Impact of Source Control in Patients With Severe Sepsis and Septic Shock*

Martínez, María Luisa Martínez; Ferrer, Ricard; Torrents, Eva; Guillamat-Prats, Raquel; Gomà, Gemma; Suarez, David L.; Álvarez–Rocha, Luis; Laderas, Juan Carlos Pozo; Martín‐Loeches, Ignacio; Levy, Mitchell M.; Artigas, Antonio

doi:10.1097/ccm.0000000000002011

Cited by 138 publications

(76 citation statements)

References 31 publications

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“…A third issue is a delay in interventions related to transfer from outside hospitals where the diagnosis of sepsis may not be considered prior to transfer or early sepsis care bundles may not have been effectively implemented. This is particularly important in surgical patients where transfer can significantly delay source control interventions (e.g., NSTI debridement) which are known to have substantial impact on outcomes [35]. Moreover, protective barriers and defense mechanisms are unique to each anatomic as is the burden of organisms and type of bacterial infection.…”

Section: Discussionmentioning

confidence: 99%

Phenotypic heterogeneity by site of infection in surgical sepsis: a prospective longitudinal study

et al. 2020

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Background: The role of site of infection in sepsis has been poorly characterized. Additionally, sepsis epidemiology has evolved. Early mortality has decreased, but many survivors now progress into chronic critical illness (CCI). This study sought to determine if there were significant differences in the host response and current epidemiology of surgical sepsis categorized by site of infection.Study design: This is a longitudinal study of surgical sepsis patients characterized by baseline predisposition, insult characteristics, serial biomarkers, hospital outcomes, and long-term outcomes. Patients were categorized into five anatomic sites of infection. Results:The 316 study patients were predominantly Caucasian; half were male, with a mean age of 62 years, high comorbidity burden, and low 30-day mortality (10%). The primary sites were abdominal (44%), pulmonary (19%), skin/soft tissue (S/ST, 17%), genitourinary (GU, 12%), and vascular (7%). Most abdominal infections were present on admission and required source control. Comparatively, they had more prolonged proinflammation, immunosuppression, and persistent organ dysfunction. Their long-term outcome was poor with 37% CCI (defined as > 14 in ICU with organ dysfunction), 49% poor discharge dispositions, and 30% 1-year mortality. Most pulmonary infections were hospitalacquired pneumonia. They had similar protracted proinflammation and organ dysfunction, but immunosuppression normalized. Long-term outcomes are similarly poor (54% CCI, 47% poor disposition, 32% 1-year mortality). S/ST and GU infections occurred in younger patients with fewer comorbidities, less perturbed immune responses, and faster resolution of organ dysfunction. Comparatively, S/ST had better long-term outcomes (23% CCI, 39% poor disposition, 13% 1-year mortality) and GU had the best (10% CCI, 20% poor disposition, 10% 1-year mortality). Vascular sepsis patients were older males, with more comorbidities. Proinflammation was blunted with baseline immunosuppression and organ dysfunction that persisted. They had the worst long-term outcomes (38% CCI, 67% poor disposition, 57% 1-year mortality). Conclusion: There are notable differences in baseline predisposition, host responses, and clinical outcomes by site of infection in surgical sepsis. While previous studies have focused on differences in hospital mortality, this study provides unique insights into the host response and long-term outcomes associated with different sites of infection.

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Section: Discussionmentioning

confidence: 99%

Phenotypic heterogeneity by site of infection in surgical sepsis: a prospective longitudinal study

et al. 2020

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“…Waiting for patients to clinically stabilize prior to intervention is not recommended, as delaying adequate source control may lead to further clinical deterioration [6]. Although source control as an adjunct to antimicrobial and other medical therapy has been best described for abdominal infections in adults and has been associated with reduction in mortality [172], the role of source control for pediatric sepsis has been less well elucidated [173].…”

Section: We Recommend Removal Of Intravascular Access Devices That Armentioning

confidence: 99%

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

et al. 2020

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Objectives: To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.Design: A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those The Society of Critical Care Medicine guidelines are intended for general information only, are not medical advice, and do not replace professional advice, which should be sought for any medical condition. The full disclaimer for guidelines can be accessed at https ://www.sccm.org/Resea rch/Guide lines /Guide lines . panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. Methods:The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. Results:The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified. Conclusions:A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research. S14 the group heads, panel members, and methodologists. Searches utilized ...

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“…FiO 2 inspired oxygen fraction, PaO 2 partial pressure (or tension) of arterial oxygen, MDROs multi-drug resistant organisms is gaining importance as a pivotal measure to improve patients' outcomes, particularly in intra-abdominal, skin and soft tissue, implant-associated infections and CRI. In the Edusepsis study conducted in Spanish ICUs, patients who underwent source control were older, had a greater prevalence of shock, major organ dysfunction, bacteremia, inflammatory markers, lactic academia and worse compliance with the resuscitation bundle compared with those who did not undergo source control [12]. The source control group had lower crude ICU and hospital mortality even after adjustment for confounding factors.…”

Section: Only Viruses Identifiedmentioning

confidence: 98%

Principles of antimicrobial stewardship for bacterial and fungal infections in ICU

2017

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Impact of Source Control in Patients With Severe Sepsis and Septic Shock*

Abstract: Despite greater severity and worse compliance with resuscitation bundles, mortality was lower in septic patients who underwent source control than in those who did not. The time to source control could not be linked to survival in this observational database.

Cited by 138 publications

References 31 publications

Phenotypic heterogeneity by site of infection in surgical sepsis: a prospective longitudinal study

Phenotypic heterogeneity by site of infection in surgical sepsis: a prospective longitudinal study

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

Principles of antimicrobial stewardship for bacterial and fungal infections in ICU

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