Epidemiology and management trends of patients with severe sepsis and septic shock in Trinidadian Intensive Care Units: A prospective multicenter trial

Objectives: To investigate the epidemiology, management and predictors of mortality in severe sepsis. Design and Methodology: Prospective observational study in 4 Trinidadian Intensive Care Units (ICU) over a one year period August 2017-August 2018. Physiologic and treatment data was collected on admission to ICU and patients were followed up until ICU discharge and then at 28 days to determine mortality. Results: 163 patients fit the criteria for severe sepsis and were enrolled. Twenty-eight day and ICU mortality rate were 42% (68) and 34 % (56) respectively. Case distribution by the various hospitals were San Fernando General Hospital 62% (101), Port of Spain General Hospital 16% (26), Eric Williams Medical Sciences Complex 12.3% (20) and Sangre Grande Hospital 9.8% (16). The most common source of sepsis was pulmonary (54%) followed by abdominal (17%) and urological sepsis (14%). Acute Kidney Injury (AKI) was present in 71% (115) patients and 43% (46) of patients with stage 2 and above AKI received Renal Replacement Therapy (RRT) in the ICU. In the regression model, the only factors that were found to predict both 28 day and ICU mortality were stage 2 AKI [OR 6.2 (95% CI 1.7- 23.1, p = .007)], stage 3 AKI [OR 7.2 (95% CI, 2.1-24.0, p=.001)] , mean arterial pressure of < 60mmHg in the first 24 hours [OR 10.8 (95% CI 1.7-68.1, p= .001)], presence of either moderate-severe Acute Respiratory Distress Syndrome [OR 4.1 (95% CI 1.8 ­ 9.2, p = .002)] and Acute Physiology, Age, Chronic Health Evaluation (APACHE) II score [OR 1.08 (95% CI, 1.0-1.2, p=.039)]. Conclusion: Severe sepsis is associated with a high hospital mortality rate and this sepsis burden varies according to region. Limited access to RRT remains a problem in certain centers.

Performance of Sepsis Scoring Systems in a developing country ­ a prospective cohort study

Background: Sepsis and its sequelae poses a significant socio-economic burden on health care systems globally. Risk stratification plays a fundamental role in emergency department management, since early and aggressive management in high-risk cohorts leads to improved outcomes. Several risk stratification tools exist but in the local setting (developing country with high chronic disease burden) there is no standardised recommendation for beside utilisation. Objectives: We aimed to compare the ability of the quick Sepsis-related Organ Failure Assessment (qSOFA) score with the Systemic Inflammatory Response Syndrome (SIRS) criteria and National Early Warning Score (NEWS) to detect and risk stratify patients with presumed sepsis outside of the intensive care unit (ICU). Methods: A prospective observational cohort study was conducted at a public tertiary hospital during the period May to June 2017. Ethical and institutional approval was secured and informed consent was sought from study participants aged eighteen (18) years and older. Demographic and clinical data were collected via a data collection instrument and statistical analysis was undertaken using IBM SPSS v23. Results: 304 patients were treated for presumed sepsis. The primary outcomes of in-hospital death or intensive care unit admission were seen in 14.8%. Discrimination for the primary outcome was highest for NEWS (AUROC 0.88 [95% CI 0.83-0.94]) followed by qSOFA (AUROC 0.82 [95% CI 0.74-0.89]) and SIRS (AUROC 0.69 [95% CI 0.61-0.77]). A NEWS value of ≥4 resulted in a sensitivity of 93.3%, and negative predictive value of 98.3% (p<0.001). A qSOFA score ≥2 demonstrated a specificity of 94.6 % and a negative predictive value of 91.4% (p<0.001). A SIRS criteria score ≥2 resulted in a sensitivity of 88.9%, and a negative predictive value of 95.0% (p=0.001). Univariate analysis showed that: need for supplemental oxygen, an oxygen saturation less than 91%, a Glasgow Coma Scale <15 and non-selfpresentation were associated with the highest odds ratios for death in-hospital or ICU admission. Conclusions: Urgent identification of high-risk patients with presumed infection is critical in achieving a positive outcome. NEWS was superior to both qSOFA AND SIRS in predicting in-hospital mortality and need for ICU admission A qSOFA score ≥2 demonstrated a high specificity but poor sensitivity, thus limiting its use as a bedside tool. The findings of this study are consistent with the Sepsis-3 guidelines, which recommend qSOFA as being superior to SIRS criteria. However, we found that NEWS had a superior predictive value to both. Its role in the identification of high-risk subjects should be further evaluated.

