Outcome and Management of Sepsis at RozhHalat Emergency Hospital in Erbil –Kurdistan region of Iraq

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Samir Qader Ahmad Shakawan Muhamad Ismaeel Dara Ahmed Mohammed Ahmed Mohammed Halgurd Fathulla Ahmed

Abstract

Sepsis is a very common condition in emergency hospitals and presentation is variable, it is under diagnosed with very high mortality rate. All patients with infection are at risk of developing sepsis.


Sepsis is a complex condition characterized by activation of inflammatory process and coagulation system in response to microbial insult. An observational prospective study was carried out at RozhHalat emergency hospital in Erbil-Kurdistan region of Iraq between February 2017 to January 2018.The study was approved by the scientific and ethical committee of Kurdistan board of medical specialties. 50 patients aged between (10 - 80) years old presented to this hospital with sign and symptoms of infection were recruited to this study. 50 patients with signs and symptoms of sepsis were recorded in this study. The mean age was 47 with male to female ration of 2:3 (42% male and 58% female). The overall mortality rate was high at 68% with higher rate among female and older age group. The blood culture was positive in 74% of cases of which 52% were gram positive and 22% were gram-negative microorganisms. A Positive blood culture associated with higher mortality rate of 81% compared with 21% if the blood culture was negative. In majority of cases the site of infection was from multiple source (34%) followed by respiratory infection (26%).Skin and soft tissue infection was associated with the lowest mortality of 2.9%. High number of cases (82%) developed complications and 52% of cases developed more than 2 organ failures. All patients received empirical antibiotic therapy however 46% of cases received the wrong antimicrobials. The survival rate was higher


 


(44%) among patients given the right antibiotics. Similarly patients had better chance of survival if appropriate fluid resuscitation therapy was give. The overall mortality among vasopressor treated patients were 72% compared with 78% chance of mortality if they were not treated with any vasopressor therapy, among those who received inotropic support Noradrenaline associated with higher survival rate(72%). A qSOFA score of more than 2 associated with 86.4 % of mortality compared with 75.5% mortality with similar SIRS criteria. Factors associated with high mortality were: female gender, older age group, positive blood culture, wrong antibiotics therapy, less fluid resuscitation, multisource of infection, multi-organ failure, high lactic acid level and high qSOFA score. This study shows that sepsis is associated with high overall mortality rate of 68% in the RozhHalat emergency hospital and higher rate of death among female and older age group. Negative blood culture, appropriate use of antibiotics and fluid therapy associated with better chance of survival. Vasopressor therapy did not result in better survival outcome except for Noradrenaline. The qSOFA score is as good as SIRS criteria in predicting mortality. High lactate, multi-organ failure and multisource of infection associated with the worst outcome.

Keywords

Sepsis, Blood culture, Lactic acid, Vasopressor.

