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Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study.

Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T - Crit Care (2015)

Bottom Line: Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown.We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013.A higher likelihood of infection does not adversely influence outcome in this population.

View Article: PubMed Central - PubMed

Affiliation: Department of Intensive Care Medicine, University Medical Center Utrecht, Room F06.149, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. p.m.c.kleinklouwenberg@umcutrecht.nl.

ABSTRACT

Introduction: A clinical suspicion of infection is mandatory for diagnosing sepsis in patients with a systemic inflammatory response syndrome. Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown. We therefore assessed the likelihood of infection in patients who were treated for sepsis upon admission to the ICU, and quantified the association between plausibility of infection and mortality.

Methods: We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013. The likelihood of infection was categorized as none, possible, probable or definite by post-hoc assessment. We used multivariable competing risks survival analyses to determine the association of the plausibility of infection with mortality.

Results: Among 2579 patients treated for sepsis, 13% had a post-hoc infection likelihood of "none", and an additional 30% of only "possible". These percentages were largely similar for different suspected sites of infection. In crude analyses, the likelihood of infection was associated with increased length of stay and complications. In multivariable analysis, patients with an unlikely infection had a higher mortality rate compared to patients with a definite infection (subdistribution hazard ratio 1.23; 95% confidence interval 1.03-1.49).

Conclusions: This study is the first prospective analysis to show that the clinical diagnosis of sepsis upon ICU admission corresponds poorly with the presence of infection on post-hoc assessment. A higher likelihood of infection does not adversely influence outcome in this population.

Trial registration: ClinicalTrials.gov NCT01905033. Registered 11 July 2013.

No MeSH data available.


Related in: MedlinePlus

Plausibility of infection in patients with presumed sepsis upon presentation for the most frequent sites of infection. Distribution of plausibility of infection for lung infections (community-acquired pneumonia and hospital-acquired pneumonia), abdominal infections (primary and secondary peritonitis), bloodstream infections (primary bloodstream infections, catheter-related bloodstream infections, and endocarditis), urinary tract infections, and skin/soft tissue infections
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Fig2: Plausibility of infection in patients with presumed sepsis upon presentation for the most frequent sites of infection. Distribution of plausibility of infection for lung infections (community-acquired pneumonia and hospital-acquired pneumonia), abdominal infections (primary and secondary peritonitis), bloodstream infections (primary bloodstream infections, catheter-related bloodstream infections, and endocarditis), urinary tract infections, and skin/soft tissue infections

Mentions: Of all patients treated for sepsis, 13 % had an infection likelihood of “none” upon post-hoc analysis (Table 1). An additional 30 % had an infection likelihood of possible, whereas slightly more than half scored a higher infection likelihood (25 % probable and 33 % definite). Limiting the analysis to infections that were diagnosed within 48 hours before admission resulted in a similar distribution (n = 2117): 15 %, 32 %, 25 %, and 28 % were classed as none, possible, probable, and definite infections, respectively. Figure 1 shows the plausibility of infection after post-hoc analysis for the whole cohort, and stratified by sepsis severity. Although the accuracy of the infection diagnosis according to the post-hoc adjudication increased with greater sepsis severity, there was still considerable misclassification in patients with organ failure (40 % of patients classified as none or possible) or shock (34 %). Figure 2 shows the plausibility of infection after post-hoc analysis for the five most prevalent sources of infection. The proportion of definite and probable infections was largely similar in patients with different sources of infection, although the percentage of definite cases in pneumonia patients was significantly lower compared with the whole cohort (16 % vs. 33 %, p <0.001). Furthermore, there were no likelihoods of “none” in the cases with skin or soft tissue infection. Additional file 1 shows all (both sepsis and nonsepsis) diagnoses that were registered in patients by category of infection likelihood.Fig. 1


Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study.

Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T - Crit Care (2015)

Plausibility of infection in patients with presumed sepsis upon presentation for the most frequent sites of infection. Distribution of plausibility of infection for lung infections (community-acquired pneumonia and hospital-acquired pneumonia), abdominal infections (primary and secondary peritonitis), bloodstream infections (primary bloodstream infections, catheter-related bloodstream infections, and endocarditis), urinary tract infections, and skin/soft tissue infections
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4562354&req=5

Fig2: Plausibility of infection in patients with presumed sepsis upon presentation for the most frequent sites of infection. Distribution of plausibility of infection for lung infections (community-acquired pneumonia and hospital-acquired pneumonia), abdominal infections (primary and secondary peritonitis), bloodstream infections (primary bloodstream infections, catheter-related bloodstream infections, and endocarditis), urinary tract infections, and skin/soft tissue infections
Mentions: Of all patients treated for sepsis, 13 % had an infection likelihood of “none” upon post-hoc analysis (Table 1). An additional 30 % had an infection likelihood of possible, whereas slightly more than half scored a higher infection likelihood (25 % probable and 33 % definite). Limiting the analysis to infections that were diagnosed within 48 hours before admission resulted in a similar distribution (n = 2117): 15 %, 32 %, 25 %, and 28 % were classed as none, possible, probable, and definite infections, respectively. Figure 1 shows the plausibility of infection after post-hoc analysis for the whole cohort, and stratified by sepsis severity. Although the accuracy of the infection diagnosis according to the post-hoc adjudication increased with greater sepsis severity, there was still considerable misclassification in patients with organ failure (40 % of patients classified as none or possible) or shock (34 %). Figure 2 shows the plausibility of infection after post-hoc analysis for the five most prevalent sources of infection. The proportion of definite and probable infections was largely similar in patients with different sources of infection, although the percentage of definite cases in pneumonia patients was significantly lower compared with the whole cohort (16 % vs. 33 %, p <0.001). Furthermore, there were no likelihoods of “none” in the cases with skin or soft tissue infection. Additional file 1 shows all (both sepsis and nonsepsis) diagnoses that were registered in patients by category of infection likelihood.Fig. 1

Bottom Line: Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown.We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013.A higher likelihood of infection does not adversely influence outcome in this population.

View Article: PubMed Central - PubMed

Affiliation: Department of Intensive Care Medicine, University Medical Center Utrecht, Room F06.149, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. p.m.c.kleinklouwenberg@umcutrecht.nl.

ABSTRACT

Introduction: A clinical suspicion of infection is mandatory for diagnosing sepsis in patients with a systemic inflammatory response syndrome. Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown. We therefore assessed the likelihood of infection in patients who were treated for sepsis upon admission to the ICU, and quantified the association between plausibility of infection and mortality.

Methods: We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013. The likelihood of infection was categorized as none, possible, probable or definite by post-hoc assessment. We used multivariable competing risks survival analyses to determine the association of the plausibility of infection with mortality.

Results: Among 2579 patients treated for sepsis, 13% had a post-hoc infection likelihood of "none", and an additional 30% of only "possible". These percentages were largely similar for different suspected sites of infection. In crude analyses, the likelihood of infection was associated with increased length of stay and complications. In multivariable analysis, patients with an unlikely infection had a higher mortality rate compared to patients with a definite infection (subdistribution hazard ratio 1.23; 95% confidence interval 1.03-1.49).

Conclusions: This study is the first prospective analysis to show that the clinical diagnosis of sepsis upon ICU admission corresponds poorly with the presence of infection on post-hoc assessment. A higher likelihood of infection does not adversely influence outcome in this population.

Trial registration: ClinicalTrials.gov NCT01905033. Registered 11 July 2013.

No MeSH data available.


Related in: MedlinePlus