Cost-effectiveness of pneumococcal conjugate vaccination in Latin America and the Caribbean: a regional analysis

OBJECTIVE: In Latin America and the Caribbean, routine vaccination of infants against Streptococcus pneumoniae would need substantial investment by governments and donor organizations. Policymakers need information about the projected health benefits, costs, and cost-effectiveness of vaccination when considering these investments. Our aim was to incorporate vaccine, demographic, epidemiologic, and cost data into an economic analysis of pneumococcal vaccination of infants in Latin America and the Caribbean. METHODS: We previously used a structured literature review to develop regional estimates of the incidence of disease. Cost data were collected from physician interviews and public fee schedules. We then constructed a decision analytic model to compare pneumococcal conjugate vaccination of infants with no vaccination across this region, examining only vaccine's direct effects on children. RESULTS: Pneumococcal vaccination at the rate of diphtheria-tetanus-pertussis vaccine coverage was projected to prevent 9500 deaths per year in children aged 0 to 5 years in the region, or approximately one life saved per 1 100 infants vaccinated. These saved lives as well as averted cases of deafness, motor deficit, and seizure result in 321000 disability-adjusted life years (DALYs) being averted annually. At vaccine prices between US$5 and US$53 per dose, the cost per DALY averted from a societal perspective would range from US$154 to US$5252. CONCLUSION: Pneumococcal conjugate vaccine was highly cost-effective up to $40 per dose. Introduction of pneumococcal vaccine in the Latin American and Caribbean region is projected to reduce childhood mortality and to be highly cost-effective across a range of possible costs.

Polymorphisms in the myosin light chain kinase gene that confer risk of severe sepsis are associated with a lower risk of asthma

BACKGROUND: Myosin light chain kinase (MYLK) is a multifunctional protein involved in regulation of airway hyperreactivity and other activities relevant to asthma. OBJECTIVE: To determine the role of MYLK gene variants in asthma among African Caribbean and African American populations. METHODS: We performed association tests between single nucleotide polymorphisms (SNPs) in the MYLK gene and asthma susceptibility and total serum IgE concentrations in 2 independent, family-based populations of African descent. Previously we identified variants/haplotypes in MYLK that confer risk for sepsis and acute lung injury; we compared findings from our asthma populations to findings in the African American sepsis and acute lung injury groups. RESULTS: Significant associations between MYLK SNPs and asthma and total serum IgE concentrations were observed in the African Caribbean families: a promoter SNP (rs936170) in the smooth muscle form gave the strongest association (P=.009). A haplotype including rs936170 corresponding to the actin-binding activity of the nonmuscle and smooth muscle forms was negatively associated with asthma (eg, decreased risk in both the American (P=.005) and Caribbean families (P=.004), and was the same haplotype that conferred risk for severe sepsis (P=.002). RNA expression studies on PBMCs and rs936170 suggested a significant decrease in MYLK expression among patients with asthma with this variant (P=.025). CONCLUSION: MYLK polymorphisms may function as a common genetic factor in clinically distinct disease involving broanchial smooth muscle contraction and inflammation. CLINICAL IMPLICATIONS: Genetic variants in MYLK are significantly associated with both asthma and sepsis in populations of African ancestry (AU)

Sepsis and the scalpel: Anatomic compartments and the diabetic foot

The foot comprises 3 compartments bounded by bone and fascia, each compartment containing muscle and vascular and nervous structures. Infection leading to an increase in pressures in the compartments results in rapid necrosis, a pathologic process characteristic of diabetic feet. Treatment involves fasciotomy and complete debridement of devitalized tissue with possible amputation of the involved digits. Knowledge of the anatomic structure of the foot and its compartments is therefore essential in effectively managing the diabetic foot.

