Maternal morbidity and mortality from severe sepsis: a national cohort study.

OBJECTIVES: To describe the incidence, characteristics and risk factors for critical care admission with severe maternal sepsis in the UK. DESIGN: National cohort study. SETTING: 198 critical care units in the UK. PARTICIPANTS: 646 pregnant and recently pregnant women who had severe sepsis within the first 24 hours of admission in 2008-2010. PRIMARY AND SECONDARY OUTCOME MEASURES: Septic shock, mortality. RESULTS: Of all maternal critical care admissions, 14.4% (n=646) had severe sepsis; 10.6% (n=474) had septic shock. The absolute risk of maternal critical care admission with severe sepsis was 4.1/10 000 maternities. Pneumonia/respiratory infection (irrespective of the H1N1 pandemic influenza strain) and genital tract infection were the most common sources of sepsis (40% and 24%, respectively). We identified a significant gradient in the risk of severe maternal sepsis associated with increasing deprivation (RR=6.5; 95% CI 4.9 to 8.5 most deprived compared with most affluent women). The absolute risk of mortality was 1.8/100 000 maternities. The most common source of infection among women who died was pneumonia/respiratory infection (41%). Known risk factors for morbidity supported by this study were: younger age, multiple gestation birth and caesarean section. Significant risk factors for mortality in unadjusted analysis were: age ≥35 years (unadjusted OR (uOR)=3.5; 95% CI 1.1 to 10.6), ≥3 organ system dysfunctions (uOR=12.7; 95% CI 2.9 to 55.1), respiratory dysfunction (uOR=6.5; 95% CI1.9 to 21.6), renal dysfunction (uOR=5.6; 95% CI 2.3 to 13.4) and haematological dysfunction (uOR=6.5; 95% CI 2.9 to 14.6). CONCLUSIONS: This study suggests a need to improve timely recognition of severe respiratory tract and genital tract infection in the obstetric population. The social gradient associated with the risk of severe sepsis morbidity and mortality raises important questions regarding maternal health service provision and usage.

Severe sepsis in women with group B Streptococcus in pregnancy: an exploratory UK national case-control study.

OBJECTIVE: To estimate the incidence of severe maternal sepsis due to group B Streptococcus (GBS) in the UK, and to investigate the associated outcomes for mother and infant. DESIGN: National case-control study. SETTING: All UK consultant-led maternity units. PARTICIPANTS: 30 women with confirmed or suspected severe GBS sepsis, and 757 control women. MAIN OUTCOME MEASURES: Disease incidence, additional maternal morbidity, critical care admission, length of stay, infant infection, mortality. RESULTS: The incidences of confirmed and presumed severe maternal GBS sepsis were 1.00 and 2.75 per 100,000 maternities, respectively, giving an overall incidence of 3.75 per 100,000. Compared with controls, severe GBS sepsis was associated with higher odds of additional maternal morbidity (OR 12.35, 95% CI 3.96 to 35.0), requiring level 2 (OR 39.3, 95% CI 16.0 to 99.3) or level 3 (OR 182, 95% CI 21.0 to 8701) care and longer hospital stay (median stay in cases and controls was 7 days (range 3-29 days) and 2 days (range 0-16 days), respectively, p<0.001). None of the women died. Severe maternal GBS sepsis was associated with higher odds of infant sepsis (OR 32.7, 95% CI 8.99 to 119.0); 79% of infants, however, did not develop sepsis. There were no associated stillbirths or neonatal deaths. CONCLUSIONS: Severe maternal GBS sepsis is a rare occurrence in the UK. It is associated with adverse maternal and neonatal outcomes.

Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-resistant Tuberculosis in the WHO European Region 2011-2015: Cost-effectiveness analysis.

