Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study

IntroductionSepsis is a leading cause of admission to non-cardiological intensive care units (ICUs) and the second leading cause of death among ICU patients. We present the first extensive dataset on the epidemiology of severe sepsis treated in ICUs in Spain.MethodsWe conducted a prospective, observational, multicentre cohort study, carried out over two 3-month periods in 2002. Our aims were to determine the incidence of severe sepsis among adults in ICUs in a specific area in Spain, to determine the early (48 h) ICU and hospital mortality rates, as well as factors associated with the risk of death.ResultsA total of 4,317 patients were admitted and 2,619 patients were eligible for the study; 311 (11.9%) of these presented at least 1 episode of severe sepsis, and 324 (12.4%) episodes of severe sepsis were recorded. The estimated accumulated incidence for the population was 25 cases of severe sepsis attended in ICUs per 100,000 inhabitants per year. The mean logistic organ dysfunction system (LODS) upon admission was 6.3; the mean sepsis-related organ failure assessment (SOFA) score on the first day was 9.6. Two or more organ failures were present at diagnosis in 78.1% of the patients. A microbiological diagnosis of the infection was reached in 209 episodes of sepsis (64.5%) and the most common clinical diagnosis was pneumonia (42.8%). A total of 169 patients (54.3%) died in hospital, 150 (48.2%) of these in the ICU. The mortality in the first 48 h was 14.8%. Factors associated with early death were haematological failure and liver failure at diagnosis, acquisition of the infection prior to ICU admission, and total LODS score on admission. Factors associated with death in the hospital were age, chronic alcohol abuse, increased McCabe score, higher LODS on admission, ΔSOFA 3-1 (defined as the difference in the total SOFA scores on day 3 and on day 1), and the difference of the area under the curve of the SOFA score throughout the first 15 days.ConclusionsWe found a high incidence of severe sepsis attended in the ICU and high ICU and hospital mortality rates. The high prevalence of multiple organ failure at diagnosis and the high mortality in the first 48 h suggests delays in diagnosis, in initial resuscitation, and/or in initiating appropriate antibiotic treatment.

[1]  S. Lowry,et al.  An overview of mortality risk prediction in sepsis. , 1995, Critical care medicine.

[2]  E. Draper,et al.  APACHE II: A severity of disease classification system , 1985, Critical care medicine.

[3]  G. Clermont,et al.  Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care , 2001, Critical care medicine.

[4]  J. Vincent,et al.  Serial evaluation of the SOFA score to predict outcome in critically ill patients. , 2001, JAMA.

[5]  Derek C. Angus,et al.  Epidemiology of sepsis: An update , 2001, Critical care medicine.

[6]  Corinne Alberti,et al.  The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. , 1996, JAMA.

[7]  Djillali Annane,et al.  Current epidemiology of septic shock: the CUB-Réa Network. , 2003, American journal of respiratory and critical care medicine.

[8]  F. Gordo,et al.  Sepsis incidence and outcome: Contrasting the intensive care unit with the hospital ward* , 2007, Critical care medicine.

[9]  Rolf Rossaint,et al.  Epidemiology of sepsis in Germany: results from a national prospective multicenter study , 2007, Intensive Care Medicine.

[10]  Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock , 2003, Current infectious disease reports.

[11]  S Lemeshow,et al.  The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. , 1996, JAMA.

[12]  Corinne Alberti,et al.  Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study , 2002, Intensive Care Medicine.

[13]  C. Brun-Buisson,et al.  The epidemiology of the systemic inflammatory response , 2000, Intensive Care Medicine.

[14]  C. Sprung,et al.  Sepsis in European intensive care units: Results of the SOAP study* , 2006, Critical care medicine.

[15]  Margaret M Parker,et al.  Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock , 2004, Critical care medicine.

[16]  G. Jackson,et al.  Gram-Negative Bacteremia: I. Etiology and Ecology , 1962 .

[17]  D. Mannino,et al.  The epidemiology of sepsis in the United States from 1979 through 2000. , 2003, The New England journal of medicine.

[18]  M. Levy,et al.  Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. , 2008, JAMA.

[19]  W. Knaus,et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. , 1992, Chest.

[20]  C. Sprung,et al.  The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study , 1999, Intensive Care Medicine.

[21]  François Gouin,et al.  Incidence, Risk Factors, and Outcome of Severe Sepsis and Septic Shock in Adults: A Multicenter Prospective Study in Intensive Care Units , 1995 .

[22]  Herwig Gerlach,et al.  Reply to Zandstra and van der Voort , 2004, Intensive Care Medicine.

[23]  B. Yangco,et al.  CDC definitions for nosocomial infections. , 1989, American journal of infection control.

[24]  D. Bates,et al.  Epidemiology of sepsis syndrome in 8 academic medical centers. , 1997, JAMA.

[25]  M. Langer,et al.  The Italian SEPSIS study: Preliminary results on the incidence and evolution of SIRS, sepsis, severe sepsis and septic shock , 1995, Intensive Care Medicine.

[26]  F Doyon,et al.  Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. , 1995, JAMA.

[27]  Véronique Sébille,et al.  Effect of Treatment With Low Doses of Hydrocortisone and Fludrocortisone on Mortality in Patients With Septic Shock , 2002 .

[28]  J M Hughes,et al.  CDC definitions for nosocomial infections, 1988. , 1988, American journal of infection control.

[29]  J. Helterbrand,et al.  Efficacy and safety of recombinant human activated protein C for severe sepsis , 2003 .

[30]  Duncan Young,et al.  Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland , 2003, Critical care medicine.

[31]  J. le Gall,et al.  Systemic inflammatory response and progression to severe sepsis in critically ill infected patients. , 2005, American journal of respiratory and critical care medicine.

[32]  D. Pittet,et al.  The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. , 1995, JAMA.

[33]  C. Brun-Buisson,et al.  EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units , 2004, Intensive Care Medicine.

[34]  J. Vincent,et al.  The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure , 1996, Intensive Care Medicine.

[35]  Epidemiology of sepsis syndrome in 8 academic medical centers. , 1997 .

[36]  R. Bellomo,et al.  Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units , 2004, Intensive Care Medicine.

[37]  Sumita Sinha,et al.  Seasonal variation in the epidemiology of sepsis* , 2007, Critical care medicine.

[38]  J Ean,et al.  Efficacy and safety of recombinant human activated protein C for severe sepsis. , 2001, The New England journal of medicine.

[39]  Stanley Lemeshow,et al.  The Logistic Organ Dysfunction System , 1997 .