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References

[1] L.-Z. W. L. J. C. G. C. J. P. M. Angus DC, "Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care," Society of Critical Care Medicine and Lippincott Williams, vol. 29, no. 7, pp. 1303-1310, 2001.
[2] E. G. G. J. S. J. W. A. A. D. I. T. Liu V, "Hospital deaths in patients with sepsis," Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA, pp. 90-92, 2014.
[3] R. S. M. L. L. O. S. M. R. K. T. I. R. &. V. J.-L. Hotchkiss, "Sepsis and septic shock.," Nature reviews Disease primers., pp. 16-45, 2016.
[4] "National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management.," 17 5 2017. [Online]. Available: https://www.nice.org.uk. [Accessed 13 7 2016].
[5] M. D. C. S. S. C. W. S.-H. M. A. D. B. M. …. A. D. C. (. Singer, "The Third International Consensus Definitions for Sepsis and Septic Shock," Sepsis-3. JAMA., vol. 315(8), pp. 801-810, 2016.
[6] C. W. L. V. X. I. T. J. B. F. M. R. T. D. S. A. Seymour, "Assessment of Clinical Criteria for Sepsis," Third International Consensus Definitions for Sepsis and Septic Shock, vol. 315(8), pp. 762-774, 2016.
[7] M. M. Z. F. J. W. C. H. M. D. &. E. D. P. Churpek, "Incidence and Prognostic Value of the Systemic Inflammatory Response Syndrome and Organ Dysfunctions in Ward Patients," American Journal of Respiratory and Critical Care Medicine, vol. 192(8), pp. 958-964, 2015.
[8] N. T. M. G. Daniels R, "The sepsis six and the severe sepsis resuscitation bundle,a prospective observational cohort study," Emergency medicine journal: EMJ., vol. 28(6), pp. 507-512, 2010.
[9] P. K. O. M. A. R. M. M. D. V. V. E. S. D. M. S. E. M. B. &. d. S. O. F. P. Yokota, "Impact of Appropriate Antimicrobial Therapy for Patients with Severe Sepsis and Septic Shock," A Quality Improvement Study, pp. 9-11, 2014.
[10] M.-L. I. P. G. Ferrer R, "Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock," guideline-based performance improvement program., vol. 42(8), pp. 1749-1755, 2014.
[11] F. R. P. R. R. G. E. P. B. B. M. J. M. G. K. S. L. D. R. D. K. A. Amaral AC, "Patient and Organizational Factors Associated With Delays in Antimicrobial Therapy for Septic Shock.," Antimicrobial Therapy of Septic Shock, vol. 44(12), pp. 2145-2153, 2016.
[12] E. P. A. Y. Kumar A, "Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock.," Antimicrobial Therapy of Septic Shock, vol. 136(5), pp. 1237-1248, 2009.
[13] M. W. &. R. T. W. Semler, "Sepsis Resuscitation: Fluid Choice and Dose," Clinics in Chest Medicine, vol. 37(2), pp. 241-250, 2016.
[14] R. A. P. G. Levy MM, "association between performance metrics and outcomes in a 7.5-year study," Surviving Sepsis Campaign, vol. 43(1), pp. 3-12, 2015.
[15] P. G. S. C. e. a. Casserly B, "Lactate measurements in sepsis-induced tissue hypoperfusion," Surviving Sepsis Campaign database, vol. 43(3), pp. 567-573, 2015.
[16] T. H. H. Z. e. a. Yu B, "Comparison of the effect of fluid resuscitation as guided either by lactate clearance rate or by central venous oxygen saturation in patients with sepsis.," vol. 25(10), pp. 578-583, 2013.
[17] T. L. A. L. S. L. L. P. M. &. G. A. Avni, "Vasopressors for the Treatment of Septic Shock," 3 8 2015. [Online]. Available: http://doi.org/10.1371/journal.pone.0129305.
[18] T. E. M. G. e. a. Keh D, "Effect of hydrocortisone on development of shock among patients with severe sepsis," HYPRESS randomized clinical trial. JAMA, vol. 316(17), pp. 1775-1782, 2016.
[19] E. R. W. M. White DB, "The language of prognostication in intensive care units," An International Journal of the Society for Medical Decision Making, vol. 30(1), pp. 76-83, 2010.
[20] M. D. M. M. M. Martin G. S., "The effect of age on the development and outcome of adult sepsis.," vol. 34(1), pp. 15-21, 2006.
[21] J. D. S. O. Nasa P, "Severe sepsis and septic shock in the elderly," World Journal of Critical Care Medicine, vol. 1(1), pp. 23-30, 2012.
