Impact of Lymphocyte and Neutrophil Counts on Mortality Risk in Severe Community-Acquired Pneumonia with or without Septic Shock.

BACKGROUND: Community-acquired pneumonia (CAP) is a frequent cause of death worldwide. As recently described, CAP shows different biological endotypes. Improving characterization of these endotypes is needed to optimize individualized treatment of this disease. The potential value of the leukogram to assist prognosis in severe CAP has not been previously addressed. METHODS: A cohort of 710 patients with CAP admitted to the intensive care units (ICUs) at Hospital of Mataró and Parc Taulí Hospital of Sabadell was retrospectively analyzed. Patients were split in those with septic shock (n = 304) and those with no septic shock (n = 406). A single blood sample was drawn from all the patients at the time of admission to the emergency room. ICU mortality was the main outcome. RESULTS: Multivariate analysis demonstrated that lymphopenia <675 cells/mm3 or <501 cells/mm3 translated into 2.32- and 3.76-fold risk of mortality in patients with or without septic shock, respectively. In turn, neutrophil counts were associated with prognosis just in the group of patients with septic shock, where neutrophils <8850 cells/mm3 translated into 3.6-fold risk of mortality. CONCLUSION: lymphopenia is a preserved risk factor for mortality across the different clinical presentations of severe CAP (sCAP), while failing to expand circulating neutrophils counts beyond the upper limit of normality represents an incremental immunological failure observed just in those patients with the most severe form of CAP, septic shock.

Differences in Hypotensive vs. Non-Hypotensive Sepsis Management in the Emergency Department: Door-to-Antibiotic Time Impact on Sepsis Survival.

BACKGROUND: Sepsis diagnosis can be incorrectly associated with the presence of hypotension during an infection, so the detection and management of non-hypotensive sepsis can be delayed. We aimed to evaluate how the presence or absence of hypotension, on admission at the emergency department, affects the initial management and outcomes of patients with community-onset severe sepsis. METHODS: Demographic, clinical, laboratory, process of care, and outcome variables were recorded for all patients, at the emergency department of our university hospital, who presented with community-onset severe sepsis, between 1 March and 31 August in three consecutive years. Patient management consisted of standardized bundled care with five measures: Detection, blood cultures and empirical antibiotics, oxygen supplementation and fluid resuscitation (if needed), clinical monitoring, and noradrenalin administration (if needed). We compared all variables between patients who had hypotension (mean arterial pressure <65 mmHg), on admission to the emergency department, and those who did not. RESULTS: We identified 153 episodes (84 (54.5%) men; mean age 73.6 ± 1.2; mean Sequential Organ Failure Assessment (SOFA) score 4.9 ± 2.7, and 41.2% hospital mortality). Hypotension was present on admission to the emergency department in 57 patients (37.2%). Hemodynamic treatment was applied earlier in patients who presented hypotension initially. Antibiotics were administered 48 min later in non-hypotensive sepsis (p = 0.08). A higher proportion of patients without initial hypotension required admission to the intensive care unit (ICU) (43.1% for patients initially hypotensive vs. 56.9% in those initially non-hypotensive, p < 0.05). Initial hypotension was not associated with mortality. A delay in door-to-antibiotic administration time was associated with mortality [OR 1.150, 95%CI: 1.043⁻1.268). CONCLUSIONS: Initial management of patients with community-onset severe sepsis differed according to their clinical presentation. Initial hypotension was associated with early hemodynamic management and less ICU requirement. A non-significant delay was observed in the administration of antibiotics to initially non-hypotensive patients. The time of door-to-antibiotic administration was related to mortality.

Epidemiología de la sepsis grave adquirida en la comunidad. Estudio de base poblacional / Epidemiology of community-acquired severe sepsis. A population-based study

Antecedentes y objetivo: La mayoría de los estudios destinados a conocer la incidencia de sepsis grave poseen limitaciones metodológicas que condicionan resultados difícilmente comparables y poco aplicables a la hora de estimar los recursos necesarios. Nuestro objetivo es conocer la incidencia real de sepsis grave de adquisición comunitaria que requieren de UCI y analizar aspectos epidemiológicos relacionados. Pacientes y método: Estudio observacional prospectivo en una base poblacional de 180.000 adultos>15 años y un hospital general de 350 camas de hospitalización con 14 camas de UCI. Se registrarontodos los pacientes con sepsis grave o shock séptico adquiridos en la comunidad, con requerimiento de ingreso en UCI, durante un período de 9 años. Las variables recogidas fueron: edad, sexo, SAPS II, días de estancia en UCI, tipo de infección, microorganismo aislado y fallecimientos (durante su estancia en UCI). Se ha realizado un análisis estadístico bivariante y una regresión logística múltiple. Resultados: Se incluyeron 917 episodios en pacientes con una edad media de 65,2 años. El foco infeccioso más frecuente es el respiratorio (55,2%). El índice de gravedad SAPS II medio fue de 37,87 y la mortalidad de 19,7%. La incidencia anual media de las sepsis graves adquiridas en la comunidad ha sido de 51,54 episodios por 100.000 habitantes, precisando 1,97 camas de UCI/día. En el análisis multivariante el SAPS II y tener etiología conocida se muestran como factores de riesgo de mortalidad. Conclusiones: El estudio aporta datos epidemiológicos desde una perspectiva de base poblacional que contribuyen a cuantificar la necesidad de recursos asistenciales para atender la sepsis grave adquirida en la comunidad en nuestra área geográfica. La incidencia anual media es de 51,5 casos por 100.000 habitantes adultos, lo que supone la necesidad de disponer de 2 camas de UCI/día para atender a dicha población (AU)