Evaluation of neonatal sepsis screening in a tropical area. Part III: neonatal sepsis in meconium stained deliveries

Of the 6,060 consecutive live births delivered at the University Maternity Unit of Guadeloupe (French West Indies) during a 30-month period, 635 newborns (10.4 percent) presented with meconium stained (MS) amniotic fluid, of which 595 (94 percent) received bacteriological screening at birth (light MS, n=543; thick MS, n=52). Thirty (5 percent) of MS newborn had a bacteraemia (n=13, group B streptococcus, GBS), and 128 (21.5 percent) a bacterial positive gastric aspirate (n=54, GBS). Sixty-six newborns among MS babies needed tracheal suctioning (11 percent) in the delivery room for meconium inhalation. Among these 595 screening MS newborn, 286 (48 percent) presented clinical signs of postmaturity of birth, having therefore an explanation for their MS condition. For the other MS newborn without the postmaturity explanation, we experienced twofold increased risk of neonatal sepsis (OR 1.88 for bacteraemia and 2.61 for external carriage p < 0.02, Chi square) as compared with their MS postmature counterparts. We conclude that when meconium stained deliveries are associated with postmaturity signs, one may not need to initiate prophylactic antibiotic treatment at birth unless they present with other traditional risk factros for neonatal sepsis such as intrapartum fever and prolonged rupture of membranes.(Au)

Evaluation of neonatal sepsis screening in a tropical area. Part II: Evaluation of intrapartum chemoprophylaxis protocol

The authors report on an analysis of a chemoprophylaxis protocol at the University Hospital of Guadeloupe in the Caribbean. This study comprised 6,060 consecutive deliveries and was initiated to assess the application of an intrapartum chemoprophylaxis protocol, evaluate the results, and try to identify possible necessary modifications to the existing protocol. Although more than 90 percent of women had at least one bacterial screening (vaginal or urinary) during the last trimester of pregnancy, approximately 75 percent of mothers who were heavily colonized group B streptococcus (GSB) at delivery were not detected by this systematic screening. As is also reported in other tropical areas where a great portion of nenonatal sepsis occurs in term babies, low birthweight was not a specific risk factor in this study when controlling for other major risk factor such as fever and premature rupture of membranes. Intrapartum chemoprophlaxis was associated wiyh an approximate three fold decrease in the risk of GBS neonatal bacteraemia among at risk deliveries. The results suggest that, in our tropical context, prolonged rupture of membranes of at least 12 hours' duration should be considered as a cause for intrapartum chemopropylaxis as it accounted for the majority of neonatal bacteraemia that escaped the existing protocol. (AU)

Neonatal sepsis and mortality in a regional hospital in Trinidad: aetiology and risk factors

A total of 132 neonatal deaths among 627 infants admitted to the neonatal ward of the San Fernando General Hospital, Trinidad over a 2-year period were reviewed. The most common cause of death was prematurity (43.9%). Infection was the second most common cause (21.2%). Pseudomonas aeruginosa and Staphylococcus aureus were the most frequently isolated organisms (43%). The major drugs used empirically in suspected cases of sepsis were ampicillin or ceftazidime plus gentamicin. About 85% of S. aureus were resistant to ampicillin, and P. aeruginosa resistance to ceftazidime and gentamicin was 76.7% and 72.1%, respectively. Significant risk factors in maternal history were infrequent antenatal care and prolonged rupture of membranes. The incidence of infection among low birthweight infants was 85.6%. Early-onset sepsis (86.4%) seemed to have a nosocomial origin because of the type of pathogens seen. There is an urgent need to improve the staff-to-patient ratio in the neonatal unit and for staff to be constantly reminded to employ simple infection control practices such as proper hand-washing to reduce cross-infections.