Drug-resistant tuberculosis (TB) has increased at an alarming rate in the WHO European Region. Of the 27 countries worldwide with a high burden of multidrug resistant-TB (MDR-TB), 15 are in the European Region. An estimated 78,000 new cases of MDR-TB occur annually in the Region, of which approximately 10% are extensively drug-resistant (XDR)-TB. In response, the WHO Regional Office for Europe developed a Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-resistant Tuberculosis (2011-2015). Our objective was to analyse the cost-effectiveness of implementing the plan, with the expected achievements of diagnosing 85% of estimated MDR-TB cases and treating at least 75% successfully. A transmission model, using epidemiological data reported to WHO was developed to calculate expected achievements. WHO-CHOICE database was used for cost analyses. The highly cost-effective plan is expected to prevent the emergence of 250,000 new MDR-TB and 13,000 XDR-TB patients respectively, saving US$7 billion and 120,000 lives. The plan and accompanying Resolution were fully endorsed by the sixty-first session of the WHO Regional Committee for Europe in 2011. Member States need to continuously improve health system performance and address TB determinants. Research and development of new medicines, tools and patient-friendly services are also crucial.

Tuberculosis control in prisons: current situation and research gaps.

BACKGROUND: Tuberculosis (TB) in penitentiary services (prisons) is a major challenge to TB control. This review article describes the challenges that prison systems encounter in TB control and provides solutions for the more efficient use of limited resources based on the three pillars of the post-2015 End TB Strategy. This paper also proposes research priorities for TB control in prisons based on current challenges. METHODS: Articles (published up to 2011) included in a recent systematic review on TB control in prisons were further reviewed. In addition, relevant articles in English (published 1990 to May 2014) were identified by searching keywords in PubMed and Google Scholar. Article bibliographies and conference abstracts were also hand-searched. RESULTS: Despite being a serious cause of morbidity and mortality among incarcerated populations, many prison systems encounter a variety of challenges that hinder TB control. These include, but are not limited to, insufficient laboratory capacity and diagnostic tools, interrupted supply of medicines, weak integration between civilian and prison TB services, inadequate infection control measures, and low policy priority for prison healthcare. CONCLUSIONS: Governmental commitment, partnerships, and sustained financing are needed in order to facilitate improvements in TB control in prisons, which will translate to the wider community.

Severe maternal sepsis in the UK, 2011-2012: a national case-control study.

BACKGROUND: In light of increasing rates and severity of sepsis worldwide, this study aimed to estimate the incidence of, and describe the causative organisms, sources of infection, and risk factors for, severe maternal sepsis in the UK. METHODS AND FINDINGS: A prospective case-control study included 365 confirmed cases of severe maternal sepsis and 757 controls from all UK obstetrician-led maternity units from June 1, 2011, to May 31, 2012. Incidence of severe sepsis was 4.7 (95% CI 4.2-5.2) per 10,000 maternities; 71 (19.5%) women developed septic shock; and five (1.4%) women died. Genital tract infection (31.0%) and the organism Escherichia coli (21.1%) were most common. Women had significantly increased adjusted odds ratios (aORs) of severe sepsis if they were black or other ethnic minority (aOR = 1.82; 95% CI 1.82-2.51), were primiparous (aOR = 1.60; 95% CI 1.17-2.20), had a pre-existing medical problem (aOR = 1.40; 95% CI 1.01-1.94), had febrile illness or were taking antibiotics in the 2 wk prior to presentation (aOR = 12.07; 95% CI 8.11-17.97), or had an operative vaginal delivery (aOR = 2.49; 95% CI 1.32-4.70), pre-labour cesarean (aOR = 3.83; 95% CI 2.24-6.56), or cesarean after labour onset (aOR = 8.06; 95% CI 4.65-13.97). Median time between delivery and sepsis was 3 d (interquartile range = 1-7 d). Multiple pregnancy (aOR = 5.75; 95% CI 1.54-21.45) and infection with group A streptococcus (aOR = 4.84; 2.17-10.78) were associated with progression to septic shock; for 16 (50%) women with a group A streptococcal infection there was <2 h-and for 24 (75%) women, <9 h-between the first sign of systemic inflammatory response syndrome and a diagnosis of severe sepsis. A limitation of this study was the proportion of women with sepsis without an identified organism or infection source (16.4%). CONCLUSIONS: For each maternal sepsis death, approximately 50 women have life-threatening morbidity from sepsis. Follow-up to ensure infection is eradicated is important. The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of early administration of high-dose intravenous antibiotics within 1 h of admission to hospital for anyone with suspected sepsis. Signs of severe sepsis in peripartum women, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency. Please see later in the article for the Editors' Summary.

