Safety Network and European Centre for Disease Prevention and Control, do not include sepsis as a distinct entity 19 26 27…”

Sepsis Among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012–2018*

“…Anyone can develop sepsis. Children younger than 1 year, adults 65 years old and older, persons with weakened immune systems, and persons with chronic medical conditions are at increased risk (1)(2)(3). According to recent (2016) Centers for Disease Control and Prevention estimates, 1.7 million adult Americans become septic each year; of those, nearly 270,000 Americans die, and one in three patients who die in a hospital have sepsis (4).…”

Excess Length of Acute Inpatient Stay Attributable to Acquisition of Hospital-Onset Gram-Negative Bloodstream Infection with and without Antibiotic Resistance: A Multistate Model Analysis

“…The possible explanation for this absolute difference in LOS is that the previous study included both community-onset and HO infections, and HO infections accounted for only 20% of all cases, while our study only included HO infections. HO sepsis is known to be associated with higher mortalities and a longer LOS compared to community-onset sepsis [14].…”