Evaluation of neonatal sepsis screening in a tropical area. Part I: Major risk factors of bacterial carriage at birth in Guadeloupe

This prospective study reports on screening for neonatal sepsis among 3,372 live births out of 6,060 consecutive deliveries at the University Hospital of Pointe-a-Pitre, Guadeloupe, during a 30 month period. Group B Streptococcus (GBS) was the most common pathogen, representing 46 percent (89/194) of positive blood cultures and 52 percent (335/637) of positive gastric aspirates. Although only 3,372 (55 percent) of all live births were screened, 637 (10 percent) had gastric bacterial carriage at birth; of those, 335 (5.5 percent) involved GBS. Similarly, there were 194 (3.2 percent) positive blood cultures, of which 89 (1.5 percent) involved GBS. In this report, all newborns who presented with a positive GBS blood culture had at least one of the external tests positive for GBS (gastric, ear canal, rectum and placenta). Thirty-seven per cent (14/38) of positive neonatal blood cultures occurred in newborns with foetid liquor while in deliveries with intrapartum fever 16.5 percent (32/195) of blood cultures were positive. In our clinical practice, characteristics that were evident in the delivery room (without knowledge of prenatal follow-up) such as foetid liquor, intrapartum fever, prolonged rupture of membranes, foetal tachycardia and meconium staining were associated with the great majority of neonatal sepsis.(Au)

A study of admissions to Ward 1, Port of Spain General Hospital for early pregnancy loss: May-June 1999 - Poster abstract

OBJECTIVE: To compare early pregnancy loss in spontaneous versus induced abortions and determine the most common methods of pregnancy termination. DESIGN AND METHODS: In this prospective study, 205 patients admitted to Ward 1, Port of Spain General Hospital from May 1 to June 31, 1999 were interviewed with respect to age and circumstances surrounding thier pregnancy loss. Patient records were subsequently examined to obtain results of investigations and medical or surgical interventions undertaken. RESULTS: Patient were placed into 3 groups: spontaneous abortions (SA), induced abortions (1A) (all types) and mosprostol-induced abortions (MA). Patients' ages ranged from 14 to 43 years (mean 25 years). Length of hospital stay ranged from 1 to 24 days (mean 2.1 days). There was no difference in patient age or length of hospital stay among the three groups. Patients in the MA group exhibited increased rates of sepsis (53.7 percent vs 34.5 percent in the SA group), more episodes of blood transfusion (18.5 percent, MA vs 8.8 percent, SA) and had a higher rate of incomplete abortions (79.8 percent, MA vs. 59.0 percent SA). This led to an increased need for surgical intervention (72.2 percent, MA vs 49.1 percent, IA). Patients in the SA group display intermediate values in all parameters. CONCLUSIONS: Self-medication with Misoprostol is by far the most popular method of termination of unwanted pregnancy in this population. It was associated with increased rates of sepsis, anaemia and necessity for surgical evacuation of the uterus when compared with IA in the same population.(AU)

Improved survival in homozygous sickle cell disease: lessons from a cohort study

OBJECTIVE: To examine whether simple interventions in a sickle cell clinic improve survival in sickle cell disease. DESIGN: Survival curve analysis and hazard ratios in a cohort study followed from birth. SETTING: MRC Laboratories (Jamaica) at the University of the West Indies, and Victoria Jubilee Hospital, Kingston, Jamaica. SUBJECTS: 315 patients with homozygous sickle cell disease detected during the screening of 100,000 consecutive non-operative deliveries between June 1973 and December 1981 at the main government maternity hospital, Kingston, Jamaica. INTERVENTIONS: Prophylactic penicillin to prevent pneumococcal septicaemia, parental education in early diagnosis of acute splenic sequestration, close monitoring in sickle cell clinic. MAIN OUTCOME MEASURES: Survival. RESULTS: Survival appeared to improve, the log rank test for trend comparing the first, second, and last third of the study reaching borderline significance (P = 0.05). Combined deaths from acute splenic sequestration and pneumococcal septicaemia-meningitis declined significantly (test for trend, P = 0.02). CONCLUSION: Early diagnosis and simple prophylactic measures significantly reduce deaths associated with homozygous sickle cell disease (AU)

Neonatal meningitis: a 3-year retrospective study at the Mount Hope Women's Hospital, Trinidad, West Indies