Background and objective: Most studies aimed at getting to know the incidence of severe sepsis have methodological limitations which condition results that are difficult to compare and are inapplicable when it comes to estimating the necessary resources. Our objective is to evaluate the incidence and epidemiological aspects of community-acquired severe sepsis which require intensive care unit admission. Patients and method: Prospective observational population-based study in a population of 180,000 adults over 15 years old and a general hospital with 350 beds and 14 ICU beds. All episodes of community-acquired infection requiring admission to ICU due to severe sepsis were registered over a period of 9 years. The variables analyzed were: age, sex, SAPS II score, length of stay in ICU, type of infection, isolated microorganism, and deaths during their ICU admission. A statistical bivariate analysis and a multiple logistic regression were performed. Results: Nine hundred and seventeen episodes with an average age of 65.2 years. The most frequent infectious focus was pulmonary (55.2%). The average SAPS II severity score index was 37.87 and mortality 19.7%. The annual incidence was 51.54 episodes per 100,000 adult inhabitants, meaning 1.97 ICU beds per day. In the multivariate analysis, the SAPS II score and a known aetiology were demonstrated as mortality risk factors. Conclusions: This study brings us some epidemiological data from a population-based perspective which help us to care for patients better in our geographical area. The average annual incidence is 51.5 cases per 100,000 adult inhabitants which means that 2 ICU beds per day to attend this population (AU)

[Epidemiology of community-acquired severe sepsis. A population-based study]. / Epidemiología de la sepsis grave adquirida en la comunidad. Estudio de base poblacional.

BACKGROUND AND OBJECTIVE: Most studies aimed at getting to know the incidence of severe sepsis have methodological limitations which condition results that are difficult to compare and are inapplicable when it comes to estimating the necessary resources. Our objective is to evaluate the incidence and epidemiological aspects of community-acquired severe sepsis which require intensive care unit admission. PATIENTS AND METHOD: Prospective observational population-based study in a population of 180,000 adults over 15 years old and a general hospital with 350 beds and 14 ICU beds. All episodes of community-acquired infection requiring admission to ICU due to severe sepsis were registered over a period of 9 years. The variables analyzed were: age, sex, SAPS II score, length of stay in ICU, type of infection, isolated microorganism, and deaths during their ICU admission. A statistical bivariate analysis and a multiple logistic regression were performed. RESULTS: Nine hundred and seventeen episodes with an average age of 65.2 years. The most frequent infectious focus was pulmonary (55.2%). The average SAPS II severity score index was 37.87 and mortality 19.7%. The annual incidence was 51.54 episodes per 100,000 adult inhabitants, meaning 1.97 ICU beds per day. In the multivariate analysis, the SAPS II score and a known aetiology were demonstrated as mortality risk factors. CONCLUSIONS: This study brings us some epidemiological data from a population-based perspective which help us to care for patients better in our geographical area. The average annual incidence is 51.5 cases per 100,000 adult inhabitants which means that 2 ICU beds per day to attend this population.

Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters after incorrect handling.

OBJECTIVE: Disinfectable needle-free closed connectors were designed to avoid needle-stick injuries and to be easily disinfected before handling. Workloads or lack of knowledge, however, could impede the correct handling of these devices, allowing endoluminal catheter colonization. The aim of our study was to assess the barrier effect of different disinfectable needle-free closed connectors during correct and incorrect handling using an experimental model. DESIGN: We used a model consisting of a blood culture bottle with a peripheral venous catheter inserted under sterile conditions. Three different disinfectable needle-free closed connectors with different valve designs (microClave, Bionector, and Smartsite plus) were used to close the catheters. The external surfaces of the disinfectable needle-free closed connectors were contaminated with different concentrations of a Staphylococcus epidermidis culture broth. After contamination, 10 units of each connector and each concentration were assigned to the correct handling group (cleaned with 70% ethylic alcohol before handling) and the same number to the incorrect handling group (handled without disinfection) with a total of 180 bottles. RESULTS: Increases in concentrations of external contamination and incorrect handling of the connectors resulted in an increase in connectors' permeability to the pass of microorganisms to the endoluminal way. MicroClave proved the best barrier in the experimental conditions described. CONCLUSION: The barrier effect of disinfectable needle-free closed connectors is adversely affected by incorrect handling, the quantity of external valve colonization, and the valve design.