[22] E. C. M. L. e. a. Sakr Y, "The influence of gender on the epidemiology of and outcome from severe sepsis," 18 3 2013. [Online]. Available: https://ccforum.biomedcentral.com/articles/10.1186/cc12570.
[23] S. N. L. P. e. a. Fowler RA, "Sex-and age-based differences in the delivery and outcomes of critical care," Canadian Medical Association Journal., vol. 177(12), pp. 1513-1519, 2007.
[24] J. D. M. K. e. a. Finkelsztein EJ, "Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit.," vol. 21, p. 73, 2017.
[25] G. J. S. J. A. Serafim R, "comparison of the quick-SOFA (qSOFA) and SIRS criteria for the diagnosis of sepsis and prediction of mortality : A Systematic Review and Meta-Analysis," American College of Chest Physicians, vol. 153, pp. 646-655, 2017.
[26] K. W. K. M. e. a. Park HK, "Quick sequential organ failure assessment compared to systemic inflammatory response syndrome for predicting sepsis in emergency department," Journal of Critical Care, vol. 42, pp. 12-17, 19 6 2017.
[27] R. L. C. T. e. a. Filho RR, "Blood Lactate Levels Cutoff and Mortality Prediction in Sepsis-Time for a Reappraisal? a Retrospective Cohort Study," vol. 46(5), pp. 480-485, 5 11 2016.
[28] N. T. B. J. e. a. Wacharasint P, "Normal-range blood lactate concentration in septic shock is prognostic and predictive," vol. 38, pp. 1:4-10, 1 7 2012.
[29] U. S. K. W. e. a. Kang YR, "Initial lactate level and mortality in septic shock patients with hepatic dysfunction.," vol. 39, no. 5, pp. 862-867, 2011.
[30] N. W. S. K. e. a. Phua J, "Characteristics and outcomes of culture-negative versus culture-positive severe sepsis," vol. 17, no. 5, 12 9 2013.
[31] M.-B. A. S. V. e. a. Blanco J, "Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study," vol. 12, no. 6, 17 12 2008.
[32] N. M. P. L. e. a. Sogaard M, "Blood culture status and mortality among patients with suspected community acquired bacteremia: a population-based cohort study," vol. 11, p. 139, 20 5 2011.
[33] A. M. J. M. e. a. Vibeke K, "Site of infection and mortality in patients with severe sepsis or septic shock:A cohort study of patients admitted to a Danish general intensive care unit, .," Infectious Diseases Journal, vol. 48, no. 10, pp. 726-731, 8 7 2016.
[34] Y. S. A. D. Mayr FB, "Epidemiology of severe sepsis," Journal Virulence , vol. 5, no. 1, pp. 4-11, 11 12 201.
[35] L. A. Lueangarun S, "Impact of Inappropriate Empiric Antimicrobial Therapy on Mortality of Septic Patients with Bacteremia: A Retrospective Study," Interdisciplinary Perspectives on Infectious Diseases, pp. 1-13, 28 5 2012.
[36] S. D. L. K. e. a. Pradipta IS, "Antibiotic Resistance in Sepsis Patients: Evaluation and Recommendation of Antibiotic Use.," North American Journal of Medical Sciences, vol. 5, no. 6, pp. 344-352, 2013.
[37] A. C. N. H. V. J. De Backer D, "Dopamine versus norepinephrine in the treatment of septic shock," a meta-analysis. Crit Care Med., vol. 40, pp. 725-730, 1 3 2012.
[38] E. S. A. C. Pollard S, "Vasopressor and Inotropic Management Of Patients With Septic Shock.," Pharmacy and Therapeutics., vol. 40, no. 7, pp. 438-450, 2015.
[39] H. S. Kim WY, "Sepsis and Acute Respiratory Distress Syndrome: Recent Update.," Tuberculosis and Respiratory Diseases., vol. 79, no. 2, pp. 53-57, 2016.
[40] B. C. B. F. e. a. Machado FR, "Epidemiology of sepsis in Brazilian ICUs,a nationwide stratified sample.," Intensive Care Medicine Experimental, vol. 3, no. 1, 2015.
[41] C. S. B. M. Todi S, "Epidemiology of severe sepsis in India," Critical Care, vol. 11, no. 2, p. 65, 2007.
[42] B. R. Khwannimit B, "The epidemiology of, and risk factors for mortality from severe sepsis and septic shock in a tertiary care university hospital setting," Cambridge University Press, vol. 137, no. 9, pp. 1333-1341, 4 2 2009.
[43] S. M. B. R. e. a. Dagher GA, "Descriptive analysis of sepsis in a developing country," International Journal of Emergency Medicine, vol. 8, no. 19, 6 6 2015.