The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study.

OBJECTIVE: To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort. METHODS: This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors. RESULTS: 1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI = 9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR = 1.29; ≥35 years: aOR = 1.41), had ≤high-school education (aOR = 1.63), public/no-insurance (aOR = 1.22) or a cesarean section (primary: aOR = 1.99; repeat: aOR = 1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI = 4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR = 2.09), Asian (aOR = 1.59), Hispanic (aOR = 1.42), had public/no-insurance (aOR = 1.52), delivered in hospitals with <1,000 births/year (aOR = 1.93), were primiparous (aOR = 2.03), had a multiple birth (aOR = 3.5), diabetes (aOR = 1.47), or chronic hypertension (aOR = 8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR = 3.72; aOR = 4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI = 17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI = 40.8-74.4). CONCLUSIONS: The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

Sepsis and maternal mortality.

PURPOSE OF REVIEW: Despite global progress towards reducing maternal mortality, sepsis remains a leading cause of preventable maternal death. This review focuses on current measurement challenges, trends, causes and efforts to curb maternal death from sepsis in high and low-income countries. RECENT FINDINGS: Under-reporting using routine registration data, compounded by misclassification and unreported deaths, results in significant underestimation of the burden of maternal death from sepsis. In the UK and the Netherlands the recent increase in maternal death from sepsis is mainly attributed to an increase in invasive group A streptococcal infections. Susceptibility to infection may be complicated by modulation of maternal immune response and increasing rates of risk factors such as caesarean section and obesity. Failure to recognize severity of infection is a major universal risk factor. Standardized Surviving Sepsis Campaign (SSC) recommendations for management of severe maternal sepsis are continuing to be implemented worldwide; however, outcomes differ according to models of intensive care resourcing and use. SUMMARY: The need for robust data with subsequent analyses is apparent. This will significantly increase our understanding of risk factors and their causal pathways, which are critical to informing effective treatment strategies in consideration of resource availability.

National survey of preventive health services in US emergency departments.

STUDY OBJECTIVE: We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services. METHODS: Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services. RESULTS: Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%). CONCLUSION: Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention-recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.

Characteristics of pediatric trauma transfers to a level i trauma center: implications for developing a regionalized pediatric trauma system in california.

BACKGROUND: since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children. OBJECTIVES: this study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out-of-catchment transfers would come from hospitals in close geographic proximity to the study center. METHODS: this was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000-2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD-9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight-line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers. RESULTS: of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15-18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS) > 18 (RR = 0.26; p < 0.01). The out-of-catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight-line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0-136.4), compared to 33.6 miles (IQR = 13.9-61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out-of-catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15-18 (RR = 1.28; p < 0.001) were predictive of out-of-catchment patients bypassing other pediatric-capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity. CONCLUSIONS: from the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols.

Gender-related factors influencing tuberculosis control in shantytowns: a qualitative study.

BACKGROUND: There is evidence that female gender is associated with reduced likelihood of tuberculosis diagnosis and successful treatment. This study aimed to characterize gender-related barriers to tuberculosis control in Peruvian shantytowns. METHODS: We investigated attitudes and experiences relating gender to tuberculosis using the grounded theory approach to describe beliefs amongst key tuberculosis control stakeholders. These issues were explored in 22 semi-structured interviews and in four focus group discussions with 26 tuberculosis patients and 17 healthcare workers. RESULTS: We found that the tuberculosis program was perceived not to be gender discriminatory and provided equal tuberculosis diagnostic and treatment care to men and women. This contrasted with stereotypical gender roles in the broader community context and a commonly expressed belief amongst patients and healthcare workers that female health inherently has a lower priority than male health. This belief was principally associated with men's predominant role in the household economy and limited employment for women in this setting. Women were also generally reported to experience the adverse psychosocial and economic consequences of tuberculosis diagnosis more than men. CONCLUSIONS: There was a common perception that women's tuberculosis care was of secondary importance to that of men. This reflected societal gender values and occurred despite apparent gender equality in care provision. The greatest opportunities for improving women's access to tuberculosis care appear to be in improving social, political and economic structures, more than tuberculosis program modification.