The objective of this 3-year (1988-1990) retrospective study was to report the experience with neonatal meningitis at the Neonatal Intensive Care Unit, Mount hope women's Hospital, Trinidad, West Indies. Neonates were included in the study if organisms were cultured from the cerebrospinal fluid (CSF) and/or if there was a pleocytosis (greater than or equal to 100/mm to 3rd power) in the CSF. There were 49 neonates with meningitis out of a total of 17048 live born (LB) infants during the 3-year period to give an overall incidence of 2.87/1000 LB. This was five times higher than the incidence reported in the literature. there were an additional five who were outborns to give a total of 54 cases. There were 34 males (63 per cent), prolonged rupture of the amniotic membranes (37 per cent). Associated maternal conditions included hypertension and antepartum haemorrhage (9 per cent). In contrast to other reported studies, there was early onset of the condition (mean age at presentation was 4 days) and the commonest organism found was Group B streptococcus while the least common were the Gram-negative organisms. Also different in the present study was the high percentage (56 per cent) of meningitis associated with Group B septicaemia, the low mortality rate (13) and the low rate of neurological sequelae (40 per cent)

Salmonella septicaemia in sickle-cell disease - abstract

The association of Salmonella osteomyelitis with sickle-cell disease is well described. There are few data on the frequency, morbidity or mortality of the salmonella septicaemia which precedes the development of focal bone infection. We have reviewed 34 cases (19 male, 15 female, 29 SS, 3 SB thalassaemia, 1 SC, 1 SO Arab) of salmonella septicaemia without clinical evidence of osteomyelitis. Clinical presentation: 44 percent occurred in children between 4 and 7 years old; 17 had fever > 38.5§C associated with painful crisis, 8 had increased jaundice and hepatomegaly, 6 hepatomegaly alone, 3 increased jaundice alone, 6 acute chest syndrome, 6 a diarrhoeal illness and 4 splenic enlargement. Laboratory findings:- 16 had leucocytosis and neutrophilia, 8 erythroid hypoplasia and 3 erythroid aplasia. A variety of salmonella species were isolated. Outcome:- 18 recovered without sequelae. Osteomyelitis developed in 11 (between 5 days and 2 months from positive blood culture). There were 5 fatalities, their illness being characterised by its rapid onset and overwhelming nature. There was no predominant organism responsible for progression to osteomyelitis or death. A review of positive blood culture results (1973 to date) in this clinic shows salmonella species present in 22 percent (this figure excludes patients with salmonella osteomyelitis who subsequently had a positive blood culture). Salmonella septicaemia without progression to osteomyelitis seems more common than previously assumed and we suggest that in dealing with the febrile sick child, in whom blood culture results are not yet available, this association should be borne in mind when selecting antimicrobial therapy (AU)

Considerations for implementing an antibiotic policy in hospital practice

An antibiotic policy should aim for the safe, effective and economical use of antimicrobial drugs, and to prevent their indiscriminate use and development of resistant bacterial strains. The term 'antibiotic' is used as a general term for all antimicrobial drugs. Antibiotics prescriptions should be based on clinical evidence of bacterial infection, preferably substantiated by appropriate laboratory culture and sensitivity tests. Viral infections are not an indication for antibiotic prescriptions. Patient factors to be considered for choice and dose of an antibiotic are age, pregnancy, lactation, renal and hepatic impairment. Immunodeficient patients should receive only bactericidal drugs. Severity of infection determines the route of administration. Duration of therapy should not exceed five days, unless specifically prescribed by the physician. An antibiotic should, if started as an empirical therapy not be changed before a minimum of three days trial. Prescriptions of drugs such as aztreonam, imipenem, vancomycin, piperacillin and amphotericin are to be restricted due to cost and toxicity and should be reviewed by the microbiologist (AU)

Coagulase-negative staphylococcal bacteremia in severely malnourished Jamaican children

Immunosupression increases the susceptibility to infection and changes the inflammatory response in children with severe protein-energy malnutrition. In this 5-year prospective study bacteremia was documented in 16 percent of the 336 severely malnourished children, 2 to 34 months of age, who were hospitalized consecutively in the Tropical Metabolism Research Unit, Kingston, Jamaica. The 53 children had 60 episodes of nosocomial and community-acquired bacteremia with 69 blood isolates. Community-acquired bacteremia accounted for 72 percent (43 of 60) of bactermic episodes. Thirty-five percent (24 of 69) of the strains were coagulase-negative staphylococci, 19 percent (13 of 69) were Staphylococcus aureus and 11 percent (8 of 69) were Streptococcus Group D. Seventeen episodes of coagulase negative staphylococcal bacteremia were acquired in the community and 7 nosocominal. These patients were more likely to have pneumonic consolidation than children with all other bacteremias combined (p < 0.02, Fisher's exact test). The bacteremia-related case fatality rate was 8 percent (5 of 60). Polymicrobial and Gram-negative septicemia were independent positive predictive factors for mortality when compared with single-agent and Gram-positive sepsis (P < 0.02). This 71 percent (49 of 69) prevalence of Gram-positive organism suggests a change in the epidemiology from the predominant Gram-negative etiologies (76 percent) described in previous reports (AU)

Prophylactic penicillin in young chidlren with homozygous sickle-cell diseases: lack of effect on manifestations other than pneumococcal septicaemia - abstract

This study investigates the effects of prophylactic penicillin in young children with homozygous sickle-cell (SS) disease, on clinical manifestations other than the known effect of preventing pneumococcal septicaemia. Thirty-nine patients received monthly injections of intramuscular penicillin for the 30-month period between age 6 and 36 months (treatment group) and 36 SS patients were followed without penicillin prophylaxis (control group). The features investigated included common manifestations before the age of 3 years such as haematological abnormalities, dactylitis, acute chest syndrome, acute splenic sequestration, and growth delay. No significant differences were found between the two groups in haematology, the incidence of dactylitis, acute chest syndrome, or acute sequestration during the study period, or in attained weight and height at age 3 years or at 8 years. Prophylactic penicillin given as monthly IM injections has no beneficial effect for children under 3 years with homozygous sickle-cell disease, other than the known effect of preventing pneumococcal sepsis (AU)

Microorganisms encountered in blood cultures at the Queen Elizabeth Hospital and their antibiotic sensitivity pattern

The importance of blood cultures in the early detection of organisms is examined with the following conclusions. The isolation of of gram-positive and gram negative organisms are isolated from blood cultures with equal frequency. K. pneumoniae and E. coli are the most frequently isolated gram gram-negataive organisms. Staph, epidermis is isolated more frequently than Stap. aureus. Gentamcin was found to be the most effective antibiotic against Gram-negative blood culture isolates. Clindamycin and cloxacillin were found to be the most effective antibiotics against the gram-positive isolates. Chloramphenicol was found to be the most effective agent against the anaerobes as a group

Systemic salmonella infections in sickle cell anaemia

Salmonella infections remain a significant cause of morbidity and mortality in patients with sickle cell disease. In Jamaica, 16 episodes of systemic Salmonella infection were recognised in 308 children with sickle cell disease followed prospectively in a cohort study from birth. There were eight cases with osteomyelitis, seven with septicaemia, and one with meningitis. Salmonella dactylitis and dactylitis owing to avascular bone necrosis showed that children with osteomyelitis had significantly higher fever, prolonged history and fluctuant swelling. Fever above 38.5§C occurred in four of five children with Salmonella dactylitis, but in only one of 59 with uncomplicated dactylitis (P=0.01). Chloramphenicol and co-trimoxazole were both effective for systemic infection, and ampicillin alone was inadequate. Three deaths occurred, two from septicaemia and one from meningitis. (AU)

Sonographically guided percutaneous aspiration of intra abdominal - abstract

Percutaneous sonographically-guided drainage (PSGD) of intra-abdominal fluid collections is a relatively new techniqe which can often achieve the results of open surgery without having to take the patient through a major operative procedure. Eighteen consecutive cases treated by this technique are presented. There were 12 liver abscesses, 3 paracolic abscesses and 3 renal cysts. One abscess recurred and was successfully treated by repeat PSGD. One patient died from preceding overwhelming sepsis which persisted 4 hours after PSGD. In no case was there any evidence of spread of infection or other complications of PSGD. Because many patients with intra-abdominal abscesses are very ill, the additional morbidity of open surgery can be avoided by using PSGD. Our success with this technique suggest that it should be more widely used throughout the region wherever appropriate ultrasonography is available (AU)